Innovative C-Arm-Free Navigation Technique for Posterior Spinal Fixation for Atlantoaxial Subluxation: A Technical Note

Study design: Technical note. Objectives: To present a novel C-arm-free technique guided by navigation to insert and place a C1 lateral mass screw. Background and Objectives: Atlantoaxial subluxation (AAS) is a relatively common sequelae in patients with rheumatoid arthritis (RA) and upper cervical trauma. If they present with severe symptoms, surgical intervention such as posterior fusion is indicated. The established treatment for AAS is fixation with a C1 lateral mass screw and C2 pedicle screw (modified Goel technique) to achieve bony fusion. However, this technique requires fluoroscopy for C1 screw insertion. To avoid exposing the operating team to radiation, we present here a novel C-arm-free C1 lateral mass screw insertion technique for AAS. Materials and Methods: A 67-year-old man was referred to our hospital with neck pain, quadriparesis, and clumsiness and numbness of both upper and lower limbs. He had undergone C3-6 posterior fusion previously in another hospital. In physical examination, he had severe muscle weakness of bilateral upper limbs and hypoesthesia of all four limbs. He had hyper-reflexia of bilateral lower limbs and pollakiuria. His Japanese orthopedic score was 8 points out of 17. Preoperative radiograms showed AAS with an atlantodental interval (ADI) of 7 mm. MRI indicated retro-odontoid pseudotumor and severe spinal cord compression at the C1-2 level. The patient underwent posterior atlantoaxial fixation under navigation guidance. To prevent epidural bleeding during the insertion and placement of a C1 lateral mass screw, we have here defined a novel screw insertion technique. Results: The surgical time was clocked as 127 min and blood loss was 100 mL. There were no complications per-operatively or in the postoperative period. The patient showed almost full recovery (JOA 16/17) at two months follow-up and a solid bony fusion was noticed in the radiograms at one year follow-up. Conclusions: This novel surgical procedure and C1 lateral mas screw placement technique is a practical and safe method in recent advances of AAS treatment. Procedurally, the technique helps prevent epidural bleeding from the screw entry point and also allows for proper C1 screw insertion under navigation guidance without exposing surgeons and staff to the risk of fluoroscopic radiation.

Posterolateral Floating Technique for the Thoracic Ossification of the Posterior Longitudinal Ligament with Navigation: A Technical Note

We describe a floating technique via a posterolateral approach with intraoperative O-arm navigation to facilitate decompression of the spinal cord in thoracic myelopathy due to severe ossification of the posterior longitudinal ligament (OPLL). A 62-year-old man with myelopathy due to thoracic OPLL had left-leg muscle weakness, urinary disturbance, and spastic gait. Bilateral leg pain and gait disturbance had persisted for 2 years. He was successfully treated by the posterolateral OPLL floating procedure and posterior pedicle fixation under O-arm navigation. At a 2-year follow-up, manual muscle testing results and sensory function of the left leg had recovered fully. His cervical Japanese Orthopedic Association score had improved from 5/12 to 11/12. The novel intraoperative O-arm navigation-guided posterolateral floating procedure for thoracic OPLL is effective for achieving precise decompression and strong fixation with a posterior approach only and can provide an excellent result for severe thoracic OPLL without the risk of adverse events from intraoperative radiation.

POS1413 INTERSTITIAL LUNG DISEASE(ILD) PREVALENCE AND TRENDS IN SYSTEMIC LUPUS ERYTHEMATOSUS(SLE), RHEUMATOID ARTHRITIS(RA), SCLERODERMA(SCL), MYOSITIS AND MIXED CONNECTIVE TISSUE DISEASES(MCTD) ALONG WITH COMPARISON OF LENGTH OF HOSPITALIZATION STAY(LOS), COST AND RACIAL PREDISPOSITION AMONG THESE PATIENTS

Background

ILD includes a category of lung disorders seen in a variety of autoimmune conditions. Prevalence of ILD in autoimmune diseases is variable and poorly studied. ILD is more commonly seen in systemic sclerosis, with 90% of patients showing some interstitial changes on High resolution CT scan. ILD is less common in SLE compared to SCL, with ILD not only a complication but also a poor prognostic factor in these patients. Prior studies have shown increased prevalence of ILD in RA patients over the years. For myositis, ILD can develop during the course of disease or can precede the diagnosis in a small subset of patients.

Objectives

Our study aims to determine the prevalence of ILD in diseases like SLE, Scleroderma, RA, MCTD, and Myositis over the years as well as identify racial predisposition, LOS, Cost of hospitalization in these patients

Methods

We used the Nationwide Inpatient Sample database (years 2003-2018) and extracted patients with ILD using validated International Classification of Disease (ICD) codes. Data from 2015 was excluded from the study in light of the transition of the coding system from version 9 to 10. We identified cases having the diagnosis of SLE, RA, Scleroderma, MCTD or Myositis. Prevalence as well as demographics, cost of hospitalization, and length of stay (LOS) was analyzed and charted. Data was analyzed using statistical analysis system 9.4 software.

Results

We identified a total of 149,691 cases of ILD over 15 years. Patients with RA had the highest prevalence of ILD amongst the 5 studied autoimmune diseases. The prevalence rate of RA in ILD patients in 2003 was 3.3% which significantly reduced to 0.93% in 2018, with a peak of 6.42% seen in 2010 (p <0.0001). Prevalence rate of ILD with myositis decreased from 0.72% in 2003 to 0.46% in 2018 (p 0.0001). The prevalence rates of SLE, Scleroderma, and MCTD in cases with ILD significantly increased from 1.38% to 1.63%, 1.38% to 1.76%, and 0.14% to 0.54% from 2003 to 2018 respectively.

The average age of ILD cases with SLE was significantly younger compared to ILD without autoimmune disease (59.28 vs 72.32 years, p <0.0001), RA (69.72 vs 72.17 years, p <0.0001), Scleroderma (62.01 vs 72.28 years, p < 0.0001), Myositis (59.56 vs 72.19 years, p <0.0001) and MCTD (59.6 vs 72.18 years, p <0.0001). On examining the racial distribution, the African American population with ILD when compared to other races were more likely to have underlying SLE, MCTD, Myositis or Scleroderma. In ILD with RA, Native Americans were the most affected racial demographic followed by African Americans.

Average cost of hospitalization was higher in ILD with MCTD ($104,631 vs $71,264.6, p<0.0001), Myositis ($105,623 vs $71,232.9, p<0.0001) and Scleroderma ($88,736.2 vs $71,135.5, p<0.0001). Average LOS was significantly longer in RA (7.17 vs 6.66 days, p value 0.0006), MCTD (7.71 vs 6.67 days, p value 0.0008), Myositis (8.33 vs 6.66 days, p value <0.0001) and Scleroderma (7.07 vs 6.67 days, p value 0.0176). Though not significant, average LOS was longer in SLE (6.79 vs 6.67 days, p value 0.4999).

Conclusion

Our study shows that the prevalence of RA in ILD cases has significantly reduced through the years. This can be attributed to the better understanding of the disease and its risk factors as well as the availability and use of newer biologic agents to obtain better control. However, the prevalence of SLE, Scleroderma, and MCTD in ILD cases has increased over the years. This points to the need for better therapies as well as highlights the fact that the overall recognition and diagnosis of these diseases have increased over the years. Racial predilection also comes to light, suggesting the need for special attention to certain races to diagnose the autoimmune disease earlier. Average LOS and cost of hospitalization were also higher in ILD cases with autoimmune disease, reflecting the higher socioeconomic burden.

Disclosure of Interests

None declared

Perinatal and infant outcome of fetuses with prenatally diagnosed hyperechogenic kidneys

OBJECTIVE

Hyperechogenic kidneys are a relatively rare antenatal finding, which can generate significant parental anxiety due to uncertain prognosis. We report on the perinatal and infant outcomes of a large cohort of fetuses with antenatally diagnosed hyperechogenic kidneys.

METHODS

This was a retrospective analysis of all cases diagnosed prenatally with hyperechogenic kidneys between 2002 and 2017 in a large tertiary fetal medicine unit. Hyperechogenicity was defined as kidney parenchyma with greater echogenicity than that of the liver. Pregnancy, pathological and postnatal outcomes were collected from hospital and general practitioner records up to 1 year of age. Abnormal renal outcome was defined as elevated creatinine beyond 6 months of age, hypertension requiring medication or major kidney surgery, such as nephrectomy. Severe abnormal renal outcome was defined as the need for dialysis or kidney transplant at any stage.

RESULTS

Three-hundred and sixteen fetuses with hyperechogenic kidneys were identified at a mean gestational age of 21 (range, 13-37) weeks. The majority of cases (97%) had bilateral hyperechogenic kidneys. In the 265 cases with available follow-up data, other associated renal tract abnormalities were identified prenatally in 36%, concomitant extrarenal structural abnormalities in 39% and abnormal karyotype in 15% of cases. Of the 316 included cases, 139 did not survive, including 105 terminations of pregnancy, five intrauterine deaths and 29 early neonatal deaths. Only 4.3% (6/139) of these fetuses had isolated hyperechogenic kidneys while 28.1% (39/139) had associated multiple renal tract abnormalities alongside hyperechogenic kidneys and over two-thirds (67.6%; 94/139) had concomitant extrarenal abnormalities. Of the 177 cases that survived beyond 1 month of age, outcome data were available in 126. Of these, based on the antenatal findings, 60 (47.6%) cases had isolated hyperechogenic kidneys, 56 (44.4%) had associated renal structural abnormalities and 10 (7.9%) had additional extrarenal abnormalities. Considering renal outcome alone, kidney function was abnormal in 13 (21.7%), 10 (17.9%) and 0 (0%) infants in these three groups, respectively, although concurrent pathology clearly affected global outcome in the more complex cases. Neonatal mortality of 1.6% was observed in the isolated renal hyperechogenicity group. The presence of oligohydramnios or abnormal renal volume was not associated significantly with abnormal renal function (odds ratio (OR), 2.32 (99% CI, 0.54-10.02) and OR, 0.74 (99% CI, 0.21-2.59), respectively) in this group.

CONCLUSIONS

Hyperechogenic kidneys are often complicated by associated renal tract and extrarenal abnormalities, aberrant karyotype and genetic disease, and these factors have a greater effect on overall outcome than does kidney echogenicity. The renal outcome of fetuses with isolated hyperechogenic kidneys is good generally, with over 70% of cases having normal renal function postpartum. Importantly, for prognostic counseling, all of the fetuses in this non-selected series with isolated hyperechogenic kidneys and normal amniotic fluid levels had normal renal outcome in infancy. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

158 Oral Submucous Fibrosis in A 2-Year-Old Girl Due to Chewing BIDI Stubs

A 2-year-old girl, complaining of a gradual increase in the restriction of the mouth opening for 3 months, was referred to the Otolaryngologists based on background history of recurrent oral ulcers. The local examination showed the presence of oral ulcers on the cheek in addition to abnormal oral mucosa which appeared blanched, opaque and fibrotic. This was clinically diagnosed as Oral Submucous Fibrosis, owing to classical presentation and the lack of systemic features. A detailed social and family history revealed that the father of the child used to smoke BIDI, a traditional form of nonfiltered cigarette. The child used to play with the burnt stubs and keep them in her mouth, chewing them for long durations. This was assumed to be the aetiological factor behind the development of the pathology, in absence of any other contributing factors. The patient was treated conservatively, and symptomatic improvement was noted on follow-up. This is the youngest reported patient with OSMF, and this case history brought an unusual aetiological factor to the fore.

Society of pediatric liver transplantation: Current registry status 2011-2018

BACKGROUND

SPLIT was founded in 1995 in order to collect comprehensive prospective data on pediatric liver transplantation, including waiting list data, transplant, and early and late outcomes. Since 2011, data collection of the current registry has been refined to focus on prospective data and outcomes only after transplant to serve as a foundation for the future development of targeted clinical studies.

OBJECTIVE

To report the outcomes of the SPLIT registry from 2011 to 2018.

METHODS

This is a multicenter, cross-sectional analysis characterizing patients transplanted and enrolled in the SPLIT registry between 2011 and 2018. All patients, <18 years of age, received a first liver-only, a combined liver-kidney, or a combined liver-pancreas transplant during this study period.

RESULTS

A total of 1911 recipients from 39 participating centers in North America were registered. Indications included biliary atresia (38.5%), metabolic disease (19.1%), tumors (11.7%), and fulminant liver failure (11.5%). Greater than 50% of recipients were transplanted as either Status 1A/1B or with a MELD/PELD exception score. Incompatible transplants were performed in 4.1%. Kaplan-Meier estimates of 1-year patient and graft survival were 97.3% and 96.6%. First 30 days of surgical complications included reoperation (31.7%), hepatic artery thrombosis (6.3%), and portal vein thrombosis (3.2%). In the first 90 days, biliary tract complications were reported in 13.6%. Acute cellular rejection during first year was 34.7%. At 1 and 2 years of follow-up, 39.2% and 50.6% had normal liver tests on monotherapy (tacrolimus or sirolimus). Further surgical, survival, allograft function, and complications are detailed.

Nanoparticles carrying fingolimod and methotrexate enables targeted induction of apoptosis and immobilization of invasive thyroid cancer

Metastatic tumors are the main cause of cancer-related death, as the invading cancer cells disrupt normal functions of distant organs and are nearly impossible to eradicate by traditional cancer therapeutics. This is of special concern when the cancer has created multiple metastases and extensive surgery would be too dangerous to execute. Therefore, combination chemotherapy is often the selected treatment form. However, drug cocktails often have severe adverse effects on healthy cells, whereby the development of targeted drug delivery could minimize side-effects of drugs and increase the efficacy of the combination therapy. In this study, we utilized the folate antagonist methotrexate (MTX) as targeting ligand conjugated onto mesoporous silica nanoparticles (MSNs) for selective eradication of folate receptor-expressing invasive thyroid cancer cells. The MSNs was subsequently loaded with the drug fingolimod (FTY720), which has previously been shown to efficiently inhibit proliferation and invasion of aggressive thyroid cancer cells. To assess the efficiency of our carrier system, comprehensive in vitro methods were employed; including flow cytometry, confocal microscopy, viability assays, invasion assay, and label-free imaging techniques. The in vitro results show that MTX-conjugated and FTY720-loaded MSNs potently attenuated both the proliferation and invasion of the cancerous thyroid cells while keeping the off-target effects in normal thyroid cells reasonably low. For a more physiologically relevant in vivo approach we utilized the chick chorioallantoic membrane (CAM) assay, showing decreased invasive behavior of the thyroid derived xenografts and an increased necrotic phenotype compared to tumors that received the free drug cocktail. Thus, the developed multidrug-loaded MSNs effectively induced apoptosis and immobilization of invasive thyroid cancer cells, and could potentially be used as a carrier system for targeted drug delivery for the treatment of diverse forms of aggressive cancers that expresses folate receptors.

P2806A novel sirolimus drug eluting stent for Small-Vessel Disease: results from en-ABL e-registry

Objective

The aim of the study was to assess the clinical outcome of Abluminus DES in patients with small vessels.

Background

Percutaneous coronary intervention (PCI) of small coronary vessel (≤2.75 mm) associated with more chances of restenosis and repeat revascularization even when drug eluting stent employed.

Methods

A total of 2,500 patients enrolled in en-ABL e-registry which is a prospective, multicentre observational post market registry. Out of 2,500 patients, 1,253 patients had small vessel (SV, ≤2.75 mm) while 1,247 had large vessel (LV, >3mm) disease. The primary endpoint was major adverse cardiac events (MACE) which is composite of cardiac death, target vessel myocardial infraction (TV-MI) and target lesion/vessel revascularization (TLR) at 1 year follow up. The secondary endpoint were stent thrombosis and MACE up to 2 years.

Results

Baseline characteristics were well matched in both groups. In the SV group had higher prevalence of diabetes as compared to large vessel 43.0% vs 25.7%. Total 1,400 lesions treated with 1,612 Abluminus DES and 1,569 lesions treated with 1,675 Abluminus DES in SV and LV groups respectively. The mean diameter of stent was 2.61±0.23 and 3.3±0.3 mm in SV and LV groups respectively. There was a significant difference in MACE in treatment groups (3.7% vs. 1.4%, p=0.004 respectively) at 1 year. No significant differences were observed between SV and LV groups in terms of death/myocardial infarction or stent thrombosis. There were increment of only one TLR and no stent thrombosis reported at 2-year follow-up.

Conclusion

This result suggests the efficacy and safety of novel Abluminus DES in small vessel disease.

Bioactivities and molecular networking-based elucidation of metabolites of potent actinobacterial strains isolated from the Unkeshwar geothermal springs in India

The bioactive potential of Actinobacteria endemic to hot springs has rarely been investigated. This study highlights the cultivable diversity and bioactivities of Actinobacteria associated with the Unkeshwar hot springs, India. Potent strains were evaluated for their biosynthetic potentials and metabolite analysis was performed using effective dereplication molecular networking tools. A total of 86 actinobacterial strains were isolated and grouped into 21 distinct genera, based on 16S rRNA gene sequence analysis. These strains included rare members such as Micromonospora, Marmoricola, Actinomadura, Cellulomonas, Cellulosimicrobium, Janibacter, Rothia, Barrentisimonas, Dietzia and Glycomyces. In antimicrobial screening, Micromonospora sp. strain GH99 and Streptomyces sp. strain GH176 were found to be potent antimicrobial strains. The metabolic extracts of these strains exhibited strong antimicrobial activity against Staphylococcus epidermidis (NCIM 2493), Shigella flexneri (NCIM 5265), Klebsiella pneumonia (NCIM 2098), and Salmonella abony (NCIM 2257). The extracts also displayed strong anti-biofilm and anticancer activities against Pseudomonas aeruginosa (NCIM 5029), Acinetobacter junii (NCIM 5188) and breast cancer cell line MCF7, respectively. Both strains also tested positive for the presence of the PKS biosynthetic gene cluster in their genomes. To effectively delineate the secondary metabolites, the extracts were subjected to MS/MS-guided molecular networking analysis. Structurally diverse compounds including the polyketides 22-dehydroxymethyl-kijanolide (GH99 strain) and Abyssomicin I (GH176 strain) were detected in the extracts. Interestingly, Brevianamide F was detected in the extract of Micromonospora, which has previously been mostly found in fungal species. Other compounds such as cyclic tripeptides, Cyclo(l-Pro-d-Ile) and Cyclo(d-Pro-l-Phe), were also identified in this strain. In summary, for the first time, we explored the diversity of Actinobacteria and evaluated their bioactive potential from the Unkeshwar hot springs. The potent strains isolated in the study could be useful in drug discovery programs.

The bioactive potential of Actinobacteria endemic to hot springs has rarely been investigated.

Two-stage hypospadias repair with a free graft for severe primary and revision hypospadias: A single surgeon's experience with long-term follow-up

INTRODUCTION

Repair of severe primary and revision hypospadias is a demanding procedure. Debate continues as to whether a two-stage approach or single-stage technique is superior. The two-stage procedure with a free graft involves penile straightening followed by application of a graft for the neourethral plate at stage one; with tubularization at stage two after graft maturation.

OBJECTIVE

To report the outcomes of a single surgeon's experience with the two-stage repair using a free graft for both severe primary and revision hypospadias with long-term follow-up.

MATERIALS AND METHODS

Between July 1998 and January 2010, 301 boys underwent a two-stage reconstruction. The surgical technique is described in the manuscript. Primary repairs (n = 208): indications for a two-stage approach with a free graft included meatal position, presence of corporal chordee, and poor glans development. Median follow-up from completion of the second stage was 75 months. Revision repairs (n = 93): indications included urethral fistula, excessive scarring/meatal stenosis, balanitis xerotica obliterans (BXO), and residual or untreated chordee. Median follow-up from completion of the second stage was 85 months.

RESULTS

For the primary repairs (n = 208), the graft took well in all but one case. Second-stage complications included fistula (7), meatal stenosis (3), partial glans dehiscence (3), and all were re-operated (13). For the revision repairs (n = 93), the graft took well in all but four cases. Second-stage complications included fistula (5), meatal stenosis (3), breakdown (1) and reoperation (8).

DISCUSSION

In a systematic review of 20 years of publications on the repair of primary severe hypospadias, the two-stage procedure with a free graft demonstrated an overall complication rate of 22%; this was a distinct overall benefit when compared with the single-stage procedures in terms of lower complication rates (Castagnetti and El-Ghoneimi, 2010). Our results for the severe primary repairs revealed significantly lower complication rates than those in the literature, with an overall re-operation rate of 6.3%, a fistula rate of 3.4%, and meatal stenosis and partial glans dehiscence at 1.4% each. Several papers have documented outcomes following the single-stage tubularized incised plate urethroplasty for re-operative hypospadias, giving overall complication rates ranging from 15.4 to 30%. Our data show a re-operative rate of 8.6%, a fistula rate of 5.3%, breakdown in 1.1%, and meatal stenosis in 3.2%.

CONCLUSION

The two-stage repair with a free graft for correction of both severe primary and failed primary hypospadias is a safe, viable, and durable procedure offering low morbidity and excellent cosmetic results. The authors advocate the two-stage repair with a free graft as the technique of choice for treatment of both of these challenging groups of the deformity.

Pain and Opioid Addiction: A Systematic Review and Evaluation of Pain Measurement in Patients with Opioid Dependence on Methadone Maintenance Treatment

BACKGROUND

While chronic pain has been said to impact patient's response to methadone maintenance treatment for opioid dependence, the reported findings are inconsistent. These discrepancies may be a direct result of variations in the measurement of chronic pain or definitions of response to methadone treatment. The goal of this study is to evaluate the association between pain and substance use behaviour to determine the real impact of comorbid pain in the methadone population. We also aim to examine sources of variation across the literature with a specific focus on the measurement of pain.

METHODS/DESIGN

We performed a systematic review using an electronic search strategy across CINAHL, MEDLINE, Web of Science, PsychINFO, EMBASE, and the Cochrane Library including Cochrane Reviews and the Cochrane Central Register of Controlled Trials databases. Title, abstract, as well as full text screening and extraction were performed in duplicate. Studies evaluating the association between chronic pain and methadone maintenance treatment response were eligible for inclusion in this review. Using a sample of 297 methadone patients from the Genetics of Opioid Addiction (GENOA) research collaborative, we assessed the reliability of patient self-reported pain and the validated Brief Pain Inventory (BPI) assessment tool.

RESULTS

After screening 826 articles we identified five studies eligible for full text extraction, of which three showed a significant relationship between the presence of pain and the increase in substance abuse among patients on methadone for the treatment of opioid dependence. Studies varied largely in the definitions and measurement of both pain and response to treatment. Results from our validation of pain measurement in the GENOA sample (n=297) showed the use of a simple self-reported pain question is highly correlated to the use of the BPI. Simply asking patients whether they have pain showed a 44.2% sensitivity, 88.8% specificity, 84.4% PPV and 53.6% NPV to the BPI. The area under the ROC curve was 0.67 and the Pearson χ(2) was 37.3; (p<0.0001).

DISCUSSION

The field of addiction medicine is at a lack of consensus as to the real effect of chronic pain on treatment response among opioid dependent patients. Whether it be the lack of a single "gold standard" measurement of response, or a lack of consistent measurement of pain, it is difficult to summarize and compare the results of these relatively small investigations. In comparison to the BPI, use of the simple self-reported pain has lower sensitivity for identifying patients with pain, suggesting the inconsistencies in these studies may result from differences in pain measurement. Future validation studies of pain measurement are required to address the predictive value of self-reported pain.

Mathematical Model-Based Accelerated Development of Extended-release Metformin Hydrochloride Tablet Formulation

A computational fluid dynamic (CFD) model was developed to predict metformin release from a hydroxypropylmethylcellulose (HPMC) matrix-based extended-release formulation that took into consideration the physical and chemical properties of the drug substance, composition, as well as size and shape of the tablet. New high dose strength (1000 mg) tablet geometry was selected based on the surface area/volume (SA/V) approach advocated by Lapidus/Lordi/Reynold to obtain the desired equivalent metformin release kinetics. Maintaining a similar SA/V ratio across all extended-release metformin hydrochloride (Met XR) tablet strengths that had different geometries provided similar simulations of dissolution behavior. Experimental dissolution profiles of three lots of high-strength tablets agreed with the simulated release kinetics. Additionally, a pharmacokinetic absorption model was developed using GastroPlus™ software and known physicochemical, pharmacokinetic, and in vitro dissolution properties of metformin to predict the clinical exposure of the new high strength (1000 mg) tablet prior to conducting a human clinical bioequivalence study. In vitro metformin release kinetics were utilized in the absorption model to predict exposures in humans for new 1000-mg Met XR tablets, and the absorption model correctly projected equivalent in vivo exposure across all dose strengths. A clinical bioequivalence study was pursued based on the combined modeling results and demonstrated equivalent exposure as predicted by the simulations.

Shape engineering boosts antibacterial activity of chitosan coated mesoporous silica nanoparticle doped with silver: a mechanistic investigation

Mechanism of antibacterial activity of MSPs with high aspect ratio and surface modification.

A field study of lignite as a drying aid in the superheated steam drying of anaerobically digested sludge

Dried sludge is preferred when the sludge is either to be incinerated or used as a soil amendment. This paper focuses on superheated steam drying which has many benefits, because the system is totally enclosed, thereby minimising odours and particulate emissions. This work reports on field trials at a wastewater treatment plant where anaerobically digested sludge is dried immediately after being dewatered by belt press. The trials showed that unlike previous off-site tests, the sludge could be dried without the addition of a filter aid at a low production rate. However, the trials also confirmed that the addition of the lignite (brown coal) into the anaerobically digested sludge led to a more productive drying process, improved product quality and a greater fraction of the product being in the desired product size range. It is concluded that these results were achieved because the lignite helped to control the granule size in the dryer. Furthermore neither Salmonella spp or E coli were detected in the dried samples. Tests on spontaneous combustion show that this risk is increased in proportion to the amount of lignite used as a drying aid.

Accuracy of conventional digital palpation and ultrasound of the cricothyroid membrane in obese women in labour

Success of cricothyroidotomy depends on accurate identification of anatomical neck landmarks. Anaesthetists palpated the cricothyroid membrane of 28 obese and 28 non-obese women in labour (cut-off BMI 30 kg.m(-2) ) and marked the entry point for device insertion with an ultraviolet invisible pen. Ultrasonography was used to mark the midpoint of the cricothyroid membrane and the distance between the two marks was measured. The median (IQR [range]) distance between the two marks was significantly greater in the obese than the non-obese patients (5 (2-9.5 [0-34]) mm vs 1.8 (0.1-6 [0-15]) mm, respectively; p = 0.02). The cricothyroid membrane was accurately identified with digital palpation in only 39% (11/28) of obese compared with 71% (20/28) of non-obese patients (p = 0.03). Increased neck circumference in obese patients was significantly associated with inaccuracy in locating the cricothyroid membrane. Percutaneous identification of the cricothyroid membrane in obese women in labour was poor. Pre-procedural ultrasound may help improved the identification of neck landmarks for cricothyroidotomy.

Clinical significance of small airway obstruction markers in patients with asthma

BACKGROUND

The role of small airway obstruction in the clinical expression of asthma is incompletely understood.

OBJECTIVE

We tested the hypotheses that markers of small airway obstruction are associated with (i) increased asthma severity, (ii) impaired asthma control and quality of life and (iii) frequent exacerbations.

METHODS

Seventy-four adults with asthma and 18 healthy control subjects underwent impulse oscillometry (IOS), multiple breath inert gas washout (MBW), body plethysmography, single-breath determination of carbon monoxide uptake and spirometry. Patients completed the six-point Asthma Control Questionnaire (ACQ-6) and standardized Asthma Quality of Life Questionnaire [AQLQ(S)]. Asthma severity was classified according to the Global Initiative for Asthma (GINA) treatment steps.

RESULTS

The putative small airway obstruction markers Sacin , resistance at 5 Hz minus resistance at 20 Hz (R5-R20) and reactance area (AX) were not independently associated with asthma severity, control, quality of life or exacerbations. In contrast, markers of total (R5) and mean airway resistance of large and small airways (R20) were significantly higher in the severe asthma group compared with the mild-moderate group (0.47 vs. 0.37, P < 0.05 for R5; 0.39 vs. 0.31, P < 0.01 for R20). The strongest independent contributors to ACQ-6 score were R20 and forced expiratory volume in one second (% pred.), and the strongest independent contributors to AQLQ(S) score were R20 and forced vital capacity (% pred.). A history of one or more exacerbations within the previous year was independently associated with R20.

CONCLUSIONS AND CLINICAL RELEVANCE

Previously reported markers of small airway obstruction do not appear to be independently associated with asthma disease expression. In contrast, the IOS parameter R20, a marker of mean airway resistance of both large and small airways, appears to have independent clinical significance. These observations require confirmation in prospective longitudinal studies.

Immunohistochemical assessment of proliferating cell nuclear antigen protein expression in plaque, reticular and erosive types of oral lichen planus

BACKGROUND

Proliferating cell nuclear antigen (PCNA) is a nuclear protein synthesized in the late G1 and S-phase of the cell cycle. Immunodetection of this protein represents a useful marker of the proliferation status of lesions.

AIMS

The aim of this study is to evaluate the immunohistochemical expression of PCNA in oral lichen planus (OLP) and to assess the PCNA expression in a different layer of epithelium in different types of OLP.

SUBJECTS AND METHODS

A total of 96 cases of histologically proven OLP, 32 cases each of erosive, reticular and plaque type were selected. Two sections were taken from each one for H and E. Other sections were stained according to super sensitive polymer horseradish peroxidase method for identifying PCNA expression.

RESULTS

Of the three types of OLP, erosive type showed higher expression of PCNA (average 66.8%, minimum of 55% and maximum of 80.3%) followed by reticular (average 37.7%, minimum of 26% and maximum of 47%) and plaque type (average 17%, minimum of 5% and maximum of 25%) indicating increased proliferative activity. The erosive type also showed higher expression of PCNA in all the layers of epithelium followed by reticular and plaque type.

CONCLUSION

PCNA is a good marker to indicate proliferation status of disease. Out of three types, erosive type possess more proliferative ratio, chances of malignant changes is more in this type.

CCL2 release by airway smooth muscle is increased in asthma and promotes fibrocyte migration

BACKGROUND

Asthma is characterized by variable airflow obstruction, airway inflammation, airway hyper-responsiveness and airway remodelling. Airway smooth muscle (ASM) hyperplasia is a feature of airway remodelling and contributes to bronchial wall thickening. We sought to investigate the expression levels of chemokines in primary cultures of ASM cells from asthmatics vs healthy controls and to assess whether differentially expressed chemokines (i) promote fibrocyte (FC) migration towards ASM and (ii) are increased in blood from subjects with asthma and in sputum samples from those asthmatics with bronchial wall thickening.

METHODS

Chemokine concentrations released by primary ASM were measured by MesoScale Discovery platform. The chemokine most highly expressed by ASM from asthmatics compared with healthy controls was confirmed by ELISA, and expression of its cognate chemokine receptor by FCs was examined by immunofluorescence and flow cytometry. The role of this chemokine in FC migration towards ASM was investigated by chemotaxis assays.

RESULTS

Chemokine (C-C motif) ligand 2 (CCL2) levels were increased in primary ASM supernatants from asthmatics compared with healthy controls. CCR2 was expressed on FCs. Fibrocytes migrated towards recombinant CCL2 and ASM supernatants. These effects were inhibited by CCL2 neutralization. CCL2 levels were increased in blood from asthmatics compared with healthy controls, and sputum CCL2 was increased in asthmatics with bronchial wall thickening.

CONCLUSIONS

Airway smooth muscle-derived CCL2 mediates FC migration and potentially contributes to the development of ASM hyperplasia in asthma.

Primary bladder exstrophy closure in neonates: challenging the traditions

PURPOSE

We describe a novel approach to neonatal bladder exstrophy closure that challenges the role of postoperative immobilization and pelvic osteotomy.

MATERIALS AND METHODS

We reviewed the primary management of bladder exstrophy at our institutions between 2007 and 2011. In particular we compared postoperative management in the surgical ward using epidural analgesia to muscle paralysis and ventilation in the intensive care unit. Clinical outcome measures were time to full feed, length of stay, postoperative complications and redo closure. Cost-effectiveness was also evaluated using hospital financial data. Data are expressed as median (range). Significance was explored by Fisher exact test and unpaired t-test.

RESULTS

A total of 74 patients underwent primary closure without osteotomy. Successful closure was achieved in 70 patients (95%). A total of 48 cases (65%) were managed on the ward (group A) and 26 (35%) were transferred to the intensive care unit (group B). The 2 groups were homogeneous for gestational age (median 39 weeks, range 27 to 41) and age at closure (3 days, 1 to 152). Complications requiring surgical treatment were noted in 4 patients (8.3%) in group A and 3 (11.5%) in group B (p = 0.609). Length of stay was significantly shorter for the group managed on the ward (11 vs 18 days, p <0.0001). Median costs were $42,732 for patients admitted to the intensive care unit and $16,214 for those admitted directly to the surgical ward (p <0.0001).

CONCLUSIONS

Primary closure of bladder exstrophy without lower limb immobilization and osteotomy is feasible. Postoperative care on the surgical ward using epidural analgesia results in shorter hospitalization.

Isolation of filamentous fungi from sputum in asthma is associated with reduced post-bronchodilator FEV1

Background

Fungal sensitization is common in severe asthma, but the clinical relevance of this and the relationship with airway colonization by fungi remain unclear. The range of fungi that may colonize the airways in asthma is unknown.

Objective

To provide a comprehensive analysis on the range of filamentous fungi isolated in sputum from people with asthma and report the relationship with their clinico-immunological features of their disease.

Methods

We recruited 126 subjects with a diagnosis of asthma, 94% with moderate-severe disease, and 18 healthy volunteers. At a single stable visit, subjects underwent spirometry; sputum fungal culture and a sputum cell differential count; skin prick testing to both common aeroallergens and an extended fungal panel; specific IgE to Aspergillus fumigatus. Fungi were identified by morphology and species identity was confirmed by sequencing. Four patients had allergic bronchopulmonary aspergillosis.

Results

Forty-eight percent of asthma subjects were IgE-sensitized to one fungal allergen and 22% to ≥ 2. Twenty-seven different taxa of filamentous fungi were isolated from 54% of their sputa, more than one species being detected in 17%. This compared with 3 (17%) healthy controls culturing any fungus (P < 0.01). Aspergillus species were most frequently cultured in isolation followed by Penicillium species. Post-bronchodilator FEV₁ (% predicted) in the subjects with asthma was 71(± 25) in those with a positive fungal culture vs. 83 (± 25) in those culture-negative, (P < 0.01).

Conclusion and Clinical Relevance

Numerous thermotolerant fungi other than A. fumigatus can be cultured from sputum of people with moderate-to-severe asthma; a positive culture is associated with an impaired post-bronchodilator FEV₁, which might be partly responsible for the development of fixed airflow obstruction in asthma. Sensitization to these fungi is also common.

Ileal bladder augmentation and vitamin B12: levels decrease with time after surgery

OBJECTIVE

We investigated vitamin B12 deficiency following ileocystoplasty in children.

METHODS

Patients who underwent ileocystoplasty between December 1993 and September 2006 were included and B12 levels were retrospectively analysed. Patients with a serum B12 of less than 150 pg/ml were considered deficient. The distance of the ileal segment from the ileocaecal valve was recorded.

RESULTS

There were 105 patients in the series; 61 were male. Mean age at surgery was 7.7 years (SD = 3.9). The mean interval from surgery to most recent B12 level was 50 months (SD = 30). None of the patients were on B12 supplementation. Two patients were B12 deficient, both more than 7 years after surgery; 44% of patients with levels available 7 years after surgery had a B12 below 300 pg/ml. There was a significant negative correlation between B12 level and length of follow up (Spearman's rank, P < 0.01). Twenty patients with an ileal segment sparing 60 cm from the ileocaecal valve had a higher mean B12 (524 vs 419, SEM 60 vs 28). This was not statistically significant.

CONCLUSION

We demonstrate a reduction in serum B12 level with time following ileocystoplasty. These patients should have their B12 levels measured in the long term.