Octyl cyanoacrylate skin adhesive with or without subcuticular suture for skin closure after implantable venous port placement for oncology patients: a propensity-score matching analysis

AIM

To compare peri-operative outcomes of skin closure with octyl cyanoacrylate (OCA) skin adhesive (Dermabond) with or without subcuticular sutures after deep dermal suturing for implantable venous port placement closure.

MATERIALS AND METHODS

Seven hundred and ninety-two single-lumen implantable venous port insertions for chemotherapy were reviewed from September 2019 to March 2021 in a retrospective single-centre study. Propensity-score matching by a 1:1 nearest neighbour algorithm was conducted to control for confounding baseline differences. Distances were determined by logistic regression. Propensity-score matching was performed based on the following variables: age at procedure, gender, race, operator's seniority, use of anchoring polypropylene suture (PROLENE), port model, and volume of intra-operative local analgesia. The primary outcome was wound dehiscence at the first follow-up (∼1 week).

RESULTS

The 792 port insertions were conducted in 302 males (38.1%), median age 63 years (IQR: 54-69). Of the 656 wounds closed with subcuticular sutures and skin adhesive, 136 were matched in a 1:1 fashion against procedures closed without a subcuticular suture. No significant differences were demonstrated in pain scores, bleeding, swelling, bruising, fever, wound dehiscence, and discharge at postoperative day 1 (POD1) and at first follow-up between the groups (all p>0.05). Of note, no significant differences in wound dehiscence at first follow-up was found in both unmatched (p=0.133) and matched cohorts (McNemar-Bowker's χ² = 1.167, p=0.761).

CONCLUSION

These findings suggest that the omission of subcuticular sutures during implantable venous port closure may not compromise peri-operative outcomes when OCA skin adhesives were used.

Role of pre-operative ureteral stent on outcomes of retrograde intra-renal surgery (RIRS): systematic review and meta-analysis of 3831 patients and comparison of Asian and non-Asian cohorts

PURPOSE

To evaluate the outcomes of pre-stented (PS) versus non-pre-stented (NPS) patients who have undergone retrograde intrarenal surgery (RIRS) for renal calculi with subgroup analysis of Asian and non-Asian cohorts.

METHODS

Protocol is registered in PROSPERO, CRD42021261123. Eligible studies identified from four electronic databases. Meta-analysis was done to enumerate the outcomes of RIRS in between PS and NPS. Secondary sub-analysis was done to look for differences in outcomes in Asian and non-Asian cohorts.

RESULTS

Fourteen studies involving 3831 patients (4 prospective, 10 retrospective studies) were included. PS patients experienced higher success rates of ureteral access sheath (UAS) insertion than NPS (RR 1.09, 95% CI 1.05-1.13, p < 0.00001). PS patients had lower risk of ureteral injuries from UAS placement (RR 0.69, 95% CI 0.50-0.96, p = 0.03). No significant differences in intra- and postoperative complications between two groups were found. Stone-free rate (SFR) outcomes for residual fragment (RF) cut-off of < 1 mm and < 4 mm favoured the PS patients (RR 1.10, 95% CI 1.04-1.17, p = 0.002 for < 4 mm, RR1.10, 95% CI 1.02-1.19, p = 0.02 for < 1 mm). In the subgroup analysis, PS Asian patients had similar SFR as NPS patients for SFR(< 4 mm) but non-Asian population showed better outcomes in the PS patients for SFR(< 4 mm) (RR 1.31, 95% CI 1.13-1.52, p = 0.0005).

CONCLUSIONS

This meta-analysis suggests that pre-stenting results in a higher success for UAS placement, minimising intraoperative ureteric injury, with higher overall SFR for any RF cut-off in PS cohorts. In non-Asian cohort, significant differences occurred at SFR < 4 mm but not for SFR < 1 mm. No difference was seen in our Asian cohort for any SFR cut-off in both PS and NPS patients.

Review: Revisiting the human cholinergic nucleus of the diagonal band of Broca

Although the nucleus of the vertical limb of the diagonal band of Broca (nvlDBB) is the second largest cholinergic nucleus in the basal forebrain, after the nucleus basalis of Meynert, it has not generally been a focus for studies of neurodegenerative disorders. However, the nvlDBB has an important projection to the hippocampus and discrete lesions of the rostral basal forebrain have been shown to disrupt retrieval memory function, a major deficit seen in patients with Lewy body disorders. One reason for its neglect is that the anatomical boundaries of the nvlDBB are ill defined and this area of the brain is not part of routine diagnostic sampling protocols. We have reviewed the history and anatomy of the nvlDBB and now propose guidelines for distinguishing nvlDBB from other neighbouring cholinergic cell groups for standardizing future clinicopathological work. Thorough review of the literature regarding neurodegenerative conditions reveals inconsistent results in terms of cholinergic neuronal loss within the nvlDBB. This is likely to be due to the use of variable neuronal inclusion criteria and omission of cholinergic immunohistochemical markers. Extrapolating from those studies showing a significant nvlDBB neuronal loss in Lewy body dementia, we propose an anatomical and functional connection between the cholinergic component of the nvlDBB (Ch2) and the CA2 subfield in the hippocampus which may be especially vulnerable in Lewy body disorders.

Hepatitis C-induced hepatocyte apoptosis following liver transplantation is enhanced by immunosuppressive agents

In recurrent hepatitis C (HCV) post-liver transplantation (OLT), the combination of immunosuppressants and HCV is postulated to increase hepatocyte apoptosis and liver fibrosis. We evaluated hepatocyte apoptosis within the liver tissue of patients with postOLT HCV recurrence compared to HCV-negative individuals and correlated these findings with the effects of immunosuppressants on HCV-induced cell death and its inhibition in primary mouse hepatocytes (PMoH). Liver biopsies from patients with and without HCV were evaluated by immunohistochemistry for markers of apoptosis M30 CytoDEATH (M30) and cleaved PARP (clPARP). PMoH from C57BL/6 mice were infected with recombinant adenoviruses (rAdHCV) that expressed HCV proteins in hepatocytes. Infected cells were treated with cyclosporine, tacrolimus, sirolimus and/or MMF with or without pan-caspase inhibitor Q-VD-Oph. Cell viability and apoptosis were evaluated using crystal violet assays and Western immunoblots probed for cleaved caspase-3 (clCas3) and clPARP. Both M30 and clPARP were increased in the liver biopsies of patients with postOLT HCV recurrence compared to HCV-negative individuals. Treatment of rAdHCV-infected PMoH with cyclosporine, tacrolimus or sirolimus reduced cell viability and increased clCas3 and clPARP compared to rAdHCV infection alone. Addition of MMF to cyclosporine, tacrolimus or sirolimus further reduced cell viability and increased clCas3 and clPARP. Q-VD-Oph improved cell viability in HCV-infected PMoH treated with immunosuppressants alone and in combination and reduced clCas3 and clPARP by approximately 90%. Immunosuppressive agents, especially in combination, enhanced apoptosis in HCV-infected hepatocytes. The finding that Q-VD-Oph reversed hepatocyte death suggests that treatments utilizing apoptosis inhibition might reduce liver injury in postOLT HCV recurrence.

Novel signaling axis for ROS generation during K-Ras-induced cellular transformation

Reactive oxygen species (ROS) are well known to be involved in oncogene-mediated cellular transformation. However, the regulatory mechanisms underlying ROS generation in oncogene-transformed cells are unclear. In the present study, we found that oncogenic K-Ras induces ROS generation through activation of NADPH oxidase 1 (NOX1), which is a critical regulator for the K-Ras-induced cellular transformation. NOX1 was activated by K-Ras-dependent translocation of p47(phox), a subunit of NOX1 to plasma membrane. Of note, PKCδ, when it was activated by PDPK1, directly bound to the SH3-N domain of p47(phox) and catalyzed the phosphorylation on Ser348 and Ser473 residues of p47(phox) C-terminal in a K-Ras-dependent manner, finally leading to its membrane translocation. Notably, oncogenic K-Ras activated all MAPKs (JNK, ERK and p38); however, only p38 was involved in p47(phox)-NOX1-dependent ROS generation and consequent transformation. Importantly, K-Ras-induced activation of p38 led to an activation of PDPK1, which then signals through PKCδ, p47(phox) and NOX1. In agreement with the mechanism, inhibition of p38, PDPK1, PKCδ, p47(phox) or NOX1 effectively blocked K-Ras-induced ROS generation, anchorage-independent colony formation and tumor formation. Taken together, our findings demonstrated that oncogenic K-Ras activates the signaling cascade p38/PDPK1/PKCδ/p47(phox)/NOX1 for ROS generation and consequent malignant cellular transformation.

Prevention of hepatitis C virus infection and liver cancer

Hepatocellular carcinoma (HCC) is the fifth most prevalent cancer and the third leading cause of cancer-related death, and its incidence is increasing. The majority of HCC cases are associated with chronic viral hepatitis. With over 170 million individuals chronically infected with hepatitis C virus (HCV) worldwide, HCV is currently a serious global health concern, leading to chronic hepatitis, cirrhosis and HCC, thereby causing significant morbidity and mortality. With the incidence of HCV infection increasing, the problem of HCV-associated HCC is expected to worsen as well, with the majority of HCCs developing in the setting of cirrhosis. Thus, it is imperative to provide antiviral therapy to infected individuals prior to the development of established cirrhosis in order to reduce the risk of subsequent HCC. Indeed, the successful eradication of HCV is associated with clinical and histological improvement as well as a greatly reduced risk of subsequent HCC development. Even after the development of cirrhosis, successful viral clearance is still associated with reduced HCC risk. Current standard of care antiviral treatment consists of pegylated interferon-α and ribavirin, but viral clearance rates are suboptimal with this regimen, especially in difficult to treat cohorts. However, there is a myriad of different classes of HCV-specific direct-acting antiviral agents currently in development, which can be used in combination with one another or with standard of care treatment to improve HCV cure rates. Preventative and therapeutic vaccines against HCV remain an area of ongoing research with good progress towards developing an effective vaccine in the future.

Post-liver transplantation multicentric Castleman disease treated with valganciclovir and weaning of immunosuppression

Multicentric Castleman disease is a lymphoproliferative disorder which when seen in the setting of HIV/AIDS is often associated with human herpes virus 8 (HHV-8) infection. We describe the case of a HIV-negative man who developed HHV-8-associated multicentric Castleman disease 11 years after liver transplantation. The patient presented with fevers and weight loss. Physical examination revealed enlarged cervical, axillary and inguinal lymph nodes. Widespread lymphadenopathy was confirmed on computed tomography (CT) scanning. Histology of an enlarged lymph node showed a polymorphous infiltrate with mature plasma cells, plasmacytoid lymphocytes and occasional blasts within the cortex and paracortex. The diagnosis of Castleman disease was confirmed by the finding of numerous HHV-8-immunopositive cells around the regressed lymph node follicles and the detection of HHV-8 on plasma PCR. Although the conventional treatment for this condition has been combination chemotherapy, in the post-transplant context it was decided to treat the patient with valganciclovir and cessation of immunosuppression. His symptoms resolved rapidly and repeat plasma PCR done 3 months after starting treatment was negative for HHV-8. A follow-up CT scan showed a dramatic reduction in the size and amount of lymphadenopathy. After 15 months of treatment, he remains well with no evidence of graft dysfunction or rejection.

Cervical screening uptake in immunocompromised women in Waikato, New Zealand

A one-year retrospective case study was undertaken of cervical cytology in two cohorts of immunocompromised women: those with HIV infection or renal transplants in the Waikato region of New Zealand. Uptake of cervical screening in the two groups was compared with national guidelines. The results showed that HIV patients' uptake was close to the national recommendation for annual cytology (84% had a smear in 18 months); they were more likely to have cytology performed in an HIV-related care setting. Renal transplant patients had lower uptake (56% in 18 months), a finding similar to internationally reported data. Local discussions of these results identified potential influencing factors, which included inadequate dissemination of updated guidelines and inadequate documentation of immunocompromised health status on the national cervical screening programme database. This audit supports including cervical cytology as part of an annual review in all immunocompromised patients.

Can text messaging results reduce time to treatment of Chlamydia trachomatis?

We assessed the impact of text messaging as the preferred method of communicating positive Chlamydia trachomatis test results in an urban sexual health clinic. Following the introduction of a text messaging service to communicate positive C trachomatis test results to patients, the time between test and treatment in 293 consecutive patients was compared with 303 historic controls. No significant difference was found in either median time to treatment for all patients (3 days in 2005; 4 days in 2007) or median time to treatment (both 7 days) for those not treated immediately. There was no significant difference in time to treatment between those using a landline or mobile phone. Mobile phone use was significantly higher in 2007. Overall, we treated more cases within 4 weeks in 2007 (98.6% cf 96%). The lack of difference in time to treatment showed the use of this technology is as effective as more traditional means of communication. The increase in cases of C trachomatis treated within 4 weeks may reflect the significant increase in mobile phone use and improved ability to contact people rather than simply the introduction of text messaging.

Isolated ligamentous cervical spinal injury in the polytrauma patient with a head injury

The evaluation of the cervical spine in the unconscious trauma patient is a difficult and controversial topic in trauma management. Conventional cervical clearance protocols consisting of plain radiology and computed tomography may not adequately detect unstable cervical ligament and disc injuries, even though a high-risk mechanism of injury has occurred. We present two cases where cervical clearance protocols, utilising plain X-rays and multi-slice computed tomography, failed to identify significant ligamentous spinal injuries. A delay in diagnosis or a missed spinal injury can lead to delays in treatment, thereby increasing the risk of neurological deterioration with the potential devastating sequela of quadriplegia. Therefore, in the unconscious trauma patient who, by definition, has sustained a high-risk mechanism injury, we routinely recommend the use of magnetic resonance imaging in addition to plain X-rays and computed tomography, to evaluate further discoligamentous status.

Intracisternal administration of chemokines facilitated formalin-induced behavioral responses in the orofacial area of freely moving rats

The present study investigated the effects of intracisternal administration of MCP-1, Rantes or IL-8 on pain transmission in the orofacial area. We also investigated mechanisms of hyperalgesic responses produced by intracisternal administration of IL-8. An orofacial formalin test was employed to assess the effects of chemokines on nociceptive processing. For each animal, the number of behavioral responses and the time spent grooming, rubbing and/or scratching the facial region proximal to the formalin injection site was recorded for nine successive 5-min intervals. Intracisternal administration of MCP-1, Rantes or IL-8 significantly increased formalin-induced scratching behavioral responses in the orofacial area. Intracisternal pretreatment with indomethacin, a non-selective cyclooxygenase inhibitor, did not block IL-8-induced hyperalgesia. Pretreatment with 100 microg propranolol, a non-selective beta-adrenergic receptor antagonist and 50 microg atenolol, a selective beta(1)-adrenergic receptor antagonist, inhibited the number of scratches and the duration of scratching produced by 1 ng of IL-8 injected intracisternally. These results indicate that intracisternal administration of chemokines produce a hyperalgesic response with an orofacial inflammatory pain model and that the IL-8-induced hyperalgesia is mediated by central beta(1)-adrenergic receptor.

Factor V inhibitor in neonatal intracranial hemorrhage secondary to severe congenital factor V deficiency

We report a newborn infant girl, born to consanguineous parents, with recurrent intracranial hemorrhage secondary to congenital factor V deficiency with factor V inhibitor. Repeated transfusions of fresh-frozen plasma (FFP) and platelet concentrates, administrations of immunosuppressive therapy (prednisolone and cyclophosphamide), and intravenous immunoglobulin failed to normalize the coagulation profiles. Exchange transfusion followed-up by administrations of activated prothrombin complex and transfusions of FFP and platelet concentrates caused a temporary normalization of coagulation profile, enabling an insertion of ventriculoperitoneal (VP) shunt for progressive hydrocephalus. The treatment was complicated by thrombosis of left brachial artery and ischemia of left middle finger. The child finally died from another episode of intracranial hemorrhage 10 days after insertion of the VP shunt.

Bone marrow and peripheral blood changes in non-Hodgkin's lymphoma

BACKGROUND

47 patients with non-Hodgkin's lymphoma (NHL) were studied retrospectively to determine their marrow and blood changes at diagnosis.

METHODS

The blood counts, blood films, marrow smears, trephine and tissue biopsies of patients at diagnosis were reviewed. The scheme proposed by the International Lymphoma Study Group (REAL) was utilised for lymphoma subclassification.

RESULTS AND CONCLUSION

21.3% had lymphoblastic lymphoma, 21.3% had peripheral T-cell lymphoma (unspecified), 29.8% had diffuse large B-cell NHL, 10.6% had Burkitt's lymphoma and 17% had others. The incidences of anaemia, one or more abnormal counts, lymphocytopenia, increased marrow reticulin and marrow eosinophilia at diagnosis were 66%, 85.1%, 41.3%, 40.9% and 44.7% respectively. Marrow involvement was present in 46.8% of the patients, with diffuse infiltration noted in 71.4% of these cases. Abnormal counts and anaemia were common in all the NHL subtypes. In lymphoblastic lymphoma, the common haematological abnormalities were peripheral atypical lymphocytes and diffuse marrow involvement. In peripheral T-cell lymphoma (unspecified), common features were peripheral lymphocytopenia, increased marrow reticulin and eosinophilia. In diffuse large B-cell NHL, peripheral lymphocytopenia, peripheral myeloid precursors and/or nucleated red cells and marrow involvement were common. In Burkitt's lymphoma, diffuse marrow involvement and eosinophilia were common. No significant differences were noted between most of the haematological parameters of B and T-NHLs. In comparison with other reports, we recorded higher overall incidences of anaemia and diffuse marrow involvement, and a lower incidence of marrow infiltration in peripheral T-cell lymphoma (unspecified).

Purification and characterization of biosurfactants from Nocardia sp. L-417

The Nocardia sp. L-417 strain grown with n-hexadecane as a carbon source produced two types of biosurfactant that have different characteristics. These biosurfactants were purified by procedures that included ammonium sulphate fractionation, chilled acetone and hexane treatments, silica-gel column chromatography and Sephadex LH-20 gel filtration. The purified biosurfactants were very stable over a broad range of pHs (2-12) and temperatures (100 degrees C, 3 h). The biosurfactant type I had strong properties as an emulsifying agent and as an emulsion-stabilizing agent, whereas type II had a strong ability to reduce surface tension.

Mutational analysis of aspartate residues in the transmembrane regions and cytoplasmic loops of rat vesicular acetylcholine transporter

The vesicular acetylcholine transporter (VAChT) is responsible for the transport of the neurotransmitter acetylcholine (ACh) into synaptic vesicles using an electrochemical gradient to drive transport. Rat VAChT has a number of aspartate residues within its predicted transmembrane domains (TM) and cytoplasmic loops, which may play important structural or functional roles in acetylcholine transport. In order to identify functional charged residues, site-directed mutagenesis of rVAChT was undertaken. No effect on ACh transport was observed when any of the five aspartate residues in the cytoplasmic loop were converted to asparagine. Similarly, changing Asp-46 (D46N) in TM1 or Asp-255 (D255N) in TM6 had no effect on ACh transport or vesamicol binding. However, replacement of Asp-398 in TM10 with Asn completely eliminated both ACh transport and vesamicol binding. The conservative mutant D398E retained transport activity, but not vesamicol binding, suggesting this residue is critical for transport. Mutation of Asp-193 in TM4 did not affect ACh transport activity; however, vesamicol binding was dramatically reduced. With mutant D425N of TM11 transport activity for ACh was completely blocked, without an effect on vesamicol binding. Activity was not restored in the conservative mutant D425E, suggesting the side chain as well as the negative charge of Asp-425 is important for substrate binding. These mutants, as well as mutant D193N, clearly dissociated ACh binding and transport from vesamicol binding. These data suggest that Asp-398 in TM10 and Asp-425 in TM11 are important for ACh binding and transport, while Asp-193 and Asp-398 in TM4 and TM10, respectively, are involved in vesamicol binding.

Clinical and molecular heterogeneity in carbonic anhydrase II deficiency and prenatal diagnosis in an Italian family

Carbonic anhydrase (CA) II deficiency is characterized by osteopetrosis, renal tubular acidosis, cerebral calcification, and usually severe mental retardation. We describe an Italian boy with this disease whose mental retardation was relatively mild and whose renal tubular acidosis had only a distal component. A novel mutation of a gt-->tt change of splice donor site at the 5' end of intron 6 was demonstrated. Comparison of this patient with two previous Italian families with different mutations illustrates the clinical and molecular heterogeneity of this disease. The identification of the mutation in this family provided the opportunity for prenatal diagnosis in a subsequent pregnancy.

Efficiency of blood usage for elective surgery in the University Hospital Kuala Lumpur

Provision of quality care, service and blood products to patients while containing costs and the amount of blood used should be the aim of every blood bank. Therefore a prospective audit was carried out over three months to determine how efficiently blood was being used in elective surgery in the University Hospital, Kuala Lumpur. Every case with blood crossmatched was monitored to determine the amount transfused and the posttransfusion haemoglobin level. Overcrossmatching of varying degrees was noted in almost all surgical procedures and overtransfusion in 45.5% of patients transfused. The rate of case postponement was 18.1%. These indicate inefficient utilization of blood and other resources. The transfusion index (TI) and range of units transfused were calculated for each procedure. They can be used as indicators of blood requirement and potential severity of hemorrhage. Suggestions to improve efficiency of blood utilization include the introduction and ongoing monitoring of guidelines on crossmatching and transfusion based on the data obtained here, by the hospital blood transfusion committee; the "group, screen and hold" practice for surgical procedures with high crossmatch transfusion ratios, low transfusion indices and a small range of units transfused could also be adopted.