[A female patient with a weak, painful thumb]

Here we present the case of a 64-year-old female patient with a painful thumb. This case demonstrates how, with proper physical examination, a correct diagnosis of 'skier's thumb' with concomitant Stener lesion can be made. This condition is a tear of the ulnar collateral ligament (UCL) of the metacarpophalangeal joint with an interposition of the UCL and the aponeurosis adductor pollicis muscle. It is usually treated surgically.

Satisfaction with cosmetic outcomes of breast reconstruction: Investigations into the correlation between the patients' Breast-Q outcome and the judgment of panels

Objectives

We aimed to determine the relation between breast reconstruction method, patient satisfaction, and surgeon reported cosmetic outcome among women who underwent breast reconstruction after mastectomy.

Study Design

A cross-sectional study of patients treated between 2006 and 2010.

Main Outcome

Women's satisfaction with cosmetic outcomes after breast reconstruction.

Measures

Cosmetic outcomes were evaluated by (1) women using the Breast-Q to rate satisfaction with breasts outcomes, and (2) an independent panel using the Strasser score. The relationships between the Breast-Q rating, Strasser scores, and breast reconstruction methods, including laterality and timing, were evaluated by Mann–Whitney U tests, Spearman's rank correlations, and Wilcoxon signed-rank tests.

Results

Ninety-four women were included. Patients were more satisfied with their breasts if they had undergone autologous, unilateral, or secondary breast reconstruction compared with those who underwent alloplastic, bilateral, or primary breast reconstruction (p-values 0.008, 0.011, and 0.001, respectively). The Strasser system did not reveal significant cosmetic differences, with all breast reconstructions graded as mediocre or poor.

Conclusions

Patient satisfaction with breast outcomes, as measured by the Breast-Q, was described as mediocre or poorly reflected by the Strasser score. If doctors are to support patients to make informed decisions on the optimal method of breast reconstruction, we need a more sensitive, comprehensive tool reflecting patients’ cosmetic outcomes.

MIR21 Drives Resistance to Heat Shock Protein 90 Inhibition in Cholangiocarcinoma

BACKGROUND & AIMS

Cholangiocarcinomas (CCA) are resistant to chemotherapy, so new therapeutic agents are needed. We performed a screen to identify small-molecule compounds that are active against CCAs. Levels of microRNA 21 (MIR21 or miRNA21) are increased in CCAs. We investigated whether miRNA21 mediates resistance of CCA cells and organoids to HSP90 inhibitors.

METHODS

We performed a high-throughput screen of 484 small-molecule compounds to identify those that reduced viability of 6 human CCA cell lines. We tested the effects of HSP90 inhibitors on cells with disruption of the MIR21 gene, cells incubated with MIR21 inhibitors, and stable cell lines with inducible expression of MIR21. We obtained CCA biopsies from patients, cultured them as organoids (patient-derived organoids). We assessed their architecture, mutation and gene expression patterns, response to compounds in culture, and when grown as subcutaneous xenograft tumors in mice.

RESULTS

Cells with IDH1 and PBRM1 mutations had the highest level of sensitivity to histone deacetylase inhibitors. HSP90 inhibitors were effective in all cell lines, irrespective of mutations. Sensitivity of cells to HSP90 inhibitors correlated inversely with baseline level of MIR21. Disruption of MIR21 increased cell sensitivity to HSP90 inhibitors. CCA cells that expressed transgenic MIR21 were more resistant to HSP90 inhibitors than cells transfected with control vectors; inactivation of MIR21 in these cells restored sensitivity to these agents. MIR21 was shown to target the DnaJ heat shock protein family (Hsp40) member B5 (DNAJB5). Transgenic expression of DNAJB5 in CCA cells that overexpressed MIR21 re-sensitized them to HSP90 inhibitors. Sensitivity of patient-derived organoids to HSP90 inhibitors, in culture and when grown as xenograft tumors in mice, depended on expression of miRNA21.

CONCLUSIONS

miRNA21 appears to mediate resistance of CCA cells to HSP90 inhibitors by reducing levels of DNAJB5. HSP90 inhibitors might be developed for the treatment of CCA and miRNA21 might be a marker of sensitivity to these agents.

Abstract 1069: MiR-21 may serve as a predictive biomarker of response in the assessment of efficacy of HSP-90 inhibition in gastrointestinal (GI) cancers

Background and Aims: MicroRNAs mediate drug resistance and are often deregulated in cancer with miR-21 upregulation being shared across different gastrointestinal (GI) cancers. In this study we aim to identify small drugs for which miR-21 may be considered a biomarker of sensitivity.

Methods: High throughput screening technologies (HST) was applied in RKO colorectal cancer (CRC) cells engineered to knock out miR-21 locus (miR-21KO) and parental isogenic wild type (WT) cells, as well as 6 Biliary Tract Cancer (BTC) cell lines that were NGSed for a panel of 64 genes. Library included 484 small molecules that were screened at 3 doses against each cell line in triplicate. Transient miR-21 inhibition was achieved by reverse transfection. Stable doxycycline-activated miR-21 expressing clones of BTC and CRC cells were generated with doxycycline-inducible TRIPZ lentiviral vectors.

Results: Twenty four drugs reduced cell viability compared to DMSO at a greater extent in miR-21KO RKO in comparison to WT cells. Enrichment in HSP-90 inhibitors (including 17-DMAG, 17-AAG and AUY-922) was noticed, suggesting that miR-21 may be involved in resistance to HSP-90 inhibition. HST in BTC cells showed enrichment of HSP-90 inhibitors independently on mutational status. However IC50 to AUY-922 was correlated to baseline miR-21 expression in BTC cells. Transient inhibition of miR-21 enhanced sensitivity to AUY-922 in BTC cells. AUY-922 IC50 was 35nM for WT and 17nM for miR-21KO RKO cells. Knock-out of miR-21 in DLD-1 cells did not change sensitivity to AUY-922 in line with the lower baseline levels of miR-21 in DLD-1 wild type cells. However, the reduced levels of baseline miR-21 made them more sensitive to AUY-922 than RKO. Doxycycline-activated overexpression of miR-21 in miR-21KO DLD-1 cells conferred resistance to AUY-922. When co-cultured with non-infected miR-21KO DLD-1 cells, miR-21 overexpressing miR-21KO DLD-1 cells were able to drive cell growth in presence of AUY-922. To similar extent CCLP with enforced expression of miR-21 were more resistant compared to control cells; inactivation of the induction of miR-21 overexpression recovered sensitivity to the drug. HSP Array blot of AUY-922-treated cells with induced expression of miR-21 showed reduction of the co-chaperone HSP-40 protein expression compared to control cells.

Conclusions: Our data suggest the development of studies looking at the biomarker potential of miR-21 to guide treatment with HSP-90 inhibitors in GI cancers, as well as pursuing the combination with miR-21 inhibitors that may enhance the effect of the drug and avoid toxicity by enabling dose reduction.

Citation Format: Andrea Lampis, Luciano Cascione, Rosemary Burke, Paul Clarke, Michele Simbolo, Aldo Scarpa, Else Bosma, Sijia Yu, Rebecca Cole, Mark Stubbs, Swee Sharp, Rob Van Montfort, Jens C. Hahne, Matteo Fassan, Paul Workman, Nicola Valeri, Chiara Braconi. MiR-21 may serve as a predictive biomarker of response in the assessment of efficacy of HSP-90 inhibition in gastrointestinal (GI) cancers. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 1069.

The impact of complications on quality of life following colorectal surgery: a prospective cohort study to evaluate the Clavien-Dindo classification system

AIM

This prospective cohort study was performed to evaluate the impact of complications on quality of life (QOL) in colorectal surgery. The Clavien-Dindo complication classification (CDCC) is promising, but has not been evaluated by relating the classification to patient-reported outcome measures.

METHOD

Patients undergoing colorectal surgery were evaluated prospectively 12 months postoperatively using the WHOQOL-BREF questionnaire. Patient data were prospectively recorded and complications were classified using the CDCC. Postoperative QOL in patients with minor and severe complications and patients without complications was compared using a general linear model. Relationships between CDCC and QOL were examined using correlations and multivariate regression.

RESULTS

Of 218 patients, 130 (59.6%) had complications. In patients with severe complications there was a greater decrease in overall QOL (P = 0.043), QOL-physical (P < 0.001) and QOL-psychological (P = 0.013) domains in the first six postoperative weeks, whereas patients with minor complications had QOL scores comparable to those of patients without complications. QOL recovered to preoperative levels in all groups at 12 months. Change in QOL at 6 weeks was significantly correlated with CDCC grade, especially in the physical domain (Spearman's rho -0.287, P < 0.001). The presence of severe complications was an independent predictor of overall QOL, QOL-physical and QOL-psychological at 6 weeks.

CONCLUSION

Severe complications are associated with reduced postoperative QOL at 6 weeks, but QOL recovers after 12 months. CDCC grade negatively correlates with change in QOL in the early postoperative period. These findings support the theoretical framework of the CDCC.

Incidence, nature and impact of error in surgery

Background

Adverse events occur in 3·8–17 per cent of hospital admissions. The purpose of this study was to analyse the incidence of medical errors and assess the feasibility of an error registry for quality improvement programmes.

Methods

Errors were recorded prospectively in a complication registry between 1 June 2005 and 31 December 2007. Events were coded according to the Trauma Registry of the American College of Surgeons; the nature of events was recorded and the severity graded using the 1992 Clavien system. Recorded events were discussed by the medical staff on a daily basis and, if by consensus judged to be errors, were saved to the registry database.

Results

Of 12 121 patients admitted to the surgical ward during the study interval, 2033 (16·8 per cent) had a complication and 735 (6·1 per cent) had an error documented in the registry. Of 873 recorded errors, 607 (69·5 per cent) were of little or no consequence (Clavien grade I) and 220 (25·2 per cent) required therapeutic intervention (Clavien grade IIa and IIb). Errors leading to permanent injury (Clavien grade III) occurred in 41 instances (4·7 per cent) and five patients (0·6 per cent) died (Clavien grade IV).

Conclusion

This study shows that errors are common in surgery, and that near misses are more frequent than errors with serious consequences. It is hypothesized that registration of near misses might prevent errors with serious consequences and thus improve quality of care.

Prediction models for complications in trauma patients

BACKGROUND

Because the death rate among the total trauma population is low, other performance indicators in addition to the classical dependent variable mortality are required to assess the overall quality of trauma care. The aim of this study was to develop and validate a prediction model for the occurrence of complications that can be used to adjust a measure of quality of trauma care for case mix.

METHODS

Complications recorded in a trauma registry between 1997 and 2008 were analysed. Formulas for different types of complication (institution- or diagnosis-related) derived from logistic regression models were used to calculate the probability of absence of complications (PAC). Discriminative power was tested by calculating the area under the receiver operating characteristic curve (AUC) in test and validation samples. Calibration was tested using Hosmer and Lemeshow methodology.

RESULTS

Some 5944 surgical trauma admissions were included in the analysis. A significant association between both institution- and diagnosis-related complications and Injury Severity Score was found. Diagnosis-related complications were also associated with Glasgow Coma Score and age. The AUCs of the PACs for institution- and diagnosis-related complications were 0·64 and 0·75 respectively in the test sample, and 0·66 and 0·76 in the validation sample. The AUCs increased when the outcomes of the models were divided into subcategories of complications. Hosmer and Lemeshow tests were not significant for all models, except that for institutional complications.

CONCLUSION

To predict complications, a distinction should be made between institution- and diagnosis-related complications. The development of more detailed diagnosis-related prediction models is preferable because of better performance. The formulas predicting the PAC can be used to compare expected and observed complications.

Operative treatment of patients with pertrochanteric femoral fractures outside working hours is not associated with a higher incidence of complications or higher mortality

This retrospective cohort study was conducted to investigate whether operative treatment of patients with a pertrochanteric femoral fracture outside working hours is associated with an increased risk of complications and higher mortality. During the study period 165 patients were operated on outside working hours and 123 were operated on during working hours (08.00 to 17.00). There was no difference in the rate of early complications (outside working hours 33% versus working hours 33%, p = 0.91) or total complications during follow-up (outside working hours 40% versus working hours 41%, p = 0.91). Both in-hospital mortality (outside working hours 12% versus working hours 11%, p = 0.97) and mortality after one year (outside working hours 29% versus working hours 27%, p = 0.67) were comparable. Adjustment for possible confounders by multivariate logistic regression analysis revealed no increased risk of complications when patients were operated on outside working hours.

On the basis of these data, there is no medical reason to postpone operative reduction and fixation in patients with a proximal femoral fracture until working hours.

[Stump appendicitis after previous appendicectomy]

Two patients, a 25-year-old male and a 57-year-old female, were treated for stump appendicitis. Both patients had undergone appendicectomy 6 months previously and again presented with pain in the right lower abdominal region. On physical examination, the first patient had tenderness as well as rebound tenderness over the entire abdomen, indicative of a general peritonitis. The second patient had tenderness and rebound tenderness in the right iliac fossa alone. Both patients underwent a laparotomy. In the first patient a perforated appendiceal stump was found and removed. In the second patient an acutely inflamed appendiceal stump was found and removed. Appendicitis of a residual appendiceal stump following incomplete appendicectomy is a rare cause of abdominal pain. A lack of familiarity with this condition frequently causes a delay in diagnosis, which increases the chance of perforation and intra-abdominal sepsis. Therefore, all clinicians need to be aware of the possibility of stump appendicitis and to take appropriate measures to prevent serious complications should they suspect this.

Sympathetic mediated vasomotion and skin capillary permeability in diabetic patients with peripheral neuropathy

AIMS/HYPOTHESIS

A loss of sympathetic function could lead to changes in capillary fluid filtration in diabetic patients. We investigated whether a decreased sympathetically mediated vasomotion in the skin in diabetic patients with peripheral neuropathy is associated with an abnormal capillary leakage.

METHODS

Three matched groups were studied: 18 diabetic patients with documented peripheral neuropathy (DN), 18 diabetic patients without peripheral neuropathy (D), and 18 healthy control subjects (C). Sensory and motor nerve function of the distal extremities were assessed by standard neurography, and expressed in a sensory-motor nerve function score. Sympathetic vasomotion of the skin microcirculation was assessed by determining the power of blood flow variability in the low-frequency (0.02-0.14 Hz) band by spectral analysis of laser Doppler flowmetry at the median ankle. Skin capillary leakage was evaluated by sodium fluorescein videodensitometry at the same site of the foot.

RESULTS

Sympathetically mediated vasomotion of the foot skin microcirculation was lower in diabetic patients with documented peripheral neuropathy compared with diabetic patients without peripheral neuropathy and control subjects (p<0.001). Capillary sodium fluorescein leakage was larger in 18 diabetic patients with documented peripheral neuropathy than in diabetic patients without peripheral neuropathy (p<0.02) and C (p<0.005). Multiple regression analysis disclosed that a reduced sympathetically mediated vasomotion, together with a lower sensory-motor nerve function score, independently contributed to the variance in sodium fluorescein leakage, for 30% (p<0.001) and 17% (p<0.01), respectively.

CONCLUSIONS

A loss of sympathetic tone, apart from sensory-motor nerve dysfunction, seems to be a major determinant of an increased capillary permeability in diabetic patients with neuropathy.

Reduced capillary permeability and capillary density in the skin of GH-deficient adults: improvement after 12 months GH replacement

OBJECTIVE

Several lines of evidence suggest that the GH-IGF-1 axis affects capillary permeability and angiogenesis. We evaluated skin capillary permeability and capillary density in GH-deficient adults, before and after GH replacement therapy.

PATIENTS

Seven normotensive, nondiabetic GH-deficient adults (two women) were matched with 14 control subjects.

MEASUREMENTS

Large-window videodensitometry with sodium fluorescein was performed in all subjects. Capillary permeability was expressed as the average relative light intensity over the first 7 min after the appearance of fluorescein in the skin capillaries; Iav(7). Skin capillary density was determined by counting the visualized capillaries and was expressed as n/mm2. The GH-deficient patients were restudied after 12 months of GH replacement therapy (2 U/day).

RESULTS

Both capillary permeability and capillary density were lower in untreated GH-deficient patients than in control subjects (median, interquartile range): Iav(7) in GH-deficient patients 47.1 (45.1-52.2)% vs. 57.5 (50.5-64.8)% in controls, P < 0.05; capillary density in GH-deficient patients 18 (12-24)/mm2 vs. 32 (26-36)/mm2 in controls, P < 0.05. GH treatment normalized plasma IGF-1 from 4.3 (1.0-13.4) to 22.2 (19.8-48.2) nmol/l (P < 0.05). Furthermore, both capillary permeability [Iav(7) 53.1 (48.8-58.4)%, P < 0.05] and capillary density [26 (17-34)/mm2, P < 0.05] increased to a level that was not different from that in control subjects.

CONCLUSIONS

The present study demonstrates that the growth hormone deficiency syndrome is associated with microvascular alterations, which are responsive to growth hormone replacement therapy.

Automated on-line solid-phase extraction-gas chromatography with nitrogen-phosphorus detection: determination of benzodiazepines in human plasma

An automated sample preparation module, the ASPEC (automated sample preparation with extraction columns) was interfaced with a capillary gas chromatograph (GC) by means of a loop-type interface. The system was optimized for the determination of four benzodiazepines in plasma. Extraction from the untreated plasma was carried out on disposable C18 cartridges and involved several washing steps. The analytes were desorbed with 2 ml of ethyl acetate and a 110-microliter aliquot of the eluate was injected into the gas chromatograph via the loop-type interface using fully concurrent solvent evaporation conditions. Detection of the benzodiazepines was carried out with a nitrogen-phosphorus detector (NPD). The ASPEC-GC-NPD was fully automated and could run unattended overnight. With a sample volume of 1 ml the procedure showed good linearity and repeatability in the range 5-50 ng/ml using a sample volume of 1 ml. The limits of detection in plasma were 0.5-2 ng/ml.

[Continuous intravenous antibiotic home treatment in 11 patients with cystic fibrosis in The Northern Netherlands]

OBJECTIVE

Assessment of intravenous home treatment of respiratory infections of cystic fibrosis (CF) patients.

SETTING

Provinces Groningen, Drente, Friesland and Overijssel.

DESIGN

Open study.

PATIENTS AND METHODS

Eleven CF patients, aged 10 to 28 years participated. Thirty episodes of home i.v. treatment with antibiotics were arranged. Differences in vital capacity (VC) and forced expiratory volume in one second (FEV1) and in body weight before and after treatment were compared with the same variables obtained during hospitalisation in the year before they were treated at home. Adverse events during home treatment were recorded.

RESULTS

No differences were noted in changes in VC, FEV1 and body weight between home and hospital treatments. During 30 episodes of home treatment a new intravenous catheter had to be implanted only twice.

CONCLUSION

In these 11 patients, intravenous treatment of respiratory infections at home was as efficacious as in hospital. No serious adverse events were observed.