1638 Decade-Long Trends in Surgery for Acute Type A Aortic Dissection

Background

Little is known about unwarranted variations in care and outcomes of patients who undergo surgical repair for type A acute aortic dissection(TAAD). We aim to investigate decade-long trends in TAAD surgical repair in England.

Method

Retrospective review of the National Institute for Cardiovascular Outcomes Research (NICOR) National Adult Cardiac Surgery Audit (NACSA) registry from January 2009 to December 2018 , which prospectively collects demographic and peri-operative clinical information for all adult cardiac surgery procedures in the UK.

Results

Over the 10-year period,3,686 TAAD patients underwent surgical repair in England. A steady doubling in the overall number of operations conducted in England was observed from 237 cases recorded in 2009 to 510 in 2018. Number of procedures per hospital per year also doubled, from 10 in 2009 to 21 in 2018. The risk profile of the operated patients remained unchanged. Overall, in-hospital mortality was 17.4% with a trend toward lower mortality in the most recent years (from 22.8% in 2009 to 14.7% in 2018). There was a significant variation in operative mortality across regions with a trend towards lower mortality in regions with a high-volume hospital.

Conclusions

Surgery is the only treatment for acute TAAD but is associated with high mortality. Prompt diagnosis and referral to a specialist center is paramount. The number of operations conducted in England has doubled in 10 years and the associated survival following surgery has improved. Regional variations exist in service provision with a trend towards better survival in high volume centers.

All delays before radiotherapy risk progression of Merkel cell carcinoma

Prolonged waiting times for radiotherapy have resulted in many centres assigning priorities to various patient or diagnostic groups. A high risk of progression on a waiting list is one factor that would reasonably influence the priority. The present descriptive study of 27 patients with Merkel cell carcinoma (MCC) found that a median wait of 24 days for radiotherapy is associated with a high risk of progression. Eleven (41%) of 27 patients developed progressive disease, including five (45%) of 11 patients waiting for adjuvant radiotherapy. Patients treated adjuvantly also had longer waiting times prior to their initial radiotherapy consultation (median 41 days), which may have contributed to the rate of progression. Merkel cell carcinoma is an aggressive but curable malignancy and appropriate management should include efforts to minimize all potential delays prior to the commencement of radiotherapy.

Drosophila p53 binds a damage response element at the reaper locus

The tumor suppressor gene p53 regulates multiple cellular responses to DNA damage, but the transcriptional targets that specify these responses are incompletely understood. We describe a Drosophila p53 homolog and demonstrate that it can activate transcription from a promoter containing binding sites for human p53. Dominant-negative forms of Drosophila p53 inhibit both transactivation in cultured cells and radiation-induced apoptosis in developing tissues. The cis-regulatory region of the proapoptotic gene reaper contains a radiation-inducible enhancer that includes a consensus p53 binding site. Drosophila p53 can activate transcription from this site in yeast and a multimer of this site is sufficient for radiation induction in vivo. These results indicate that reaper is a direct transcriptional target of Drosophila p53 following DNA damage.

mus304 encodes a novel DNA damage checkpoint protein required during Drosophila development

Checkpoints block cell cycle progression in eukaryotic cells exposed to DNA damaging agents. We show that several Drosophila homologs of checkpoint genes, mei-41, grapes, and 14-3-3epsilon, regulate a DNA damage checkpoint in the developing eye. We have used this assay to show that the mutagen-sensitive gene mus304 is also required for this checkpoint. mus304 encodes a novel coiled-coil domain protein, which is targeted to the cytoplasm. Similar to mei-41, mus304 is required for chromosome break repair and for genomic stability. mus304 animals also exhibit three developmental defects, abnormal bristle morphology, decreased meiotic recombination, and arrested embryonic development. We suggest that these phenotypes reflect distinct developmental consequences of a single underlying checkpoint defect. Similar mechanisms may account for the puzzling array of symptoms observed in humans with mutations in the ATM tumor suppressor gene.

An exploration of the sequence of a 2.9-Mb region of the genome of Drosophila melanogaster: the Adh region

A contiguous sequence of nearly 3 Mb from the genome of Drosophila melanogaster has been sequenced from a series of overlapping P1 and BAC clones. This region covers 69 chromosome polytene bands on chromosome arm 2L, including the genetically well-characterized "Adh region." A computational analysis of the sequence predicts 218 protein-coding genes, 11 tRNAs, and 17 transposable element sequences. At least 38 of the protein-coding genes are arranged in clusters of from 2 to 6 closely related genes, suggesting extensive tandem duplication. The gene density is one protein-coding gene every 13 kb; the transposable element density is one element every 171 kb. Of 73 genes in this region identified by genetic analysis, 49 have been located on the sequence; P-element insertions have been mapped to 43 genes. Ninety-five (44%) of the known and predicted genes match a Drosophila EST, and 144 (66%) have clear similarities to proteins in other organisms. Genes known to have mutant phenotypes are more likely to be represented in cDNA libraries, and far more likely to have products similar to proteins of other organisms, than are genes with no known mutant phenotype. Over 650 chromosome aberration breakpoints map to this chromosome region, and their nonrandom distribution on the genetic map reflects variation in gene spacing on the DNA. This is the first large-scale analysis of the genome of D. melanogaster at the sequence level. In addition to the direct results obtained, this analysis has allowed us to develop and test methods that will be needed to interpret the complete sequence of the genome of this species. Before beginning a Hunt, it is wise to ask someone what you are looking for before you begin looking for it. Milne 1926

Comparison of primary coronary artery bypass surgery in a British Indo-Asian and white Caucasian population

AIM

To compare the clinical characteristics, at the time of admission and after coronary revascularization by bypass surgery, among British patients of Indo-Asian and white Caucasian descent.

METHOD

One hundred and ninety-four pairs of patients admitted between November 1994 and January 1997 were matched for age (within 3 years), sex and date of admission (within 3 months). Their clinical characteristics at the time of admission for coronary artery bypass grafting surgery, and the incidence of hospital morbidity, hospital mortality and length of stay in the intensive therapy unit or hospital following coronary artery bypass grafting were determined.

RESULTS

A higher proportion of Indo-Asian patients underwent coronary revascularization on a non-elective basis (43% vs 32% white Caucasian patients, P =0.018), had a higher prevalence of diabetes (39% vs 12%, P =0.0001), a lower prevalence of smoking (36% vs 80%, P =0.0001) and a lower rate of previous myocardial infarction (47% vs 62%, P =0.012). As regards revascularization, although there was no significant difference in the number of vessels revascularized, there was a lower use of the arterial conduit (internal mammary artery) in the Indo-Asian patients (72% vs 81%, P =0.028) particularly for those undergoing emergency/urgent surgery (59% vs 72%, P =0.001) and with a previous myocardial infarction (65% vs 81%;P =0.01) when compared with their white Caucasian counterparts. Following surgery there were no differences in the types of support required for vital functions. There was no significant difference in the proportion of major post-operative complications, that is, haemorrhage, cerebrovascular accident, renal failure requiring dialysis or respiratory failure. Similarly, there were no differences in the length of intensive therapy unit stay (median stay 1 day vs 1 day, P =0.4) and hospital stay following surgery (median stay 6 days vs 6 days, P =0.5) between the two groups. Although there was a trend towards a higher in-hospital (30 day) mortality (6.7% [95% confidence intervals CI 3.18-10.21] vs 2.6% [CI 0.35-4.9;P =0.0618]), in Indo-Asians compared to white Caucasians this trend disappeared when patients in the two groups undergoing non-elective surgery only were compared (9% vs 7%;P =0.7).

CONCLUSIONS

A higher proportion of Indo-Asians underwent non-elective coronary revascularization, with a significantly lower use of the arterial conduit and a relatively higher in-hospital mortality. Following coronary revascularization the medical management, length of stay and hospital morbidity in Indo-Asian patients was no different from that of their white Caucasian counterparts. This is despite a perceived poorer outcome in Indo-Asians compared to white Caucasians.

Is there a role for video-assisted thoracoscopy in the staging of non-small cell lung cancer?

OBJECTIVE

To evaluate the role of video-assisted thoracoscopy (VAT) in the staging of non-small cell lung cancer (NSCLC).

METHODS

In 30 patients (18 male, 12 female, median age 62 (50-78) years) VAT was used to assess the operability of NSCLC in cases where doubt existed after conventional staging investigations had been performed.

RESULTS

VAT was used to assess direct tumour invasion of adjacent organs in 17 patients (mediastinal invasion in 14 and chest wall invasion in 3 patients). In 4 patients with limited respiratory reserve, VAT confirmed the need only for lobectomy prior to thoracotomy. Mediastinal lymph node biopsy was performed in 5 patients with significant (> 1.5 cm) lymphadenopathy on CT scan. VAT was also used to assess bilateral lesions in 4 patients with suspected synchronous tumours. Conversion to thoracotomy was necessary in 4 patients for technical reasons. Successful resection was possible in 17 of the remaining 26 cases, while unnecessary thoracotomy was avoided in 9 patients (30%) with unresectable or benign disease. In 4 patients deemed inoperable on CT scan, VAT staging enabled subsequent resection.

CONCLUSIONS

Video-assisted thoracoscopy appears to have a complementary role in staging NSCLC when other methods are equivocal. It has the potential for increased sensitivity over conventional staging methods.

Sports causing most injuries in Hong Kong

A prospective survey was carried out on 2293 patients attending the Sports Injury Clinic in the Prince of Wales Hospital between May 1984 and December 1990. A Sports Injury Report Form was completed for each patient. Subjects in this study represent a group of nonprofessional and non-élite athletes in a metropolitan area. Soccer, basketball, volleyball, long-distance running and cycling in descending order were the five most common sports causing injury. Different sports produced different injury patterns. In four of the five sports, the knee (27.27-50.47%) and the ankle (16.78-24.67%) were the commonest sites of injury. In cycling, the face (19.46%) was the commonest site of injury. There was a higher injury rate to the lower than the upper limb in soccer, basketball, volleyball and long-distance running, with a ratio of upper- to lower-limb injury ranging from 1:1.13 to 1:46.10. In cycling, upper limb injury was more frequent (upper- to lower-limb injury ratio was 1:0.53). Sprain was the commonest injury overall (44.60%). It was also the commonest injury condition in volleyball (55.15%), basketball (55.34%), soccer (51.41%) and long-distance running (39.33%). In cycling, abrasion (24.83%) was commonest.

Respiratory changes and structure of sleep in young high-altitude dwellers in the Andes of Peru

Sleep organisation in eight young [mean (SD); 20.9 (2.6) years] Peruvian high-altitude residents was studied in a laboratory in Cerro de Pasco at 4300 m. Electroencephalograms, electromyograms, electro-oculograms, electrocardiograms, respiratory movements and arterial oxygen saturation were recorded on an 8-channel Medilog recorder and analysed later in England. Haematocrits ranged from 48% to 64% [57.9 (5.6)%]. The amount of slow wave rapid eye movement (REM) sleep was similar to that reported in young lowlanders sleeping at sea level but very different to the disturbed sleep in visitors sleeping at high altitude. All the Peruvians showed episodes of periodic breathing and respiratory apnoeas [29 (15) night-1] resulting in marked arterial oxygen desaturation [81 (4.5)%; changes of 6 (2.5)%]. These events occurred either during stage 2 or REM sleep and were more frequent in those with lower haematocrits. The amount of wakefulness during the night was 2-3 times greater than would be expected in an age-matched lowland population at sea level. The awakenings were strongly associated with apnoeas (P < 0.02) but were negatively correlated with haematocrit, although this was only significant for seven of the subjects (P < 0.05).

Sleep of Andean high altitude natives

The structure of sleep in lowland visitors to altitudes greater than 4000 m is grossly disturbed. There are no data on sleep in long-term residents of high altitudes. This paper describes an electroencephalographic study of sleep in high altitude dwellers who were born in and are permanent residents of Cerro de Pasco in the Peruvian Andes, situated at 4330 m. Eight healthy male volunteers aged between 18 and 69 years were studied. Sleep was measured on three consecutive nights for each subject. Electroencephalographs, submental electromyographs and electro-oculograms were recorded. Only data from the third night were used in the analysis. The sleep patterns of these subjects resembled the normal sleep patterns described by others in lowlanders at sea level. There were significant amounts of slow wave sleep in the younger subjects and rapid eye movement sleep seemed unimpaired.