An Update on Recent Advances in Cubosome: A Novel Drug Delivery System

Cubosomes are highly stable nanostructured liquid crystalline dosage delivery form derived from amphiphilic lipids and polymer-based stabilizers converting it in a form of effective biocompatible carrier for the drug delivery. The delivery form comprised of bicontinuous lipid bilayers arranged in three dimensional honeycombs like structure provided with two internal aqueous channels for incorporation of number of biologically active ingredients. In contrast liposomes they provide large surface area for incorporation of different types of ingredients. Due to the distinct advantages of biocompatibility and thermodynamic stability, cubosomes have remained the first preference as method of choice in the sustained release, controlled release and targeted release dosage forms as new drug delivery system for the better release of the drugs. As lot of advancement in the new form of dosage form has bring the novel avenues in drug delivery mechanisms so it was matter of worth to compile the latest updates on the various aspects of mentioned therapeutic delivery system including its structure, routes of applications along with the potential applications to encapsulate variety drugs to serve health related benefits.

Mirabegron in Overactive Bladder and Its Role in Exit Strategy After Botulinum Toxin Treatment in Children

PURPOSE

Mirabegron is a recent addition to the management options of overactive bladder (OAB) in children. The purpose of this study was to ascertain the role of Mirabegron in the treatment algorithm of therapy-resistant OAB especially after botulinum toxin.

METHODS

Case notes of all children receiving Mirabegron between July 2017 and February 2020 were reviewed.

RESULTS

Forty one children (21 females, 20 males), mean age 12.6 [8-17] years old, commenced Mirabegron: 35 idiopathic OAB, 6 neuropathic OAB. The mean duration of treatment was 20.7 [3-45] months. In total 24 (59%) had Mirabegron after partial/no response to anticholinergics, and 17 (41%) patients had Mirabegron subsequent to botulinum toxin A (BtA) as an exit strategy. In total 35 (85%) patients had combination therapy (Mirabegron and anticholinergics), and 6 (15%) patients had Mirabegron only. Fourteen (34%) had complete response, 17 (41%) had partial response, and 10 (24%) had no response. Side effects were reported in 7 (17%) patients with discontinuation necessitated in 3.

CONCLUSION

Mirabegron when used alone or in combination with anticholinergics resulted in complete/partial response in 76% of anticholinergic therapy-resistant OAB. In addition to being an important step in treatment escalation after no/partial response to anticholinergics, it has a crucial role in the exit strategy for recurring symptoms after BtA wears off.

Reducing admission hypothermia in newborns at a tertiary care NICU of northern India: A quality improvement study

BACKGROUND

Hypothermia at admission to neonatal intensive care units (NICU) is associated with increased morbidity and mortality in newborns. A baseline study at a tertiary care hospital with all out-born babies showed admission hypothermia of 82%.

OBJECTIVE

To reduce admission hypothermia (moderate) in newborns at least by 50% in next 6 months.

METHODS

A quality improvement (QI) study was planned using WHO Point of Care Quality Improvement Model (POCQI), [17] using PDSA (Plan-Do-Study-Act) cycle approach from April 2018 to March 2019, and including 427 term and preterm babies. We educated the staff, reinforced the use of caps, cling wraps, warm linen, introduced Ziploc bags and ensured adequate use of transport incubator.

RESULTS

After 6 months, overall admission hypothermia decreased from 82% to 45%, moderate hypothermia reduced from 46% to <10% (P < 0.001) and severe hypothermia (3%) was completely eliminated. There was also significant reduction in incidence of Intraventricular hemorrhage (13% Vs 4.7%), Late onset neonatal sepsis (38% Vs 19%) and metabolic acidosis (43% Vs 28%). We were able to sustain this improvement for the next 6 months and is ongoing. The strongest predictor of hypothermia was newborns being in the phase before QI initiative was started (OR 2.36, 95% CI 1.47, 3.23).

CONCLUSION

This study is a cost effective approach in reducing admission hypothermia in NICU in a resource limited setting with all outborn babies, and further decreasing the morbidity associated with it. Hence, emphasizing the importance of maintaining euthermia, not only in delivery rooms, but also during transportation.

Novel approach to vaginal calculus in a girl with urogenital sinus anomaly

Isolated urogenital sinus can cause distended bladder and/or vagina and may present with an abdominal mass and sepsis during infancy. Older children may present with recurrent urinary tract infections and hematocolpos. We describe a 3-year-old girl with recurrent urinary tract infections thought to be secondary to vesicoureteric reflux. On further investigation, an isolated urogenital sinus anomaly with a calculus inside one of the hemivaginae was noted. She was managed expectantly with a plan to intervene at puberty. At puberty, during removal of the stone, the hemivaginal introitus was found to be stenotic. Gradually increasing sizes of Amplatz type graduated renal dilators were introduced from the introitus of the urogenital sinus into the hemivaginal stone until a size 22F Amplatz sheath could be passed easily. Size 10F cystoscope was passed through this channel, and the stone was fragmented using electrohydraulic lithotripsy. At a later date, she underwent staged anterior sagittal transvulval mobilization of the urogenital sinus.

Three-year outcomes of trabeculectomy and Ahmed valve implant in patients with prior failed filtering surgeries

PURPOSE

To compare three-year surgical outcomes of trabeculectomy versus Ahmed valves in patients with prior failed trabeculectomy.

METHODS

This is a longitudinal retrospective comparative study of one-hundred twenty adult patients with prior failed trabeculectomy who underwent a repeat trabeculectomy or Ahmed valve implant. Demographic and clinical data were collected up to 3 years on all study participants at the Kresge Eye Institute from 2004 to 2016. Visual acuity, intraocular pressure, number of intraocular pressure reducing medications, and success rates at various time points up to 3 years after repeat surgery were the main outcome variables.

RESULTS

Sixty-five and sixty eyes were included in the trabeculectomy and the Ahmed valve groups, respectively. Baseline intraocular pressure significantly decreased in both groups at 3 years (p < 0.01). The number of medications was relatively similar to baseline in both study groups at 3 years (p > 0.05). There was no statistically significant difference between the two groups in visual acuity, percentage of intraocular pressure reduction, number of medications, or success rates at any follow-up time points (p > 0.05 for all).

CONCLUSIONS AND RELEVANCE

After 3 years, both trabeculectomy and Ahmed valves significantly reduced intraocular pressure from baseline, but with relatively similar number of medications compared to baseline. There was no significant difference in any outcome measure between trabeculectomy and Ahmed valves at any follow-up time points. These results may suggest neither trabeculectomy or Ahmed valves are superior in patients with previously failed trabeculectomies.

Therapeutic Monoclonal Antibodies in Clinical Practice against Cancer

The importance of monoclonal antibodies in oncology has increased drastically following the discovery of Milstein and Kohler. Since the first approval of the monoclonal antibody, i.e. Rituximab in 1997 by the FDA, there was a decline in further applications but this number has significantly increased over the last three decades for various therapeutic applications due to the lesser side effects in comparison to the traditional chemotherapy methods. Presently, numerous monoclonal antibodies have been approved and many are in queue for approval as a strong therapeutic agent for treating hematologic malignancies and solid tumors. The main target checkpoints for the monoclonal antibodies against cancer cells include EGFR, VEGF, CD and tyrosine kinase which are overexpressed in malignant cells. Other immune checkpoints like CTLA-4, PD-1 and PD-1 receptors targeted by the recently developed antibodies increase the capability of the immune system in destroying the cancerous cells. Here, in this review, the mechanism of action, uses and target points of the approved mAbs against cancer have been summarized.

High burden of cardiometabolic risk factors in spouses of Indian women with hyperglycaemia in pregnancy

AIM

To evaluate the burden and association of cardiometabolic risk factors in the spouses of women with and without hyperglycaemia in pregnancy.

METHODS

Women with (n = 204) and without (n = 197) hyperglycaemia in pregnancy, along with their spouses, participated in this cross-sectional study. The hyperglycaemia in pregnancy group included women with gestational diabetes and diabetes in pregnancy. A detailed questionnaire was completed for all participants (men and women), documenting relevant personal and medical history, along with biochemical investigations (men).

RESULTS

A total of 401 couples were evaluated at the time point during the pregnancy of 24.7 ± 5.2 gestational weeks (mean ± sd). Dysglycaemia (prediabetes or diabetes), overweight/obesity (BMI ≥25 kg/m² ) and metabolic syndrome were detected in 120 (58.9%), 123 (60.3%) and 98 spouses (48.3%) of women with hyperglycaemia in pregnancy, respectively. In the fully adjusted model, an increased risk of dysglycaemia [odds ratio 1.43 (95% CI 0.95-2.17); P = 0.088], overweight/obesity [odds ratio 1.49 (95% CI 0.98-2.27); P = 0.064] and metabolic syndrome [odds ratio 2.00 (95% CI 1.30-3.07); P = 0.001] was seen in the spouses of women with hyperglycaemia in pregnancy. The prevalence of these metabolic conditions was higher in spouses of women with diabetes in pregnancy compared to spouses of women with gestational diabetes mellitus.

CONCLUSIONS

A high burden of cardiometabolic risk factors was observed in the spouses of women with hyperglycaemia in pregnancy. The opportunity provided by pregnancy could be used by the healthcare system not only to improve the health of the woman and her offspring, but also her spouse.

Cardiological society of India document on safety measure during echo evaluation of cardiovascular disease in the time of COVID-19

An echocardiographic investigation is one of the key modalities of diagnosis in cardiology. There has been a rising presence of cardiological comorbidities in patients positive for COVID-19. Hence, it is becoming extremely essential to look into the correct safety precautions, healthcare professionals must take while conducting an echo investigation. The decision matrix formulated for conducting an echocardiographic evaluation is based on presence or absence of cardiological comorbidity vis-à-vis positive, suspected or negative for COVID-19. The safety measures have been constructed keeping in mind the current safety precautions by WHO, CDC and MoHFW, India.

Mycosis fungoides: developments in incidence, treatment and survival

BACKGROUND

Prior studies have demonstrated improved disease-specific survival of mycosis fungoides (MF) patients over the last 50 years.

OBJECTIVE

To analyse patterns of survival and incidence from 1973 to 2016 and determine whether apparent improvements in MF-specific survival are due to lead-time bias rather than improvements in treatment.

METHODS

We performed an analysis of 10 155 patients diagnosed with MF from 1973 to 2016 in the United States cancer registries of SEER-18. We also performed a literature review of papers including stage data for unselected populations of MF patients prior to 2000.

RESULTS

Incidence of MF increased from 3.0 per million person-years in the 1970s to 5.9 in the 2010s. For all cohorts, non-Hodgkin lymphoma (including MF) was the leading cause of death. Survival analysis demonstrated marked improvement in disease-specific and overall survival from the 1970s to 2010s. Based on systematic review of the literature, 32%-73% of patients diagnosed prior to 2000 were diagnosed with early-stage disease, as opposed to 81% of patients in the SEER 2000-2016 cohort (P < 0.035 for all cohorts).

CONCLUSIONS

Although there have been improvements in MF-related survival over the last 50 years, these may reflect improvements in our ability to diagnose early-stage disease rather than improved treatment.

Lyme Disease: What the Neuroradiologist Needs to Know

Lyme disease is the most common tick-borne disease in Canada and the United States, caused by Borrelia burgdorferi, which affects multiple organ systems. Epidemiology, clinical presentation, and neuroimaging findings are reviewed.

Pyrazoline as a medicinal scaffold

Heterocyclic Chemistry is the backbone of medicinal compounds that exhibits numerous biological activities. Pyrazole and its derivatives possess nitrogen atom along with carbon atom as a substitution and show a diversity of biological activities such as antibacterial, antimicrobial, anti-inflammatory, antioxidant, antidiabetic, anticancer, antifungal, antidepressant, anticonvulsant, analgesic, and monoamine oxidases (MAOs)as shown by pyrazoline prepared from chalcone(Intermediate). The synthesized compounds are checked by the TLC and further analyzed by the IR, NMR, and UV spectroscopy.

Knowledge of Australian primary education providers towards dental avulsion injuries: a cross-sectional study

BACKGROUND/AIM

The aim of this study was to evaluate the knowledge of school professionals regarding the emergency management of dental avulsion.

METHODS

This cross-sectional study utilised a self-administered, pilot-tested questionnaire for school staff from primary schools. Descriptive statistics were used for the analysis - the prevalence and univariate associations between a categorical outcome and the variables under consideration, were evaluated using Pearson's Chi-squared test.

RESULTS

This survey yielded a response rate of 43.5% (n = 313). Approximately 60% of participants held valid first-aid certificates and 23% had received avulsion advice previously. Over 80% of participants expressed an unwillingness to replant an avulsed tooth, and over 90% believed that there should be greater awareness in this area. This unwillingness to replant was influenced by respondents' age (x2 = 8.13 df = 3, P = 0.043) and receiving advice previously (x2 = 13.15, df = 1, P < 0.001). Under-preparedness was related to years of experience (x2 = 15.03, df = 5, P = 0.010), first-aid training (x2 = 6.41, df = 1, P = 0.011) and receiving advice previously (x2 = 43.47, df = 1, P < 0.001). It was also evident that first-aid training positively influenced appropriate dental referral in the management pathway (x2 = 10.49, df = 1, P = 0.001).

CONCLUSION

This study suggests that there is an inadequate level of knowledge on the appropriate management of dental avulsion injuries amongst primary school professionals in Australia.

Use of Fluoridated Dentifrices among Children: Are We in the Right Direction?

Introduction Use of topical fluorides in dentifrices has always been an important tool in prevention of dental caries in young children. Due to the easy availability of various low and high fluoride dentifrices, the parents have no clear understanding about their correct age-appropriate use in children. This study was undertaken to evaluate and understand the trend and current practices among the end user.

Materials and Methods A total of 173 children aged 4 to 6 years were enrolled in the study from schools located in two different geographical areas of the Chandigarh city; group 1 (n = 90) from a peri-urban slum cluster: (Govt. Primary School, Indira Colony, Mani Majra, n = 51); Govt. Middle School, Mani Majra (n = 39); group 2 (n = 83) from an urban private city school (Ankur, Punjab University, Sector 14) using cluster sampling method. Two examiners using type IV examination examined all the children aged 4 to 6 years present using a preinstructed close-ended questionnaire. Data were analyzed using SPSS Software Version 25 (SPSS Inc., Chicago, IL, United States).

Results The data regarding the knowledge of fluoride in pastes showed that 85% of the children were using high fluoride pastes, 10% were using nonfluoride pastes, and 5% were using low fluoride pastes. In group 1, none of the users were aware about the benefits/risk of using fluoride toothpastes and only 22% were aware in group 2. Only 27% of children in group 1 dispensed the correct amount of dentifrice for this age group i.e., a pea head size versus 67% in group 2; a half brush length was dispensed by 61.5% in group 1 and 28% in group 2, and just a smudge by 11.5% in group 1 and 5% in group 2. Forty one percent children in both the groups had a history of having intentionally consumed the toothpaste. The toothpaste was dispensed to the child by parent in 89% of cases in group 2 and only 50% in group 1 and 88% parents claimed to always supervise the child while tooth brushing versus only 53% in group 1. Majority of the respondents’, i.e., 97% in group 1 and 63% in group 2 had never been explained about the correct method of use of fluoride paste in children.

Conclusion Knowledge about fluoridated toothpastes is low among the population. The children in peri-urban slums areas are exposed to the high fluoride pastes from very early in life and there is no other toothpaste which is brought home except for those which are commonly used among the members. In the city schools; however, a small percentage of population uses low fluoride pastes in children, possibly due to a greater awareness and access to information, but has no clear idea about their limitations and benefits of age-appropriate use. Till appropriate guidelines are available for the country, a safe practice to follow is tailoring individual need based protocol. The children in peri-urban slums areas need to be educated more on the health practices and importance of use of fluoride dentifrices and the children in the city schools need to be guided more on the age appropriate use of high and low fluoride dentifrices.

Efficacy of electromotive drug administration in delivering botulinum toxin a in children with neuropathic detrusor overactivity-outcomes of a pilot study

BACKGROUND

Intravesical botulinum toxin A (BtA) injection is well established in managing paediatric neuropathic detrusor overactivity (NDO). Electromotive drug administration (EMDA) is a less invasive method, which can be performed in the clinic, using pulsed electrical current for drug delivery via a urethral catheter. Few small studies report good outcomes following BtA via EMDA (BtA/EMDA) into bladders of children with NDO.

OBJECTIVE

The objective of this study is to assess the efficacy of BtA/EMDA in children with NDO, reduced bladder capacity and compliance.

METHODS

Twelve children with NDO on baseline urodynamic study were prospectively included. Pre-BtA/EMDA and post-BtA/EMDA results compared the following four parameters: maximal cystometric capacity, bladder compliance, maximal detrusor pressure (pDetmax) during detrusor overactivity and pDetmax at capacity. The Wilcoxon matched-pairs signed-rank test using Graphpad Prism 8 was used for analysis. Secondary outcomes include adverse effects and symptomatic improvement.

RESULTS

Fourteen episodes of BtA/EMDA were performed. Five patients received 3.3 IU/kg of Botox®, and five received 10 IU/kg (maximum 300 IU). Four patients received 10 IU/kg of Dysport®. Two patients in the Dysport®/EMDA group also received Botox®/EMDA more than six months previously. Thirteen of 14 post-EMDA results were completed and included in the paired analysis. No statistically significant improvements in any cystometric parameters were demonstrated. Eight patients subsequently had intravesical BtA injections with significant improvements in both cystometric parameters and symptoms. Two patients subsequently transitioned to adult services; one was commenced on mirabegron, and one has undergone ileocystoplasty with Mitrofanoff appendicovesicostomy.

DISCUSSION

Despite some evidence to support BtA/EMDA in children with NDO, the authors were unable to replicate previously published positive cystometric and symptomatic outcomes. In addition, BtA/EMDA performed poorly when compared with conventional intravesical BtA injections. This implies failure of EMDA to deliver BtA correctly to the target tissue. The large size of the BtA molecule or the abnormal bladder wall in NDO could account for the negative results. Thorough preparation and consultation was undertaken before this study with BtA/EMDA, and it is discouraging that the authors were unable to reproduce the positive results of other groups.

CONCLUSIONS

Although safe and acceptable to most patients, the authors cannot recommend the use of BtA/EMDA for NDO in children at present.

P4632Impact of intracardiac thrombosis in patients with acute myocardial infarction: insights from nationwide inpatient sample in the United States

Background

Intracardiac thrombosis (ICT) is a complication of Acute myocardial infarction (AMI).

Hypothesis

Our aim was to evaluate the impact of ICT on mortality, thromboembolism, length of stay in patients with AMI.

Methods

Data was collected from the Nationwide Inpatient Sample (NIS) for the year 2016, where patients with a primary diagnosis of ICT as a complication of AMI (ICD10-CM code I23.6) were included. Comparisons were made between patients with ICT post-AMI (ICD10-CM code I23.6) vs those with AMI (ICD10-CM I21.0).

Results

Of a total of 200930 cases of AMI, 488 (0.5%) had ICT. The patients with ICT had an increased length of stay (LOS) (8.5±9.8 vs 5.7±7.4 days; p<0.001), increased ischemic stroke (10.6% vs 2.9%; p<0.001), and cardiogenic shock (15% vs 7%; p<0.001). There was no difference in mortality between the groups.

Table 1. Patient characteristics AMI% (n=200,930) ICT post AMI% (n=488) p-values Demographic variables   a. Males 59 73   b. Females 41 27 <0.001 Race   a. Caucasian 71 68 0.10   b. African American 11 15 0.01   c. Hispanic 7.5 6.1 0.23   d. Other races 5.6 6.2 0.80   e. Race not specified 4.4 4.9 0.59 Comorbidities   Drug abuse 23.9 31.1 <0.001   Atrial Arrhythmias 33.1 41.6 <0.001   Ventricular Arrhythmias 5.6 9.2 <0.001   Chronic pulmonary disease 27.7 21.1 <0.001   Diabetes Mellitus 38.9 31.1 <0.001   Hypertension 81.2 70.2 <0.001   Peripheral Vascular disease 10.5 3.52 <0.001   Current or past smoker 20.5 26.1 <0.001   Chronic kidney disease 28.1 20.4 <0.001   History of coronary artery bypass surgery 10.6 5.9 <0.001   HFrEF 23.3 50 <0.001 HFrEF = Heart failure with reduced ejection fraction; pVAD = Percutaneous ventricular assist device.

Conclusion

ICT as a complication of AMI is associated with increased hospital LOS and adverse events.

Zika Virus Infects Trabecular Meshwork and Causes Trabeculitis and Glaucomatous Pathology in Mouse Eyes

Zika virus (ZIKV) infection during pregnancy leads to devastating fetal outcomes, including neurological (microcephaly) and ocular pathologies such as retinal lesions, optic nerve abnormalities, chorioretinal atrophy, and congenital glaucoma. Only clinical case reports have linked ZIKV infection to causing glaucoma, a major blinding eye disease. In the present study, we have investigated the role of ZIKV in glaucoma pathophysiology using in vitro and in vivo experimental models. We showed that human primary trabecular meshwork (Pr. TM) cells, as well as a human GTM3 cell line, were permissive to ZIKV infection. ZIKV induced the transcription of various genes expressing pattern recognition receptors (TLR2, TLR3, and RIG-I), cytokines/chemokines (TNF-α, IL-1β, CCL5, and CXCL10), interferons (IFN-α2, IFN-β1, and IFN-γ), and interferon-stimulated genes (ISG15 and OAS2) in Pr. TM cells. ZIKV infection in IFNAR1-/- and wild-type (WT) mouse eyes resulted in increased intraocular pressure (IOP) and the development of chorioretinal atrophy. Anterior chamber (AC) inoculation of ZIKV caused infectivity in iridocorneal angle and TM, leading to the death of TM cells in the mouse eyes. Moreover, anterior segment tissue of infected eyes exhibited increased expression of inflammatory mediators and interferons. Furthermore, ZIKV infection in IFNAR1-/- mice resulted in retinal ganglion cell (RGC) death and loss, coinciding with optic nerve infectivity and disruption of anterograde axonal transport. Because of similarity in glaucomatous pathologies in our study and other experimental glaucoma models, ZIKV infection can be used to study infectious triggers of glaucoma, currently an understudied area of investigation.IMPORTANCE Ocular complications due to ZIKV infection remains a major public health concern because of their ability to cause visual impairment or blindness. Most of the previous studies have shown ZIKV-induced ocular pathology in the posterior segment (i.e., retina) of the eye. However, some recent clinical reports from affected countries highlighted the importance of ZIKV in affecting the anterior segment of the eye and causing congenital glaucoma. Because glaucoma is the second leading cause of blindness worldwide, it is imperative to study ZIKV infection in causing glaucoma to identify potential targets for therapeutic intervention. In this study, we discovered that ZIKV permissively infects human TM cells and evokes inflammatory responses causing trabeculitis. Using a mouse model, we demonstrated that ZIKV infection resulted in higher IOP, increased RGC loss, and optic nerve abnormalities, the classical hallmarks of glaucoma. Collectively, our study provides new insights into ocular ZIKV infection resulting in glaucomatous pathology.

Prevalence, defect characteristics and distribution of other phenotypes in 3- to 6-year-old children affected with Hypomineralised Second Primary Molars

PURPOSE

To assess the prevalence, severity and defect characteristics of hypomineralised second primary molars in schoolgoing children along with distribution of other phenotypes.

METHODS

A total of 3013, 3- to 6-year-old children were examined for the presence of hypomineralised second primary molars (HSPMs) using an adapted version of EAPD Criteria (2003). The molars were evaluated for the presence, location and colour of demarcated opacities along with associated post-eruptive breakdown (PEB) and atypical restorations. A thorough examination of the entire dentition was followed for evaluation of teeth other than primary second molars for the presence of similar hypomineralised defects. Data were analysed using Chi Square, Fisher exact's and Mann-Whitney U tests at α = 0.05.

RESULTS

A total of 3013 out of 3200 children were included having a mean age of 4.25 ± 0.5 years and deft of 2.1 ± 0.5. Using the adapted version of EAPD 2003 criteria for MIH, the children were evaluated for the presence of hypomineralised second primary molars, the prevalence of which was found to be 7.9%. Hypomineralisation defects were more commonly observed in the maxillary arch (53.4% vs. 42.8%, p = 0.04) with creamish white opacities involving the buccal and lingual surfaces being the most common defects (43.6%). The mean number of HSPMs per child was 1.9. Other phenotypes included demarcated opacities majorly on primary canines (6.6%) followed by primary first molars (4.6%).

CONCLUSIONS

Hypomineralised primary second molars are a fairly common condition affecting approximately 7.9% of the population thus warranting early recognition and management.

Parental home removal of urethral catheters after urological surgery-a prospective benchmarking study

INTRODUCTION

Many urological operations require placement of a urethral Foley catheter. The catheter often needs to remain in situ for a period of time after discharge; and patients subsequently require either a further hospital admission or community nurse review for catheter removal. Parents can easily remove the catheter at home by cutting the balloon port. This disrupts the valve and hence deflates the retaining balloon, thereby facilitating spontaneous passage of the catheter. The authors introduced this practice to their institution.

AIM

The aim was to assess safety and success of parental home catheter removal.

METHODS

A prospective data study was performed in a large pediatric urology center over a 12-month time period. Patients <16 years after single-stage hypospadias repair or other penile surgery were included on a voluntary basis. Parents of eligible patients were instructed verbally and with an information leaflet, including date for removal. Telephone follow-up after removal was undertaken to assess the outcome.

RESULTS

Thirty-eight patients were included over a 12-month time period. Patient age ranged from 9 months to 12 years (median age 2.5 years). The majority (82%) of patients had required a catheter after hypospadias repair. Home catheter removal was successful in 92% cases. Three children required professional support for catheter removal. Median time until catheter passage was 3 h (range 0-24 h). Considering that cost for day case admission for catheter removal averages at 130£ per patient, home catheter removal saved the NHS 4550£ in the time period.

DISCUSSION

This is the first study to report the safety and feasibility of parental home catheter removal by cutting the balloon port valve in the pediatric population. It offers a number of distinct advantages compared with traditional methods for removal. These include, namely, (i) positive patient experience: catheter removal in a familiar environment by a relative minimizes stressful experiences for the family; (ii) minimal trauma to healing tissues through spontaneous catheter passage; and (iii) health care-related cost savings. This was an initial benchmarking study, so patient numbers were relatively small. Nevertheless, it shows that the method is safe and received positive parental feedback.

CONCLUSION

Parental home removal of a urethral catheter is a feasible and safe alternative to catheter removal by a health-care professional. It minimizes parental anxiety and inconvenience related to the catheter removal appointment and allows for significant cost savings.

Abstract PD8-05: POSNOC - Positive sentinel node: Adjuvant therapy alone versus adjuvant therapy plus clearance or axillary radiotherapy

Background: Role of additional axillary treatment (AxT) (axillary lymph node dissection (ALND) or axillary radiotherapy (ART)) in women with ≤2 macrometastases and undergoing systemic therapy remains unclear. Z11 included both micro and macrometastases (around 40% micrometastases) and showed that ALND may be omitted in women with ≤2 positive nodes undergoing breast conserving surgery (BCS) and receiving whole breast RT. Paradoxically, NCIC MA20, demonstrated improved DFS following the addition of regional RT. 51.8% (949/1832) had 1 or 2 positive nodes. 98.9% (1812/1832) had T1/T2 tumours. A post-Z11 survey shows that most US radiation oncologists treat the undissected axilla in women with macrometastases with ART rather than omitting AxT. Therefore, a confirmatory study is needed to clarify the role of additional AxT in women with ≤2 macrometastases undergoing BCS and other subgroups that were not included in Z11 e.g. mastectomy, microscopic extranodal invasion and sentinel node biopsy (SNB) before neoadjuvant chemotherapy.

Methods: Primary objective is to assess whether for women with ≤2 macrometastases at SNB, systemic therapy alone is non-inferior to systemic therapy plus AxT in terms of axillary recurrence at 5 years. Secondary objectives are arm morbidity assessed by LBCQ and QuickDASH questionnaires; QoL assessed by FACT-B+4 questionnaire; anxiety assessed by STAI; loco-regional recurrence; distant metastasis; time to axillary recurrence; axillary recurrence-free survival; DFS; OS; contralateral breast cancer; non-breast malignancy; and economic evaluation. Eligibility criteria include: ≥18 y, uni or multifocal invasive cancer, T1/T2, 1 or 2 macrometastases, with or without extranodal invasion. Target sample size is 1900 with a projected drop-out and non-compliance with treatment allocation rate of 10%. Primary analysis will be per protocol. The following pre-specified subgroup analyses shall be performed: number of macrometastases (1, 2), age (&lt;50, ≥50), breast surgery (mastectomy, BCS), ER (positive, negative), tumour grade (1 or 2, 3), SN assessment technique (OSNA, non-OSNA), extranodal invasion (present, absent). POSNOC opened to recruitment in July 2014. To date 1100 women have been recruited at 82 sites in the UK and 18 sites in Australia and New Zealand. Clinicaltrials.gov NCT02401685.

Citation Format: Goyal A, Mann B, Thompson AM. POSNOC - Positive sentinel node: Adjuvant therapy alone versus adjuvant therapy plus clearance or axillary radiotherapy [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD8-05.

Onabotulinum toxin A in children with refractory idiopathic overactive bladder: medium-term outcomes

INTRODUCTION

Botulinum toxin-A (BtA) has been used for refractory idiopathic overactive bladder (IOAB) in children. Data on the optimum dose success rates, duration of effect, complications and medium-term outcomes are limited. This study aims to analyse the authors' experience to provide medium-term results of BtA in symptomatic refractory patients.

MATERIALS AND METHODS

Patients with refractory IOAB who were treated with BtA (Botox®) were retrospectively analysed. All patients had urodynamic study before treating with BtA. Group A had low-dose BtA (LDBtA) at 5 units/kg (maximum 150 units), and Group B had high-dose BtA (HDBtA) at 10 units/kg (maximum 300 Units). Post-BtA clinical response, functional bladder capacity (FBC) and postvoid residual (PVR) were assessed in addition to the duration of response.

RESULTS

Thirty-nine patients, 11 male and 28 female, were analysed. Forty-six percentage had symptom improvement (73% of males and 36% of females [P = 0.072, ns]). The difference in response rates between LDBtA and HDBtA was not statistically significant (P = 0.684). Increase in total bladder capacity (TBC) was greater in those given HDBtA (P ≤ 0.001), but the increase in FBC was not different between the groups, due to greater PVRs in the HDBtA group. Nine patients (23%) developed UTI; however, six of these patients suffered with UTI pre-BtA as well. Only three were asymptomatic after a single treatment with BtA. The remainder required further BtA or oral anticholinergic therapy. At a median follow-up of 35.4 months (interquartile range [IQR] 25.2-46.6), 12 (31%) were asymptomatic and off all therapy, 18 (46%) were still symptomatic despite therapy and 9 (23%) had their symptoms controlled on continuing treatment.

DISCUSSION AND CONCLUSIONS

Botulinum toxin-A improves symptoms in 46% of children after the first injection in refractory IOAB. Although HDBtA resulted in greater increase in bladder capacity, it conferred no advantage in terms of success rate or duration of response. Five units/kg may be an optimum dose to use as a first treatment with the understanding that some patients will require a higher dose. And, there will be a cohort of patients who need a dose lower than 5 units/kg. A higher dose is more likely to lead to PVR leading to urine stasis and UTIs. The success of BtA only lasts until its effect wears off, and the majority of this cohort (36/39) required continuing treatment with repeat BtA or anticholinergic agents. However, it remains a useful option in patients who are intolerant or unresponsive to anticholinergic medication with symptomatic resolution in 30% at medium-term follow-up.

Significance of Ferritin as a Marker in Head and Neck Malignancies

The efficiency of the combination of two tumor-associated antigens in recognising head and neck cancer was evaluated. The markers studied were CEA and ferritin by radioimmunoassay. CEA was estimated in 22 controls and 41 head and neck cancer patients. There was no difference in CEA values of controls and head and neck cancer patients, suggesting that CEA was not specific for head and neck malignancies. We measured serum ferritin in 27 controls and 58 patients with head and neck cancer. The mean ferritin level was significantly higher in patients (P < 0.001) than in normal subjects. The ferritin level in patients with no evidence of clinical disease 8 months after treatment showed approximately normal levels, whereas the levels showed a tendency to increase or remain at high levels in patients with a poor prognosis, giving support to the contention that ferritin may prove to be a valuable adjunct in head and neck cancer.

Multi-organ IgG4-related disease: Demystifying the diagnostic enigma

IgG4-related disease (IgG4-RD) is a multisystemic mass forming immune-mediated disease entity, commonly creating confusion and diagnostic challenges. We present a case of a 25-year-old female who presented with bilateral orbital masses, lymphadenopathy, paraspinal and renal masses, which clinicoradiologically simulated lymphoma. The lymph node biopsy revealed interfollicular sheets of plasma cells creating confusion with Castleman's disease and marginal zone lymphoma. The orbital biopsy revealed ductular destruction, periductular plasma cells, and fibrosis, mimicking Sjogren's syndrome and Castleman's disease. However, the correlation of the clinical features with histopathological findings, IgG4 immunopositivity, and serum studies helped in clinching the diagnosis. This case presents an uncommon combination of clinical features infrequently reported in literature. Furthermore, and more importantly, it highlights the need to keep a differential of IgG4-RD in mind, to aid early and correct treatment of the disease.

Sialendoscopic Approach in Management of Juvenile Recurrent Parotitis

To assess the role of sialendoscopy as a diagnostic and therapeutic modality in juvenile recurrent parotitis. Juvenile recurrent parotitis (JRP) is the second most frequent salivary gland disease in childhood and is characterized by recurrent non suppurative and non obstructive parotid inflammation. These attacks influence the quality of life and can even lead to gland destruction, and there are no definitive treatment to avoid them. Sialendoscopic dilatation is emerging as the new treatment modality in this aspect.

STUDY DESIGN

 retrospective study.

STUDY SETTING

Department of Otorhinolaryngology in tertiary care hospital. 17 cases of juvenile recurrent parotitis (i.e. children of age group 3-11 years presenting with complaints of recurrent parotid region swelling and pain, sometimes associated with fever) were included in the study during October 2012-September 2015. All cases underwent sialendoscopy under general anaesthesia. Diagnostic (classifying the ductal lesion) and interventional sialendoscopic procedure (dilatation with instillation of steroid) were carried out in single sitting. Follow up was done for a minimum of 6 months (range 6-36 months). 17 patients with mean age of 5.6 years and gender distribution of 47:53 (boys:girls) underwent sialendoscopy for JRP. 8 patients presented with unilateral parotitis and 9 with bilateral. The mean number of attacks in previous 1 year were 9.2. Average time for procedure was 20 min. All cases had ductal stenosis and ductal mucosa was pale in 15 cases on endoscopy. 1 patient underwent repeat endoscopy after 2 years. 50% had complete resolution of symptoms and 6 patients had one mild (swelling not associated with fever which subsided on its own) attack after treatment. Follow up period ranged from 6 months to 3 years. No complications were observed. Sialendoscopy has emerged as a viable option for assessment and treatment of JRP. Dilatation of the parotid duct and steroid instillation has significantly reduced the morbidity of this condition.

Axillary tumour burden in women with a fine-needle aspiration/core biopsy-proven positive node on ultrasonography compared to women with a positive sentinel node

Background

The sensitivity of axillary ultrasonography (AUS) has increased in recent years, enabling detection of even low-volume axillary nodal metastases. The aim here was to evaluate the axillary tumour burden in women with a fine-needle aspiration/core biopsy-proven positive node on AUS and in those with a positive sentinel node biopsy (SNB).

Methods

This retrospective cohort study included all patients with early breast cancer who had AUS and axillary lymph node dissection (ALND) between 2011 and 2014.

Results

A total of 332 patients who had ALND were eligible for the study, 191 (57·5 per cent) in the AUS-positive group and 141 (42·5 per cent) in the SNB-positive group. Patients in the AUS-positive group were older at diagnosis (P = 0·018), more likely to have larger tumours (P = 0·002), higher tumour grade (P = 0·005), positive human epidermal growth factor 2 status (P = 0·015), and negative oestrogen receptor status (P &lt; 0·001). The AUS-positive group also had a larger number of lymph nodes with macrometastases (P &lt; 0·001) and were more likely to have extranodal invasion (P &lt; 0·001). In the AUS-positive group, 40·3 per cent of patients (77 of 191) had only one or two nodes with macrometastases identified at histology after ALND. Tumour size no larger than 20 mm, invasive ductal or lobular histology and breast-conserving surgery were associated with the presence of two or fewer macrometastases at ALND. Only tumour size and tumour histology remained significant in multiple logistic regression analysis.

Conclusion

Patients with AUS-detected metastases had a higher axillary tumour burden than those with SNB-detected metastases. Around 40 per cent of patients with AUS-detected nodal disease had one or two nodes with macrometastases and were thus overtreated by ALND.

Involvement of atrial natriuretic peptide in abrogated cardioprotective effect of ischemic preconditioning in ovariectomized rat heart

BACKGROUND

Nitric oxide (NO) is an effective mediator of ischemic preconditioning (IPC)-induced cardioprotection. Atrial natriuretic peptide (ANP) is downregulated after ovariectomy, which results in reduction in the level of NO. The present study deals with the investigation of the role of ANP in abrogated cardioprotective effect of IPC in the ovariectomized rat heart.

METHODS

Heart was isolated from ovariectomized rat and mounted on Langendorff's apparatus, subjected to 30 min of ischemia and 120 min of reperfusion. IPC was given by four cycles of 5 min of ischemia and 5 min of reperfusion with Krebs-Henseleit solution. The myocardial infract size was estimated employing triphenyltetrazolium chloride stain, and coronary effluent was analyzed for creatine kinase-MB (CK-MB) and lactate dehydrogenase (LDH) release to consider the degree of myocardial injury. The cardiac release of NO was estimated by measuring the level of nitrite in coronary effluent.

RESULTS

IPC-mediated cardioprotection was significantly attenuated in ovariectomized rat as compared to normal rat, which was restored by perfusion with ANP. However, this observed cardioprotection was significantly attenuated by perfusion with L-NAME, an endothelial nitric oxide synthase inhibitor, and Glibenclamide, a K_ATP channel blocker, alone or in combination noted in terms of increase in myocardial infract size, release of CK-MB and LDH, and also decrease in release of NO.

CONCLUSION

Thus, it is suggested that ANP restores the attenuated cardioprotective effect of IPC in the ovariectomized rat heart which may be due to increase in the availability of NO and consequent increase activation of mitochondrial K_ATP channels.

Abstract OT3-03-02: Maximising recruitment and retention of patients into UK-ANZ POSNOC trial

The success of a clinical trial is often dependant on whether recruitment targets can be met in the required time frame. Surgeons want to gather robust evidence but may experience considerable discomfort in relation to their clinical instincts and concerns about patient eligibility and safety. The ongoing POSNOC study design is pragmatic to maximise recruitment. A patient information DVD is used as an adjunct to patient information leaflet. The protocol allows for either axillary radiotherapy or axillary node clearance. Here we report recruitment and retention of participants into POSNOC, the associated barriers and challenges, and various strategies employed to overcome these barriers.

A total of 368 participants were recruited till May 2016. A total of 90%(331) of participants were recruited via non intra-operative pathway, and 10%(37) from intra-operative pathway. The most common known reasons for non-participation of eligible women were - woman wanting axillary treatment and clinician/MDT deciding woman needs axillary treatment. The mean randomisation yield from screening was 30% (range 6 to 100%). The highest recruiting sites were Derby, Manchester, Oxford, Belfast and Bristol.

The screening logs identified barriers as: fewer than estimated eligible women, clinicians not offering trial to all eligible patients and patient acceptability.

To reach recruitment targets in a timely fashion, a multifaceted approach is being employed. a) Protocol amendments to widen the inclusion criteria, b) 250 patients to be recruited by Australia and New Zealand sites, c) additional 50 sites to be opened in the UK, d) encourage OSNA centres to follow the non intra-operative pathway, e) communication workshops, f) POSNOC poster in breast units to raise awareness, g) questionnaire survey - sites to identify local issues and their perceptions about recruitment, h) social media - POSNOC WhatsApp group i) newsletters and briefings, j) competitions, k) tips to maximise recruitment document that includes a template script of one way to introduce the study l) regional telephone conferences for research nurses, m) investigator meeting.

The success of these strategies remains to be assessed and shall be reported separately.

Citation Format: Goyal A, Coleman RE, Dodwell D, Fallowfield L, Jenkins VA, Mann B, Reed MW, POSNOC Trial Management Group. Maximising recruitment and retention of patients into UK-ANZ POSNOC trial [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT3-03-02.