S2k guidelines (consensus statement) for diagnosis and therapy of dermatitis herpetiformis initiated by the European Academy of Dermatology and Venereology (EADV)

INTRODUCTION

Dermatitis herpetiformis (DH) is a chronic, pruritic, gluten-induced skin disorder characterized by subepidermal granular IgA deposition and a variable degree of enteropathy identical to that seen in coeliac disease. So far, there has been no European consensus about the management of DH.

METHODS

The guidelines were created by small subgroups of a guideline committee consisting of 26 specialists from various medical fields and one patients' representative. The members of the committee then discussed the guidelines and voted for the final version at two consensus meetings. The guidelines were developed under the support of the European Academy of Dermatology and Venereology (EADV) and in collaboration with the European Dermatology Forum (EDF).

RESULTS

The guidelines summarize evidence-based and expert-based recommendations (S2 level) for the management of DH (see Appendix).

CONCLUSION

These guidelines will improve the quality of management of DH and support dermatologists in their diagnostic and therapeutic decisions.

Differences in rapid increases in county-level COVID-19 incidence by implementation of statewide closures and mask mandates - United States, June 1-September 30, 2020

BACKGROUND AND OBJECTIVE

Community mitigation strategies could help reduce COVID-19 incidence, but there are few studies that explore associations nationally and by urbanicity. In a national county-level analysis, we examined the probability of being identified as a county with rapidly increasing COVID-19 incidence (rapid riser identification) during the summer of 2020 by implementation of mitigation policies prior to the summer, overall and by urbanicity.

METHODS

We analyzed county-level data on rapid riser identification during June 1-September 30, 2020 and statewide closures and statewide mask mandates starting March 19 (obtained from state government websites). Poisson regression models with robust standard error estimation were used to examine differences in the probability of rapid riser identification by implementation of mitigation policies (P-value< .05); associations were adjusted for county population size.

RESULTS

Counties in states that closed for 0-59 days were more likely to become a rapid riser county than those that closed for >59 days, particularly in nonmetropolitan areas. The probability of becoming a rapid riser county was 43% lower among counties that had statewide mask mandates at reopening (adjusted prevalence ratio = 0.57; 95% confidence intervals = 0.51-0.63); when stratified by urbanicity, associations were more pronounced in nonmetropolitan areas.

CONCLUSIONS

These results underscore the potential value of community mitigation strategies in limiting the COVID-19 spread, especially in nonmetropolitan areas.

Faire face au COVID-19, mise en place de novo d’une unité mutualisée « COVID-19 non réanimatoire » : organisation et résultats

Introduction

La pandémie à COVID-19 a touché presque tous les pays du monde, dont la France. Tous les départements français ont ouvert des unités dédiées pour la gestion de la phase aiguë de l’épidémie. Au sein de notre site, notre structure a été la seule à accueillir une unité pour gérer des patients confirmés COVID-19 positifs. En l’absence de soins intensifs sur place, ces patients étaient triés au SAU et ne venaient que les patients sans indication de soins intensifs en raison du bénéfice/risque attendu (âge, comorbidités). Pour activer cette unité, une équipe mutualisée a été mise en place que ce soit au niveau du personnel médical PM (seniors, internes, externes) que personnel non médical (PNM) détachés des services de médecine interne, pédiatrie, médecine du sport, consultation, endocrinologie, hépatologie de notre CHU. Un support psychologique a été proposé aux soignants et aux familles par une équipe mobile de psychiatrie. L’activité quotidienne a été réorganisée après la création de plusieurs binômes junior-senior, en service de 8 h à 19 h, 7 j/7. La continuité des soins a été assurée chaque jour par 3 staffs pour permettre respectivement les transmissions de la nuit entre PM et PNM ; l’état des lieux après la visite du matin ; les projets pour le lendemain. Tous les patients ont été réévalués chaque jour et réorientés selon une échelle de gravité structurée par 5 codes-couleurs. Les externes ont eu pour mission de contacter les familles du fait de la limitation des visites, ainsi que les médecins traitants afin d’améliorer la gestion après le RAD. Les patients ont été traités par oxygénothérapie et protocoles d’antibiothérapie et morphine.

Matériels et méthodes

Analyse descriptive des données personnelles, de la mortalité brute et des issues de l’hospitalisation.

Résultats

Entre le 13 mars et le 19 mai, 147 patients, 56 % d’eux de sexe féminin, ont été hospitalisés dans cette unité d’une capacité maximale de 25 lits. L’âge moyen était de 69 ans [18 ; 97]. La durée moyenne du séjour a été de 5 jours [0 : 29]. La mortalité totale était du 20,4 %, dont 51 % des patients sont rentrés vers leur domicile ou vers des EHPAD. Ensuite, 14,3 % des patients ont été transférés vers un autre service de médecine aiguë, et 12,2 % des patients a poursuit les soins dans un SSR.

Conclusion

L’organisation de ce service montre comme une équipe de PM et PNM avec fonds de travail différentes peut être rapidement mise en place pendant une période de crise. La présence d’un service dédié à la gestion des cas de COVID-19 sans indication à soins intensifs peut soulager des autres services au sein d‘un groupe hospitalier qui travaille en coordination. La mortalité des patients hospitalisés dans ce service reste baisse considérant les comorbidités et l’âge des patients. La durée courte du séjour a permis d’accueillir un grand nombre de patients et de garantir de places en médecine aiguë standard au sein du GH.

Functional Outcomes among a Cohort of Children in Northeastern Brazil Meeting Criteria for Follow-Up of Congenital Zika Virus Infection

Following the large outbreak of Zika virus in the Western Hemisphere, many infants have been born with congenital Zika virus infection. It is important to describe the functional outcomes seen with congenital infections to allow for their recognition and appropriate interventions. We evaluated 120 children conceived during the 2015-2016 Zika virus outbreak in Paraíba, Brazil, who were approximately 24 months old, to assess functional outcomes. All children met either anthropometric criteria or laboratory criteria suggestive of possible congenital Zika virus infection. We collected results of previous medical evaluations, interviewed parents, and performed physical examinations and functional assessments, for example, the Hammersmith Infant Neurological Examination (HINE). We compared patterns of neurologic outcomes and developmental delay at age 24 months by whether children met anthropometric or laboratory criteria, or both. Among children meeting both criteria, 60% (26/43) were multiply affected (had severe motor impairment, severe developmental delay, and suboptimal HINE scores), compared with 5% (3/57) meeting only laboratory criteria and none (0/20) meeting only anthropometric criteria. Of the remaining 91 children, 49% (45) had developmental delay, with more severe delay seen in children meeting both criteria. Although children meeting physical and laboratory criteria for potential congenital Zika virus infection were more severely affected, we did identify several children with notable adverse neurologic outcomes and developmental delay with no physical findings but potential laboratory evidence of Zika virus infection. Given this, all children who were potentially exposed in utero to Zika virus should be monitored in early childhood for deficits to allow for early intervention.

Adapting the Ages and Stages Questionnaire to Identify and Quantify Development Among Children With Evidence of Zika Infection

This article describes novel methods of applying the Ages and Stages Questionnaire-3rd edition (ASQ-3) to assess and quantify developmental delay among children following the 2015-2016 Zika virus outbreak in Brazil. Many of the children with Zika virus infection were expected to have severe developmental delay. However, administering the ASQ-3 to caregivers of these children according to standard protocol would have screened for the overall presence of delay but not the severity of delay. We adopted an amended protocol for administration of the ASQ-3 to quantify the developmental functioning of children severely affected by Zika virus infection in this investigation. Protocols for administering the ASQ-3 among this population were drafted in consultation with developmental measurement experts and are presented here. Specific developmental estimates are discussed, including developmental age equivalents, developmental quotients, and developmental quotient z scores. The calculations of these estimates are presented with examples in the context of the 2015-2016 Zika virus outbreak and associated microcephaly among prenatally infected children from 2 states in northeastern Brazil. Potential applications of these methods for estimating developmental ability among similar pediatric populations are discussed.

Size-dependent influence of NOx on the growth rates of organic aerosol particles

Atmospheric new-particle formation (NPF) affects climate by contributing to a large fraction of the cloud condensation nuclei (CCN). Highly oxygenated organic molecules (HOMs) drive the early particle growth and therefore substantially influence the survival of newly formed particles to CCN. Nitrogen oxide (NOx) is known to suppress the NPF driven by HOMs, but the underlying mechanism remains largely unclear. Here, we examine the response of particle growth to the changes of HOM formation caused by NOx. We show that NOx suppresses particle growth in general, but the suppression is rather nonuniform and size dependent, which can be quantitatively explained by the shifted HOM volatility after adding NOx. By illustrating how NOx affects the early growth of new particles, a critical step of CCN formation, our results help provide a refined assessment of the potential climatic effects caused by the diverse changes of NOx level in forest regions around the globe.

A Bayesian approach to sequential analysis in post-licensure vaccine safety surveillance

With rapid development of computing technology, Bayesian statistics have increasingly gained more attention in various areas of public health. However, the full potential of Bayesian sequential methods applied to vaccine safety surveillance has not yet been realized, despite acknowledged practical benefits and philosophical advantages of Bayesian statistics. In this paper, we describe how sequential analysis can be performed in a Bayesian paradigm in the field of vaccine safety. We compared the performance of the frequentist sequential method, specifically, Maximized Sequential Probability Ratio Test (MaxSPRT), and a Bayesian sequential method using simulations and a real world vaccine safety example. The performance is evaluated using three metrics: false positive rate, false negative rate, and average earliest time to signal. Depending on the background rate of adverse events, the Bayesian sequential method could significantly improve the false negative rate and decrease the earliest time to signal. We consider the proposed Bayesian sequential approach to be a promising alternative for vaccine safety surveillance.

Attenuation of oxidative stress in arthritic rats by ethanolic extract of Albizia procera benth bark through modulation of the expression of inflammatory cytokines

ETHNOPHARMACOLOGICAL RELEVANCE

Albizia procera L. (Leguminosae) commonly known as Konda vagai in Tamil, is used for the treatment of stomach and intestinal disorders. A decoction of the bark is prescribed for rheumatism and haemorrhage. Traditionally, literature claims Albizia procera as a drug to have antirheumatic properties and hence used by Tribal for the management of chronic rheumatism. Consequently, the present study has been undertaken to illustrate the beneficial outcome of Albizia procera in adjuvant induced arthritic rat model with respect to its antioxidant and anti-inflammatory activities.

AIM OF THE STUDY

The present study is aimed to investigate the oxidative stress and the expression of inflammatory markers in arthritic rats treated with ethanolic bark extract of Albizia procera.

MATERIALS AND METHODS

Ethanolic bark extract was characterized by HPTLC analysis. Acute oral toxicity study was performed according to the OECD test guideline 423 - Acute toxic class method. The anti-inflammatory effect of ETBE (100, 200 mg/kg/day/p.o.) was evaluated in complete Freund's adjuvant induced arthritic rats using diclofenac as positive control (0.3 mg/kg/day/p. o.). Plasma levels of interleukins TNF- α, IFN-α, IL-2, IL-6, myeloperoxidase and Cathepsin D levels were measured to assess the inflammatory effect of ETBE extract of Albizia procera. Further, the effect of ETBE on superoxide dismutase (SOD), glutathione peroxidase (GPX), reduced glutathione (GSH) and lipid peroxidation (LPO) were assessed in plasma.

RESULTS

HPTLC analysis showed the presence of 0.57% w/w of biochanin-A in ETBE. ETBE did not show any toxic signs up to 2000 mg/kg body weight. It exhibited the significant anti-inflammatory and antioxidant potential and did not show mortality up to 2000 mg/kg body weight. ETBE treatment significantly reduced the levels of TNF- α, IFN-α, IL-2, IL-6 and myeloperoxidase, and increased cathepsin D levels compared to vehicle treated animals. SOD, GSH and GPX levels were significantly restored to normal levels while LPO was significantly reduced at 200 mg/kg b. wt. Treated animals. Histopathological studies showed complete cartilage regeneration and near normal joint in ETBE treated arthritic rats.

CONCLUSION

ETBE demonstrated potent anti-inflammatory activity by modulating the expression of inflammatory cytokines and restoring the antioxidant enzyme levels.

[Pyogenic granuloma with satellitosis]

A 16-year-old female developed a satellite-like recurrence of a pyogenic granuloma on her thorax 2 weeks after complete excision. Treatment with a pulsed dye laser led to a complete resolution. BRAF and RAS mutations detected in the pyogenic granuloma are considered major driver mutations. Whether these findings are also of importance for the etiopathogenesis of satellitosis is unknown. In our patient, no BRAF or NRAS mutation could be detected.

[Granulomatous reaction pattern of the skin : Interstitial granulomatous dermatitis - lymphoma - vasculitis]

A particular diagnostic situation in the classification of a granulomatous dermatitis results when no circumscribed granulomas but instead a diffuse interstitial histiocytic inflammatory infiltrate, a granulomatous vasculitis or a neoplastic lymphocytic infiltrate is found. Interstitial granulomatous dermatitis was originally described in patients with arthritis. Later, it was recognized that there are also associations with other usually immunological diseases. Differentiating between interstitial granulomatous dermatitis and the interstitial form of granuloma annulare, early morphea and variants of borreliosis or scleromyxedema as well as interstitial granulomatous drug reaction can be very difficult. In long-standing cutaneous granulomatous infiltrates, T‑cell lymphoma should be excluded. Occasionally only a small number of atypical lymphocytes can be found. The detection of a monoclonal T‑cell expansion is then particularly helpful. Only recently, a CD8-positive granulomatous cutaneous T‑cell lymphoma was described which occurred in patients with immunodeficiencies. A granulomatous vasculitis in the skin is extremely rare. According to the Chapel Hill classification from 2012, systemic granulomatous vasculitis is equated with giant cell arteritis. Extracutaneous large arteries are involved. On rare occasions, involvement of the temporal artery can result in skin necrosis. More commonly granulomatous infiltrates in combination with vasculitis can be observed, whereby various infectious diseases, sarcoidosis and nodular vasculitis should be considered. Granulomatosis with polyangiitis (formerly Wegener's granulomatosis), presents in the skin as leukocytoclastic vasculitis. Here granulomas are extremely rare.

Folate and Vitamin B12 Status in Women of Reproductive Age in Rural Areas in Haryana, Northern India (P10-117-19)

Objectives

To conduct a household and biomarker survey to assess the baseline prevalence of folate deficiency and insufficiency and vitamin B12 deficiency in women of reproductive age prior to the start of a wheat flour fortification program in the Ambala District in Haryana, India.

Methods

A multistage cluster probability household and biomarker survey was conducted. Participants were women of reproductive age (18–49 y) who were not pregnant and resided in rural areas of two subdistricts in Ambala District in Haryana. Venous blood samples were collected among 866 women. Plasma, serum, and red blood cells (RBC) were separated by centrifugation, processed, and stored at <-80ºC until analysis. RBC and serum folate concentrations were measured using microbiologic assay and serum vitamin B12 was measured via chemiluminescence. Serum folate deficiency was defined as serum folate <7 nmol/L and RBC folate deficiency and insufficiency were defined as RBC folate <305 nmol/L and <748 nmol/L, respectively. Vitamin B12 deficiency was defined as vitamin B12 <200 pg/mL and vitamin B12 marginal deficiency was defined as vitamin B12 ≥200 and <300 pg/mL.

Results

The geometric mean concentrations for serum folate, RBC folate, and serum vitamin B12 were 12.3 (95% confidence interval [CI]: 11.8, 12.9) nmol/L, 544 (95% CI: 516, 573) nmol/L, and 190 (95% CI: 176, 206) pg/mL, respectively. The prevalence of folate deficiency was 11.3% (95% CI: 9.2, 13.9) for serum folate and 9.7% (95% CI: 7.8, 12.0) for RBC folate, and the prevalence of RBC folate insufficiency was 78.6% (95% CI: 74.8, 82.5). A total of 58.3% (95% CI: 54.2, 62.5) of women were vitamin B12 deficient (<200 pg/mL) and an additional 22.9% (95% CI: 19.7, 26.1) were marginally deficient for vitamin B12.

Conclusions

The magnitude of folate insufficiency and vitamin B12 deficiency in this Northern Indian population is a substantial public health concern. The findings from the survey help establish the baseline for a planned wheat flour fortification program aimed at reducing these micronutrient deficiencies.

Funding Sources

Centers for Disease Control and Prevention.

Lower serum adiponectin level is associated with lipodystrophy among HIV-infected men in the Study to Understand the Natural History of HIV/AIDS in the Era of Effective Therapy (SUN) study

OBJECTIVES

Adiponectin levels are inversely related to cardiovascular risk and are low in diabetics and obese persons. We examined the association between adiponectin concentration and HIV-associated lipodystrophy, which remains unclear.

METHODS

The Study to Understand the Natural History of HIV/AIDS in the Era of Effective Therapy (SUN) was a prospective cohort study of HIV-infected adults conducted in four US cities. Lean body and fat masses were assessed using dual-energy X-ray absorptiometry scans. Using baseline data from 2004 to 2006, we defined lipodystrophy using a sex-specific fat mass ratio and performed cross-sectional analyses of associated risks using multivariable logistic regression.

RESULTS

Among 440 male participants (median age 42 years; 68% non-Hispanic white; 88% prescribed combination antiretroviral therapy; median CD4 lymphocyte count 468 cells/μL; 76% with viral load < 400 HIV-1 RNA copies/mL; 5% diabetic; median body mass index 25 kg/m² ), median concentrations of leptin and adiponectin were 3.04 ng/L [interquartile range (IQR) 1.77-5.43 ng/L] and 8005 μg/mL (IQR 4950-11 935 μg/mL), respectively. The prevalence of lipodystrophy was 14%. Lipodystrophy was significantly associated with increasing age [prevalence ratio (PR) 1.50; 95% confidence interval (CI) 1.10-2.06, per 10 years], adiponectin < 8005 μg/mL (PR 5.02; 95% CI 2.53-9.95), ever stavudine use (PR 2.26; 95% CI 1.36-3.75), CD4 cell count > 500 cells/μL (PR 2.59; 95% CI 1.46-4.61), viral load < 400 copies/mL (PR 3.98; 95% CI 1.25-12.6), highly sensitive C-reactive protein < 1.61 mg/L (PR 1.91; 95% CI 1.11-3.28) and smoking (PR 0.42; 95% CI 0.22-0.78).

CONCLUSIONS

Among men in this HIV-infected cohort, the prevalence of lipodystrophy was similar to previous estimates for persons living with HIV, and was associated with lower adiponectin levels, potentially indicating increased cardiovascular disease risk.

Abstract P2-08-26: High expression of CYP27A1 in breast cancer is associated with poor tumor pathological features and may differentially predict prognosis depending on menopausal status

Background: Pre-clinical and epidemiological data strongly link high cholesterol with breast cancer progression and poor prognosis. It was recently uncovered that the pathogenicity of cholesterol in breast cancer is directly propagated by 27-hydroxycholesterol (27HC), an oxysterol produced when cholesterol is hydroxylated by cytochrome P450, family 27, subfamily A, polypeptide 1 (CYP27A1) during bile acid synthesis. 27HC promotes breast tumor growth and metastasis via interactions with the estrogen receptor (ER) and liver x receptors respectively. Consequently, pharmaceutical approaches that directly interfere with CYP27A1 activity have been proposed to mitigate the adverse impact of 27HC in breast cancer. However, CYP27A1 expression or deregulation in clinical breast cancer is not well characterised. The aim of this study was to comprehensively describe the impact of tumor-specific expression of CYP27A1 protein on clinical breast cancer pathobiology and prognosis.

Methods: CYP27A1 expression in tumor cells was evaluated by immunohistochemistry in two independent population based cohorts including female patients with primary invasive breast cancer diagnosed between 1991 and 2010 (cohort 1) and between 2002 and 2012 (cohort 2). Staining was evaluable in 645 and 813 cases in cohort 1 and cohort 2, respectively. Associations between CYP27A1 expression with tumor pathological factors and survival were assessed by using logistic and Cox regression models respectively. Multivariable models adjusted for age at diagnosis, nodal status, histological grade, tumor size, ER and BMI.

Results: CYP27A1 was overexpressed in 21% and 28% in cohort 1 and cohort 2 respectively. High CYP27A1 expression was significantly associated with adverse tumor pathological features including negative hormone receptor (ER and PgR) status and histological grade 3 in both cohorts and with larger tumors (&gt;20 mm) in cohort two only (p&lt;0.05, for all comparisons). In multivariable Cox regression analyses, overexpression of CYP27A1 was neither independently prognostic for recurrence-free survival (cohort 2: HR=1.3, 95% CI= 0.88 – 1.9) nor overall survival (cohort 1: HR=1.3, 95% CI= 0.88 – 1.9 and Cohort 2: HR=1.3, 95% CI= 0.81 – 2.0, respectively). Upon stratification for menopausal status using age at diagnosis (&lt; 50 years vs ≥ 50 years) as surrogate, the relationship between CYP27A1 expression and prognosis remained non-significant for older (postmenopausal) patients. Interestingly, among younger (premenopausal) women, elevated CYP27A1 expression was independently prognostic for shorter time to recurrence or death (HR=3.3, 95% CI= 1.5 – 7.4; cohort 2).

Conclusions: Collectively, these results indicate that intratumoral CYP27A1 expression supports the notion that 27HC plays an important pathological role in breast cancer progression but tumor cell-specific CYP27A1 expression is not sufficient to independently predict overall survival in postmenopausal patients. Further sufficiently sized studies are needed to clarify the prognostic significance of CYP27A1 in younger and presumably premenopausal patients and evaluate its role as a treatment predictive factor.

Citation Format: Kimbung S, Stålhammar T, Inasu M, Nodin B, Elebro K, Tryggvadottir H, Jirström K, Rose C, Ingvar C, Jernström H, Borgquist S. High expression of CYP27A1 in breast cancer is associated with poor tumor pathological features and may differentially predict prognosis depending on menopausal status [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 P2-08-26.

"Just too busy living in the moment and surviving": barriers to accessing health care for structurally vulnerable populations at end-of-life

BACKGROUND

Despite access to quality care at the end-of-life (EOL) being considered a human right, it is not equitable, with many facing significant barriers. Most research examines access to EOL care for homogenous 'normative' populations, and as a result, the experiences of those with differing social positioning remain unheard. For example, populations experiencing structural vulnerability, who are situated along the lower rungs of social hierarchies of power (e.g., poor, homeless) will have unique EOL care needs and face unique barriers when accessing care. However, little research examines these barriers for people experiencing life-limiting illnesses and structural vulnerabilities. The purpose of this study was to identify barriers to accessing care among structurally vulnerable people at EOL.

METHODS

Ethnography informed by the critical theoretical perspectives of equity and social justice was employed. This research drew on 30 months of ethnographic data collection (i.e., observations, interviews) with structurally vulnerable people, their support persons, and service providers. Three hundred hours of observation were conducted in homes, shelters, transitional housing units, community-based service centres, on the street, and at health care appointments. The constant comparative method was used with data collection and analysis occurring concurrently.

RESULTS

Five significant barriers to accessing care at EOL were identified, namely: (1) The survival imperative; (2) The normalization of dying; (3) The problem of identification; (4) Professional risk and safety management; and (5) The cracks of a 'silo-ed' care system. Together, findings unveil inequities in accessing care at EOL and emphasize how those who do not fit the 'normative' palliative-patient population type, for whom palliative care programs and policies are currently built, face significant access barriers.

CONCLUSIONS

Findings contribute a nuanced understanding of the needs of and barriers experienced by those who are both structurally vulnerable and facing a life-limiting illness. Such insights make visible gaps in service provision and provide information for service providers, and policy decision-makers alike, on ways to enhance the equitable provision of EOL care for all populations.

A Dosimetric Comparison of Breast Radiotherapy Techniques to Treat Locoregional Lymph Nodes Including the Internal Mammary Chain

AIMS

Radiotherapy target volumes in early breast cancer treatment increasingly include the internal mammary chain (IMC). In order to maximise survival benefits of IMC radiotherapy, doses to the heart and lung should be minimised. This dosimetry study compared the ability of three-dimensional conformal radiotherapy, arc therapy and proton beam therapy (PBT) techniques with and without breath-hold to achieve target volume constraints while minimising dose to organs at risk (OARs).

MATERIALS AND METHODS

In 14 patients' datasets, seven IMC radiotherapy techniques were compared: wide tangent (WT) three-dimensional conformal radiotherapy, volumetric-modulated arc therapy (VMAT) and PBT, each in voluntary deep inspiratory breath-hold (vDIBH) and free breathing (FB), and tomotherapy in FB only. Target volume coverage and OAR doses were measured for each technique. These were compared using a one-way ANOVA with all pairwise comparisons tested using Bonferroni's multiple comparisons test, with adjusted P-values ≤ 0.05 indicating statistical significance.

RESULTS

One hundred per cent of WT(vDIBH), 43% of WT(FB), 100% of VMAT(vDIBH), 86% of VMAT(FB), 100% of tomotherapy FB and 100% of PBT plans in vDIBH and FB passed all mandatory constraints. However, coverage of the IMC with 90% of the prescribed dose was significantly better than all other techniques using VMAT(vDIBH), PBT(vDIBH) and PBT(FB) (mean IMC coverage ± 1 standard deviation = 96.0% ± 4.3, 99.8% ± 0.3 and 99.0% ± 0.2, respectively). The mean heart dose was significantly reduced in vDIBH compared with FB for both the WT (P < 0.0001) and VMAT (P < 0.0001) techniques. There was no advantage in target volume coverage or OAR doses for PBT(vDIBH) compared with PBT(FB).

CONCLUSIONS

Simple WT radiotherapy delivered in vDIBH achieves satisfactory coverage of the IMC while meeting heart and lung dose constraints. However, where higher isodose coverage is required, VMAT(vDIBH) is the optimal photon technique. The lowest OAR doses are achieved by PBT, in which the use of vDIBH does not improve dose statistics.

Stenosis at the area of Transposition – An Under-Recognized Complication of Transposed Brachiobasilic Fistulas

Background

With an increased focus on native AV fistula creation in hemodialysis patients, a transposed brachiobasilic fistula (tBBF) is becoming an increasingly utilized option. This study describes the outcomes of tBBFs in a chronic hemodialysis population. In particular, we focus on the incidence and location of stenosis, and review the impact of angioplasty on these lesions.

Methods

A retrospective cohort study using all patients with a tBBF created between January 2001 and December 2004.

Results

Of the 543 fistulas created during the study period, 93 were tBBFs. The mean age of patients was 65 years, 56% were male and 55% were diabetic. Stenosis occurred in 54% (46/85) of fistulas; the location of stenosis in the majority (74%) was at or near the area of basilic vein transposition and 50% of fistulas with stenosis in this location required three or more angioplasties. Primary (unassisted) patency was 42% at one year in this cohort. Secondary patency was 68% at 1 year and 58% and 53% at 2 and 3 years respectively.

Conclusion

In a cohort of hemodialysis patients who received a tBBF, we describe a reasonable primary and secondary patency rate and a high rate of stenosis at the point of transposition of the basilic vein. Such stenosis usually requires multiple percutaneous or surgical interventions to ensure or reestablish conduit patency. Further study is required regarding the optimal surgical technique, monitoring, and treatment of stenosis of this fistula type including the utility of repeat angioplasty.