Currently recommended BK virus (BKV) plasma viral load cutoff of ≥4 log10/mL underestimates the diagnosis of BKV-associated nephropathy: a single transplant center experience

BACKGROUND

BK virus (BKV)-associated nephropathy (BKVAN) is a major cause of renal dysfunction and graft loss in renal transplant recipients. Monitoring plasma BK viral load (BKVL) is the recommended screening tool to predict BKVAN. American Society of Transplantation (AST) guidelines define a BKVL of ≥4 log10/mL (10,000 copies) as presumptive BKVAN and recommend reduction in immunosuppression. We evaluated the clinical sensitivity of the quantitative BKV DNA assay in predicting risk for BKVAN using the AST-recommended BKVL cutoff.

METHODS

In a retrospective, single-center study, all patients who underwent renal transplant at Henry Ford Hospital from January 2008 to August 2011 were analyzed (n = 490). Plasma BKVL Assay A (commercial large T antigen-based polymerase chain reaction [PCR]) was done in all patients. Renal biopsy was done if there was a rise in serum creatinine ≥0.5 mg from baseline. BKVAN was confirmed by biopsy. As a subset to this study, from the same cohort, data for a set of 20 consecutive Assays A and B (in-house VP1-based PCR assay) from 15 patients over a period of 3 months were collected. Differences in physicians' clinical decision-making (CDM) were analyzed between the 2 assays using chi-square test.

RESULTS

A total of 413 patients met the inclusion criteria, of which 222 patients had BK viremia. Among the 248 patients who had a renal biopsy done, 31 (12.5%) were found to have BKVAN. Eleven of the 31 (35%) patients had BKVL consistently <4 log10/mL, and thus were not diagnosed to have BKVAN using the AST-recommended BKVL cutoff of ≥4 log10/mL. A total of 8 patients lost their graft owing to BKVAN, including 3 patients with BKVL <4 log10/mL. Using a cutoff point of plasma BKVL of ≥4 log10/mL, the sensitivity, specificity, positive predictive value, and negative predicative value of the PCR Assay A for the diagnosis of biopsy-proven BKVAN were 64.5%, 98.4%, 87.0%, and 94.5%, respectively, and for the diagnosis of presumptive nephropathy were found to be 76.6%, 99.4%, 95.8%, and 96.4%, respectively. In the second part of the study, presumptive nephropathy was detected in 8 samples using Assay A and 14 samples using Assay B. Six samples in Assay A would have led to no changes in the CDM in terms of reduction in immunosuppression. Kidney biopsy was carried out in 5 patients, 4 of whom had BKVAN and had Assay B log count of ≥5. If Assay A had been used in CDM, BKVAN would have been missed in 1 patient.

CONCLUSION

Utilizing the current AST guideline cutoff of ≥4 log10 /mL, the PCR Assay A underestimated the diagnosis of BKVAN. Urgent standardization of the various BKVL assays and establishment of universal cutoff points is imperative to avoid BKVAN-related graft loss.

Cost-effectiveness of systemic therapies for metastatic pancreatic cancer

PURPOSE

Gemcitabine and capecitabine (gem-cap), gemcitabine and erlotinib (gem-e), and folfirinox (5-fluorouracil-leucovorin-irinotecan-oxaliplatin) are new treatment options for metastatic pancreatic cancer, but they are also more expensive and potentially more toxic than gemcitabine alone (gem). We conducted a cost-effectiveness analysis of these treatment options compared with gem.

METHODS

A Markov model was constructed to examine costs and outcomes of gem-cap, gem-e, folfirinox, and gem in patients with metastatic pancreatic cancer from the perspective of a government health care plan. Ontario health economic and costing data (2010 Canadian dollars) were used. Efficacy data for the treatments were obtained from the published literature. Resource utilization data were derived from a chart review of consecutive metastatic patients treated for pancreatic cancer at Princess Margaret Hospital, Toronto, Ontario, 2008-2009, and supplemented with data from the literature. Utilities were obtained by surveying medical oncologists across Canada using the EQ-5D. Incremental cost-effectiveness ratios (icers) were calculated.

RESULTS

The icers for gem-cap, gem-e, and folfirinox compared with gem were, respectively, CA$84,299, CA$153,631, and CA$133,184 per quality-adjusted life year (qaly). The model was driven mostly by drug acquisition costs. Given a willingness-to-pay (wtp) threshold greater than CA$130,000/qaly, folfirinox was most cost-effective treatment. When the wtp threshold was less than CA$80,000/qaly, gem alone was most cost-effective. The gem-e option was dominated by the other treatments.

CONCLUSIONS

The most cost-effective treatment for metastatic pancreatic cancer depends on the societal wtp threshold. If the societal wtp threshold were to be relatively high or if drug costs were to be substantially reduced, folfirinox might be cost-effective.

Somatic copy-neutral loss of heterozygosity and copy number abnormalities in Malaysian sporadic colorectal carcinoma patients

Colorectal cancer is one of the most common cancers in many countries, including Malaysia. The accumulation of genomic alterations is an important feature of colorectal carcinogenesis. A better understanding of the molecular events underlying the stages of colorectal carcinogenesis might be helpful in the detection and management of the disease. We used a commercially available single-nucleotide polymorphism genotyping array to detect both copy number abnormalities (CNAs) and copy-neutral loss of heterozygosity (LOH) in sporadic colorectal carcinomas. Matched tumor and normal tissues of 13 colorectal carcinomas (Dukes' stages A-D) were analyzed using a 250K single nucleotide polymorphism array. An additional assay was performed to determine the microsatellite instability status by using the National Cancer Institute-recommended BAT-26 panel. In general, copy number gain (92.3%) was most common, followed by copy number loss (53.8%) and copy-neutral LOH (46.2%). Frequent CNAs of gains and losses were observed on chromosomes 7p, 8, 13q, 17p, 18q, and 20q, and copy-neutral LOH was observed on chromosomes 2, 6, 12, 13q, 14q, 17, 20p, 19q, and 22q. Even though genomic alterations are associated with colorectal cancer progression, our results showed that DNA CNAs and copy-neutral LOH do not reflect disease progression in at least 50% tumors. Copy-neutral LOH was observed in both early and advanced tumors, which favors the involvement of these genomic alterations in the early stages of tumor development.

Review of oesophageal atresia and tracheoesophageal fistula in hospital sultanah bahiyah, alor star. Malaysia from january 2000 to december 2009

Oesophageal atresia (EA) and tracheoesophageal fistula (TEF) is one of the congenital anomaly occurring in the newborns with the incidence of 1 in 2500 births seen worldwide. A retrospective review of newborns admitted to Hospital Sultanah Bahiyah (HSB) from 1st January 2000 to 31st December 2009 was done. The objective was to look at the influence of birth weight, time of surgical intervention, presence of other congenital anomaly and presence of preoperative pneumonia to the immediate outcome (mortality) of the surgery. There were 47 patients with oesophageal atresia, out of which 26 (55%) were males and 21 (45%) females. The distribution of patients by race were 34 Malays (72%), 9 Chinese (19%) and 4 Indians (9%). The birth weight of the babies range from 0.8 kg to 4.0 kg and there was a significant association with the outcome of the surgery (p< 0.05). Most of the babies (20) were operated within 24 hours of presentation but there was no significant association to the outcome. 23 (49%) of them were born with congenital malformation and there was a significant association with the outcome of the surgery (p<0.05). Based on the chest roentgenogram, 20 (43%) of them had pneumonia with significant association with the outcome (p<0.05). The mortality rate is 23% and the causes of death were pneumonia (36%), renal failure (18%), cardiac malformation (18%) and multiple congenital malformations (28%). The outcome of EA and TEF is determined mainly by birth weight, congenital malformations and presence of preoperative pneumonia in HSB.

Public health surveillance at a mass gathering: urs of Baba Farid, Pakpattan district, Punjab, Pakistan, December 2010

The objective of this study was to identify health related problems encountered during an annual mass gathering in Pakpattan, Pakistan, the anniversary of the death (urs) of Baba Farid, and to make recommendations for planning and prevention activities. A surveillance system was established to capture health related data for the event. A list of reportable diseases was developed. Data were collected pre-, during, and post-event by health care workers trained for the purpose. A total of 5918 people reported to the 15 health care facilities providing services during the event; 58% of consultations were because of communicable diseases, 21% of which were respiratory tract infections and 26% gastrointestinal illness. Injuries accounted for 31% of cases and noncommunicable diseases for 11%. Prevalence of reportable disease during the event showed sizeable increases. No major disease outbreak was observed.

Association between Serum 25 (OH) Vitamin D Concentrations and Inflammatory Bowel Diseases (IBDs) Activity

Inflammatory bowel diseases (IBDs) are immune mediated diseases affecting the gastrointestinal tract. Several environmental factors in concert with genetic susceptibilities can trigger IBDs. Recently, one of the important environmental factors contributing to the development of autoimmune diseases is vitamin D (VitD) deficiency. Furthermore, some new evidence points to VitD deficiency and its receptor dysfunction as an underlying factor for the emergence experimental IBDs. The aim of the current study was to evaluate the correlation between serum 25(OH)D concentrations and IBD activity in patients with ulcerative colitis or Crohn's disease. Sixty patients with confirmed diagnosis of IBD were recruited for a cross sectional study. Most of the identified confounders affecting serum VitD concentrations were excluded. Disease activity was assessed using validated questionnaires, including Truelove for Ulcerative Colitis and Crohn Disease Activity Index (CDAI) for Crohn disease. Serum 25(OH)D concentrations were determined by chemiluminescent assay. Serum 25(OH)D≤10 (ng/ml) was considered as VitD deficiency and 11≤25(OH)D<29(ng/ml) as VitD insufficiency. Mean serum 25(OH)D value was 13.1 ± 11.1(ng/ml) in IBD patients. Almost 95% of patients were vitamin D insufficient or deficient. Forty one percent of IBD patients had active disease. VitD deficiency was not associated with IBD activity (p=0.23). However, VitD deficiency was significantly associated with a history of IBD related intestinal surgery (p=0.001). In conclusion, this cross-sectional prospective study suggested that there is no association between vitamin D deficiency and disease activity in a relatively small number of IBD patients in a short period of time.

Congenital von Willebrand's disease and clinical hypothyroidism

Data from case reports and systematic reviews suggest an association of Hypothyroidism and Acquired von Willebrand's syndrome. It is not known if congenital von Willebrand's disease is associated with hypothyroidism in a similar way. The aim of this study was to identify the association of congenital von Willebrand's disease (VWD) with clinical hypothyroidism. A total of 350 cases of congenital VWD were initially screened from our institution database from 1985 to 2010. A careful review of patient records was carried out to see if patients truly had congenital VWD and coexisting clinical hypothyroidism. Patients with uncertain diagnoses or other bleeding disorders were excluded, leading to 197 patients remaining in the final sample. A random age- and sex-matched parallel control group was also obtained from the hospital database. Of 197 patients (mean age 43.8 ± 17.5 years, women 72%) of congenital VWD, 32/197 (16%) were diagnosed with clinical hypothyroidism, while only 11/197 (5.6%) of the matched controls were clinically hypothyroid. Univariate and multivariate analysis demonstrated that VWD was an independent predictor of developing clinical hypothyroidism (OR 3.45; 95% CI 1.65-7.22, P = 0.001). The proportion of patients diagnosed with clinical hypothyroidism was more in the VWD group (P < 0.0001). Our analysis shows a strong association of clinical hypothyroidism in patients with congenital VWD, but future studies will be required to delineate a pathological mechanism. In our opinion, clinicians should consider checking thyroid function in the newly diagnosed and established cases of congenital VWD.

Accessory gallbladder: a new anatomical variation arising from both left and right hepatic ducts

We present a case of accessory gallbladder demonstrating an anatomical variation not previously reported. While rare, accessory gallbladders are an important consideration if a cholecystectomy is to be performed. We also present a brief literature review of accessory gallbladders.

Anoxia-induced release of colloid- and nanoparticle-bound phosphorus in grassland soils

Particle-facilitated transport is a key mechanism of phosphorus (P) loss in agroecosystems. We assessed contributions of colloid- and nanoparticle-bound P (nPP; 1-415 nm) to total P released from grassland soils receiving biannual poultry litter applications since 1995. In laboratory incubations, soils were subjected to 7 days of anoxic conditions or equilibrated at pH 6 and 8 under oxic conditions and then the extract was size fractionated by differential centrifugation/ultrafiltration for analysis of P, Al, Fe, Si, Ti, and Ca. Selected samples were characterized by transmission electron microscopy-energy dispersive spectroscopy (TEM-EDS) and field flow fractionation (FFF-ICP-MS). Particles released were present as nanoaggregates with a mean diameter of 200-250 nm, composed of ~50-nm aluminosilicate flakes studded with Fe and Ti-rich clusters (<10 nm) that contained most of the P detected by EDS. Anoxic incubation of stimulated nPP release with seasonally saturated soils released more nPP and Fe(2+)(aq) than well-drained soils; whereas, nonreductive particle dispersion, accomplished by raising the pH, yielded no increase in nPP release. This suggests Fe acts as a cementing agent, binding to the bulk soil P-bearing colloids that can be released during reducing conditions. Furthermore, it suggests prior periodic exposure to anoxic conditions increases susceptibility to redox-induced P mobilization.

Is there a need for early post-operative x-rays in primary total knee replacements? Experience of a centre in the UK

INTRODUCTION

Early post-operative x-rays are often taken in total knee replacements (TKRs). Patient mobilisation may be delayed until these x-rays are obtained and this may prolong discharge. The aim of this study was to assess the value of such early x-rays and whether they influenced the early post-operative management of these patients.

METHODS

A total of 624 consecutive TKRs performed at the Blackpool Victoria Hospital over a 34-month period were evaluated. Plain anteroposterior and lateral x-rays were examined.

RESULTS

Two patients were found to have significant abnormalities: an undisplaced periprosthetic tibial fracture and a partial inferior pole patellar avulsion. Neither of these required further treatment or influenced mobility. No other complications were noted that changed routine post-operative management.

CONCLUSIONS

These results question the need for immediate x-rays in primary TKRs.

Vitamin D status in relation to postural stability in the elderly

OBJECTIVES

Postural instability (PI) is an important risk factor for falls, especially in the frail older population. In this study, we investigated the impact of vitamin D deficiency on PI in a sample of community dwelling older subjects. Our objective was to determine the potential association between vitamin D deficiency and PI in older fallers.

DESIGN

Cross-sectional study.

SETTING

Falls and Fractures Clinic, Department of Geriatric Medicine, Nepean Hospital, Penrith, Australia.

PARTICIPANTS

One hundred and forty-five adults aged 65 years and older who have had at least one episode of a fall within the six months prior to assessment at the Falls and Fractures Clinic.

MEASUREMENTS

Serum 25(OH) vitamin D3 [25(OH)D3] and parathyroid hormone concentrations were determined at baseline. Subjects were separated into 3 groups based on serum 25(OH)D3 levels with the following cut-off values: < 30 nmol/L (deficient), 30-50 nmol/L (insufficient) and > 50 nmol/L (normal). Other baseline measurements included body mass index, mini-nutritional assessment, grip strength, serum calcium concentration and creatinine clearance, which were used as covariables. PI was assessed using a computerized virtual reality system (Medicaa, Uruguay). Measured parameters included limits of stability (LOS) and centre of pressure (COP) under eyes closed on foam (ECF) and visio-vestibular stimulation. The estimated swaying area, computed from the ellipse of confidence under eyes closed standing on foam (ECF), was also used as a PI parameter. Gait velocity (GV) was measured using a GaitRITE walkway system.

RESULTS

Posture was impaired in vitamin D deficiency (<30 nmol/L) as indicated by lower LOS (90 +/- 18), higher ECF (25 +/- 10) and slower GV (55 +/- 7) as compared with the insufficient and normal groups. After adjustment for demographic, biochemical and anthropometric variables, vitamin D deficiency significantly correlated with low LOS and high COP under ECF.

CONCLUSION

Low levels of vitamin D were associated with PI. This association could also have an effect on slow GV and increased risk of falls. In conclusion, using an objective method to measure balance in older fallers we have identified a novel role of vitamin D in balance control. Prospective studies are required to confirm the effect of vitamin D on PI and elucidate the mechanisms of this association.

Sex variations in the structure of human atrioventricular annuli

Atrioventricular annuli are important in haemodynamic flexibility, competence, and support for tricuspid and mitral valves. The anatomical features of the annuli, such as circumference, organisation of connective tissue fibres, myocardium, and cellularity, may predispose to annular insufficiency and valvular incompetence. These pathologies occur more commonly in females, although the anatomical basis for this disparity is unclear. Sex variation in the structure of the annuli is important in providing a morphological basis for the patterns of these diseases. This study therefore aimed to determine the sex variations in the structure of human atrioventricular annuli. One hundred and one hearts (48 males, 53 females) obtained from the Department of Human Anatomy of the University of Nairobi were studied. Annular circumferences were measured using a flexible ruler and corrected for heart weight. Results were analysed using SPSS version 17.0 and sex differences determined using student's t-test. A p-value of less than 0.05 was considered significant. For light microscopy, specimens were harvested within 48 hours post-mortem, processed, sectioned, and stained with Masson's trichrome and Weigert's elastic stain with van Gieson counterstaining. Females had significantly larger annular circumferences than males after correcting for heart weight (p ≤ 0.05). Histologically, myocardium was consistently present in all male annuli while this was absent in females except in one specimen. The annuli were more elastic and cellular in males especially in the annulo-myocardial and annulo-valvular zones, respectively. The corrected larger annular circumference in females may limit heart valve coaptation during cardiac cycle and may be a risk factor for valvular insufficiency. The predominance of myocardium, annular cellularity, and elasticity may be more protective against heart valve incompetence in males than in females.

Sternal foramina and variant xiphoid morphology in a Kenyan population

Sternal foramina may pose a great hazard during sternal puncture, due to inadvertent cardiac or great vessel injury. They can also be misinterpreted as osteolytic lesions in cross-sectional imaging of the sternum. On the other hand, variant xiphoid morphology such as bifid, duplicated, or trifurcated may be mistaken for fractures during imaging. The distribution of these anomalies differs between populations, but data from Africans is scarcely reported. This study therefore aimed to investigate the distribution and frequency of sternal foramina and variant xiphoid morphology in a Kenyan population. Eighty formalin-fixed adult sterna (42 males [M], 38 females [F]) of age range 18-45 years were studied during dissection at the Department of Human Anatomy, University of Nairobi. Soft tissues were removed from the macerated sterna by blunt dissection and foramina recorded in the manubrium, body, and xiphoid process. The xiphisternal ending was classified as single, bifurcated (2 xiphoid processes with a common stem), or duplicated (2 xiphoid processes with separate stems). Results were analysed using SPSS version 17.0. Foramina were present in 11 specimens (13.8%): 7 M, 4 F. The highest frequency was in the sternal body (n = 9), where they predominantly occurred at the 5th intercostal segment. Xiphoid foramina were present in 2 specimens (both males) (2.5%), while manubrial foramen was not encountered. The xiphisternum ended as a single process in 64 cases (34 M, 30 F) (80%). It bifurcated in 10 cases (5 M, 5 F) (12.5%), and duplicated in 6 cases (4 M, 2 F) (7.5%). There were no cases of trifurcation. Sternal foramina in Kenyans vary in distribution and show higher frequency than in other populations. These variations may complicate sternal puncture, and due caution is recommended. The variant xiphisternal morphology may raise alarm for xiphoid fractures and may therefore be considered a differential.

Conventional versus hypofractionated high-dose intensity-modulated radiotherapy for prostate cancer: preliminary safety results from the CHHiP randomised controlled trial

BACKGROUND

Prostate cancer might have high radiation-fraction sensitivity, implying a therapeutic advantage of hypofractionated treatment. We present a pre-planned preliminary safety analysis of side-effects in stages 1 and 2 of a randomised trial comparing standard and hypofractionated radiotherapy.

METHODS

We did a multicentre, randomised study and recruited men with localised prostate cancer between Oct 18, 2002, and Aug 12, 2006, at 11 UK centres. Patients were randomly assigned in a 1:1:1 ratio to receive conventional or hypofractionated high-dose intensity-modulated radiotherapy, and all were given with 3-6 months of neoadjuvant androgen suppression. Computer-generated random permuted blocks were used, with risk of seminal vesicle involvement and radiotherapy-treatment centre as stratification factors. The conventional schedule was 37 fractions of 2 Gy to a total of 74 Gy. The two hypofractionated schedules involved 3 Gy treatments given in either 20 fractions to a total of 60 Gy, or 19 fractions to a total of 57 Gy. The primary endpoint was proportion of patients with grade 2 or worse toxicity at 2 years on the Radiation Therapy Oncology Group (RTOG) scale. The primary analysis included all patients who had received at least one fraction of radiotherapy and completed a 2 year assessment. Treatment allocation was not masked and clinicians were not blinded. Stage 3 of this trial completed the planned recruitment in June, 2011. This study is registered, number ISRCTN97182923.

FINDINGS

153 men recruited to stages 1 and 2 were randomly assigned to receive conventional treatment of 74 Gy, 153 to receive 60 Gy, and 151 to receive 57 Gy. With 50·5 months median follow-up (IQR 43·5-61·3), six (4·3%; 95% CI 1·6-9·2) of 138 men in the 74 Gy group had bowel toxicity of grade 2 or worse on the RTOG scale at 2 years, as did five (3·6%; 1·2-8·3) of 137 men in the 60 Gy group, and two (1·4%; 0·2-5·0) of 143 men in the 57 Gy group. For bladder toxicities, three (2·2%; 0·5-6·2) of 138 men, three (2·2%; 0·5-6·3) of 137, and none (0·0%; 97·5% CI 0·0-2·6) of 143 had scores of grade 2 or worse on the RTOG scale at 2 years.

INTERPRETATION

Hypofractionated high-dose radiotherapy seems equally well tolerated as conventionally fractionated treatment at 2 years.

FUNDING

Stage 1 was funded by the Academic Radiotherapy Unit, Cancer Research UK programme grant; stage 2 was funded by the Department of Health and Cancer Research UK.

Trends in joint arthroplasty litigation over five years: the British experience

INTRODUCTION

Increasing numbers of joint arthroplasty are performed in Britain. While associated complications are well documented, it is not known which of those initiate malpractice claims.

METHOD

A five-year period was assessed for trends to highlight areas for further improvement in patient information and surgical management.

RESULTS

The National Health Service paid out almost £14 million for 598 claims. Forty per cent of this was for legal costs. The number of claims increased over time while the rate of successful claims decreased.

CONCLUSIONS

A failure to consent adequately and to adhere to policies and standard practice can result in a successful malpractice claim. Protecting patients intraoperatively and maintaining high technical expertise while implementing policies and obtaining informed consent decreases the litigation burden.

17β-estradiol and testosterone sorption in soil with and without poultry litter

17β-estradiol and testosterone are naturally occurring steroids that co-occur in poultry litter. The effects of litter on sorption of these hormones to soil are not known. Sorption isotherms were developed for C-labeled testosterone and H-labeled estradiol in a Cecil sandy clay loam with and without poultry litter addition. The effect of applying the hormones alone (single-sorbate) or together (multisorbate) was also investigated. C-testosterone sorption in soil increased from 2 to 48 h and remained relatively constant thereafter. H-estradiol sorption in soil was relatively constant from 2 to 24 h and then decreased to 72 h. These differences may reflect transformation of the parent hormones to products with different solid-phase affinity. The maximum sorption coefficient () in soil for C-testosterone (20.2 mL g) was similar to that for H-estradiol (19.6 mL g) in single-sorbate experiments. When hormones were applied together, sorption of both hormones in soil decreased, but the C-testosterone (12.5 mL g) was nearly twice as large as the H-estradiol (7.4 mL g). We propose this resulted from competition between the hormones and their transformation products for sorption sites, with C-testosterone and its expected transformation product (androstenedione) being better competitors than H-estradiol and its expected transformation product (estrone). When poultry litter was mixed with soil, sorption increased for H-estradiol but decreased for C-testosterone. This may have been because poultry litter slowed the transformation of parent hormones. Our results show that poultry litter could have important effects on the mobility of estradiol and testosterone.

Emphysematous gastritis associated with ulcerative esophagitis

Emphysematous gastritis is a rare form of gastritis characterized by gaseous dissection of the stomach wall usually secondary to invasion by gas forming organisms, corrosive ingestion, trauma, or gastric infarction. We report a unique case of emphysematous gastritis secondary to ulcerative esophagitis without an underlying history of trauma, ischemia, or ingestion of corrosive agents. The patient responded well to conservative management. Emphysematous gastritis is a deadly infectious disease. Early recognition and management are crucial as there is no specific approach to treatment despite advances in medical science.

Primary suture-less closure of gastroschisis using negative pressure dressing (wound vacuum)

INTRODUCTION

Primary suture-less closure of gastroschisis using negative pressure dressing (wound vacuum) involves the application of an initial preformed Silo with subsequent bedside suture-less closure of the defect using negative pressure dressing. The advantages of this gentle approach are the simple bedside closure without intubation, paralysis or ventilation as well as reduced risk of barotrauma, abdominal compartment syndrome, acidosis, bowel infarction and necrotizing enterocolitis. This study is a report of the technique we used for gastroschisis closure at our institute.

METHODS

The medical records of 15 newborns who underwent primary suture-less closure of gastroschisis using a negative pressure dressing (wound vacuum) technique between March 2008 and February 2010 were retrospectively reviewed. Outcome criteria such as time on ventilation, time to initiating feeds, time to full feeds, time to discharge from NICU and complications were recorded.

RESULTS

The median follow-up was 234 days (range: 13-528 days). The time on ventilation was (n = 8: no ventilation; n = 3: 1 day; n = 2: 2-5 days; n = 2: > 5 days). The median time to initiating feeds was 13 days (range: 6-61 days), the median time to full feeds was 20 days (range: 12-91 days) and the median time to discharge was 24 days (range: 21-131 days). 2 patients had a tiny umbilical hernia at last follow-up.

CONCLUSION

Primary suture-less closure of gastroschisis using a negative pressure dressing (wound vacuum) technique is easily reversible, does not need intubation/ventilation, avoids a trip to the operating room (OR), has minimal to no complications and provides good cosmetic results.

Incidence of community-acquired meticillin resistant Staphylococcus aureus hand infections in Tayside, Scotland: a guide to appropriate antimicrobial prescribing

The prevalence of community-acquired meticillin resistant Staphylococcus aureus (ca-MRSA) as an important cause of hand infections has gained much recognition. The clinical impact of this is less well documented in the United Kingdom. This study looks at the incidence of hand infections in an urban Scottish teaching hospital over a 12 month period.

Strain experienced by caregivers of stroke survivors in the Western Cape

Recovery  after  stroke  is  often  incomplete  and  many  stroke  survivors depend on family caregivers. The demands of caring can negatively impact quality  of  life  of  these  carers.  This  study  explores  levels  of strain experienced  by  caregivers  and  the  variables  that  impact  on their strain. A  concurrent,  mixed  method,  descriptive  design  was  utilized. Fifty-seven caregivers  of  stroke  survivors  who  received  rehabilitation at the  Western  Cape  Rehabilitation  Centre  participated  in  the  study.  The Barthel  Index  and Caregiver  Strain  Index  were  utilised  to  collect quantitative  data,  which  was statistically analysed (p <0.05). Qualitative data was collected through semi-structured interviews and thematically analysed.Fifty eight percent of caregivers were experiencing high levels of strain. The following variables significantly impacted on strain namely, caregiver loss of employment (0.04), emotional pressure (0.01), patient residual cognitive and perceptual impairments (0.01), personality changes (0.01) and physical dependency (0.0012).   According to the qualitative data the burden was aggravated by financial problems, patient perceptual problems and patient personality changes. The findings indicate the need for support after discharge, ongoing community support and respite care to enable time off for caregivers.

Compression neuropathy of the common peroneal nerve secondary to a ganglion cyst

There are various causes of the common peroneal nerve palsy. However, common peroneal nerve palsy caused by ganglia are uncommon. We hereby present a case of a 55-year-old man with a 1 week history of foot drop and swelling in the region of the right leg. Physical examination and nerve conduction study studies confirmed a diagnosis of common peroneal nerve palsy. Magnetic resonance imaging (MRI) revealed a lobulated, elongated cystic-appearing mass anterior to the head of fibula. Surgical decompression of the nerve with removal of the mass was performed. Surgical pathology reports confirmed the diagnosis of a ganglion cyst. Findings on physical examination, nerve conduction study and MRI results of this interesting case are being discussed. We wish to highlight that even a tumour which is benign and within the nerve sheath can cause compression.

Abstract P4-09-09: Serum SDF-1: Biomarker of Bone Relapse in the NCIC MA.14 Adjuvant Breast Cancer Trial

Background: Massague et al have shown that breast cancer cell line subpopulations with elevated bone metastatic activity overexpress chemokine receptor 4 (CXCR4), interleukin 11 (IL11), osteopontin (OPN) and connective tissue growth factor (CTGF) (Cancer Cell 3:537, 2003). CXCR4 overexpression results in bone-homing and extravasation of tumor cells in bone. In MA.14, we found that serum β-CTx was associated with bone-only relapse while Basik et.al showed that higher serum stromal cell-derived factor 1 (SDF-1) (ligand for CXCR-4) levels were associated with worse overall event-free survival (EFS) (ASCO 2010). In this study, we examined concurrently the association of both β-CTx and serum SDF-1 with bone relapse.

Methods: Serum β-CTx (Serum CrossLaps, Nordic Biosciences, Copenhagen, DN) was determined in pretreatment sera from 621 of 667 NCIC CTG MA.14 patients. SDF-1 (CXCL12) (R&D Systems, Minneapolis, MN) levels were successfully determined in the 4 month post-treatment serum (SDF-1) for 508 (76%) of the patients. Trial stratification was by administration of adjuvant chemotherapy, axillary lymph node status, and ER and/or PR status. Recurrence-free survival (RFS) was defined as the time from randomization to the time of recurrence of the primary disease. Adjusted and unadjusted Cox step-wise forward multivariate analyses were used to assess the effects of β-CTx, SDF-1, trial therapy and baseline patient characteristics on non-bone, all bone and bone-only RFS; a factor was added if p&lt;=0.05.

Results: Joint assessment of β-CTx and SDF-1 was possible for 493 (74%) of the 667 patients. Imbalances in who was, or was not, included in this subset led to the trial arm of Tamoxifen + Octreotide LAR having a significant longer unadjusted ITT non-bone RFS (p=0.03-0.06). There was shorter time to bone metastasis of any type with higher lymph node involvement (p=0.001), larger T (p=0.02), and higher log SDF-1 (p=0.03). Meanwhile, high categorical and continuous β-CTx was associated multivariately with shorter bone-only RFS (p=0.04 and 0.01, respectively); higher log SDF-1 was only associated with shorter bone-only RFS (p=0.02) when the number of strata were reduced to 2 categories per factor.

Conclusions: Higher serum SDF-1 level may be associated with bone metastasis, although there is less evidence of its relevance in bone-only relapse than there is for the biomarker β-CTx. Serum SDF-1 deserves further study as a promising predictive factor of bone relapse in breast cancer.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-09-09.

Observation of postsoliton expansion following laser propagation through an underdense plasma

The expansion of electromagnetic postsolitons emerging from the interaction of a 30 ps, 3×10¹⁸ W cm⁻² laser pulse with an underdense deuterium plasma has been observed up to 100 ps after the pulse propagation, when large numbers of postsolitons were seen to remain in the plasma. The temporal evolution of the postsolitons has been accurately characterized with a high spatial and temporal resolution. The observed expansion is compared to analytical models and three-dimensional particle-in-cell results, revealing a polarization dependence of the postsoliton dynamics.