Posterior Transdural Approach for Thoracic Corpectomies in the Setting of Complex Spine Deformity Reconstruction

BACKGROUND AND OBJECTIVE

There are many surgical approaches for execution of a thoracic corpectomy. In cases of challenging deformity, traditional posterior approaches might not be sufficient to complete the resection of the vertebral body. In this technical note, we describe indications and technique for a transdural multilevel high thoracic corpectomy.

METHODS

A 25-year-old man with a history of neurofibromatosis type 1 presented with instrumentation failure after a previous T1-T12 posterior spinal fusion, extensive laminectomy, and tumor resection. The patient presented with progressive back pain, had broad dural ectasia, and a progressive kyphotic rotational and anteriorly translated spinal deformity. To resect the medial-most aspect of the vertebral body, a bilateral extracavitary approach was attempted, but was found insufficient. A transdural approach was subsequently performed. A left paramedian durotomy was made, followed by generous arachnoid dissection, bilateral dentate ligament division, and T4 rootlet sacrifice to mobilize the spinal cord. A ventral durotomy was then made and the ventral dura was reflected over the spinal cord to protect it while drilling. The corpectomy was then completed. The ventral and dorsal durotomies were closed primarily and reinforced with fibrin glue and fibrin sealant patch. The corpectomy defect was filled with nonstructural autograft.

RESULTS

The focal kyphosis was corrected with a combination of rod contouring, compression, and in situ bending. During the surgery, the patient had stable neuromonitoring data, and postoperatively had no neurological deficits. On follow-up until 1 year, the patient presented with no signs of cerebrospinal spinal leaks, no motor or sensory deficits, minimal incisional pain, and significantly improved posture.

CONCLUSION

Complex high thoracic (T3-5) ventral pathology inaccessible via a bilateral extracavitary approach may be accessed via a transdural approach as opposed to an anterior/lateral transthoracic approach that requires mobilization of cardiovascular structures or scapula.

Virtual, Augmented, and Mixed Reality Applications for Surgical Rehearsal, Operative Execution, and Patient Education in Spine Surgery: A Scoping Review

Background and Objectives: Advances in virtual reality (VR), augmented reality (AR), and mixed reality (MR) technologies have resulted in their increased application across many medical specialties. VR's main application has been for teaching and preparatory roles, while AR has been mostly used as a surgical adjunct. The objective of this study is to discuss the various applications and prospects for VR, AR, and MR specifically as they relate to spine surgery. Materials and Methods: A systematic review was conducted to examine the current applications of VR, AR, and MR with a focus on spine surgery. A literature search of two electronic databases (PubMed and Scopus) was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The study quality was assessed using the MERSQI score for educational research studies, QUACS for cadaveric studies, and the JBI critical appraisal tools for clinical studies. Results: A total of 228 articles were identified in the primary literature review. Following title/abstract screening and full-text review, 46 articles were included in the review. These articles comprised nine studies performed in artificial models, nine cadaveric studies, four clinical case studies, nineteen clinical case series, one clinical case-control study, and four clinical parallel control studies. Teaching applications utilizing holographic overlays are the most intensively studied aspect of AR/VR; the most simulated surgical procedure is pedicle screw placement. Conclusions: VR provides a reproducible and robust medium for surgical training through surgical simulations and for patient education through various platforms. Existing AR/MR platforms enhance the accuracy and precision of spine surgeries and show promise as a surgical adjunct.

Utilization of Augmented Reality Head-Mounted Display for the Surgical Management of Thoracolumbar Spinal Trauma

Background and Objectives: Augmented reality head-mounted display (AR-HMD) is a novel technology that provides surgeons with a real-time CT-guided 3-dimensional recapitulation of a patient's spinal anatomy. In this case series, we explore the use of AR-HMD alongside more traditional robotic assistance in surgical spine trauma cases to determine their effect on operative costs and perioperative outcomes. Materials and Methods: We retrospectively reviewed trauma patients who underwent pedicle screw placement surgery guided by AR-HMD or robotic-assisted platforms at an academic tertiary care center between 1 January 2021 and 31 December 2022. Outcome distributions were compared using the Mann-Whitney U test. Results: The AR cohort (n = 9) had a mean age of 66 years, BMI of 29.4 kg/m2, Charlson Comorbidity Index (CCI) of 4.1, and Surgical Invasiveness Index (SII) of 8.8. In total, 77 pedicle screws were placed in this cohort. Intra-operatively, there was a mean blood loss of 378 mL, 0.78 units transfused, 398 min spent in the operating room, and a 20-day LOS. The robotic cohort (n = 13) had a mean age of 56 years, BMI of 27.1 kg/m2, CCI of 3.8, and SII of 14.2. In total, 128 pedicle screws were placed in this cohort. Intra-operatively, there was a mean blood loss of 432 mL, 0.46 units transfused units used, 331 min spent in the operating room, and a 10.4-day LOS. No significant difference was found between the two cohorts in any outcome metrics. Conclusions: Although the need to address urgent spinal conditions poses a significant challenge to the implementation of innovative technologies in spine surgery, this study represents an initial effort to show that AR-HMD can yield comparable outcomes to traditional robotic surgical techniques. Moreover, it highlights the potential for AR-HMD to be readily integrated into Level 1 trauma centers without requiring extensive modifications or adjustments.

The Perfect Storm: An Unusual Cause of Intestinal Perforation in a Solid Organ Transplant Patient

Immunosuppressants are used to prevent rejection in transplant patients. Many of these medications commonly cause gastrointestinal (GI) symptoms. We present a 38-year-old kidney and pancreas transplant recipient who had severe ulceration throughout his GI tract leading to perforations of his stomach and cecum, despite early discontinuation of mycophenolate mofetil-the most likely culprit medication. The ongoing injury observed despite holding mycophenolate suggests a possible compounding effect of tacrolimus and everolimus. Both these agents are underrepresented causes of GI injury. This perfect storm of agents may have accounted for the severity and extensive presentation observed in our patient.

18F-Fluorodeoxyglucose Positron Emission Tomography Parameters can Predict Long-Term Outcome Following Trimodality Treatment for Oesophageal Cancer

AIMS

¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸FDG-PET/CT) is routinely used for the pre-treatment staging of oesophageal or gastro-oesophageal junction cancers (EGEJC). The aim of this study was to identify objective ¹⁸FDG-PET/CT-derived parameters that can aid in predicting the patterns of recurrence and prognostication in patients with EGEJC.

PATIENTS AND METHODS

EGEJC patients referred for consideration of preoperative chemoradiation therapy were identified and clinicopathological data were collected. ¹⁸FDG-PET/CT imaging data were reviewed and correlated with treatment outcomes. Maximum standardised uptake value (SUV_max), metabolic tumour volume (MTV) and total lesion glycolysis were assessed and association with recurrence-free survival (RFS), locoregional recurrence-free survival (LR-RFS), oesophageal cancer-specific survival (ECSS) and overall survival were evaluated using receiver operating characteristic curves, as well as Cox regression and Kaplan-Meier models.

RESULTS

In total, 191 EGEJC patients completed trimodality treatment and 164 with ¹⁸FDG-PET/CT data were included in this analysis. At the time of analysis, 15 (9.1%), 70 (42.7%) and two (1.2%) patients were noted to have locoregional, distant and both locoregional and distant metastases, respectively. The median RFS was 30 months (9.6-50.4) and the 5-year RFS was 31.1%. The 5-year overall survival and ECSS were both noted to be 34.8%. Pre-treatment MTV₂₅ > 28.5 cm³ (P = 0.029), MTV₄₀ > 12.4 cm³ (P = 0.018) and MTV₅₀ > 10.2 cm³ (P = 0.005) predicted for worse LR-RFS, ECSS and overall survival for MTV definition of voxels ≥25%, 40% and 50% of SUV_max.

CONCLUSION

¹⁸FDG-PET/CT parameters MTV and total lesion glycolysis are useful prognostic tools to predict for LR-RFS, ECSS and overall survival in EGEJC. MTV had the highest accuracy in predicting clinical outcomes. The volume cut-off points we identified for different MTV thresholds predicted outcomes with significant accuracy and may potentially be used for decision making in clinical practice.

P10.24.A A personalized BRAF mutant glioblastoma with Human2Humanex-vivo cortical cultures

Background

Glioblastoma is among the most common primary malignancy with a poor medium survival post-diagnosis. The incredible heterogeneity of glioblastoma highlights its incurable nature. Methods to overcome difficulties leaded by glioblastoma heterogeneity remain to be explored. Here we present our Human2Human personalized autografted BRAF(V600E) mutant glioblastoma model, focusing on the idea of precision. This model, with an inoculation of self-derived glioblastoma cells, can imitate the tumor growth, invasion, metabolism and microenvironmental crosstalk within its “native” microenvironment and allows us to investigate the influence of different chemotherapies on the immunosuppressive tumor microenvironment from each specific individual glioblastoma patient.

Material and Methods

Non-neoplastic cortical tissue was obtained from a BRAF(V600E) mutant glioblastoma patient during surgical operation. Tissue was sectioned and inoculated with autografted glioblastoma cells in order to establish the ex-vivo Human2Human personalized brain slice model. Slice viability and tumor growth were monitored throughout the culture period, with and without day-wise refreshed treatments of clinically proved BRAF/MEK inhibitors. Sections were fixed and stained post cultivation. Pathway proteins p-ERK, p-Akt based on BRAF signaling along with markers (TMEM119, Iba-1, CD3, CD68, GFAP and NeuN) for major cell types in the environment were stained. Single Nuclei RNA Sequencing and Spatially Resolved Transcriptomics were applied.

Results

Tumor growth quantification over the culture period revealed different tumor reaction and tolerance towards various chemotherapies. The combination of Vemurafenib + Trametinib exhibited more efficient therapy response in comparison with either Dabrafenib + Trametinib or Encorafenib + Trametinib. Immunofluorescence and immunohistochemistry based quantification referring to neurons (NeuN), astrocytes (GFAP) and microglia/macrophage cells (Iba-1) suggested no toxic effects of the drug combinations on the tumor microenvironment. BRAF pathway proteins and immune cells showed various activation patterns upon different treatment combinations on an immunofluorescence base. Single Nuclei RNA Sequencing revealed the mesenchymal differentiation of BRAF mutant glioblastoma cells. Spatially Resolved Transcriptomics characterized tumor recurrence and suggested the therapy response accurately and visually.

Conclusion

The combination of Vemurafenib + Trametinib shows strategy to this specific BRAF mutant glioblastoma patient. And therefore, this Human2Human personalized model has a potential to provide in-depth information of the spatio-temporal tumor differentiation ex-vivo, correct inter-patient bias, and model therapy response in a very short time frame to provide drug testing results for clinical decision making.

P12.14.A The role of onco-metabolite (R2hydroxyglutarate) in the IDH mutant glioblastoma microenvironment

Background

Recently, we found that the reactive astrocytes in the IDH wild type glioblastoma contribute to anti-tumor immunity and support pro-oncogenic signaling. Here, we characterized the transcriptomic signature of IDH1/2-mutant glioma associated astrocytes and determined a unique inflammatory transformation, profoundly different to astrocytes in IDH wildtype glioma patients due to an onco-metabolite R-2-hydroxyglutarate using Next generation sequencing and human ex-vivo slice model.

Material and Methods

We purified and transcriptionally profiled astrocytes from 9 patients with confirmed IDH1-R132H mutation, by means of RNA-sequencing and the data were analyzed using the established pipelines. We also used spatial transcriptomics to evidently show the spatial distribution of astrocytes in IDH-mutated/wildtype glioma samples. We validated our findings using human organotypic slice model inoculated with IDH-mutant cell line or treated with oncometabolite 2-hydroxy glutarate. Additionally, LC-MS was further used to give us a chart of neurotransmitters due to altered microenvironment.

Results

Our results from RNA sequencing showed a transcriptional transformation of reactive astrocytes within the microenvironment of IDH-mutated tumors compared to wildtype glioma by means of RNA-sequencing of purified astrocytes. And, using our established human neocortical GBM model inoculated with IDH mutant tumor and R-2HG treatment, we showed that we were able to activate inflammatory transcriptional programs in astrocytes, mediated by the presence of microglia. Further, by spatially mapping the transcriptomic profiles of purified microglia, we were able to confirm that microglia also demonstrate inflammatory activation in IDH mutated glioma. This inflammatory astrocyte transformation is associated with a loss of neurotransmitter homeostasis (disrupted levels of glutamate) in the treated sections, as has been previously reported in IDH mutated tumors. Additionally, R-H2G increased neuronal spiking rate in, pointing to potential excitotoxicity.

Conclusion

Our work provides a crucial contribution towards understanding the role of R-2HG in the IDH mutant glioma microenvironment and sheds light on the significant microenvironmental differences to IDH wild-type glioma.

Does Loosening the Inclusion Criteria of the CROSS Trial Impact Outcomes in the Curative-Intent Trimodality Treatment of Oesophageal and Gastroesophageal Cancer Patients?

AIM

To determine the efficacy of preoperative chemoradiotherapy as per the CROSS protocol for oesophageal/gastroesophageal junction cancer (OEGEJC), when expanded to patients outside of the inclusion/exclusion criteria defined in the original clinical trial.

MATERIALS AND METHODS

Data were collected retrospectively on 229 OEGEJC patients referred for curative-intent preoperative chemoradiotherapy. Outcomes including pathological complete response (pCR), overall survival (OS), cancer-specific survival and recurrence-free survival (RFS) of patients who met CROSS inclusion criteria (MIC) versus those who failed to meet criteria (FMIC) were determined.

RESULTS

In total, 42.8% of patients MIC, whereas 57.2% FMIC; 16.6% of patients did not complete definitive surgery. The MIC cohort had higher rates of pCR, when compared with the FMIC cohort (33.3% versus 20.6%, P = 0.039). The MIC cohort had a better RFS, cancer-specific survival and OS compared with the FMIC cohort (P = 0.006, P = 0.004 and P = 0.009, respectively). Age >75 years and pretreatment weight loss >10% were not associated with a poorer RFS (P = 0.541 and 0.458, respectively). Compared with stage I-III patients, stage IVa was associated with a poorer RFS (hazard ratio (HR) = 2.158; 95% confidence interval (CI) = 1.339-3.480, P = 0.001). Tumours >8 cm in length or >5 cm in width had a trend towards worse RFS (HR = 2.060; 95% CI = 0.993-4.274, P = 0.052).

CONCLUSION

Our study showed that the robust requirements of the CROSS trial may limit treatment for patients with potentially curable OEGEJC and can be adapted to include patients with a good performance status who are older than 75 years or have >10% pretreatment weight loss. However, the inclusion of patients with celiac nodal metastases or tumours >8 cm in length or >5 cm in width may be associated with poor outcomes.

Modification of epoxy binder with multi walled carbon nanotubes in hybrid fiber systems used for retrofitting of concrete structures: evaluation of strength characteristics

The rapid development in infrastructural facilities necessitates an efficient approach for the repair and retrofitting of concrete structures and, confinement method using fiber reinforced polymer is a promising one. The commonly used carbon and glass fibers for confinement poses environmental and performance issues. The present study addresses these two major aspects by considering natural fibers along with modification of epoxy binder to impart ductile behavior ie., to investigate the effectiveness of multiwalled carbon nanotubes (MWCNT) incorporated synthetic and natural fiber reinforced polymer (FRP) systems as the external confinement. MWCNT is incorporated in 0.5-1.5wt.% in epoxy nano and epoxy multiscale and there is significant enhancement in tensile and fracture properties of the composites up to 1wt.%, beyond which it declined due to agglomeration. Various strength tests were performed with sisal, basalt, carbon and hybrid sisal-basalt FRP systems with different FRP layer thickness on plain concrete cylinders. From the test results it is outlined that external confinement with MWCNT incorporated FRP improved the axial load-carrying capacity, energy absorption and ductility of concrete with respect to that of control specimens. Compared with unconfined specimens, those strengthened with MWCNT modified hybrid FRP wraps containing sisal and basalt fibers recorded increments of 114% and 87% in their load-carrying capacity and energy absorption, due to the intrinsic rigidity of hybrid fibers and epoxy modification. Furthermore, the outcomes indicate that MWCNT incorporated hybrid sisal-basalt FRP confined specimens exhibited superior properties and the low strength of natural FRP confinement compared to artificial FRP can be improved by epoxy modification. The outer jacketing resisted abrupt and catastrophic failure to a great extent.

OS06.9A Diversity of cellular communication in glioblastoma

BACKGROUND

Owing to recent advances in understanding of the active functional states exhibited within glioblastoma (GBM), intra-tumoral cellular signaling has moved into focus of neuro-oncological research. In our study, we aim to explore the diversity of transcellular signaling and investigate correlations to transcriptional dynamics and cellular behavior.

MATERIAL AND METHODS

Electrophysiological mapping of primary GBM cultures was performed by planar microelectrodes, in conjunction with calcium imaging in a human neocortical section based GBM model. Exposure to conditions that are physiologically present within the tumor was carried out to identify specific signaling cells of interest and signaling diversity presented as response to specific environmental conditions. Transcriptional dynamics and plasticity were examined by means of scRNA-sequencing with CRISPR based perturbation, spatial transcriptomics and deep long-read RNA-sequencing.

RESULTS

Electrophysiological profiles of primary GBM cell lines revealed highly variable network activity. Despite these different characteristics, all profiled primary cell-lines exhibited characteristics of scale-free networks, confirmed in a human neocortical GBM model. When the GBM was allowed to grow in “in-vivo” like environment, basal activity was significantly increased, owing to interactions with elements within the neural environment. Cellular signaling was directly correlated to changes in the environment, like hypoxia or glutamatergic activation, and total inhibition of electrical signaling was achieved only with a combination of both gap junction and synaptic inhibitors. Using single-cell sequencing and proteomics, we identified several genes related to synaptogenesis that plays a crucial role in network formation and consequently transcellular signaling. CRISPR based perturbation of these genes resulted in alterations in cellular morphology and decreased cellular connectivity, with electrical signaling being significantly attenuated. Single-cell sequencing of perturbed tumor cells in the GBM model revealed a loss of developmental lineages and significant reduction of cellular stress response state.

CONCLUSION

Our findings highlight the role of electrical signaling in glioblastoma. Cellular stressors induce intercellular signaling, leading to transcriptional adaptation suggesting that there exists a highly complex and powerful mechanism for dynamic transcriptional state adaptation.

CNS infection with a history of recurrent epistaxis: Streptococcal meningitis as a first presentation of juvenile nasopharyngeal angiofibroma

An adolescent male with a history of recurrent epistaxis presented with headache and vomiting. Investigations revealed concurrent meningitis as well as the presence of a subarachnoid haemorrhage. Subsequent imaging identified a Juvenile Nasopharyngeal Angiofibroma; a rare but important cause of meningitis that should be considered in the young adult population.

Skin Toxicity in Early Breast Cancer Patients Treated with Field-In-Field Breast Intensity-Modulated Radiotherapy versus Helical Inverse Breast Intensity-Modulated Radiotherapy: Results of a Phase III Randomised Controlled Trial

AIMS

Skin toxicity is a common adverse effect of breast radiotherapy. We investigated whether inverse-planned intensity-modulated radiotherapy (IMRT) would reduce the incidence of skin toxicity compared with forward field-in-field breast IMRT (FiF-IMRT) in early stage breast cancer.

MATERIALS AND METHODS

This phase III randomised controlled trial compared whole-breast irradiation with either FiF-IMRT or helical tomotherapy IMRT (HT-IMRT), with skin toxicity as the primary end point. Patients received 50 Gy in 25 fractions and were assessed to compare skin toxicity between treatment arms.

RESULTS

In total, 177 patients were available for assessment and the median follow-up was 73.1 months. Inverse IMRT achieved more homogeneous coverage than FiF-IMRT; erythema and moist desquamation were higher with FiF-IMRT compared with HT-IMRT (61% versus 34%; P < 0.001; 33% versus 11%; P < 0.001, respectively). Multivariate analysis showed large breast volume, FiF-IMRT and chemotherapy were independent factors associated with worse acute toxicity. There was no difference between treatment arms in the incidence of late toxicities. The 5-year recurrence-free survival was 96.3% for both FiF-IMRT and HT-IMRT and the 5-year overall survival was 96.3% for FiF-IMRT and 97.4% for HT-IMRT.

CONCLUSIONS

Our study showed significant reduction in acute skin toxicity using HT-IMRT compared with FiF-IMRT, without significant reduction in late skin toxicities. On the basis of these findings, inverse-planned IMRT could be used in routine practice for whole-breast irradiation with careful plan optimisation to achieve the required dose constraints for organs at risk.

Kinetics of Pulmonary Leukocyte Sequestration in Man during Hemodialysis with Different Membrane-Types

Although it has been suggested that pulmonary sequestration of leukocytes could account for membrane-dependent white blood cell depletion in HD, direct evidence in patients is still lacking. Therefore a study was initiated to test whether and how leukocytes distribute in the lung circulation during HD with different membranes. Thirteen patients suffering from chronic renal failure underwent lung scintigraphy during HD with cuprophane (n = 3), hemophane (n = 8) and polysulfone (n = 2) lowflux capillary dialyzers. Isolated autologous leukocytes were labelled with 99m-Technetium and reinfused before starting HD. Distribution of leukocyte related activity was registered by lung scintigraphy. In comparison to normal lung scintigraphy performed without HD, an impressive redistribution peak was demonstrated 10-20 min after the start of HD with cuprophane and also to a lesser extent with hemophane. When HD was performed with polysulfone the decrease in activity was delayed but no real redistribution was obtained.

In accordance with other phenomena, such as peripheral leukopenia and changes in granulocyte oxidative metabolism, pulmonary sequestration of leukocytes takes place in man in the initial phase of HD and appears to be strongly dependent on the type of membrane. (Int J Artif Organs 1990; 13: 729-36)

Anschluß und On-line-Betrieb eines Szintiscanners an einem Digitalrechner

Das Betriebssystem BSC 1 steuert sowohl die Übernahme der Scanner-Informationen und die Eingaben vom Teletype als auch die verschiedenen Wiedergabemöglichkeiten eines Szintigramms. Bei der Aufnahme werden zunächst Patientennamen und verschiedene Scan-Parameter eingegeben. Vor Beginn des übemahmeprogramms errechnet das Programm Größen für eine möglichst optimale Ausnutzung des Speichers. Nach der Scan-Aufnahme werden Parameter für die Wiedergabeprogramme bestimmt. Danach geht der Rechner in die Warteschleife, in der er auf Wiedergabekommandos wartet. Das Betriebssystem enthält weiter Programmteile, mit denen der Inhalt des Datenspeichers als Lochstreifen ausgegeben, ein solcher Lochstreifen wieder eingelesen werden kann und Möglichkeiten zur zusätzlichen Beschriftung der Sichtgerätausgaben.

Anschluß und On-line-Betrieb eines Szintiscanners an einem Digitalrechner

Zur möglichst vollständigen Übernahme und Speicherung der bei der Aufnahme eines Szintigramms gewinnbaren Basis-Informationen wird ein Digitalrechner eingesetzt. Die Anlage besteht aus einem Picker Magnascanner und einem Rechner PDP 8/S als Grundeinheiten und einem Fernschreiber, einem Sichtgerät und einem x-y-Schreiber als Ausgabeeinheiten. Interface-Elektroniken dienen dazu, die Scanner-Informationen in den Rechner zu übernehmen und die Ausgabegeräte softwaremäßig vom Rechner her zu steuern. Das “Übernahme-Interface enthält ein eigenes Zählregister, Dadurch und durch die Bedienung des Interface über den Programm-Interrupt wurde erreicht, daß der Rechner während der Szintigramm-Aufnahme nur einen kleinen Prozentsatz der Zeit beansprucht wird und in der übrigen Zeit für die Auswertung der Datenmatrix oder für die Bedienung weiterer Geräte zur Verfügung steht.

Anschluß und On-line-Betrieb eines Szintiscanners an einem Digitalrechner

Das Betriebssystem enthält 2 Arten von Wiedergabeprogrammen: Wiedergaben am Sichtgerät und Druckausgaben. Beide werden durch ein Codewort vom Teletype aus aufgerufen.

Bei dem Programm SSWE werden auf dem Sichtgerät alle Werte dargestellt, die über einer bestimmten Schwelle liegen. Diese Schwelle wird bei diesem Programm mit der Hand eingestellt, während sie bei dem Programm SASW automatisch angehoben wird und so einen Bilderzyklus liefert. Weitere Programme zeichnen die Höhenschichtlinien und liefern eine perspektivische Darstellung des Aktivitätsgebirges.

Bei den Druckausgaben liefert das Programm FSWE eine Schwellendarstellung, während das Programm FVZE eine Darstellung der verschiedenen Niveaus mit verschiedenen Druckzeichen ausgibt. Ein ähnliches Programm ergibt eine Darstellung in mehrfachen Niveaugruppen. Außerdem ist in dem Betriebssystem noch ein Programm zur Druckausgabe von Höhenschichtlinien enthalten.

Rezeptorszintigraphie mit 111In-Pentetreotid beiendokrinen gastroenteropankreatischenTumoren

Die Rezeptorszintigraphie mit 111In-Pentetreotid ist ein komplementäres bildgebendesVerfahren mit einer Sensitivität von 88%, um bei Patienten mitklinischen und biochemischen Symptomen eines endokrinen Tumors desGastrointestinaltraktes oder des Pankreas den Primärtumor und dessen Metastasen zu lokalisieren. Als Ganzkörperszintigraphie erfaßt sie jede Körperregionund stellt auch kleine Tumoren dar, die mit den übrigen bildgebendenVerfahren nicht oder nur schwer zu entdecken sind. Bei 104 Patienten mit GEP-Tumoren oder nach operativer Entfernung eines solchen Tumors erwiessich die Rezeptorszintigraphie als dem Ultraschall und der Computertomographie bei 34% in der Aussagekraftüberlegen, bei 52% als gleich und bei 14%als unterlegen.

Guideline for in vivo- and in vitro procedures for thyroid diseases (version 2)

The version 2 of the guideline for diagnostic standards of thyroid disorders is an update of the guideline published in 1999 and describes standards of in vitro and in vivo procedures. The following statements are modified: In vitro procedures: When measurement of the TSH-receptor antibodies is indicated, the guideline recommends the use of a second generation assay (recombinant human TSH-receptor as antigen). The functional assay sensitivity for the measurement of thyroglobulin should reach a value ≤1 ng/ml. Moleculargenetic tests (RET proto-oncogen) are indicated in patients with a newly diagnosed medullary thyroid cancer and in the relatives of patients with hereditary medullary thyroid cancer. In vivo procedures: The sonographic examination should use a probe with a frequency of at least 7.5 MHz. Indications for the thyroid scintigraphy: nodule size ≥1 cm in diameter, autonomous goitre/nodule with clinical or subclinical hyperthyroidism, necessity of a differentiation between Graves’ disease and chronic lymphocytic thyroiditis, therapy control after a definitive treatment and – in individual cases – the follow-up of untreated autonomous nodules.

Früherkennung der thyreoidalen Autonomie durch Kombination von quantitativer Szintigrammauswertung mit einem Äquivalent des freien T4

Autonomes Schilddrüsengewebe (AFTT) fanden wir im Endemiegebiet bei eumetabolen Menschen sowohl in der umschriebenen (sog. autonomes Adenom) als auch in der disseminierten Form gleich häufig und in gleicher Ausprägung vor wie nach dem 40. Lebensjahr. Es ist im Endemiegebiet die häufigste Voraussetzung einer ungezügelten Hormonproduktion, die durch - meist iatrogene - Jodzufuhr ausgelöst wird. Die Verdachtsdiagnose der thyreoidalen Autonomie kann mit einer Treffsicherheit von etwa 80% schon bei euthyreoten Menschen durch gemeinsame Betrachtung des freien Thyroxin-Äquivalents (FTE) und eines durch quantitative Auswertung des Technetiumszintigrammes erhaltenen äquivalents der Jodidclearance (TcTU) gestellt werden. Der Suppressionstest liefert dann nicht nur qualitativ den Nachweis der fehlenden Regelbarkeit, sondern ermöglicht in der protrahiert-fraktionierten Form auch eine Abschätzung des Volumens autonomen Gewebes, denn der TcTU nach Suppression korreliert linear mit dem Volumen autonomen Gewebes. Da nach Jodzufuhr das FTE dem Volumen autonomen Gewebes proportional ansteigt, erscheint auch im Sinne einer groben Faustregel eine Prognose der thyreoidalen Autonomie möglich: oberhalb eines „kritischen‟ Volumens autonomen Gewebes wird mit an Sicherheit grenzender Wahrscheinlichkeit eine ausreichende Jodzufuhr genügender Dauer eine Hyperthyreose auslösen. Eine prospektive Studie an euthyreoten Patienten im Alter unter 50 Jahren mit unterschiedlichen Mengen autonomen Schilddrüsengewebes ergab, daß die Jodsalzprophylaxe in dieser Altersgruppe keine klinisch manifeste Hyperthyreose auslöst, wenn die tägliche zusätzliche Jodaufnahme 100 μg nicht übersteigt.

Active myofascial trigger points in head and neck muscles of patients with chronic tension-type headache in two primary health care units in Tshwane

Background: The management of patients presenting with chronic tension-type headache (CTTH) can be challenging for primary health care practitioners. As with most chronic pain disorders, a multimodal management approach is frequently required. It has been postulated that myofascial pain syndrome (MPS) and its hallmark myofascial trigger points (MTrPs) found in specific muscle tissues may play a role in the chronic pain experienced by patients with CTTH. Little is known about the prevalence of MTrPs in patients with CTTH, in primary health care settings on the African continent. This study therefore aimed to investigate the prevalence of active MTrP’s in specific head and neck muscles/muscle groups in patients with CTTH.Methods: A prospective, cross-sectional and descriptive study was done in two primary health care facilities situated in Tshwane, South Africa. The sample included 97 adult patients with CTTH. Five head and neck muscles/muscle groups were examined bilaterally for active MTrPs. Outcome measures were the prevalence and distribution of active MTrPs in these patients.Results: Active MTrPs were found in 95.9% of the patients, the majority (74.2%) having four or more active MTrPs. The temporalis muscles and suboccipital muscle group exhibited the highest number of active MTrPs (prevalence 87.6% and 80.4% respectively).Conclusion: Our study suggests a strong association between MPS and CTTH in patients, presenting in the primary health care setting. This indicates the importance of a musculoskeletal assessment of neck and pericranial muscles in patients with CTTH. This can assist in determining the most appropriate treatment strategy in these patients.

TUBERCULOSIS CONTROL IN SECURITY CHALLENGED STATES OF NORTH-EAST NIGERIA. ARE THERE SIGNIFICANT IMPACT?

BACKGROUND

Nigeria in the past few years is faced with various security challenges in different parts of the country. The most severe in the last three years has been the crisis in northern Nigeria and specifically the north-eastern States, where three of the States have been under emergency rule for a year. Health care delivery system is usually one of the major casualties in a security challenged environment leading to unavailability or low utilization of services.The aim of this paper is to share the experience of TB services in states under emergency rule.

METHODOLOGY

A retrospective review of program data (reportable indicators for TB case finding,TB/HIV and treatment outcome for periods of eight years (2006-2013) comparing national data with north-east and the three states most affected by security challenges (Borno, Adamawa & Yobe).

RESULTS

A national positive trend on case notification for all forms of TB and smear positive, with a declined in 2011 but generally the case notification has remain low (59/100,000 in 2013 compared to estimated prevalence of 338/100,000). North east data is a negative trend for case notification and this is worse for 2 states (Borno and Yobe) while Adamawa shows and increase CNR from 2012 because of TB Reach active case, finding. Treatment success rate has a positive trend both national, north east states and in the 3 challenged states (TSR above 84%). TB/HIV indicators for north east are 81%, 75%, and 58% for HCT CPT and ART respectively, these figures has serious fluctuations within and among the three security challenged states with Borno most affected.

CONCLUSIONS

Insecurity can pose a challenge for TB control activities especially case finding, therefore the need for innovative approaches for case finding in areas of insecurity. Chronic infectious diseases like TB and HIV should be incorporated into emergency responses offered by organisations and agencies for internally displaced persons.

A novel assay to diagnose hereditary angioedema utilizing inhibition of bradykinin-forming enzymes

BACKGROUND

Hereditary angioedema types I and II are caused by a functional deficiency of C1 inhibitor (C1-INH), leading to overproduction of bradykinin. The current functional diagnostic assays employ inhibition of activated C1s; however, an alternative, more physiologic method is desirable.

METHODS

ELISAs were developed using biotinylated activated factor XII (factor XIIa) or biotinylated kallikrein bound to avidin-coated plates. Incubation with plasma was followed by detection of bound C1-INH.

RESULTS

After standard curves were developed for quantification of C1-INH, serial dilutions of normal plasma were employed to validate the ability to detect known concentration of C1-INH in the plasma as a percent of normal. Hereditary angioedema (HAE) types I and II were then tested. The level of functional C1-INH in all HAE types I and II plasma tested was less than 40% of our normal control. This was evident regardless of whether we measured factor XIIa-C1-INH or kallikrein-C1-INH complexes, and the two assays were in close agreement. By contrast, testing the same samples utilizing the commercial method (complex ELISA, Quidel Corp.) revealed the levels of C1-INH between 0 and 57% of normal (mean, 38%), and 42 samples were considered equivocal (four controls and 38 patients).

CONCLUSIONS

Diagnosis of HAE types I and II can be ascertained by inhibition of enzymes of the bradykinin-forming cascade, namely factor XIIa and kallikrein. Either method yields functional C1-INH levels in patients with HAE (types I and II) that are clearly abnormal with less variance or uncertainty than the commercial method.

Genitourinary small-cell carcinoma: a single-institution experience

BACKGROUND

Small-cell carcinomas (sccs) of the genitourinary (gu) tract are rare systemic diseases, and there is no standard treatment strategy for patients with this malignancy. The objectives of the present study were to report the management and outcome of patients with scc of the gu tract treated at a tertiary-care institution from 1982 to 2009.

METHODS

In a chart review of all patients diagnosed with scc of the gu tract between 1982 and 2009, data on demographics, clinical and pathologic characteristics, treatment, and patient outcomes were collected.

RESULTS

The 58 patients identified had scc in the following primary sites: urinary bladder (n = 35), prostate (n = 17), and upper urinary tract (n = 6). In 38 patients (66%), the scc was of pure histology; in the remainder, histology was mixed. Overall, 28 patients had limited-stage disease; 24 had extensive-stage disease; and staging was unknown in 6 patients. Median survival for the entire cohort was 7.5 months, with extensive-stage disease being identified as a poor prognostic factor (survival was 22.0 months for limited-stage patients and 4.1 months for extensive-stage patients, p < 0.001). Based on site, prostate patients fared worst, with a median survival of only 5.1 months. Compared with best supportive care, treatment was associated with better outcomes (median survival: 12.3 months vs. 2.3 months, p < 0.0001).

CONCLUSIONS

Small-cell cancer of the gu tract is an aggressive cancer, with a poor prognosis overall. Although there is no standard of care, patients should be treated using a multimodality approach analogous to that used in the treatment of small-cell lung cancer.

Loss of caveolin-1 from bronchial epithelial cells and monocytes in human subjects with asthma

BACKGROUND

Caveolin-1 has emerged as a critical regulator of signaling pathways involved in lung fibrosis and inflammation.

METHODS

Therefore, we investigated whether caveolin-1 is deficient in asthmatic patients and in a murine model of asthma.

RESULTS

Immunohistochemical analyses of endobronchial biopsies showed a remarkable loss of caveolin-1 in the lungs of asthmatic patients compared with controls. This loss was most evident in bronchial epithelial cells and associated with an increase in the expression of extracellular matrix proteins: collagen I, tenascin, and periostin. Cultured primary bronchial epithelial cells of asthmatics had lower caveolin-1 expression compared with control cells. In addition, caveolin-1 expression was significantly decreased in peripheral blood monocytes from asthma patients. The loss of caveolin-1 was also observed in a mouse model for asthma (mice sensitized and challenged with aspergillus fumigatus).

CONCLUSIONS

To our knowledge, this is the first demonstration that the regulatory protein caveolin-1 is reduced in patients with asthma.

Gender differences in enrolment in an HIV-treatment programme in rural Lesotho, 2006-2008: a brief report

The southern African nation of Lesotho has an HIV seroprevalence of approximately 25%. To address the need for HIV care in rural Lesotho, a project called the Rural Health Initative (RHI) was launched in seven clinics in 2006. Data on enrolment were collected retrospectively and analysed for trends in gender enrolment over time. Of 6001 enrolled, 3904 were women (65.1%) and 2097 (34.9%) were men. When analysed by month of enrolment, there was a higher percentage of men enrolled in December compared with the other months of the year (χ(2) = 15.98, P < 0.001). This may be due to the migratory work of the men in the mines of South Africa and suggests a need for targeted interventions to increase male enrolments over the entire calendar year.

Quality-of-life outcomes in high-risk prostate cancer patients treated with helical tomotherapy in a hypofractionated radiation schedule with long-term androgen suppression

PURPOSE

We examined the impact of hypofractionated radiation therapy and androgen suppression therapy (AST) on quality of life (QOL) in high-risk prostate cancer patients.

METHODS

Between March 2005 and March 2007, 60 patients with high-risk prostate cancer were enrolled in a prospective phase ii study. All patients received 68 Gy (2.72 Gy per fraction) to the prostate gland and 45 Gy (1.8 Gy per fraction) to the pelvic lymph nodes in 25 fractions over 5 weeks. Of the 60 patients, 58 received ast. The University of California-Los Angeles Prostate Cancer Index questionnaire was used to prospectively measure QOL at baseline (month 0) and at 1, 6, 12, 18, 24, 30, and 36 months after radiation treatment. The generalized estimating equation approach was used to compare the QOL scores at 1, 6, 12, 18, 24, 30, and 36 months with those at baseline.

RESULTS

We observed a significant decrease in QOL items related to bowel and sexual function. Several QOL items related to bowel function were significantly adversely affected at both 1 and 6 months, with improvement toward 6 months. Although decreased QOL scores persisted beyond the 6-month mark, they began to re-approach baseline at the 18- to 24-month mark. Most sexual function items were significantly adversely affected at both 1 and 6 months, but the effects were not considered to be a problem by most patients. A complete return to baseline was not observed for either bowel or sexual function. Urinary function items remained largely unaffected, with overall urinary function being the only item adversely affected at 6 months, but not at 1 month. Urinary function returned to baseline and remained unimpaired from 18 months onwards.

CONCLUSIONS

In our study population, who received hypofractionated radiation delivered using dynamic intensity-modulated radiotherapy with inclusion of the pelvic lymph nodes, and 2-3 years of ast prescription, QOL with respect to bowel and sexual function was significantly affected; QOL with respect to urinary function was largely unaffected. Our results are comparable to those in other published studies.