Robot-assisted partial nephrectomy using the novel Hugo™ RAS system: Feasibility, setting and perioperative outcomes of the first off-clamp series

INTRODUCTION

Hugo Robot-Assisted Surgery (RAS) System has been conceived with enhanced modularity but its role for nephron-sparing surgery setting still remains poorly explored. We aimed to describe our experience in robot-assisted partial nephrectomy (RAPN) with a three-arms setting for the first off-clamp series using the new Hugo RAS System.

METHODS

Patients were placed on an extended flank position at the margin of the surgical bed with a slightly flexion (45°). The first 11 mm robotic trocar (camera port) was placed along the pararectal line 14 ± 2 cm far from the umbilicus. The pneumoperitoneum was then induced through the AirSeal system (SurgiQuest, Milford, Connecticut, USA©). Two more 8 mm operative robotic ports were placed under direct vision, either 8 ± 1 cm far from optic's port. Two 12 mm laparoscopic ports for bed-assistant were placed between robotic ports. Monopolar curved shears, fenestrated grasper, and large needle driver were used in a three-instruments configuration.

RESULTS

Off-clamp RAPN was successfully performed in seven patients with cT1 renal masses using a trans-peritoneal route. Median port placement and docking time was 6 min (IQR, 4-8 min). Hemostasis was achieved through renorraphy using a single transfix stitch with sliding clips technique. There was no need for additional ports placement. No intraoperative complications occurred, no clashing of robotic instruments or between the robotic arms was observed. No technical failures of the system occurred. Median console time was 83 min (IQR, 68-115 min). Median estimated blood loss were 200 ml (IQR, 50-400 ml). All patients were discharged between post-operative day 2 and 3, without the need of hospital readmission. No complications were recorded within the first 30 post-operative days.

CONCLUSIONS

We performed the first series of off-clamp RAPN using the novel HUGO RAS System. This novel robotic platform showed an easy-friendly docking system, providing excellent perioperative outcomes with a simple three-arms configuration.

Evidence of an upper ionospheric electric field perturbation correlated with a gamma ray burst

Earth's atmosphere, whose ionization stability plays a fundamental role for the evolution and endurance of life, is exposed to the effect of cosmic explosions producing high energy Gamma-ray-bursts. Being able to abruptly increase the atmospheric ionization, they might deplete stratospheric ozone on a global scale. During the last decades, an average of more than one Gamma-ray-burst per day were recorded. Nevertheless, measurable effects on the ionosphere were rarely observed, in any case on its bottom-side (from about 60 km up to about 350 km of altitude). Here, we report evidence of an intense top-side (about 500 km) ionospheric perturbation induced by significant sudden ionospheric disturbance, and a large variation of the ionospheric electric field at 500 km, which are both correlated with the October 9, 2022 Gamma-ray-burst (GRB221009A).

Omics sciences and precision medicine in breast and ovarian cancer

Background

Human breast carcinoma is a complex disease, affecting 1 in 8 women worldwide. The seriousness of the disease increases when the definite cause of the disease remains obscure, thus making prognosis challenging. Researchers are emphasizing on adapting more advanced and targeted therapeutic approaches to address the multifaceted impacts of the disease. Hence, modern multi-omics systems have gained popularity among clinicians, as they offer insights into the genomic, pharmacogenomic, metabolomic, and microbiomic factors, thus allowing researchers to develop targeted and personalized approaches for breast cancer prevention and early detection, and eventually improving patient outcomes.

Aim

The primary focus of this study is to elucidate, through the integration of multi-omics research findings, the inherent molecular origins of diverse subtypes of breast cancer and to evaluate the effectiveness of these findings in reducing breast cancer-related mortalities.

Methods

Thorough investigation was conducted by reviewing reputable and authoritative medical journals, e-books, and online databases dedicated to cancer research. The Mendelian inheritance in man database (OMIM) was used to scrutinize specific genes and their respective loci associated with the development of different types of breast cancer.

Results

Our present research revealed the holistic picture of sundry molecular, genomic, pharmacogenomic, metabolomic, and microbiomic features of breast cancer. Such findings, like genetic alterations in highly penetrant genes, plus metabolomic and microbiomic signatures of breast cancer, unveil valuable insights and show great potential for multi-omics research in breast oncology.

Conclusion

Further research in omics sciences pertaining to breast cancer are at the forefront of shaping precise treatment and bolstering patient survival.

Characterization of somatic mutations in the pathogenesis of lipedema

Background

Lipedema, a complex and enigmatic adipose tissue disorder, remains poorly understood despite its significant impact on the patients' quality of life. Genetic investigations have uncovered potential contributors to its pathogenesis, including somatic mutations, which are nonheritable genetic alterations that can play a pivotal role in the development of this disease.

Aim

This review aims to elucidate the role of somatic mutations in the etiology of lipedema by examining their implications in adipose tissue biology, inflammation, and metabolic dysfunction.

Results

Studies focusing on leukocyte clones, genetic alterations like TET2 and DNMT3A, and the intricate interplay between adipose tissue and other organs have shed light on the underlying mechanisms driving lipedema. From the study of the scientific literature, mutations to genes correlated to three main pathways could be involved in the somatic development of lipedema: genes related to mitochondrial activity, genes related to localized disorders of subcutaneous adipose tissue, and genes of leukocyte clones.

Conclusions

The insights gained from these diverse studies converge to highlight the complex genetic underpinnings of lipedema and offer potential avenues for therapeutic interventions targeting somatic mutations to alleviate the burden of this condition on affected individuals.

Novel Nanogels Loaded with Mn(II) Chelates as Effective and Biologically Stable MRI Probes

Here it is described nanogels (NG) based on a chitosan matrix, which are covalently stabilized by a bisamide derivative of Mn-t-CDTA (t-CDTA = trans-1,2-diaminocyclohexane-N,N,N',N'-tetraacetic acid). the Mn(II) complex acts both as a contrast medium and as a cross-linking agent. These nanogels are proposed as an alternative to the less stable paramagnetic nanogels obtained by electrostatic interactions between the polymeric matrix and paramagnetic Gd(III) chelates. The present novel nanogels show: i) relaxivity values seven times higher than that of typical monohydrated Mn(II) chelates at the clinical fields, thanks to the combination of a restricted mobility of the complex with a fast exchange of the metal-bound water molecule; ii) high stability of the formulation over time at pH 5 and under physiological conditions, thus excluding metal leaking or particles aggregation; iii) good extravasation and accumulation, with a maximum contrast achieved at 24 h post-injection in mice bearing subcutaneous breast cancer tumor; iv) high T1 contrast (1 T) in the tumor 24 h post-injection. These improved properties pave the way for the use of these paramagnetic nanogels as promising magnetic resonance imaging (MRI) probes for in vitro and in vivo preclinical applications.

State of the Art in Robotic Surgery with Hugo RAS System: Feasibility, Safety and Clinical Applications

Since its introduction in the early 2000s, robotic surgery has represented a significative innovation within a minimally invasive surgery approach. A variety of robotic platforms have been made available throughout the years, and the outcomes related to those platforms have been described in the literature for many types of surgeries. Medtronic's HugoTM RAS system is one of the newest robotic generations launched, but because of its recent placing on the field, comprehensive clinical data are still lacking. The aim of the present state of the art is to address the current literature concerning the use of the HugoTM RAS robot in order to report its feasibility, safety and clinical applications in different surgical branches. Two reviewers independently conducted a search on the "PubMed" electronic database, using the keywords "Hugo" and "Hugo RAS". After the initial screening of 35 results, a total of 15 articles concerning the Hugo RAS system were selected for the review, including both oncological and benign surgery. Patients' demographic and baseline data were compared including, when available, docking system times, complications and oncological outcomes in the fields of urologic, gynecologic and general surgery. With reference to urological procedures, a total of 156 robot-assisted radical prostatectomies, 10 robot-assisted partial nephrectomies, and 5 robot-assisted adrenalectomies were performed, involving a total of 171 patients. The surgical branch in which the Hugo system found its major application was urology, which was followed by gynecology and general surgery. The Hugo RAS system by Medtronic represents an innovative and safe surgical platform, with excellent perspective for the future and different clinical applications in many surgical branches. More studies are needed to validate the safety and results from this new robotic platform.

Assessment of long-term cognitive dysfunction in older patients who undergo heart surgery

INTRODUCTION

Older patients are more likely to have cognitive dysfunction, and a great proportion of patients undergone surgical procedures are older adults. Postoperative cognitive dysfunction (POCD) has been shown as a consistent complication after major surgical procedures such as heart surgery.

AIM

To determine the presence of long-term POCD in ≥65-year-old patients undergoing coronary artery bypass grafting and aortic valve replacement, and to establish related risk factors.

METHODS

We prospectively and sequentially included 44 patients with coronary disease and aortic stenosis scheduled for heart surgery. Follow-up of all patients was standardized and a neurocognitive evaluation were performed preoperatively and at 1, 6 and 12 months after surgery.

RESULTS

Patients experienced a significantly postoperative cognitive dysfunction (33.5%, 63.4% and 38.9% at 1, 6 and 12 months, respectively) from baseline (20.5%). Patient-associated aspects such as age (p<0.01), history of smoking (p<0.01), arterial hypertension (p=0.022), diabetes mellitus (p=0.024), heart failure (p=0.036) and preoperative cognitive dysfunction (p<0.01), and surgery-associated aspects such as EuroSCORE (p<0.01) and operation time (p<0.01) were identified as related risk factors.

CONCLUSIONS

Older patients who underwent heart surgery had long-term POCD. Both patient- and surgery-related risk factors were established as related risk factors. These findings suggest that the prevalence of cognitive dysfunction after cardiac surgery in older patients could be related to a possible progression to dementia. In addition, many of the risk factors identified may be modifiable but in practice, these patients are not attended to for their possible cognitive impairment.

Comparative analysis of bats and rodents' genomes suggests a relation between non-LTR retrotransposons, cancer incidence, and ageing

The presence in nature of species showing drastic differences in lifespan and cancer incidence has recently increased the interest of the scientific community. In particular, the adaptations and the genomic features underlying the evolution of cancer-resistant and long-lived organisms have recently focused on transposable elements (TEs). In this study, we compared the content and dynamics of TE activity in the genomes of four rodent and six bat species exhibiting different lifespans and cancer susceptibility. Mouse, rat, and guinea pig genomes (short-lived and cancer-prone organisms) were compared with that of naked mole rat (Heterocephalus glaber) which is a cancer-resistant organism and the rodent with the longest lifespan. The long-lived bats of the genera Myotis, Rhinolophus, Pteropus and Rousettus were instead compared with Molossus molossus, which is one of the organisms with the shortest lifespan among the order Chiroptera. Despite previous hypotheses stating a substantial tolerance of TEs in bats, we found that long-lived bats and the naked mole rat share a marked decrease of non-LTR retrotransposons (LINEs and SINEs) accumulation in recent evolutionary times.

Pouch Transfer for Single Coronary Artery With Nodal Artery Variant in Arterial Switch Operation

The arterial switch operation with single coronary artery variance is an independent risk factor for increased operative mortality. There are reports of technical modifications, such as the double-barreled sinus pouch configuration, to improve geometric reimplantation of the single coronary into the neoaortic sinus. We describe the novel application of this technique for transferring a single coronary artery with a separate nodal artery emanating from the opposite sinus during an arterial switch operation.

Intraoperative Sapien S3 Valve Placement in 2 Patients With Multi-Valvar Disease Operation: A Unique Hybrid Procedure

There has been a paradigm shift in the management of patients with congenital heart disease with a move away from conventional surgical treatment in favor of a percutaneous catheter-based approach across the spectrum of valvular heart diseases. The Sapien S3 valve implantation in the pulmonary position has been previously reported using a conventional transcatheter approach in patients with pulmonary insufficiency due to an enlarged right ventricular outflow tract. In this report, we present 2 unique cases of intraoperative hybrid implantation of Sapien S3 valves in patients with complex pulmonic and tricuspid valvular disease.

Dataset of night-time emissions of the Earth in the near UV range (290-430 nm), with 6.3 km resolution in the latitude range -51.6<L<+51.6 degrees, acquired on board the International Space Station with the Mini-EUSO detector

The data presented in this article are related to the research paper entitled "Observation of night-time emissions of the Earth in the near UV range from the International Space Station with the Mini-EUSO detector" (Remote Sensing of Environment, Volume 284, January 2023, 113336, https://doi.org/10.1016/j.rse.2022.113336). The data have been acquired with the Mini-EUSO detector, an UV telescope operating in the range 290-430 nm and located inside the International Space Station. The detector was launched in August 2019, and it has started operations from the nadir-facing UV-transparent window in the Russian Zvezda module in October 2019. The data presented here refer to 32 sessions acquired between 2019-11-19 and 2021-05-06. The instrument consists of a Fresnel-lens optical system and a focal surface composed of 36 multi-anode photomultiplier tubes, each with 64 channels, for a total of 2304 channels with single photon counting sensitivity. The telescope, with a square field-of-view of 44°, has a spatial resolution on the Earth surface of 6.3 km and saves triggered transient phenomena with a temporal resolution of 2.5 µs and 320 µs. The telescope also operates in continuous acquisition at a 40.96 ms scale. In this article, large-area night-time UV maps obtained processing the 40.96 ms data, taking averages over regions of some specific geographical areas (e.g., Europe, North America) and over the entire globe, are presented. Data are binned into 0.1° × 0.1° or 0.05° × 0.05° cells (depending on the scale of the map) over the Earth's surface. Raw data are made available in the form of tables (latitude, longitude, counts) and .kmz files (containing the .png images). These are - to the best of our knowledge - the highest sensitivity data in this wavelength range and can be of use to various disciplines.

Modified FMCW Scheme for Improved Ultrasonic Positioning and Ranging of Unmanned Ground Vehicles at Distances < 50 mm

Unmanned ground vehicles (UGVs) find extensive use in various applications, including that within industrial environments. Efforts have been made to develop cheap, portable, and light-ranging/positioning systems to accurately locate their absolute/relative position and to automatically avoid potential obstacles and/or collisions with other drones. To this aim, a promising solution is the use of ultrasonic systems, which can be set up on UGVs and can potentially output a precise reconstruction of the drone's surroundings. In this framework, a so-called frequency-modulated continuous wave (FMCW) scheme is widely employed as a distance estimator. However, this technique suffers from low repeatability and accuracy at ranges of less than 50 mm when used in combination with low-resource hardware and commercial narrowband transducers, which is a distance range of the utmost importance to avoid potential collisions and/or imaging UGV surroundings. We hereby propose a modified FMCW-based scheme using an ad hoc time-shift of the reference signal. This was shown to improve performance at ranges below 50 mm while leaving the signal unaltered at greater distances. The capabilities of the modified FMCW were evaluated numerically and experimentally. A dramatic enhancement in performance was found for the proposed FMCW with respect to its standard counterpart, which is very close to that of the correlation approach. This work paves the way for the future use of FMCWs in applications requiring high precision.

Analysis of Signal Processing Methods to Reject the DC Offset Contribution of Static Reflectors in FMCW Radar-Based Vital Signs Monitoring

Frequency-modulated continuous wave (FMCW) radars are currently being investigated for remote vital signs monitoring (measure of respiration and heart rates) as an innovative wireless solution for healthcare and ambient assisted living. However, static reflectors (furniture, objects, stationary body parts, etc.) within the range or range angular bin where the subject is present contribute in the Doppler signal to a direct current (DC) offset. The latter is added to the person's information, containing also a useful DC component, causing signal distortion and hence reducing the accuracy in measuring the vital sign parameters. Removing the sole contribution of the unwanted DC offset is fundamental to perform proper phase demodulation, so that accurate vital signs monitoring can be achieved. In this work, we analyzed different DC offset calibration methods to determine which one achieves the highest accuracy in measuring the physiological parameters as the transmitting frequency varies. More precisely, by using two FMCW radars, operating below 10 GHz and at millimeter wave (mmWave), we applied four DC offset calibration methods to the baseband radar signals originated by the cardiopulmonary activities. We experimentally determined the accuracy of the methods by measuring the respiration and the heart rates of different subjects in an office setting. It was found that the linear demodulation outperforms the other methods if operating below 10 GHz while the geometric fitting provides the best results at mmWave.

HeartMate 3 implantation for dextro-transposition of the great arteries after Mustard procedure: A technique of papillary muscle repositioning

Systemic right ventricular failure after physiologic repair for dextro-transposition of the great arteries can be managed with durable mechanical circulatory support; however, the right ventricular morphology, such as intervening papillary muscles, presents challenges to inflow cannula positioning. Papillary muscle repositioning is an innovative technique to circumvent obstructive anatomy.

Accuracy of femoral tunnel positioning in medial patellofemoral ligament reconstruction: anatomic insertion leads to better clinical outcome

PURPOSE

The medial patello-femoral ligament (MPFL) is considered the primary restraint against patellar dislocation and its reconstruction is indicated in recurrent patellar instability. An anatomical positioning of MPFL femoral insertion is recommended to achieve satisfactory clinical outcomes and prevent osteoarthritis (OA) due to an altered kinematics. The purpose of the study was first to assess the relationship between correct femoral tunnel position and better clinical outcomes and lower patellofemoral osteoarthritis rate. Second, correlation of outcomes with factors potentially affecting the results, such as the type of graft, patellar height and trochlear dysplasia.

METHODS

Fifty-three patients (58 knees) who underwent MPFL reconstruction between 2009 and 2018 by a senior knee surgeon were retrospectively evaluated. Knee radiographs were performed before surgery, 12 months later and at last follow-up to assess trochlear dysplasia, patellar height and patellofemoral OA. The tibial tuberosity-trochlear groove (TT-TG) value was measured on a CT scan. The accuracy of graft positioning was evaluated on sagittal radiographs according to Schöttle et al. Subjective outcomes were collected before surgery, at 12 months and at last follow-up using several validated scores.

RESULTS

Forty-six patients (51 knees) with a mean age of 24.1 ± 7.4 years were included in the study. Mean follow-up was 8.9 ± 2.1 years. A significant improvement in all clinical scores was observed at 12 months and final follow-up. Anatomic Insertion (AI) of reconstructed MPFL was considered optimal in 33 (64.7%) and sub-optimal in 18 (35.3%) patients. Sub-optimal AI resulted in lower Kujala, IKCD and higher VAS score (p < 0.01); moreover, for every 1 mm distance in any direction from the ideal insertion, a decrease of 0.8 [95% CI (-1.4; -0.2)] in Kujala score and 0.8 [95% CI (-1.3; -0.3)] in IKDC was observed. At final follow-up, 8 patients presented patellofemoral OA Iwano grade 3 (15.7%): although that incidence did not correlate to graft positioning, the use the artificial ligament in all these cases appeared to be significant.

CONCLUSION

The present study confirms the importance of an optimal anatomic femoral insertion in MPFL reconstruction, reporting a significant positive correlation between graft positioning and clinical outcome. No significant correlations were found between anatomic insertion and patello-femoral OA development.

LEVEL OF EVIDENCE

IV.

Designing active breaks in secondary school, results from focus group with teachers: the brave study

Background

Many adolescents are unable to accomplish the daily 60 minutes of moderate to vigorous physical activity (PA) recommended by WHO. Secondary school is a critical period for developing healthy habits and PA interventions have the potential to promote healthy development. Active Breaks (ABs) are a school-based intervention consisting of short bursts (5-15 minutes) of PA made part of the academic routine. Primary school has been ABs main setting, while secondary school interventions received less attention. The aim of the BRAVE Study is to investigate teachers’ opinion about the feasibility of ABs in Italian secondary school.

Methods

In November 2020 20 teachers from two secondary schools located in Bologna province (Italy) were enrolled in two focus groups (FGs). FGs were held online, recorded, and transcribed. Questions were asked about the role of PA in the school routine and related experiences, perceived barriers and facilitators of the intervention, suggestions regarding the intervention design. Final expectations were then discussed.

Results

Despite limited experience with PA interventions, participants felt ABs would improve psycho-physical well-being for both students and teachers. Lack of time and space and a wary attitude towards ABs were listed as barriers. Program flexibility regarding content, administration time frames and implementation mode was listed as a great facilitator: program should be adaptable to participants’ needs, favoring easy and quick exercises. Overall, expectations emphasized improving classroom behavior and promoting healthy habits.

Conclusions

Teachers felt that inclusion of ABs in secondary school was promising and could lead to many health benefits. ABs were deemed feasible given their short duration and adaptability, since the program can be implemented with current personnel resources and space configurations. Co-design is essential to overcome personal barriers and create an effective and sustainable intervention.

Key messages

• According to secondary school teachers, PA interventions have the potential to improve psycho-physical well-being and classroom environment, promoting healthy habits among students.

• ABs are deemed as a feasible and sustainable PA intervention thanks to program flexibility regarding contents, administration time frames and implementation mode.

Potential association between working memory and physical fitness status: the BRAVE study

Introduction

The World Health Organization launched a global action plan targeted to obtain a 15% relative reduction in the global prevalence of physical inactivity in adolescents by 2030 also promoting school-based PA interventions and programs in school. Active Breaks (ABs) are a school-based intervention consisting of short bursts (5-15 minutes) of Pa led by teachers or peer. Many researches investigated the implementation of ABs into primary school setting as a strategy to reduce sedentary behaviour, improve cognitive and physical function. However, this kind of intervention has not extended to secondary school, especially in Italian context. For this reason we started the BRAVE study to evaluate the potential effect of implementing ABs in secondary school. The study is currently in the administration phase of ABs to adolescents The preliminary analysis aims to underline a potential association between working memory performance (WM) and physical fitness status among secondary school students at baseline.

Methods

In March 2022 we conducted baseline assessment in a secondary school in Valsamoggia (Bologna, Italy). Working memory was evaluated using backward digit span while physical fitness status was assessed using three different fitness test: standing long-jump (SLJ), six minute Cooper Test (6MCT) and Shuttle run test (SR).

Results

A total of n = 125 adolescent, mean age 12.79±0.89, were enrolled in the study. After performing a regression analysis we found that WM is significantly associated only with age of student (b = 0.2, 95%CI 0.25, 0.11 p = 0.02). A trend also emerged between WM performance and SLJ but with no statistically significant differences (b = 0.160, 95%CI 0.03, 0.02, p = 0.09). The 6MCT and HT have no relevant associations with WM score.

Conclusions

These preliminary results suggest that age is associated with cognitive performance but no positive association were found between WM score and physical fitness status excepted for a small trend with SLJ test.

Key messages

• Age is related to WM in adolescent students.

• ABs interventions could represent a valid strategy to encourage movement, improve cognitive and physical fitness performance.

The Brave study: promoting active breaks in secondary school from students’ point of view

Background

According to the WHO recommendations, children and adolescents should perform at least 60 minutes per day of moderate to vigorous physical activity (PA). Active Breaks (ABs) interventions, short physical activity breaks of 5-15 minutes during school hours, have been examined in primary school children as a potential strategy to counteract a sedentary lifestyle, with minimal disruption to school learning activities. The aim of the BRAVE STUDY is to investigate the feasibility of ABs in a secondary school setting from the students’ point of view.

Methods

In December 2020, 10 students (age 12-13, 6 females and 4 males) attending the second and third grade of secondary schools located in Bologna province (Italy) were involved in a focus group (FG). The FG was conducted online because of COVID-19 and the answers transcribed for a later analysis. Students’ opinions were probed on the role of PA in school and possible facilitators/barriers to implementation of ABs in the school.

Results

Students reported they wanted to be more active as a consequence of time spent in class sitting at a desk. Students also reported that an organized activity like ABs conducted in the classroom setting provides an excellent opportunity to improve social relations with classmates. Students also highlighted the possible psycho-physical well-being benefits arising from PA. Among the potentially negative aspects reported, students underlined the possible confusion that would be created in classroom and the time subtracted from academic learning activities.

Conclusions

The FG represents an ideal mean to obtain in-depth information on how people feel about a pending program or a change in their routine. The current FG reinforces positive outcomes from exposure to a PA program that can be intertwined with their daily classroom activities. ABs programs can help to reconcile the needs of students that arise during the day with the PA objectives recommended by the WHO.

Key messages

• ABs can be a zero-cost intervention strategy to achieve WHO recommendations and would create conditions for a greater psycho-physical benefits in classrooms.

• A qualitative approach, such as FGs, provides a mean to collect information not obtainable with quantitative methods, that could be useful to co-design interventions for children and adolescents.

The effect of active breaks on cognitive performance and classroom behaviour: the I-move study

Background

Active Breaks (ABs) intervention involves short bouts of moderate to vigorous physical activity (MVPA) conducted during or between curricular lessons by the appropriately trained teachers. The aim of the Imola Active Breaks Study (I-MOVE study) was to evaluate the effect of an ABs intervention on cognitive function and classroom behaviour in primary school children.

Methods

The study was quasi-experimental, and it involved two groups attending a primary school in Imola (Bologna, Italy). The Active Breaks group (ABsG) performed the I-MOVE protocol consisting in 10 minutes of ABs divided in warm up, tone-up with high intensity interval training and cool-down. This is repeated three times a day for one year and half. The control group (CG) continued with regular lessons. The baseline assessment was conducted in October 2019 and the follow-up in May 2021. Cognitive performance was assessed using working memory test and classroom behaviour was monitored using an “ad hoc questionnaire”.

Results

Working memory performance increased significantly more in the ABsG (change: 1.30±1.17) than in CG (0.96±1.20), p &lt; 0.05. Almost the entire sample of the children wanted to continue with this intervention in the next following year. Children reported improvements in their school-life quality, including feeling better in class (75.40%) and in school (82.50%) when using ABs. Improvements were also reported in children time-on-task behaviours: 52.90% said they work easily in class, 52.90% that they could listen more clearly, 58.80% reported they can stay seated easily, and 59.60% that they learned better and were more focused after ABs.

Conclusions

In conclusion the program has proven to be very effective on the children's cognitive improvement and classroom behaviour. Since the ABs intervention demonstrates these positive effects, its implementation in schools can have a beneficial, sustainable and long-term impact on childhood health.

Key messages

• ABs intervention represents a cost-effective strategy to be implemented in the school settings regardless of the age and sex differences, to make the school a more dynamic environment.

• Despite the pandemic difficulties, the ABs intervention proved to be sustainable, and to have a positive effect on classroom behaviour by improving children’s concentration and attention in class.

Optimised polymer trapped-air lenses for ultrasound focusing in water exploiting Fabry-Pérot resonance

The concept of employing air volumes trapped inside polymer shells to make a lens for ultrasound focusing in water is investigated. The proposed lenses use evenly-spaced concentric rings, each having an air-filled polymer shell construction, defining concentric water-filled channels. Numerical simulations and experiments have shown that a plane wave can be focused, and that the amplification can be boosted by Fabry-Pérot resonances within the water channels with an appropriate choice of the lens thickness. The effect of the polymer shell thickness and the depth of the channels is discussed, as these factors can affect the geometry and hence the frequency of operation. The result was a lens with a Full Width at Half Maximum value of 0.65 of a wavelength at the focus. Results obtained on a metal-based counterpart are also shown for comparison. An advantage of this polymeric design is that it is easily constructed via additive manufacturing. This study shows that trapped-air lenses made of polymer are suitable for ultrasound focusing in water near 500 kHz.

Derivatives of GdAAZTA Conjugated to Amino Acids: A Multinuclear and Multifrequency NMR Study

The GdAAZTA (AAZTA = 6-amino-6-methylperhydro-1,4-diazepinetetraacetic acid) complex represents a platform of great interest for the design of innovative MRI probes due to its remarkable magnetic properties, thermodynamic stability, kinetic inertness, and high chemical versatility. Here, we detail the synthesis and characterization of new derivatives functionalized with four amino acids with different molecular weights and charges: l-serine, l-cysteine, l-lysine, and l-glutamic acid. The main reason for conjugating these moieties to the ligand AAZTA is the in-depth study of the chemical properties in aqueous solution of model compounds that mimic complex structures based on polypeptide fragments used in molecular imaging applications. The analysis of the ¹H NMR spectra of the corresponding Eu(III)-complexes indicates the presence of a single isomeric species in solution, and measurements of the luminescence lifetimes show that functionalization with amino acid residues maintains the hydration state of the parent complex unaltered (q = 2). The relaxometric properties of the Gd(III) chelates were analyzed by multinuclear and multifrequency NMR techniques to evaluate the molecular parameters that determine their performance as MRI probes. The relaxivity values of all of the novel chelates are higher than that of GdAAZTA over the entire range of applied magnetic fields because of the slower rotational dynamics. Data obtained in reconstituted human serum indicate the occurrence of weak interactions with the proteins, which result in larger relaxivity values at the typical imaging fields. Finally, all of the new complexes are characterized by excellent chemical stability in biological matrices over time, by the absence of transmetallation processes, or the formation of ternary complexes with oxyanions of biological relevance. In particular, the kinetic stability of the new complexes, measured by monitoring the release of Gd³⁺ in the presence of a large excess of Zn²⁺, is ca. two orders of magnitude higher than that of the clinical MRI contrast agent GdDTPA.

Novel GdAAZTA derivatives conjugated to four amino acids were synthesized and characterized through a multi-technique approach. The complexes maintained the favorable thermodynamic and kinetic properties of the parent compound and showed higher relaxivity values in clinical fields. Therefore, they represent a useful model of more complex bio-conjugated structures used in molecular imaging applications.

Single‐Center Experience of Hybrid Pulmonary Valve Replacement Using Left Anterior Thoracotomy With Pulmonary Artery Plication in Patients With Large Right Ventricular Outflow Tract

Background

Until recently, a large right ventricle outflow tract interfered with the feasibility of standard transcatheter pulmonary valve replacement (PVR). We are describing our experience using a hybrid approach for PVR using a left anterior thoracotomy approach to allow for plication of the main pulmonary artery followed by a transcatheter PVR using a Sapien S3 valve.

Methods and Results

This is a single‐center, retrospective review of patients who were evaluated to be appropriate for a hybrid PVR approach. The patients' demographics, procedure details, and follow‐up data were collected. Between May 2018 and April 2021, a total of 11 patients presented for hybrid transcatheter PVR. The median age and weight were 24 years (interquartile range, 19–43 years) and 81.8 kg (interquartile range, 69–91 kg), respectively. Nine out of 11 patients received a transcatheter PVR after main pulmonary artery plication. There were no procedurally related deaths. One major complication was encountered in which the valve was malpositioned requiring successful surgical PVR. Minor complications included acute kidney injury (n=1) and a broken rib (n=1). The median length of stay was 4 days (interquartile range, 2–4 days), with median follow‐up of 7 months (interquartile range, 3–18 months). A well‐functioning pulmonary valve was observed in all patients at the last follow‐up.

Conclusions

A hybrid approach using left anterior thoracotomy with pulmonary artery plication followed by transcatheter Sapien S3 PVR provides a less‐invasive option for patients with an enlarged right ventricular outflow tract. Preliminary results demonstrated this to be a safe option with good short‐term outcomes.

Epidemiological profile of patients with epilepsy attended in an emergency in a psychiatric hospital in 2020

Introduction

According to the Global Burden of Disease study (WHO, 2010), epilepsy is ranked as the second most impacting neurological disorder worldwide, in terms of disability-adjusted life years, and is often associated with psychiatric comorbidities, stigma and high economic costs. This frequent association between epilepsy and mental disorders is a fact, however, they are often underdiagnosed and undertreated in patients with epilepsy, which further reduces the quality of life of this population and induces the demand for psychiatric emergency care.

Objectives

To give the comorbid relevance between epilepsy and mental disorders, this study aims to identify the main psychiatric illnesses associated with patients with epilepsy treated at the emergency of a psychiatric hospital in 2020. In addition to establishing the clinical and epidemiological factors related to this association.

Methods

All patients diagnosed with epilepsy (G40), according to the International Classification of Diseases, who underwent emergency care at the HABM, São José do Rio Preto, São Paulo, in 2020. Epidemiological and clinical data were collected.

Results

There were 7258 consultations, with only 27 as cid G40. 71.4% were male, 55% single and age between 42-49 years old. 47.6% indicated psychiatric comorbidities (cid F06). 23.8% patients with both disorders were attended by psychiatrist.

Conclusions

The concomitant occurrence of psychiatric disorders and epilepsy has significant relevance. However, it is known that the diagnosis of psychiatric disorders in epileptic patients is sometimes late, poorly conducted or even underdiagnosed. Therefore, knowing the profile of patients with epilepsy allows us to identify the factors associated with the concomitant of psychiatric disorders.

Disclosure

No significant relationships.

High Relaxivity with No Coordinated Waters: A Seemingly Paradoxical Behavior of [Gd(DOTP)]5- Embedded in Nanogels

Nanogels (NGs) obtained by electrostatic interactions between chitosan and hyaluronic acid and comprising paramagnetic Gd chelates are gaining increasing attention for their potential application in magnetic resonance bioimaging. Herein, the macrocyclic complexes [Gd(DOTP)]⁵⁻, lacking metal-bound water molecules (q = 0), were confined or used as a cross-linker in this type of NG. Unlike the typical behavior of Gd complexes with q = 0, a remarkable relaxivity value of 78.0 mM^–1 s^–1 was measured at 20 MHz and 298 K, nearly 20 times greater than that found for the free complex. A careful analysis of the relaxation data emphasizes the fundamental role of second sphere water molecules with strong and long-lived hydrogen bonding interactions with the complex. Finally, PEGylated derivatives of nanoparticles were used for the first in vivo magnetic resonance imaging study of this type of NG, revealing a fast renal excretion of paramagnetic complexes after their release from the NGs.

Nanogels incorporating [Gd(DOTP)]⁵⁻ complexes (q = 0) exhibit remarkable relaxivity values, thanks to structured water molecules in the second coordination shell of the metal ion involved in strong H-bonding interactions with the phosphonate groups.

A135 DO VISCOUS SWALLOWS IMPROVE THE DIAGNOSTIC YIELD OF HIGH-RESOLUTION MANOMETRY?

Background

Esophageal motility disorders are diagnosed using high-resolution esophageal manometry (HR-EMS) using the Chicago Classification (CC V4.0) which is based on a series of 10 normal saline swallows (LS). Viscous swallows (VS; thickened liquid/applesauce) are often performed during esophageal manometry; however, they were not included within the framework of CC V4.0. Previous literature has suggested inconsistency between LS and VS in up to 25% of studies, yet it remains unclear whether routine use of VS offers any benefit to LS alone in diagnosing manometric abnormalities according to the CC V4.0.

Aims

To determine if the routine use of VS improves the diagnostic yield in HR-EMS

Methods

A retrospective analysis of all HR-EMS studies performed between December 2020 and July 2021 at Kingston Health Sciences Centre was completed. Demographic information including age, sex, indication for HR-EMS, surgical history, and chronic narcotic use was documented. Each study (consisting of 10 LS and 10 VS) was reviewed independently by a Gastroenterology Fellow and Neurogastroenterologist. A manometric diagnosis using CC V4.0 was made for both LS and VS. Descriptive statistics were performed.

Results

A total of 101 HR-EMS studies were reviewed (33 male, 68 female, age range 26 to 90 years). The most common indication for HR-EMS was dysphagia (87/101) with 23/101 having 2 indications, 30/101 having 3 indications, and 43/101 patients having >3 indications. Prior upper GI tract surgery and chronic narcotic use was recorded in 9/101 and 8/101 patients, respectively. Two HR-EMS studies were excluded due to incomplete protocol. In total, 38.4% (38/99) had normal HR-EMS for both LS and VS. LS and VS that resulted in a CC V4.0 diagnosis were concordant in 37.4%(37/99) and discordant in 24.2% (24/99). Of the 24 discordant studies, 6 had a CC V4.0 diagnosis for LS (4 esophagogastric outflow obstruction (EGJOO), 1 ineffective esophageal motility (IEM), 1 diffuse esophageal spasm) and normal VS. Ten studies had normal LS and a CC V4.0 diagnosis for VS (9 IEM, 1 EGJOO). Eight had differing CC V4.0 diagnoses for LS and VS.

Conclusions

LS and VS resulted in concordant diagnoses in the majority of cases. However, there were discordant results in approximately 25% of cases. In nearly half of these studies, the LS was within normal limits whereas VS yielded a diagnosis of an esophageal motility disorder which may be of clinical significance to the patient’s management. The addition of VS to HR-EMS protocol may increase diagnostic yield in symptomatic patients.

Funding Agencies

None

A Review of the EUSO-Balloon Pathfinder for the JEM-EUSO Program

EUSO-Balloon is a pathfinder for JEM-EUSO, the mission concept of a spaceborne observatory which is designed to observe Ultra-High Energy Cosmic Ray (UHECR)-induced Extensive Air Showers (EAS) by detecting their UltraViolet (UV) light tracks "from above." On August 25, 2014, EUSO-Balloon was launched from Timmins Stratospheric Balloon Base (Ontario, Canada) by the balloon division of the French Space Agency CNES. After reaching a floating altitude of 38 km, EUSO-Balloon imaged the UV light in the wavelength range ∼290-500 nm for more than 5 hours using the key technologies of JEM-EUSO. The flight allowed a good understanding of the performance of the detector to be developed, giving insights into possible improvements to be applied to future missions. A detailed measurement of the photoelectron counts in different atmospheric and ground conditions was achieved. By means of the simulation of the instrument response and by assuming atmospheric models, the absolute intensity of diffuse light was estimated. The instrument detected hundreds of laser tracks with similar characteristics to EASs shot by a helicopter flying underneath. These are the first recorded laser tracks measured from a fluorescence detector looking down on the atmosphere. The reconstruction of the direction of the laser tracks was performed. In this work, a review of the main results obtained by EUSO-Balloon is presented as well as implications for future space-based observations of UHECRs.

Case Report: Challenging Perioperative Decision-Making in a Neonate With Transposition of Great Arteries and Novel Coronary Anatomy

Transposition of great arteries (d-TGA) is often associated with various coronary artery (CA) patterns. These anomalous patterns can cause variable clinical symptoms of coronary ischemia including sudden death. CA pattern is one of the major determinants of outcome in TGA postoperatively. An advanced cardiac imaging and a multidisciplinary care approach are essential for a favorable outcome. Here, we describe a novel CA origin pattern in a neonate with d-TGA, who developed myocardial ischemia and required a coronary unroofing procedure for a full recovery.

Can treatment of posterior malleolus fractures with tibio-fibular instability be usefully addressed by Bartonicek classification?

INTRODUCTION

Ankle fractures account for 4% of all fractures and treatment of those involving the Posterior Malleolus remains controversial. Clinical and radiological outcomes in a cohort of patients with Posterior Malleolus fractures conservatively treated were retrospectively evaluated; furthermore, a treatment algorithm was suggested.

METHODS

Patients were divided according to Bartoníček classification. The clinical evaluation was made with OMAS/AOFAS scores; the radiological evaluation with Van Dijk classification for post-traumatic arthritis.

RESULTS

Clinical outcome worsened with the severity of Bartoníček classification, but early degenerative changes were not correlated neither to the clinical outcome nor to the injury pattern. Clinical and radiological outcomes depended on the damage of the syndesmosis as articular step-offs and tibio-fibular notch involvement.

DISCUSSION

We recommend conservative treatment for Bartoníček type I, type II and type III fractures, the latter when undisplaced and without tibial plafond depression. We suggest surgical treatment for type IV and displaced type III fractures.

SVEP1 IS IMPORTANT FOR MORPHOGENESIS OF LYMPHATIC SYSTEM: POSSIBLE IMPLICATIONS IN LYMPHEDEMA

SVEP1, also known as Polydom, is a large extracellular mosaic protein with functions in protein interactions and adhesion. Since Svep1 knockout animals show severe edema and lymphatic system malformations, the aim of this study is to evaluate the presence of SVEP1 variants in patients with lymphedema. We analyzed DNA from 246 lymphedema patients for variants in known lymphedema genes, 235 of whom tested negative and underwent a second testing for new candidate genes, including SVEP1, as reported here. We found three samples with rare heterozygous missense single-nucleotide variants in the SVEP1 gene. In one family, healthy members were found to carry the same variants and reported some subclinical edema. Based on our findings and a review of the literature, we propose SVEP1 as a candidate gene that should be sequenced in patients with lymphatic malformations, with or without lymphedema, in order to investigate and add evidence on its possible involvement in the development of lymphedema.

Holey-structured tungsten metamaterials for broadband ultrasonic sub-wavelength imaging in water

Metamaterials exhibiting Fabry-Pérot resonances are shown to achieve ultrasonic imaging of a sub-wavelength aperture in water immersion across a broad bandwidth. Holey-structured metamaterials of different thickness were additively manufactured using a tungsten substrate and selective laser melting, tungsten being chosen so as to create a significant acoustic impedance mismatch with water. Both broadband metamaterial behavior and sub-wavelength imaging in water are demonstrated experimentally and validated with finite element simulations over the 200-300 kHz range.

Venoarterial to venovenous extracorporeal life support conversion in pediatric acute respiratory distress syndrome

In patients with pediatric acute respiratory distress syndrome (PARDS) and hemodynamic compromise who need venoarterial (VA) extracorporeal life support (ECLS), we have adopted a strategy to promote early VA-to-venovenous (VV) conversion since 2018. A single-center retrospective review was performed of all 22 patients who underwent ECLS for PARDS from 2008 to 2019. Variables were analyzed to determine factors affecting initial cannulation mode and in-hospital mortality. Outcomes were compared between before and after 2018. Of the 22 patients, 9 patients underwent initial VA-support. Small patient size and severe cardiopulmonary compromise prior to ECLS favored initial VA- over VV-support. Lactate level and vasoactive inotrope score at 24 hours post-ECLS initiation predicted in-hospital mortality. After 2018, all five patients with initial VA-support were converted to VV-support at 4.4 ± 1.3 days post-ECLS initiation without complications. In-hospital mortality decreased after 2018 (3/9) compared with before (10/13) (p = 0.041) despite longer ECLS run time (723.4 ± 384.2 vs 286.5 ± 235.1 hours, p = 0.003). The number of ECLS-related complications per ECLS 1000 run hours decreased after 2018 (7.2 ± 4.2 vs 46.9 ± 66.5, p = 0.063). Our strategy to promote early VA-to-VV conversion may be worth further evaluation in larger cohort studies.

A106 BENZOCAINE-INDUCED METHEMOGLOBINEMIA: A RARE BUT POTENTIALLY FATAL COMPLICATION OF TOPICAL ANESTHETIC USE IN ESOPHAGOGASTRODUODENOSCOPY

Background

Methemoglobinemia is an uncommon and potentially lethal condition arising when the iron moiety of heme is oxidized from the ferrous (Fe2+) to ferric (Fe3+) state, causing a disruption of O2 binding and impairment of O2 delivery to tissue. There are two forms of methemoglobinemia: inherited and acquired. Acquired methemoglobinemia is caused by medications, including topical anesthetics (TAs) used in esophagogastroduodenoscopy (EGD).

Aims

To raise awareness of this serious complication of TA use.

Methods

A 66-year old woman underwent EGD for dysphagia and globus sensation. Her past medical history included gastroesophageal reflux disease, paraoesophageal hernia, coronary artery disease, and hypertension. Prior to EGD, her oropharynx was anesthetized with benzocaine spray and she was sedated with fentanyl 100 mcg and midazolam 3 mg. EGD was unremarkable. At completion she required no supplemental oxygen (SpO2 96%). In recovery, she became drowsy and cyanotic. Vital signs revealed an SpO2 of 86% that did not improve with 4L supplementary O2 via nasal prongs. Aside from cyanosis, physical examination was normal. ECG, chest X-ray, and CT scan with pulmonary embolism protocol did not identify a cause for hypoxia. Arterial blood gas (ABG) revealed dark brown blood with an PaO2 of 397 mmHg. Methemoglobinemia was suspected and confirmed with a serum methemoglobin (MHg) level of 18% (ref &lt;3%).

Results

Intravenous methylene blue (1g/kg) was administered with complete resolution of symptoms. She was admitted for monitoring and discharged the next day with no sequelae.

Conclusions

Methemoglobinemia is a rare condition (incidence 1/7000 procedures) of increased MHg due to the oxidation of iron in heme, compromising oxygen binding/offloading and delivery to tissues. Normal MHg levels are &lt;3%, which is maintained by NADH-MHg reductase. This enzyme reduces Fe3+ to Fe2+. TAs cause elevated methemoglobinemia by oxidizing iron (Fe2+ to Fe3+) at a rate 100-1000x faster than NADH-MHg reductase can reduce it. Benzocaine has been associated with a 3.7- fold higher risk of methemoglobinemia than other topical anesthetics, and the risk is not dose-dependent. Presentation varies with degree of MHg. Hallmark signs of cyanosis, impaired SpO2 with normal ABG, and “chocolate-colored” blood occur at levels&gt;10%. Death/coma occurs at levels &gt;50%. Incidence is idiosyncratic; however, those with smoking history or underlying cardiac/lung disease are at elevated risk for poor outcomes. The activity of NADH-MHg reductase is increased by methylene blue. When administered at doses of 1-2g/kg, it rapidly reduces MHg, restoring the physiological equilibrium. TAs are used routinely in EGD. Gastroenterologists who use TAs in procedures need to be aware of the association between TAs and methemoglobinemia. Prompt recognition/treatment will prevent morbidity/mortality.

Funding Agencies

None

Assessment of long-term cognitive dysfunction in older patients who undergo heart surgery

INTRODUCTION

Older patients are more likely to have cognitive dysfunction, and a great proportion of patients undergone surgical procedures are older adults. Postoperative cognitive dysfunction (POCD) has been shown as a consistent complication after major surgical procedures such as heart surgery.

AIM

To determine the presence of long-term POCD in ≥65-year-old patients undergoing coronary artery bypass grafting and aortic valve replacement, and to establish related risk factors.

METHODS

We prospectively and sequentially included 44 patients with coronary disease and aortic stenosis scheduled for heart surgery. Follow-up of all patients was standardized and a neurocognitive evaluation were performed preoperatively and at 1, 6 and 12 months after surgery.

RESULTS

Patients experienced a significantly postoperative cognitive dysfunction (33.5%, 63.4% and 38.9% at 1, 6 and 12 months, respectively) from baseline (20.5%). Patient-associated aspects such as age (p<0.01), history of smoking (p<0.01), arterial hypertension (p=0.022), diabetes mellitus (p=0.024), heart failure (p=0.036) and preoperative cognitive dysfunction (p<0.01), and surgery-associated aspects such as EuroSCORE (p<0.01) and operation time (p<0.01) were identified as related risk factors.

CONCLUSIONS

Older patients who underwent heart surgery had long-term POCD. Both patient- and surgery-related risk factors were established as related risk factors. These findings suggest that the prevalence of cognitive dysfunction after cardiac surgery in older patients could be related to a possible progression to dementia. In addition, many of the risk factors identified may be modifiable but in practice, these patients are not attended to for their possible cognitive impairment.

SVEP1 is important for morphogenesis of lymphatic system: Possible implications in lymphedema

SVEP1, also known as Polydom, is a large extracellular mosaic protein with functions in protein interactions and adhesion. Since Svep1 knockout animals show severe edema and lymphatic system malformations, the aim of this study is to evaluate the presence of SVEP1 variants in patients with lymphedema. We analyzed DNA from 246 lymphedema patients for variants in known lymphedema genes, 235 of whom tested negative and underwent a second testing for new candidate genes, including SVEP1, as reported here. We found three samples with rare heterozygous missense single-nucleotide variants in the SVEP1 gene. In one family, healthy members were found to carry the same variants and reported some subclinical edema. Based on our findings and a review of the literature, we propose SVEP1 as a candidate gene that should be sequenced in patients with lymphatic malformations, with or without lymphedema, in order to investigate and add evidence on its possible involvement in the development of lymphedema.

REVIEW OF THE FUNCTION OF SEMA3A IN LYMPHATIC VESSEL MATURATION AND ITS POTENTIAL AS A CANDIDATE GENE FOR LYMPHEDEMA: ANALYSIS OF THREE FAMILIES WITH RARE CAUSATIVE VARIANTS

SEMA3A is a semaphorin involved in cell signaling with PlexinA1 and Neuropilin-1 (NRP1) receptors and it is responsible for recruiting dendritic cells into lymphatics. Mutations in the SEMA3A gene result in abnormalities in lymphatic vessel development and maturation. We investigated the association of SEMA3A variants detected in lymphedema patients with lymphatic maturation and lymphatic system malfunction. First, we used NGS technology to sequence the SEMA3A gene in 235 lymphedema patients who carry wild type alleles for known lymphedema genes. We detected three different missense variants in three families. Bioinformatic results showed that some protein interactions could be altered by these variants. Other unaffected family members of the probands also reported different episodes of subclinical edema. We then evaluated the importance of the SEMA3A gene in the formation and maturation of lymphatic vessels. Our results determined that SEMA3A variants segregate in families with lymphatic system malformations and recommend the inclusion of SEMA3A in the gene panel for testing of patients with lymphedema.

Statistical and Proactive Analysis of an Inter-Laboratory Comparison: The Radiocarbon Dating of the Shroud of Turin

We review the sampling and results of the radiocarbon dating of the archaeological cloth known as the Shroud of Turin, in the light of recent statistical analyses of both published and raw data. The statistical analyses highlight an inter-laboratory heterogeneity of the means and a monotone spatial variation of the ages of subsamples that suggest the presence of contaminants unevenly removed by the cleaning pretreatments. We consider the significance and overall impact of the statistical analyses on assessing the reliability of the dating results and the design of correct sampling. These analyses suggest that the 1988 radiocarbon dating does not match the current accuracy requirements. Should this be the case, it would be interesting to know the accurate age of the Shroud of Turin. Taking into account the whole body of scientific data, we discuss whether it makes sense to date the Shroud again.

Correction of post traumatic tibial varus deviation with hexapodalic external fixator

Physeal fractures are typical in childhood and for their involvement of the germinal layer of the physis they can be followed by growth complications. Axial deviation is one of these. Considering the young age of the patients it is critical to restore articular correct alignment with the least invasive surgery possible. We report here the first case of correction of post traumatic tibial varus deviation with exapodalic external fixator.

CYP26B1 AND ITS IMPLICATIONS IN LYMPHANGIOGENESIS: LITERATURE REVIEW AND STUDY OF RARE VARIANTS IN TWO FAMILIES

CYP26B1 is a member of the cytochrome P450 family and is responsible for the breakdown of retinoic acid for which appropriate levels are important for normal development of the cardiovascular and lymphatic systems. In a cohort of 235 patients with lymphatic malformations, we performed genetic testing for the CYP26B1 gene. These probands had previously tested negative for known lymphedema genes. We identified two heterozygous missense CYP26B1 variants in two patients. Our bioinformatic study suggested that alterations caused by these variants have no major effect on the overall stability of CYP26B1 protein structure. Balanced levels of retinoic acid maintained by CYP26B1 are crucial for the lymphatic system. We identified that CYP26B1 could be involved in predisposition for lymphedema. We propose that CYP26B1 be further explored as a new candidate gene for genetic testing of lymphedema patients.

Ultrasonic Propagation in Highly Attenuating Insulation Materials

Experiments have been performed to demonstrate that ultrasound in the 100-400 kHz frequency range can be used to propagate signals through various types of industrial insulation. This is despite the fact that they are highly attenuating to ultrasonic signals due to scattering and viscoelastic effects. The experiments used a combination of piezocomposite transducers and pulse compression processing. This combination allowed signal-to-noise levels to be enhanced so that signals reflected from the surface of an insulated and cladded steel pipe could be obtained.

A111 SEVERE FAT MALABSORPTION IN A PATIENT POST ILEAL POUCH ANAL ANASTAMOSIS: A RARE PRESENTATION OF MICROSCOPIC ENTERITIS

Background

Microscopic enteritis (ME) is a rare enteropathy characterized by malabsorptive diarrhea and lymphocytic infiltration +/- collagen deposition in the subepithelial layer of the small bowel. Its etiology is unclear.

Aims

To elucidate a rare cause of fat malabsorption and vitamin deficiency in a patient with ulcerative colitis and an ileoanal pouch.

Methods

A 74 yo male with a prior IPAA was referred to Internal Medicine in August 2018 for a 36 kg weight loss over 18 months and &gt;16 bowel movements (BM) per day (baseline 6, no history of pouchitis). Celiac serology and infectious workup were negative. Medical management and nutritional supplements did not result in weight gain or improvement of diarrhea. He was admitted in June 2019 with ongoing weight loss, AKI, and signs of fat-soluble vitamin deficiency. A 72-hour fecal fat analysis showed an average fecal weight of 2100 g/d (ref &lt;250 g/d), and excretion of 70% of daily fat intake (ref &lt;7%). His fecal elastase (FE) was 147 µg/g, consistent with moderate pancreatic insufficiency (PI) with mild atrophy on CT. EGD and pouch endoscopy were macroscopically normal, with histological findings of intraepithelial lymphocytosis and mild villous blunting in the duodenum and afferent limb. CT enterography excluded small bowel abnormalities. He was started on pancreatic enzyme replacement and discharged. He returned with worsening diarrhea and AKI. He was treated with supportive care and sent home. In the ensuing 3 weeks, he had up to 24 BM per day and 4 kg of weight loss. He returned in August 2019 with AKI, lack of PO intake and worsened nutritional status. Re-examination of duodenal biopsies from June 2019 revealed an added finding of focal subepithelial collagen thickening. Budesonide was started.

Results

On budesonide, his symptoms improved within days. BMs decreased to baseline, and his ability to sustain PO intake improved. At his 4-week follow-up visit, BMs were stable with a 6 kg weight gain and no ensuing laboratory abnormalities.

Conclusions

ME is a rare enteropathy that presents with malabsorption. Fat-soluble vitamin deficiencies can develop with widespread physiological disruption of the mucosal surface. This patient was a diagnostic challenge. His steatorrhea and reduced FE levels led clinicians down a diagnostic pathway of PI. FE is the most common test used in the diagnosis of PI. Levels &lt;200 µg/g are abnormal. Specificity is highest in chronic pancreatitis; however, this decreases in the presence of mucosal atrophy (i.e. IBD and diffuse small bowel disease). Thus, FE could not delineate the cause of steatorrhea in our patient. We can surmise that he likely has diffuse disease that was underestimated on duodenal biopsy. This is supported by his response to budesonide. This case highlights the heterogeneity of clinical presentations of ME. Awareness can reduce patient morbidity.

Funding Agencies

None