Accidental Cut-Throat Injury by a Broken Glass: Bloodstain Pattern Analyses and Autopsy Findings

Injuries in the neck region are rarely observed in forensic practice, especially of accidental origin. Primarily, such cases are associated with homicide or suicide. The neck region comprises different and vital anatomical structures, and even minor trauma could be lethal. In the absence of witnesses to the accident, each finding is of utmost importance, from the death/crime scene investigation - bloodstain patterns and trace evidence - to careful examination of the deceased body. The forensic pathologist has the challenging task of analyzing all the findings to make a statement concerning the cause and manner of death and, if there is something suspicious about the current case, to inform the relevant authorities.

Impact of Differential Rates of Disease Progression in Amyloid-Positive Early Alzheimer's Disease: Findings from a Longitudinal Cohort Analysis

BACKGROUND

There is limited literature regarding the impact of differential rates of disease progression on longitudinal outcomes in individuals with early Alzheimer's disease (AD) and confirmed brain amyloid pathology.

OBJECTIVES

To describe the underlying characteristics and long-term outcomes associated with different rates of disease progression among amyloid-positive individuals with early symptomatic AD.

DESIGN

Retrospective observational study.

SETTING

Data from the National Alzheimer's Coordinating Center (NACC) Uniform Data Set (UDS) in the United States (06/2005-11/2021).

PARTICIPANTS

Individuals with a clinical assessment of mild cognitive impairment or dementia and Clinical Dementia Rating® Dementia Staging Instrument Sum of Boxes (CDR-SB) score 0.5-9.0 (inclusive; first visit defined as the index date) and confirmed amyloid positivity. Participants were stratified into No Progression (change ≤0), Slower Progression (0< change <2.0 points), Median Progression (2.0-point change), and Faster Progression (change >2.0 points) cohorts based on the observed distribution of changes in CDR-SB score between the index and first subsequent visit.

MEASUREMENTS

For each cohort, the functional and neuropsychiatric outcomes were described at index and each subsequent visit for up to five years, and least-square (LS) mean changes from baseline were estimated using linear mixed-effects models adjusting for baseline demographic and clinical characteristics.

RESULTS

Among 1,263 participants included in the analysis, the mean±standard deviation (SD) age at index was 72.7±9.7 years and 55.3% were males. Demographic characteristics and comorbidity profiles at index were similar across cohorts. However, at index, the Faster Progression (N=279) cohort had higher CDR-SB and Functional Assessment Questionnaire (FAQ) scores compared with the No Progression (N=474), Slower Progression (N=297), and Median Progression (N=213) cohorts. Adjusting for baseline characteristics, at year 5 after index the FAQ score increased by 23.6 points for Faster Progression cohort and 10.4, 15.8, and 19.2 points for the No, Slower, and Median Progression cohorts, respectively. The corresponding increases in Neuropsychiatric Inventory Questionnaire (NPI-Q) scores were 6.7 points for the Faster Progression cohort, and by 1.3, 3.1, and 8.3 points, for the No, Slower, and Median Progression cohorts, respectively.

CONCLUSIONS

Despite similar demographic and clinical profiles at baseline, amyloid-positive individuals with greater deterioration based on CDR-SB early in the AD trajectory continue to experience worse functional and behavioral outcomes over time than those with more gradual deterioration in this metric.

Potential Implications of Slowing Disease Progression in Amyloid-Positive Early Alzheimer's Disease: Estimates from Real-World Data

BACKGROUND

Emerging therapies have shown promising results for slowing the progression of Alzheimer's disease (AD). However, the potential impact of these therapies on real-world outcomes remains to be explored.

OBJECTIVE

To examine the impact of slowing AD progression on functional abilities and behavioral symptoms.

DESIGN

Retrospective observational study.

SETTING

Data from the National Alzheimer's Coordinating Center (NACC) Uniform Data Set (UDS) in the United States (06/2005-11/2021, primary analysis) and the Alzheimer's Disease Neuroimaging Initiative (ADNI) database (09/2005-03/2022, sensitivity analysis) were used.

PARTICIPANTS

Individuals with mild cognitive impairment (MCI) or mild dementia, Clinical Dementia Rating Scale Sum of Boxes (CDR-SB) score 0.5-9.0 (inclusive; first visit defined as the index date), and confirmed amyloid positivity were identified in NACC. In ADNI, individuals with at least one clinical center visit with a clinical assessment of MCI or mild dementia and confirmed amyloid positivity were identified.

MEASUREMENTS

Hypothetical effects of slowing disease progression as assessed by CDR-SB on functional and behavioral outcomes including the Functional Activities Questionnaire (FAQ) score, Neuropsychiatric Inventory Questionnaire (NPI-Q) score, and the probability of complete dependence over five years were evaluated using multivariable regression among NACC participants, separately for the subgroups with MCI and mild dementia at baseline, respectively. For the ADNI sensitivity analysis, the hypothetical effects of slowing disease progression were evaluated for FAQ score using multivariable regression among the MCI participants only.

RESULTS

Compared with natural disease progression, slowing progression by 20% over five years for NACC participants with MCI and mild dementia, respectively, would result in 1.7-point (10.8%) and 1.6-point (12.9%) less deterioration based on FAQ; 0.5-point (20.3%) and 0.5-point (19.3%) less deterioration based on NPI-Q; 4.7 percentage-point (22.2%) and 10.1 percentage-point (21.6%) lower probability of complete dependence. Among ADNI participants, delaying disease progression by 20% or 30% over 4 years would avert deterioration based on FAQ of 1.1 points (20.4%) and 1.6 points (29.6%), respectively, compared to natural disease progression.

CONCLUSIONS

Slowing early AD progression could result in preservation of functional and behavioral attributes and functional autonomy for longer.

Child Sexual Abuse: Forensic Medical Assessment of the Traumatic Injuries Over the Victim's Body

Child sexual abuse is a public health problem that affects children worldwide in all ethnic, educational, and socioeconomic groups. These assaults are extremely dangerous not only due to their direct physical traumas received at the time of the abuse, but they also have long-term consequences that can worsen the future quality of the victim's life. A retrospective study of all cases related to child sexual abuse for five years was performed by materials of the Clinic of Forensic Medicine and Deontology, Sofia, Bulgaria. Ninety-five cases involve children from both genders. The traumatic injuries were carefully examined and classified according to their localization over the victim's bodies and based on the time that had passed after the reported assaults. In cases of sexual violence, the most informative and pointing at the exact type of violence are the injuries situated in the anogenital area. Too often, there is a lack of physical findings, depending on the type of sexual violence or associated with the prolonged time that passes after the crime. Children are unaware of what they have to do after suffering such traumas, or they are scared to share their experience with different family members, which can lead to late forensic examination and lack of physical and biological findings, which are the most critical traces in the criminal prosecution of the crimes and this can be a possibility for the perpetrator not to be charged for his unlawful actions.

Patient and Caregiver Outcomes After Onasemnogene Abeparvovec Treatment: Findings from the Cure SMA 2021 Membership Survey

INTRODUCTION

Onasemnogene abeparvovec (OA) is the only gene replacement therapy currently approved for spinal muscular atrophy (SMA) treatment. We sought to assess real-world patient and caregiver outcomes after OA treatment for SMA.

METHODS

Patients who received OA were identified from the 2021 Cure SMA Membership Survey. Those treated at 6-23 months of age were matched to non-patients treated with OA on the basis of age at the time of survey and survival motor neuron 2 gene copy number. Patient characteristics, motor milestones, and resource and supportive care use, as well as caregiver proxy-reported health-related quality of life (HRQOL), were described. Caregiver unmet needs and HRQOL were also assessed.

RESULTS

Of the 614 patients in the survey, 64 received OA, and 17 were matched with 28 non-OA-treated patients. In general, a greater percentage of OA-treated patients achieved various motor milestones, including 100% sitting without support and 58.8% walking with assistance. OA-treated patients also had numerically lower rates of hospitalization and surgery. None required tracheostomy with a ventilator. The rate of using oxygen or a breathing machine for more than 16 h was also lower for OA-treated patients. OA-treated patients had less frequent trouble swallowing. HRQOL was reported to be similar to non-OA-treated patients. Caregivers of OA-treated patients reported better patient mobility scores and less work impairment.

CONCLUSIONS

The study suggests that treatment with OA is associated with greater rates of motor milestone achievements and less resource and supportive care use for patients with SMA treated at 6-23 months of age in the real world. For caregivers, it may also potentially reduce unmet needs, improve HRQOL, and reduce work impairment.

Self-Mutilation: A Way to Protect Yourself From a Committed Crime or to Gain Personal Benefits

Self-mutilation refers to the state in which a person deliberately hurts himself without the intention to commit suicide but with the motive of some personal gain. Four cases are described in the current study with four different personal motives - drug supply, accusation of intimate partner violence, confrontation of parental prohibition, and a way to hide and escape from a committed crime. Evaluating the injuries due to self-mutilation might be challenging due to atypical lesions and well-structured false stories when the victim has some level of competency. Careful analysis of the victim's story and a thorough evaluation of the sustained injuries are needed. If doubts about artificial injuries exist, immediate consultation with a forensic pathologist is required.

Health Care Resource Utilization and Costs for Patients with Spinal Muscular Atrophy: Findings from a Retrospective US Claims Database Analysis

INTRODUCTION

Spinal muscular atrophy (SMA) is a neurogenic disorder associated with progressive loss of muscle function, respiratory failure, and premature mortality. This study aimed to describe and compare real-world health care resource utilization (HCRU) and costs for US patients with SMA treated with disease-modifying treatments, including onasemnogene abeparvovec, nusinersen, and/or risdiplam.

METHODS

This study used claims and structured electronic medical record data from the HealthVerity claims database (January 1, 2017-March 31, 2021). Eligible patients were aged ≤ 2 years at index (treatment initiation or switch), diagnosed with SMA, had ≥ 1 pharmacy/medical claim for onasemnogene abeparvovec, nusinersen, and/or risdiplam, and continuous enrollment ≥ 1 month pre- and ≥ 2 months post-index. SMA-related HCRU and costs during the study period (> 12 months post-index) were compared between treatment groups before and after propensity score weighting. Costs were adjusted to 2021 USD.

RESULTS

Of 74 included patients, 62 (83.8%) received nusinersen and 12 (16.2%) received onasemnogene abeparvovec (monotherapy, n = 9; onasemnogene abeparvovec after nusinersen [switching], n = 3). After weighting, nusinersen-treated patients had greater annual numbers of inpatient (mean 5.3 nusinersen vs. 1.8 onasemnogene abeparvovec) and emergency department (mean 3.0 nusinersen vs. 1.5 onasemnogene abeparvovec; p < 0.05) visits, and greater annual SMA-related medical costs (mean $78,446 nusinersen vs. $29,438 onasemnogene abeparvovec; mean difference $49,007, p < 0.05) than onasemnogene abeparvovec-treated patients. Onasemnogene abeparvovec-treated patients incurred greater SMA-treatment pharmacy costs than nusinersen-treated patients (mean $2,241,875 onasemnogene abeparvovec vs. $693,191 nusinersen; mean difference $1,548,684, p < 0.05).

CONCLUSIONS

SMA is associated with substantial economic burden. Patients treated with onasemnogene abeparvovec had greater SMA treatment-related pharmacy costs but lower SMA-related HCRU and medical costs compared with patients receiving nusinersen monotherapy.

Abdominal Apoplexy: Sudden Death Due to Massive, Nontraumatic Intra-abdominal Hemorrhage

Abdominal apoplexy or idiopathic spontaneous intraperitoneal hemorrhage (ISIH), the modern way to describe this condition, is a rare phenomenon representing intra-abdominal bleeding with no traumatic origin. The condition is severe and potentially life-threatening. A man in his 70s was found dead at his home. The autopsy revealed a massive hemoperitoneum with no visible traumatic injuries externally or internally. The source of the bleeding was unknown despite the careful examination of the internal organs and splanchnic vessels. The cause of death was attributed to massive exsanguination due to the rupture of a small blood vessel as a complication of generalized arteriosclerosis and hypertensive disease. Despite its rare occurrence, the forensic pathologist should always consider this pathological condition when, during the autopsy, a massive intraabdominal hemorrhage with or without a visible source of the bleeding is discovered in the absence of any visible traumas.

A Rare Phenomenon of Natural Precocious Mummification

Immediately after death, specific changes occur in the human body, leading to the total dissolution of the soft tissues and internal organs. In some cases, when in suitable conditions, the decomposition process could stop and be displaced by mummification. The last one is time-consuming and needs several weeks to months to set in completely. We present a case of a 34-year-old man found dead 16 days after being last seen alive in a stage of complete mummification. Natural mummification occurring in less than one month is termed precocious mummification and is rarely observed in temperate regions. With only a few cases reported globally, this case is essential for the forensic community. It will help better know the mummification processes and estimate the time since death.

The increasing threat to European forests from the invasive foliar pine pathogen, Lecanosticta acicola

European forests are threatened by increasing numbers of invasive pests and pathogens. Over the past century, Lecanosticta acicola, a foliar pathogen predominantly of Pinus spp., has expanded its range globally, and is increasing in impact. Lecanosticta acicola causes brown spot needle blight, resulting in premature defoliation, reduced growth, and mortality in some hosts. Originating from southern regions of North American, it devastated forests in the USA's southern states in the early twentieth century, and in 1942 was discovered in Spain. Derived from Euphresco project 'Brownspotrisk,' this study aimed to establish the current distribution of Lecanosticta species, and assess the risks of L. acicola to European forests. Pathogen reports from the literature, and new/ unpublished survey data were combined into an open-access geo-database (http://www.portalofforestpathology.com), and used to visualise the pathogen's range, infer its climatic tolerance, and update its host range. Lecanosticta species have now been recorded in 44 countries, mostly in the northern hemisphere. The type species, L. acicola, has increased its range in recent years, and is present in 24 out of the 26 European countries where data were available. Other species of Lecanosticta are largely restricted to Mexico and Central America, and recently Colombia. The geo-database records demonstrate that L. acicola tolerates a wide range of climates across the northern hemisphere, and indicate its potential to colonise Pinus spp. forests across large swathes of the Europe. Preliminary analyses suggest L. acicola could affect 62% of global Pinus species area by the end of this century, under climate change predictions. Although its host range appears slightly narrower than the similar Dothistroma species, Lecanosticta species were recorded on 70 host taxa, mostly Pinus spp., but including, Cedrus and Picea spp. Twenty-three, including species of critical ecological, environmental and economic significance in Europe, are highly susceptible to L. acicola, suffering heavy defoliation and sometimes mortality. Variation in apparent susceptibility between reports could reflect variation between regions in the hosts' genetic make-up, but could also reflect the significant variation in L. acicola populations and lineages found across Europe. This study served to highlight significant gaps in our understanding of the pathogen's behaviour. Lecanosticta acicola has recently been downgraded from an A1 quarantine pest to a regulated non quarantine pathogen, and is now widely distributed across Europe. With a need to consider disease management, this study also explored global BSNB strategies, and used Case Studies to summarise the tactics employed to date in Europe.

Assessing the impact of open-label designs in patient-reported outcomes: investigation in oncology clinical trials

BACKGROUND

Knowledge of treatment assignment may affect patient-reported outcomes (PROs), which is of concern in oncology, where open-label trials are common. This study measured the magnitude of open-label bias by comparing PROs for similar patient groups in oncology trials with different degrees of concealment.

METHODS

Individual patient data from ipilimumab arms of 2 melanoma and docetaxel arms of 2 non-small cell lung cancer (NSCLC) trials were adjusted for differences using propensity score weighting. Patients were aware of treatment assignment in CA184-022 and CheckMate 057 (open-label) but not in MDX010-20 and VITAL (blinded). Overall survival (OS) and mean changes from baseline to week 12 in the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (melanoma) and Lung Cancer Symptom Scale (NSCLC) scores were compared between open-label and blinded groups.

RESULTS

After adjustment, baseline characteristics were balanced between blinded (melanoma, n = 125; NSCLC, n = 424) and open-label (melanoma, n = 69; NSCLC, n = 205) groups. Study discontinuation and PRO completion rates at week 12 and OS were similar. There was no clear direction in differences in change scores between groups. In the melanoma trials, role functioning (mean = -5.2, 95% confidence interval [CI] = -15.4 to 5.0), global health status (mean = -1.3, 95% CI = -8.7 to 6.1), and pain (mean = 6.2 , 95% CI = -1.8 to 14.2) favored the blinded, whereas emotional functioning (mean = 2.2, 95% CI = -5.8 to 10.2) and diarrhea (mean = -8.3, 95% CI = -17.3 to 0.7) favored the open-label group. In the NSCLC trials, changes in dyspnea (mean = 5.4, 95% CI = -0.7 to 11.5) favored the blinded and changes in appetite (mean = -1.2, 95% CI = -8.1 to 5.7) favored the open-label group. None were clinically or statistically significant.

CONCLUSIONS

This study adds to the growing evidence demonstrating that concerns regarding open-label bias should not prohibit the interpretation of large and meaningful treatment effects on PROs.

Disease Progression and Longitudinal Clinical Outcomes of Lewy Body Dementia in the NACC Database

INTRODUCTION

As the identification of Lewy body dementia (LBD) is often confirmed postmortem, there is a paucity of evidence on the progression of disease antemortem. This study aimed to comprehensively assess the course of LBD over time across cognitive, functional, and neuropsychiatric outcomes using real-world data.

METHODS

Adults with at least one visit to an Alzheimer's Disease Center with a diagnosis of mild cognitive impairment/dementia (index date), indication of LBD, and at least one follow-up visit were identified in the National Alzheimer's Coordinating Center database (September 2005-June 2020). Participant characteristics, medication use, comorbidities, and changes in outcomes were assessed over a 5-year follow-up period and stratified by disease severity based on the Clinical Dementia Rating (CDR®) Dementia Staging Instrument-Sum of Boxes (CDR-SB) score at index.

RESULTS

A total of 2052 participants with LBD (mean age at index 73.4 years) were included (mild, 219; moderate, 988; severe, 845). Mean annualized increase over 5 years was 0.9 points for CDR-Global Score, 5.6 points for CDR-SB, 10.4 points for the Functional Activities Questionnaire, and 2.0 points for the Neuropsychiatric Inventory-Questionnaire. Disease progression was greater among participants with moderate and severe LBD at index compared with those with mild LBD.

CONCLUSION

Participants with LBD experienced decline across all outcomes over time, and impairment increased with disease severity. Findings highlight the substantial clinical burden associated with LBD and the importance of earlier diagnosis and effective treatment. Further research is needed to understand the predictors of cognitive and functional decline in LBD which may help inform clinical trials.

Comparison of analog and digitally evaluated volume of the female breast in reconstructive breast surgery. Validation of a noninvasive measurement method with 3D camera1

BACKGROUND

Reconstructive surgery is established as a standard treatment option after mastectomy due to cancer. It is crucial to patients to achieve a natural and symmetric looking breast through reconstruction. Anthropometric measurements are used to assess the objective symmetry of the breast, which are prone to errors and difficult to reproduce.

OBJECTIVE

The aim of this work is to validate breast volumetry using three-dimensional surface imaging.

METHODS

We compared preoperatively analog and digitally evaluated volume of the breast with our gold standard, direct water displacement measurement of the mastectomy specimen. We examined 34 breast specimens in total.

RESULTS

Each measurement method (Breast Sculptor, VAM, Breast-V) for breast volume/mass determination demonstrates acceptable agreement ranges when compared with resected volumes and masses. The strongest volumetry instrument is Breast Sculptor (digital), the weakest is Breast-V (analog).

CONCLUSIONS

3D surface imaging is a quick, effective, and convenient method to evaluate breast shape and volume. The accuracy, reproducibility, and reliability of 3D surface imaging were comparable with MRI in our study.This takes us a step closer to the long-term goal of establishing robust instruments to plan breast reconstructive surgery, achieve better surgical results, and contribute to quality assurance in breast surgery.

Epidemiology and economic burden of Lewy body dementia in the United States

OBJECTIVE

To describe the trends in epidemiology, healthcare resource use (HCRU), and costs associated with Lewy body dementia (LBD), dementia with Lewy bodies (DLB), and Parkinson's disease dementia (PDD) in the United States.

METHODS

This retrospective study used administrative claims data for Medicare fee-for-service (2010-2018) and commercially-insured beneficiaries (2010-2017). The annual prevalence and incidence were calculated among the Medicare beneficiaries by dividing the number of prevalent or incident LBD, DLB, and PDD patients by the total eligible population of that calendar year. Baseline patient characteristics, HCRU, and costs over time were described for Medicare and commercially insured patients with continuous health plan enrollment for ≥12 months before and ≥24 months after first cognitive impairment (CI) diagnosis.

RESULTS

From 2010 to 2016, the incidence and prevalence rates of LBD among Medicare beneficiaries ranged from 0.21%-0.18% and 0.90%-0.83%, respectively. Of 9019 Medicare patients with LBD who met other inclusion criteria, 4796 (53.2%) had DLB and 4223 (46.8%) had PDD. The mean age was 78 years and the mean Charlson Comorbidity Index score was 1.6. On average, patients with LBD incurred $18,309 in medical costs during the 1-year pre-diagnosis and $29,174 and $22,814 at years 1 and 5 after diagnosis, respectively. The main cost drivers were inpatient and outpatient visits. Similar trends were observed for DLB and PDD as well as for commercially-insured patients.

CONCLUSIONS

Our findings highlight the substantial epidemiological and economic burden across the LBD spectrum and underscore a high unmet need for effective treatments to improve patient outcomes.

Role of clinical and CT findings in the identification of adult small-bowel intussusception requiring surgical intervention

Background

In adults, intussusception has been considered traditionally to have an underlying aetiology. The aim of this study was to determine CT and clinical features of small-bowel intussusceptions that required surgical intervention.

Methods

Adult patients were identified in whom small-bowel intussusceptions were noted on CT images. The appearance, number, type (enteroenteric versus enterocolic), length and maximum short-axis diameter of intussusceptions, and presence of bowel obstruction (short-axis diameter of proximal small bowel greater than 3 cm) were analysed. The outcome was defined as surgical (complicated) or self-limiting (uncomplicated). Associations between complicated and uncomplicated intussusceptions and patient characteristics were investigated.

Results

Among 75 patients (56 male) with a mean age of 45 years, 103 intussusceptions were identified, of which 98 (95 per cent) were enteroenteric and 5 (5 per cent) enterocolic. Only 12 of 103 intussusceptions (12 per cent) in 12 of 75 (16 per cent) patients required surgical therapy and were considered to be complicated, with half of these having a neoplastic lead point. Length (P < 0.001), diameter (P < 0.001) and type (P = 0.002) of intussusception as well as presence of vessels (P = 0.023) within an intussusception on a CT scan, clinical symptoms (P = 0.007) and signs of bowel obstruction (P < 0.001) were associated with a surgical outcome.

Conclusion

Clinical symptoms, signs of bowel obstruction, type and length of intussusception, and a visible tumour within an intussusception on CT scan were critical signs of complicated intussusception, requiring surgical intervention.

Imaging of breast implant and implant-associated complications: Capsular contracture and intra- or extracapsular rupture

BACKGROUND

In recent years, follow-up after breast reconstruction with silicone implants and the detection of complications have been relieved by the possibility of improved diagnostic methods.

METHODS

Between January 2015 and December 2019 a total of 40 patients (29-84 years) with silicone implants were included in this retrospective study. The implants were examined clinically and with modern imaging: general ultrasound imaging (US), magnetic resonance imaging (MRI), high resolution computed tomography (CT) and positron emission tomography -computed tomography (PET-CT). If necessary, a histological/cytological sample was taken. The breast implants were assessed by three radiologists specialized in breast imaging. The grade of capsular contracture was classified according to the Baker classification.

RESULTS

All 40 women obtained a clinical examination and an US diagnostic to identify early and more common complications such as implant folding and capsular fibrosis. Depending on the clinical examination and ultrasound findings additional MRI (n = 10), CT (n = 9) and/or PET-CT (n = 2) were performed. 16 patients had implants folding proven with US (n = 16), MRI (n = 6) and CT (n = 1). The grade of capsular fibrosis was determined according to the Baker classification. The following results were obtained in our study: 25 breast implants with Baker grade I and eleven breast implants with Baker grade II, both proven with US; one breast implants with Baker grade III and one breast implant with Baker grade IV, proven with US (n = 2), MRI (n = 1) and CT (n = 1). One patient had intracapsular rupture and one patient had extracapsular rupture, both detected on CT and surgically proven. No patient had a silicone accumulation in the lymph nodes. One patient had pathologically enlarged axillary lymph nodes, which were evaluated as inflammatory changes in PET-CT. Long-term complications such as the development of malignant breast tumors could not be observed.

CONCLUSION

To detect early complications after breast implant surgery, a regular clinical examination is indispensable. Imaging methods complement each other and if they are used multimodal, it is easier to identify early complications. Modern diagnostic modalities like ultrasound and magnetic resonance imaging expand the spectrum and improve diagnostic safety.

Real-world systemic therapy utilization in Medicare patients with locally advanced or metastatic urothelial carcinoma

415

Background: Several immunotherapies recently have been approved for the treatment of locally advanced or metastatic bladder cancer that is prevalent in older adults. Utilization patterns in Medicare patients have not been examined and can provide an important context for emerging therapies. Methods: We conducted a retrospective analysis of SEER-Medicare beneficiaries diagnosed with locally advanced (T3-T4, N1-N3, M0) or metastatic urothelial carcinoma (any T, any N, M1) of the bladder or upper urinary tract from 2008 to 2012 and further characterized patients undergoing initial chemotherapy (within 30 days of diagnosis). Individuals receiving neoadjuvant chemotherapy were excluded. Results: A total of 3569 patients met study criteria. Among these, 48% received chemotherapy within 2 years of diagnosis. Receipt of chemotherapy was associated with younger age (median 75 vs 80 years, P< .001) and fewer comorbid conditions, including diabetes (12% vs 16%), renal disease (6% vs 11%), and congestive heart failure (4% vs 8%). A total of 977 patients received chemotherapy, of which 38% had distant metastatic disease and 65% had locally advanced tumors. Most patients had no (70%) or only a single (14%) comorbid medical condition. These patients most commonly received doublet chemotherapy (67%) followed by single-agent (17%) or triple-agent (10%) treatment. Gemcitabine was the most common individual agent received as part of initial chemotherapy (81%), followed by carboplatin (50%), cisplatin (38%), and docetaxel or paclitaxel (each 13%). The most common combination received was gemcitabine/carboplatin (42%) followed by gemcitabine/cisplatin (36%). Conclusions: Only half of Medicare patients with advanced urothelial carcinoma received systemic therapy. Most received a platinum doublet regimen. Gemcitabine in combination with platinum-containing chemotherapy was the preferred treatment. Ongoing assessment of the risks and benefits of emerging treatments for Medicare patients may be warranted with the introduction of targeted and/or immune therapies.

EBSD investigation and magnetic properties of manganese ferrite crystallized in a sodium-silicate glass

SEM micrograph with the IPF + IQ-maps of the polygon and dendritic MnFe₂O₄ crystals and an EBSD pattern acquired from a large jacobsite crystal.

Image fusion of contrast enhanced ultrasound (CEUS) with computed tomography (CT) or magnetic resonance imaging (MRI) using volume navigation for detection, characterization and planning of therapeutic interventions of liver tumors

AIM

To evaluate, whether image fusion of contrast enhanced ultrasound (CEUS) with CT or MRI affects the diagnosis and characterization of liver lesions or the therapeutic strategy of surgical or interventional procedures compared to the preliminary diagnosis.

MATERIAL AND METHODS

In a retrospective study the image fusion scans of CEUS with contrast enhanced CT or MRI of 100 patients (71 male, mean age 59 years, 0.3-85 years) with benign or malignant liver lesions were evaluated. Fundamental B-scan, color Doppler imaging and CEUS were performed in all patients by an experienced examiner using a multifrequency convex transducer (1-5 MHz, LOGIQ 9/GE) and volume navigation (Vnav). After a bolus injections of up to 2.4 ml SonoVue® (BRACCO, Italy) digital raw data was stored as cine-loops up to 5 min. In 74 patients, CEUS was fused with a pre-existing ceCT, in 26 patients a ceMRI was used.

RESULTS

In all 100 patients (100%) the image quality in all modalities (ceCT, ceMRI and CEUS) was excellent or with only minor diagnostic limitations. Regarding the number of lesions revealed in image fusion of CEUS/ceCT/ceMRI and the preceding diagnostic method, concordant results were found in 84 patients. In 12 patients, additional lesions were found using fusion imaging causing subsequently a change of the therapeutical strategy. In 15 out of 21 patients with either concordant or discordant results regarding the number of lesions, image fusion allowed a definite diagnosis due to a continuous documentation of the microcirculation of the tumor and its contrast enhancement. A significant coherency (p < 0.05) among image fusion with either ceCT or ceMRI and CEUS and a subsequent change of therapeutic strategy was found.

CONCLUSION

Image fusion with volume navigation (VNav) of CEUS with ceCT or ceMRI frequently allows a definite localization and diagnosis of hepatic lesions in patients with primary hepatic carcinoma or metastatic diseases. This might cause a change of the therapeutic strategy in many patients with hepatic lesions.

Investigation of the spread of brucellosis among human and animal populations in southeastern Bulgaria, 2007

Three human cases of brucellosis were reported in summer 2007 in the region of Haskovo in southeastern Bulgaria. Subsequently, the regional veterinary and public health authorities carried out investigations to determine the spread of infection in domestic animals and in the human population. As a result, over 90,000 animals were tested, and 410 were found infected with brucellosis. The screening of 561 people believed to have been at risk of infection yielded 47 positive results. The majority of these persons had direct contact with domestic animals or had consumed unpasteurised dairy products. The investigations revealed evidence of disease among animals in the region and a considerable risk to humans, thus emphasising the need for effective prevention and control programmes.

Investigation of the spread of brucellosis among human and animal populations in southeastern Bulgaria, 2007

Three human cases of brucellosis were reported in summer 2007 in the region of Haskovo in southeastern Bulgaria. Subsequently, the regional veterinary and public health authorities carried out investigations to determine the spread of infection in domestic animals and in the human population. As a result, over 90,000 animals were tested, and 410 were found infected with brucellosis. The screening of 561 people believed to have been at risk of infection yielded 47 positive results. The majority of these persons had direct contact with domestic animals or had consumed unpasteurised dairy products. The investigations revealed evidence of disease among animals in the region and a considerable risk to humans, thus emphasising the need for effective prevention and control programmes.

Induction of apoptosis by electrotransfer of positively charged proteins as Cytochrome C and Histone H1 into cells

Cytochrome C (Cyt. C) is a mitochondrial protein inducing apoptosis when it is accumulated in the cytosol by a currently unknown mechanism, but regulated by the bcl-2 family of proteins. The linker Histone H1 is another basic protein with highly conservative structure, composition, and equal molecular weight, not changed during the evolution. An attempt was made to understand better the apoptotic processes by electroloading of leukemic cells, such as K562, HL-60, and SKW3, and human lymphocytes with positively charged proteins, such as Cyt. C, Histone H1, and methylated BSA albumin (mBSA). The triggering apoptotic processes followed by MTT test, FACS analysis, and DNA fragmentation after the electrotransfer of these proteins into the cells were observed. Histone H1 and mBSA induce the release of Cyt. C from rat liver mitochondria. Cytochrome C release was higher when mitochondria were in "high-energy" state. It is supposed that release of Cyt. C from mitochondria is due to the mechanical rupture of the outer mitochondrial membrane, rich in negatively charged groups, predominately due to cardiolipin. The reason for the morphological rupture of the outer mitochondial membrane could be the rigidification and segregation of the membrane and the destroyed membrane asymmetries of both monolayers in the presence of positively charged proteins at higher linear charges such as Histone H1. We suggested that Histone H1, at a given moment of activated signaling for apoptosis, could be not transported to the nucleus and could lead to the release of Cyt. C from the mitochondria in the cytoplasm. It is temping to speculate that Histone H1 has other physiological extranuclear functions involved in apoptosis.

[Urinary ascites and perirenal urinoma - a renoprotective "Complication" of posterior urethral valves]

We report on a male newborn with urinary ascites and perirenal urinoma due to calyceal rupture caused by bladder outlet obstruction and posterior urethral valves. Despite the presence of left-sided high-grade reflux, the "pop-off" mechanism occurred in the non-refluxing right kidney. Impressive normalization of the upper urinary tract anomalies and renal function occurred after surgical treatment of the valves and removal of obstruction.