Obstetric outcomes in Jehovah's Witnesses: case series over nine years in a London teaching hospital

OBJECTIVES

The aim of the study is to assess obstetric and fetal outcomes of Jehovah's Witnesses (JWs) mothers in an inner city teaching hospital, as well as to examine the acceptance rates of various blood fractions and blood transfusion alternatives.

METHODS

Case series to evaluate the maternal and fetal outcomes of JWs over a nine period between 2013 and 2021.

RESULTS

There were 146 pregnancies extracted from our database, of which 10 were early pregnancy losses. Data from 136 deliveries > 24 weeks' gestation were assessed, with a mean maternal age and gestational age of 30.26 (± 5.4) years and 38.7 (± 5.3) weeks, respectively. 57% had normal vaginal deliveries, 8% had instrumental births and 35% had caesarean births. Mean estimated blood loss at caesarean was 575 (± 305.6) mls, while the overall mean estimated loss was 427.8 (± 299.8) mls. Cell salvage was performed in all caesarean sections but autologous transfusion was only necessary for 26%. Consultant presence was documented in 62% of caesarean births. The mean birthweight and 5-min Apgar scores were 3.31 (± 0.05) kg and 9.1 (± 0.09), respectively. There were no maternal deaths or admissions to the adult intensive care unit and the most serious complication was a uterine rupture following a trial of scar, after which the baby required cooling for hypoxic ischaemic encephalopathy.

CONCLUSIONS

Pregnant JWs received obstetric care led by senior clinicians, with optimisation of haematinics, minimizing of blood loss at delivery and access to technology such as cell salvage.

341 Is CT Imaging Mandated for Confirming the Diagnosis of Acute Appendicitis in Patients Over the Age of 40?

Aim

Acute appendicitis remains a largely clinical diagnosis, with clinical scoring systems such as the Alvarado score calculated to give a quantitative assessment of the diagnostic probability. It remains common practice amongst surgeons to rely on CT scanning to confirm the diagnosis however, especially in older patients. Our aim was to assess the diagnostic performance of CT scanning compared with that of the Alvarado score in patients aged over 40 years old.

Method

We conducted a retrospective observational study of 149 patients greater than 40 years old who had a diagnosis of acute appendicitis and had undergone an appendicectomy with subsequent histological analysis. Data was extracted from patients’ electronic medical records. This was recorded in Microsoft Excel and analysed using NCSS.

Results

When using an Alvarado score cut-off point of ≥7, the sensitivity and specificity were 44.1% and 60.0% respectively. The sensitivity of the test improved to 80.3% when using a cut-off point of ≥ 5, however the specificity decreased to 50%. The accuracy improved to 78.1% from 45.3%, when using ≥ 5 as a cut-off point. On the other hand, the sensitivity of the CT scan was 84.9% and the specificity was 45.5%. The accuracy of CT scanning was 81.8%.

Conclusions

When comparing performance, pre-operative CT scanning did not show a statistically significant improvement in the diagnosis of acute appendicitis relative to Alvarado score. We recommend using an Alvarado score cut-off point of ≥ 5 to aid in diagnosing appendicitis in patients older than 40, as it accounts for a higher sensitivity.

571 Evaluating the Effectiveness of Extracorporeal Shockwave Lithotripsy (ESWL) for Ureteric Stones During COVID-19 Pandemic - A Single Centre Experience

Aim

Reliance on ESWL for treating ureteric stone has increased during the COVID-19 pandemic. We examined the outcomes for ureteric stones treated with our on-site lithotripter to assess the success rate and determine the variables that could affect the outcome results.

Method

A retrospective review using electronic records and images of patients who underwent ESWL for ureteric stones (January to December 2020). Univariate and multivariate analysis used to determine stone-free rate predictors (Stone Free rate/SFR: No residual stones on post-ESWL imagining).

Results

A total of 36 patients underwent ESWL for ureteric stones. Mean age was 58 years (21–90), and mean stone size was 8 mm (5–20). Stones were located in the proximal (67%) or lower ureter (33%). Overall SFR was 64% (67% proximal, 33% distal). 64% of patients required only one session to be stone free, with 60% stone free after two sessions. Stones <10mm had a SFR of 67%, compared to 58% for stone >10 mm. The only statistically significant predictor was stone size (longest dimension, p=0.04). No statistical significance with stone location (P=0.09), skin-to-stone distance (SSD) (P=0.7), stone density (P=0.3) or stone volume (P=0.3). In treatment failure, time to definitive ureteroscopy was 4 weeks.

Conclusion

Our overall SFR was slightly lower than expected but comparable to available literature. This data highlights the importance of patient selection for ESWL and would be useful in counselling about local success rate. More than half of the patients required only one session for stone clearance and stone size was the only significant predictor for successful ESWL.

Histopathologic features predictive of metastasis and survival in 230 patients with cutaneous squamous cell carcinoma of the head and neck and non-head and neck locations: a single-center retrospective study

BACKGROUND

Staging systems for cutaneous squamous cell carcinoma (cSCC) produce inconsistent risk stratification.

OBJECTIVE

The aim of this study was to identify further prognostic parameters for better stratification.

METHODS

We retrospectively analysed the prognostic significance of clinicopathologic parameters of 230 patients who underwent primary excision of invasive cSCC of the head and neck (n = 115) and non-head and non-neck (n = 115) locations. In addition to known high-risk features, we analysed tumour nest shape, invasion pattern, lymphoid response pattern and tumour budding.

RESULTS

On multivariable analysis, lymphovascular invasion (LVI) and high tumour budding predicted worse disease-specific survival, and ulceration, LVI and high tumour budding predicted worse overall survival. Only ulceration was independently associated with risk of nodal metastasis.

CONCLUSION

High tumour budding, LVI and ulceration are independently associated with poor outcome in cSCC and may be used to refine cSCC prognostic stratification, which is crucial to optimize clinical decision and to identify patients who are more likely to benefit from more aggressive interventions or clinical trials.

Correlation between ASA Grade with reversal of Hartmann's procedure - a retrospective study

Hartmann's procedure involves resecting the rectosigmoid colon, closure of the distal rectal stump, and forming an end colostomy for complicated left colon diverticulitis or malignancy. Recovery from the initial operation can, in a second stage, be followed by a reversal stage with the restoration of bowel continuity. This study aimed to assess the reversal rate and its correlation with demographic data, ASA grade, and length of hospital stay. All patients who underwent Hartmann's emergency procedure from 2014 to 2018 at Lewisham and Greenwich hospital were enrolled in this retrospective study. Data was collected from the inpatient electronic files and NELA (UK National Laparotomy Audit). 118 patients were included in the study, with 57.6% females and a median age of patients of 69 years (range 35-91). Findings of the study indicate that the most common indications for Hartmann's procedure were diverticular complications 60% (n=71) and benign perforated sigmoid or rectosigmoid cancer 16% (n=19). The average length of hospital stay was 24 days (range n=2 - 212 days). The reversal rate was 34.9% (41/118 cases). No significant difference was observed between gender and length of hospital stay in relation to the reversal rate while there was a significant correlation between age and ASA grade in relation to reversal rate; the calculated P values were recorded as (<0.000) and (<0.009) respectively. Our results show that the highest reversal rate was observed in younger and fitter (I-II) ASA grade patients. The most common medical complication from reversal of Hartmann's procedure was an anastomotic leak (n=6, 16.7%). Reversal rate of Hartmann's procedure was 34.9%. The average timeframe for reversal was within 18-20 months. There was a significant correlation between age and ASA grade in relation to reversal rate.

Spitzoid melanoma with histopathological features of ALK gene rearrangement exhibiting ALK copy number gain: a novel mechanism of ALK activation in spitzoid neoplasia

Spitzoid neoplasms pose diagnostic difficulties because their morphology is not consistently predictive of their biological potential. Recent advances in the molecular characterization of these tumours provides a framework by which they can now begin to be categorized. In particular, spitzoid lesions with ALK rearrangement have been specifically associated with a characteristic plexiform growth pattern of intersecting fascicles of amelanotic spindled melanocytes. We report the case of an 87-year-old man with a 3-cm nodule on his mid-upper back comprised of an intradermal proliferation of fusiform amelanotic melanocytes arranged in intersecting fascicles with occasional peritumoral clefts. Immunohistochemical studies demonstrated diffuse, strong expression of SOX10 and S100 by the tumour cells and diffuse, weak-to-moderate cytoplasmic positivity for anaplastic lymphoma kinase (ALK), suggestive of ALK rearrangement. Fluorescence in situ hybridization revealed no ALK rearrangements but instead revealed at least three intact ALK signals in 36% of the tumour cells, confirming ALK copy number gain. To our knowledge, this is the first reported case of a plexiform spitzoid neoplasm exhibiting ALK copy number gain instead of ALK rearrangement. This case suggests that ALK copy number gain is a novel mechanism of ALK activation but with the same characteristic histopathological growth pattern seen among ALK-rearranged spitzoid neoplasms.

Rheological characterization of Poloxamer 407 lidocaine hydrochloride gels

Thermal gelation of Poloxamer 407 lidocaine hydrochloride gels was characterized by rheological studies. Lidocaine, a local anesthetic used for treatment of acute and chronic pain, presents short duration action; thus a long-action single-dose injection would be of clinical importance. Poloxamer 407 gel can extend the release and the action of lidocaine. In the present work, aqueous gels with lidocaine containing different concentrations of Poloxamer 407 and additives like inorganic salts (NaCl, NaH(2)PO(4), Na(2)CO(3)) and PEG 400 were obtained. Viscosity measurements and the optimal sol-gel transition temperature were obtained by these rheological studies. Poloxamer 407 gels are viscoelastic materials because they have elastic modulus (G'), characteristic of solid materials, and viscous modulus (G"), characteristic of liquid materials. Poloxamer 407 gels are pseudoplastic; therefore, when shear deformed, their viscosity decreases. Increase of the polymer concentration increases the viscosity of the gels, which can change the releasing process of lidocaine from the gel. The sol-gel transition temperature was decreased by increasing the polymer concentration and by the presence of additives. The rheological behaviour of Poloxamer gels characterized in this work can be useful for understanding further studies of drug release.

Primary mediastinal liposarcoma: a case report and review of the literature

A case of mediastinal liposarcoma (LPS) in a 49-year-old female is described. Primary LPS of the mediastinum are very rare tumors. They occur mainly in adults but may be encountered in children. They are characterized by their large size and their variable histologic subtypes, which correlate with the clinical behavior and the prognosis. The radiologic features are nonspecific but are suggestive of the diagnosis. A tissue biopsy is needed for the final diagnosis. The treatment of choice is surgical with wide margin resection. Chemotherapy and radiotherapy are ineffective modalities, used in unresectable or incompletely resected tumors. The prognosis depends on the histologic subtypes and completeness of surgical excision.

[Cystic dystrophy in an aberrant pancreas in the duodenal wall causing a megaduodenum]

One case of cystic dystrophy in an aberrant pancreas of the duodenal wall with a megaduodenum is reported. It is a rare affection which is difficult diagnostic, helped by echoendoscopy. Difficult therapeutic dilemma is raised by cystic dystrophy in heterotopic pancreas: duodenopancreatectomy or limited local excision?

Isolation of two new antiinflammatory biflavanoids from Sarcophyte piriei

Two new flavano flavanone glycosides, diinsininol (1) and diinsinin (2), have been isolated from the rhizome of Sarcophyte piriei, together with one known flavanone glycoside, naringenin 5-glucoside. Their structures were elucidated on spectroscopic evidence as 5,7,3',4'-tetrahydroxyflavanyl-7-O-beta-glucosyl-(4beta-8; 2beta-O-7)-eriodietyol (1) and 5,7,3',4'-tetrahydroxyflavanyl 7-O-beta-glucosyl-(4beta-8;2beta-O-7)-naringenin (2), respectively. The compounds were tested for their ability to inhibit prostaglandin synthesis, with 1 and 2 giving IC50 values of 9.20 microM and 13.14 microM, respectively, and in the inhibition of platelet-activating-factor-induced exocytosis, IC50 values of 49 and 39 microM.

Microperfusion of sheep bronchioles

We isolated segments of sheep bronchioles (length 406 +/- 46 microns, diameter 227 +/- 53 microns, n = 27). These segments were placed in a 37 degree C bath and cannulated at both ends with glass micropipettes. The proximal end was cannulated and held by three concentrically arranged micropipettes that delivered perfusion solution by gravity. The distal end was cannulated and held by two concentrically arranged micropipettes for fluid collection. When both the lumen and the bath contained oxygenated Krebs-Henseleit buffer (pH 7.40), spontaneous potential difference (PD) was 2.46 +/- 0.39 mV, lumen negative. KCN in the bath diminished PD by 1.48 +/- 0.29 mV (P = 0.00003, n = 25). The isolated bronchiole was depolarized when the luminal solution was Na free (delta PD -1.78 +/- 0.11 mV, P = 0.00007, n = 5) or when the submucosal bath was Cl free (delta PD -2.63 +/- 0.81, P = 0.018, n = 7). In preparations pretreated with 10 microM indomethacin, 1 microM isoproterenol raised PD by 0.75 +/- 0.29 mV (P = 0.03, n = 8), whereas 0.1 mM submucosal bumetanide reduced PD by 0.21 +/- 0.04 mV (P = 0.0005, n = 8). The data show that microperfusion technique is applicable for investigating ion transport by distal bronchioles and that the bronchiolar epithelium probably has both Na and Cl conductive pathways.

Serological evidence of dengue fever among refugees, Hargeysa, Somalia

Epidemics of a malaria-like illness affected several thousand residents of the Dam Camp, a refugee camp near Hargeysa in Somalia, during 1985, 1986, and 1987. The disease was characterized by fever, chills, sweats, headache, back and joint pains for as long as 10 days in some patients. Blood smears from acutely ill patients were negative for malaria. Of 28 acute and 10 convalescent sera tested by the indirect fluorescent antibody (IFA) and by the hemagglutination inhibition (HI) tests, all were negative for antibody to Rift Valley fever, Crimean-Congo hemorrhagic fever, Sindbis, Chikungunya, yellow fever, and Zika viruses. However, antibody reactive to dengue 2 virus was detected by the IFA test in 39% (15/38), and 11 of 29 (38%) of the same sera were antibody positive by the HI test. Also, IgG antibody reactive to dengue 2 was demonstrated in 60% (17/28) of the same sera by the enzyme immunoassay (EIA), and 14% (4/28) were positive for IgM antibody. Of ten patients for which acute and convalescent sera were available, two developed four fold or greater rises in antibody titer evidencing infection. These data suggested that dengue virus may have been the cause of the epidemic among the Dam Camp refugees.

Histopathologic and immunohistopathologic features of subretinal fibrosis and uveitis syndrome

We studied histopathologic and immunohistopathologic features of an eye from a patient who had hypopigmented choroidal lesions with subsequent development of progressive subretinal fibrotic tissue associated with minimal signs of vitreal inflammation. A 24-year-old woman had a rapid and severe onset of the disease, which led to blindness within a few months despite treatment with corticosteroids and cyclophosphamide. Histopathologic studies disclosed a marked gliotic retina and thick subretinal fibrotic tissue as well as a granulomatous lymphocytic infiltration in the choroid. Electron microscopy demonstrated that the subretinal tissue was derived from retinal pigment epithelial cells. The immunoperoxidase staining showed similar proportions of T and B lymphocytes, indicating a relative increase of B cells. There was a predominance of the helper/inducer T lymphocyte subset in the infiltrating area. The Müller cells in the retina expressed class II antigens of the major histocompatibility complex.

Two visual systems in mental imagery: dissociation of "what" and "where" in imagery disorders due to bilateral posterior cerebral lesions

We studied two patients with impaired visual perception and imagery caused by bilateral posterior cerebral lesions. The first had prosopagnosia and achromatopsia, and the imagery disorder involved the description of objects from memory, especially faces and animals, and colors of objects. The second had visual disorientation; the imagery problem involved the description of spatial relations from memory. Impairments of visual imagery, like disorders of visual perception, can be dissociated. Object and color imagery may be dissociated from imagery for spatial relations. A given imagery deficit tends to be associated with the corresponding type of perceptual deficit.

[Sodium and potassium content of various Chilean foods]

Sodium and potassium contents of 40 high-protein dietary products were determined in order to complete the Table de Composición Química se Alimentos Chilenos (Chemical Composition Table of Chilean Foods). These cations' level must be strictly controlled in diets of many renal and heart patients. In Chile, Nutritionists who are in charge of preparing these diets, do not have a national composition table related to the sodium and potassium content for most of the food products. Samples of fluid cow's milk, dried milk with different fat contents, some cheeses, hen eggs, bovine entrails, some meat derivates and several meat cuts, including bovine, pork, lamb and chicken were studied.

[Influence of age on several parameters of the Doppler signal at the carotid level (author's transl)]

Doppler recordings are an interesting method of exploration of the circulatory system and more information can be obtained than is generally accepted. This study demonstrates the influence of age on the Doppler signal treated in 3 different ways. This is done in order to obtain supplementary criteria if possible, which can be used to assess arterial aging and its possible pathological character. The results show the dispersion of the resistance index R after 50 years of age, many subjects having an increased index. The influence of various factors such as hypertension, smoking..., are analyzed. Particular attention is drawn to the morphological changes in the curve. Hard echos that are usually filtered are specifically analyzed. These represent the reflexion of ultrasounds on the arterial wall and it could be possible to obtain information on flow rate and vessel wall elasticity. Preliminary results show important variations of the signal with age. Doppler recordings from the carotid vessels can be used to follow, in an approximate manner, the rapid variations of cerebral blood perfusion. The during of circulatory disturbance was studied when the cerebral circulation was exposed to a particular situation requiring rapid adaptation: in this case the squatting-standing test. Large differences were observed according to age.