Vascular access surgery training in the United Kingdom is currently perceived (by trainees) to be inadequate

INTRODUCTION

Vascular access surgery (VAS) involves the creation and maintenance of arteriovenous access to facilitate haemodialysis. The prevalence of haemodialysis is rising despite increases in kidney transplants on a yearly basis. There is currently only one access surgery fellowship accredited by the Royal College of Surgeons of England. We aimed to establish the experience and perceived competence in access surgery of senior vascular surgery trainees.

METHODS

A short questionnaire (SurveyMonkey) was used to survey all senior (ST6-ST8) vascular surgery trainees in Health Education England (HEE) vascular surgery training programmes. The short survey asked trainees to report their: (1) training grade; (2) training deanery; (3) experience of access surgery; and (4) whether senior trainees thought they would be able to independently undertake primary access surgery post-completion of training (post Certificate of Completion of Training). The survey was circulated via HEE deaneries and the vascular surgery trainees' society: the Rouleaux Club.

RESULTS

Twenty-eight senior (ST6-ST8) vascular surgery trainees responded to the survey: 29.6% were ST6 level, 33.3% were ST7 and 37.1% were ST8. Deanery respondence was evenly spread, although London was overrepresented (37.1%). In total, 28.6% had been involved in fewer than 10 cases, 35.7% in 10-25 cases, and 35.7% in more than 25 cases. Almost 54% of senior vascular surgery trainees believed they would not be able to undertake independent access surgery once they had completed training.

CONCLUSIONS

Competence in access surgery is an increasing requirement of a consultant vascular surgeon. More formalised training is required to adequately train the next generation of vascular surgeons.

Vascular access surgery training in the United Kingdom is currently perceived (by trainees) to be inadequate

INTRODUCTION

Vascular access surgery (VAS) involves the creation and maintenance of arteriovenous access to facilitate haemodialysis. The prevalence of haemodialysis is rising despite increases in kidney transplants on a yearly basis. There is currently only one access surgery fellowship accredited by the Royal College of Surgeons of England. We aimed to establish the experience and perceived competence in access surgery of senior vascular surgery trainees.

METHODS

A short questionnaire (SurveyMonkey) was used to survey all senior (ST6-ST8) vascular surgery trainees in Health Education England (HEE) vascular surgery training programmes. The short survey asked trainees to report their: (1) training grade; (2) training deanery; (3) experience of access surgery; and (4) whether senior trainees thought they would be able to independently undertake primary access surgery post-completion of training (post Certificate of Completion of Training). The survey was circulated via HEE deaneries and the vascular surgery trainees' society: the Rouleaux Club.

RESULTS

Twenty-eight senior (ST6-ST8) vascular surgery trainees responded to the survey: 29.6% were ST6 level, 33.3% were ST7 and 37.1% were ST8. Deanery respondence was evenly spread, although London was overrepresented (37.1%). In total, 28.6% had been involved in fewer than 10 cases, 35.7% in 10-25 cases, and 35.7% in more than 25 cases. Almost 54% of senior vascular surgery trainees believed they would not be able to undertake independent access surgery once they had completed training.

CONCLUSIONS

Competence in access surgery is an increasing requirement of a consultant vascular surgeon. More formalised training is required to adequately train the next generation of vascular surgeons.

Enhanced Risk Stratification for Children and Young Adults with B-Cell Acute Lymphoblastic Leukemia: A Children's Oncology Group Report

Current strategies to treat pediatric acute lymphoblastic leukemia rely on risk stratification algorithms using categorical data. We investigated whether using continuous variables assigned different weights would improve risk stratification. We developed and validated a multivariable Cox model for relapse-free survival (RFS) using information from 21199 patients. We constructed risk groups by identifying cutoffs of the COG Prognostic Index (PICOG) that maximized discrimination of the predictive model. Patients with higher PICOG have higher predicted relapse risk. The PICOG reliably discriminates patients with low vs. high relapse risk. For those with moderate relapse risk using current COG risk classification, the PICOG identifies subgroups with varying 5-year RFS. Among current COG standard-risk average patients, PICOG identifies low and intermediate risk groups with 96% and 90% RFS, respectively. Similarly, amongst current COG high-risk patients, PICOG identifies four groups ranging from 96% to 66% RFS, providing additional discrimination for future treatment stratification. When coupled with traditional algorithms, the novel PICOG can more accurately risk stratify patients, identifying groups with better outcomes who may benefit from less intensive therapy, and those who have high relapse risk needing innovative approaches for cure.

234 Remote Surgical Teaching During COVID-19: Early Feedback from Students and Teachers

Background

On the 23rd March 2020 the government issued a nationwide lockdown in response to COVID-19. Using Microsoft Teams software, Brighton and Sussex Medical School transitioned to remote surgical teaching. We discuss the early feedback from students and tutors.

Method

All students (N = 40) and tutors (N = 7) were invited to complete an online feedback survey.

Results

Twenty students responded. Nine preferred remote teaching. The teaching was described as either good (10/20) or excellent (10/20). Small group teaching, lectures and student lead seminar sessions all received positive feedback. Students preferred sessions that were interactive. One hour was optimal (17/20). There was no consensus over class size. 15/20 (75%) would like remote teaching to continue after the pandemic.

All tutors responded. There was a preference towards shorter sessions: 45 minutes (2/7) one hour (5/7). Tutors found virtual sessions less interactive (6/7). All tutors would like remote teaching to continue after the pandemic. Three suggested extending teaching to remote surgical ward rounds.

Concern was raised by both students and tutors regarding the absence of practical skills.

Conclusions

The value of remote teaching has been highlighted by COVID-19. Our feedback recommends a transition towards blended learning; using the convenience of remote teaching to help augment traditional medical school teaching.

Increasing the human chorionic gonadotrophin cut-off to ≤1000 IU/l for starting actinomycin D in post-molar gestational trophoblastic neoplasia developing resistance to methotrexate spares more women multi-agent chemotherapy

Background

A human chorionic gonadotropin (hCG) cut-off of ≤300 IU/l for starting actinomycin D (ActD) in post-molar gestational trophoblastic neoplasia (GTN) patients developing methotrexate resistance (MTX-R) reduced the number of women needing toxic multi-agent chemotherapy (etoposide, MTX and ActD alternating weekly with cyclophosphamide and vincristine; EMA/CO) without affecting survival. Here we assess whether an increased hCG cut-off of ≤1000 IU/l spares more women EMA/CO.

Patients and methods

All post-molar GTN patients treated with first-line methotrexate and folinic acid (MTX/FA) were identified in a national cohort between 2009 and 2016. Data collected included age, FIGO score, the hCG levels at MTX-R, and treatment outcomes.

Results

In total, 609 GTN patients commenced treatment with MTX/FA achieving a complete response in 57% (348/609). Resistance developed in 25.1% (153/609) at an hCG ≤ 1000 IU/l and switching to ActD achieved remission in 92.8% without any major toxicity with the remaining 7.2% remitting on EMA/CO. Comparative analysis of patients switching at an hCG <100 versus 100-300 versus 300-1000 IU/l revealed a significant fall in the cure rate with second-line ActD from 97% (93/96) to 87% (34/39) to 78% (14/18), respectively, P = 0.009. However, by increasing the hCG cut-off from ≤300 to ≤1000 IU/l, 14 patients were spared EMA/CO chemotherapy. Moreover, in the present series, all post-molar GTN remain in remission.

Conclusion

This study demonstrates that increasing the hCG cut-off from ≤300 to ≤1000 IU/l for choosing patients for ActD following MTX-R spares more women with GTN from the greater toxicity of EMA/CO without compromising 100% survival outcomes.

•

An hCG cut-off of ≤1000 IU/l for ActD over EMA/CO treatment in MTX-R GTN spares women toxicity without affecting survival.

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On developing MTX-R, as the hCG cut-off for selecting ActD versus EMA/CO rises, the complete response rate for ActD falls.

•

Half of FIGO-7 patients were cured on single-agent treatment (MTX/FA or sequential ActD), warranting further investigation.

Single cell sequencing reveals endothelial plasticity with transient mesenchymal activation after myocardial infarction

 

After myocardial infarct (MI), followed by ischemia and scar formation, interstitial cells play key roles in the adaptation to injury. Endothelial cells (ECs), for instance, can clonally expand, migrate into the infarct area and facilitate crucial functions promoting revascularization, reestablishment of oxygen supply and secretion of paracrine factors. Moreover, ECs can transiently undergo changes towards a mesenchymal phenotype (Endothelial-to-mesenchymal transition; EndMT). Whether this process contributes to long-term cardiac fibrosis or helps to facilitate post-ischemic vessel growth remains controversial. Here, we aim to delineate kinetics and characteristics of phenotypic changes in ECs with single cell RNA-sequencing (scRNA-seq).

We performed a time course (homeostasis or 0 day (d), 1d, 3d, 5d, 7d, 14d, 28d post-MI) in mice and isolated the non-cardiomyocyte fraction for scRNA-seq (n=35,312 cells). Pecam1/Cdh5 double positive ECs showed expression of apoptosis, hypoxia and inflammation markers at 3d. Bioinformatic cell cycle analysis predicted high association with proliferative capacities at 3d, indicative of EC turnover post-MI. Metabolism, recently linked to regulate EndMT, was altered. We found genes of the glycolysis and the TCA-cycle pathway upregulated at 1d to 3d, and a decrease of fatty acid signaling genes. At 3d, mesenchymal markers Fn1, Vim, S100a4, Serpine1 transiently increased compared to homeostasis (&gt;1.6-fold, p&lt;0.05) together with a reduction of EC genes such as Pecam1. Interestingly, mesenchymal transition was transient and returned to baseline levels at 28d after MI. Cell fate trajectory analysis confirmed these findings by identifying an EC state characterized by high proliferation and mesenchymal but low EC properties. At 3d to 7d the majority of the ECs were assigned to this state, based on their transcriptomic profile.

We additionally used Cdh5-CreERT2; R26-mT/mG mice followed by scRNA-seq to trace the fate of ECs. Bioinformatic analysis of GFP-positive ECs confirmed the gain in mesenchymal marker but revealed no full transition to the mesenchymal state at later timepoints. This suggests a transient mesenchymal activation of ECs rather than a complete lineage transition. We further induced EndMT with TGF-β2 in ECs in vitro and observed reversibility of the phenotype after withdrawal of the stimulus. After treatment, ECs upregulated various mesenchymal marker genes. Withdrawal of TGF-β2 at 3d or 7d, reverted expression to baseline levels. We further determined DNA methylation of EndMT gene loci to assess if TGF-β2 leads to a true fate change but did not observe changes after TGF-β2 stimulation and withdrawal. Taken together, our data suggests that ECs undergo a transient mesenchymal activation concomitant with a metabolic adaptation early after MI but do not acquire a long-term mesenchymal fate. This activation may facilitate EC migration and clonal expansion to regenerate the vascular network.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): German Center of Cardiovascular Research (DZHK), Deutsche Forschungsgemeinschaft (DFG) CRC1366 Project B4

Demographics, natural history and treatment outcomes of non-molar gestational choriocarcinoma: a UK population study

OBJECTIVE

To investigate the demographics, natural history and treatment outcomes of non-molar gestational choriocarcinoma.

DESIGN

A retrospective national population-based study.

SETTING

UK 1995-2015.

POPULATION

A total of 234 women with a diagnosis of gestational choriocarcinoma, in the absence of a prior molar pregnancy, managed at the UKs two gestational trophoblast centres in London and Sheffield.

METHODS

Retrospective review of the patient's demographic and clinical data. Comparison with contemporary UK birth and pregnancy statistics.

MAIN OUTCOMES

Incidence statistics for non-molar choriocarcinoma across the maternal age groups. Cure rates for patients by FIGO prognostic score group.

RESULTS

Over the 21-year study period, there were 234 cases of non-molar gestational choriocarcinoma, giving an incidence of 1:66 775 relative to live births and 1:84 226 to viable pregnancies. For women aged under 20, the incidence relative to viable pregnancies was 1:223 494, for ages 30-34, 1:80 227, and for ages 40-45, 1:41 718. Treatment outcomes indicated an overall 94.4% cure rate. Divided by FIGO prognostic groups, the cure rates were low-risk group 100%, high-risk group 96% and ultra-high-risk group 80.5%.

CONCLUSIONS

Non-molar gestational choriocarcinoma is a very rare diagnosis with little prior detailed information on the demographics and natural history. The data in this study give age-related incidence data based on a large national population study. The results also demonstrated the widely varying natural history of this rare malignancy and the marked correlation of disease incidence with rising maternal age.

TWEETABLE ABSTRACT

National gestational choriocarcinoma database indicates a close association between increasing maternal age and incidence.

Determination of Pesticide Residues in Nonfatty Fooda by Percritical Extraction aqnd Gas Chromatography/Mass Spectrometry: Collaborative Study

A collaborative study was conducted to determine multiple pesticide residues in apple, green bean, and carrot by using supercritical fluid extraction(SFE) and gas chromatography/mass spectrometry(GC/MS). Seventeen laboratories from 7 countries participated in the final study, and a variety of different instruments was used by collaborators. The procedure simply entails 3 steps: (1) mix 1.1 g drying agent (Hydromatrix) per 1 g frozen precomminuted sample, and load 4–5.5 g of this mixture into a 7–10 mL extraction vessel; (2) perform SFE for 20–30 min with a 1–2 mL/min flow rate of carbon dioxide at 0.85 g/mL density (320 atm, 60°C); and (3) inject the extract, which was collected on a solid–phase or in a liquid trap, into the gas chromatograph/mass spectrometer, using either an ion-trap instrument in full-scan mode or a quadrupole-type instrument in selected-ion monitoring mode. The ability of GC/MS to simultaneously quantitate and confirm the identity of the semivolatile analytes at trace concentrations is a strong feature of the approach. The selectivity of SFE and GC/MS avoids the need for post-extraction cleanup steps, and the conversion of the CO2 solvent to a gas after SFE eliminates the solvent evaporation step common in traditional methods. The approach has several advantages, but its main drawback is the lower recoveries for the most polar analytes, such as methamidophos and acephate, and the most nonpolar analytes, such as pyrethroids. Recoveries for most pesticides are &gt;75%, and recoveries of nonpolar analytes are still &gt;50%. The(within-laboratory) repeatability relative standard deviation (RSDr) values of the recoveries are generally &lt;15%. More specifically, the average results from the 9–14 laboratories in the final analysis of 6 blind duplicates at 3 concentrations for each pesticide are as follows: carbofuran in apple (75–500 ng/g), 89% recovery, 7% RSDr, 9% reproducibility relative standard deviation (RSDR); diazinon in apple (60–400 ng/g), 83% recovery, 13% RSDr, 17% RSDMR; vinclozolin in apple (6–400 ng/g), 97% recovery, 13% RSDr, 18% RSDR; chlorpyrifos in apple (50–300 ng/g), 105% recovery, 11% RSDr, 13% RSDR; endosulfan sulfate in apple (150–1000 ng/g), 95% recovery, 15% RSDr, 17% RSDR; trifluralin in green bean (30–200 ng/g), 58% recovery, 11% RSDr, 27% RSDR; dacthal in green bean (60–400 ng/g), 88% recovery, 11% RSDr, 17% RSDR; quintozene in green bean (60–400 ng/g), 79% recovery, 13% RSDr, 18% RSDR; chlorpyrifos in green bean (50–300 ng/g), 84% recovery, 11% RSDr, 17% RSDR; p,p′ -DDE in green bean (45–300 ng/g), 64% recovery, 14% RSDr, 27% RSDR; atrazine in carrot (75–500 ng/g), 90% recovery, 11% RSDr, 15% RSDR; metalaxyl in carrot (75–500 ng/g), 89% recovery, 8% RSDr, 12% RSDR; parathion–methyl in carrot (75–500 ng/g), 84% recovery, 14% RSDr, 15% RSDR; chlorpyrifos in carrot (50–300 ng/g), 77% recovery, 13% RSDr, 19% RSDR; and bifenthrin in carrot (90–600 ng/g), 63% recovery, 12% RSDr, and 25% RSDR. All analytes except for the nonpolar compound strifluralin, p,p′ -DDE, and bifenthrin gave average Horwitz ratios of &lt;1.0 when AOAC criteria were used. These 3 analytes had high RSDr values but lower RSDR values, which indicated that certainSFE instruments gave consistently lower recoveries for nonpolar compounds. The collaborative study results demonstrate that the method meets the purpose of many monitoring programs for pesticide residue analysis, and the Study Director recommends that it be adopted Official

P5540Familial clustering of spontaneous coronary artery dissection

Background

There is increasing evidence that patients with spontaneous coronary artery dissection (SCAD) have an underlying genetic susceptibility (Goel et al JAMA Intern Med175:821–826, 2015). Moreover, in a collaborative study involving 1,055 SCAD cases and 7,190 controls, we recently reported the first risk allele for SCAD, a variant (rs9349379-A) in the PHACTR1/EDN1 genetic locus (Adlam et al J Amer Coll Cardiol73:58–66, 2019).

Purpose

We sought to determine the clinical characteristics and initial genetic data for 11 families, in which more than one member has had an episode of SCAD.

Methods

Participants were recruited largely via a social media platform. Informed consent was obtained in all cases for analysis of genetic information using whole genome sequencing, as well as collection of clinical information. SCAD was confirmed by review of coronary angiogram images and clinical data collected by phone interview, as well as review of specialist letters and hospital records.

Results

Of 235 participants recruited to date, 23 cases showed familial clustering involving sister-sister pairs in six families, three first-degree cousins in one family (picture), two first-degree cousins in two families, a mother-son pair, and a family with concordant monozygotic twins, that is both twins having had SCAD. In an additional family, SCAD is discordant in monozygotic twins. A comparison of symptoms, age at SCAD, clinical syndrome, cardiovascular risk factors, SCAD risk factors, environmental triggers, SCAD location, acute management, left ventricular function and recurrent SCAD events in these families versus isolated cases, will be presented. Three sister-sister pairs have undergone whole genome sequencing and these data sets are undergoing segregation analysis to identify rare variants that are present exclusively in affected family members.

Family E Pedigree. Shaded circles represent first cousins affected with SCAD. The top number represents age (in years) of the SCAD event and the bottom number represents current age (in years).

Conclusions

To our knowledge, this is the largest assembly of SCAD cases with familial clustering reported to date. It provides strong evidence supporting an underlying genetic basis for SCAD, which most likely is a multi-genic disorder that also involves important gene-environment interactions.

Can the FIGO 2000 scoring system for gestational trophoblastic neoplasia be simplified? A new retrospective analysis from a nationwide dataset

Background

Worldwide introduction of the International Fedaration of Gynaecology and Obstetrics (FIGO) 2000 scoring system has provided an effective means to stratify patients with gestational trophoblastic neoplasia to single- or multi-agent chemotherapy. However, the system is quite elaborate with an extensive set of risk factors. In this study, we re-evaluate all prognostic risk factors involved in the FIGO 2000 scoring system and examine if simplification is feasible.

Patients and methods

Between January 2003 and December 2012, 813 patients diagnosed with gestational trophoblastic neoplasia were identified at the Trophoblastic Disease Centre in London and scored using the FIGO 2000. Multivariable analysis and stepwise logistic regression were carried out to evaluate whether the FIGO 2000 scoring system could be simplified.

Results

Of the eight FIGO risk factors only pre-treatment serum human chorionic gonadotropin (hCG) levels exceeding 10 000 IU/l (OR = 5.0; 95% CI 2.5-10.4) and 100 000 IU/l (OR = 14.3; 95% CI 4.7-44.1), interval exceeding 7 months since antecedent pregnancy (OR = 4.1; 95% CI 1.0-16.2), and tumor size of over 5 cm (OR = 2.2; 95% CI 1.3-3.6) were identified as independently predictive for single-agent resistance. In addition, increased risk was apparent for antecedent term pregnancy (OR = 3.4; 95% CI 0.9-12.7) and the presence of five or more metastases (OR = 3.5; 95% CI 0.4-30.4), but patient numbers in these categories were relatively small. Stepwise logistic regression identified a simplified risk scoring model comprising age, pretreatment serum hCG, number of metastases, antecedent pregnancy, and interval but omitting tumor size, previous failed chemotherapy, and site of metastases. With this model only 1 out 725 patients was classified different from the FIGO 2000 system.

Conclusion

Our simplified alternative using only five of the FIGO prognostic factors appears to be an accurate system for discriminating patients requiring single as opposed to multi-agent chemotherapy. Further work is urgently needed to validate these findings.

The extent of B-cell activation and dysfunction preceding lymphoma development in HIV-positive people

OBJECTIVES

B-cell dysfunction and activation are thought to contribute to lymphoma development in HIV-positive people; however, the mechanisms are not well understood. We investigated levels of several markers of B-cell dysfunction [free light chain (FLC)-κ, FLC-λ, immunoglobulin G (IgG), IgA, IgM and IgD] prior to lymphoma diagnosis in HIV-positive people.

METHODS

A nested matched case-control study was carried out within the EuroSIDA cohort, including 73 HIV-positive people with lymphoma and 143 HIV-positive lymphoma-free controls. Markers of B-cell dysfunction were measured in prospectively stored serial plasma samples collected before the diagnosis of lymphoma (or selection date in controls). Marker levels ≤ 2 and > 2 years prior to diagnosis were investigated.

RESULTS

Two-fold higher levels of FLC-κ [odds ratio (OR) 1.84; 95% confidence interval (CI) 1.19, 2.84], FLC-λ (OR 2.15; 95% CI 1.34, 3.46), IgG (OR 3.05; 95% CI 1.41, 6.59) and IgM (OR 1.46; 95% CI 1.01, 2.11) were associated with increased risk of lymphoma > 2 years prior to diagnosis, but not ≤ 2 years prior. Despite significant associations > 2 years prior to diagnosis, the predictive accuracy of each marker was poor, with FLC-λ emerging as the strongest candidate with a c-statistic of 0.67 (95% CI 0.58, 0.76).

CONCLUSIONS

FLC-κ, FLC-λ and IgG levels were higher > 2 years before lymphoma diagnosis, suggesting that B-cell dysfunction occurs many years prior to lymphoma development. However, the predictive value of each marker was low and they are unlikely candidates for risk assessment for targeted intervention.

Managing pregnancy of unknown location based on initial serum progesterone and serial serum hCG levels: development and validation of a two-step triage protocol

OBJECTIVES

A uniform rationalized management protocol for pregnancies of unknown location (PUL) is lacking. We developed a two-step triage protocol to select PUL at high risk of ectopic pregnancy (EP), based on serum progesterone level at presentation (step 1) and the serum human chorionic gonadotropin (hCG) ratio, defined as the ratio of hCG at 48 h to hCG at presentation (step 2).

METHODS

This was a cohort study of 2753 PUL (301 EP), involving a secondary analysis of prospectively and consecutively collected PUL data from two London-based university teaching hospitals. Using a chronological split we used 1449 PUL for development and 1304 for validation. We aimed to assign PUL as low risk with high confidence (high negative predictive value (NPV)) while classifying most EP as high risk (high sensitivity). The first triage step assigned PUL as low risk using a threshold of serum progesterone at presentation. The remaining PUL were triaged using a novel logistic regression risk model based on hCG ratio and initial serum progesterone (second step), defining low risk as an estimated EP risk of < 5%.

RESULTS

On validation, initial serum progesterone ≤ 2 nmol/L (step 1) classified 16.1% PUL as low risk. Second-step classification with the risk model selected an additional 46.0% of all PUL as low risk. Overall, the two-step protocol classified 62.1% of PUL as low risk, with an NPV of 98.6% and a sensitivity of 92.0%. When the risk model was used in isolation (i.e. without the first step), 60.5% of PUL were classified as low risk with 99.1% NPV and 94.9% sensitivity.

CONCLUSION

PUL can be classified efficiently into being either high or low risk for complications using a two-step protocol involving initial progesterone and hCG levels and the hCG ratio. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Intranasal corticosteroids do not affect intraocular pressure or lens opacity: a systematic review of controlled trials

BACKGROUND

Intranasal corticosteroids (INCS) are prescribed for the long-term prophylactic treatment of inflammatory upper airway conditions. Although some systemic absorption can occur via topical routes, the clinical relevance is controversial. The effects of orally administered corticosteroids on intraocular pressure (IOP) and lens opacity (LO) are well established, but the impact of the INCS is less well defined. This study aims to systematically review the literature for evidence of adverse occular events with INCS use.

METHODOLOGY

A systematic review of literature from Medline and Embase databases (January 1974 to 21st of November 2013) was performed. Using the PRISMA guidelines, all controlled clinical trials of patients using INCS, that reported original measures of IOP, LO, glaucoma or cataract incidences were included. Studies with adjuvant administration of oral, inhaled and intravenous steroids were excluded.

RESULTS

665 articles were retrieved with 137 were considered for full-text review. Of these, 116 (85%) were literature reviews and two were case reports. 19 studies (10 RCTs, 1 case-control, 8 case series) were included for the qualitative review, of which 18 reported data on IOP and 10 on cataract/LO. None (n=0) of the 10 RCT reporting data on glaucoma or IOP demonstrated changes in IOP compared to control. Also none (n=0) of the 6 RCTs reporting cataract or lens opacity demonstrated changes compared to control.

CONCLUSION

Data from studies with low levels of bias, do not demonstrate a clinically relevant impact of INCS on neither ocular pressure, glaucoma, lens opacity nor cataract formation.

Hormonal contraceptive use before hCG remission does not increase the risk of gestational trophoblastic neoplasia following complete hydatidiform mole: a historical database review

OBJECTIVE

To re-evaluate the safety of hormonal contraceptives (HC) after uterine evacuation of complete hydatidiform mole (CHM).

DESIGN

Historical database review.

SETTING

Charing Cross Hospital Gestational Trophoblastic Disease Centre, London, United Kingdom.

POPULATION

Two thousand four hundred and twenty-three women with CHM of whom 154 commenced HC while their human chorionic gonadotropin (hCG) was still elevated, followed between 2003 and 2012.

METHODS

We compared time to hCG remission between HC users and nonusers. The relationship between HC use and gestational trophoblastic neoplasia (GTN) development was assessed. The relationship between HC use and a high International Federation of Gynecology and Obstetrics (FIGO) risk score was determined.

MAIN OUTCOME MEASURES

Time to hCG remission, risk of developing postmolar GTN and proportion of women with high FIGO risk score.

RESULTS

No relationship was observed between HC use with mean time to hCG remission (HC users versus non-users: 12 weeks in both, P = 0.19), GTN development (HC users versus non-users: 20.1 and 16.7%, P = 0.26) or high-risk FIGO score (HC users versus nonusers: 0% and 8%, P = 0.15). Moreover, no association between HC and GTN development was found, even when an age-adjusted model was used (OR = 1.37, 95% CI 0.91-2.08, P = 0.13).

CONCLUSIONS

The use of current HC is not associated with development of postmolar GTN or delayed time to hCG remission. Therefore, HC can be safely used to prevent a new conception following CHM regardless of hCG level.

TWEETABLE ABSTRACT

Non-concurrent cohort study to re-evaluate the safety of low dose HCs after uterine evacuation of CHM.

Nasal peak inspiratory flow (NPIF) as a diagnostic tool for differentiating decongestable from structural nasal obstruction

BACKGROUND

Identifying the cause of nasal obstruction is critical before surgical intervention. Structural nasal obstruction, due to nasal valve stenosis, is unlikely to benefit from simple septoplasty and turbinate reduction. This study assesses changes in nasal peak inspiratory flow (NPIF) as a tool for discriminating decongestable versus structural obstruction.

METHODOLOGY

Cross-sectional study of patients undergoing nasal airflow assessment was performed. Rhinomanometry, nasal obstruction visual analogue scores (VAS) and NPIF were performed pre- and post-decongestion. Population groups were defined with decongestable or structural obstruction by relative post-decongestion changes in airways resistance and symptoms.

RESULTS

Fifty two patients were assessed, 24 with decongestable, 28 with structural obstruction. Pre- and post-decongestion NPIF were similar between groups. Absolute and percentage NPIF change were larger with decongestable versus structural obstruction. Sensitivity and specificity for predicting decongestable obstruction were 75.0% and 60.7% for NPIF increase >20 L/min; 75.0% and 64.3% for NPIF increase >20%. The respective positive predictive values were 62.1% and 64.3%.

CONCLUSION

NPIF increase after decongestion is larger with decongestable than structural nasal obstruction. NPIF alone cannot discriminate the two conditions and does not replace more formal assessment.

Phenotypic effects of maternal immune activation and early postnatal milieu in mice mutant for the schizophrenia risk gene neuregulin-1

Risk of schizophrenia is likely to involve gene × environment (G × E) interactions. Neuregulin 1 (NRG1) is a schizophrenia risk gene, hence any interaction with environmental adversity, such as maternal infection, may provide further insights into the basis of the disease. This study examined the individual and combined effects of prenatal immune activation with polyriboinosinic-polyribocytidilic acid (Poly I:C) and disruption of the schizophrenia risk gene NRG1 on the expression of behavioral phenotypes related to schizophrenia. NRG1 heterozygous (NRG1 HET) mutant breeding pairs were time-mated. Pregnant dams received a single injection (5mg/kg i.p.) of Poly I:C or vehicle on gestation day 9 (GD9). Offspring were then cross-fostered to vehicle-treated or Poly I:C-treated dams. Expression of schizophrenia-related behavioral endophenotypes was assessed at adolescence and in adulthood. Combining NRG1 disruption and prenatal environmental insult (Poly I:C) caused developmental stage-specific deficits in social behavior, spatial working memory and prepulse inhibition (PPI). However, combining Poly I:C and cross-fostering produced a number of behavioral deficits in the open field, social behavior and PPI. This became more complex by combining NRG1 deletion with both Poly I:C exposure and cross-fostering, which had a robust effect on PPI. These findings suggest that concepts of G × E interaction in risk of schizophrenia should be elaborated to multiple interactions that involve individual genes interacting with diverse biological and psychosocial environmental factors over early life, to differentially influence particular domains of psychopathology, sometimes over specific stages of development.

Uterine artery pulsatility index improves prediction of methotrexate resistance in women with gestational trophoblastic neoplasia with FIGO score 5-6

OBJECTIVE

The Uterine Artery Pulsatility Index (UAPI) is an ultrasound measure of tumour vascularity. In this study, we hypothesised that a UAPI ≤ 1 (high vascularity) would identify women with gestational trophoblastic neoplasia (GTN) at increased risk of resistance to first-line single-agent methotrexate (MTX-R).

DESIGN

Single-centre cohort study.

SETTING

Charing Cross Hospital, a UK national centre for the treatment of trophoblastic disease.

POPULATION

All women with a GTN FIGO score 5-6 treated with methotrexate (n = 92), between 1999 and 2011, at Charing Cross Hospital.

METHODS

UAPI was measured before the start of chemotherapy, and women were monitored for the development of MTX-R.

MAIN OUTCOME MEASURES

Frequency of MTX-R in women with UAPI ≤ 1 compared with UAPI >1.

RESULTS

UAPI was measured before chemotherapy in 73 of 92 women with GTN FIGO score 5-6. UAPI ≤ 1 predicted MTX-R independent of the FIGO score (hazard ratio 2.9, P = 0.04), with an absolute risk of MTX-R in women with a UAPI ≤ 1 of 67% (95% CI 53-79%) compared with 42% (95% CI 24-61%) with a UAPI >1 (P = 0.036).

CONCLUSION

Our results suggest UAPI is an independent predictor of MTX-R in women with FIGO 5-6 GTN.