Radioiodine Uptake at Suture Site Granuloma Mimicking Neck Node Metastasis on 131 I Whole-Body Iodine Scintigraphy

ABSTRACT

Differentiated thyroid carcinoma constitutes over 90% of all thyroid cancers. The standard treatment approach involves total or near-total thyroidectomy with or without neck dissection followed by 131 I whole-body scintigraphy (WBS) to detect local or distant metastases. Radioiodine offers high sensitivity and specificity for detection of metastatic disease in well differentiated thyroid carcinoma. However, despite its high accuracy, 131 I WBS demonstrates false-positive results, mostly at inflammatory or infective site. These false-positive radioiodine accumulation can lead to misdiagnosis and unwarranted radioiodine treatment. This case presents localization of 131 I to the suture site granuloma leading to false-positive results on 131 I WBS.

A lung cyst harbouring a congenital pulmonary varix

A non-smoker man in his second decade presented to a medical centre with intermittent haemoptysis over 2 years. The haemoptysis was infrequent initially to be ignored, but later, the episodes increased in amount and frequency. Routine blood tests including coagulation profile showed normal results. The chest radiography and echocardiography were normal. The contrast-enhanced CT scan of the chest showed a cystic lesion with intracystic abnormality and surrounding ground-glass opacity in the left upper lobe. The CT pulmonary angiography and invasive pulmonary angiography showed the abnormality to be a dilated pulmonary vessel draining into the left atrium, thereby confirming the diagnosis of congenital pulmonary varix contained within a lung cyst. The patient underwent a successful lobectomy following which he experienced no further haemoptysis.

Impact of nutritional status on the outcome of transjugular intrahepatic portosystemic shunt in patients with cirrhosis: a systematic review

OBJECTIVES

Malnutrition and sarcopenia have been reported to adversely affect the outcome of patients with cirrhosis of the liver. There is an emerging body of evidence suggesting malnutrition and sarcopenia increase the risk of hepatic encephalopathy (HE) and mortality after transjugular intrahepatic portosystemic shunt (TIPS). The current systematic review aims to determine whether the body of evidence supports an association between nutritional status and post-TIPS outcomes in patients with cirrhosis.

METHODS

Electronic databases of PubMed, Embase, and Scopus were searched from inception to June 3, 2023, for studies analysing the effect of nutritional status on post-TIPS outcomes in patients with cirrhosis.

RESULTS

A total of 22 studies were included in the systemic review. Assessment of sarcopenia was done by skeletal muscle index (SMI) at the L3 level, transversal psoas muscle thickness, psoas muscle density, malnutrition as per ICD, relative sarcopenia with excess adiposity, lipid profile, controlling nutritional status score, body composition analysis, hospital frailty risk score, and visceral and subcutaneous fat area index. Ten out of 12 studies in this systematic review showed a significant association with the incidence of post-TIPS HE. Thirteen out of 14 studies reported that the presence of malnutrition was associated with increased odds of mortality following TIPS. One study reported sarcopenia as an independent predictor of liver failure, and another study reported that Pre-TIPS SMI was an independent predictor of substantial improvement in post-TIPS SMI.

CONCLUSIONS

The current systematic review shows that the presence of pre-TIPS malnutrition or sarcopenia is an independent predictor of adverse outcomes after TIPS. Incorporating these parameters into present prediction models can provide additional prognostic information.

ADVANCES IN KNOWLEDGE

Nutritional assessment should be part of the evaluation of patients planned for TIPS for prediction of adverse events after the procedure.

Role of contrast-enhanced ultrasound for differentiation of benign vs. malignant portal vein thrombosis in hepatocellular carcinoma - A systematic review a meta-analysis

Introduction/Purpose

Patients with cirrhosis and hepatocellular carcinoma (HCC) can develop both benign and malignant portal vein thrombosis (PVT). Characterising the nature of PVT is important for planning an optimal therapeutic strategy. In the absence of typical findings or contraindications to computed tomography (CT) or magnetic resonance imaging (MRI), contrast-enhanced ultrasound (CEUS) could help in this differentiation. The present meta-analysis aimed to evaluate the performance of CEUS for characterising PVT in patients with HCC.

Methods

Electronic databases of PubMed, Embase and Scopus were searched from inception to 31 December 2022 for studies analysing the role of CEUS in the differentiation of benign and malignant PVT in HCC. Using the bivariate random effect model, pooled sensitivity and specificity were calculated, and the summary receiver operating characteristic (sROC) curve was plotted.

Results

A total of 12 studies with data from 712 patients were included in the meta-analysis. The pooled sensitivity and specificity of CEUS for the diagnosis of tumour in vein were 97.0% (95% CI: 93.0-98.7) and 96.8% (95% CI: 92.1-98.7), respectively, without significant heterogeneity. A sROC curve was plotted, and the area under the receiver operating characteristic was 0.99 (95% CI: 0.98-1.00). Despite the presence of publication bias, sensitivity analysis did not show any change in sensitivity and specificity.

Discussion

Our meta-analysis summarises the accuracy data from 12 studies, including >700 subjects. Contrast-enhanced ultrasound had excellent diagnostic accuracy with pooled sensitivity and specificity of 97.5% (95% CI: 93.5-99.1) and 98.2% (95% CI: 91.5-99.6), respectively, without any significant heterogeneity. Additionally, the pooled positive LR, negative LR and DOR were 54.6 (95% CI: 11.1-25.6), 0.02 (0.01-0.07) and 2186.8 (318.3-15022.2), respectively. A positive result increases the pretest probability of malignant PVT from 50% to 98%, whereas a negative result decreases it from 50% to 2%. Most of the studies included in our meta-analysis used identical techniques and 6-12-month follow-up scans to check for thrombus progression or regression. Our analysis showed no significant heterogeneity in the studies, and area under receiver operating characteristic curve (AUROC) with 95% CI was 1.00 (95% CI: 0.99-1.00). This critical meta-analysis thus propels CEUS to the forefront for differentiating benign from tumoural PVT and suggests routinely using CEUS in patients presenting with HCC and evidence of thrombus on greyscale ultrasound.

Conclusion

Contrast-enhanced ultrasound is an effective diagnostic modality differentiation of benign and malignant PVT in patients with HCC and can be an alternative modality to CT or MRI. Further studies are required to study the role of CEUS as initial diagnostic modality for the characterisation of PVT in HCC.

Role of Interventional Radiology (IR) in vascular emergencies among cirrhotic patients

Gastrointestinal hemorrhage remains one of the most common causes of morbidity and mortality among patients with liver cirrhosis. Mostly, these patients bleed from the gastroesophageal varices. However, nonvariceal bleeding is also more likely to occur in these patients. Because of frequent co-existing coagulopathy, cirrhotics are more prone to bleed from a minor vascular injury while performing percutaneous interventions. Ultrasound-guided bedside vascular access is an essential procedure in liver critical care units. Transjugular portosystemic shunts (TIPS) with/without variceal embolization is a life-saving measure in patients with refractory variceal bleeding. Whenever feasible, balloon-assisted retrograde transvenous obliteration (BRTO) is an alternative to TIPS in managing gastric variceal bleeding, but without a risk of hepatic encephalopathy. In cases of failed or unfeasible endotherapy, transarterial embolization using various embolic agents remains the cornerstone therapy in patients with nonvariceal bleeding such as ruptured hepatocellular carcinoma, gastroduodenal ulcer bleeding, and procedure-related hemorrhagic complications. Among various embolic agents, N-butyl cyanoacrylate (NBCA) enables better vascular occlusion in cirrhotics, even in coagulopathy, making it a more suitable embolic agent in an expert hand. This article briefly entails the different interventional radiological procedures in vascular emergencies among patients with liver cirrhosis.

Assessing ChatGPT's Proficiency in Simplifying Radiological Reports for Healthcare Professionals and Patients

Background Clear communication of radiological findings is crucial for effective healthcare decision-making. However, radiological reports are often complex with technical terminology, making them challenging for non-radiology healthcare professionals and patients to comprehend. Large language models like ChatGPT (Chat Generative Pre-trained Transformer, by OpenAI, San Francisco, CA) offer a potential solution by translating intricate reports into simplified language. This study aimed to assess the capability of ChatGPT-3.5 in simplifying radiological reports to facilitate improved understanding by healthcare professionals and patients. Materials and methods Nine radiological reports were taken for this study spanning various imaging modalities and medical conditions. These reports were used to ask ChatGPT a set of seven questions (describe the procedure, mention the key findings, express in a simple language, suggestions for further investigation, need of further investigation, grammatical or typing errors, and translation into Hindi). A total of eight radiologists rated the generated content in detailing, summarizing, simplifying content and language, factual correctness, further investigation, grammatical errors, and translation to Hindi. Results The highest score was obtained for detailing the report (94.17% accuracy) and the lowest score was for drawing conclusions for the patient (85% accuracy); case-wise scores were similar (p-value = 0.97). The Hindi translation by ChatGPT was not suitable for patient communication. Conclusion The current free version of ChatGPT-3.5 was able to simplify radiological reports effectively, removing technical jargon while preserving essential diagnostic information. The free version adeptly simplifies radiological reports, enhancing accessibility for healthcare professionals and patients. Hence, it has the potential to enhance medical communication, facilitating informed decision-making by healthcare professionals and patients.

Dynamic hysteresis at a noisy saddle node shows power-law scaling but nonuniversal exponent

Dynamic hysteresis, viz., delay in switching of a bistable system on account of the finite sweep rate of the drive, has been extensively studied in dynamical and thermodynamic systems. Dynamic hysteresis results from slowing of the response around a saddle-node bifurcation. As a consequence, the hysteresis area increases with the sweep rate. Mean-field theory, relevant for noise-free situations, predicts power-law scaling with the area scaling exponent of 2/3. We have experimentally investigated the dynamic hysteresis for a thermally driven metal-insulator transition in a high-quality NdNiO_{3} thin film and found the scaling exponent to be about 1/3, far less than the mean-field value. To understand this, we have numerically studied Langevin dynamics of the order parameter and found that noise, which can be thought to parallel finite temperature effects, influences the character of dynamic hysteresis by systematically lowering the dynamical exponent to as small as 0.2. The power-law scaling character, on the other hand, is unaffected in the range of chosen parameters. This work rationalizes the ubiquitous power-law scaling of the dynamic hysteresis as well as the wide variation in the scaling exponent between 0.66 and 0.2 observed in different systems over the last 30 years.

Noninvasive differentiation of porto-sinusoidal vascular disorder from cirrhosis: a systematic review

BACKGROUND

Porto-sinusoidal vascular disorder (PSVD) is one of the common causes of portal hypertension and has overlapping features with early cirrhosis. The differentiation of PSVD from cirrhosis requires a liver biopsy, which is invasive and has potential complications. This systematic review aimed at summarizing the current evidence on the performance of noninvasive modalities for differentiating PSVD from cirrhosis.

METHODS

A comprehensive search of electronic databases of MEDLINE, Embase, and Scopus was conducted from 2000 to October 2022 for the studies comparing the elastographic and radiological features of PSVD and cirrhosis, using liver biopsy as the gold standard.

RESULTS

A total of 12 studies were included in the systematic review. Transient elastography (TE) as a modality was studied in five studies, MR elastography (MRE) in two, contrast CT in two, Contrast CT and MRI in two, and ARFI in only one. Both TE and MRE showed a significantly lower liver stiffness measurement and a higher splenic stiffness measurement with a higher SSM/LSM ratio with PSVD, compared to cirrhosis. Among the radiological features, focal nodular hyperplasia-like lesions, portal vein abnormalities (intrahepatic and extrahepatic), and a larger spleen size favored a diagnosis of PSVD. In contrast, surface nodularity and atrophy of segment IV with a segment I hypertrophy favored a diagnosis of cirrhosis.

CONCLUSION

Elastography and cross-sectional imaging can help differentiate PSVD from early cirrhosis with good accuracy. Further studies are required to assess the diagnostic role of a combination of both modalities.

Lower extremity pseudoaneurysms and their interventional radiological management: a pictorial review

Lower extremity pseudoaneurysms (PsAs) are mostly developed after traumatic or iatrogenic injury to the arteries. Unless treated, they can be complicated by adjacent mass effects, distal embolism, secondary infection, and rupture. Imaging helps in the diagnosis and planning of therapeutic intervention. Ultrasonography (USG) is often diagnostic, while CT angiography aids in vascular mapping required for intervention. Image-guided therapy offers to manage these pseudoaneurysms in a minimally invasive approach, obviating the need for surgery. A smaller, superficial, and narrow-necked PsA can easily be managed with local USG-guided compression or thrombin injection. When the percutaneous approach is not a feasible option, PsA from expendable arteries can also be managed with coiling or glue injection. Wide-necked PsA from an unexpendable artery necessitates stent graft placement, although coiling of the neck may be a viable and cheaper alternative for a long- and narrow-necked PsA. Presently, vascular closure devices are also used to seal a small arterial rent through a direct percutaneous approach. This pictorial review entails various techniques to deal with lower extremity pseudoaneurysms. An idea about the various intervention radiological approaches will help in choosing appropriate methods to tackle lower extremity pseudoaneurysms.

Percutaneous ablative therapies for hepatocellular carcinoma in the caudate lobe of the liver: efficacy and outcome

OBJECTIVE

To assess the efficacy and outcomes of percutaneous ablative therapies for hepatocellular carcinoma (HCC) in the caudate lobe.

METHODS

Patients within Milan criteria, who underwent thermal ablation (RFA/MWA) for HCC were analyzed. Based on the inclusion-criteria, patients were categorized in two groups. Group-1 (caudate-lobe HCC) and Group-2 (non-caudate-lobe HCC). Both the groups were analyzed for technical success (TS), local tumor progression (LTP), disease-free survival (DFS), and overall survival (OS) were compared between both the groups. Predictive factors for LTP, DFS, or OS in the study cohort were analyzed using appropriate statistical analyses.

RESULTS

Twenty-one patients qualified to be in Group-1 while 130 patients fulfilled the criteria for Group-2. TS of 90.5 and 97.7% was seen after the first session of ablation for Group-1 and group-2 respectively, while a TS of 95.2% (Group-1) and 100% (Group-2) was achieved after second session. The right-intercostal-approach was used in 66.7% (n = 14) and the anterior-epigastric-approach was used in 33.3% (n = 7) of patients having caudate-lobe HCC. Procedure-related complications in both the groups were comparable. Although, statistically insignificant, LTP in the Group-1 (19.5%, n = 4) was twice that of non-caudate lobe HCC (8.5%, n = 11). The cumulative DFS rate was better in Group-2 while OS in both groups were comparable. Multivariate analysis showed: tumor size and ablative margin of 5 mm being independent predictors of LTP after percutaneous-ablation of caudate-lobe HCC.

CONCLUSION

Ablative therapies for HCC in caudate lobe is feasible and safe with comparable LTP and OS to non-caudate lobe HCC. Tumor size >2 cm and lack of 5 mm ablative margin are independent predictors of LTP.

ADVANCES IN KNOWLEDGE

1. Percutaneous ablation of caudate lobe HCC is feasible using anterior epigastric approach or right intercostal approach.2. These approaches may allow a safe and effective ablation of caudate lobe HCC with results comparable to non-caudate HCC ablation.

A pilot study for development of a pulmonary function test induction jacket to automate effort in performing the forced vital capacity manoeuvre

The pulmonary function test (PFT) induction jacket was invented to make the process of performing the forced vital capacity (FVC) manoeuvre with a computerized spirometer effortless and productive for both the patient and the medical practitioner. The jacket is composed of three layers of PVC material sealed together to form a single jacket with two chambers. The inner chamber is formed between the inner layer and the middle layer, in which cold water at a temperature of 10 °C is circulated using a connected water unit when triggered. Similarly, the outer chamber is formed between the middle layer and the outer layer, in which air is pressurized using a connected air unit. Thirty volunteers performed the FVC manoeuvre with and without wearing the jacket. There was no difference between the results in spirometry parameters in the participants without a jacket and those with a jacket. However, use of the jacket significantly reduced the number of trials the participants had to undergo to perform spirometry. The jacket automated the FVC manoeuvre by triggering a physiological inspiratory gasp using cold water and circumscribing pressurized air for expiration. Additionally, subsequent advancements in the jacket have been suggested.

Combined Bile Duct Ablation and Fistulous Tract Embolization Using N-Butyl Cyanoacrylate to Manage a Biliary-Cutaneous Fistula Following Percutaneous Transhepatic Biliary Drainage (PTBD) for Hilar Cholangiocarcinoma

Biliary fistula and bile leak are known complications following hepatobiliary surgery, trauma, and percutaneous biliary interventions. In the case of an isolated biliary system with a prolonged indwelling percutaneous transhepatic biliary drainage (PTBD) catheter, a biliary-cutaneous fistula (BCF) may develop after catheter blockage or its accidental slippage. Due to the absence of internal drainage, secreted bile flows through the matured PTBD tract to form a fistula. If left untreated, chronic BCF will result in malabsorption, infection, and delayed wound healing. Here, we report a case of left-sided BCF following prolonged PTBD for Bismuth type II cholangiocarcinoma (metastatic disease), which was initially managed by bile duct ablation using N-butyl cyanoacrylate. The patient further needed fistulous tract embolization to obliterate the BCF.

Comparative outcome of transjugular intrahepatic portosystemic shunt with or without variceal obliteration: a systematic review and meta-analysis

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) has been used for the secondary prevention of variceal bleeding. TIPS can be combined with variceal embolization (TIPS-VO), but its benefit remains controversial. The present systematic review and meta-analysis were conducted to compare the incidence of rebleeding, adverse events, and mortality among patients with TIPS alone and with TIPS-VO.

METHODS

A literature search from January 2000 to June 2022 was done for studies comparing the outcome of patients undergoing TIPS alone or TIPS-VO. A subgroup analysis was conducted for patients undergoing TIPS with covered stents.

RESULTS

A total of 11 studies with data from 1044 patients were included. The incidence of rebleeding was significantly higher in the TIPS alone group in both overall population OR 2.01 (1.42-2.83) and the subgroup (OR 1.92, 95% CI 1.21-3.04). There was no difference between the two groups concerning the risk of hepatic encephalopathy (OR 1.15, 95% CI 0.83-1.59), procedural adverse events (OR 0.86, 95% CI 0.54-1.39), shunt dysfunction (OR 1.20, 95% CI 0.82-1.75), overall mortality (OR 1.03, 95% CI 0.73-1.46), and mortality due to variceal rebleeding (OR 1.58, 95% CI 0.44-5.64). There was no significant heterogeneity or publication bias among the included studies. The certainty of evidence remains low for all the outcome expect for variceal rebleeding.

CONCLUSION

The present meta-analysis provides a moderate-quality evidence for the benefit of TIPS-VO in reducing the incidence of rebleeding. However, the decision for combining variceal embolization with TIPS should be made on a case-to-case basis.

Cystic retroperitoneal metastasis from testicular seminoma, radiologically mimicking as lymphangioma

Background

Retroperitoneal nodal metastasis in a primary testicular tumor is not uncommon and usually presents as solid or solid-cystic nodal masses. A completely cystic appearance with fluid attenuation or fluid signal intensity on computed tomography (CT) and magnetic resonance imaging (MRI), respectively, is an uncommon presentation. There are many case reports of different types of cystic retroperitoneal masses; however, to our knowledge, metastatic retroperitoneal cystic masses showing fluid attenuation/fluid signal intensity on CT/ MRI secondary to primary testicular seminoma masquerading as cystic lymphangioma has been rarely reported in the medical literature. Our case report reports a case of a metastatic retroperitoneal cystic mass in a known case of testicular seminoma patient, which was misdiagnosed as cystic lymphangioma initially based on imaging.

Case presentation

A 55-year-old—patient presented to our hospital with abdominal pain, which was on and off in character. The patient underwent routine ultrasound abdomen, CT and MRI, which revealed multiple cystic lesions in the retroperitoneum. Initially, a provisional diagnosis of cystic lymphangioma was made based on the utterly cystic nature of the lesion and the presence of calcification. However, fine-needle aspiration cytology (FNAC) confirmed the metastatic origin of the lesion and was strengthened by the previous clinical history of orchidectomy.

Conclusion

The treatment strategy for cystic retroperitoneal masses varies depending on the cause and its nature, so differentiation between the cystic masses is essential. Metastasis should also be kept in the differentials in all cystic retroperitoneal masses. Moreover, clinical history and FNAC can assist in making the correct diagnosis.

Prognostic implications of clinical phenotype and severity of cardiac involvement in patients presenting with immunoglobulin light chain amyloidosis

Background

Patients with systemic immunoglobulin light chain (AL) amyloidosis may present with a wide array of signs and symptoms due to the multi-systemic organ involved. The presence of cardiac involvement is the key determinant of survival. Cardiac magnetic resonance (CMR) has the unique ability to measure the continuum of cardiac amyloidosis (CA) infiltration providing a deep characterisation from early CA involvement to severe degree of CA burden.

Purpose

The aim of this study was to characterise the clinical profiles and the severity of organ involvement in patients presenting with AL amyloidosis and to investigate implications for long-term outcome.

Methods

Patients newly diagnosed with AL amyloidosis at the National Amyloidosis Centre underwent comprehensive clinical, laboratory and instrumental work up, including CMR imaging with left ventricular (LV) mass, late gadolinium enhancement (LGE) and extracellular volume (ECV). The clinical phenotypes were classified in cardiac, renal and other according to the symptoms at presentation. The degree of CA was investigated by CMR: 0= no features of CA (normal LV mass, no LGE and normal ECV); 1=early cardiac amyloid infiltration (normal LV mass, raised ECV no LGE); 2= characteristic of CA with normal mass (diffuse subendocardial or transmural LGE, altered gadolinium kinetics and raised ECV); 3= characteristic of CA with elevated mass (diffuse subendocardial or transmural LGE and raised ECV). The study outcome was all-cause mortality.

Results

The study population included 241 AL patients presenting with cardiac and renal (22.8%, n=55), cardiac (28.2%, n=68), renal (33.2%, n=80) and other (15.8% n=38) phenotypes. During a median follow up of 33 (IQR 7–52) months, cardiac phenotype either in isolation or in combination with renal phenotype was associated with a higher rate of all-cause mortality compared to the others (p<0.001) (Figure). On CMR imaging, 43.2% of patients without cardiac phenotype (49%, n=118/241) had characteristic scans of CA (CMR grade 2 and 3) whilst 13.8% of patients with cardiac phenotype (51%, n=123/241) had no features of CA on CMR images (CMR grade 0) in (p<0.001). With Kaplan Meier analysis, the risk of all-cause death increased in patients with characteristic features of CA on CMR scan (Figure 1) and in patients with cardiac phenotype and features of CA on CMR scans compared to the others (both p<0.001) (Figure). At multivariable analysis, age at diagnosis (hazard ratio [HR] 1.03, p=0.009), clinical phenotype at presentation (HR 1.35, p=0.014) and ECV measured by CMR (HR 56, p<0.001) emerged as independent prognostic parameters.

Conclusions

Patients with newly diagnosed AL amyloidosis present most frequently with renal and cardiac phenotypes. CMR detects CA in >40% of patients with non-cardiac phenotype. ECV is an independent predictor of all-cause mortality across the full clinical spectrum of AL amyloidosis.

Funding Acknowledgement

Type of funding sources: None.

Myocardial ischaemia in cardiac amyloidosis: a change of perspective

Introduction

Cardiac involvement is the main driver of clinical outcomes in systemic amyloidosis; however many clinical observations are not explained by the concept of replacement of the interstitium by amyloid material. Preliminary studies support the hypothesis that myocardial ischaemia contributes to cellular damage.

Purpose

This study assesses the presence and mechanisms of myocardial ischaemia using cardiovascular magnetic resonance (CMR) with multiparametric mapping and histopathological assessment.

Methods

Ninety-two patients with cardiac amyloidosis (CA) (AL = 41, ATTR = 51) and 97 without CA (3-vessel coronary disease (3VD) = 47, unobstructed coronary arteries = 26, healthy volunteers (HV) = 24) underwent quantitative stress perfusion CMR with myocardial blood flow (MBF) mapping. Twenty-six myocardial biopsies and 3 explanted hearts with CA were analysed histopathologically.

Results

Stress MBF was severely reduced in patients with CA with lower values than patients with 3VD, unobstructed coronary arteries and HV (CA = 1.03±0.51 ml/min/g, 3VD = 1.35±0.50 ml/min/g, Unobstructed coronaries = 2.92±0.52 ml/min/g, HV = 3.14±0.69 ml/min/g; CA vs 3VD p=0.008, CA vs Unobstructed coronaries p<0.001, CA vs HV p<0.001). After adjustment for intracellular volume the MBF in patients with CA remained significantly lower than in HV (stress MBF/ICV: AL = 2.24±1.12, ATTR = 2.22±0.93, HV = 4.38±1.06; AL vs. ATTR p=1.000, AL vs HV p<0.001, ATTR vs. HV p<0.001). Myocardial perfusion reserve (MPR) was severely reduced in CA patients, compared to HV and patients with unobstructed coronary arteries, with the degree of reduction being comparable only to patients with 3VD (CA = 1.55±0.60, 3VD = 1.54±0.51, unobstructed coronaries = 2.78±0.70, HV = 4.08±0.86; CA vs 3VD p=1.000, CA vs unobstructed coronary arteries p<0.001, CA vs. HV p<0.001). Myocardial perfusion abnormalities correlated with amyloid burden, systolic and diastolic function, structural parameters and blood biomarkers (p<0.05). Biopsies demonstrated diffuse hypoxia with abnormal VEGF staining in cardiomyocytes and endothelial cells. Amyloid infiltration in intramural arteries was associated with severe lumen reduction in 20% of vessels, and severe reduction in capillary density.

Conclusion

CA is associated with severe myocardial ischaemia demonstrable by histology and CMR stress perfusion mapping. Histological evaluation indicates a complex pathophysiology, where systolic and diastolic dysfunction, amyloid infiltration of the epicardial arteries and disruption and rarefaction of the capillaries play a role in contributing to myocardial ischaemia.

Funding Acknowledgement

Type of funding sources: None.

Changes in referral pathway and phenotypic status of patients diagnosed with ATTR cardiac amyloidosis during the past 20 years

Background

Diagnostic and therapeutic advances have led to much increased awareness of transthyretin (ATTR) cardiac amyloidosis (CA).

Purpose

We sought to characterise the impact of this on referral practice, cardiac phenotype at diagnosis and specifically to determine whether patients are now being diagnosed at an earlier stage in their disease process.

Methods

We studied 1845 patients diagnosed with ATTR-CA at the National Amyloidosis Centre (NAC) from 2002–2021, all of whom underwent deep clinical phenotyping and follow-up.

Results

Analysis by 5-year quartiles revealed a substantial incremental increase in patients diagnosed with ATTR-CA (35 vs 260 vs 704 vs 846), which was associated with greater proportions of patients referred following advanced cardiac imaging (referrals following cardiac magnetic resonance and bone scintigraphy: 3% vs 44% vs 67% vs 76%; P<0.001). Over time, median duration of symptoms prior to diagnosis diminished from 36-months between 2002–2006 to 12-months between 2017–2021 (P<0.001) and a greater proportion of patients presented with milder disease across the 5-yearly quartiles (NAC stage 1: 40% vs 43% vs 44% vs 57%; P<0.001). The latter was associated with more favourable echocardiographic parameters of structure and function, including an incremental reduction in maximal left ventricular wall thickness (18.26mm vs 17.41mm vs 17.09mm vs 16.68mm; P=0.017). This was associated with improved survival in the overall population (2007–2011 vs 2012–2016: HR=1.65, 95% CI [1.33–2.06]; P<0.001 and 2012–2016 vs 2017–2021: HR =1.83, 95% CI [1.45–2.31]; P<0.001) and in each genotype (wtATTR, T60A and V122I). Despite a significant increase in the proportion of patients enrolled into clinical trials (0.0% vs 0.0% vs 2.6% vs 23.9%; P<0.001) and prescribed disease modifying therapy (5.7% vs 0.4% vs 4.8% vs 13.5%; P<0.001); the improved survival remained significant even after adjusting for clinical trials and disease modifying therapy (2012–2016 vs. 2017–2021: HR=1.65 95% CI [1.29–2.11], P<0.001).

Conclusion

Increased awareness and advances in cardiac imaging have been associated with a substantial increase in the diagnosis of ATTR-CA and at a progressively earlier stage of the disease, which has contributed to improved survival in recent years. These changes may have important implications for initiation and outcome of therapy. Given that ATTR-CA is now being diagnosed earlier, more data are needed to guide decisions on in whom and when to initiate treatment, and which treatments should be used at each disease stage. Furthermore, the changes in ATTR-CA phenotype at diagnosis urgently need to be factored into clinical trial design, given that pre-determined end-points based on trials performed in the past may no longer be appropriate, or at least sufficiently powered, or of adequate duration to evaluate efficacy of novel agents.

Funding Acknowledgement

Type of funding sources: None.

Multi-imaging characterisation of cardiac phenotype in different types of amyloidosis

Background

Bone scintigraphy is extremely valuable when assessing patients with suspected cardiac amyloidosis (CA), but the clinical significance and associated phenotype of different degrees of myocardial tracer uptake across different types of amyloidosis is yet to be defined.

Purpose

We sought to define the phenotypes of patients with varying degrees of cardiac uptake on bone scintigraphy, across multiple types of systemic amyloidosis using extensive characterisation comprising of biomarkers, echocardiographic and cardiac magnetic resonance (CMR) imaging.

Methods

A total of 296 patients (117 immunoglobulin light-chain [AL] amyloidosis, 165 transthyretin [ATTR] amyloidosis, 7 apolipoprotein-A1-amyloidosis [AApoAI],and 7 apolipoprotein-A4-amyloidosis [AApoA4]) underwent deep characterisation of their cardiac phenotype.

Results

AL-amyloidosis patients with grade 0 myocardial radiotracer uptake spanned the spectrum of CMR findings from no evidence of CA to characteristic features of CA, while AL-amyloidosis patients with grade 1–3 always produced characteristic CMR features. In ATTR-amyloidosis the CA burden strongly correlated with myocardial tracer uptake (correlation between bone scintigraphy cardiac uptake and CMR derived extracellular volume: R=0.88, 95% CI [0.84–0.91], P<0.001), except in patients with the Ser77Tyr variant. AApoAI-amyloidosis presented with grade 0–1 myocardial tracer uptake, and unique features of disproportionate right sided involvement such as disproportionate right ventricular (RV) and right atrial uptake on bone scintigraphy, RV free wall thickening, and tricuspid valve thickening and dysfunction. Within our cohort, AApoAIV-amyloidosis always presented with grade 0 myocardial tracer uptake, and characteristic features of CA on CMR. All AL-amyloidosis patients with grade 1 myocardial tracer uptake had characteristic CMR features of CA (n=48, 100%), while only ATTR-amyloidosis grade 1 patients with the Ser77Tyr variant had characteristic features of CA on CMR (n=5, 11.4%). Following the exclusion of Ser77Tyr and AApoAI, a CMR showing characteristic features of CA or an extracellular volume >0.40 in a patient with grade 1 myocardial tracer uptake had a sensitivity and specificity of 100% for diagnosing AL-amyloidosis.

Conclusion

Deep characterisation of the cardiac phenotype in different types of amyloidosis, across a range of bone scintigraphy cardiac uptake grades has identified clear differences between each amyloidosis type. The distinctive characteristics in each cohort has allowed the development of a diagnostic pathway to help define the diagnostic differentials and the clinical phenotype in each individual patient, following comprehensive assessment with bone scintigraphy and CMR.

Funding Acknowledgement

Type of funding sources: None.

Hepatic Arterioportal Fistula in Patients with Cirrhosis with Endovascular Management—A Series of 4 Cases with Review of Literature

Hepatic arterioportal fistula (APF) in the setting of cirrhosis may aggravate the preexisting portal hypertension and its complications. Cirrhotic patients undergo various percutaneous invasive procedures and are at risk of developing an APF. These should be diagnosed early and should be treated accordingly at the earliest when indicated. Presently embolization is the treatment of choice with coil embolization as the most commonly used method. We describe four cases from our institute with a history of liver parenchymal disease and were found to have acquired APF on imaging. These were successfully managed with transarterial embolization with resolution or improvement in their clinical symptoms on follow-up. The present case series and review emphasize the importance of APF in the setting of liver parenchymal disease and the role of early diagnosis and therapeutic intravascular interventions.

Bleeding Stomal Varices and Their Interventional Management- A Series of Three Cases

Although stomal and parastomal varices are uncommon causes of variceal bleeding, the mortality rate might be as high as 40%. Timely intervention is essential for the management of these ectopic bleeding varices. Due to the rarity of such varices, no standard treatment guideline is available. We present three cases of bleeding stomal varices managed with an endovascular approach, one through percutaneous transhepatic and the other two through transjugular intrahepatic portosystemic shunt approach.

Demographic and Clinicoradiological Presentation of Tuberculosis in Patients with Sickle Cell Haemoglobinopathy: A Cross-sectional Study

Introduction: Infectious disease is an important contributor to disability and death in Sickle Cell Haemoglobinopathy (SCH). India has a high burden of Tuberculosis (TB) and SCH is widespread among residents in and around Burla, Odisha. This was the first attempt to find the prevalence of SCH in active cases of TB in Indian adults. Aim: To estimate the prevalence of SCH in TB and to evaluate the demographic and clinicoradiological presentation of TB in patients with SCH in a subset of Indian population. Materials and Methods: A cross-sectional study was done from October 2010 to September 2012 in Department of Pulmonary Medicine of V.S.S.M.C, Burla, Odisha, India. The primary inclusion criterion was patients with TB and SCH. Demographic characteristics, clinical, radiological, microbiological and histopathology data were collected. Statistical analysis was done using Statistical Package of the Social Sciences (SPSS) 18.0. Association between categorical data was calculated using Chi-square test and Fischer’s exact test. A p-value of <0.05 was considered to be significant. Results: Out of 1243 TB patients who were screened, 64 TB patients had SCH. The mean age of the patients was 30 (±13) years with female predominance 33 (51.56%). The prevalence of SCH in TB was 51.49/1000, Sickle Cell Anaemia (SCA) was 13.68/1000 and Sickle Cell Trait (SCT) was 37.81/1000. 47 (73.43%) patients had SCT and 17 (26.56%) patients had SCA. Majority of patients with SCA 15 (88.23%) and SCT 35 (74.46%) belonged to the age of ≤40 years. 38 (59.37%) patients had Pulmonary TB (PTB) and 26 (40.62%) had Extrapulmonary TB (EPTB). EPTB 11 (64.70%) was common in patients with SCA than PTB 6 (35.29%) and vice-versa in SCT 15 (31.91% vs 32 (68.08%) (p=0.018). Among PTB patients, cough was the most common symptom seen in 7(10.93%) patients of SCA and in 26 (40.62%) patients of SCT. The mean (±SD) haemoglobin in patients with SCA was 7.270 (±2.007) gm% and SCT was 9.021 (±1.578) gm% (p=0.002). The most common chest radiographic finding was nodules in patients with SCA 9 (52.94%), reticular opacities and pleural effusion 11 (23.40%) each in SCT. Conclusion: In the present study, 5.14% of TB patients had SCH. PTB was more common than EPTB in patients with SCH.

Complications of transjugular intrahepatic portosystemic shunt (TIPS) in the era of the stent graft - What the interventionists need to know?

Transjugular intrahepatic portosystemic shunt (TIPS) is created between a hepatic vein (HV) and the portal vein (PV) to alleviate the symptoms of portal hypertension. Despite high procedural success rates, a myriad of complications may occur at every step of TIPS creation. These complications may be attributable to the procedure itself or the shunt. Portal vein puncture is the most challenging and rate-limiting step, with extrahepatic portal vein puncture being the most devastating tabletop complication. Hepatic encephalopathy is the most common shunt-related complication after TIPS. Unlike bare metallic stents, covered stents have a longer patency rate and lower incidence of TIPS dysfunction. Most of the TIPS dysfunction that occurs with stent-grafts is due to technical errors and mechanical factors. TIPS revision often requires a combination of angioplasty, mechanical thrombectomy, and thrombolytics with a need for additional stenting in some cases. This review article focuses on procedure and shunt-related complications, as well as preventive and management strategies.

0816 Sleep Correlates Of Nightmares Among Veterans

Introduction

There is an increased prevalence of Nightmare disorder (ND) among patients with obstructive sleep apnea (OSA). A further investigation of objectively measured sleep parameters among patients with and without ND could inform on potential comorbidities. We hypothesize ND correlates with Epworth sleepiness scale (ESS), apnea hypopnea index (AHI), Trough 02% (Sp02 nadir), and periodic limb movement (PLM) index.

Methods

Data presented herein are interim results from an IRB approved study to determine correlates and sequelae of nightmares. A cohort of all patients with ND visiting James A Haley Veterans Hospital between 2007 and 2011 was defined along with a random cohort of control patients. Demographic and outpatient visit data between January 2006 and April 2016 was pulled from VISTA for both the ND and control cohorts, and patients who had undergone a sleep study were identified. To date, sleep summary data has been individually extracted for 111 ND patients and 835 control patients. Logistic regression (SAS 9.4) was used to compare ESS, AHI, Sp02 nadir, and PLM Index.

Results

Mean age for ND was significantly lower at 49.7 ± 14, compared to 58.4 ± 12 for controls. Other demographic measures were similar including gender, race, and marital status. PLM index was significantly lower in ND compared to controls, however this relationship disappeared after adjusting for age. There were neither significant differences between other polysomnographic (PSG) variables, specifically AHI and Sp02 nadir, nor did OSA severity significantly different between ND and controls.

Conclusion

Among veterans undergoing a PSG, there were no significant differences between measured sleep parameters. Our results contradict our hypothesis that ND correlates with ESS, AHI, Sp02 nadir, and PLM index.

Support

This material is the result of work supported with resources and the use of facilities at the James A. Haley Veterans’ Hospital.

Evaluation of variation of interfraction doses to organs at risk during brachytherapy of cervical cancer

Background

Two-dimensional treatment planning using radiographs or simulator films was the standard in planning brachytherapy for patients with cervical cancer. Three-dimensional (3D) treatment planning has improved treatment efficacy. This retrospective study compares conventional and 3D treatment planning of brachytherapy in patients with cervical cancer and interfraction dose variation to bladder and rectum (D2cc).

Methods

The mean doses to bladder and rectum (D2cc) were computed by computed tomography (CT)-based planning during 100 sessions of intracavitary brachytherapy for carcinoma cervix with the same source configuration as generated for conventional planning, and these estimates were compared with the doses at International Commission on Radiation Units and measurements (ICRU) rectal, bladder points and point A. Interfraction variation of doses to bladder and rectum during various sessions was also analysed.

Result

The mean ICRU bladder dose and D2cc of the bladder for all patients was 3.7 Gy and 7.4 Gy, respectively (p < 0.001). The mean ICRU rectal dose from conventional plan was 4.3Gy and with CT planning, 4.45 Gy (p = 0.04). Interfraction dose variations for D2cc of the bladder were min -5.3 Gy and max 4.8 Gy and those of the rectum were min -1.8 Gy and max 1.72Gy.

Conclusion

Dosimetric evaluation of conventional and 3D CT-based treatment planning for the same brachytherapy sessions demonstrated underestimation of ICRU bladder dose points (p < 0.001) and the rectal ICRU point dose and D2cc (p=0.04). The doses to organs at risk did not show a statistically significant variation between the fractions. However, large variation was noted between the interfractional maximum and minimum doses to bladder and rectum.

The perils of inhibiting deficient factors

Essentials Anticoagulation in patients with factor X deficiency is an evidence-poor area. A patient with factor X deficiency was anticoagulated with warfarin followed by rivaroxaban. Warfarin may be a safer anticoagulant option than rivaroxaban in hereditary factor X deficiency. A baseline coagulation screen should be performed prior to commencement of anticoagulation.

SUMMARY

We report a case of a previously undiagnosed factor X deficiency in an 83-year-old man who had no previous bleeding history despite multiple hemostatic challenges. He was anticoagulated with warfarin for atrial fibrillation without bleeding complications; however, major hemorrhage occurred soon after a switch to rivaroxaban.

Perineal hernia formation following extralevator abdominoperineal excision

AIM

Extralevator abdominoperineal excision (ELAPE) has become increasingly used because of some evidence of improved oncological outcome. It is, however, thought to be associated with a higher incidence of perineal hernia formation, although the exact incidence is not known. The aim of this study was to identify the incidence of perineal hernia after ELAPE.

METHOD

The case notes of patients over a 54-month period were reviewed. The perineal closure technique, perineal complications and management plan were recorded.

RESULTS

During the study period, 56 patients underwent ELAPE, of whom 24 (44%) developed a perineal wound complication. Primary perineal closure was performed with (eight patients) and without (32 patients) insertion of a biological mesh or myocutaneous flap. Perineal hernia was the commonest complication (26%) and occurred in nine (45%) of 20 patients who had a laparoscopic ELAPE.

CONCLUSION

Perineal hernia formation was the commonest perineal complication of ELAPE and occurred in nearly half of patients having a laparoscopic ELAPE.

Simultaneous analysis and quantification of markers of manjisthadi churna using high performance thin layer chromatography

Manjisthadi churna has been traditionally used in the Ayurvedic system of medicine and by traditional medical practices of India to treat hyperlipidemia. A rapid, simple and accurate method with high performance thin layer chromatography has been developed to standardised Manjisthadi churna using rubiadin, sennoside and ellagic acid as markers. Methanol extract of Manjisthadi churna were used for high performance thin layer chromatography on silica gel plates. The Rf of rubiadin, sennoside-A and ellagic acid were found to 0.48, 0.23 and 0.72, respectively with densitometric scanning at 280 nm and the calibration plot were linear in the range of 100-600 ng of markers. The correlation coefficients were higher than 0.99 were indicative of good linear dependence of peaks area on concentration. The rubiadin, sennoside-A and ellagic acid contents in Manjisthadi churna were found to be 0.014, 0.038 and 0.534% w/w, respectively. This method permits reliable quantification of rubiadin, sennoside-A and ellagic acid with good resolution and separation of the same from other constitutes of the extract of Manjisthadi churna. Recovery value from 95.66-102.33% showed the reliability and reproducibility of the method. The proposed high performance thin layer chromatography method for simultaneous quantification of markers in Manjisthadi churna can be used for routine quality testing.

Biosorption of arsenic (III) from aqueous solution by living cells of Bacillus cereus

In this work, removal of arsenic (III) from aqueous solution by living cells (Bacillus cereus), biosorption mechanism, and characterization studies have been reported. B. cereus cell surface was characterized using SEM-EDX and FTIR. Dependence of biosorption on pH of the solution, biosorbent dose, initial arsenic (III) concentration, contact time, and temperature had been studied to achieve optimum condition. The maximum biosorption capacity of living cells of B. cereus for arsenic (III) was found to be 32.42 mg/g at pH 7.5, at optimum conditions of contact time of 30 min, biomass dosage of 6 g/L, and temperature of 30 ± 2 °C. Biosorption data of arsenic (III) are fitted to linearly transformed Langmuir isotherm with R (2) (correlation coefficient) >0.99. The pseudo-second-order model description of the kinetics of arsenic (III) is successfully applied to predict the rate constant of biosorption. Thermodynamic parameters reveal the endothermic, spontaneous, and feasible nature of sorption process of arsenic (III) onto B. cereus biomass. The arsenic (III) ions are desorbed from B. cereus using both 1 M HCl and 1 M HNO(3).

Women's views on and adherence to low-molecular-weight heparin therapy during pregnancy and the puerperium

BACKGROUND

Non-adherence to prescribed medication represents a significant factor associated with treatment failure. Pregnant women identified at risk of venous thromboembolism are increasingly being prescribed low-molecular-weight heparin (LMWH) during pregnancy and the puerperium. It is important to understand women's views on and adherence to LMWH during pregnancy and the puerperium, so that women gain maximum benefit from the treatment.

OBJECTIVES

To monitor women's adherence to enoxaparin, when prescribed during pregnancy and the puerperium, and explore their beliefs about the enoxaparin therapy prescribed.

PATIENTS/METHODS

A prospective cohort study involving 95 nullparous and multiparous women prescribed enoxaparin for recognized antenatal indications. Adherence to enoxaparin was assessed through self-completion of a diary, additionally verified through laboratory tests. An adapted beliefs about medication questionnaire was administered to women during their pregnancy.

RESULTS

Women were highly adherent to enoxaparin: antenatally, mean percentage adherence 97.92%; postnatally, mean percentage adherence 93.37% (paired t-test, P = 0.000). In the cohort of women we followed, their perceived necessity for enoxaparin therapy outweighed any concerns they had regarding enoxaparin antenatally, necessity-concerns differential 2.20. In some women, however, this perceived necessity does decrease postnatally.

CONCLUSIONS

Our results suggest that most women prescribed enoxaparin are highly adherent to their therapy during the antenatal period and that women's antenatal beliefs about enoxaparin are able to predict a decrease in postnatal adherence. Our results have important clinical implications, particularly when women are initiated on LMWH just during the postnatal period.

Hydrogeochemical processes controlling the high fluoride concentration in groundwater: a case study at the Boden block area, Orissa, India

The present investigation reports the assessment of hydrochemical/geochemical processes controlling the concentration of fluoride in groundwater of a village in India (Boden block, Orissa). Boden block is one of the severely affected fluoride-contaminated areas in the state of Orissa (India). The sampling and subsequent analysis of water samples of the study area was carried out following standard prescribed methods. The results of the analysis indicate that 36.60% groundwater F(-) concentration exceeds the limit prescribed by the World Health Organization for drinking water. The rock interaction with groundwater containing high concentration of HCO(3)(-) and Na(+) at a higher pH value of the medium could be one of the important reasons for the release of F(-) from the aquatic matrix into groundwater. Geochemical classification of groundwater based on Chadha rectangular diagram shows that most of the groundwater samples having fluoride concentration more than 1.5 mg L(-1) belongs to the Na-K-HCO(3) type. The saturation index values evaluated for the groundwater of the study area indicated that it is oversaturated with respect to calcite, whereas the same is undersaturated with respect to fluorite content. The deficiency of calcium ion concentration in the groundwater from calcite precipitation favors fluorite dissolution leading to excess of fluoride concentration. The risk index was calculated as a function of fluoride level in drinking water and morbidity of fluorosis categorizes high risk for villages of Amera and Karlakote panchayat of Boden block.

Biosorption of As(V) from aqueous solutions by living cells of Bacillus cereus

In this work, the biosorption of As(V) from aqueous solutions by living cells of Bacillus cereus has been reported. The batch biosorption experiments were conducted with respect to biosorbent dosage 0.5 to 15 g/L, pH 2 to 9, contact time 5 to 90 min, initial concentration 1 to 10 mg/L and temperature 10 to 40 °C. The maximum biosorption capacity of B. cereus for As(V) was found to be 30.04 at pH 7.0, at optimum conditions of contact time of 30 min, biomass dosage of 6 g/L, and temperature of 30 ± 2 °C. Biosorption data were fitted to linearly transformed Langmuir isotherms with R(2) (correlation coefficient) >0.99. Bacillus cereus cell surface was characterized using AFM and FTIR. The metal ions were desorbed from B. cereus using both 1 M HCl and 1 M HNO(3). The pseudo-second-order model was successfully applied to predict the rate constant of biosorption.

P3-07-22: Combined Approach for Staging the Axilla in Breast Cancer Patients with Clinically (−)Nodes Versus Sentinel Node Biopsy Alone

Background

Prognostic information and local control for managing the majority of clinically node (−) breast cancer patients may be achieved by sentinel node biopsy (SNB) alone and/or limited axillary dissections (LAD). Currently, 20 - 30% of clinically node (−) patients have unnecessary surgery. This study compares the results from staging the axilla using SNB alone versus using the combined approach shown below.

Methods: Clinically node (−) patients (n=176) were subclassified according to their primary tumor histology, axillary ultrasound (US) data, and US guided Fine Needle Aspiration (US-FNA) results, as follows: Low Risk (LR) for axillary metastasis (n = 62); High Risk (HR) with normal axillary US (n = 17); HR with US suggesting minimal N1a disease (n = 23); HR with US suggesting N1a disease (n = 52); HR with US suggesting N2-3 disease (n = 22). All patients with (+) SNB or (+) US-FNA had Axillary Lymph Node Dissections (ALND). The number of (+) Sentinel Nodes (SN), Non Sentinel Nodes (NSN) and (+) LN after a (+) US-FNA from each patient category was correlated with corresponding preoperative data. HR patients were defined as having grade II tumors ≥ 1.5 cm and grade III tumors &gt; 1.0 cm. US abnormalities in the axilla were interpreted as follows: minimal N1a disease equivalent to cortical defects &lt; 5mm in 1–3 LN; N1a disease, cortical defects &gt; 5mm in 1–3 LN and N2-3 disease, complete nodal replacement in ≥ 1 LN. LAD refers to level I dissections (1-5 LN).

Results: Three subgroups of patients were identified: Group A, patients not requiring ALND (128/176 = 72%); Group B, patients requiring ALND bypassing SNB (22/176 =13%) and Group C, patients requiring LAD (26/176 = 15%). Preoperatively these 3 groups were categorized as follows: Group A included patients at LR for axillary metastasis, HR patients with normal axillary US, HR patients with axillary US suggesting minimal N1a disease and HR patients with axillary US suggesting N1a disease with (−) US-FNA; Group B included HR patients with axillary US suggesting N2-3 disease and (+) US-FNA; Group C included HR patients with axillary US suggesting N1a disease and (+) US-FNA. The post ALND characteristics for these 3 groups are summarized as follows: all Group A patients had N1a disease represented by ≤ 2 (+) LN, 94% (17/18) were SN (+) only, 85% (15/18) with 1 (+) LN and 15% with 2 (+) LN; in Group B, 20 patients had N2-3 disease and 2 patients had N1a disease, all Group B patients had &gt; 2 (+) LN; in group C, 20 patients had N1a disease and 2 patients had N2 disease, and 77% had single (+) node disease.

Conclusion: By following this approach a more patient oriented method for staging the axilla can be implemented as follows: 1. SNB alone for LR patients and for HR patients with axillary US findings suggesting no axillary disease, minimal N1a disease and/or N1a disease with (−) US-FNA; 2. ALND for HR patients with axillary findings suggesting N2-3 disease and a (+) US-FNA; 3. LAD for HR patients with US findings suggesting N1a disease and (+) US-FNA. This approach would result in a 38% (48/176) reduction in the number of SNB and a 30% (22/66) reduction in the number of ALND. This translates in to $200,000 (30-40%) in procedure-associated savings.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-22.

Studies on the removal of arsenic (III) from water by a novel hybrid material

The present work provides a method for removal of the arsenic (III) from water. An ion-exchanger hybrid material zirconium (IV) oxide-ethanolamine (ZrO-EA) is synthesized and characterized which is subsequently used for the removal of selective arsenic (III) from water containing 10,50,100mg/L of arsenic (III) solution. The probable practical application for arsenic removal from water by this material has also been studied. The various parameters affecting the removal process like initial concentration of As (III), adsorbent dose, contact time, temperature, ionic strength, and pH are investigated. From the data of results, it is indicated that, the adsorbent dose of 0.7mg/L, contact time 50min after which the adsorption process comes to equilibrium, temperature (25±2), solution pH (5-7), which are the optimum conditions for adsorption. The typical adsorption isotherms are calculated to know the suitability of the process. The column studies showed 98% recovery of arsenic from water especially at low concentration of arsenic in water samples.

Serum phosphate and outcome at one year after deceased donor renal transplantation

Traditional risk factors do not adequately explain the increased prevalence of cardiovascular disease in renal patients. This study considered a "non-traditional" risk factor, serum phosphate and outcome in renal transplant recipients. Data from 377 patients who received a first deceased donor renal transplant between January 1, 1999, and December 31, 2008, were recorded; 10% (n=38) had diabetes, 16.7% (n=63) were smokers, and 18.8% (n=71) had a history of vascular disease. Three hundred and thirty-three patients were alive at the time of the analysis. Survivors were significantly younger, less likely to be smokers or diabetic, and had a higher estimated glomerular filtration rate at one yr post-transplantation. Serum phosphate was significantly lower in these patients (0.95 ± 0.23 vs. 1.04 ± 0.26, p = 0.031). Analysis of recipient survival, stratified by serum phosphate at one yr post-transplant, revealed that serum phosphate > 1.11 mMol/L was a significant predictor of all-cause mortality (p=0.006). Serum phosphate between 0.9 and 1.11 mMol/L afforded the best outcome. In multivariate analysis, serum phosphate remained a significant predictor of mortality (p=0.016). Serum phosphate at one yr after transplant seems to have a J-shaped relationship with mortality, and this effect is independent of traditional cardiovascular risk factors.

Toxicity and bioaccumulation potential of Cr (VI) and Hg (II) on differential concentration by Eichhornia crassipes in hydroponic culture

In this work, the phytoremediation of Cr (VI) and Hg (II) ion from water by an aquatic plant Eichhornia crassipes has been studied. Plants were cultured in a double distillated water with modified Hoagland's nutrient solution at pH 6.8 supplemented with 0, 0.75, 1.50, 2.50, and 4 mg Cr/L as potassium dichromate (K(2)Cr(2)O(7)) and 0, 5, 10, 15, and 20 mg Hg/L as mercuric chloride (HgCl(2)). They were separately harvested after 3, 6 and 9 days. Plants treated with 4 mg/L of Cr (VI) accumulated the highest concentration of metal in roots (1.22 mg/g, dry weight) and shoots (0.24 mg/g, dry weight) after 9 days; while those treated with 20 mg/L of Hg (II) accumulated the highest concentration of metal in roots (4.22 mg/g, dry weight) and shoots (2.43 mg/g, dry weight) after 9 days. Eichhornia crassipes biomass was characterised using AAS, SEM and FTIR. The accumulation and relative growth of metal ions at different concentrations of chromium and mercury solution significantly increased (P<0.05) with the passage of time. The maximum values of bio-concentration factor (BCF) for Cr (VI) and Hg (II) were found to be 413.33 and 502.40 L/kg respectively.

The effect of estrone on thrombin generation may explain the different thrombotic risk between oral and transdermal hormone replacement therapy

BACKGROUND

The metabolism of estrogen contained within hormone replacement therapy (HRT) is influenced by the route of administration, and this may affect the risk of venous thromboembolism. Thrombin generation, a global coagulation assay, is a marker of hypercoagulability and is of potential use in determining the thrombotic risk associated with particular HRT administration routes.

OBJECTIVES

To determine whether any effect of oral and transdermal HRT on thrombin generation is related to the plasma estrogen profile.

METHODS

We investigated the effects of oral, transdermal and no HRT (controls) in 52, 39 and 52 postmenopausal women, respectively, on thrombin generation, standard markers of thrombophilia, estradiol level and estrone level.

RESULTS

All parameters of thrombin generation were altered in women using oral HRT as compared with controls (P<0.001 for all comparisons). No such differences were found in women using transdermal HRT. Estrone levels correlated with peak thrombin generation (R=0.451, P<0.001) in women using oral HRT, but there was no correlation in women using the transdermal route.

CONCLUSIONS

Thrombin generation is significantly increased in women who use HRT administered by the oral route. This is probably mediated by the hepatic first-pass metabolism of estrone, the main metabolite of oral estradiol, which is avoided by the transdermal route. The effect of estrone on thrombin generation may provide the explanation for the higher thrombotic risk seen in women using oral rather than transdermal HRT.

The use of an exclusion-based risk-assessment model for venous thrombosis improves uptake of appropriate thromboprophylaxis in hospitalized medical patients

BACKGROUND

Venous thromboembolism is a common condition in hospitalized medical patients. Numerous studies have demonstrated that low molecular weight heparin significantly reduces this risk but, despite this, the use of thromboprophylaxis remains poor.

AIM

To evaluate the use of an exclusion based risk-assessment model (RAM) for venous thrombosis in improving the uptake of appropriate thromboprophylaxis in hospitalized medical patients.

DESIGN

A survey with a subsequent audit cycle of three separate audits over 36 months.

METHODS

497 hospitalized patients with acute medical conditions on general medical wards were audited at a secondary care centre in London, UK. The survey and subsequent audits were performed by reviewing the notes and medication charts of medical patients, prior to the launch of the RAM and at 12, 28 and 36 months following its introduction.

RESULTS

Prior to launching the RAM, 49% of hospitalized medical patients received appropriate thromboprophylaxis. This did not change 12 months after the RAM was introduced but increased significantly to 71% following formal education of the health care professionals involved in thromboprophylaxis prescription. This improvement was maintained as demonstrated by a subsequent audit 8 months later (75.9%).

CONCLUSION

The introduction of a simple exclusion-based RAM for venous thrombosis in medical patients significantly improved delivery of thromboprophylaxis. The successful uptake of the RAM appears to have been dependent on direct education of those health carers involved in its use. A similar exclusion-based model used nationally could have a significant impact on the burden of VTE currently experienced in the UK.

The prevalence of the activating JAK2 tyrosine kinase mutation in chronic porto-splenomesenteric venous thrombosis

BACKGROUND

Occult myeloproliferative disorders (MPD) are present in 25% of patients with chronic portal, splenic and mesenteric venous thrombosis (PSMVT). A somatic mutation of JAK2 (JAK2V617F) can be used to identify patients with latent MPD.

AIM

We evaluated the prevalence and clinical significance of JAK2V617F in patients with chronic PSMVT.

METHODS

Allele-specific polymerase chain reaction was performed to screen for JAK2V617F.

RESULTS

Thirty-five patients were tested for JAK2V617F. The underlying pro-coagulant condition was MPD in seven of 35 (20.0%) patients; other aetiologies included hereditary thrombophilia (n = 5), chronic pancreatitis (n = 2), liver abscess (n = 1) and umbilical vein sepsis (n = 3). The remainder were labelled idiopathic, i.e. 17/35 (48.6%) patients. JAK2V617F was detected in 16/35 (45.7%) patients: seven of seven (100%) with MPD, two of 11 (18.1%) with non-MPD acquired conditions and seven of 17 (41.2%) with 'idiopathic' chronic PSMVT. Mean haemoglobin concentration (P = 0.04), haematocrit (P = 0.04), white cell count (P = 0.002) and platelet count (P = 0.05) were significantly higher in patients with JAK2V617F. None of the seven patients with latent MPD have progressed to overt MPD over median follow-up of 85 months.

CONCLUSION

JAK2V617F occurs in 41% of patients with idiopathic chronic portal, splenic and mesenteric venous thrombosis, confirming the presence of latent myeloproliferative disorders, and should form part of the routine pro-coagulant screen.