Towards the personalization of septic shock resuscitation: the fundamentals of ANDROMEDA-SHOCK-2 trial

Septic shock is a highly lethal and prevalent disease. Progressive circulatory dysfunction leads to tissue hypoperfusion and hypoxia, eventually evolving to multiorgan dysfunction and death. Prompt resuscitation may revert these pathogenic mechanisms, restoring oxygen delivery and organ function. High heterogeneity exists among the determinants of circulatory dysfunction in septic shock, and current algorithms provide a stepwise and standardized approach to conduct resuscitation. This review provides the pathophysiological and clinical rationale behind ANDROMEDA-SHOCK-2, an ongoing multicenter randomized controlled trial that aims to compare a personalized resuscitation strategy based on clinical phenotyping and peripheral perfusion assessment, versus standard of care, in early septic shock resuscitation.

Methodology optimization to quantify microplastic presence in planktonic copepods, chaetognaths and fish larvae

Two of the groups most impacted by microplastics (MPs) are zooplankton and fish larvae, either through MPs ingestion or absorption. Although there has been an increase of studies focusing on MPs ingestion by these organisms, there is still no standardized methodology for the quantification of MPs present in plankton. For example, some reagents normally used to digest plankton and recover MPs appear adversely to affect some plastic characteristics. This can potentially lead to underestimating the amount and types of MPs present in the organisms analyzed. Hence, this work aimed to optimize a methodology to quantify MPs present in plankton, namely zooplankton and fish larvae, and ensuring MPs integrity. Hence, the planktonic organism tissues were digested using 30% (v/v) H2O2 solution at different temperatures and incubation periods while preserving the integrity and polymer characteristics of 13 types of MPs. MPs' characteristics were register before and after the tests, by visual inspection and Fourier Transform Infrared Spectroscopy (FTIR) analysis, to evaluate the integrity and features of MPs. With this methodology, MPs recovery was above 85% for all types of plastic tested. The proposed methodology is a rapid protocol, with a maximum of 7 h of incubation, that ensures simultaneously the full digestion of the organism tissues and the complete preservation of all the plastic characteristics, namely color, size and polymer type.•A methodology was optimized to quantify microplastics present in zooplankton (copepods, chaetognaths and fish larvae).•Thirteen types of microplastics (fibers and fragments of different polymers) were used to test the efficiency of the methodology ensuring the maintenance of the integrity of plastics.•With this methodology, microplastic recovery was above 85% for all the types of microplastic tested and no changes in their characteristics were observed.

Integration of an App-Based Cognitive Evaluation Program into Radiosurgery Practice: Outcomes and Patient Survey Analysis from a Prospective Observational Study

PURPOSE/OBJECTIVE(S)

Cognitive decline is a significant consequence of stereotactic radiosurgery (SRS) in patients with brain metastases. This is often underrecognized and understudied outside of a formal clinical trial setting as traditional methods are often logistically difficult and need specialized personnel and additional time. To address these challenges, we implemented a prospective study (NCT05504681), incorporating an innovative app-based solution to monitor patient assessments over time, collect patient data easily, and be suitable for cross-cultural use in multiple languages for monitoring post-SRS cognitive decline.

MATERIALS/METHODS

Patients undergoing SRS from December 2021 to October 2022 were enrolled in this study and completed feedback surveys. The assessments consisted of learning and memory (Hopkins verbal learning test-revised [HVLT-R]), attention and processing speed (Digit symbols modalities test [SDMT]), verbal fluency (Controlled oral word association test [COWAT]) and executive function (Trail making test [TMT]). Baseline and 3-month follow-up testing were conducted in conjunction with routine imaging and clinical assessments. Neurocognitive deterioration (ND) was defined as a decrease of ≥2 standard errors of the mean in any of the tests, without evidence of new intracranial disease. Any differences between the baseline and follow-up assessments were confirmed using the reliable change index.

RESULTS

A total of 30 patients with median age of 68 (range: 47-87) were enrolled. The median KPS was 90 and 60% were female. 43% of participants had a high school or equivalent level of education. 19 (63%) patients were Hispanic and 43% tested in Spanish. The median number of treated lesions was 2 (1-13) and 7 (23%) patients were treated to ≥5 lesions. The median mean left and right hippocampal doses were 0.3 Gy (0-3 Gy) and 0.2 Gy (0-5.2 Gy), respectively. Overall, 50% of patients met criteria for ND at 3 months. 20% of patients showed ND in HVLT-R-immediate recall (IMM), 23% in HVLT-R-delayed recall (DR), 13% in HVLT-R-recognition (Rec), 3% in COWAT and 20% in TMT. None of the patients had ND in SDMT. The mean relative decline was 28% for HVLT-R- IMM, 34% for HVLT-R-DR, 6% for HVLT-R- Rec, 25% for COWAT, and 21% for TMT. There was no significant association between the number of treated lesions and ND. Based on the feedback results, the majority of patients found the system easy to use (94%) and relevant to their care (73%). Most patients reported that app-based evaluation improved discussions with clinicians (77%), made them feel more in control of their care (79%), and they would recommend the system to other patients (87%).

CONCLUSION

Our study showed a high incidence of ND using an app-based tool in a patient who underwent SRS and from diverse education and language backgrounds. Patient survey results demonstrated that the tool was easy to use and relevant to the patient's care, especially due to improvements in discussions with clinicians and a sense of being in control of their own care.

Life-threatening hypereosinophilic syndrome in a patient with rheumatoid arthritis: a case report

Hypereosinophilia is unusual in rheumatoid arthritis (RA), but can occur in severe long-lasting disease, especially in patients with extra-articular manifestations and high titers of rheumatoid factor (RF). The association of RA and hypereosinophilic syndrome (HES) remains yet poorly known. We present a case of a 46 years old woman with long-standing untreated RA, that presented to emergency department with severe symptoms of constrictive pericarditis with cardiac tamponade and bilateral pleural effusion, that progressed to cardiac arrest, associated to symmetrical polyarthritis and pruritic erythematous skin papules. She was submitted to urgent pericardial drainage and partial pericardiotomy. Laboratory analyses revealed hypereosinophilia, and elevated inflammatory parameters and immunoglobulin E. The histological study of the pericardium showed results consistent with inflammatory fibrinous pericarditis. Taking into account the presence of some characteristics that are usually present in cases of reactive HES instead of idiopathic HES, and after an intensive diagnostic study, that could rule out other potential causes of secondary HES, the diagnosis of HES associated with RA was made. She started glucocorticoids during hospitalization and methotrexate 15mg per week at the first outpatient rheumatology visit. After 12 weeks of treatment, we considered that she was in clinical and analytical remission, consistently maintaining that after a complete tapering of glucocorticoids. This case illustrates that clinicians should be aware that HES (including severe life-threatening cases) can occur in patients with RA, especially in cases of long-lasting disease with high titters of RF and without treatment, even in the absence of extra-articular features.

Chronic constrictive pericarditis: a rare cardiac involvement in primary Sjögren's syndrome

BACKGROUND

Constrictive pericarditis represents a chronic condition and systemic inflammatory diseases are a known, yet uncommon, cause. Pericardial involvement is seldom reported in primary Sjögren's syndrome, usually occurring in association with pericardial effusion or pericarditis. We report a case of constrictive pericarditis with an insidious course and unusual evolution associated with primary Sjögren's syndrome. Due to the challenging nature of the diagnosis, clinical suspicion and multimodality imaging are essential for early identification and prompt initiation of treatment. Long-term outcomes remain uncertain. To the best of our knowledge, no other cases linking this autoimmune disease to constrictive pericarditis have been reported.

CASE PRESENTATION

We present the case of a 48-year-old male patient with moderate alcohol habits and a history of two prior hospitalizations. On the first, the patient was diagnosed with primary Sjögren's syndrome after presenting with pleural effusion and ascites, and empirical corticosteroid regiment was initiated. On the second, two-years later, he was readmitted with complaints of dyspnea and abdominal distension. Thoracic computed tomography revealed a localized pericardial thickening and a thin pericardial effusion, both of which were attributed to his rheumatic disease. A liver biopsy showed hepatic peliosis, which was considered to be a consequence of glucocorticoid therapy. Diuretic therapy was adjusted to symptom-relief, and a tapering corticosteroid regimen was adopted. Four years after the initial diagnosis, the patient was admitted again with recurrent dyspnea, orthopnea and ascites. At this time, constrictive pericarditis was diagnosed and a partial pericardiectomy was performed. Although not completely asymptomatic, the patient reported clinical improvement since the surgery, but still with a need for baseline diuretic therapy.

CONCLUSION

Albeit uncommon, connective tissue disorders, such as primary Sjögren's syndrome, should be considered as a potential cause of constrictive pericarditis, especially in young patients with no other classical risk factors for constriction. In this case, after excluding possible infectious, neoplastic and autoimmune conditions, a primary Sjögren´s syndrome in association with constrictive pericarditis was assumed. This case presents an interesting and challenging clinical scenario, highlighting the importance of clinical awareness and the use of multimodal cardiac imaging for early recognition and treatment.

Is myocardial fibrosis appropriately assessed by calibrated and 2D strain derived integrated backscatter?

AIMS

Increased collagen content of the myocardium modifies tissue reflectivity and integrated backscatter (IBS) indexes are suggested as markers of myocardial fibrosis (MF). We sought to assess the correlation between calibrated (c) IBS and bidimensional (2D) strain derived IBS with left ventricular (LV) MF in patients with severe aortic stenosis (AS).

METHODS AND RESULTS

We made a prospective observational cohort study including 157 patients with severe AS referred for surgical aortic valve replacement (AVR), with complete preoperative transthoracic echocardiography, cardiac magnetic resonance (CMR) and endomyocardial biopsy (EMB) obtained from the anterior basal septum at the time of surgery. Two groups of 30 patients were specifically evaluated, with and without late gadolinium enhancement (LGE) at CMR. IBS was obtained at QRS peak from both parasternal long axis (PLAX) and apical-three-chamber (AP3C) views and measured in decibels (dB). Whole-cardiac cycle IBS at basal anterior septum was obtained from 2D longitudinal strain. Correlation analysis of reflectivity indexes was performed with global and segmental (anterior basal septum) values of native T1 and extracellular volume (ECV), and EMB collagen volume fraction (CVF) (Masson´s Trichrome). IBS values were compared in both group of patients (LGE + vs. LGE -). 60 patients (74 [36-74] years, 45% male) with high gradient (mean gradient: 63 ± 20mmHg), normal flow (45 ± 10mL/m2) AS and preserved left ventricular ejection fraction (60 ± 9%) were included. Basal septum cIBS was - 17.45 (-31.2-10.95) and - 9.17 ± 9.45dB from PLAX and A3C views, respectively. No significant correlations were found between IBS and both non-invasive CMR tissue characterization and CVF: median MF of 9.7(2.1-79.9)%. Acoustic indexes were not significantly different according to the presence of pre-operative LGE.

CONCLUSION

In this group of patients with classical severe AS, IBS reflectivity indexes are of no added value to discriminate the presence of MF.

Observation of Collider Muon Neutrinos with the SND@LHC Experiment

We report the direct observation of muon neutrino interactions with the SND@LHC detector at the Large Hadron Collider. A dataset of proton-proton collisions at sqrt[s]=13.6  TeV collected by SND@LHC in 2022 is used, corresponding to an integrated luminosity of 36.8  fb^{-1}. The search is based on information from the active electronic components of the SND@LHC detector, which covers the pseudorapidity region of 7.2<η<8.4, inaccessible to the other experiments at the collider. Muon neutrino candidates are identified through their charged-current interaction topology, with a track propagating through the entire length of the muon detector. After selection cuts, 8 ν_{μ} interaction candidate events remain with an estimated background of 0.086 events, yielding a significance of about 7 standard deviations for the observed ν_{μ} signal.

Fibrosis of Peritoneal Membrane, Molecular Indicators of Aging and Frailty Unveil Vulnerable Patients in Long-Term Peritoneal Dialysis

Peritoneal membrane status, clinical data and aging-related molecules were investigated as predictors of long-term peritoneal dialysis (PD) outcomes. A 5-year prospective study was conducted with the following endpoints: (a) PD failure and time until PD failure, (b) major cardiovascular event (MACE) and time until MACE. A total of 58 incident patients with peritoneal biopsy at study baseline were included. Peritoneal membrane histomorphology and aging-related indicators were assessed before the start of PD and investigated as predictors of study endpoints. Fibrosis of the peritoneal membrane was associated with MACE occurrence and earlier MACE, but not with the patient or membrane survival. Serum α-Klotho bellow 742 pg/mL was related to the submesothelial thickness of the peritoneal membrane. This cutoff stratified the patients according to the risk of MACE and time until MACE. Uremic levels of galectin-3 were associated with PD failure and time until PD failure. This work unveils peritoneal membrane fibrosis as a window to the vulnerability of the cardiovascular system, whose mechanisms and links to biological aging need to be better investigated. Galectin-3 and α-Klotho are putative tools to tailor patient management in this home-based renal replacement therapy.

Diagnostic challenges of recurrent left atrial mass: a case report

Background

Differential diagnosis of left atrial (LA) masses is challenging because there is a significant overlap in the epidemiological, clinical, and imaging characteristics. Even some histological features can be similar across different types of cardiac masses. Therefore, continuous case discussion between the clinician and the pathologist is essential for a correct diagnosis.

Case summary

We present a case of a patient with a history of cardiac surgery for LA tumour. Histology was compatible with thrombus, although no predisposing causes nor genetic or acquired thrombophilia were identified. After 14 years, the recurrence of LA mass was diagnosed with a routine echocardiography. A review of histological preparations from 2007 with immunohistochemistry techniques not available at that time (calretinin) was consistent with a myxoma. The patient underwent cardiac reoperation with LA mass and interatrial septum excision. Final diagnosis was compatible with a myxoma recurrence.

Discussion

Myxoma is the second most frequent benign primary cardiac tumour. Left atrial thrombi can occasionally mimic the typical echocardiographic appearance of a myxoma, and pathological features can sometimes overlap generating diagnostic confusion. Calretinin fixation is useful for differential diagnosis once it is only identified in myxomas but not in thrombi. Any discrepancy between clinical findings and histology should always mandate a review of histological preparations.

Alpha-klotho and peritoneal membrane status: A hypothesis generating study

BACKGROUND

Long-term success of peritoneal dialysis relies on the integrity of the peritoneal membrane. This proof-of-concept study addressed the hypothesis that fibrosis is already present in the membrane at pre-dialysis and that the membrane status is related to the individual's uraemic fingerprint.

METHODS

A clinical-mechanistic, transversal, single-centre study was conducted. Pre-dialysis peritoneal biopsies were scored considering the submesothelial compact zone thickness (STM), vasculopathy and inflammation. We investigated if the membrane status could be inferred from a panel of proteins (α-Klotho, Galectin-3, FGF21, FGF23, Tweak, TNFα and hsPCR) in blood.

RESULTS

A total 58 incident patients aged 56 ± 15 years old were included, 31% female, 55% hypertension, 29% diabetic and 24% obese. Person-to-person STM was found to be highly variable and 38% of patients were fibrosis positive. Both α-Klotho (Spearman r = -.7491, p < 0.001) and FGF21 (Spearman r = -.5102, p < 0.001) were negatively associated with STM. α-Klotho, but not FGF21, was able to discriminate fibrosis from nonfibrosis with/without inflammation and vasculopathy. PLS models identified α-Klotho as the protein most relevant for fibrosis. α-Klotho was independently associated with fibrosis of the peritoneal membrane (OR = .991 (.896-.997), p = 0.002).

CONCLUSION

Before the start of dialysis in incident patients, some patients already present fibrosis of the peritoneal membrane and other patients do not. Our findings suggest that α-Klotho may be implicated in fibrosis of the peritoneal membrane.

Relative apical sparing in severe aortic stenosis: does it mean concomitant amyloid cardiomyopathy?

Background

Relative apical sparing (RAS) of left ventricular (LV) longitudinal strain (LS) is a red flag marker for the suspicion of amyloid cardiomyopathy. However, it has also been described in patients with severe aortic stenosis (AS).

Aim

To assess the prevalence of RAS in patients with severe symptomatic AS referred for surgical aortic valve replacement (AVR), to evaluate its clinical significance and assess its presence after surgery.

Methods

We prospectively studied 135 consecutive patients (age: 73 y [IQR 68–77 y], 49% men) with severe symptomatic AS – mean transaortic pressure gradient (AVmean): 60.9±17.7 mmHg; mean aortic valve area: 0.7±0.2 cm2, referred for surgical AVR with no previous history of ischemic cardiomyopathy or other. Beyond 12 lead-ECG and transthoracic echocardiography (TTE), all patients underwent cardiac magnetic resonance (CMR) before surgery. RAS was defined by the ratio &gt;1 of average LS at apical segments/sum of the average basal and mid LS at speckle tracking analysis. AVR with septal myocardial biopsy, for investigational purposes, was performed in 80 patients. AS severity indexes, LV remodeling and tissue characterization parameters were compared in both groups of patients, with and without RAS. LS deformation pattern was reassessed at 3–6 months after AVR.

Results

RAS was present in 24 patients (18%). In the whole cohort there were neither pseudoinfarct pattern or low voltage ECG criteria, nor infiltration suspicion from CMR (native T1 value 1053 ms [IQR 1025–1071 ms] for institutional reference values: 972–1070 ms; ECV 24% [IQR 21–27%]). None of the patients had amyloid deposition at histopathology. Overall, mean CMR LV ejection fraction (LVEF) was 59.6±10.5% and 98 patients (74%) had non-ischemic delayed enhancement, with a median fibrosis fraction of 4.1% [IQR 1.6–7.8%]. RAS cohort had a significantly higher AVmean gradient, relative wall thickness, maximum septal thickness, peak systolic dispersion, with lower global LS at TTE, as well as higher LV mass and lower LVEF at CMR. RAS group has also higher NT-proBNP ambulatory values (Table 1). Follow-up evaluation after AVR revealed RAS disappearance in 19 patients (79.2%).

Conclusions

RAS occurs in almost one-fifth of the patients in this cohort despite the absence of signs of myocardial infiltration. This deformation pattern elapses with worse indexes of LV remodeling consistent with a more advanced stage of the disease, being reversible after AVR, which stands for the absence of concomitant myocardial infiltration.

Funding Acknowledgement

Type of funding sources: None.

Histology-verified myocardial fibrosis and quantification in severe AS patients: correlation with non-invasive LV myocardial tissue assessment

Background

Myocardial fibrosis (MF) is a common finding and a potential adverse prognostic marker in several cardiac diseases, including in severe aortic stenosis (AS). While histological analysis obtained through endomyocardial biopsy remains the gold-standard for MF assessment, non-invasive cardiac imaging may offer surrogate biomarkers for fibrosis. We tried to assess the correlation between MF quantification at histopathology and cardiac magnetic resonance (CMR)-derived tissue characterization data in patients with severe AS.

Methodology

Single-center prospective cohort enrolling 71 patients with severe symptomatic high-gradient AS undergoing surgical aortic valve replacement (SAVR) (mean age 71±9 years; 49% male, mean valvular transaortic gradient 60±20 mmHg; mean left ventricle [LV] ejection fraction 58±9%). Those with past history of myocardial infarction or cardiomyopathy were excluded. All patients underwent pre-operative CMR study with LV tissue characterization and quantification. Normal T1 mapping value was defined as &gt;1021ms as per center protocol. Myocardial tissue was obtained during SAVR either through myocardial biopsy at basal LV septum or harvested from surgical myectomy specimens. Masson's trichrome stain was used for collagen/fibrosis assessment. Automatic quantification was obtained at QuPathTM digital pathology software after applying a dedicated artificial intelligence algorithm on ultra-high-resolution digital slide scanning images.

Results

Histology-confirmed MF was observed in all patients (median percentage of fibrotic myocardial tissue 15% [IQR 9–22%]). Median global T1 mapping and extracellular volume (ECV) percentage was 1048ms (IQR 1027–1078) and 24% (IQR 20–30%), respectively. Late gadolinium enhancement (LGE) with a non-ischemic pattern was present in 42 patients (59%) with a median LGE mass of 5.8g [IQR 1.0–10.2]; median percentage of 3.7% [IQR 0.6–10.4]. While neither T1 mapping (global or basal LV septum), ECV nor LGE had any significant correlation with histology-confirmed MF (Figure 1) the vast majority had significantly elevated global and basal LV septum T1 mapping – 81% and 92%, respectively.

Conclusion

In this single-center prospective study, microscopic MF was present in all patients with severe symptomatic high-gradient AS, was accompanied by elevated T1 mapping values but no correlation was found between myocardial fibrosis at histopathology analysis and CMR-derived LV tissue characterization parameters. This may not only stem from sampling (single point biopsy vs. whole myocardial tissue assessment) but also from distinct evaluation of different types of fibrosis by different methods.

Funding Acknowledgement

Type of funding sources: None.

Continuous thoracic paravertebral analgesia after minimally invasive atrial septal defect closure surgery in pediatric population: Effectiveness and safety analysis

INTRODUCTION

Lateral thoracotomy is replacing traditional median sternotomy for atrial septal defect (ASD) closure in children in order to improve cosmetic outcomes. Continuous paravertebral block has been described as an effective and safe analgesic technique in children. The aim of this study is to assess pain management by continuous perfusion of local anesthetic through a thoracic paravertebral catheter (PVC) in a pediatric population after thoracotomy closure of ASD, and its effectiveness in a fast-track program.

METHODS

Descriptive cross-sectional study. Analgesic effectiveness, perioperative and safety-related data were analyzed in 21 patients who underwent thoracotomy closure of ASD with PVC. In the postoperative period, patients received continuous perfusion of bupivacaine 0.125% and fentanyl (1 mcg.ml-1) at 0.2 ml.kg-1.h-1 through the PVC.

RESULTS

The median of mean pain scale score for each patient was 1.5. All patients were extubated in the operating theatre. No patient with PVC required opioid rescue. The median length of stay in the Pediatric Intensive Care Unit was 48 hours. There were 3 adverse events related to PVC: 1 due to malposition and 2 due to accidental removal. No other complications or cases of local anesthetic toxicity were recorded.

CONCLUSIONS

PVC provides effective, safe, opioid-saving analgesia in the postoperative period of ASD closure by thoracotomy in the context of a fast-track protocol.

The Role Of Comorbidities On Outcome Prediction In Acute Burn Patients

Burn trauma is a leading cause of mortality and morbidity. None of the currently available formulas for mortality prediction take into account the impact of comorbidities on burn patients' outcome. In this study, we evaluate the impact of comorbidities on in-hospital mortality and prolonged length of hospital stay (≥30 days). A retrospective analysis of burn patients' medical records, over a 5-year period, was undertaken. A total of 677 patients were included. The mortality rate was 6.5%. Deceased patients and survivors with length of hospital stay (LOS) of 30 or more days were significantly older, had larger %TBSA burned, were more likely to have inhalation injury and comorbidities, and had higher Charlson Comorbidity Index (CCI) scores. On the multivariate logistic regression models, age, %TBSA burned, CCI score and the presence of inhalation injury were independently associated with mortality and prolonged LOS. In conclusion, the authors suggest that the inclusion of comorbidities should be considered on burn admission scores in an attempt to better predict burn mortality.

Magnetic-field-controlled spin fluctuations and quantum critically in Sr3Ru2O7

When the transition temperature of a continuous phase transition is tuned to absolute zero, new ordered phases and physical behaviour emerge in the vicinity of the resulting quantum critical point. Sr₃Ru₂O₇ can be tuned through quantum criticality with magnetic field at low temperature. Near its critical field B_c it displays the hallmark T-linear resistivity and a \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$T\,{{{{{{\mathrm{log}}}}}}}\,(1/T)$$\end{document}Tlog(1/T) electronic heat capacity behaviour of strange metals. However, these behaviours have not been related to any critical fluctuations. Here we use inelastic neutron scattering to reveal the presence of collective spin fluctuations whose relaxation time and strength show a nearly singular variation with magnetic field as B_c is approached. The large increase in the electronic heat capacity and entropy near B_c can be understood quantitatively in terms of the scattering of conduction electrons by these spin-fluctuations. On entering the spin-density-wave ordered phase present near B_c, the fluctuations become stronger suggesting that the order is stabilised through an “order-by-disorder” mechanism.

Sr₃Ru₂O₇ exhibits a quantum critical point tunable by magnetic field and has been widely used in the study of criticality. Here, by using inelastic neutron scattering, the authors measure collective magnetic excitations near the quantum critical point and relate them to thermodynamic properties and spin density wave order.

Machine learning approach to muon spectroscopy analysis

In recent years, artificial intelligence techniques have proved to be very successful when applied to problems in physical sciences. Here we apply an unsupervised machine learning (ML) algorithm called principal component analysis (PCA) as a tool to analyse the data from muon spectroscopy experiments. Specifically, we apply the ML technique to detect phase transitions in various materials. The measured quantity in muon spectroscopy is an asymmetry function, which may hold information about the distribution of the intrinsic magnetic field in combination with the dynamics of the sample. Sharp changes of shape of asymmetry functions-measured at different temperatures-might indicate a phase transition. Existing methods of processing the muon spectroscopy data are based on regression analysis, but choosing the right fitting function requires knowledge about the underlying physics of the probed material. Conversely, PCA focuses on small differences in the asymmetry curves and works without any prior assumptions about the studied samples. We discovered that the PCA method works well in detecting phase transitions in muon spectroscopy experiments and can serve as an alternative to current analysis, especially if the physics of the studied material are not entirely known. Additionally, we found out that our ML technique seems to work best with large numbers of measurements, regardless of whether the algorithm takes data only for a single material or whether the analysis is performed simultaneously for many materials with different physical properties.

Left Ventricular Remodeling in Degenerative Aortic Valve Stenosis

Aortic stenosis was once considered a pure isolated valve obstacle challenging left ventricle driving force of contraction and flow generation. Left ventricular (LV) adaptation was merely interpreted as a uniform hypertrophic response to increased afterload. However, in these last 2 decades cardiac imaging research and some histopathology correlation studies brought insight towards the complex interaction between the vasculature, the valve and the myocardium. Verily, LV remodeling in this setting is a complex multidetermined process that goes further beyond myocardial hypertrophy. Ultrastructural changes involving both diffuse and replacement fibrosis of the myocardium take part and might explain the transition of clinical phenotypes with distinct prognosis, from compensated hypertrophy to LV maladaptive dysfunction and heart failure. Presently, the combined appropriate use of echocardiography and cardiac magnetic resonance may better assess the global LV afterload, hypertrophy and geometric remodeling, global and regional LV function, beyond ejection fraction, and structural changes that include the fibrotic burden of the myocardium. As a whole these may not only better stratify individual risk of disease progression but also identify patients benefiting from earlier valve intervention. In this paper, we review the maladaptive response of the LV to chronic pressure overload, describing the different signaling pathways and mechanisms that underly both hypertrophy and remodeling. Histomorphology changes in this setting are described and we try to make sense of the use of new imaging tools for LV characterization.

Directed, Elliptic, and Higher Order Flow Harmonics of Protons, Deuterons, and Tritons in Au+Au Collisions at sqrt[s_{NN}]=2.4 GeV

Flow coefficients v_{n} of the orders n=1-6 are measured with the High-Acceptance DiElectron Spectrometer (HADES) at GSI for protons, deuterons, and tritons as a function of centrality, transverse momentum, and rapidity in Au+Au collisions at sqrt[s_{NN}]=2.4  GeV. Combining the information from the flow coefficients of all orders allows us to construct for the first time, at collision energies of a few GeV, a multidifferential picture of the angular emission pattern of these particles. It reflects the complicated interplay between the effect of the central fireball pressure on the emission of particles and their subsequent interaction with spectator matter. The high precision information on higher order flow coefficients is a major step forward in constraining the equation of state of dense baryonic matter.

Relative apical sparing in patients with severe aortic stenosis: prevalence and significance

 

Relative apical sparing (RAS) of LV longitudinal strain (LS) is a red flag for diagnostic suspicion of amyloid cardiomyopathy (AC). However, it may present in pts with aortic stenosis (AS), where the prevalence of transthyretin AC is being increasingly reported.

Aim

To describe the prevalence of RAS deformation pattern in patients with AS and its clinical significance.

Methods

We prospectively studied 53 pts (71±8y, 54.7% men) with severe symptomatic AS - mean gradient (AVM): 54.6 mmHg; aortic valve area 0.74cm2, referred for surgical replacement with no previous history of ischemic cardiomyopathy. Beyond ECG and transthoracic echo (TTE), all pts underwent CMR, with tissue characterization before surgery. RAS was defined as average apical LS / average basal LS + average mid LS &gt;1 at 2D LV LS analysis. Aortic valve replacement and septal myocardial biopsy were already performed in 26 pts. AS severity indexes, LV remodelling and tissue characterization were compared in both groups, with and without RAS.

Results

RAS was present in 16 pts (30.8%). There were neither pseudoinfarct pattern or low voltage at ECG, nor infiltration suspicion from CMR study (native T1 value 1047ms [IQR 1028–1084]; ECV 22% [IQR 18–25]). Furthermore, none of the pts had suspicion of amyloid deposition at histopathology. Median CMR LVEF was 64.5% [IQR 51.3–70.8%] and 36 pts (67.9%) had non-ischemic DE, with a median fraction of 6.0% [IQR 4.9–12.7%] of LV mass. Comparing both groups, RAS cohort showed a significantly higher AVM, relative wall thickness, maximum septal thickness, peak systolic dispersion and higher LV indexed mass, DE and lower LVEF at CMR. RAS group has also higher NT pro BNP (Table).

Conclusions

RAS is common in this group of pts despite the absence of clinical and histological signs of myocardial infiltration. RAS occurs with worse indexes of LV remodeling and fibrosis consistent with a more advanced stage of the disease.

Funding Acknowledgement

Type of funding source: None

Clinical implications of the American Joint Committee on Cancer (AJCC) 8th edition update in seminoma pT1 subclassification

Background

Seminoma accounts for 30–50% of testicular germ cell tumors (TGCT)—the most common solid malignancy in men aged 15–35 years. The American Joint Committee on Cancer (AJCC) 8th edition (2018) created the subclassifications pT1a (tumor size < 3 cm) and pT1b (≥ 3 cm), despite not being universally recognized. Rete testis invasion (RTI) and tumor size > 4 cm are considered features associated with a higher recurrence risk, but not formally used for staging. The authors propose further understanding the subclassification’s potential impact in clinical practice, by summarizing current evidence and reviewing clinical cases in their institutions.

Methods

All consecutive cases of seminoma stage I, pT1 treated in two institutions between January 2005 and December 2016 were included. Clinical data were retrieved, and variables were analyzed using SPSS. Relevant literature on the topic was reviewed.

Results

Seminoma pT1 was identified in 58 patients. By using newly AJCC criteria, 29 (50%) would have been staged as pT1a and 29 (50%) pT1b. Median age at diagnosis was similar (33 in pT1a vs 32 in pT1b). Median follow-up time 5.8 years. Almost half (45%) of pT1b patients had a tumor size < 4 cm. The majority of either pT1a or pT1b were treated with chemotherapy or radiotherapy, reflecting more intensive approaches in the past. Three retroperitoneal recurrences were recorded (two in pT1a, one in pT1b, all under surveillance protocol); no deaths occurred. RTI and extensive necrosis (EN) were associated with pT1b (P <  0.0001 and P = 0.023, respectively), known adverse biological features.

Conclusions

In our population, the exploratory analysis of the newly created AJCC criteria showed no significant difference in recurrence or death, although pT1b was associated with adverse biomarkers, such as RTI and EN, but its clinical relevance remains incompletely understood. Our results confirm an excellent prognosis, regardless of subcategorization, thus a larger population and a longer follow-up time are needed to understand prospectively the impact of the recently updated criteria. We would recommend using the latest AJCC staging system, although the individual risk of relapse, long-term toxicities and patient preferences should be taken into account when considering surveillance or active treatment adjuvant options.

Eyes absent in the cockroach panoistic ovaries regulates proliferation and differentiation through ecdysone signalling

Eyes absent (Eya), is a protein structurally conserved from hydrozoans to humans, for which two basic roles have been reported: it can act as a transcription cofactor and as a protein tyrosine phosphatase. Eya was discovered in the fly Drosophila melanogaster in relation to its function in eye development, and the same function was later reported in other insects. Eya is also involved in insect oogenesis, although studies in this sense are limited to D. melanogaster, which has meroistic ovaries, and where eya mutations abolish gonad formation. In the present work we studied the function of eya in the panoistic ovary of the cockroach Blattella germanica. We show that eya is essential for correct development of panoistic ovaries. In B. germanica, eya acts at different level and in a distinct way in the germarium and the vitellarium. In the germarium, eya contributes to maintain the correct number of somatic and germinal cells by regulating the expression of steroidogenic genes in the ovary. In the vitellarium, eya facilitates follicle cells proliferation and contributes to regulate the cell program, in the context of basal ovarian follicle maturation. Thus, eya-depleted females of B. germanica arrest the growth and maturation of basal ovarian follicles and become sterile.

Intraparotid mucous retention cyst in an infant: a rare case report

Mucocoeles can be defined as benign lesions that have resulted from extravasation or retention of saliva in the extraglandular spaces, and commonly affect the minor salivary glands. This case details a mucous retention cyst within the parotid gland of an infant, and its management.

Cardiac tumors: three decades of experience from a tertiary center: are we changing diagnostic work-up with new imaging tools?

BACKGROUND

Primary cardiac tumours are relatively rare. Cardiac myxomas are the most prevalent and in a significant proportion of cases they are accidentally discovered in asymptomatic patients. Noninvasive definitive diagnosis remains challenging despite improvements provided by newer imaging tools. Our aim was to describe the long-term experience of a tertiary cardiac center managing cardiac tumours.

METHODS

We analyzed 154 consecutive patients admitted to a single-tertiary center with the diagnosis of a cardiac mass or tumor between 1990 and 2018. Data files including clinical presentation, noninvasive investigations, presumptive diagnosis and histopathology were collected. The follow-up was obtained from clinical records or telephone contact.

RESULTS

In 154 patients with a median age at diagnosis of 61 (51-71) years, 62% were females. Anatomopathology studywas obtained in 144 cases, from which 81% were benign tumours (106 myxomas; 11 papillary fibroelastomas). In comparison with malignant lesions, patients with benign tumours were older (62 versus 48 years) and more often women (65% versus 27%, P = .021). Incidental diagnosis of a benign tumor occurred in 36% of the cases. Transthoracic echocardiography was the initial technique for diagnostic suspicion in the great majority of patients. Both cardiac computed tomography and magnetic resonance were rarely performed before excision. Imaging based (mostly echocardiography) pre-operative presumptive diagnosis was discordant with histopathologic findings in 21% of the benign and in 55% of malignant lesions (previously considered as benign). Uncommon histologic findings were found in 18% of myxomas. During the follow-up period of 11 ± 12 years there were 12 recurrences.

CONCLUSION

Among surgically excised cardiac tumours benign cardiac tumors are far more common than both primary and secondary malignancies. In this series of patients, there was a significant proportion of asymptomatic lesions. Preoperative misdiagnosis could be related to the scarce use of adjunctive noninvasive imaging tools beyond echocardiography. Preoperative noninvasive investigation should be expanded to improve diagnostic presumption and better plan the best therapeutic approach.

High-grade urothelial carcinoma in a kidney transplant recipient after JC virus nephropathy: The first evidence of JC virus as a potential oncovirus in bladder cancer

Kidney transplant (KT) recipients have an increased risk for urothelial carcinoma. A role for JC virus (JCV) in human cancers is not yet proved but there is an increasingly reported association between BK virus (BKV) nephropathy and renourinary neoplasms. We report a KT recipient who developed a high-grade urothelial carcinoma 5 years after a diagnosis of JCV nephropathy and 9 years after kidney transplantation. Neoplastic tissue was positive for JCV DNA by real-time polymerase chain reaction (PCR). Immunochemical staining showed strong positivity for cell cycle markers (p16, p53, and Ki67) and for early viral protein JCV large T antigen (JCV LTag; using a broad polyomavirus antibody); however, late viral protein (VP1) stained negative. In contrast, in non-neoplastic urothelium, JCV DNA and all immunochemical markers were negative. These facts suggest that malignancy was induced by JCV. To the best of our knowledge, this is the first report of urothelial high-grade carcinoma associated with JCV nephropathy in a KT recipient.

1098 Atrial thickening: a surprisingly "gouty" heart

Case Presentation

A 49 year-old male presented to the emergency department with fever and lower limb myalgia for 5 days. His past history was notable for acute episodes of microcrystalline pyrophosphate oligoarthritis for which he was receiving allopurinol 100mg, colchicine 1mg and prednisolone 5mg. Physical examination was unrevealing. Laboratory workup showed normocytic normochromic anemia (Hb 12.8g/dL), leukocytosis (22 490 /mm3), neutrophilia (86.8%), increased C-reactive protein (CRP

26mg/dL), low procalcitonin (0.82ng/mL) and mildly elevated creatinine-kinase (83 UI/L). The patient was admitted with fever of unknown origin and started on ceftriaxone after blood and urine cultures.

He remained febrile with persistently heightened inflammation. Cultures, infectious and auto-immune tests, bone marrow biopsy, myelogram and abdominopelvic CT scan were negative. Three weeks later, syncope due to complete atrioventricular (AV) block led to temporary pacemaker implantation. Transoesophageal echocardiography (TOE) revealed a left atrial (LA) wall thickening,

evident on MRI as an 8-10mm T2-hyperintensity sign, with right atrial (RA) and ventricular sparing. PET/CT scan showed an 18F FDG uptake exclusively in the LA. As a neoplasia was highly suspected, a transspeptal biopsy was attempted, yet the sample was scarce for analysis. Thus, a biopsy via sternotomy was performed, now sampling both the LA and RA. Indeed, repeated TOE showed de novo RA involvement with a prominent nodular finding (19x24mm) in the lateral wall.

Myocyte inflammation and necrosis accompanied with granulocyte infiltration (mostly neutrophils but also eosinophils) was observed in all samples. There were no findings suggestive of neoplasia. The patient was still on allopurinol, which has been reported to involve the myocardium in a late (type IV) hypersensitivity reaction (the so-called DRESS syndrome), even in the absence of systemic inflammation. Thus, allopurinol was stopped and 1mg/Kg prednisolone was started. The patient

significantly improved and was discharged home with negative CRP the following two weeks. After 1 month, MRI was repeated and no atrial inflammation was found. After 4 months follow-up, he is doing well on 2.5mg of prednisolone and febuxostat 80mg.

Diphtheritic angina in the tongue and floor of the mouth: unusual presentation

Diphtheria is an infectious disease caused by Corynebacterium diphtheriae, and is generally characterised by proliferation of the bacteria in the upper respiratory tract, formation of a pseudomembrane, and systemic diffusion of the diphtheria toxin throughout the body. We present the case of a young man with pseudomembranous plaques on the tongue and floor of the mouth, who received systemic and locoregional medical treatment, with a satisfactory outcome after 14 days.

P4657Cardiac myxomas: are we dealing with distinct clinical entities?

Background

Cardiac myxomas are rare, despite being the most common primary cardiac tumours. A significant number of myxomas are discovered accidentally in asymptomatic patients (pts), as there is increased use of non-invasive cardiac imaging. Our aim was to describe the experience of a cardiac surgery centre managing cardiac myxomas during the last 28 years.

Methods

Single-center retrospective study of consecutive pts admitted with the diagnosis of a cardiac myxomas between 1990 and 2018. Registry data concerning clinical presentation, non-invasive imaging assessment and definitive histopathology were collected.

Results

From 154 pts with the diagnosis of cardiac tumours, we identified 106 (68.8%) myxomas (67% females; mean age at diagnosis 61,5±13,1 years). Myxoma diagnosis increased throughout the 3 decades (27 cases until 2000; 26 cases in the second decade; 52 cases from 2010 until present). 30% of the pts were asymptomatic at diagnosis. Obstructive symptoms (heart failure and syncope) and embolic events were the most common complaints among symptomatic pts. Transthoracic echocardiography firstly identified the tumours in 88% of the cases. Cardiac magnetic resonance and computed tomography were performed for further investigation in 7% of the cases. Presumptive pre-operative diagnosis was correct in 83.8% pts.

Surgical excision was successfully achieved in all cases. 89% of the tumours were located in the left atrium with inter-atrial septum implantation (13 in right chambers; 1 valvular tumour). There were 10 multifocal tumours.

At histopathology myxomas were grossly described as mucous jelly appearance (80%), solid (15%) and mixed type lesions (5%). Rare histologic findings were described in 30% of the cases (8 tumours with bone tissue; 1 with forming bone marrow; 4 with endocrine type glandular epithelium; 16 with lympho-plasmocytic infiltrates; 3 with high mitotic grade; 5 with concomitant thrombus).

For a median follow up of 86 [31–214] months there were 15 deaths (2 of them with tumour related deaths). There were 3 recurrences (2 with high mitotic grade histology), mostly occurring 3 years after the first intervention.

Conclusion

In this case series cardiac myxomas are the most common cardiac tumours, with a significant proportion of asymptomatic lesions. Clinical heterogeneity followed polymorphic histology, with recognized differences when compared to classical descriptions of this kind of tumour.

Microplastic contamination in an urban estuary: Abundance and distribution of microplastics and fish larvae in the Douro estuary

Estuaries are productive environments used by many fish as nursery grounds. The initial stages of fishes are highly vulnerable to (a)biotic factors, and anthropogenic pressures, influencing fish larvae assemblages along the estuary. Microplastics (MPs < 5 mm) are particularly dangerous to early life stages of fishes because their ingestion can induce gut blockage, limiting food intake or exposing organisms to contamination due to MPs capacity to absorb pollutants. Present work aimed to investigate the contamination of an urban impacted estuary (Douro estuary, NW Portugal) by MPs, and study the abundance and distribution of MPs and fish larvae in this estuary. Monthly sampling surveys were performed from December 2016 to December 2017, in nine stations along the estuary. Sub-surface planktonic horizontal trawls were performed to collect fish larvae and MPs. Planktonic samples were sorted, and fish larvae identified. MPs density was determined using a protocol optimized in our laboratory. A total of 1498 fish larvae belonging to 32 taxa were collected, with a mean density of 11.66 fish larvae 100 m^-3. During the spring-summer period, it was observed the typical increase in the density and diversity of the larval assemblage. Diversity was generally low, with the high dominance of very few taxa, namely the common goby, Pomatoschistus microps. Different types of MPs were found, namely fibers, soft/hard plastic, colorful/transparent plastic, in a total of 2152 particles, with a mean density of 17.06 MPs 100 m^-3. Hard MPs and fibers were the most predominant types, representing 83% of the total MPs collected. In some months the number of MPs surpassed the number of fish larvae, with an average ratio of 1.0 fish larvae:1.5 MPs. Such results are concerning, highlighting that a higher availability of MPs may facilitate their ingestion by fish and therefore increase possible impacts in these communities.

Time-Like Baryon Transitions studies with HADES

The HADES collaboration uses the e+e− production as a probe of the resonance matter produced in collisions at incident energies of 1-3.5 GeV/nucleon at GSI. Elementary reactions provide useful references for these studies and give information on resonance Dalitz decays (R→Ne+e−). Such processes are sensitive to the structure of time-like electromagnetic baryon transitions in a kinematic range where (off-shell) vector mesons play a crucial role. Results obtained in proton-proton reactions and in a commissioning pion-beam experiment are reported and prospects for future pion beam experiments and for first hyperon Dalitz decay measurements are described. The connection with the investigations of medium effects to be continued with HADES in the next years at SIS18 and SIS100 is also discussed.

Spin rotation induced by applied pressure in the Cd-doped Ce2RhIn8 intermetallic compound

The pressure evolution of the magnetic properties of the Ce₂RhIn_7.79Cd_0.21 heavy fermion compound was investigated by single crystal neutron magnetic diffraction and electrical resistivity experiments under applied pressure. From the neutron magnetic diffraction data, up to P = 0.6 GPa, we found no changes in the magnetic structure or in the ordering temperature T _N = 4.8 K. However, the increase of pressure induces an interesting spin rotation of the ordered antiferromagnetic moment of Ce₂RhIn_7.79Cd_0.21 into the ab tetragonal plane. From the electrical resistivity measurements under pressure, we have mapped the evolution of T _N and the maximum of the temperature dependent electrical resistivity (T _MAX) as a function of the pressure (P ≲ 3.6 GPa). To gain some insight into the microscopic origin of the observed spin rotation as a function of pressure, we have also analyzed some macroscopic magnetic susceptibility data at ambient pressure for pure and Cd-doped Ce₂RhIn₈ using a mean-field model including tetragonal crystalline electric field (CEF). The analysis indicates that these compounds have a Kramers doublet Γ 7 - -type ground state, followed by a Γ 7 + first excited state at Δ₁ ∼ 80 K and a Γ₆ second excited state at Δ₂ ∼ 270 K for Ce₂RhIn₈ and Δ₂ ∼ 250 K for Ce₂RhIn_7.79Cd_0.21. The evolution of the magnetic properties of Ce₂RhIn₈ as a function of Cd doping and the rotation of the direction of the ordered moment for the Ce₂RhIn_7.79Cd_0.21 compound under pressure suggest important changes of the single ion anisotropy of Ce³⁺ induced by applying pressure and Cd doping in these systems. These changes are reflected in modifications in the CEF scheme that will ultimately affect the actual ground state of these compounds.

Non-adenomatous sellar lesions: single-centre 10-year experience

OBJECTIVE

A minority of lesions found in the sellar region are non-adenomatous neoplastic, inflammatory, or cystic masses. Our study aims to describe the prevalence and characteristics of these lesions in a multidisciplinary pituitary outpatient clinic.

DESIGN

We conducted an observational study which included 36 patients (15.9% of those followed up in this outpatient clinic between 2006 and 2016 who had pituitary surgery) submitted to pituitary surgery with histological results showing a non-adenomatous sellar lesion. We evaluated clinical, radiological, and biochemical (pituitary function) characteristics during the pre-operative and post-operative period.

RESULTS

Thirty-six patients (50% female) with a mean age of 41.3 ± 21.9 years and a mean follow-up duration of 8.0 ± 9.0 years were included. Histologic diagnoses were divided into benign neoplasms (80.6%), malignant neoplasms (11.1%), inflammatory lesions (5.6%), and cystic masses (2.8%). The most common clinical presentation was headache (66.7%) and visual defects (61.1%). Forty-seven percent of patients had at least one pituitary axis insufficiency at the time of diagnosis. In the majority of cases (58.3%), a transsphenoidal approach was used for the initial pituitary surgery. Thirteen patients had more than one pituitary surgery and eight also had radiotherapy. At the time of data retrieval, five patients had no pituitary hormonal insufficiency and 13 patients had some visual defect improvement.

CONCLUSIONS

Although rare, non-adenomatous sellar lesions may be associated with significant causes of morbidity, such as hypopituitarism and visual defects, per se or due to the various treatment modalities employed. Moreover, since the lesions are difficult to distinguish from adenomas, these patients require a careful multidisciplinary approach.

Patient preferences for attributes of topical anti-psoriatic medicines

Background: Patient preferences should be considered when prescribing topical treatments to drive up adherence and improve clinical outcomes. Objective: The aim of this work was to identify the most important attributes of topical medicines for psoriasis treatment in the patients' view, and explore the sociodemographic and clinical determinants of these preferences. Methods: A questionnaire for the evaluation of the relevancy given to specific attributes of topical medicines used for psoriasis treatment was developed (PSO-TOPAP) and was applied to a total of seventy-nine patients, members of the Portuguese Association of Psoriasis (PSOPortugal) or outpatients of a dermatology unit of a central hospital. Results: Overall, attributes belonging to the formulation and application domains were greatly valued over attributes related to the container. Only a small number of patient preferences was influenced by age, gender, duration of the disease and age at first diagnosis. Limitations: Our findings need to be verified in larger and more diverse patient samples before generalization can be made. Conclusion: The insight obtained in this work can provide guidance to pharmaceutical drug product design and has also the potential to improve patient care through the acknowledgment of patient preferences in clinical practice.

The cancer registry as an ally in monitoring treatment effectiveness

OBJECTIVE

To evaluate if the cancer registry database can be used to monitor treatment effectiveness using nivolumab treatment of non-small cell lung cancer (NSCLC) as an example.

METHOD

An observational inception cohort was used, where all registered cases of NSCLC with authorisation to initiate treatment with nivolumab were monitored retrospectively to evaluate disease characteristics and response to prior treatments. Current exposure to nivolumab was prospectively characterised and treatment outcomes classified based on the clinical information registered in the patient medical record. The main outcome measure used to assess treatment effectiveness was overall survival (OS). Secondary outcomes considered were progression free survival (PFS) as a measure of effectiveness and occurrence of Adverse Drug Reaction (ADRs) as a measure of safety. Data were analysed using SPSS, version 24.

RESULTS

A total of 115 patients received treatment with nivolumab for NSCLC, between November 1st 2015 and July 31st 2016, and were registered in the database. The majority were non-squamous type (n=107). The median OS was 11.4 months {CI_95%: 11.1-11.7}, with a 1-year survival of 44%, in line with clinical trial data. Median PFS was 5.4 months {CI_95%: 2.8-7.9}. Treatment was discontinued in 82 cases, most frequently due to disease progression. There were 38 cases of ADRs documented in the patient medical chart, 21 of which led to treatment discontinuation.

CONCLUSION

The analysed data suggest that the cancer registry is a powerful tool to monitor treatment effectiveness, although considerable investment is needed to improve the medical culture of recording treatment exposure, particularly documentation of ADRs.

The role of microsurgical flaps in primary burn reconstruction

Despite the wide and growing use of microsurgery, its application in primary burn reconstruction is not very frequent as it faces a number of additional challenges in this setting. A retrospective analysis of the clinical records of all patients submitted to microvascular free tissue transfer for primary burn reconstruction over an 8-year period (from January 2009 to December 2016) was performed. An evaluation of the indications, timing, principles of flap selection, complications and outcomes of free tissue transfer in primary burn reconstruction was made. Fourteen patients required 18 microsurgical flaps for acute soft tissue reconstruction (1.1% of all patients admitted). 64.3% of the patients were male. The mean age was 59.64 years, and mean TBSA was 10.5%. The majority of the injuries were caused by flames (71.4%), followed by electrical contact (21.4%). The primary indication for microsurgical reconstruction was tissue deficit with exposure of tendons, nerves, vessels, bone and/or joints after debridement. The procedure was more often performed in the early period after injury (between the 5th and 22nd day). The most frequently used flaps were the Latissimus dorsi and the anterolateral thigh flap. Major complications included 2 total flap failures (11.1%) and a partial flap failure that required reconstruction with another free flap. Microsurgical free flaps have a valuable role in primary burn reconstruction. Despite the reported higher complication rate in this specific clinical scenario, their use may reduce the total number of surgeries needed to achieve wound closure.

Concomitant presence of JAK2V617F mutation and BCR‑ABL translocation in two patients: A new entity or a variant of myeloproliferative neoplasms (Case report)

Myeloproliferative neoplasms (MPNs) are classically divided into BCR RhoGEF and GTPase activating protein (BCR)-ABL proto‑oncogene 1 non‑receptor tyrosine kinase (ABL) positive chronic myeloid leukemia (CML) and BCR‑ABL negative MPNs, including essential thrombocythemia (ET). One of the major diagnostic criteria for ET is the absence of the philadelphia chromosome, thus when present it is almost indicative of CML. ET and CML are considered to be mutually exclusive; however, there are rare situations in which patients with ET present positive BCR‑ABL without the features of CML. Although from the literature review, the frequency of JAK2V617F mutation and BCR‑ABL translocation coexistence in MPNs is low, it may be higher than expected. The current study reported cases of two patients with an initial diagnosis of ET in the presence of JAK2V617F mutation and BCR‑ABL translocation by fluorescent in situ hybridization. Both patients presented with a heterozygous BCR‑ABL translocation, and absence of p190 and p210 transcripts, seemingly a der(9) in the background of an ET JAK2V617F mutation.