Proton beam radiotherapy for choroidal and ciliary body melanoma in the UK-national audit of referral patterns of 1084 cases

INTRODUCTION

Proton beam therapy has been utilised for the treatment of uveal melanoma in the UK for over 30 years, undertaken under a single centre. In the UK, all ocular tumours are treated at one of four centres. We aimed to understand the variation in referral patterns to the UK proton service, capturing all uveal melanoma patients treated with this modality.

METHODS

Retrospective analysis of data regarding all patients treated at the Clatterbridge Proton service between January 2004 and December 2014.

RESULTS

A total of 1084 patients with uveal melanoma were treated. The mean age was 57 years (range 9-90 years), basal diameter of 11.5 mm (range 2.0-23.4 mm) and tumour thickness of 3.9 mm (range 0.1-15.4 mm). The majority were TNM stage I (39%) or II (36%). The distance to the optic nerve varied from 0 to 24.5 mm with 148 (14%) of patients having ciliary body involvement. There were variations in the phenotypic characteristic of the tumours treated with protons from different centres, with London referring predominantly small tumours at the posterior pole, Glasgow referring large tumours often at the ciliary body and Liverpool sending a mix of these groups.

DISCUSSION

In the UK, common indications for the use of proton treatment in uveal melanoma include small tumours in the posterior pole poorly accessible for plaque treatment (adjacent to the disc), tumours at the posterior pole affecting the fovea and large anterior tumours traditionally too large for brachytherapy. This is the first UK-wide audit enabling the capture of all patients treated at the single proton centre.

Household air pollution and COPD: cause and effect or confounding by other aspects of poverty?

SETTING :

Household air pollution (HAP) and chronic obstructive pulmonary disease (COPD) are both major public health problems, reported to cause around 4 million and 3 million deaths every year, respectively. The great majority of these deaths, as well as the burden of disease during life is felt by people in low- and middle-income countries (LMICs).

OBJECTIVE AND DESIGN :

The extent to which HAP causes COPD is controversial; we therefore undertook this review to offer a viewpoint on this from the Global Initiative for COPD (GOLD).

RESULTS :

We find that while COPD is well-defined in many studies on COPD and HAP, there are major limitations to the definition and measurement of HAP. It is thus difficult to disentangle HAP from other features of poverty that are themselves associated with COPD. We identify other limitations to primary research studies, including the use of cross-sectional designs that limit causal inference.

CONCLUSION :

There is substantial preventable morbidity and mortality associated with HAP, COPD and poverty, separately and together. Although it may not be possible to define clear causal links between HAP and COPD, there is a clear urgency to reduce the avoidable burden of disease these inflict on the world’s poor.

Assessment of asthma control in users of oral anti-asthma medications

BACKGROUND: Despite guidelines recommending inhalation therapy as the preferred choice, oral therapy is still widely used in the treatment of asthma in India. However, data about the level of asthma control and healthcare use in patients on oral anti-asthma medications are scarce.METHODS: A retrospective study was conducted to assess the level of asthma control and healthcare use in patients taking oral anti-asthma medications.RESULTS: The study population consisted of 381 adults randomly selected from health screening programmes. All subjects were already receiving oral anti-asthma medications; however, up to 72% had not been diagnosed with asthma by their treating doctors prior to the screening programmes. The cohort had a mean age of 48.26 ± 13.83 years (70% males) and mean peak expiratory flow of 245 ± 78.93 mL/sec. The mean Asthma Control Questionnaire 5 (ACQ-5) score was 2.53 ± 1.15, with respectively 33%, 49.3% and 32.6% reporting at least one episode of breathlessness, one emergency doctor visit and one hospitalisation due to asthma or its symptoms in the past year.CONCLUSION: Underdiagnosis and inappropriate management, as indicated by the poor asthma control and increased hospitalisations seen in this study, is probably a key contributor to the increased burden of the disease in India.

Clinical role of lung ultrasound for diagnosis and monitoring of COVID-19 pneumonia in pregnant women

Lung ultrasound has been suggested recently by the Chinese Critical Care Ultrasound Study Group and Italian Academy of Thoracic Ultrasound as an accurate tool to detect lung involvement in COVID-19. Although chest computed tomography (CT) represents the gold standard to assess lung involvement, with a specificity superior even to that of the nasopharyngeal swab for diagnosis, lung ultrasound examination can be a valid alternative to CT scan, with certain advantages, particularly for pregnant women. Ultrasound can be performed directly at the bed-side by a single operator, reducing the risk of spreading the disease among health professionals. Furthermore, it is a radiation-free exam, making it safer and easier to monitor those patients who require a series of exams. We report on four cases of pregnant women affected by COVID-19 who were monitored with lung ultrasound examination. All patients showed sonographic features indicative of COVID-19 pneumonia at admission: irregular pleural lines and vertical artifacts (B-lines) were observed in all four cases, and patchy areas of white lung were observed in two. Lung ultrasound was more sensitive than was chest X-ray in detecting COVID-19. In three patients, we observed almost complete resolution of lung pathology on ultrasound within 96 h of admission. Two pregnancies were ongoing at the time of writing, and two had undergone Cesarean delivery with no fetal complications. Reverse transcription polymerase chain reaction analysis of cord blood and newborn swabs was negative in both of these cases. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Respiratory health status is associated with treatment outcomes in pulmonary tuberculosis

<sec id="st1"> <title>BACKGROUND</title> The association between respiratory impairment and tuberculosis (TB) treatment outcomes is not clear. </sec> <sec id="st2"> <title>METHODS</title> We prospectively evaluated respiratory health status, measured using the Saint George's Respiratory Questionnaire (SGRQ), in a cohort of new adult pulmonary TB cases during and up to 18 months following treatment in India. Associations between total SGRQ scores and poor treatment outcomes of failure, recurrence and all-cause death were measured using multivariable Poisson regression. </sec> <sec id="st3"> <title>RESULTS</title> We enrolled 455 participants contributing 619 person-years at risk; 39 failed treatment, 23 had recurrence and 16 died. The median age was 38 years (interquartile range 26-49); 147 (32%) ever smoked. SGRQ scores at treatment initiation were predictive of death during treatment (14% higher risk per 4-point increase in baseline SGRQ scores, 95%CI 2-28, P = 0.01). Improvement in SGRQ scores during treatment was associated with a lower risk of failure (1% lower risk for every per cent improvement during treatment, 95%CI 1-2, P = 0.05). Clinically relevant worsening in SGRQ scores following successful treatment was associated with a higher risk of recurrence (15% higher risk per 4-point increase scores, 95%CI 4-27, P = 0.004). </sec> <sec id="st4"> <title>CONCLUSION</title> Impaired respiratory health status was associated with poor TB treatment outcomes. The SGRQ may be used to monitor treatment response and predict the risk of death in pulmonary TB. </sec>.

Gestational weight gain as an independent risk factor for adverse pregnancy outcomes in women with gestational diabetes

OBJECTIVE

Obesity and gestational diabetes mellitus (GDM) are rising worldwide. This study retrospectively evaluated the role of excessive gestational weight gain (eGWG) in women with GDM and different pre-pregnancy body mass indices (BMIs).

PATIENTS AND METHODS

Optimal glycaemic control was defined as achieving glucose target thresholds in more than 80% of measurements. 283 women with GDM were categorized as underweight, normal weight, overweight or obese based on WHO's classification scheme. eGWG was defined as >18.0 kilograms for women who were underweight, >15.8 kilograms for those who were normal weight, >11.3 kilograms for those who were overweight and >9.0 kilograms for those who were obese. For the analysis, women were divided into two groups: normal and excessive GWG. The main outcomes measured were incidences of large/small for gestational age (LGA/SGA), macrosomia, preterm delivery, hypertensive disorders and caesarean sections (CS).

RESULTS

Excessive GWG was associated with higher birth weight and percentile (p<0.001), and with a higher prevalence of LGA (p<0.001), macrosomia (p=0.002) and hypertensive disorders (p=0.036). No statistical differences were found for the week of delivery, or prevalence of CS and SGA. The multivariate analysis highlighted both pre-pregnant BMI and eGWG as independent risk factors for LGA and macrosomia. Women with a pre-pregnant BMI of at least 25 and eGWG have a 5.43-fold greater risk of developing LGA (p=0.005).

CONCLUSIONS

When combined with an inadequate pre-pregnant BMI, eGWG acts as a "synergic risk factor" for a poor outcome. When obesity or GDM occur, an optimal GWG can guarantee a better pregnancy outcome.

Electrochemical characteristics of ultramicro-dimensioned SIROF electrodes for neural stimulation and recording

OBJECTIVE

With ever increasing applications of neural recording and stimulation, the necessity for developing neural interfaces with higher selectivity and lower invasiveness is inevitable. Reducing the electrode size is one approach to achieving such goals. In this study, we investigated the effect of electrode geometric surface area (GSA), from 20 μm² to 1960 μm², on the electrochemical impedance and charge-injection properties of sputtered iridium oxide (SIROF) coated electrodes in response to current-pulsing typical of neural stimulation. These data were used to assess the electrochemical properties of ultra-small SIROF electrodes (GSA  <  200 μm²) for stimulation and recording applications.

APPROACH

SIROF charge storage capacities (CSC), impedance, and charge-injection characteristics during current-pulsing of planar, circular electrodes were evaluated in an inorganic model of interstitial fluid (model-ISF).

MAIN RESULTS

SIROF electrodes as small as 20 μm² could provide 1.3 nC/phase (200 μs pulse width, 0.6 V versus Ag|AgCl interpulse bias) of charge during current pulsing. The 1 kHz impedance of all electrodes used in this study were below 1 MΩ, which is suitable for neural recording.

SIGNIFICANCE

Ultra-small SIROF electrodes are capable of charge injection in buffered saline at levels above some reported thresholds for neural stimulation with microelectrodes.

The GOLD Summit on chronic obstructive pulmonary disease in low- and middle-income countries

Chronic obstructive pulmonary disease (COPD) is one of the top three causes of death worldwide, but governments and non-governmental organisations have not given its prevention and treatment the priority it requires. This is particularly true in low- and middle-income countries, where most of the people suffering from this disease live. The United Nations (UN) has targeted a reduction of premature deaths from non-communicable diseases (NCDs) by a third by 2030; however, a coordinated UN/World Health Organization (WHO) strategy to address the burden of COPD (one of the most important NCDs) is still lacking. To explore the extent of the problem and inform the development of policies to improve the situation, the Board of Directors of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) held a 1-day Summit. The key themes that emerged were the need to ensure accurate data on prevalence, raise awareness of the disease among the public, healthcare professionals and governments, including the fact that COPD aetiology goes beyond smoking (and other inhaled pollutants) and includes poor lung development in early life, and ensure that spirometry and both pharmacological and non-pharmacological therapies are available and affordable. Here, we present the actions that must be taken to address the impact of COPD. We believe that the WHO is particularly well-positioned to co-ordinate an attack on COPD, and GOLD will do all it can to help and rally support.

Sustainable bioenergy for climate mitigation: developing drought-tolerant trees and grasses

BACKGROUND AND AIMS

Bioenergy crops are central to climate mitigation strategies that utilize biogenic carbon, such as BECCS (bioenergy with carbon capture and storage), alongside the use of biomass for heat, power, liquid fuels and, in the future, biorefining to chemicals. Several promising lignocellulosic crops are emerging that have no food role - fast-growing trees and grasses - but are well suited as bioenergy feedstocks, including Populus, Salix, Arundo, Miscanthus, Panicum and Sorghum.

SCOPE

These promising crops remain largely undomesticated and, until recently, have had limited germplasm resources. In order to avoid competition with food crops for land and nature conservation, it is likely that future bioenergy crops will be grown on marginal land that is not needed for food production and is of poor quality and subject to drought stress. Thus, here we define an ideotype for drought tolerance that will enable biomass production to be maintained in the face of moderate drought stress. This includes traits that can readily be measured in wide populations of several hundred unique genotypes for genome-wide association studies, alongside traits that are informative but can only easily be assessed in limited numbers or training populations that may be more suitable for genomic selection. Phenotyping, not genotyping, is now the major bottleneck for progress, since in all lignocellulosic crops studied extensive use has been made of next-generation sequencing such that several thousand markers are now available and populations are emerging that will enable rapid progress for drought-tolerance breeding. The emergence of novel technologies for targeted genotyping by sequencing are particularly welcome. Genome editing has already been demonstrated for Populus and offers significant potential for rapid deployment of drought-tolerant crops through manipulation of ABA receptors, as demonstrated in Arabidopsis, with other gene targets yet to be tested.

CONCLUSIONS

Bioenergy is predicted to be the fastest-developing renewable energy over the coming decade and significant investment over the past decade has been made in developing genomic resources and in collecting wild germplasm from within the natural ranges of several tree and grass crops. Harnessing these resources for climate-resilient crops for the future remains a challenge but one that is likely to be successful.

Influence of Biliopancreatic Diversion on Pregnancy Outcomes in Comparison to Other Bariatric Surgery Procedures

BACKGROUND

Pregnancy after bariatric surgery (BS) has an increased risk for small-for-gestational-age infants (SGA), shorter length of gestation, and probably perinatal mortality. The aim of this study was to investigate if biliopancreatic diversion could impair pregnancy outcomes in comparison to other bariatric surgery procedures.

METHODS

We conducted a cohort retrospective single-center study in 65 women before and after BS. Thirty-one pregnancies occurred before BS, while 109 after BS, amongst which n = 51 after biliopancreatic diversion (BPD) and n = 58 after non-malabsorptive procedures.

RESULTS

The pregnancy outcomes after BS in comparison with those before BS resulted less affected by diabetes, hypertensive disorders, macrosomia, and large-for-gestational-age (LGA), but more complicated by preterm births (14.5 versus 4.0%) and low birth weight (LBW) infants (28.9 versus 0%). Moreover, mean birth weight resulted lower after BS than before BS (p < 0.001). In pregnancies after BPD in comparison to those before BS, the LBW rate (42.5%) resulted a drastic increase (p < 0.001), and mean birth weight (p < 0.001) and mean birth weight centile (p < 0.001) were lower after BPD. When pregnancy outcomes after BPD were compared with those after non-malabsorptive procedures, the rate of congenital anomalies, preterm births, LBW, and SGA resulted an increase (p = 0.002, 0.008, 0.032, and < 0.001, respectively).

CONCLUSIONS

BPD drastically reduced diabetes, hypertensive disorders, macrosomia, and LGA; however, it was associated with the poorest pregnancy outcomes in comparison to those observed after other BS procedures. On the basis of the present study, we recommend a cautious multidisciplinary selection of severely obese patients for BPD during the fertile age.

Complementemia in pregnancies with antiphospholipid syndrome

Prognosis of pregnancies in women with antiphospholipid syndrome has dramatically improved over the past two decades using conventional treatment with low molecular weight heparin and low-dose aspirin. However, despite this regimen, 10-15% of antiphospholipid syndrome patients experience pregnancy losses. Several studies have been performed in order to identify risk factors predictive of complications. Thrombosis has been generally accepted as the key pathogenetic mechanism underlying pregnancy morbidity. However, the thrombogenic state alone is not able to explain all the different mechanisms leading to pregnancy failure. In fact, emerging evidence shows that complement pathway could play an important role in mediating clinical events in antiphospholipid syndrome. However, the exact mechanism through which complement mediates antiphospholipid syndrome complications remains unknown. Low complement levels (C3 and C4) are associated with poor pregnancy outcome in women with antiphospholipid syndrome in different studies. Hypocomplementemia could be indicated as an early predictor of adverse pregnancy outcome, available at the beginning of pregnancy for starting, if necessary, additional treatment to conventional therapy. However, future studies need to better understand the impact of low complement level on antiphospholipid syndrome pregnancy outcome.

Reproducibility of the fetal cerebral vessels assessment in full and late term pregnancies

Objective: Data concerning feasibility of the fetal cerebral Doppler examination in full term and late term pregnancy is lacking. Our purpose was to perform an evaluation of these arteries with power Doppler ultrasound, calculating the percentage of identification and measurement and the intraobserver reproducibility.Methods: This was a cross sectional study evaluating a population of 578 normally grown fetuses divided according to the week of examination. The first group included fetuses examined at week 40 (N = 323) and the second fetuses examined at week 41 (N = 255). The three major branches of the internal carotid artery (anterior, middle and posterior cerebral arteries, ACA, middle cerebral artery (MCA), posterior cerebral arteries (PCA)) and their anastomosis (A1, A2, P1, P2) were examined with power Doppler ultrasonography by three independent ultrasonographers. The proportion of vessel identified and measured was calculated and the reproducibility among the three operators was investigated.Results: The major arteries at the circle of Willis were fully identified/measured in 65/56 and 62/48% of fetuses at 40 and 41 weeks. The MCA obtained the higher percentage of identification and measurement at both periods (> 80 and >70%). The entire set of anastomosis were less frequently identified/measured at both periods (50/< 50% of cases), especially in the A2 segment. The best agreement was obtained in the MCA and the worst in the PCA-P1 segment.Conclusions: At 40 and 41 weeks, the fetal cerebral vessels, especially the MCA, are suitable for power Doppler evaluation, providing an interesting tool to evaluate fetal hemodynamics in full and late term pregnancy.

[Superior vena cava thrombosis or stricture secondary to implanted central venous access: Six cases of endovascular and direct surgical treatment in cancer patients]

Superior vena cava (SVC) stenosis or thrombosis is a well-known complication of central venous catheterization for endocavitary treatments, hemodialysis, or chemotherapy. In cancer patients, these SVC lesions are often symptomatic due to intimal damage and chemotherapy toxicity. We report our experience with six patients treated between 2007 and 2012 via an endovascular approach (n=5) or a direct surgical approach (n=1). All patients had SVC syndrome with facial edema, headache and upper limb edema. In three cases, the catheter was in place when the clinical symptoms occurred. Duplex Doppler and computed tomography (CT)-angiography identified the following lesions: isolated SVC stenosis (n=2); SVC stenosis with right Pirogoff confluence stenosis (n=1); SVC stenosis associated with left innominate vein thrombosis and right Pirogoff confluence stenosis (n=1); SVC thrombosis affecting azygos flow (n=2). In one patient, the thrombus extended into the right atrium. Five patients underwent endovascular repair via a right jugular approach (n=2) or a double jugular approach (n=3). Treatment involved: SVC angioplasty with stent (n=2); right Pirogoff angioplasty and SVC stent (n=1); kissing angioplasty of both innominate trunks with a SVC stent (n=1); and SVC angioplasty without stent because of an incomplete result with a residual lumen less than 8mm (n=1). One patient had a complete SVC occlusion with extension of thrombus into the right atrium. She was treated via a median sternotomy for open surgical control of both innominate trunks and lateral clamping of the right atrium. A long cavotomy prolonged on the right atrium allowed thrombo-intimectomy and pericardial patch angioplasty. Postoperative follow-up was uneventful in five cases. However, postoperative hemorrhage required pericardial drainage in one patient. The CT scan showed a good morphological aspect in five patients and an incomplete result in one case. Patients have been followed up annually with a duplex scan from two to six years. One patient had a restenosis at 7 months treated by a new angioplasty via a femoral approach. A new catheter was positioned via a cervical approach. Two patients died of metastatic diffusion at 8 and 32 months. The other four patients have remained asymptomatic, with a satisfactory duplex scan. In conclusion, VCS lesions after implanted central access for chemotherapy can often be treated endovascularly. Conventional surgery still has indications when lesions extend into the right atrium.

Association between false-positive TORCH and antiphospholipid antibodies in healthy pregnant women

The present study investigated: (a) the presence of antiphospholipid antibodies and (b) the obstetric outcome in healthy pregnant women showing false-positive TORCH-Toxoplasmosis, Other: syphilis, varicella-zoster, Rubella, Cytomegalovirus (CMV), and Herpes infections-results. Data from 23 singleton healthy pregnancies with false-positive TORCH results were collected. Each woman was systematically screened for TORCH IgG and IgM during the pre-conception assessment and/or at the beginning of pregnancy. In the presence of IgM positivity, when indicated (CMV, toxoplasmosis, rubella, herpes simplex virus), IgG avidity was evaluated and, if possible, polymerase chain reaction was performed on an amniotic fluid sample in order to distinguish between primary infection or false positivity. The antiphospholipid antibodies tests were: lupus anticoagulant, anticardiolipin antibodies IgG, IgM, and anti-β2glicoprotein I IgG, IgM. The antiphospholipid antibodies tests, if positive, were repeated after 12 weeks to confirm the results. In pregnant women with false-positive TORCH, the overall prevalence of positive antiphospholipid antibodies for one or more tests was 52.2%. To clarify the correlation of false-positive TORCH results with clinical practice, obstetric outcome was analyzed in terms of live births, week of delivery, neonatal birth weight, and neonatal birth weight percentile. A statistically significant lower neonatal birth weight and neonatal birth weight percentile were observed in women with false-positive TORCH associated with antiphospholipid antibodies positivity (Group A) in comparison with those in women with false-positive TORCH without antiphospholipid antibodies positivity (Group B). No statistically significant difference was found for the week of delivery between the two groups. It is hoped that future studies will verify the life-long persistence of antiphospholipid antibodies positivity by follow-up of these women and identify who will develop a classical antiphospholipid syndrome or other autoimmune disorders.

Androgen receptor gene status in plasma DNA associates with worse outcome on enzalutamide or abiraterone for castration-resistant prostate cancer: a multi-institution correlative biomarker study

BACKGROUND

There is an urgent need to identify biomarkers to guide personalized therapy in castration-resistant prostate cancer (CRPC). We aimed to clinically qualify androgen receptor (AR) gene status measurement in plasma DNA using multiplex droplet digital PCR (ddPCR) in pre- and post-chemotherapy CRPC.

METHODS

We optimized ddPCR assays for AR copy number and mutations and retrospectively analyzed plasma DNA from patients recruited to one of the three biomarker protocols with prospectively collected clinical data. We evaluated associations between plasma AR and overall survival (OS) and progression-free survival (PFS) in 73 chemotherapy-naïve and 98 post-docetaxel CRPC patients treated with enzalutamide or abiraterone (Primary cohort) and 94 chemotherapy-naïve patients treated with enzalutamide (Secondary cohort; PREMIERE trial).

RESULTS

In the primary cohort, AR gain was observed in 10 (14%) chemotherapy-naïve and 33 (34%) post-docetaxel patients and associated with worse OS [hazard ratio (HR), 3.98; 95% CI 1.74-9.10; P < 0.001 and HR 3.81; 95% CI 2.28-6.37; P < 0.001, respectively], PFS (HR 2.18; 95% CI 1.08-4.39; P = 0.03, and HR 1.95; 95% CI 1.23-3.11; P = 0.01, respectively) and rate of PSA decline ≥50% [odds ratio (OR), 4.7; 95% CI 1.17-19.17; P = 0.035 and OR, 5.0; 95% CI 1.70-14.91; P = 0.003, respectively]. AR mutations [2105T>A (p.L702H) and 2632A>G (p.T878A)] were observed in eight (11%) post-docetaxel but no chemotherapy-naïve abiraterone-treated patients and were also associated with worse OS (HR 3.26; 95% CI 1.47-not reached; P = 0.004). There was no interaction between AR and docetaxel status (P = 0.83 for OS, P = 0.99 for PFS). In the PREMIERE trial, 11 patients (12%) with AR gain had worse PSA-PFS (sPFS) (HR 4.33; 95% CI 1.94-9.68; P < 0.001), radiographic-PFS (rPFS) (HR 8.06; 95% CI 3.26-19.93; P < 0.001) and OS (HR 11.08; 95% CI 2.16-56.95; P = 0.004). Plasma AR was an independent predictor of outcome on multivariable analyses in both cohorts.

CONCLUSION

Plasma AR status assessment using ddPCR identifies CRPC with worse outcome to enzalutamide or abiraterone. Prospective evaluation of treatment decisions based on plasma AR is now required.

CLINICAL TRIAL NUMBER

NCT02288936 (PREMIERE trial).

Fresh frozen amniotic membrane for conjunctival reconstruction after excision of neoplastic and presumed neoplastic conjunctival lesions

PurposeSuspicious neoplastic conjunctival lesions often require wide excision with tumour-free margins, leaving significant conjunctival defects requiring reconstruction. In this study we report the results of using fresh frozen amniotic membrane grafts (AMG) after wide excision of potentially malignant lesions.MethodsRetrospective review of 53 patients; between January 2011 and April 2014. Conjunctival lesions were excised with a non-touch technique (2 mm margin) and sent for histopathological analysis. The surgical margins were treated with cryotherapy and a fresh frozen AMG was used to cover the defect. The main features examined were for any signs of recurrence, the conjunctivalisation of the AMG, complications and cosmetic appearance.ResultsFifty-three patients; 35 males and 18 females. Mean age was 54.9 (range 19-88). The mean follow up to January 2015 for all lesions was 21.4 months (range 8-48 months). The most common lesions were invasive malignant melanoma. There were no local surgical complications in 77.3% of patients; minimal scarring (11.3%), symblepharon (11.3%), and granuloma (7.5%). Five patients with conjunctival melanoma developed in-transit metastasis and orbital extension, none of it was at the site of the AMG.ConclusionOur case series is the largest reported to date, with the largest number of melanomas. The use of fresh frozen AMG has improved the local surgical outcomes by improving healing and reducing scarring as well as allowing for a wider surgical margin.

The transition from intra to extra-uterine life in late preterm infant: a single-center study

BACKGROUND

Infants born at 34 to 36 weeks of gestation (late preterm) are at greater risk for adverse outcomes than those born at 37 weeks of gestation or later. Aim of this paper is to examine risk factors for late preterm births and to investigate the complications of the transition period in late preterm infants (LPIs).

METHODS

All consecutive late preterm deliveries, excluded stillbirths, were included. Maternal and neonatal data, need for delivery room resuscitative procedures, temperature at birth (T1) and two hours after the admission (T2) were analyzed in all LPIs stratified by Gestational Age (GA) and divided into three groups (34, 35 and 36 weeks).

RESULTS

Two hundred seventy-six LPIs were analyzed. Pregnancy complications were present in 72 mothers (26.1 %), more frequently at 34 weeks of gestation respect to 35 and 36 weeks (p = 0.008, p = 0.006 respectively). Forty seven LPIs (17.1 %) needed for any resuscitation and 37 (13.4 %) were ventilated at birth. LPIs at 34 weeks were significantly more likely to receive ventilation respect to those at 35 and 36. At T1 the mean temperature resulted lower at 34 weeks respect to 36 weeks (p = 0.03). At T2 respect to T1, the rate of normothermic neonates increased at 35 and 36 weeks (p = 0.003, p = 0.005, respectively). Hypoglicemia rate was similar among the groups; 66.7 % of hypoglicemic neonates were hypothermic at T1. The rate of respiratory diseases and NICU admission decreased with increasing GA. Higher number of neonates ventilated at birth developed respiratory disorders respect to those unventilated (40.5 % vs 8.4 %; p < 0.001).

CONCLUSIONS

Transition period in LPIs may become critical, as resuscitation strategies can be required and heat loss can occur. LPIs, especially at 34 gestational weeks, are higher-risk group needing adequate and targeted management at birth.

The prognostic value of stromal and epithelial periostin expression in human breast cancer: correlation with clinical pathological features and mortality outcome

Background

PN is a secreted cell adhesion protein critical for carcinogenesis. In breast cancer, it is overexpressed compared to normal breast, and a few reports suggest that it has a potential role as a prognostic marker.

Methods

Tumour samples obtained at the time of mastectomy from 200 women followed for a median time of 18.7 years (range 0.5–29.5 years) were investigated through IHC with a polyclonal anti-PN antibody using tissue microarrays. Epithelial and stromal PN expression were scored independently according to the percentage of coloured cells; the 60^th percentile of PN epithelial expression, corresponding to 1 %, and the median value of PN stromal expression, corresponding to 90 %, were used as arbitrary cut-offs. The relationships between epithelial and stromal PN expression and clinical-pathological features, tumour phenotype and the risk of mortality following surgery were analysed. Appropriate statistics, including the Fine and Gray competing risk proportional hazard regression model, were used.

Results

The expression of PN in tumour epithelial cells was significantly lower than that which was observed in stromal cells (p < 0.000). No specific association between epithelial or stromal PN expression and any of the clinical-pathological parameters analysed was found as it was observed in respect to mortality when these variables were analysed individually. However, when both variables were considered as a function of the other one, the expression of PN in the stromal cells maintained a statistically significant predictive value with respect to both all causes and cancer-specific mortality only in the presence of high epithelial expression levels. No significant differences in either all causes or BCa-specific mortality rates were shown according to epithelial expression for tumours displaying higher stromal PN expression rates. However, the trends were opposite for the higher stromal values and the patients with high epithelial expression levels denoted the group with the worst prognosis, while higher epithelial values in patients with lower stromal expression levels denoted the group with the best prognosis, suggesting that PN epithelial/stromal interactions play a crucial role in breast carcinogenesis, most likely due to functional cross-talk between the two compartments. On the basis of PN expression in both compartments, we defined 4 subgroups of patients with different mortality rates with the group of patients characterized by positive epithelial and low stromal PN expression cells showing the lowest mortality risk as opposed to the groups of patients identified by a high PN expression in both cell compartments or those identified by a low or absent PN expression in both cell compartments showing the worst mortality rates. The differences were highly statistically significant and were also retained after multiparametric analysis. Competing risk analysis demonstrated that PN expression patterns characterizing each of previous groups are specifically associated with cancer-specific mortality.

Conclusions

Although they require further validation through larger studies, our findings suggest that the patterns of expression of PN in both compartments can allow for the development of IHC “signatures” that maintain a strong independent predictive value of both all causes and, namely, of cancer-specific mortality.

Uveal Melanoma UK National Guidelines

The United Kingdom (UK) uveal melanoma guideline development group used an evidence based systematic approach (Scottish Intercollegiate Guidelines Network (SIGN)) to make recommendations in key areas of uncertainty in the field including: the use and effectiveness of new technologies for prognostication, the appropriate pathway for the surveillance of patients following treatment for primary uveal melanoma, the use and effectiveness of new technologies in the treatment of hepatic recurrence and the use of systemic treatments. The guidelines were sent for international peer review and have been accredited by NICE. A summary of key recommendations is presented. The full documents are available on the Melanoma Focus website.

Outcomes of treatment with stereotactic radiosurgery or proton beam therapy for choroidal melanoma

AIM

To present our experience of the use of stereotactic radiosurgery and proton beam therapy to treat posterior uveal melanoma over a 10 year period.

METHODS AND MATERIALS

Case notes of patients treated with stereotactic radiosurgery (SRS), or Proton beam therapy (PBT) for posterior uveal melanoma were reviewed. Data collected included visual acuity at presentation and final review, local control rates, globe retention and complications. We analysed post-operative visual outcomes and if visual outcomes varied with proximity to the optic nerve or fovea.

RESULTS

191 patients were included in the study; 85 and 106 patients received Stereotactic radiosurgery and Proton beam therapy, respectively. Mean follow up period was 39 months in the SRS group and 34 months in the PBT group. Both treatments achieved excellent local control rates with eye retention in 98% of the SRS group and 95% in the PBT group. The stereotactic radiosurgery group showed a poorer visual prognosis with 65% losing more than 3 lines of Snellen acuity compared to 45% in the PBT group. 33% of the SRS group and 54% of proton beam patients had a visual acuity of 6/60 or better.

CONCLUSIONS

Stereotactic radiosurgery and proton beam therapy are effective treatments for larger choroidal melanomas or tumours unsuitable for plaque radiotherapy. Our results suggest that patients treated with proton beam therapy retain better vision post-operatively; however, possible confounding factors include age, tumour location and systemic co-morbidities. These factors as well as the patient's preference should be considered when deciding between these two therapies.

Is there any role for the hydroxychloroquine (HCQ) in refractory obstetrical antiphospholipid syndrome (APS) treatment?

The best therapy regimen for refractory obstetrical antiphospholipid syndrome remains to be determined. Additional treatments with steroids, plasma exchanges and immunoglobulins failed to show any beneficial effect. We present a case of a woman who had a better pregnancy outcome after the administration of hydroxychloroquine (HCQ) as additional treatment. Furthermore, we highlighted that HCQ was able to dramatically reduce the antiphospholipid antibodies levels.

Epidermal growth factor-like domain 7 promotes migration and invasion of human trophoblast cells through activation of MAPK, PI3K and NOTCH signaling pathways

Epidermal growth factor-like domain 7 (Egfl7) is a gene that encodes a partially secreted protein and whose expression is largely restricted to the endothelia. We recently reported that EGFL7 is also expressed by trophoblast cells in mouse and human placentas. Here, we investigated the molecular pathways that are regulated by EGFL7 in trophoblast cells. Stable EGFL7 overexpression in a Jeg3 human choriocarcinoma cell line resulted in significantly increased cell migration and invasiveness, while cell proliferation was unaffected. Analysis of mitogen-activated protein kinase (MAPK) and phosphatidylinositol 3-kinase (PI3K) pathways showed that EGFL7 promotes Jeg3 cell motility by activating both pathways. We show that EGFL7 activates the epidermal growth factor receptor (EGFR) in Jeg3 cells, resulting in downstream activation of extracellular regulated kinases (ERKs). In addition, we provide evidence that EGFL7-triggered migration of Jeg3 cells involves activation of NOTCH signaling. EGFL7 and NOTCH1 are co-expressed in Jeg3 cells, and blocking of NOTCH activation abrogates enhanced migration of Jeg3 cells overexpressing EGFL7. We also demonstrate that signaling through EGFR and NOTCH converged to mediate EGFL7 effects. Reduction of endogenous EGFL7 expression in Jeg3 cells significantly decreased cell migration. We further confirmed that EGFL7 stimulates cell migration by using primary human first trimester trophoblast (PTB) cells overexpressing EGFL7. In conclusion, our data suggest that in trophoblast cells, EGFL7 regulates cell migration and invasion by activating multiple signaling pathways. Our results provide a possible explanation for the correlation between reduced expression of EGFL7 and inadequate trophoblast invasion observed in placentopathies.

Cerebral sinovenous thrombosis in neonatal antiphospholipid syndrome: a new entity?

Neonatal antiphospholipid syndrome (neonatal APS) seems to be exceedingly rare, as the antiphospholipid antibodies (aPL) related thrombosis in the neonatal period. The pathogenesis of perinatal aPL related thrombosis may be explained both by the transplacental passage of the maternal antibodies and by the production of de novo antibodies by the neonate. However, few cases of neonatal APS are reported in the literature, especially regarding arterial thrombotic events. In particular, only two cases of neonatal aPL related isolated cerebral sinovenous thrombosis (CSVT) are described in the literature. Despite its frequency, CSVT results in significant mortality and morbidity, probably also due to the difficulty in early diagnosis and then in correct managing in the neonatal period. A diagnosis of neonatal APS should be considered in the evaluation of neonates with CSVT, as well as in any case of neonatal thrombosis, to correctly manage the affected neonates and counsel the mother for future pregnancies.

A prognostic model based on combining estrogen receptor expression and Ki-67 value after neoadjuvant chemotherapy predicts clinical outcome in locally advanced breast cancer: extension and analysis of a previously reported cohort of patients

BACKGROUND

Ki-67 expression has gained attention as a breast cancer prognostic factor, however its significance in the remaining malignant cells after neoadjuvant chemotherapy (NAC) has been rarely examined. This investigation, extension and analysis of a previously reported cohort of patients, evaluates the significance of Ki-67 and estrogen receptor (ER) expression after NAC in LABC (locally advanced breast cancer).

PATIENTS AND METHODS

clinical stage, tumor size, clinical and pathological lymph node involvement, Ki-67, ER, progesterone receptor (PgR), HER2 expression, grading and clinical response were evaluated before and after NAC in 110 patients with LABC. Ki-67 expression was assessed both in pre and post-therapy histological samples, using >15% positive cells as cut-off value to distinguish high from low Ki-67 expressing tumors.

RESULTS

six patients (5.45%) attained pCR after NAC. A significant relationship between elevated post-CT Ki-67 and ER expression was showed at Cox multivariate analysis of disease free survival (DFS). On univariate analysis high post-chemotherapy Ki-67 and ER status were associated with worse survival; at multivariate model included these results were confirmed. Based on these two parameters, a prognostic model identified two different groups: low risk (low postchemotherapy Ki-67 and ER positive, or either high post-chemotherapy Ki-67 or ER negative), and high risk (high post-chemotherapy Ki-67 and ER negative). The low risk group showed a good prognosis (median OS still not reached), while the high risk group had a worse OS (median 41 months).

CONCLUSIONS

Ki-67 value after NAC and ER status could predict a worse prognosis among LABC patients treated with NAC.

Environmental radioactivity analyses in Italy following the Fukushima Dai-ichi nuclear accident

Following the Fukushima power plants accident on the 11th March 2011, the radioactivity monitoring programme at the Italian ENEA research centres was activated in order to detect the possible new input of radionuclides through atmospheric transport and precipitation. Measurements of (131)I and (134,137)Cs were carried out on atmospheric particulate, atmospheric deposition, seawater and mussels and sheep milk. In the daily samples of air particulate, (131)I was detectable between March 28 and April 12, with extremely low concentrations (<1 mBq m(-3); the detection limit for (131)I was ~0.2 mBq m(-3)) while Cs isotopes were always below the detection limit (<0.2 mBq m(-3)). The two main episodes of (131)I atmospheric deposition were registered in La Spezia research centre, around March 28 and April 15, reaching values of 17.8 ± 1.1 and 8.0 ± 2.5 Bq m(-2) respectively; maximum values of (134)Cs and (137)Cs were 0.11 ± 0.03 and 0.17 ± 0.02 Bq m(-2), respectively, detected in Brasimone research centre in April (reference date April 15). Mussels and seawater were collected in the Gulf of La Spezia: only mussels after the main (131)I deposition, on March 28, contained a measurable, although very small, amount of (131)I (0.18 ± 0.05 Bq kg(-1), detection limit (131)I = 0.03 Bq kg(-1) wet weight - soft parts). The (131)I was also detected in sheep milk in Rome (Casaccia research centre) until May 5, showing a maximum concentration of 4.9 ± 0.4 Bq L(-1). As for other European Countries for which data are available, activity levels remain of no concern for public health.

The relationship between TORCH complex false positivity and obstetric outcome in patients with antiphospholipid syndrome

OBJECTIVE

The presence of TORCH IgM positivity is not a specific indicator of primary infection; the assessment of IgG avidity index has been shown to be useful in identifying or excluding primary infection in pregnant women with no pre-gestational TORCH serology. TORCH is an acronym for Toxoplasmosis, Others (HBV, syphilis, Varicella-Zoster virus, Epstein Barr virus, Coxsackie virus and Parvovirus), Rubella, Cytomegalovirus (CMV) and Herpes Simplex.

PATIENTS AND METHODS

Data from 54 pregnancies in women with antiphospholipid syndrome (APS) were assessed in comparison with data from 222 healthy pregnant women as controls. Each woman in both groups was systematically screened for TORCH IgG and IgM during pre-conceptional evaluation and/or at the beginning of pregnancy. The assessment of IgG avidity was also evaluated in order to identify primary infection or false positivity.

RESULTS

A significant increase of CMV IgM false positivity in APS in comparison with controls was detected. A worse pregnancy outcome was observed among APS patients having CMV IgM false positivity in comparison with APS patients without false positivity; in particular a statistically significant lower neonatal birth weight and a lower neonatal birth weight percentile were observed.

CONCLUSION

Our data suggest that the presence of CMV IgM false positivity could represent a novel prognostic factor for poor pregnancy outcome in APS patients.

PP158. Hypertensive disorders in pregnant women affected by type I diabetes

INTRODUCTION

Type I diabetes in pregnancy is associated with an increased incidence of hypertensive disorders.

OBJECTIVES

The aim of the present study was to evaluate the incidence of hypertensive disorders in pregnant women affected by type I diabetes and pregnancy outcome in women with and without hypertension.

METHODS

One hundred seventy two pregnancies in 150 women affected by type I diabetes were assessed. Twelve pregnancies were excluded (8 because of spontaneous abortions, 1 for voluntary abortion and 3 twin pregnancies), and 160 pregnancies were considered for the study.

RESULTS

Twenty-five pregnancies (15.6%) were complicated by hypertensive disorders: 4.4% by chronic hypertension (CH), 5% by gestational hypertension (GH), 4.4% by preeclampsia (PE) and 1.8% by preeclampsia superimposed on chronic hypertension (PE+CH); 32% of the women presented a vascular disease (renal or retinal disease). The diabetic women with hypertensive complications were compared with diabetic women without hypertension. The main results are shown in Table 1. Significant differences in mean birth weight and mean gestational age were found. The group affected by preeclampsia showed 14.7% of small for gestational age (SGA) neonates (birth weight percentile less than 10th pc), and 57.1% of large for gestational age (LGA) neonates (birth weight percentile greater than 90th pc), two of them were over 4000 g. Only one case of very preterm delivery (<32 weeks) was observed in the sample.

CONCLUSION

As expected, the incidence of hypertensive disorders in population affected by type 1 diabetes is higher than in general population and a poor pregnancy outcome was observed in this group of women. However, the neonatal outcome of women affected by preeclampsia is not different from that observed in women without hypertensive complications (diabetic controls) in terms of mean birth weight despite a significantly lower mean week gestation at delivery.

PP029. Gestational hypertension and birth weight in twin pregnancies

INTRODUCTION

It is well known that hypertensive disorders of pregnancy are most frequent in twin pregnancies than in singleton ones. As demonstrated by a previous work of our group, twin pregnancies complicated by preeclampsia are associated with a higher rate of "small for gestational age" (SGA) neonates and inter-twin weight discordance than normotensive ones.

OBJECTIVES

The present study investigates the effect of gestational hypertension (GH) on neonatal birth weight, inter-twin weight discordance and growth restriction rate among twin pregnancies.

METHODS

A 26 year retrospective study was undertaken by examining 196 twin pregnancies complicated by GH, from January 1, 1980 to December 31, 2006, and comparing them to 912 normotensive twin pregnancies.

RESULTS

No significant differences were observed between the two groups in relationship to birth weight, inter-twin weight discordance and growth restriction rate, with a trend towards a higher birth weight in GH group. In normotensive group, the discordance >25% was associated with a lower gestational age at the delivery (p<0.00001). Moreover, the rate of pregnancies with SGA second twin gradually rose while paralleling the degree of discordance.

CONCLUSION

Contrary to preeclampsia in twin pregnancies the outcome of those complicated by GH is similar to normotensive ones. The trend towards a higher birth weight in GH seems apparently paradoxical, but it may reflect the role of uncomplicated hypertension in twin pregnancies: the increased blood pressure could be a physiologic response for more blood nutrient supply to the fetuses.

Innovative self management system for guided cardiac rehabilitation

This paper describes the design and development of a system for cardio rehabilitation of patients that suffered a myocardial infarction. The proposed solution focuses on exercise prescriptions and the encouragement of healthy behaviors. The innovative strategy of the design takes into account health promotion models to provide safe, assistive exercise training sessions, personalized feedbacks, and educational contents.