Autofluorescence-guided hemithyroidectomy in a low-volume thyroid institution with no experience in parathyroid surgery: randomized clinical trial

BACKGROUND

Recent studies suggest that low-volume surgeons with no experience in parathyroid surgery are at increased risk of causing parathyroid gland damage during thyroid surgery. The aim of this RCT was to evaluate the impact of using autofluorescence in hemithyroidectomy on parathyroid gland identification and preservation in a low-volume institution with no experience in parathyroid surgery.

METHODS

Patients referred for hemithyroidectomy were randomized 1 : 1 to either autofluorescence-guided hemithyroidectomy (the near-infrared autofluorescence group) or conventional hemithyroidectomy (the control group). The primary outcome was parathyroid gland identification rate. Secondary outcomes were the rate of parathyroid gland autotransplantation and the rate of inadvertent parathyroid gland excision.

RESULTS

A total of 170 patients were randomized to either autofluorescence-guided hemithyroidectomy (84 patients) or conventional hemithyroidectomy (86 patients). In the near-infrared autofluorescence group, 81.0% of parathyroid glands were identified, compared with 57.0% in the control group (P < 0.001). Autofluorescence enabled parathyroid gland visualization before the naked eye in 46.3% of cases. Surgeons had lower confidence in the parathyroid gland identification process in the control group than in the near-infrared autofluorescence group (59.1% versus 87.5% respectively; P < 0.001). In the near-infrared autofluorescence group, the parathyroid gland autotransplantation rate was initially high, but declined over time. There was no difference in the rate of inadvertent parathyroid gland excision.

CONCLUSION

Autofluorescence guidance significantly improved the parathyroid gland identification rate in hemithyroidectomy in a low-volume institution with no experience in parathyroid surgery and provided an increase in surgical confidence. The pattern of parathyroid gland autotransplantation in autofluorescence-guided surgery indicates the presence of a learning curve.

REGISTRATION NUMBER

NCT05044351 (http://www.clinicaltrials.gov).

Aneuploidy is frequent in heterozygous diploid and triploid hydatidiform moles

Hydatidiform moles are abnormal conceptuses. Many hydatidiform moles are diploid androgenetic, and of these, most are homozygous in all loci. Additionally, most hydatidiform moles are euploid. Using Single Nucleotide Polymorphism (SNP) array analysis, in two studies a higher frequency of aneuploidy was observed in diploid androgenetic heterozygous conceptuses, than in their homozygous counterparts. In the Danish Mole Project, we analyze conceptuses suspected to be hydatidiform moles due to the clinical presentation, using karyotyping and Short Tandem Repeat (STR) analysis. Among 278 diploid androgenetic conceptuses, 226 were homozygous in all loci and 52 (18.7%) were heterozygous in several loci. Among 142 triploid diandric conceptuses, 141 were heterozygous for paternally inherited alleles in several loci. Here we show that the frequencies of aneuploidy in diploid androgenetic heterozygous and triploid diandric heterozygous conceptuses were significantly higher than the frequency of aneuploidy in diploid androgenetic homozygous conceptuses. In diploid androgenetic and triploid diandric conceptuses that are heterozygous for paternally inherited alleles, the two paternally inherited sets of genomes originate in two spermatozoa. Each spermatozoon provides one pair of centrioles to the zygote. The presence of two pairs of centrioles may cause an increased risk of aneuploidy.

"We're the very bottom, so it's going to be hard for you to 'catch any fish' around here…" understanding vulnerable Greenlanders' perspectives on cancer and barriers to screening in Denmark- A qualitative study

BACKGROUND

Cancer is a major global health concern. Unfortunately, Indigenous populations such as Greenlanders living in Denmark, face significant disparities in cancer risk, incidence, diagnosis, care quality, and outcomes. In Denmark, vulnerable Greenlanders face challenges accessing cancer screening. The aim of this study was to explore their perceptions of cancer, barriers to participation in cancer screening, and potential for developing a tailored intervention.

METHODS

This qualitative study was based on participant observations and qualitative interviews. The sample comprised 46 participants from four distinct drop-in centres. Of these, 28 were vulnerable Greenlanders (19 women and 9 men), 9 were staff members (6 women and 3 men), and 6 were relatives (4 women and 2 men). The data were analysed through inductive content analysis.

RESULTS

Vulnerable Greenlanders in Denmark believed they were responsible for their own health and were generally satisfied with the healthcare system. However, they found it challenging to manage their own health and many depended on support from others. Fear of cancer and death shaped their attitudes towards screening.

CONCLUSION

For vulnerable Greenlanders in Denmark participation in cancer screening programmes was positively viewed for most but could be challenging. Different intervention ideas raised by the vulnerable Greenlanders, relatives and staff members could guide the development of strategies to increase participation rates.

Revisiting the association between treatment with antidepressants and mania: A nationwide within-individual study of 3554 patients with bipolar disorder

INTRODUCTION

Antidepressants are commonly used "off-label" for bipolar depression, despite concerns over the risk of potential treatment-emergent mania (or "manic switch"). Treatment-emergent mania is difficult to study with adequate power in clinical trials as it requires a large group of participants and long follow-up. Therefore, naturalistic register-based studies have been applied to assess this phenomenon. Here, we aimed to replicate previous findings and address key methodological limitations that were not previously taken into account.

METHODS

We utilized data from nationwide Danish health registries to identify patients with bipolar disorder treated with an antidepressant, either with or without concomitant treatment with a mood stabilizer (drug treatment proxied via redeemed prescriptions). We plotted the incidence of manic and depressive episodes relative to the initiation of antidepressant treatment and compared the incidence of mania in the period prior to and following initiation of antidepressant treatment (within-individual design).

RESULTS

In 3554 patients with bipolar disorder initiating treatment with an antidepressant, the number of manic episodes peaked approximately 3 months prior to initiation of antidepressant treatment, and the number of depressive episodes peaked around the initiation of antidepressant prescription. This temporal pattern suggests that antidepressants were used to treat post-manic depression.

CONCLUSION

Within-individual designs do not control sufficiently for confounding by indication, when the treatment indication is time-varying. Thus, results from prior within-individual studies of antidepressant treatment in the context of bipolar disorder may be invalid due to time-varying confounding by indication.

Circulating DNA and frequency of colorectal cancer brain metastases in a presumed high-risk group

This explorative prospective observational pilot study investigated if suggested risk factors, rectal cancer and lung metastases, could add to a relevant detection rate of asymptomatic brain metastases (BM) from colorectal cancer (CRC). Secondary, prognostic biological aspects were investigated by translational analysis of plasma samples. The study enrolled patients with rectal cancer and lung metastases. At inclusion, patients underwent a standard MRI scan of the brain. Cell-free DNA (cfDNA) level was measured by a direct fluorescence assay (DFA), and circulating tumor DNA (ctDNA) by ddPCR. BM was detected in one of twenty-nine included patients. Patients had higher cfDNA levels than healthy subjects (p < 0.01). Patients with the primary tumor in situ had higher cfDNA levels than those with resected primary tumor (p < 0.01). Patients with liver involvement had higher cfDNA levels (p = 0.12) and circulating tumor DNA levels (p = 0.01) than those without liver involvement. In conclusion, the modest incidence of BM does not justify routine MRI of the brain in this selected population. cfDNA by DFA could be a valuable tool when planning treatment and follow-up for CRC patients. Future studies should focus on identifying further characteristics and biomarkers associated with a high risk of BM, enhancing the possibility for early intervention.

Accelerated -Rule-Out of acute Myocardial Infarction using prehospital copeptin and in-hospital troponin: The AROMI study

AIMS

The present acute myocardial infarction (AMI) rule-out strategies are challenged by the late temporal release of cardiac troponin. Copeptin is a non-specific biomarker of endogenous stress and rises early in AMI, covering the early period where troponin is still normal. An accelerated dual-marker rule-out strategy combining prehospital copeptin and in-hospital high-sensitivity troponin T could reduce length of hospital stay and thus the burden on the health care systems worldwide. The AROMI trial aimed to evaluate if the accelerated dual-marker rule-out strategy could safely reduce length of stay in patients discharged after early rule-out of AMI.

METHODS AND RESULTS

Patients with suspected AMI transported to hospital by ambulance were randomized 1:1 to either accelerated rule-out using copeptin measured in a prehospital blood sample and high-sensitivity troponin T measured at arrival to hospital or to standard rule-out using a 0 h/3 h rule-out strategy. The AROMI study included 4351 patients with suspected AMI. The accelerated dual-marker rule-out strategy reduced mean length of stay by 0.9 h (95% confidence interval 0.7-1.1 h) in patients discharged after rule-out of AMI and was non-inferior regarding 30-day major adverse cardiac events when compared to standard rule-out (absolute risk difference -0.4%, 95% confidence interval -2.5 to 1.7; P-value for non-inferiority = 0.013).

CONCLUSION

Accelerated dual marker rule-out of AMI, using a combination of prehospital copeptin and first in-hospital high-sensitivity troponin T, reduces length of hospital stay without increasing the rate of 30-day major adverse cardiac events as compared to using a 0 h/3 h rule-out strategy.

Dual intron-targeted CRISPR-Cas9-mediated disruption of the AML RUNX1-RUNX1T1 fusion gene effectively inhibits proliferation and decreases tumor volume in vitro and in vivo

Oncogenic fusion drivers are common in hematological cancers and are thus relevant targets of future CRISPR-Cas9-based treatment strategies. However, breakpoint-location variation in patients pose a challenge to traditional breakpoint-targeting CRISPR-Cas9-mediated disruption strategies. Here we present a new dual intron-targeting CRISPR-Cas9 treatment strategy, for targeting t(8;21) found in 5-10% of de novo acute myeloid leukemia (AML), which efficiently disrupts fusion genes without prior identification of breakpoint location. We show in vitro growth rate and proliferation reduction by 69 and 94% in AML t(8;21) Kasumi-1 cells, following dual intron-targeted disruption of RUNX1-RUNX1T1 compared to a non t(8;21) AML control. Furthermore, mice injected with RUNX1-RUNX1T1-disrupted Kasumi-1 cells had in vivo tumor growth reduction by 69 and 91% compared to controls. Demonstrating the feasibility of RUNX1-RUNX1T1 disruption, these findings were substantiated in isolated primary cells from a patient diagnosed with AML t(8;21). In conclusion, we demonstrate proof-of-principle of a dual intron-targeting CRISPR-Cas9 treatment strategy in AML t(8;21) without need for precise knowledge of the breakpoint location.

Targeted left ventricular lead positioning to the site of latest activation in cardiac resynchronization therapy: a systematic review and meta-analysis

AIMS

Several studies have evaluated the use of electrically- or imaging-guided left ventricular (LV) lead placement in cardiac resynchronization therapy (CRT) recipients. We aimed to assess evidence for a guided strategy that targets LV lead position to the site of latest LV activation.

METHODS AND RESULTS

A systematic review and meta-analysis was performed for randomized controlled trials (RCTs) until March 2023 that evaluated electrically- or imaging-guided LV lead positioning on clinical and echocardiographic outcomes. The primary endpoint was a composite of all-cause mortality and heart failure hospitalization, and secondary endpoints were quality of life, 6-min walk test (6MWT), QRS duration, LV end-systolic volume, and LV ejection fraction. We included eight RCTs that comprised 1323 patients. Six RCTs compared guided strategy (n = 638) to routine (n = 468), and two RCTs compared different guiding strategies head-to-head: electrically- (n = 111) vs. imaging-guided (n = 106). Compared to routine, a guided strategy did not significantly reduce the risk of the primary endpoint after 12-24 (RR 0.83, 95% CI 0.52-1.33) months. A guided strategy was associated with slight improvement in 6MWT distance after 6 months of follow-up of absolute 18 (95% CI 6-30) m between groups, but not in remaining secondary endpoints. None of the secondary endpoints differed between the guided strategies.

CONCLUSION

In this study, a CRT implantation strategy that targets the latest LV activation did not improve survival or reduce heart failure hospitalizations.

Long-term effects of asparaginase-associated pancreatitis

Pancreatitis is a common and severe toxicity that occurs during asparaginase treatment for acute lymphoblastic leukemia, and has received increasing attention during the last decades. However, no consensus regarding follow-up exists. In this commentary, we highlight potential long-term health-related effects following asparaginase-associated pancreatitis, thereby providing clinicians with a framework when following these patients during and after cessation of therapy.

Healthcare providers' perceptions and expectations of video-assisted debriefing of real-life obstetrical emergencies: a qualitative study from Denmark

OBJECTIVES

Video-assisted debriefing (VAD) of real-life obstetrical emergencies provides an opportunity to improve quality of care, but is rarely used in clinical practice. A barrier for implementation is the expected mental reservations among healthcare providers. The aim of this study was to explore healthcare providers' perceptions and expectations of VAD of real-life events.

SETTING

Participants were recruited from two Labour and Delivery Units in Denmark. In both units, VAD of real-life obstetrical emergencies had never been conducted.

PARTICIPANTS

22 healthcare providers (10 physicians, 9 midwives and 3 nursing assistants). During the study period (August-October 2021), semi-structured, individual interviews were conducted. Interviews were analysed using thematic analysis.

PRIMARY AND SECONDARY OUTCOME MEASURES

A qualitative description of healthcare providers' perceptions and expectations of VAD of real-life events.

RESULTS

Three major themes were identified: (1) Video-assisted debriefing (VAD) as an opportunity for learning: All participants expected VAD to provide an opportunity for learning and improving patient care. All participants expected the video to provide a 'bigger picture', by showing 'what was actually done' instead of 'what we believed was done'. (2) Video-assisted debriefing (VAD) as a cause for concern: The primary concern for all participants was the risk of being exposed as less competent. Participants were concerned that being confronted with every minor detail of their clinical practice would enhance their self-criticalness. (3) Preconditions for video-assisted debriefing (VAD): Participants emphasised the importance of organisational support from management. In addition, creating a safe environment for VAD, for example, by using only expert debriefers was considered an essential precondition for successful implementation.

CONCLUSIONS

The risk of being exposed as less competent was a barrier towards VAD of real-life events. However, the majority found the educational benefits to outweigh the risk of being exposed.

Training of radiology specialists in local staging of primary rectal cancer on MRI: a prospective intervention study exploring the impact of various educational elements on the interpretive performance

Background

MRI interpretation and accurate radiological staging are crucial to the important treatment decisions and a consequent successful patient outcome in rectal cancer.

Aims

To investigate the effect of intensive training on rectal cancer MRI staging performance of radiologists and the impact of different course elements on learning outcomes.

Methods

In this prospective intervention study, 17 radiology specialists and 1 radiology registrar participated in a training programme including a 6-hour imaging workshop, a 3-hour session of individual feedback and independent MRI readings of primary rectal cancer cases. Their rectal MRI interpretive performance was evaluated through repeated readings of 30 training cases before and after each course element and a time interval with no educational intervention. A proforma template for MRI staging of primary rectal cancer was used and the results were compared with a reference standard of an expert panel. Participants repeatedly reported on confidence scores and self-assessed learning outcome. Outcomes were analysed using mixed-effects models.

Results

At baseline the quality of rectal MRI assessment varied significantly, with a higher interpretive performance among participants with shorter radiological experience (10.2 years vs 19.9 years, p=0.02). The ability to perform correct treatment allocation improved from 72% to 82% (adjusted OR=2.36, 95% CI 1.64 to 3.39). The improvement was largely driven by the participants with lower performance at baseline and by prevention of overstaging. Individual feedback had a significant impact on the improved interpretive performance (adjusted OR=1.82, 95% CI 1.27 to 2.63), whereas no significant change was seen after workshop or case readings only. Confidence scores increased significantly during training.

Conclusions

Targeted and individualised training improves the rectal cancer MRI interpretive performance essential to successful patient treatment, especially among radiology specialists with lower performance at baseline.