1301 Early MRI in the Diagnosis of Suspected Scaphoid Fractures – An Audit of a Redesigned Diagnostic Pathway

Introduction

MRI is the gold standard for investigation of suspected scaphoid fractures, which can be missed on initial x-rays. This full cycle audit reports the impact of our new patient pathway, which changes repeat x-rays at 2 weeks to urgent limited sequence scaphoid MRI for those with normal initial x-rays, but clinical suspicion of fracture at initial clinic visit.

Method

A second cycle audited MRI requests for suspected scaphoid fractures at Southmead hospital following implementation of the new pathway in October 2020. We collected wait times from request to scan, and radiologist reports. Results were compared to our first cycle, 6-month time period.

Results

he results for 24 limited sequence MRIs via our new pathway were compared to 134 full wrist MRIs of the first cycle. Two scans (9.1%) were positive for scaphoid fracture versus 12% in the first cycle. 19 scans (86%) identified alternate pathology including sprain (6), bone bruise (5), non-scaphoid fractures (4) and degenerative change (3). 1 scan (4.5%) was reported as normal. 73% of MRIs were performed within 14 days, compared to 63% in previous cohort.

Conclusions

Our new pathway using limited sequence MRI identified similar rates of scaphoid fractures. Reduced time to MRI was observed compared to the previous cohort due to shorter scan durations and resulted in earlier diagnosis and fewer outpatient follow-up appointments. Our new pathway has benefits to patient experience and also reduces footfall in hospital, during a time of global Covid-19 pandemic, with no increase in costs.

Three-vessel view debridement of the open tibial fracture: a surgical technique

Adequate debridement of an open fracture is a key component of successful management. Despite having set debridement principles, there is no structured technique available in the literature to guide the surgeon in achieving this. We therefore present a technical note detailing the structured approach to the debridement of any open tibial fracture. Our unit has developed a novel stepwise technique termed locally as the "three-vessel view". Identifying all three primary vessels of the leg facilitates confirmation of inspection of all lower limb compartments thus minimising the risk of missed devitalised tissue or neglected areas of contamination and the potential for consequent disastrous outcomes as a result of inadequate exposure.

Effective rescue treatment with vemurafenib of an infant with high-risk Langerhans cell histiocytosis

INTRODUCTION

The recently identified role of a BRAF somatic mutation in the pathophysiology of Langerhans cell histiocytosis (LCH) offers new therapeutic options. Herein we describe the case of a 10-month-old infant with refractory high-risk LCH successfully treated with vemurafenib.

OBSERVATION

The patient first presented with cutaneous LCH at the age of 2 months. The disease remained undiagnosed until she was 6 months old, when it rapidly evolved to a multisystemic high-risk and life-threatening disease, refractory to 2 lines of chemotherapy. BRAFV600E mutation was found at skin biopsy, and targeted therapy with vemurafenib was started when she was 10 months old. The treatment induced a fast and sustained response, but rapid relapse occurred after treatment discontinuation, leading to resumption of treatment, once more resulting in a sustained response.

CONCLUSION

Our case highlights the first-line role of dermatologists in establishing the diagnosis of LCH, especially in children, in whom the eruption may be difficult to identify, leading to delayed diagnosis. Targeted therapy with vemurafenib has recently been described in children in this indication and our results support its efficacy, highlighting the need for prolonged treatment and raising the question of maintenance therapy, as well as the necessity for large-scale and long-term studies.

Quantifying the effects of a low-ozone event and shallow stratocumulus clouds on ultraviolet erythemal radiation exposure

Meteorological and dosimetric ultraviolet (UV) erythemal radiation (UVER) measurements were performed in Didcot, England, on 6 and 7 April 2017. Both days were characterized by clear-sky conditions in the morning and the afternoon with development of shallow stratocumulus clouds (SSC) around noon. In addition, a low-ozone event occurred on 7 April characterized by a 34 DU (Dobson Unit) drop in total stratospheric ozone content. Compared to 6 April, the ozone mini-hole caused UVER increases of 2.67 standard erythema dose (SED) for diffuse and 4.32 SED for global radiation characterized by radiation amplification factors (RAF) of 1.62 and 1.52, respectively. The total global UVER dose reductions due to SSC coverage amount to 2.33 SED (6 April) and 2.81 SED (7 April). As innovation the RAF is decomposed into two parts, named cloud ozone factor (COF) and radiation amplification factor based on measured data (RAF_m), to quantify the low-ozone event's effect and the SSC influence in independently modifying the UVER doses. Hereby, the weight of each of these two effects acting during the same low-ozone event is expressed by the new COF. In this case, the COF values range between -0.13 and -0.11 for diffuse UVER and -0.03 to -0.07 for the global UV and UV-B parts. A positive COF value (0.18) results for the global UV-A range.

Enhancer hijacking activates oncogenic transcription factor NR4A3 in acinic cell carcinomas of the salivary glands

The molecular pathogenesis of salivary gland acinic cell carcinoma (AciCC) is poorly understood. The secretory Ca-binding phosphoprotein (SCPP) gene cluster at 4q13 encodes structurally related phosphoproteins of which some are specifically expressed at high levels in the salivary glands and constitute major components of saliva. Here we report on recurrent rearrangements [t(4;9)(q13;q31)] in AciCC that translocate active enhancer regions from the SCPP gene cluster to the region upstream of Nuclear Receptor Subfamily 4 Group A Member 3 (NR4A3) at 9q31. We show that NR4A3 is specifically upregulated in AciCCs, and that active chromatin regions and gene expression signatures in AciCCs are highly correlated with the NR4A3 transcription factor binding motif. Overexpression of NR4A3 in mouse salivary gland cells increases expression of known NR4A3 target genes and has a stimulatory functional effect on cell proliferation. We conclude that NR4A3 is upregulated through enhancer hijacking and has important oncogenic functions in AciCC.

TGFβ1 regulates HGF-induced cell migration and hepatocyte growth factor receptor MET expression via C-ets-1 and miR-128-3p in basal-like breast cancer

Breast cancer is the most common cancer in women worldwide. The tumor microenvironment contributes to tumor progression by inducing cell dissemination from the primary tumor and metastasis. TGFβ signaling is involved in breast cancer progression and is specifically elevated during metastatic transformation in aggressive breast cancer. In this study, we performed genomewide correlation analysis of TGFBR2 expression in a panel of 51 breast cancer cell lines and identified that MET is coregulated with TGFBR2. This correlation was confirmed at the protein level in breast cancer cell lines and human tumor tissues. Flow cytometric analysis of luminal and basal‐like breast cancer cell lines and examination of 801 tumor specimens from a prospective cohort of breast cancer patients using reverse phase protein arrays revealed that expression of TGFBR2 and MET is increased in basal‐like breast cancer cell lines, as well as in triple‐negative breast cancer tumor tissues, compared to other subtypes. Using real‐time cell analysis technology, we demonstrated that TGFβ1 triggered hepatocyte growth factor (HGF)‐induced and MET‐dependent migration in vitro. Bioinformatic analysis predicted that TGFβ1 induces expression of C‐ets‐1 as a candidate transcription factor regulating MET expression. Indeed, TGFβ1‐induced expression of ETS1 and breast cancer cell migration was blocked by knockdown of ETS1. Further, we identified that MET is a direct target of miR‐128‐3p and that this miRNA is negatively regulated by TGFβ1. Overexpression of miR‐128‐3p reduced MET expression and abrogated HGF‐induced cell migration of invasive breast cancer cells. In conclusion, we have identified that TGFβ1 regulates HGF‐induced and MET‐mediated cell migration, through positive regulation of C‐ets‐1 and negative regulation of miR‐128‐3p expression in basal‐like breast cancer cell lines and in triple‐negative breast cancer tissue.

miRNA-1246 induces pro-inflammatory responses in mesenchymal stem/stromal cells by regulating PKA and PP2A

The tumor microenvironment (TME) has an impact on breast cancer progression by creating a pro-inflammatory milieu within the tumor. However, little is known about the roles of miRNAs in cells of the TME during this process. We identified six putative oncomiRs in a breast cancer dataset, all strongly correlating with poor overall patient survival. Out of the six candidates, miR-1246 was upregulated in aggressive breast cancer subtypes and expressed at highest levels in mesenchymal stem/stroma cells (MSCs). Functionally, miR-1246 led to a p65-dependent increase in transcription and release of pro-inflammatory mediators IL-6, CCL2 and CCL5 in MSCs, and increased NF-κB activity. The pro-inflammatory phenotype of miR-1246 in MSCs was independent of TNFα stimulations and mediated by direct targeting of the tumor-suppressors PRKAR1A and PPP2CB. In vitro recapitulation of the TME revealed increased Stat3 phosphorylation in breast epithelial (MCF10A) and cancer cells (SK-BR-3, MCF7, T47D) upon incubation with conditioned medium (CM) of MSCs overexpressing miR-1246. Additionally, this stimulation enhanced proliferation of MCF10A cells, increased migration of MDA-MB-231 cells and induced attraction of THP-1 monocytic cells. Our data shows that miR-1246 acts as both key-enhancer of pro-inflammatory responses in MSCs and putative oncomiR in breast cancer, suggesting its influence on cancer-related inflammation and breast cancer progression.

MicroRNA-519a-3p mediates apoptosis resistance in breast cancer cells and their escape from recognition by natural killer cells

Aggressive breast cancer is associated with poor patient outcome and characterized by the development of tumor cell variants that are able to escape from control of the immune system or are resistant to targeted therapies. The complex molecular mechanisms leading to immune escape and therapy resistance are incompletely understood. We have previously shown that high miR-519a-3p levels are associated with poor survival in breast cancer. Here, we demonstrate that miR-519a-3p confers resistance to apoptosis induced by TRAIL, FasL and granzyme B/perforin by interfering with apoptosis signaling in breast cancer cells. MiR-519a-3p diminished the expression of its direct target genes for TRAIL-R2 (TNFRSF10B) and for caspase-8 (CASP8) and its indirect target gene for caspase-7 (CASP7), resulting in reduced sensitivity and tumor cell apoptosis in response to apoptotic stimuli. Furthermore, miR-519a-3p impaired tumor cell killing by natural killer (NK) cells via downregulation of the NKG2D ligands ULBP2 and MICA on the surface of tumor cells that are crucial for the recognition of these tumor cells by NK cells. We determined that miR-519a-3p was overexpressed in more aggressive mutant TP53 breast cancer that was associated with poor survival. Furthermore, low levels of TRAIL-R2, caspase-7 and caspase-8 correlated with poor survival, suggesting that the inhibitory effect of miR-519a-3p on TRAIL-R2 and caspases may have direct clinical relevance in lowering patient’s prognosis. In conclusion, we demonstrate that miR-519a-3p is a critical factor in mediating resistance toward cancer cell apoptosis and impairing tumor cell recognition by NK cells. This joint regulation of apoptosis and immune cell recognition through miR-519a-3p supports the hypothesis that miRNAs are key regulators of cancer cell fate, facilitating cancer progression and evasion from immunosurveillance at multiple and interconnected levels.

Co-Inflammatory Roles of TGFβ1 in the Presence of TNFα Drive a Pro-inflammatory Fate in Mesenchymal Stem Cells

High plasticity is a hallmark of mesenchymal stem cells (MSCs), and as such, their differentiation and activities may be shaped by factors of their microenvironment. Bones, tumors, and cardiomyopathy are examples of niches and conditions that contain MSCs and are enriched with tumor necrosis factor α (TNFα) and transforming growth factor β1 (TGFβ1). These two cytokines are generally considered as having opposing roles in regulating immunity and inflammation (pro- and anti-inflammatory, respectively). Here, we performed global gene expression analysis of human bone marrow-derived MSCs and identified overlap in half of the transcriptional programs that were modified by TNFα and TGFβ1. The two cytokines elevated the mRNA expression of soluble factors, including mRNAs of pro-inflammatory mediators. Accordingly, the typical pro-inflammatory factor TNFα prominently induced the protein expression levels of the pro-inflammatory mediators CCL2, CXCL8 (IL-8), and cyclooxygenase-2 (Cox-2) in MSCs, through the NF-κB/p65 pathway. In parallel, TGFβ1 did not elevate CXCL8 protein levels and induced the protein expression of CCL2 at much lower levels than TNFα; yet, TGFβ1 readily induced Cox-2 and acted predominantly via the Smad3 pathway. Interestingly, combined stimulation of MSCs by TNFα + TGFβ1 led to a cooperative induction of all three inflammatory mediators, indicating that TGFβ1 functioned as a co-inflammatory cytokine in the presence of TNFα. The cooperative activities of TNFα + TGFβ1 that have led to CCL2 and CXCL8 induction were almost exclusively dependent on p65 activation and were not regulated by Smad3 or by the upstream regulator TGFβ-activated kinase 1 (TAK1). In contrast, the TNFα + TGFβ1-induced cooperative elevation in Cox-2 was mostly dependent on Smad3 (demonstrating cooperativity with activated NF-κB) and was partly regulated by TAK1. Studies with MSCs activated by TNFα + TGFβ1 revealed that they release factors that can affect other cells in their microenvironment and induce breast tumor cell elongation, migration, and scattering out of spheroid tumor masses. Thus, our findings demonstrate a TNFα + TGFβ1-driven pro-inflammatory fate in MSCs, identify specific molecular mechanisms involved, and propose that TNFα + TGFβ1-stimulated MSCs influence the tumor niche. These observations suggest key roles for the microenvironment in regulating MSC functions, which in turn may affect different health-related conditions.

Preparation and electrochemical behavior of gramicidin-bipolar lipid monolayer membranes supported on gold electrodes

Gramicidin-containing synthetic bolalipid membranes comprised of 2,2'-di-O-decyl-3,3'-O-1,20-eicosanyl-bis-rac-glycero-1,1'-diphosphocholine (C20BAS) have been synthesized and supported on gold electrodes. Supported membranes were prepared by first depositing a partial bolalipid layer on the electrode using a thioctic acid-modified bolalipid (1'-O-omega-thioctamidetetraethylene glycol-2,2'-di-O-decyl-3,3'-di-O-1,20-eicosanyl-bis-rac-glycero-1-phosphate, SSC20BAS) as an anchoring group, followed by a vesicle fusion step using either pure C20BAS or gramicidin-containing C20BAS (C20BAS-GA) vesicles. The latter configuration was designed to immobilize single, continuously-on channels of gramicidin in the C20BAS membrane. Vesicle deposition to form supported bolalipid monolayer membranes was monitored by impedance spectroscopy and cyclic voltammetry. Impedances were observed to increase with vesicle deposition time. Pretreatment of the impedance electrode with SSC20BAS accelerated the supported monolayer membrane deposition rate. Impedances decreased in a gramicidin concentration-dependent manner when gramicidin was incorporated into the C20BAS membrane. These supported bolalipid membranes are also surprisingly inert to organic solvent exposure (CH(3)CH(2)OH;CH(2)Cl(2)), suggesting that they may serve as robust host matrices for integral membrane protein-based sensors.

Routine analysis of 101 polychlorinated biphenyl congeners in human serum by parallel dual-column gas chromatography with electron capture detection

Polychlorinated biphenyl (PCB) exposure has been linked to a variety of toxic effects in animal experiments and in certain human case reports and epidemiologic studies. A total of 209 individual PCB congeners are possible, based on chlorination level and ring substitution pattern. Commercial PCBs are a complex mixture of congeners, and over 75 of these have been reported to be present in human tissues at widely varying levels. Because the biologic activity of individual PCBs is a function of extent and pattern of chlorine substitution, "congener-specific" PCB analysis of human tissue has gained increasing importance in assessing possible links between PCB exposure and toxic effects. A high-sensitivity analytical method using dual-column gas chromatography (GC) with electron capture detection (ECD) for determining 101 PCB congeners (83 individual, 18 as pairs/triplets) plus 1,1-dichloro-2,2-bis(p-chlorophenyl)ethylene (p,p'-DDE), hexachlorobenzene (HCB), and mirex, in human serum is described. Separation is performed concurrently on parallel-configured DB-5 and Apiezon-L capillary columns. The current method is a modification of previously reported dual-column GC-ECD systems with improvements to the extraction and analytical protocols and the implementation of a comprehensive QA/QC program. The method employs two surrogate standards (PCBs IUPAC 125 and 192) and internal standard (IUPAC 104)-based quantitation, in addition to per-batch check standards and method blanks. Although optimized for serum, the method is applicable to all human, experimental animal, and environmental biota samples. The accuracy, precision, and reliability of the method were assessed using a variety of QA/QC endpoints. Finally, the use of the method in determining level and prevalence of PCB congeners in a cohort of adult Native-American individuals with historical environmental PCB exposure is reported.

[Atropine poisoning. Importance of the clinical diagnosis]

A case of suspected high dose atropine poisoning is described. In a veterinarian good healthy young man the appearance of light coma with psychomotor agitation and the contemporary presence of evident symptoms of muscarinic peripheral block, suggesting an anticholinergic syndrome, an atropine-like intoxication in absence of toxicological analysis. The safely clinical course of the poisoning during observation in intensive care unit permitted the discharge of the patient without sequelae and without treatment with physostigmine as antidote.

[The nutritive effect of Bacillus cereus as a probiotic in the raising of piglets. 2. Effect and microbial count, composition and resistance determination of gastrointestinal and fecal microflora]

After a feeding trial of 42 days with 4 x 12 piglets 4 x 6 piglets were slaughtered and the influence of spores of the Bacillus cereus strain FH 1457 S added to the feed on the microorganism counts of Lactobacillus/Bifidobacterium, Eubacteria, Bacteroidaceae, E. coli, Enterococcus and passants (Bacillus cereus) in duodenum, jejunum, ileum, caecum and colon was investigated. Beside a negative control the feed was supplemented with 10(7), 10(8) and 10(9) CFU Bacillus cereus/kg. The feeding trial included two periods each of 21 days. In each period faeces was collected from all animals and the influence on the microorganism counts and also the frequency of resistance of the E. coli and Enterococcus germs against selected antibiotics and chemotherapeutics investigated. The addition of 10(8) CFU Bacillus cereus decreased E. coli counts in duodenum and jejunum, however increased them in ileum, caecum and colon. In the highest dosage the counts of Bacillus cereus in duodenum, caecum, colon and faeces were significantly higher. The addition of Bacillus cereus reduced the counts of E. coli and Enterococcus in faeces in the first period. In the second period the dosage 10(8) CFU showed significant increased counts of E. coli and the sums of microorganisms of the main and satellite flora. The additions had no influence on the frequency of resistance of E. coli and enterococci against the tested antibiotics and synthetic chemotherapeutics. From the addition of Bacillus cereus in this case a selection of factors influencing resistance is not to be expected.

External ATP antagonizes the effect of potassium channel openers in guinea-pig ventricular papillary muscle

Right ventricular papillary muscles of the guinea-pig heart were electrically stimulated. Cromakalim 10-100 microM and Ro 31-6930 3 microM depressed the contractile force and shortened the duration of action potentials. Glibenclamide 0.3-3 microM, ATP 100 microM and alpha, beta-methylene ATP (alpha, beta-meATP) 30 microM antagonized these effects. Suramin 300 microM failed to reverse the alpha, beta-meATP-evoked antagonism of the action of cromakalim. It is concluded that both intra- and extracellular ATP may interfere with potassium channel openers and that extracellular ATP does not act via the known P2-purinoceptor subtypes.

Dysmorphophobia: body dysmorphic disorder or delusional disorder, somatic subtype?

The DSM-III-R proposes to divide dysmorphophobia into two separate disorders: delusional disorder, somatic subtype and dysmorphic disorder. We believe that this distinction of delusional and nondelusional is impossible from a phenomenological point of view, and that dysmorphophobic beliefs are better classified as overvalued ideas. The concept of dysmorphophobia and its relationship to monosymptomatic hypochondriacal psychoses and DSM-III-R categories is reviewed. A case report is described to support these arguments.

Isolation of a mycotoxin (gliotoxin) from a bovine udder infected with Aspergillus fumigatus

A bovine udder infected with Aspergillus fumigatus was analysed by physico-chemical methods (thin layer chromatography, high performance liquid chromatography and direct exposure probe-mass spectrometry) for the presence of mycotoxins. Gliotoxin, a fungal metabolite with cytotoxic and immunosuppressive properties was isolated for the first time from naturally infected tissue. The gliotoxin concentration analysed (9.2 mg kg-1 udder) was approximately 100 times higher than the concentration known to produce morphological changes of cells. Gliotoxin may play an important role in the establishment and development of an infection with A fumigatus.

Influence of two non-steroidal anti-inflammatory drugs on lipolysis and on plasma post-heparin lipoprotein lipase activity in normal man

Indomethacin 50 mg i.v. or p.o. and diclofenac sodium 50 mg p.o. produced a prompt and significant increase in plasma free fatty acid concentration. In 10 subjects who took indomethacin 150 mg/d p.o. for 3 days, plasma post-heparin lipoprotein lipase activity was also significantly increased. The same effect occurred in 9 subjects treated for 3 days with diclofenac sodium 50 mg t.d.s. Since both indomethacin and diclofenac sodium are potent inhibitors of prostaglandin synthetase, these findings are consistent with the hypothesis tht prostaglandins are involved in the feed-back regulation of lipolysis, and mediate the inhibitory effect of lipolysis on lipoprotein lipase activity.