The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

Intracranial arachnoid cyst in pregnancy: case report, literature review and evaluation of neuraxial anaesthesia risk

Choosing the type of intrapartum anaesthesia for pregnant women with intracranial arachnoid cysts can be challenging due to a lack of research. We report the intrapartum anaesthetic management of a 25-year-old woman with a known 10 cm arachnoid cyst. By means of a literature review and discussion of safety surrounding neuraxial techniques, this report will help to inform obstetric anaesthesia practice. Overall, in the absence of raised intracranial pressure, neuraxial analgesia and anaesthesia during the intrapartum period appears to be a safe option.

Provision of smoking cessation support for patients following a diagnosis of cancer in Ireland

There is growing evidence that smoking cessation (SC) improves outcomes following diagnosis of cancer. Notwithstanding adverse outcomes, a significant number of those diagnosed with cancer continue to smoke. Our objective was to document the SC services provided for patients with cancer by specialist adult cancer hospitals across Ireland, a country with a stated tobacco endgame goal. A cross-sectional survey based on recent national clinical guidelines was used to determine SC care delivery across eight adult cancer specialist hospitals, and one specialist radiotherapy centre. Qualtrics was used. The response rate was 88.9% with data reported from seven cancer hospitals and one specialist radiotherapy centre, all indicating they had some SC related provision (100%). Stop smoking medications were provided to cancer inpatients in two hospitals, at outpatients and attending day ward services in one hospital. Smokers with cancer were referred automatically to the SC service in two hospitals at diagnosis. While stop smoking medications were available 24 h a day in five hospitals, most did not stock all three (Nicotine Replacement Therapy, Bupropion, Varenicline). One hospital advised they had data on uptake of SC services for smokers with cancer but were unable to provide detail. There is considerable variation in SC information and services provided to cancer patients across adult cancer specialist centres in Ireland, reflecting the suboptimal practice of smoking cessation for patients with cancer found in the limited international audits. Such audits are essential to demonstrate service gaps and provide a baseline for service improvement.

Outcomes of complex colorectal polyps managed by multi-disciplinary team strategies-a multi-centre observational study

PURPOSE

Team management strategies for complex colorectal polyps are recommended by professional guidelines. Multi-disciplinary meetings are used across the UK with limited information regarding their impact. The aim of this multi-centre observational study was to assess procedures and outcomes of patients managed using these approaches.

METHOD

This was a retrospective, observational study of patients managed by six UK sites. Information was collected regarding procedures and outcomes including length of stay, adverse events, readmissions and cancers.

RESULTS

Two thousand one hundred ninety-two complex polyps in 2109 patients were analysed with increasing referrals annually. Most presented symptomatically and the mean polyp size was 32.1 mm. Primary interventions included endoscopic therapy (75.6%), conservative management (8.3%), colonic resection (8.1%), trans-anal surgery (6.8%) or combined procedures (1.1%). The number of primary colonic resections decreased over the study period without a reciprocal increase in secondary procedures or recurrence. Secondary procedures were required in 7.8%. The median length of stay for endoscopic procedures was 0 days with 77.5% completed as day cases. Median length of stay was 5 days for colonic resections. Overall adverse event and 30-day readmission rates were 9.0% and 3.3% respectively. Malignancy was identified in 8.8%. Benign polyp recurrence occurred in 13.1% with a median follow up of 30.4 months. Screening detected lesions were more likely to undergo bowel resection. Colonic resection was associated with longer stays, higher adverse events and more cancers on final histology.

CONCLUSION

Multi-disciplinary team management of complex polyps is safe and effective. Standardisation of organisation and quality monitoring is needed to continue positive effects on outcomes and services.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.

Smoking cessation for cancer patients through the lens of cancer specialists: challenges & solutions

Background

The benefits of smoking cessation (SC) for cancer patients are widely recognised. However, there has been a limited emphasis on SC in this context and it continues to be a challenge for cancer patients. As part of a larger feasibility study aiming to develop a structured SC pathway for cancer patients in Ireland, this qualitative study explored the SC practices, experiences and opinions of oncology healthcare professionals (HCPs).

Methods

Semi-structured interviews were conducted with 18 HCPs from lung, breast, cervical, head and neck and general oncology, across 4 specialist adult cancer hospitals in Ireland. Interview transcripts were analysed using thematic analysis.

Results

Four key themes emerged:

(1) Frequently ask and advise but infrequently assist: most HCPs ask about smoking and many advise about available supports, but few refer patients to SC services. Where offered, referrals were to hospital SC services and/or nicotine replacement therapy was prescribed; no HCP prescribed varenicline or bupropion. Barriers included lack of time, ill-defined referral pathways and lack of knowledge.

(2) Increased willingness but differing ability to quit: most patients were interested in quitting post diagnosis and had varying support needs, linked to cancer stage, social circumstances and stress levels.

(3) Need for an integrated or parallel service: all HCPs suggested that a structured and defined referral pathway will facilitate SC.

(4) Motivational counselling and pharmacotherapy combination: many HCPs suggested face to face as the best mode of intervention initially, with regular follow ups and ongoing support virtually, started pre-treatment, with an empathetic and empowering approach with provision of both motivational counselling and SC pharmacotherapy.

Conclusions

Smoking post cancer diagnosis has serious implications for cancer treatment and prognosis but is frequently overlooked. These findings will inform the design of a SC pathway for cancer patients.

Key messages

• Despite increased willingness to quit, there is inadequate and inconsistent SC support provision for cancer patients.

• Tailored SC support should be an integral part of comprehensive cancer care.

'Pretty in Pink' and 'Girl Power': An analysis of the targeting and representation of women in alcohol brand marketing on Facebook and Instagram

BACKGROUND

Alcohol marketing helps shape how gender roles and relations are understood, and the gendered nature of drinking learned. In recent years, changes in how women are presented and addressed in marketing, including alcohol marketing, have been observed. This reflects the shifting social, political and regulatory context, in which increased attention has been given to gender inequality and the damaging impact of gender stereotypes. Research is yet to explore the gendered nature of alcohol marketing within this contemporary context.

METHODS

A quantitative content and qualitative thematic analysis of alcohol marketing posts (N = 2600) by 20 alcohol brands on Facebook and Instagram pages over an 18 month period (1st January 2019-30th June 2020) was conducted. Marketing strategies were identified, and the way in which posts targeted, represented and engaged women analysed.

FINDINGS

New (e.g. 'influencer' collaborations) and established (e.g. competitions) strategies were being used to target both women and men. Drinking was presented as a feminine practice and as an important component of 'doing' a combination of traditional, post-feminist and feminist femininities. Women were assigned a range of gender roles that acknowledged their individual pleasures and achievements, and traditional gender roles and stereotypes were both reinforced and rejected to promote alcohol use. An important move away from sexualising and demeaning women to the appropriation of feminist and equality messages was observed, which may appeal to a wider range of women, including those embracing feminist identities.

CONCLUSION

Alcohol brand marketing encourages alcohol use to women through both perpetuating and challenging gender stereotypes. Claims by brands of a commitment to equality are at odds with the harms related to alcohol consumption that contribute to the widening of health and social inequalities. It is important that future work on women's drinking and alcohol marketing is situated within the shifting social-political climate in which traditional, post-feminist and new fourth wave feminist rhetoric and femininities co-exist.

Has the national fall in smoking rate in Ireland been replicated in cancer patients? a 5-year report

Background

Population smoking rates are falling in Ireland, however many cancer patients continue smoking post diagnosis, despite its association with poorer treatment and clinical outcomes. As part of a feasibility study of smoking cessation for cancer patients in Ireland, a review of smoking rates in cancer patients was undertaken.

Methods

The Hospital Inpatient Enquiry system (HIPE), a national database which collects administrative, demographic & clinical data on discharges from public hospitals in Ireland, provided data (2014-2018) on smoking status of adult discharges with a cancer diagnosis (overall, breast, lung, cervical and head & neck (H&N). Smoking trends were compared with Healthy Ireland data (2015-2018), from a national survey for adults on health & wellbeing.

Results

During 2014-18, current smoking rose for all cancers (10.5%-11.4%), cervical cancer (11%-19.8%) and initially (2014-2016) for H&N (3%-12.7%) and lung (24.7%-27.2%), which dropped to 7.6% and 24% respectively in 2018; breast was stable at 6 ± 0.6%. Rates are lower than the general population (23%-20%). During 2014-17, past smoking rates demonstrated an upward trend among all cancers and specific cancers, with the highest prevalence among lung (30.3-39%) and lowest among breast (7.3-11%); comparative general population data was 23-28%. Current smoking rates for all cancers were highest among 50-59-year-olds (14-16%), which contrasts with the general population (24-35 years at 32-28%). Current and past smoking rates for all cancers were consistently higher among males, similar to the general population.

Conclusions

HIPE data is limited by duplicate episodes of care, and it is recognised that smoking documentation may be an underestimate. However, it is useful to analyse trends, as these limitations should be stable over the 5-year study period. Rates remain high; our further research will document barriers and facilitators to smoking cessation among cancer patients.

Key messages

Smoking rates in cancer patients are high despite proven benefits of smoking cessation. Supportive smoking cessation services as part of routine cancer care are indicated.

1431 Stoma Intubation, Isolation and Negative Pressure Wound Therapy for Complex Stoma-Associated Wounds: New Technique and Case Series

Background

The use of negative pressure wound therapy (NPWT) in colorectal surgery has been demonstrated for treating perineal defects, enterocutaneous fistula and stoma dehiscence. Here we describe a technique for closure of complex stoma-associated wounds using a novel commercial intubation device alongside NPWT to protect the surrounding wound from the stoma effluent. The device has previously described for use with enterocutaneous fistula. We present two cases that have been successfully treated with this technique.

Technique and Cases

The first case is of 88-year-old women with a retracted loop ileostomy and the second a 48 year-old male with a retracted end colostomy. Both patients underwent significant emergency peristomal debridement and in both cases the commercial device was deployed to intubate the stoma. VAC foam and standard adhesive dressings were used to form a quality seal and the pressure set to 125mmHg. In both cases near complete healing was achieved to the point that standard stoma bags and management could be used.

Conclusions

This is the first description of the use of an isolation device in complex stoma associated wounds. We have found the Fistula Funnel to be highly effective in this context.

Ten millennia of hepatitis B virus evolution

[Figure: see text].

A descriptive retrospective study on mortality and involuntary culling in beef and dairy cattle production systems of Western Australia (1981-2018)

Identifying and quantifying the relative frequency of involuntary losses is an essential first step in developing fit-for-purpose herd health programmes. The objective of this study was to provide an estimate of the relative frequency of reasons for mortality among south-west Western Australian beef and dairy cattle, based on necropsy findings from a university-based veterinary pathology referral centre over 38 years. A total of 904 cattle were submitted for postmortem examination throughout the study period. Gastrointestinal, cardiopulmonary and reproductive conditions were the most common causes of mortality in cattle submitted for necropsy at Murdoch University for the period 1981-2018. In dairy cattle, the common problems were gastrointestinal (bloat, abomasal displacements) 18% (59/320), cardiovascular (traumatic reticulo-pericarditis) 9% (30/320) and respiratory conditions (pneumonia) 8% (27/320). In beef cattle, the most common conditions were gastrointestinal (bloat, rumen acidosis) 11% (39/358), reproductive (metritis) 11% (38/358), cardiovascular (traumatic reticulo-pericarditis) 7% (25/358), respiratory (pneumonia) 7% (24/358), lameness (fractures) 6%, (21/358) and hepatobiliary conditions (blue-green algae poisoning, hepatotoxicity) 6% (21/358). Selection bias and missing data were potential confounders in this study. Although necropsy investigations provide useful information on animal mortalities and avenues for future herd health programmes, there is a need to standardise data capture methods and disease definition criteria, and conduct more detailed recording of data both at the farm level and at necropsy diagnostic centres.

Super-resolution time-resolved imaging using computational sensor fusion

Imaging across both the full transverse spatial and temporal dimensions of a scene with high precision in all three coordinates is key to applications ranging from LIDAR to fluorescence lifetime imaging. However, compromises that sacrifice, for example, spatial resolution at the expense of temporal resolution are often required, in particular when the full 3-dimensional data cube is required in short acquisition times. We introduce a sensor fusion approach that combines data having low-spatial resolution but high temporal precision gathered with a single-photon-avalanche-diode (SPAD) array with data that has high spatial but no temporal resolution, such as that acquired with a standard CMOS camera. Our method, based on blurring the image on the SPAD array and computational sensor fusion, reconstructs time-resolved images at significantly higher spatial resolution than the SPAD input, upsampling numerical data by a factor \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$12 \times 12$$\end{document}12×12, and demonstrating up to \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$4 \times 4$$\end{document}4×4 upsampling of experimental data. We demonstrate the technique for both LIDAR applications and FLIM of fluorescent cancer cells. This technique paves the way to high spatial resolution SPAD imaging or, equivalently, FLIM imaging with conventional microscopes at frame rates accelerated by more than an order of magnitude.

Rational design, synthesis and testing of novel tricyclic topoisomerase inhibitors for the treatment of bacterial infections part 2

Building on our previously-reported novel tricyclic topoisomerase inhibitors (NTTIs), we disclose the discovery of REDX07965, which has an MIC90 of 0.5 μg mL-1 against Staphylococcus aureus, favourable in vitro pharmacokinetic properties, selectivity versus human topoisomerase II and an acceptable toxicity profile. The results herein validate a rational design approach to address the urgent unmet medical need for novel antibiotics.

Simultaneous pelvic exenteration and liver resection for primary rectal cancer with synchronous liver metastases: results from the PelvEx Collaborative

AIM

At presentation, 15-20% of patients with rectal cancer already have synchronous liver metastases. The aim of this study was to determine the surgical and survival outcomes in patients with advanced rectal cancer who underwent combined pelvic exenteration and liver (oligometastatic) resection.

METHOD

Data from 20 international institutions that performed simultaneous pelvic exenteration and liver resection between 2007 and 2017 were accumulated. Primarily, we examined perioperative outcomes, morbidity and mortality. We also assessed the impact that margin status had on survival.

RESULTS

Of 128 patients, 72 (56.2%) were men with a median age of 60 years [interquartile range (IQR) 15 years]. The median size of the liver oligometastatic deposits was 2 cm (IQR 1.8 cm). The median duration of surgery was 406 min (IQR 240 min), with a median blood loss of 1090 ml (IQR 2010 ml). A negative resection margin (R0 resection) was achieved in 73.5% of pelvic exenterations and 66.4% of liver resections. The 30-day mortality rate was 1.6%, and 32% of patients had a major postoperative complication. The 5-year overall survival for patients in whom an R0 resection of both primary and metastatic disease was achieved was 54.6% compared with 20% for those with an R1/R2 resection (P = 0.006).

CONCLUSION

Simultaneous pelvic exenteration and liver resection is feasible, with acceptable morbidity and mortality. Simultaneous resection should only be performed where an R0 resection of both pelvic and hepatic disease is anticipated.

Learning from calorie posting/traffic light systems introduction in a University hospital canteen

Key messages

Introduction of traffic light system and calorie posting needs evaluation. Females appear more likely to avail of traffic light systems and calorie posting in relation to food choices.

The mad leading the blind: Perceptions of the vaccine-refusal movement among Australians who support vaccination

BACKGROUND

Vaccine refusal is shaped by the social ecology in which it occurs. How people who refuse vaccines are communicated to and treated may affect the nature and strength of their negative vaccine beliefs, and their responsiveness to health promotion messages. Yet little is known about how people who refuse vaccines are perceived by the public. Our research examined perceptions among pro-vaccine Australians of the vaccine-refusal movement.

METHODS

Descriptions of the vaccine-refusal movement by 2666 pro-vaccine Australians were analysed using thematic discourse analysis. Descriptive themes were identified via inductive, iterative coding. Discourse analysis techniques were then used to interpret latent beliefs about the vaccine-refusal movement.

RESULTS

Participants had negative and stigmatising perceptions of the vaccine-refusal movement. They believed the movement is dangerous, misinformed, and comprised of charlatans and fools who are unintelligent, selfish, overly emotional, conspiratorial and scientifically illiterate. Discursive analysis showed that these perceptions were underpinned by beliefs that people would have to be defective in some way to believe anti-vaccine rhetoric. Furthermore, perceptions were underpinned by beliefs that the movement spreads not only disease, but also dangerous ideas that were seen to attack the social order, institutions, values and reason. Participants' intensely-negative views related to their inability to imagine why someone would refuse vaccines.

CONCLUSIONS

This research provides a focused, qualitative account of public perceptions of the vaccine-refusal movement. The findings are concerning: stigma towards vaccine-refusing people may adversely affect their wellbeing and entrench their negative vaccine beliefs. The research suggests that more compassionate, nuanced discussion of vaccine refusal in the public sphere is needed. It also supports the need to systematically examine public attitudes towards vaccine refusal as a determinant of vaccine confidence.

Patient Texting in General Practice: Who, Why, Why Not? A National Survey of Text Messaging in Irish General Practice

Introduction The benefits of text messaging patients are well documented. The General Medical Council recently published guidance endorsing text messaging. The use of text messaging by GPs in Ireland is currently unknown. The survey aims to address this knowledge deficit and ascertain the extent, benefits, risks, barriers and clinical role of text messaging in Irish general practice. Methods An online survey was emailed to 1,375 members of the Irish College of General Practitioners (ICGP). Results A total of 536 GPs completed the questionnaire; a response rate of 40%. Overall, 66% (n=353) of respondents text patients and 27% have a written policy for texting patients. Texting is used primarily to send test results (71%), to advise the patient to phone the practice (52%) and as appointment reminders (43%). Discussion GPs text messaging patients is widespread. Complex issues to resolve include consent, confidentiality, children/young adults and the clinical content of text messages. Guidance is required to enable GPs and patients harness the benefits of text messaging, while minimising potential risks.

The financial burden for the surgical management of osteoradionecrosis

Osteoradionecrosis (ORN) remains a difficult clinical problem. In large refractory cases surgery appears to be the only option but it does not guarantee a cure and is expensive. Cost analysis of 31 patients who had resection with or without reconstruction of their mandible was £892,357. The largest cost was in-patient stay, which accounted for 62% of the total. This article explores in detail the expenditure associated with major ORN surgery and its subsequent implications.

Recombinant β-defensin 126 promotes bull sperm binding to bovine oviductal epithelia

Primate β-defensin 126 regulates the ability of spermatozoa to bind to oviductal epithelial cells in vitro. Bovine β-defensin 126 (BBD126) exhibits preferential expression in the cauda epididymis of the bull, but there have been few studies on its functional role in cattle. The aim of the present study was to examine the role of BBD126 in bull sperm binding to bovine oviductal epithelial cell (BOEC) explants. BBD126 has been shown to be highly resistant to the standard methods of dissociation used in other species and, as a result, corpus epididymal spermatozoa, which have not been exposed to the protein, were used to study the functional role of BBD126. Corpus epididymal spermatozoa were incubated with recombinant (r) BBD126 in the absence or presence of anti-BBD126 antibody. Addition of rBBD126 significantly enhanced the ability of epididymal spermatozoa to bind to BOEC explants (P < 0.05). Anti-BBD126 antibody blocked the BBD126-mediated increase in sperm binding capacity. Ejaculated spermatozoa, which are coated with native BBD126 protein but also a large number of seminal plasma proteins in vivo, were incubated with rBBD126 in the absence or presence of the anti-BBD126 antibody. Addition of rBBD126 significantly enhanced the ability of ejaculated spermatozoa to bind to BOEC explants (P < 0.05), whereas rBBD126 also reduced corpus sperm agglutination (P < 0.05). These results suggest that, similar to the role of its analogue in the macaque, spermatozoa with more BBD126 in their acrosome may represent spermatozoa with more oviduct binding capacity.

Postnatal depression: Can visual media and dramatisation of a young woman's experiences, enable student health care professionals develop knowledge to enhance clinical practice skills?

Introduction

Since the presentation of the symptoms of postnatal depression (PND) can vary; healthcare professionals must receive the appropriate level of training to develop the knowledge required for the effective assessment and referral of women. Yet, healthcare professionals may have limited knowledge in perinatal mental health and students may lack practice opportunities to develop the knowledge and clinical skills. For these reasons, the use of alternative learning resources within perinatal mental health education is vital.

Objectives

To explore the use of visual media in perinatal mental health education.

Aims

Against the background of increasing concerns about the ability of professionals to assess women with PND, this paper will consider how using dramatisation as a teaching approach can enable students to develop their knowledge and guide clinical skill development.

Methods

Three separate groups of senior student midwives and health visitors were asked to evaluate a dramatisation developed from women's lived experience of PND. Pre and post verbal evaluation of the drama were undertaken with the use of focus groups guided by semi-structured questions. Ethical approval was granted by the university.

Results

Following thematic analysis three issues were identified:

–the role of the healthcare professional;

–improvements needed in care;

–issues of education and training.

Conclusions

Against the background of limited placement experience and opportunity for assessment of PND, the use of visual media can improve student healthcare professionals’ learning; with the use of structured facilitation, there is a great potential for multidisciplinary learning.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

In vitro addition of docosahexaenoic acid improves the quality of cooled but not frozen-thawed stallion semen

The aim of the present study was to assess the effect of the addition of docosahexaenoic acid (DHA) on the in vitro quality of cooled and frozen-thawed stallion semen. In Experiment 1, semen from 10 stallions was collected (three ejaculates per stallion). Semen was diluted to 100×10⁶ spermatozoa mL^-1 with 0.02mM vitamin E (VE) and 0, 1, 10 or 20ng mL^-1 DHA and frozen. Semen was thawed and total motility (TM), rapid progressive motility (PM), acrosome integrity, membrane fluidity and morphology were assessed. In Experiment 2, semen from three stallions was collected (three ejaculates per stallion) and frozen as in Experiment 1, but VE and DHA were added after thawing. TM and PM were assessed at 30, 60 and 120min and viability, acrosome integrity and membrane fluidity were evaluated at 30min. In Experiment 3, semen from five stallions was collected (one to three ejaculates per stallion), diluted to 20×10⁶ spermatozoa mL^-1 and stored at 4°C. After 1, 24, 48 and 72h, TM, PM, viability, membrane fluidity and lipid peroxidation were assessed. The addition of DHA had no effect on frozen semen (Experiments 1 and 2) but improved TM, PM and membrane fluidity in cooled stallion semen.

The use of a negative pressure wound management system in perineal wound closure after extralevator abdominoperineal excision (ELAPE) for low rectal cancer

BACKGROUND

Perineal wound healing is a significant challenge after extralevator abdominoperineal excision (ELAPE) due to a high rate of wound breakdown. Negative pressure therapy has proven benefits in open wounds, and recently a negative pressure system has been developed for use on closed wounds at high risk of breakdown, such as apronectomy and hysterectomy. The aim of the present study was to determine whether negative pressure therapy applied to closed perineal wounds after ELAPE improved wound healing and compare outcomes to the published literature and outcomes from a historical cohort of patients who had undergone 'standard' abdominoperineal resection (APR) and primary closure of the perineal wounds.

METHODS

Prospective data on consecutive patients having ELAPE in the period from November 2012 to April 2015 were collected. The pelvic floor defect was reconstructed with biologic mesh. The adipose tissue layer was closed with vicryl sutures, a suction drain was left in the deep layer, the subcuticular layer and skin were closed, and the negative pressure system was applied. Any wound breakdown within the first 30 days postoperatively was recorded.

RESULTS

Of the 32 consecutive ELAPE patients whose perineal wounds were closed within 30 days with the use of the negative pressure system, there was 1 patient with major perineal wound breakdown and 2 patients with a 1 cm superficial wound defect, which needed no further treatment. In the remaining 29 (90 %) patients, the perineal wounds healed fully without complications. Twenty-five patients underwent standard APR in 2010-2011 with primary closure of their perineal wounds. Ten out of 25(40 %) of patients who had undergone standard APR and primary closure of perineal wounds had major wound complications (p = 0.01).

CONCLUSIONS

Our results suggest that after ELAPE the application of a negative pressure system to the perineal wound closed with biologic mesh may reduce perineal wound complications and may reduce the need for major perineal reconstruction.

Use of antiretroviral treatment among people living with HIV in Australia between 1997 and 2012

Current international targets aim for 90% of people diagnosed with HIV to be on antiretroviral treatment (ART). This paper aims to identify sociodemographic and attitudinal factors associated with ART non-use over time in three samples of Australian people living with HIV (PLHIV). Data for this paper were derived from an Australian cross-sectional survey of PLHIV that was repeated at three different time points: 1997, 2003, and 2012. There were approximately 1000 respondents to each survey (n = 3042 in total). The survey included approximately 250 items related broadly to health and well-being, ART use, and attitudes towards ART use. Univariate and multivariate logistic regression analyses were used. While the proportion of participants using ART increased between 1997 and 2012 (78.8-87.6%, p < .001), there was a decrease between 1997 and 2003 to 70.6% (p < .001). Factors linked to ART non-use remained steady over those 15 years. In all cohorts, people less likely to be using ART were younger and had a more recent diagnosis of HIV. In 2003 and 2012, people in full-time employment were less likely to be using ART, while those whose main source of income was a pension or social security were more likely to be using ART. Multivariate models showed that, at each time point, a belief in the health benefits of delayed ART uptake was associated with non-use. These findings suggest that there may be barriers to ART uptake that have persisted over time despite changes to clinical guidelines that now encourage early uptake.

Iron Age and Anglo-Saxon genomes from East England reveal British migration history

British population history has been shaped by a series of immigrations, including the early Anglo-Saxon migrations after 400 CE. It remains an open question how these events affected the genetic composition of the current British population. Here, we present whole-genome sequences from 10 individuals excavated close to Cambridge in the East of England, ranging from the late Iron Age to the middle Anglo-Saxon period. By analysing shared rare variants with hundreds of modern samples from Britain and Europe, we estimate that on average the contemporary East English population derives 38% of its ancestry from Anglo-Saxon migrations. We gain further insight with a new method, rarecoal, which infers population history and identifies fine-scale genetic ancestry from rare variants. Using rarecoal we find that the Anglo-Saxon samples are closely related to modern Dutch and Danish populations, while the Iron Age samples share ancestors with multiple Northern European populations including Britain.

Postnatal MRI Brain in Infants Treated for Twin-Twin Transfusion Syndrome

Untreated twin-twin transfusion syndrome (TTTS) is associated with significant mortality and neurological impairment. Fetoscopic laser surgery (FLS) is the treatment of choice. We sought to assess intracranial abnormalities in TTTS twins following treatment. In this prospective, blinded study MRI scans were performed on 3 groups; (1) monochorionic diamniotic (MCDA) twins with TTTS who had undergone FLS (n = 10), (2) MCDA twins without TTTS (n = 8) and (3) dichorionic twins (n = 8). Scans were scored as either normal or abnormal. The primary outcome was a composite of abnormal MRI brain or intrauterine fetal demise. The primary outcome occurred in 6/10 (60%) of the TTTS group versus 3/8 (37.5%) in the MCDA group. The primary outcome was significantly different across all study groups [p = 0.029; X2 = 7.112]. We found that twins treated for TTTS are more likely to have abnormalities on MRI brain at term than other twin groups. This group merits term-corrected MRI as part of their postnatal assessment.

Evaluation of dengue virus strains for human challenge studies

Discordance between the measured levels of dengue virus neutralizing antibody and clinical outcomes in the first-ever efficacy study of a dengue tetravalent vaccine (Lancet, Nov 2012) suggests a need to re-evaluate the process of pre-screening dengue vaccine candidates to better predict clinical benefit prior to large-scale vaccine trials. In the absence of a reliable animal model and established correlates of protection for dengue, a human dengue virus challenge model may provide an approach to down-select vaccine candidates based on their ability to reduce risk of illness following dengue virus challenge. We report here the challenge of flavivirus-naïve adults with cell culture-passaged dengue viruses (DENV) in a controlled setting that resulted in uncomplicated dengue fever (DF). This sets the stage for proof-of-concept efficacy studies that allow the evaluation of dengue vaccine candidates in healthy adult volunteers using qualified DENV challenge strains well before they reach field efficacy trials involving children. Fifteen flavivirus-naïve adult volunteers received 1 of 7 DENV challenge strains (n=12) or placebo (n=3). Of the twelve volunteers who received challenge strains, five (two DENV-1 45AZ5 and three DENV-3 CH53489 cl24/28 recipients) developed DF, prospectively defined as ≥2 typical symptoms, ≥48h of sustained fever (>100.4°F) and concurrent viremia. Based on our study and historical data, we conclude that the DENV-1 and DENV-3 strains can be advanced as human challenge strains. Both of the DENV-2 strains and one DENV-4 strain failed to meet the protocol case definition of DF. The other two DENV-4 strains require additional testing as the illness approximated but did not satisfy the case definition of DF. Three volunteers exhibited effusions (1 pleural/ascites, 2 pericardial) and 1 volunteer exhibited features of dengue (rash, lymphadenopathy, neutropenia and thrombocytopenia), though in the absence of fever and symptoms. The occurrence of effusions in milder DENV infections counters the long-held belief that plasma leakage syndromes are restricted to dengue hemorrhagic fever/dengue shock syndromes (DHF/DSS). Hence, the human dengue challenge model may be useful not only for predicting the efficacy of vaccine and therapeutic candidates in small adult cohorts, but also for contributing to our further understanding of the mechanisms behind protection and virulence.

The utility of molecular diagnostics to predict recurrence of head and neck carcinoma

BACKGROUND

Locoregional recurrence is the major cause of treatment failure after surgery for oral squamous cell carcinoma. Molecular diagnostics have the potential to improve on clinicopathological parameters to predict this recurrence and plan adjuvant treatment. The test most frequently applied is based on detecting TP53 mutations, but alternative methodology is required for cases that harbour the wild-type gene.

METHODS

One hundred and two cases with tumour-adjacent margins, considered to be clear margins by microscopy, were examined using carefully optimised molecular diagnostics based on detection of the TP53 and Ly-6D markers. The markers were also combined to provide a dual approach.

RESULTS

The dual molecular diagnostic identified cases with a significant increase in the probablility of developing locoregional recurrence when tumour-adjacent positive and clear margins were compared (P=0.0001). These tests were most useful when the clearance at the resection margins was 5 mm or less. The TP53-based diagnostic was a better predictor of locoregional recurrence than established clinicopathological parameters.

CONCLUSION

The optimised TP53-based diagnostic rapidly identifies an important subgroup of cases with close margins that will benefit from new treatment modalities to reduce the risk of recurrence.

A human challenge model for dengue infection reveals a possible protective role for sustained interferon gamma levels during the acute phase of illness

Dengue has recently been defined by the World Health Organization as a major international public health concern. Although several vaccine candidates are in various stages of development, there is no licensed vaccine available to assist in controlling the further spread of this mosquito borne disease. The need for a reliable animal model for dengue disease increases the risk to vaccine developers as they move their vaccine candidates into large-scale phase III testing. In this paper we describe the cellular immune responses observed in a human challenge model for dengue infection; a model that has the potential to provide efficacy data for potential vaccine candidates in a controlled setting. Serum levels of sIL-2Rα and sTNF-RII were increased in volunteers who developed illness. Supernatants from in vitro stimulated PBMC were tested for cytokines associated with a T(H)1 or T(H)2 T-cell response (IL-2, TNF-α, IFN-γ, IL-4, IL-10, IL-5) and only IFN-γ was associated with protection against fever and/or viremia. Interestingly, IFN-γ levels drop to 0 pg/mL for volunteers who develop illness after challenge suggesting that some mechanism of immunosuppression may play a role in dengue illness. The human challenge model provides an opportunity to test potential vaccine candidates for efficacy prior to large-scale phase III testing, and hints at a possible mechanism for immune suppression by dengue.