Follow-up of women with cervical adenocarcinoma in situ treated by conization: A single centre clinical experience

OBJECTIVE

Hysterectomy has been the historical gold standard final step in the treatment algorithm of adenocarcinoma in situ (AIS) recommended by most North American colposcopy guidelines. AIS disproportionately affects young childbearing age women, therefore a fertility sparing treatment option is desirable. Our study examines the impact of conservative treatment of AIS with conization followed by serial surveillance.

METHODS

A retrospective chart review was completed of patients treated for AIS from 2006 to 2020. Charts were identified by pathologic diagnosis of AIS on cervical and uterine specimens. Charts were excluded if AIS was not treated with conization, if AIS was not confirmed on initial conization specimen, or if invasive disease was found at initial conization.

RESULTS

121 patient charts were analyzed. Median age of patients at first conization and hysterectomy was 34.8 and 40.9, respectively. First conization was by Cold Knife Cone in 58% of patients, and by Loop Electrosurgical Excisional Procedure in 42% of patients. Median follow-up period in our study was 609 days. 5% of patients had recurrence, with only one patient who recurred as cancer. One case of recurrence had a positive initial conization margin. Median time to recurrence was 700 days. 47% of patients underwent eventual hysterectomy. Residual AIS was found in 23% of hysterectomy specimens. Adenocarcinoma was diagnosed on hysterectomy specimen in four patients.

CONCLUSION

Our study demonstrates the oncologic safety of treating AIS with conization and serial surveillance. Routine hysterectomy completed as a part of the AIS treatment algorithm, as in current clinical guidelines, is unnecessary.

Impact of changing from autopsy to post-mortem CT in an entire HM Coroner region due to a shortage of available pathologists

A significant problem facing routine medicolegal coroner-referred autopsies is a shortfall of pathologists prepared to perform them. This was particularly acute in Lancashire, where the coroner decided to initiate a service that relied on post-mortem computed tomography (PMCT). This involved training anatomical pathology technologists (APTs) to perform external examinations, radiographers to perform scans, and radiologists to interpret them. The service started in 2018 and now examines over 1,500 cases per year. This study outlines the PMCT process using NHS staff, with CT equipment and logistics managed by the commercial sector. It compares the demographics and outcomes of PM investigations for two 6-month periods: the autopsy service prior to 2018, and then the PMCT service. These data were then compared with previous UK PMCT data. Referrals for adult non-suspicious deaths were made in 913 cases of which 793 (87%) had PMCT between 01/10/2018 and 31/03/2019. Fifty-six cases had autopsy after PMCT, so 81% of cases potentially avoided autopsy. The PMCT service did not delay release of bodies to the next-of-kin. Comparing the cause of death given shows no difference in the proportions of natural and unnatural deaths. There was an increase in diagnosis of coronary artery disease for PMCT, with less respiratory diagnoses, a feature not previously demonstrated. These data suggest PMCT is a practical solution for potentially failing autopsy services. By necessity, this involves changes in diagnoses, as PMCT and autopsy have different strengths and weakness, but the ability to pick up unnatural death appears unaffected.

Technical success of endoscopic stenting for malignant gastric outlet obstruction

BACKGROUND

Palliation of irresectable malignant gastric outlet obstruction (GOO) using self-expanding metal stents (SEMS) is gaining popularity with high technical success rates. The aim of this study was to review and compare GOO stenting for malignancy with other series.

METHODS

A retrospective review of all patients undergoing pyloroduodenal stenting for malignant GOO at Groote Schuur Hospital, 1 March 2018-31 August 2021, evaluating demographics, technical success, pathology, and stentrelated complications was done.

RESULTS

One hundred and fourteen patients, of which 38.6% were female, were included, with gastric malignancies (74.6%) being the most frequent underlying pathology. Median age was 64 years (IQR 53-70 years), with 48.2% having at least one comorbidity. The majority (96 patients; 85.7%) required only one stent. In total, 132 stent insertion attempts were undertaken. Three technical failures were experienced (one incorrect stent placement and two failed insertions), equating to a 97.4% technical success rate. Four immediate complications occurred (3.1%): two related to sedation, one incorrect stent placement and an oesophagogastric junction perforation with procedural death. Fifteen delayed complications occurred: 13 tumour in-growth blockages, one stent fracture and one case of poor radial stent expansion. Stent blockages occurred at a median of 107 days (IQR 80-275 days). Salvage stenting was 100% successful in 14 cases requiring re-stenting.

CONCLUSION

Technical insertion success rates of primary and salvage duodenal stenting for malignant GOO are on par with international high-volume units. The leading pathology locally is gastric adenocarcinoma, with palliative stenting remaining a feasible and accessible option.

Impact of the COVID-19 pandemic on a post-mortem CT service for adult non-suspicious death

Due to the COVID-19 pandemic, the post-mortem computed tomography (PMCT) service was expanded from three to seven cases per day to help mortuary services and avoid invasive autopsy. Additional targeted angiography and pulmonary ventilation procedures were stopped and triage rules relaxed to allow more indications to be scanned, including those requiring toxicology. A service evaluation was performed for the first 3-months of the COVID-19 pandemic compared to the equivalent period the previous year to study the impact of these changes. It was found that, despite the increase in deaths regionally, coronial referrals remained about 100 per month, a reduction in referral rate. The number undergoing PMCT rose from 28% to 74% of cases. Turnaround time remained the same. For cases triaged to PMCT, the need for subsequent autopsy increased from 7.9% to 15.8%. No significant changes were seen in diagnosis rates, including cardiac or respiratory. There was an increase in patients with coronary death without severe coronary calcification who underwent autopsy after PMCT. These may have been diagnosed by targeted coronary angiography. Fifty-three cases requiring toxicology/biochemistry had PMCT, with 38 having PMCT only. In 8/11 (72.7%) cases with normal PMCT and toxicology as the key diagnostic test, autopsy was performed prior to results. This suggests the pathology team were reluctant to risk an "unascertained" outcome. This study shows that it is possible to increase PMCT services by widening referral criteria and by limiting the use of enhanced imaging techniques, without significantly changing diagnosis rates of key diseases; however, selectively restarting targeted angiography may help avoid autopsy in some cases.

Measuring success: A comparison of ultrasound and landmark guidance for knee arthrocentesis in a cadaver model

OBJECTIVE

Knee arthrocentesis can be performed by landmark (LM) or ultrasound (US) guidance. The goal of performing knee arthrocentesis is to obtain synovial fluid, however, it is also important to consider the number of attempts required and accidental bone contacts that occur. This study evaluates procedural success without bone contact in knee arthrocentesis and compares both LM and US guided techniques in a cadaver model.

METHODS

This was a randomized crossover study comparing US vs LM guidance for arthrocentesis in a single academic center. Volunteers were randomized to perform both LM and US guided knee arthrocentesis on cadavers. The primary outcome was procedural success, defined as first attempt aspiration of synovial fluid without bone contact. Secondary outcomes included number of attempts, number of bone contacts, time to aspiration, and confidence.

RESULTS

Sixty-one participants completed the study with a total of 122 procedures performed. Procedural success without bone contact was greater in the US group (84% vs 64% p = 0.02). Time to aspiration was longer for US (38.75 s vs 25.54 s p = 0.004). Participants were more confident with US compared to LM both before the procedure on a Visual Analog Scale from 1 to 100 (29 vs 21 p = 0.03) as well as after the procedure (83 vs 69 p = 0.0001). Participants had a greater median increase in confidence with US following training (44 vs 26 p = 0.01).

CONCLUSIONS

Study participants had greater procedural success without bone contact when US guidance was used. The increase in confidence following training was greater for US guidance than the LM method. Use of US guidance may offer a benefit by allowing for better needle control and avoidance of sensitive structures for clinicians performing knee arthrocentesis.

Glacier retreat reorganizes river habitats leaving refugia for Alpine invertebrate biodiversity poorly protected

Alpine river biodiversity around the world is under threat from glacier retreat driven by rapid warming, yet our ability to predict the future distributions of specialist cold-water species is currently limited. Here we link future glacier projections, hydrological routing methods and species distribution models to quantify the changing influence of glaciers on population distributions of 15 alpine river invertebrate species across the entire European Alps, from 2020 to 2100. Glacial influence on rivers is projected to decrease steadily, with river networks expanding into higher elevations at a rate of 1% per decade. Species are projected to undergo upstream distribution shifts where glaciers persist but become functionally extinct where glaciers disappear completely. Several alpine catchments are predicted to offer climate refugia for cold-water specialists. However, present-day protected area networks provide relatively poor coverage of these future refugia, suggesting that alpine conservation strategies must change to accommodate the future effects of global warming.

Does the model reflect the system? When two-dimensional biomechanics is not 'good enough'

Models are mathematical representations of systems, processes or phenomena. In biomechanics, finite-element modelling (FEM) can be a powerful tool, allowing biologists to test form-function relationships in silico, replacing or extending results of in vivo experimentation. Although modelling simplifications and assumptions are necessary, as a minimum modelling requirement the results of the simplified model must reflect the biomechanics of the modelled system. In cases where the three-dimensional mechanics of a structure are important determinants of its performance, simplified two-dimensional modelling approaches are likely to produce inaccurate results. The vertebrate mandible is one among many three-dimensional anatomical structures routinely modelled using two-dimensional FE analysis. We thus compare the stress regimes of our published three-dimensional model of the chimpanzee mandible with a published two-dimensional model of the chimpanzee mandible and identify several fundamental differences. We then present a series of two-dimensional and three-dimensional FE modelling experiments that demonstrate how three key modelling parameters, (i) dimensionality, (ii) symmetric geometry, and (iii) constraints, affect deformation and strain regimes of the models. Our results confirm that, in the case of the primate mandible (at least), two-dimensional FEM fails to meet this minimum modelling requirement and should not be used to draw functional, ecological or evolutionary conclusions.

P16.03.A Epithelioid gliobastoma requires rapid treatment and BRAF inhibitors should be made readily available for their treatment

Background

Epithelioid glioblastoma is a rare subtype of Glioblastoma. We examine two cases who presented acutely with symptoms of headache, neck stiffness and an eye squint. The purpose of this case review is to look at their management, the spread of the disease and propose the availability of BRAF inhibiting agents be made readily available for this subtype.

Material and Methods

The clinical records including pathology and surgical reports, multi-disciplinary team meeting documents, oncology plans and inpatient notes have all been reviewed alongside the literature on epithelioid GBM and BRAF V600e mutations and inhibitors.

Results

Patients were females aged 25 and 32 presenting with acute onset headache and neck stiffness to emergency Department. The 25 year old had developed a right eye squint within seven days of the other symptoms, her tumour was right frontal with midline shift. The 32 year old had symptoms for 10 days prior to presentation, the tumour was right temporal. They both underwent craniotomies. The frontal tumour was totally resected, while the temporal lobe tumour was haemorrhagic in nature and minimally de-bulked. Pre-operative stealth imaging showed that there had been an increase in the size of the temporal lesion in the fourteen days since presentation. Histology proved these to be epithelioid GBM’s with BRAF V600e mutations, IDH wild-type and TERT promoter mutant. Full pathology reports with molecular markers were available within ten days. The frontal lobe patient began chemo-radiation sixteen days from her surgical date. On day two she was admitted with severe headache and nausea. She became agitated, confused, and transferred back to the neurosurgery unit for management of hydrocephalus. She was diagnosed with PRES and simultaneously treated for this and hydrocephalus. Clinically she suffered storming, passing away exactly eight weeks from presentation. Seven days after surgery the temporal lobe tumour patient suffered a seizure and admitted for symptom management and expedite oncology treatment. She passed away six days later suffering continual neurological deterioration and the tumour progression with leptomeningeal spread. This was exactly four weeks from initial presentation.

Conclusion

The prognosis for epithelioid Glioblastoma is limited to weeks to short months. Extent of resection in these case studies demonstrates benefit in delaying progression though it is clear that time is of the essence from presentation, to surgery, to adjuvant treatment. Neither of these tumours were methylated meaning the standard treatment for glioblastoma is likely to lack efficacy. BRAF inhibitors should be made readily available for this rare sub-type to commence treatment expediently. Both patients suffered distressing neurological symptoms in their final days which require expert management and are best managed in a neurosurgical centre.

P11.06.A benefits of carbohydrate loading drinks pre-operatively for patients with a presumed high-grade glioma planned for an awake craniotomy

Background

As part of enhanced recovery after surgery in neuro oncology, carbohydrate loading drinks were reviewed to see if there were any benefits in administering this pre operatively, in particularly for patients for awake craniotomy electively. This method is currently used in colorectal and spinal teams within the trust. Carbohydrate loading drinks are clear, and can be consumed up to 2 hours before induction of anaesthesia. Currently reviewed for patients for awake craniotomy with the vision to implement for all patients planned for craniotomy, both asleep and awake. The concept of this drink, is that it helps with post-operative nausea and vomiting , insulin resistance, helps with energy boost which is helpful during awake craniotomies and potentially during their engagement with therapists post operatively and wound healing (Hausel J et al, 2005). This could essentially lead to safer discharge, reduced risk of wound infection and reduced length of stay.

Material and Methods

In a single centre, data for patients who have undergone awake craniotomies this year were abstracted. Patients planned for an awake surgery were prescribed carb-loading drinks. Due to the start date of this study, there were already a number of patients who have had their awake craniotomies without having carb-loading drinks prescribed. The data for both cohorts enabled comparison on engagement during and after awake craniotomies with therapists and length of stay.

Results

The current data collected has found that the average length of stay in the group who were not prescribed carbohydrate loading drinks pre operatively, had an average length of stay 7.2 days in total, 50% had experienced nausea and vomiting post operatively, which led therapists unable to perform assessments. 66% of patients in this group were found to have some form of difficulties engaging with the therapists during the awake phase of their craniotomies. Compared with patients who were prescribed the carbohydrate loading drink, the average length of stay was 4.6 days, with no post operative nausea and vomiting, no difficulties engaging with therapists post operatively.

Conclusion

Though the current data is of a small volume, carbohydrate loading pre-operatively can help patients for elective awake craniotomies and reduce length of stay in hospital, optimising their recovery in a fast yet safe manner to ensure they are in the best performance status prior to commencing oncology treatment. With further analysis into the use of carb-loading drinks pre-operatively, this can be used widely within neuro-oncology surgeries.

Hausel J, Nygren J, Thorell A et al Randomized clinical trial of the effects of oral preoperative carbohydrates on postoperative nausea and vomiting after laparoscopic cholecystectomy. Br J Surg 2005; : 415-421. [PubMed] [Google Scholar]

Hospital re-admission after critical care survival: a systematic review and meta-analysis

Survivors of critical illness frequently require increased healthcare resources after hospital discharge. We undertook a systematic review and meta-analysis to assess hospital re-admission rates following critical care admission and to explore potential re-admission risk factors. We searched the MEDLINE, Embase and CINAHL databases on 05 March 2020. Our search strategy incorporated controlled vocabulary and text words for hospital re-admission and critical illness, limited to the English language. Two reviewers independently applied eligibility criteria and assessed quality using the Newcastle Ottawa Score checklist and extracted data. The primary outcome was acute hospital re-admission in the year after critical care discharge. Of the 8851 studies screened, 87 met inclusion criteria and 41 were used within the meta-analysis. The analysis incorporated data from 3,897,597 patients and 741,664 re-admission episodes. Pooled estimates for hospital re-admission after critical illness were 16.9% (95%CI: 13.3-21.2%) at 30 days; 31.0% (95%CI: 24.3-38.6%) at 90 days; 29.6% (95%CI: 24.5-35.2%) at six months; and 53.3% (95%CI: 44.4-62.0%) at 12 months. Significant heterogeneity was observed across included studies. Three risk factors were associated with excess acute care rehospitalisation one year after discharge: the presence of comorbidities; events during initial hospitalisation (e.g. the presence of delirium and duration of mechanical ventilation); and subsequent infection after hospital discharge. Hospital re-admission is common in survivors of critical illness. Careful attention to the management of pre-existing comorbidities during transitions of care may help reduce healthcare utilisation after critical care discharge. Future research should determine if targeted interventions for at-risk critical care survivors can reduce the risk of subsequent rehospitalisation.

Epigenetics of Neurotrauma

Epigenetic changes have been linked to a host of disease states. Besides the physiological function of epigenetic changes in regulating cellular function, recent data indicates that key changes in epigenetic activity also play an important pathophysiologic role following neurotrauma specifically. Such manifestations occur through the activation or silencing of different genes. Histone methylation has emerged as a critical component of this process and can be selectively modulated after injury. Pre-clinical studies have resulted in key discoveries regarding specific methylation sites of interest. This focused review highlights some of these early findings and their relationship to clinical outcomes. These findings suggest areas of future investigation and discovery in the quest to develop ideal biomarkers and methods to utilize them in developing therapeutic interventions.

Comparative biomechanics of the Pan and Macaca mandibles during mastication: finite element modelling of loading, deformation and strain regimes

The mechanical behaviour of the mandibles of Pan and Macaca during mastication was compared using finite element modelling. Muscle forces were calculated using species-specific measures of physiological cross-sectional area and scaled using electromyographic estimates of muscle recruitment in Macaca. Loading regimes were compared using moments acting on the mandible and strain regimes were qualitatively compared using maps of principal, shear and axial strains. The enlarged and more vertically oriented temporalis and superficial masseter muscles of Pan result in larger sagittal and transverse bending moments on both working and balancing sides, and larger anteroposterior twisting moments on the working side. The mandible of Pan experiences higher principal strain magnitudes in the ramus and mandibular prominence, higher transverse shear strains in the top of the symphyseal region and working-side corpus, and a predominance of sagittal bending-related strains in the balancing-side mandible. This study lays the foundation for a broader comparative study of Hominidae mandibular mechanics in extant and fossil hominids using finite element modelling. Pan's larger and more vertical masseter and temporalis may make it a more suitable model for hominid mandibular biomechanics than Macaca.

Universal preprocedural SARS-CoV-2 testing protocol within a large healthcare system

This research letter details the safety of a universal asymptomatic preprocedural SARS-CoV-2 testing protocol implemented within a large, integrated healthcare system. Among over 145 000 tests administered, fewer than 1 in 1000 patients had subsequent positive tests within 10 days of an initial negative SARS-CoV-2 test. Despite the infrequency of positive tests after negative screening tests, patient-to-provider transmission was documented in five instances.

Clinical academic radiographers - A challenging but rewarding career

OBJECTIVES

To explain what a clinical academic career can be, what it can lead to for the individual, profession and most importantly the patient, and why these roles are so important to radiography.

KEY FINDINGS

Multiple challenges to the adoption of clinical academic careers exist, including achievable measurable outcomes, visibility & senior support, and balancing different time demands. Equally the rewards are wide ranging and can advance both the individual and profession through role extension opportunities, increased career progression, patient benefits, and academic and research skills.

CONCLUSION

Clinical academic careers can provide advantages for the individual, department, profession and most importantly the patient with advanced clinical practice through evidenced based research.

IMPLICATIONS FOR PRACTICE

Improving clinical academic careers within Radiography will promote research participation and increase radiographic roles in patient-centred research delivery and development. Combining evidenced based research with academic skills will lead to improved patient care and better clinical outcomes.

Novel homozygous variant in BMP1 associated with a rare osteogenesis imperfecta phenotype

Osteogenesis imperfecta (OI) is characterized by bone fragility and increased fracture susceptibility. BMP1 variants have been reported in the rare OI type XIII, specifically referred to herein as BMP1-associated autosomal recessive (AR) OI. We report the clinical presentation and diagnostic evaluation of a patient found to have a novel homozygous variant in BMP1. We also provide an overview of reported BMP1 variants to date, with discussion focusing on the use of bisphosphonate therapy in these patients. A 7-year-old male with speech and motor delay sustained five bilateral tibial fractures with minimal trauma since age 2.5 years. At age 6, he developed severe back pain after a fall. Diffuse spinal osteopenia and multiple vertebral compression fractures (VCF) at T9, L1, L3, and L5 were identified. Total hip BMD was generous (adjusted Z-score* = 1.76), and femoral neck BMD was high (adjusted Z-score* = 2.67). VCFs precluded assessment of lumbar spine BMD. Genetic analysis identified a homozygous missense variant in exon 4 of BMP1 (c.C505T; p.Arg169Cys). Unlike most forms of OI, patients with BMP1-associated AR OI may have normal or paradoxically increased BMD, making BMD and fracture risk correlation difficult. While bisphosphonates (BP) may help reduce recurrent fractures and provide symptomatic relief, the broad phenotypic spectrum and underlying bone pathology, often in the setting of increased BMD, complicate management. HR-pQCT assessment of bone microarchitecture and quality may aid in the decision of BP therapy and subsequent monitoring. Evidence is limited with respect to the effectiveness of BP in this rare form of OI. *Z-score was adjusted for height Z-score.

Clinical Characteristics and Outcomes in Patients with COVID-19 and Cancer: a Systematic Review and Meta-analysis

Much of routine cancer care has been disrupted due to the perceived susceptibility to SARS-CoV-2 infection in cancer patients. Here, we systematically review the current evidence base pertaining to the prevalence, presentation and outcome of COVID-19 in cancer patients, in order to inform policy and practice going forwards. A keyword-structured systematic search was conducted on Pubmed, Cochrane, Embase and MedRxiv databases for studies reporting primary data on COVID-19 in cancer patients. Studies were critically appraised using the NIH National Heart, Lung and Blood Institute's quality assessment tool set. The pooled prevalence of cancer as a co-morbidity in patients with COVID-19 and pooled in-hospital mortality risk of COVID-19 in cancer patients were derived by random-effects meta-analyses. In total, 110 studies from 10 countries were included. The pooled prevalence of cancer as a co-morbidity in hospitalised patients with COVID-19 was 2.6% (95% confidence interval 1.8%, 3.5%, I2: 92.0%). Specifically, 1.7% (95% confidence interval 1.3%, 2.3%, I2: 57.6.%) in China and 5.6% (95% confidence interval 4.5%, 6.7%, I2: 82.3%) in Western countries. Patients most commonly presented with non-specific symptoms of fever, dyspnoea and chest tightness in addition to decreased arterial oxygen saturation, ground glass opacities on computer tomography and non-specific changes in inflammatory markers. The pooled in-hospital mortality risk among patients with COVID-19 and cancer was 14.1% (95% confidence interval 9.1%, 19.8%, I2: 52.3%). We identified impeding questions that need to be answered to provide the foundation for an iterative review of the developing evidence base, and inform policy and practice going forwards. Analyses of the available data corroborate an unfavourable outcome of hospitalised patients with COVID-19 and cancer. Our findings encourage future studies to report detailed social, demographic and clinical characteristics of cancer patients, including performance status, primary cancer type and stage, as well as a history of anti-cancer therapeutic interventions.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Variation in accessory mental foramen frequency and number in extant hominoids

Nerves providing sensation to the lower face and jaw exit the mandibular canal via the mental foramen. In humans, there are many documented occurrences of additional foramina (accessory mental foramina, AMFs) on the lateral mandibular surface that may also contain nervous structures. There are large discrepancies in the literature regarding how often AMFs occur in humans, and investigations of non-human hominoid AMFs are rare. Consequently, the causes of interspecific diversity in this variable have not been explored. This project seeks to compare the frequency and number of AMFs between males and females, and among human regional groups and hominoid subspecies and species, and to investigate possible causal factors for any differences identified. No significant differences were found between males and females in any group. Gorillas and orangutans had the highest percentages of individuals with AMFs and the highest mean number of foramina, while modern humans and siamangs had the lowest figures for these variables. Significant differences (p < .05) were found for the mean number of foramina between most pairs of species. The results also showed that species with mandibles that are larger overall, have a larger area anterior to mental foramen, and a longer mandibular canal typically present more AMFs. The strongest correlation was found between the mean number of mental foramina and mandibular canal length. We suggest that these results provide preliminary support for the hypothesis that increasing mandibular canal length increases the likelihood that that nerves will ramify, leading to greater frequencies of accessory mental foramina.

Determination of Glyphosate and Aminomethylphosphonic Acid in Crops by Capillary Gas Chromatography with Mass-Selective Detection: Collaborative Study

A collaborative study was conducted to validate a method for the determination of glyphosate and aminomethylphosphonic acid (AMPA) in crops. The analytes are extracted from crops with water, and the crude extracts are then subjected to a cation exchange cleanup. The analytes are derivatized by the direct addition of the aqueous extract into a mixture of heptafluorobutanol and trifluoroacetic anhydride. The derivatized analytes are quantitated by capillary gas chromatography with mass-selective detection (MSD). The collaborative study involved 13 laboratories located in 5 countries 12 laboratories returned valid data sets. The crops tested were field corn grain, soya forage, and walnut nutmeat at concentrations of 0.050, 0.40, and 2.0 mg/kg. The study used a split-level pair replication scheme with blindly coded laboratory samples. Twelve materials were analyzed, including 1 control and 3 split-level pairs for each matrix, 1 pair at each nominal concentration. For glyphosate, the mean recovery was 91%, the average intralaboratory variance, the repeatability relative standard deviation (RSDr), was 11%, and the interlaboratory variance, the reproducibility relative standard deviation (RSDR), was 16%. For AMPA, the mean recovery was 87%, the RSDr was 16%, and the RSDR was 25% at mg/kg levels.

Post-mortem CT: is coronary angiography required in the presence of a high coronary artery calcium score?

AIM

To test whether a high coronary artery score predicts that the subsequent post-mortem computed tomography (PMCT) with angiography (PMCTA) will diagnose significant coronary artery disease (CAD); to test the diagnostic impact of assuming there is significant CAD based on a high coronary artery calcium (CAC) score alone; and (3) to test whether the clinical CAC score threshold (400) is the most accurate to make this prediction.

MATERIALS AND METHODS

CAC scoring and PMCTA were performed in cases of adult sudden natural death. Angiography was reviewed to determine if there was sufficient CAD to give as the cause of death. Data were analysed to test whether high calcium score predicts significant CAD.

RESULTS

PMCTA with CAC score was successful in 100/104 PMCT examinations and in 87/100 angiography examinations (87%). Forty-six cases (46%) had a CAC score of >400, the clinical level of severe disease. CAD was given as the cause of death in 31 (67%) of these cases. Angiography was successful in 39 of these cases (84.7%) and showed severe CAD in all but one (97%). Twenty-five (25%) cases were diagnosed with a CAD death without a high CAC score.

CONCLUSION

Although CAC score can neither diagnose nor exclude death due to CAD, the addition of angiography adds little diagnostic information to a high CAC score. If PMCT investigation is to exclude trauma and provide a medical cause of death on the "balance of probabilities", angiography is not required when the calcium score >400. This could reduce the number of patients requiring angiography by almost 50%.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Tuning the endothelial response: differential release of exocytic cargos from Weibel-Palade bodies

Essentials Endothelial activation initiates multiple processes, including hemostasis and inflammation. The molecules that contribute to these processes are co-stored in secretory granules. How can the cells control release of granule content to allow differentiated responses? Selected agonists recruit an exocytosis-linked actin ring to boost release of a subset of cargo.

SUMMARY

Background Endothelial cells harbor specialized storage organelles, Weibel-Palade bodies (WPBs). Exocytosis of WPB content into the vascular lumen initiates primary hemostasis, mediated by von Willebrand factor (VWF), and inflammation, mediated by several proteins including P-selectin. During full fusion, secretion of this large hemostatic protein and smaller pro-inflammatory proteins are thought to be inextricably linked. Objective To determine if secretagogue-dependent differential release of WPB cargo occurs, and whether this is mediated by the formation of an actomyosin ring during exocytosis. Methods We used VWF string analysis, leukocyte rolling assays, ELISA, spinning disk confocal microscopy, high-throughput confocal microscopy and inhibitor and siRNA treatments to demonstrate the existence of cellular machinery that allows differential release of WPB cargo proteins. Results Inhibition of the actomyosin ring differentially effects two processes regulated by WPB exocytosis; it perturbs VWF string formation but has no effect on leukocyte rolling. The efficiency of ring recruitment correlates with VWF release; the ratio of release of VWF to small cargoes decreases when ring recruitment is inhibited. The recruitment of the actin ring is time dependent (fusion events occurring directly after stimulation are less likely to initiate hemostasis than later events) and is activated by protein kinase C (PKC) isoforms. Conclusions Secretagogues differentially recruit the actomyosin ring, thus demonstrating one mechanism by which the prothrombotic effect of endothelial activation can be modulated. This potentially limits thrombosis whilst permitting a normal inflammatory response. These results have implications for the assessment of WPB fusion, cargo-content release and the treatment of patients with von Willebrand disease.

Stability of Prostacyclin in Human Plasma and Whole Blood: Studies on the Protective Effect of Albumin

The biological half-life of prostacyclin in Krebs solution, human cell-free plasma or whole blood was measured by bracket assay on ADP-induced platelet aggregation. At 37°C, pH 7.4, plasma and blood reduced the rate of loss of antiaggregatory activity compared with Krebs solution. The protective effect of plasma was greater than that of whole blood. This effect could be partially mimicked by the addition of human or bovine serum albumin to the Krebs solution. The stabilisation afforded by human serum albumin was dependent on the fatty acid content of the albumin, although this was less important for bovine serum albumin.