Step-by-step Peritoneal Bladder Flap Bunching (PBFB) technique: an innovative approach following lymph node dissection in robotic radical prostatectomy

INTRODUCTION

Robot-assisted radical prostatectomy (RARP) has become a popular surgical approach for localized prostate cancer due to its favorable oncological and functional outcomes, as well as lower morbidity. In cases of intermediate- and high-risk prostate cancer, bilateral pelvic lymphadenectomy (PLND) is recommended as an adjunct to RARP (1-3). Despite its benefits, PLND can lead to surgical complications, with postoperative lymphocele formation being the most common. Most postoperative lymphoceles are clinically insignificant with variable incidence, reaching up to 60% of cases 4. However, a small percentage of patients 2-8% may experience symptomatic lymphoceles (SL), which can cause significant morbidity (4, 5).

SURGICAL TECHNIQUE

We perform our RARP technique with our standard approach in all patients (6). After vesicourethral anastomosis a modified PF created to prevent symptomatic lymphocele. We start by suturing the peritoneal fold on the right side, medially to the vas deferens, followed by a similar stitch on the left side to approximate the edges in the midline. A running suture bunches the bladder peritoneum from both sides, passing through the pubic bone periosteum to secure it in place (7). This approach keeps the lateral pelvic gutters open for lymphatic drainage, while allowing fluid drainage from the true pelvis into the abdomen. A pelvic ultrasound was done for all patients at 6 weeks post operative, and additional clinical follow-up was carried out at 3 months following surgery.

CONSIDERATIONS

We have demonstrated a modified technique of peritoneal flap (PBFB) with an initial decrease in postoperative symptomatic lymphoceles, the technique is feasible, safe, does not add significant morbidity, and does not require a learning curve.

Assessing Muscular Pain and Ergonomics Among Robotic Surgeons in China: A Validation

INTRODUCTION

Robotic surgery has transformed minimally invasive procedures, offering precision and efficiency. However, the ergonomic aspects of robotic consoles and their impact on surgeon health remain understudied. This review investigates the burden of ergonomics and muscle fatigue among robotic surgeons in China, comparing the findings to a multinational study.

METHODOLOGY

A literature review identified themes related to physical discomfort in robotic surgery. A questionnaire was administered to Chinese robotic surgeons, yielding 40 responses. The study assessed demographic characteristics, surgeon experience, ergonomic practices, reported discomfort, and pain-relief mechanisms.

RESULTS

The study revealed that most surgeons experienced shoulder and neck pain, with mixed opinions on whether robotic surgery was the primary cause. Stretching exercises were commonly used for pain relief. Surgeons believed that case volume and surgery duration contributed to discomfort. Comparisons with a multinational study suggested potential demographic and experience-related differences.

CONCLUSION

While the study has limitations, including a small sample size and potential translation issues, it underscores the importance of addressing ergonomic concerns and providing proper training to robotic surgeons to ensure their well-being and longevity in the field. Further research with larger cohorts and platform-specific analyses is warranted.

Peritoneal Flap Following Lymph Node Dissection in Robotic Radical Prostatectomy: A Novel "Bunching" Technique

BACKGROUND

Pelvic lymph node dissection (PLND) is recommended while performing robot-assisted radical prostatectomy (RARP) for patients with localized intermediate or high-risk prostate cancer. However, symptomatic lymphoceles can occur after surgery, adding significant morbidity to patients. Our objective is to describe a novel Peritoneal Bladder Flap Bunching technique (PBFB) to reduce the risk of clinically significant lymphoceles in patients undergoing RARP and PLND.

METHODS

We evaluated 2267 patients who underwent RARP with PLND, dividing them into two groups: Group 1, comprising 567 patients who had the peritoneal flap (PBFB), and Group 2, comprising 1700 patients without the flap; propensity score matching carried out at a 1:3 ratio. Variables analyzed included estimated blood loss (EBL), operative time, postoperative complications, lymphocele formation, and the development of symptomatic lymphocele.

RESULTS

The two groups exhibited similar preoperative characteristics after matching. There was no statistically significant difference in the occurrence of lymphoceles between the flap group and the non-flap group, with rates of 24% and 20.9%, respectively (p = 0.14). However, none of the patients in the flap group (0%) developed symptomatic lymphoceles, whereas 2.2% of patients in the non-flap group experienced symptomatic lymphoceles (p = 0.01).

CONCLUSION

We have demonstrated a modified technique for a peritoneal flap (PBFB) with the initial elimination of postoperative symptomatic lymphoceles and promising short-term outcomes.

Impact of Prostate Size on the Functional and Oncological Outcomes of Robot-assisted Radical Prostatectomy

BACKGROUND AND OBJECTIVE

Robot-assisted radical prostatectomy (RARP) is the main surgical approach for treatment of prostate cancer in the USA. Prostate size is always depicted as a factor affecting the outcomes of RARP as shown by many studies, but these studies are limited to a small number of patients. Our aim was to evaluate functional and oncologic outcomes of RARP across varying prostate size measured as prostate specimen weight.

METHODS

A cohort of 14 481 patients who underwent RARP in a single center was divided into four groups according to prostate specimen weight: group 1, <50 g; group 2, 50-100 g; group 3, 100-150 g; and group 4, >150 g. Perioperative and postoperative variables and pathological and functional outcomes were compared among the four groups. Cumulative incidence functions were plotted to visualize the distribution of event-time variables among the groups, and differences were evaluated using the log-rank test.

KEY FINDINGS AND LIMITATIONS

Patients with larger prostates (groups 3 and 4) were more likely to have higher prostate-specific antigen (PSA), lower biopsy grade group, and worse baseline urinary and sexual characteristics. Group 4 had lower rates of full nerve-sparing surgery (13.7% vs 38.3%) and lymph node dissection (51.3% vs 71.4%), more pT2 disease (69.8% vs 60.3%), less pT3 disease (30.2% vs 39.7%), and lower rates of positive surgical margins (12.8% vs 19.3%) and biochemical recurrence (5.9% vs 7.5%) than group 1. Finally, we observed differences in functional outcomes among the groups for greater prostate size, and patients in group 4 had worse rates of urinary continence (77.8% vs 89.5%) and recovery of sexual function (70.0% vs 84.1%) than group 1. Our study is limited by its retrospective design.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The results demonstrate that in this large cohort of patients, greater prostate size affects multiple outcomes, including the rate of nerve-sparing surgery, potency and continence recovery, and oncological and pathological outcomes. These data will be valuable when counseling patients regarding possible RARP outcomes and the timeline for recovery.

PATIENT SUMMARY

Our study shows that prostate size can affect the outcomes of robot-assisted removal of the prostate for patients with prostate cancer. Larger prostate size can be associated with worse functional outcomes after surgery.

Clinical applications of robotic surgery platforms: a comprehensive review

Robotic surgery has expanded globally across various medical specialties since its inception more than 20 years ago. Accompanying this expansion were significant technological improvements, providing tremendous benefits to patients and allowing the surgeon to perform with more precision and accuracy. This review lists some of the different types of platforms available for use in various clinical applications. We performed a literature review of PubMed and Web of Science databases in May 2023, searching for all available articles describing surgical robotic platforms from January 2000 (the year of the first approved surgical robot, da Vinci® System, by Intuitive Surgical) until May 1st, 2023. All retrieved robotic platforms were then divided according to their clinical application into four distinct groups: soft tissue robotic platforms, orthopedic robotic platforms, neurosurgery and spine platforms, and endoluminal robotic platforms. Robotic surgical technology has undergone a rapid expansion over the last few years. Currently, multiple robotic platforms with specialty-specific applications are entering the market. Many of the fields of surgery are now embracing robotic surgical technology. We review some of the most important systems in clinical practice at this time.

Technical and ethical considerations in telesurgery

Telesurgery, a cutting-edge field at the intersection of medicine and technology, holds immense promise for enhancing surgical capabilities, extending medical care, and improving patient outcomes. In this scenario, this article explores the landscape of technical and ethical considerations that highlight the advancement and adoption of telesurgery. Network considerations are crucial for ensuring seamless and low-latency communication between remote surgeons and robotic systems, while technical challenges encompass system reliability, latency reduction, and the integration of emerging technologies like artificial intelligence and 5G networks. Therefore, this article also explores the critical role of network infrastructure, highlighting the necessity for low-latency, high-bandwidth, secure and private connections to ensure patient safety and surgical precision. Moreover, ethical considerations in telesurgery include patient consent, data security, and the potential for remote surgical interventions to distance surgeons from their patients. Legal and regulatory frameworks require refinement to accommodate the unique aspects of telesurgery, including liability, licensure, and reimbursement. Our article presents a comprehensive analysis of the current state of telesurgery technology and its potential while critically examining the challenges that must be navigated for its widespread adoption.

Oncologic outcomes with and without amniotic membranes in robotic-assisted radical prostatectomy: A propensity score matched analysis

Objective

Placement of human placenta derived grafts during robotic-assisted radical prostatectomy (RARP) hastens the return of continence and potency. The long-term impact on the oncologic outcomes remains to be investigated. Our objective was to determine the oncologic outcomes of patients with dehydrated human amnion chorion membrane (dHACM) at RARP compared to a matched cohort.

Methods

In a referral centre, from August 2013 to October 2019, 599 patients used dHACM in bilateral nerve-sparing RARP. We excluded patients with less than 12 months follow-up, simple prostatectomy, and unilateral nerve-sparing. Patients with dHACM (amnio group) were 529, and were propensity score matched 1:1 to 2465 patients without dHACM (non-amnio group) and a minimum follow-up of 36 months. At the time of RARP, dHACM was placed around the neurovascular bundle in the amnio group. Continuous and categorical variables in matched groups was tested by two-sample Kolmogorov-Smirnov test and Fisher's exact test respectively. Outcomes measured were biochemical recurrence (BCR), adjuvant and salvage therapy rates.

Results

Propensity score matching resulted in two groups of 444 patients. Cumulative incidence functions for BCR did not show a difference between the groups (p=0.3). Patients in the non-amnio group required salvage therapy more frequently than the amnio group, particularly after partial nerve-sparing RARP (6.3% vs. 2.3%, p=0.001). Limitations are the absence of prospective randomization.

Conclusion

The data suggest that using dHACM does not have a negative impact on BCR in patients. Outcomes of cancer specific and overall survival will require follow-up study to increase our understanding of these grafts' impact on prostate cancer biology.

Muscle fatigue and physical discomfort reported by surgeons performing robotic-assisted surgery: a multinational survey

Robotic surgery has revolutionized surgical procedures and has provided many advantages over traditional laparoscopic and open surgeries. Despite the benefits, there are concerns about the physical discomfort and injuries that may be experienced by surgeons during robotic surgeries. This study aimed to identify the most common muscle groups implicated in robotic surgeons' physical pain and discomfort. A questionnaire was created and sent to 1000 robotic surgeons worldwide, with a response rate of 30.9%. The questionnaire consisted of thirty-seven multiple-choice questions, three short answer questions, and one multiple-option question pertaining to the surgeon's workload as well as their level of discomfort while and after performing surgery. The primary endpoint was to identify the most common muscle groups implicated in robotic surgeons' physical pain and discomfort. Secondary endpoints were to highlight any correlation between age group, BMI, hours of operation, workout regimen, and significant pain levels. The results showed that the most common muscle groups implicated in physical pain and discomfort were the neck, shoulders, and back, with many of the surgeons attributing their muscular fatigue and discomfort to the ergonomic design of the surgeon console. Despite the level of surgeon comfort the robotic console provides when compared to other conventional forms of surgery, the findings suggest the need for better ergonomic practices during robotic surgeries to minimize physical discomfort and injuries for surgeons.

Association between APOE genotype and microglial cell morphology

APOE is the largest genetic risk factor for late-onset Alzheimer disease (AD) with E4 conferring an increased risk for AD compared to E3. The ApoE protein can impact diverse pathways in the brain including neuroinflammation but the precise impact of ApoE isoforms on inflammation remains unknown. As microglia are a primary source of neuroinflammation, this study determined whether ApoE isoforms have an impact on microglial morphology and activation using immunohistochemistry and digital analyses. Analysis of ionized calcium-binding adaptor molecule 1 (Iba1) immunoreactivity indicated greater microglial activation in both the hippocampus and superior and middle temporal gyrus (SMTG) in dementia participants versus non-demented controls. Further, only an increase in activation was seen in E3-Dementia participants in the entire SMTG, whereas in the grey matter of the SMTG, only a diagnosis of dementia impacted activation. Specific microglial morphologies showed a reduction in ramified microglia in the dementia group. For rod microglia, a reduction was seen in E4-Control patients in the hippocampus whereas in the SMTG an increase was seen in E4-Dementia patients. These findings suggest an association between ApoE isoforms and microglial morphologies and highlight the importance of considering ApoE isoforms in studies of AD pathology.

Impact of thyroid hormone perturbations in adult mice: brain weight and blood vessel changes, gene expression variation, and neurobehavioral outcomes

Mouse models of hyper- and hypothyroidism were used to examine the effects of thyroid hormone (TH) dyshomeostasis on the aging mammalian brain. 13-14 month-old mice were treated for 4months with either levothyroxine (hyperthyroid) or a propylthiouracil and methimazole combination (PTU/Met; hypothyroid). Hyperthyroid mice performed better on Morris Water Maze than control mice, while hypothyroid mice performed worse. Brain weight was increased in thyroxine-treated, and decreased in PTU/Met-treated animals. The brain weight change was strongly correlated with circulating and tissue T4. Quantitative measurements of microvessels were compared using digital neuropathologic methods. There was an increase in microvessel area in hyperthyroid mice. Hypothyroid mice showed a trend for elevated glial fibrillary acidic protein-immunoreactive astrocytes, indicating an increase in neuroinflammation. Gene expression alterations were associated with TH perturbation and astrocyte-expressed transcripts were particularly affected. For example, expression of Gli2 and Gli3, mediators in the Sonic Hedgehog signaling pathway, were strongly impacted by both treatments. We conclude that TH perturbations produce robust neurobehavioral, pathological, and brain gene expression changes in aging mouse models.

Examining the association between blood-based biomarkers and human post mortem neuropathology in the University of Kentucky Alzheimer's Disease Research Center autopsy cohort

INTRODUCTION

Clinically, detection of disease-causing pathology associated with Alzheimer's disease (AD) and vascular contributions to cognitive impairment and dementia (VCID) is limited to magnetic resonance imaging and positron emission tomography scans, which are expensive and not widely accessible. Here, we assess angiogenic, inflammatory, and AD-related plasma biomarkers to determine their relationships with human post mortem neuropathology.

METHOD

Plasma samples were analyzed using a digital immunoassay and pathological evaluation was performed by University of Kentucky Alzheimer's Disease Research Center neuropathologists. The association of plasma markers with neuropathology was estimated via proportional odds and logistic regressions adjusted for age.

RESULTS

Included cases (N = 90) showed increased tau/amyloid beta (Aβ)42 ratio, glial fibrillary acidic protein (GFAP), vascular endothelial growth factor A (VEGF-A), and placental growth factor (PlGF) were positively associated with higher level of AD neuropathological change, while higher Aβ42/Aβ40 ratio was inversely associated. Higher PlGF, VEGF-A, and interleukin 6 were inversely associated with chronic cerebrovascular disease, while Aβ42/Aβ40 ratio was positively associated.

DISCUSSION

Our results provide support for the continued study of plasma biomarkers as a clinical screening tool for AD and VCID pathology.

Genetic expression changes and pathologic findings associated with hyperhomocysteinemia in human autopsy brain tissue

Introduction

Vascular contributions to cognitive impairment and dementia (VCID) are a leading cause of dementia. An underappreciated, modifiable risk factor for VCID is hyperhomocysteinemia (HHcy), defined by elevated levels of plasma homocysteine, most often due to impaired B vitamin absorption in aged persons. Studies aimed at identifying neuropathologic features and gene expression profiles associated with HHcy have been lacking.

Methods

A subset of research volunteers from the University of Kentucky Alzheimer's Disease Research Center longitudinal cohort came to autopsy and had ante mortem plasma homocysteine levels available. Brain tissue and blood plasma drawn closest to death were used to measure homocysteine and related metabolites in the current pilot study. Genetic expression profiles of inflammatory markers were evaluated using the Human Neuroinflammation NanoString panel. Further analyses included an evaluation of plasma homocysteine effects on amyloid beta, tau, ionized calcium-binding adaptor molecule 1, and glial fibrillary acidic protein immunohistochemistry in the frontal and occipital cortices. Analytes and other study outcomes were evaluated in relation to ante mortem HHcy status: We identified 13 persons with normal ante mortem plasma homocysteine levels (<14 µmol/L) and 18 who had high plasma homocysteine levels (≥14 µmol/L).

Results

Participants with HHcy demonstrated increased levels of several plasma homocysteine cycle metabolites such as total cysteine, S-adenosyl-homocysteine, cystathionine, and choline. Inflammatory gene expression profiles showed a general downregulation in the setting of elevated plasma homocysteine. HHcy was associated with more and longer microglial processes, but smaller and fewer astrocytes, especially in participants of older age at death. HHcy in older participants was also associated with occipital cortex microhemorrhages and increased severity of atherosclerosis throughout the cerebral vasculature.

Conclusions

Increased plasma homocysteine and older age were associated with the downregulation of inflammatory gene expression markers in association with significant glial and vascular pathology changes. Impaired immune function is a plausible mechanism by which HHcy increases cerebrovascular damage leading to impaired cognitive function.

Step-by-step optimisation of robotic-assisted radical prostatectomy using augmented reality

Introduction:

Surgical Technique:

Considerations:

Step-by-step optimisation of robotic-assisted radical prostatectomy using augmented reality

Introduction:

Surgical training will be complemented by digitalisation, as the COVID 19 pandemic continues (1 ). Proximie is an augmented reality (AR) platform that can display up to 4 native camera views, with live or semi live telementoring. It can optimise ergonomics of the surgeon at the console (2 ), and robotic instrument orientation. We describe the utilisation of Proximie as a step-by-step guide in a robotic assisted radical prostatectomy (RARP).

Surgical Technique:

Author V. P. performed a transperitoneal multiport da Vinci Xi RARP with the Proximie platform: a laptop computer, multiple HD webcams, microphones and speakers. Using an HDMI cable to the Intuitive Surgical tower, output display from the console and an additional laparoscopic tower is shown. Each webcam was mounted to the side armrests of the console, directed at the surgeon's hands. An independent ‘drop in’ laparoscope via an additional 5mm left upper quadrant port was utilised. Observers can visualise the AR platform's recordings on a laptop and/or smartphone. A PTZ (pan-tilt-zoom) camera can capture the operating room, bedside assistant, ports and patient position. Our video demonstrates three of four camera views for posture, forearm, wrist, hand, and finger orientation, relative to the translated robotic steps. A pincer grasp of the endowrist manipulator during anastomosis allows optimal robotic wrist rotation. The second laparoscopic camera view demonstrated intracorporeal angles of robotic arm and bedside assistant's instrument position for critical steps such as nerve sparing and anastomosis (3 ). The console time was 100 minutes, no intraoperative complications, or delay in image transmission occurred with utilising the platform.

Considerations:

An AR platform can create deeper learning for RARP in real time or recorded sessions. Two-way verbal and visual communication with ability to annotate on screen, allows long distance mentoring. The platform's utility can be accessed in anywhere, to project surgeons beyond their immediate environment. This allows for democratisation of access to high volume institutions and their evolution of techniques (4 ), to assist patients globally. Potential developments are artificial intelligence (AI) networks analysing repository of such recorded data, to identify intraoperative hand motion and robotic instrument tracking. AR is a pertinent building block to enhance robotic training, skill dissemination, precision medicine (5 ) and surgery overall.

Inflammatory Pathways Are Impaired in Alzheimer Disease and Differentially Associated With Apolipoprotein E Status

Alzheimer disease (AD) is a neurodegenerative disease characterized by a cognitive decline leading to dementia. The most impactful genetic risk factor is apolipoprotein E (APOE). APOE-ε4 significantly increases AD risk, APOE-ε3 is the most common gene variant, and APOE-ε2 protects against AD. However, the underlying mechanisms of APOE-ε4 on AD risk remains unclear, with APOE-ε4 impacting many pathways. We investigated how the APOE isoforms associated with the neuroinflammatory state of the brain with and without AD pathology. Frozen brain tissue from the superior and middle temporal gyrus was analyzed from APOE-ε3/3 (n = 9) or APOE-ε4/4 (n = 10) participants with AD pathology and APOE-ε3/3 (n = 9) participants without AD pathology. We determined transcript levels of 757 inflammatory related genes using the NanoString Human Neuroinflammation Panel. We found significant pathways impaired in APOE-ε4/4-AD individuals compared to APOE-ε3/3-AD. Of interest, expression of genes related to microglial activation (SALL1), motility (FSCN1), epigenetics (DNMT1), and others showed altered expression. Additionally, we performed immunohistochemistry of P2RY12 to confirm reduced microglial activation. Our results suggest APOE-ε3 responds to AD pathology while potentially having a harmful long-term inflammatory response, while APOE-ε4 shows a weakened response to pathology. Overall, APOE isoforms appear to modulate the brain immune response to AD-type pathology.

The Development of Therapeutic Radiographers in Imaging and Adaptive Radiotherapy Through Clinical Trial Quality Assurance

AIMS

Adaptive radiotherapy (ART) is an emerging advanced treatment option for bladder cancer patients. Therapeutic radiographers (RTTs) are central to the successful delivery of this treatment. The purpose of this work was to evaluate the image-guided radiotherapy (IGRT) and ART experience of RTTs before participating in the RAIDER trial. A plan of the day (PoD) quality assurance programme was then implemented. Finally, the post-trial experience of RTTs was evaluated, together with the impact of trial quality assurance participation on their routine practice.

MATERIALS AND METHODS

A pre-trial questionnaire to assess the experience of the RTT staff group in IGRT and ART in bladder cancer was sent to each centre. Responses were grouped according to experience. The PoD quality assurance programme was implemented, and the RAIDER trial commenced. During stage 1 of the trial, RTTs reported difficulties in delivering PoD and the quality assurance programme was updated accordingly. A follow-up questionnaire was sent assessing experience in IGRT and ART post-trial. Any changes in routine practice were also recorded.

RESULTS

The experience of RTTs in IGRT and ART pre-trial varied. For centres deemed to have RTTs with more experience, the initial PoD quality assurance programme was streamlined. For RTTs without ART experience, the full quality assurance programme was implemented, of which 508 RTTs completed. The quality assurance programme was updated (as the trial recruited) and it was mandated that at least one representative RTT (regardless of pre-trial experience) participated in the update in real-time. The purpose of the updated quality assurance programme was to provide further support to RTTs in delivering a complex treatment. Engagement with the updated quality assurance programme was high, with RTTs in 24/33 centres participating in the real-time online workshop. All 33 UK centres reported all RTTs reviewed the updated training offline. Post-trial, the RTTs' experience in IGRT and ART was increased.

CONCLUSION

Overall, 508 RTTs undertook the PoD quality assurance programme. There was a high engagement of RTTs in the PoD quality assurance programme and trial. RTTs increased their experience in IGRT and ART and subsequently updated their practice for bladder cancer and other treatment sites.

Dystrophic microglia are associated with neurodegenerative disease and not healthy aging in the human brain

Loss of physiological microglial function may increase the propagation of neurodegenerative diseases. Cellular senescence is a hallmark of aging; thus, we hypothesized age could be a cause of dystrophic microglia. Stereological counts were performed for total microglia, 2 microglia morphologies (hypertrophic and dystrophic) across the human lifespan. An age-associated increase in the number of dystrophic microglia was found in the hippocampus and frontal cortex. However, the increase in dystrophic microglia was proportional to the age-related increase in the total number of microglia. Thus, aging alone does not explain the presence of dystrophic microglia. We next tested if dystrophic microglia could be a disease-associated microglia morphology. Compared with controls, the number of dystrophic microglia was greater in cases with either Alzheimer's disease, dementia with Lewy bodies, or limbic-predominant age-related TDP-43 encephalopathy. These results demonstrate that microglia dystrophy, and not hypertrophic microglia, are the disease-associated microglia morphology. Finally, we found strong evidence for iron homeostasis changes in dystrophic microglia, providing a possible molecular mechanism driving the degeneration of microglia in neurodegenerative disease.

The complete mitochondrial genome of a gray reef shark, Carcharhinus amblyrhynchos (Carcharhiniformes: Carcharhinidae), from the Western Indian Ocean

We present the mitochondrial genome sequence of a gray reef shark, Carcharhinus amblyrhynchos (Bleeker 1856), a coral reef associated species. This is the first mitogenome for this species from the western Indian Ocean. The mitogenome is 16,705 bp in length, has 13 protein-coding genes, 22 tRNA genes, 2 rRNA genes and a non-coding control region, and demonstrates a gene arrangement congruent with other shark and most vertebrate species. This mitogenome provides a genomic resource for assisting with population, evolutionary and conservation studies for the gray reef shark, which is increasingly under threat from fisheries.

Assessment of the threatened carnivore community in the recently expanded rainforest protected area Anjanaharibe-Sud Special Reserve, Madagascar

Madagascar is an island nation renowned for its biodiversity and species endemism, yet it is still largely understudied despite intense anthropogenic threats including forest loss and edge effects. Anjanaharibe-Sud Special Reserve is a recently expanded rainforest protected area that is lacking detailed surveys and assessments of the native carnivore community of the endemic family Eupleridae. To identify which terrestrial carnivores occupy the reserve and what anthropogenic disturbances and factors best explain their occurrence patterns, we deployed 35 motion-activated cameras to detect native and introduced carnivores. From November 2018 to February 2019, we collected 2918 unique capture events (all species) and confirmed the presence of 5 euplerids: Galidia elegans, Galidictis fasciata, Eupleres goudotii, Fossa fossana, and Cryptoprocta ferox. These results extend the known range of E. goudotii and G. fasciata. In the reserve, F. fossana and G. elegans were the most common and widespread native carnivores, while E. goudotii was the rarest. We highlight the negative impact of edge effects on G. fasciata and F. fossana and the threat posed by the free-ranging non-native carnivore C. familiaris. This study represents the first detailed survey and occurrence estimates of the carnivore community of this protected area, allowing comparison with other protected areas in Madagascar. Our empirical findings show that anthropogenic disturbance negatively impacts carnivore existence within the Anjanaharibe-Sud Special Reserve and provide important management recommendations for protecting the carnivore community and the co-occurring wildlife living within this area.

Diffuse Amyloid-β Plaques, Neurofibrillary Tangles, and the Impact of APOE in Elderly Persons' Brains Lacking Neuritic Amyloid Plaques

Data from a large autopsy series were analyzed to address questions pertinent to primary age-related tauopathy (PART) and Alzheimer's disease (AD): what factors are associated with increased severity of neurofibrillary degeneration in brains that lack neuritic amyloid plaques?; is there an association between Apolipoprotein E (APOE) alleles and PART pathologic severity independent of amyloid-β (Aβ) deposits?; and, how do the stains used to detect plaques and tangles impact the experimental results? Neuropathologic data were evaluated from elderly research volunteers whose brain autopsies were performed at University of Kentucky Alzheimer's Disease Center (UK-ADC; N = 145 subjects). All of the included subjects' brains lacked neuritic amyloid plaques according to the CERAD diagnostic criteria and the average final MMSE score before death was 26.8±4.6 stdev. The study incorporated evaluation of tissue with both silver histochemical stains and immunohistochemical stains to compare results; the immunohistochemical stains (Aβ and phospho-tau) were scanned and quantified using digital pathologic methods. Immunohistochemical stains provided important advantages over histochemical stains due to sensitivity and detectability via digital methods. When AD-type pathology was in its presumed earliest phases, neocortical parenchymal Aβ deposits were associated with increased medial temporal lobe neurofibrillary tangles. The observation supports the NIA-AA consensus recommendation for neuropathologic diagnoses, because even these "diffuse" Aβ deposits signal that AD pathobiologic mechanisms are occurring. Further, the data were most compatible with the hypothesis that the APOEɛ4 allele exerts its effect(s) via driving Aβ deposition, i.e., an "upstream" influence, rather than being associated directly with Aβ- independent PART pathology.

The Amygdala as a Locus of Pathologic Misfolding in Neurodegenerative Diseases

Over the course of most common neurodegenerative diseases the amygdala accumulates pathologically misfolded proteins. Misfolding of 1 protein in aged brains often is accompanied by the misfolding of other proteins, suggesting synergistic mechanisms. The multiplicity of pathogenic processes in human amygdalae has potentially important implications for the pathogenesis of Alzheimer disease, Lewy body diseases, chronic traumatic encephalopathy, primary age-related tauopathy, and hippocampal sclerosis, and for the biomarkers used to diagnose those diseases. Converging data indicate that the amygdala may represent a preferential locus for a pivotal transition from a relatively benign clinical condition to a more aggressive disease wherein multiple protein species are misfolded. Thus, understanding of amygdalar pathobiology may yield insights relevant to diagnoses and therapies; it is, however, a complex and imperfectly defined brain region. Here, we review aspects of amygdalar anatomy, connectivity, vasculature, and pathologic involvement in neurodegenerative diseases with supporting data from the University of Kentucky Alzheimer's Disease Center autopsy cohort. Immunohistochemical staining of amygdalae for Aβ, Tau, α-synuclein, and TDP-43 highlight the often-coexisting pathologies. We suggest that the amygdala may represent an "incubator" for misfolded proteins and that it is possible that misfolded amygdalar protein species are yet to be discovered.

Detergent Insoluble Proteins and Inclusion Body-Like Structures Immunoreactive for PRKDC/DNA-PK/DNA-PKcs, FTL, NNT, and AIFM1 in the Amygdala of Cognitively Impaired Elderly Persons

Misfolded protein in the amygdala is a neuropathologic feature of Alzheimer disease and many other neurodegenerative disorders. We examined extracts from human amygdala (snap-frozen at autopsy) to investigate whether novel and as yet uncharacterized misfolded proteins would be detectable. Polypeptides from the detergent-insoluble, urea-soluble protein fractions of amygdala were interrogated using liquid chromatography-electrospray ionization-tandem mass spectrometry. Among the detergent-insoluble proteins identified in amygdala of demented subjects but not controls were Tau, TDP-43, Aβ, α-synuclein, and ApoE. Additional detergent-insoluble proteins from demented subjects in the high-molecular weight portion of SDS gels included NNT, TNIK, PRKDC (DNA-PK, or DNA-PKcs), ferritin light chain (FTL), AIFM1, SYT11, STX1B, EAA1, COL25A1, M4K4, CLH1, SQSTM, SYNJ1, C3, and C4. In follow-up immunohistochemical experiments, NNT, TNIK, PRKDC, AIFM1, and FTL were observed in inclusion body-like structures in cognitively impaired subjects' amygdalae. Double-label immunofluorescence revealed that FTL and phospho-PRKDC immunoreactivity colocalized partially with TDP-43 and/or Tau inclusion bodies. Western blots showed high-molecular weight "smears", particularly for NNT and PRKDC. A preliminary genetic association study indicated that rare NNT, TNIK, and PRKDC gene variants had nominally significant association with Alzheimer-type dementia risk. In summary, novel detergent-insoluble proteins, with evidence of proteinaceous deposits, were found in amygdalae of elderly, cognitively impaired subjects.

Abstract TMP118: Potential Therapeutic Benefits of Perlecan Domain V in Preclinical Vascular Dementia and Cerebral Angiopathy

Vascular contributions to cognitive impairment and dementia (VCID), the second leading cause of dementia behind Alzheimer’s disease (AD), is a broad term that encompasses a spectrum of initial asymptomatic cerebrovascular changes (seen in small vessel disease and cerebral amyloid angiopathy where pathologic Aβ1-42 protein accumulates around brain blood vessels) to the profound symptomatic damage following acute stroke(s). Cerebrovascular remodeling and new blood vessel growth (angiogenesis) may represent early compensatory changes to reduced cerebral blood flow that can initiate VCID. Angiogenesis, in turn, is supported by various growth factors and the proteolytic turnover of surrounding extracellular matrix. We have demonstrated that one such extracellular matrix protein, perlecan (a heparan sulfate proteoglycan), possesses a C terminal domain V (DV) protein that upon cleavage greatly enhances brain angiogenesis. We characterized VCID induced changes in DV expression in the human parietal cortex and a distinct mouse model (diabetic APP/PS1 knock in (db/AD)), that has a gradual cognitive decline by 9 months with microangiopathy, Aβ1-42 deposition, aneurysms, and microhemorrhages. We also utilized an in vitro model of the blood-brain barrier (BBB) to assess the transport of human Aβ1-42 in the presence of DV. In the human parietal cortex, dementia patients had increased expression of DV despite having fewer cells. In db/AD animals (3-6 months), we observed a decrease in BBB proteins (i.e. claudin-5), indicating that altered function correlated with an increase in brain DV expression during the asymptomatic angiogenic stage, which precedes cognitive changes (9-12 months). In vitro, DV doubled the transport of Aβ1-42 into the lumen of cerebral microvessels over 24 hours with increased activity and total protein expression of P-glycoprotein (P-gp), one of Aβ’s known transport proteins. Collectively, these data indicate that early cerebrovascular changes induce angiogenic-remodeling that correlates with increased expression of DV. DV, in turn, may further enhance angiogenesis and increase brain Aβ clearance into the vascular compartment through P-gp, suggesting that DV could represent a novel therapeutic for VCID.

Rod-shaped microglia morphology is associated with aging in 2 human autopsy series

A subtype of microglia is defined by the morphological appearance of the cells as rod shaped. Little is known about this intriguing cell type, as there are only a few case reports describing rod-shaped microglia in the neuropathological literature. Rod-shaped microglia were shown recently to account for a substantial proportion of the microglia cells in the hippocampus of both demented and cognitively intact aged individuals. We hypothesized that aging could be a defining feature in the occurrence of rod-shaped microglia. To test this hypothesis, 2 independent series of autopsy cases (total n = 168 cases), which covered the adult lifespan from 20 to 100+ years old, were included in the study. The presence or absence of rod-shaped microglia was scored on IBA1 immunohistochemically stained slides for the hippocampus and cortex. We found that age was one of the strongest determinants for the presence of rod-shaped microglia in the hippocampus and the cortex. We found no association with the presence of rod-shaped microglia and a self-reported history of a TBI. Alzheimer's disease-related pathology was found to influence the presence of rod-shaped microglia, but only in the parietal cortex and not in the hippocampus or temporal cortex. Future studies are warranted to determine the functional relevance of rod-shaped microglia in supporting the health of neurons in the aged brain, and the signaling processes that regulate the formation of rod-shaped microglia.

A proteomic approach for the rapid, multi-informative and reliable identification of blood

Blood evidence is frequently encountered at the scene of violent crimes and can provide valuable intelligence in the forensic investigation of serious offences.

Brain pathologies in extreme old age

With an emphasis on evolving concepts in the field, we evaluated neuropathologic data from very old research volunteers whose brain autopsies were performed at the University of Kentucky Alzheimer's Disease Center, incorporating data from the Georgia Centenarian Study (n = 49 cases included), Nun Study (n = 17), and University of Kentucky Alzheimer's Disease Center (n = 11) cohorts. Average age of death was 102.0 (range: 98-107) years overall. Alzheimer's disease pathology was not universal (62% with "moderate" or "frequent" neuritic amyloid plaque densities), whereas frontotemporal lobar degeneration was absent. By contrast, some hippocampal neurofibrillary tangles (including primary age-related tauopathy) were observed in every case. Lewy body pathology was seen in 16.9% of subjects and hippocampal sclerosis of aging in 20.8%. We describe anatomic distributions of pigment-laden macrophages, expanded Virchow-Robin spaces, and arteriolosclerosis among Georgia Centenarians. Moderate or severe arteriolosclerosis pathology, throughout the brain, was associated with both hippocampal sclerosis of aging pathology and an ABCC9 gene variant. These results provide fresh insights into the complex cerebral multimorbidity, and a novel genetic risk factor, at the far end of the human aging spectrum.

Disease-related microglia heterogeneity in the hippocampus of Alzheimer's disease, dementia with Lewy bodies, and hippocampal sclerosis of aging

Introduction

Neuropathological, genetic, and biochemical studies have provided support for the hypothesis that microglia participate in Alzheimer’s disease (AD) pathogenesis. Despite the extensive characterization of AD microglia, there are still many unanswered questions, and little is known about microglial morphology in other common forms of age-related dementia: particularly, dementia with Lewy bodies (DLB) and hippocampal sclerosis of aging (HS-Aging). In addition, no prior studies have attempted to compare and contrast the microglia morphology in the hippocampus of various neurodegenerative conditions.

Results

Here we studied cases with pathologically-confirmed AD (n = 7), HS-Aging (n = 7), AD + HS-aging (n = 4), DLB (n = 12), and normal (cognitively intact) controls (NC) (n = 9) from the University of Kentucky Alzheimer’s Disease Center autopsy cohort. We defined five microglia morphological phenotypes in the autopsy samples: ramified, hypertrophic, dystrophic, rod-shaped, and amoeboid. The Aperio ScanScope digital neuropathological tool was used along with two well-known microglial markers: IBA1 (a marker for both resting and activated microglia) and CD68 (a lysosomal marker in macrophages/microglia associated with phagocytic cells). Hippocampal staining analyses included studies of subregions within the hippocampal formation and nearby white matter. Using these tools and methods, we describe variation in microglial characteristics that show some degree of disease specificity, including, (1) increased microglia density and number in HS-aging and AD + HS-aging; (2) low microglia density in DLB; (3) increased number of dystrophic microglia in HS-aging; and (4) increased proportion of dystrophic to all microglia in DLB.

Conclusions

We conclude that variations in morphologies among microglial cells, and cells of macrophage lineage, can help guide future work connecting neuroinflammatory mechanisms with specific neurodegenerative disease subtypes.

Digital pathology and image analysis for robust high-throughput quantitative assessment of Alzheimer disease neuropathologic changes

Quantitative neuropathologic methods provide information that is important for both research and clinical applications. The technologic advancement of digital pathology and image analysis offers new solutions to enable valid quantification of pathologic severity that is reproducible between raters regardless of experience. Using an Aperio ScanScope XT and its accompanying image analysis software, we designed algorithms for quantitation of amyloid and tau pathologies on 65 β-amyloid (6F/3D antibody) and 48 phospho-tau (PHF-1)-immunostained sections of human temporal neocortex. Quantitative digital pathologic data were compared with manual pathology counts. There were excellent correlations between manually counted and digitally analyzed neuropathologic parameters (R² = 0.56-0.72). Data were highly reproducible among 3 participants with varying degrees of expertise in neuropathology (intraclass correlation coefficient values, >0.910). Digital quantification also provided additional parameters, including average plaque area, which shows statistically significant differences when samples are stratified according to apolipoprotein E allele status (average plaque area, 380.9 μm² in apolipoprotein E [Latin Small Letter Open E]4 carriers vs 274.4 μm² for noncarriers; p < 0.001). Thus, digital pathology offers a rigorous and reproducible method for quantifying Alzheimer disease neuropathologic changes and may provide additional insights into morphologic characteristics that were previously more challenging to assess because of technical limitations.

P3-07-42: Lymphovascular Invasion Best Correlates with Presence of Nodal Metastasis in Sentinel Lymph Node Biopsy

Background. Sentinel lymph node biopsy (SLNB) biopsy is routinely practised for axillary staging with 25–30% having positive SLN. Tumour size is the most important parameter taken into consideration in decision making in node negative patients with a size cut off for 4–5cm dependant on different units. Lymphovascular invasion (LVI) and Ki-67 a cell-cycle antigen are known important prognostic markers along with the tumour grade, oestrogen receptor and herceptin receptor status.

Aim. To examine whether lymphovascular invasion, Ki-67 or any other factors can be used as a predictor for axillary lymph node involvement and hence prognosis.

METHODS. A prospective study of 264 patients with invasive breast cancer undergoing SLN biopsy between January 2009 and December 2010.

Histopathology reports were reviewed regarding LVI, Ki-67, grade, oestrogen, Progesterone and Herceptin receptor and SLN status. Stats direct was used to analyse data. Logistic regression was used and p-value calculated.

RESULTS. LVI (p value=0.0001) and size(p value=0.0273) were the two most significant factors associated with node positivity. Grade of tumour had a p-value of 0.0825 and Ki67 had a p-value of 0.5217 which were not significant.

Hippocampal sclerosis in advanced age: clinical and pathological features

Hippocampal sclerosis is a relatively common neuropathological finding (∼10% of individuals over the age of 85 years) characterized by cell loss and gliosis in the hippocampus that is not explained by Alzheimer's disease. Hippocampal sclerosis pathology can be associated with different underlying causes, and we refer to hippocampal sclerosis in the aged brain as hippocampal sclerosis associated with ageing. Much remains unknown about hippocampal sclerosis associated with ageing. We combined three different large autopsy cohorts: University of Kentucky Alzheimer's Disease Centre, the Nun Study and the Georgia Centenarian Study to obtain a pool of 1110 patients, all of whom were evaluated neuropathologically at the University of Kentucky. We focused on the subset of cases with neuropathology-confirmed hippocampal sclerosis (n=106). For individuals aged≥95 years at death (n=179 in our sample), each year of life beyond the age of 95 years correlated with increased prevalence of hippocampal sclerosis pathology and decreased prevalence of 'definite' Alzheimer's disease pathology. Aberrant TAR DNA protein 43 immunohistochemistry was seen in 89.9% of hippocampal sclerosis positive patients compared with 9.7% of hippocampal sclerosis negative patients. TAR DNA protein 43 immunohistochemistry can be used to demonstrate that the disease is usually bilateral even when hippocampal sclerosis pathology is not obvious by haematoxylin and eosin stains. TAR DNA protein 43 immunohistochemistry was negative on brain sections from younger individuals (n=10) after hippocampectomy due to seizures, who had pathologically confirmed hippocampal sclerosis. There was no association between cases with hippocampal sclerosis associated with ageing and apolipoprotein E genotype. Age of death and clinical features of hippocampal sclerosis associated with ageing (with or without aberrant TAR DNA protein 43) were distinct from previously published cases of frontotemporal lobar degeneration TAR DNA protein 43. To help sharpen our ability to discriminate patients with hippocampal sclerosis associated with ageing clinically, the longitudinal cognitive profile of 43 patients with hippocampal sclerosis associated with ageing was compared with the profiles of 75 controls matched for age, gender, education level and apolipoprotein E genotype. These individuals were followed from intake assessment, with 8.2 (average) longitudinal cognitive assessments. A neuropsychological profile with relatively high-verbal fluency but low word list recall distinguished the hippocampal sclerosis associated with ageing group at intake (P<0.015) and also 5.5-6.5 years before death (P<0.005). This may provide a first step in clinical differentiation of hippocampal sclerosis associated with ageing versus pure Alzheimer's disease in their earliest stages. In summary, in the largest series of autopsy-verified patients with hippocampal sclerosis to date, we characterized the clinical and pathological features associated with hippocampal sclerosis associated with ageing.

Gastric emptying of hexose sugars: role of osmolality, molecular structure and the CCK₁ receptor

BACKGROUND

It is widely reported that hexose sugars slow gastric emptying (GE) via osmoreceptor stimulation but this remains uncertain. We evaluated the effects of a panel of hexoses of differing molecular structure, assessing the effects of osmolality, intra-individual reproducibility and the role of the CCK(1) receptor, in the regulation of GE by hexoses.

METHODS

Thirty one healthy non-obese male and female subjects were studied in a series of protocols, using a (13) C-acetate breath test to evaluate GE of varying concentrations of glucose, galactose, fructose and tagatose, with water, NaCl and lactulose as controls. GE was further evaluated following the administration of a CCK(1) receptor antagonist. Three subjects underwent repeated studies to evaluate intra-individual reproducibility.

KEY RESULTS

At 250 mOsmol, a hexose-specific effect was apparent: tagatose slowed GE more potently than water, glucose and fructose (P < 0.05). Fructose (P < 0.05) also slowed GE, but with substantial inter-, but not intra-, individual differences. As osmolality increased further the hexose-specific differences were lost. At 500 mOsmol, all hexoses slowed GE compared with water (P < 0.05), whereas lactulose and saline did not. The slowing of GE by hexose sugars appeared to be CCK(1) receptor-dependent.

CONCLUSIONS & INFERENCES

The effects of hexose sugars on GE appear related to their molecular structure rather than osmolality per se, and are, at least in part, CCK(1) receptor-dependent.

Brains with medial temporal lobe neurofibrillary tangles but no neuritic amyloid plaques are a diagnostic dilemma but may have pathogenetic aspects distinct from Alzheimer disease

Brains that have many neurofibrillary tangles (NFTs) in medial temporal lobe structures (Braak stage III or IV) but no cortical neuritic plaques (NPs) may be a diagnostic dilemma; they also raise questions about the amyloid cascade hypothesis of Alzheimer disease (AD) in which NFT development is thought to occur downstream of the development of amyloid plaques. To determine the clinical, demographic, and biological factors related to NFT+/NP- cases, we analyzed 26 NFT+/NP- patient brains identified from the University of Kentucky AD Center autopsy cohort (n=502); most of these patients were at least 85 years old and lacked profound antemortem cognitive impairment. A subset of the cases had NFTs in the medulla oblongata. Aberrant trans-activator regulatory DNA-binding protein 43 immunohistochemical staining was seen in 5 of the 26 cases with the clinical diagnoses of AD or mild cognitive impairment. We also queried cases in the National Alzheimer's Coordinating Center Registry (n=5,108) and found 219 NFT+/NP- cases. Those patients had a relatively high likelihood of belonging to a birth cohort with the highest incidence of influenza infection during the 1918 to 1919 pandemic. This observation may link the pathogenesis in NFT+/NP- cases to encephalitis during childhood. We conclude that NFT+/NP- cases comprise approximately 5% of aged individuals in multiple data sets; these cases are not necessarily within the spectrum of AD.

Modeling the association between 43 different clinical and pathological variables and the severity of cognitive impairment in a large autopsy cohort of elderly persons

We evaluated the association between mini-mental status examination (MMSE) scores proximal to death and the values of 43 different clinical and pathological parameters. Studies were performed using data from 334 elderly, longitudinally evaluated research subjects who had undergone autopsy and satisfied inclusion criteria from an initial study group of 501. Interindividual variance in MMSE scores was used as a surrogate for the severity of cognitive impairment linked to aging (CILA). A statistical linear regression-based model provided a framework for assessing the parameters with significant, direct impact on CILA severity. Strong association between CILA and Alzheimer's disease (AD) pathology, especially isocortical neurofibrillary tangles, was evident. The pattern of association between AD lesion densities with cognitive impairment severity was biologically informative, with neuritic plaques having more impact in relatively high-functioning individuals. Abundant isocortical Lewy bodies tended to be an additive pathology correlating with final MMSE scores approximately 10 points lower. In a subset of cases we found evidence for association between TDP-43-related pathology and CILA severity, independent of AD or hippocampal sclerosis. There was no support for independent association between CILA severity and most evaluated indices including diffuse plaques, argyrophilic grains, heart disease, education level, apolipoprotein E alleles or diabetes.

Alzheimer's-type neuropathology in the precuneus is not increased relative to other areas of neocortex across a range of cognitive impairment

We studied Alzheimer's disease (AD) pathology in the precuneus and surrounding brain areas. Anatomically, the precuneus corresponds to the medial portion of human cerebral cortical Brodmann Area 7. This study utilized patients from the University of Kentucky Alzheimer's Disease Center autopsy cohort. Data from 47 brains were used comprising patients of differing antemortem cognitive impairment severities, each with longitudinal clinical data and extensive neuropathological data. We assessed whether the precuneus and surrounding areas are differentially vulnerable to AD-type pathological lesions (diffuse amyloid plaques, neuritic amyloid plaques, and neurofibrillary tangles). Eleven areas of brain were evaluated for each case: amygdala, hippocampal CA1, subiculum, entorhinal cortex, frontal cortex, superior and middle temporal gyri, inferior parietal lobule, occipital cortex, posterior cingulate gyrus, Brodmann Area 31, and the precuneus proper. Like other areas of neocortex, the precuneus demonstrated increased diffuse and neuritic amyloid plaques early in the evolution in AD, and increased neurofibrillary tangles late in AD. Correcting for the antemortem cognitive status of the patients, there was no evidence of an increase in the density of AD-type pathology in the precuneus or neighboring areas relative to other areas of cerebral neocortex. Our results are not consistent with the idea that the precuneus is involved in a special way with plaques or tangles relative to other areas of neocortex.