811 DELIRIUM IN COVID-19: COMMON AND CLINICALLY SIGNIFICANT: EXPERIENCES FROM THE NIGHTINGALE HOSPITAL EXETER

Background

Delirium is an independent predictor of mortality in patients admitted with community-acquired pneumonia (Pieralli, 2014), but significance and incidence in Covid-19 infection has not been established. The Nightingale Hospital Exeter (NHE) as a multidisciplinary team model, managed 242 patients with Covid-19 from November 2020 to February 2021. This study identifies the delirium incidence, outcome, premorbid function and demographics of this cohort.

Methods

Electronic records were retrospectively reviewed for keywords ‘Delirium’, ‘Hyperactive’, ‘Hypoactive’, ‘Confused’ and ‘Muddled’. Patients were categorised as Hyperactive, Hypoactive or Confused/non-specified. Prior functional support (independent, package of care, residential or nursing care) and presence of pre-established neurological conditions (including dementia) were noted.

Results

242 patients were included, average age 84 years (range 59–102). Of these patients, 130 (54%) developed delirium (29 (22%) hyperactive, 37 (28%) hypoactive, 2 (1%) mixed and 62 (48%) ‘confused’/non-specified). Of those with delirium, 56 (43%) were previously living independently and 51 (39%) were living at home with a package of care. 60 (46%) of those diagnosed had no pre-existing neurological condition, 32% had underlying dementia. There were 37 deaths at NHE (mortality 15%), 73% of these patients had delirium during their admission compared to 50% of those who survived.

Conclusions

Over half this cohort developed delirium, a high proportion of whom had been living independently prior to admission with no pre-existing neurological condition, emphasising how common delirium is in patients with Covid-19. In a comparable cohort with pneumonia (mean age 82 years, range 65–99) 25% developed delirium, and it was an independent predictor of in-hospital mortality (Pieralli, 2014). The fact that 73% of all patients who died developed delirium suggests it may have important prognostic implications, and both this and the high incidence indicate further work is required to fully understand how to prevent and manage delirium in Covid-19.

Optimizing biologic sequencing in metastatic colorectal cancer: first line and beyond

Significant advances in the treatment of metastatic colorectal cancer (mcrc) since the early 2000s have led to improved clinical outcomes, including overall survival (os). When fluorouracil was the sole treatment agent for mcrc, os in phase iii studies was approximately 12 months. Now, in 2019, the median os (mos) in the most recent mcrc clinical trials has been approaching 3 years. The biologic agents that target the vascular endothelial growth factor (vegf), epithelial growth factor receptor (egfr), human epidermal growth factor receptor 2 (her2), PD-1, ctla-4, ntrk, and braf pathways play important roles in the mcrc treatment algorithm, given their significant-sometimes dramatic-activity. Emerging data indicate that the choice of a specific biologic at a particular time (line of treatment) for specific patient populations (based on tumour characteristics) is critical. In the present review, we discuss the available evidence for optimal biologic sequencing in the management of mcrc.

Abstract P6-21-03: Phase I trial of intratumoral (IT) administration of a NIS-expressing derivative manufactured from a genetically engineered strain of measles virus (MV)

Background: The live attenuated non-pathogenic Edmonston MV vaccine strain has advantages as an oncolytic platform given its tumor specificity, potent bystander effect, and ability to be engineered and retargeted. MV-NIS expresses the human thyroidal sodium-iodide symporter (NIS) and is selectively oncolytic, entering tumor cells through CD46 (overexpressed on many cancers, including breast cancer of all subtypes) and Nectin-4. NIS expression in MV-NIS infected cells permits noninvasive monitoring of virus spread by SPECT-CT imaging of Tc-99m pertechnetate or I-123 uptake.

Methods: NCT01846091 is a standard 3+3 phase I trial of a single IT administration of MV-NIS in pts with recurrent/metastatic squamous cell carcinoma of the head and neck (SCCHN) or metastatic breast cancer (MBC). Primary objectives are (a) safety and tolerability and (b) maximally tolerated single dose. The secondary clinical objective is to preliminarily assess antitumor efficacy at and away from the MV injection site. Key eligibility criteria were: absence of standard therapy with life prolonging intent; at least one lesion >1 cm amenable to percutaneous injection; and no impending visceral crisis. MV-NIS was administered on D1 with mandatory SPECT-CT at baseline (BL) and on D3&D8; repeat SPECT-CT on D15&D21 if the prior result was positive; mandatory tumor biopsies on D3&D21; optional tumor biopsies on D8&D15; assessments for viremia and viral shedding at BL and on D3,D8,D15,D21; and standard imaging for restaging at BL,D21,W6,W12.

Results: Accrual completed with 12 evaluable pts (6 SCCHN and 6 MBC) at 3 dose levels (108, 3x108, 109 TCID50). The MBC group included 5 HR+/HER2- pts and 1 pt with mixed HR+/HER2- and HR+/HER2+ disease. 5 pts had evidence of disease progression prior to study participation. No dose limiting toxicities were observed among the MBC pts; AEs possibly related to MV-NIS in this group were gr2 fatigue, gr1 flu-like illness, gr2 lymphopenia (all n=1). No SCCHN responses were observed. Best response for the MBC pts was: stable disease (SD) >6 wks, n=4; clinical response, n=1; progression, n=1. One MBC pt with SD for 12 wks had positive SPECT/CT imaging at and away from the injection site on D3&D8 and was the only pt seronegative for measles IgG antibodies prior to MV-NIS exposure. The MBC pt who responded after initial MV-NIS exposure was the only pt with low viral RNA in blood (D3); she received additional doses at W9&W13 without toxicity through an expanded access protocol exemption and had disease progression by W19. No viral shedding was detected from mouth rinse or urine in any pt. MV was detected in tumor samples from all pts treated at the highest dose level. Additional blood and tissue analyses are in progress.

Conclusion: These results demonstrate the safety of IT MV-NIS administration, provide early evidence of biologic activity in MBC, and support the possibility of viral replication in tumors remote from the IT injection site. A MV strain encoding the immunomodulatory neutrophil activating protein transgene has been constructed (MV-s-NAP) with preclinical evidence of improved antitumor activity and immunogenicity. The phase I MV-s-NAP trial will start recruitment in Fall 2018.

Citation Format: Liu MC, Peng K-W, Federspiel MJ, Russell SJ, Brunton BA, Zhou Y, Packiriswamy N, Hubbard JM, Loprinzi CL, Peethambaram PP, Ruddy KJ, Allred JB, Galanis E, Okuno SH. Phase I trial of intratumoral (IT) administration of a NIS-expressing derivative manufactured from a genetically engineered strain of measles virus (MV) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-21-03.

Abstract P5-07-16: Role of collagen X in enhancing the metastatic potential of breast cancer cells using a MDA-MB-231 cell line model

Breast cancer is the second highest cause of cancer related deaths for women in developed countries. Breast cancer patients with distant metastasis at the time of diagnosis have an estimated 5-year relative survival rate of 26% as compared to a 99% survival rate of patients who have localized tumors. Evidence suggests that collagens play a role in enhancing the metastatic capability of breast cancer cells. Short chain collagen, collagen X, is encoded by the collagen type x alpha 1 chain (COL10A1) gene and is normally expressed exclusively by hypertrophic chondrocytes during endochondral ossification. Recently, COL10A1 gene expression has been found to be overexpressed in various tumor types, including breast tumors. It is hypothesized that an increase in COL10A1 expression may play a role in breast cancer metastasis. The goal of our project was to evaluate the role of collagen X in breast cancer metastasis using the MDA-MB-231 breast cancer cell line. Stable cell lines were generated to express either GFP only (MDA-VEC) or GFP tagged COL10A1 (MDA-COL). GFP and COL10A1 transcript and protein levels were examined to confirm overexpression of collagen X and transwell assays were used to determine changes in the invasive capability of the cells. Cells overexpressing collagen X demonstrated a higher rate of invasion suggesting that collagen X may play a role in enhancing the metastatic potential of breast cancer cells. Understanding the role collagen X plays in breast cancer metastasis may provide a mechanism for developing diagnostic and prognostic strategies for identifying patients whose breast cancer is more prone to metastasize.

Citation Format: McKiernan K, Jimenez H, McEachern M, Hubbard J, O'Connell M. Role of collagen X in enhancing the metastatic potential of breast cancer cells using a MDA-MB-231 cell line model [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-07-16.

191 The effect of high and low doses of follicle-stimulating hormone on embryo collection in Romanov sheep

The use of embryo transfer in small ruminants has served as a way of increasing superior female genetics. This technique, although not new, has been adopted by an increasing number of breeders over the past few years. The Romanov sheep breed is considered a natural litter-bearing breed compared with other small ruminant species, which generally have only 1 or 2 offspring during a natural parturition. This experiment was designed to evaluate the effect of FSH dosage on embryo production and collection in Romanov sheep. Sheep donors (n=12), with an average age of 2±1.4 years and an average body weight of 43±6.7kg, were randomly assigned to either a high (175mg) or low (140mg) dosage treatment of FSH during the breeding season. Hormone injections were given in a decreasing dosage twice daily over a period of 5 days. Donors were naturally cycling before being subjected to a CIDR-G protocol for a period of 15 days, with hormone injections beginning on Day 11. Donors were mated with rams (n=2) of known fertility for a total of 3 hand matings. After the third hand mating, the ram was turned into the breeding pen with the ewes. Embryos were collected 7 days after breeding and evaluated for transfer. A one-way ANOVA was utilised to analyse statistical differences between groups with significance set at (0.05). Results are given as mean±s.e.m. Only embryos of quality grades 1 and 2 were transferred during this study. No differences were detected between the 2 groups for total embryos collected between both high (7.6±6) and low (6.6±5) FSH groups. Furthermore, no differences were detected between both high and low FSH groups for the number of embryos transferred (5.6±5 and 6.3±4, respectively). The results of this study suggest that a lower total dosage (140mg) of FSH can be used in superovulation programs of Romanov ewes without affecting the total number of embryos collected and transferred. However, further investigation should be performed with various levels of FSH to determine the most accurate dosage for Romanov sheep.

Identifying Spatial Variation Along the HIV Care Continuum: The Role of Distance to Care on Retention and Viral Suppression

Distance to HIV care may be associated with retention in care (RIC) and viral suppression (VS). RIC (≥ 2 HIV visits or labs ≥ 90 days apart in 12 months), prescribed antiretroviral therapy (ART), VS (< 200 copies/mL at last visit) and distance to care were estimated among 3623 DC Cohort participants receiving HIV care in 13 outpatient clinics in Washington, DC in 2015. Logistic regression models and geospatial statistics were computed. RIC was 73%; 97% were on ART, among whom 77% had VS. ZIP code-level clusters of low RIC and high VS were found in Northwest DC, and low VS in Southeast DC. Those traveling ≥ 5 miles had 30% lower RIC (adjusted odds ratio (aOR) 0.71, 95% CI 0.58, 0.86) and lower VS (OR 0.70, 95% CI 0.52, 0.94). Geospatial clustering of RIC and VS was observed, and distance may be a barrier to optimal HIV care outcomes.

Real-time gait analysis with accelerometer-based smart shoes

In this paper, we present the evaluation of a new smart shoe capable of performing gait analysis in real time. The system is exclusively based on accelerometers which minimizes the power consumption. The estimated parameters are activity class (rest/walk/run), step cadence, ground contact time, foot impact (zone, strength, and balance), forward distance, and speed. The different parameters have been validated with a customized database of 26 subjects on a treadmill and video data labeled manually. Key measures for running analysis such as the cadence is retrieved with a maximum error of 2%, and the ground contact time with an average error of 3.25%. The classification of the foot impact zone achieves a precision between 72% and 91% depending of the running style. The presented algorithm has been licensed to ICON Health & Fitness Inc. for their line of wearables under the brand iFit.

The transcriptome of human oocytes is related to age and ovarian reserve

STUDY QUESTION

How does the human oocyte transcriptome change with age and ovarian reserve?

SUMMARY ANSWER

Specific sets of human oocyte messenger RNAs (mRNAs) and non-coding RNAs (ncRNAs) are affected independently by age and ovarian reserve.

WHAT IS KNOWN ALREADY

Although it is well established that the ovarian reserve diminishes with increasing age, and that a woman's age is correlated with lower oocyte quality, the interplay of a diminished reserve and age on oocyte developmental competence is not clear. After maturation, oocytes are mostly transcriptionally quiescent, and developmental competence prior to embryonic genome activationrelies on maternal RNA and proteins.

STUDY DESIGN, SIZE, DURATION

A total of 36 vitrified/warmed MII oocytes from 30 women undergoing oocyte donation were included in this study, processed and analyzed individually.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Total RNA from each oocyte was independently isolated, amplified, labeled, and hybridized on HTA 2.0 arrays (Affymetrix). Data were analyzed using TAC software, in four groups, each including nine oocytes, according to the woman's age and antral follicular count (AFC) (mean ± SD): Young with High AFC (YH; age 21 ± 1 years and 24 ± 3 follicles); Old with High AFC (OH; age 32 ± 2 years and 29 ± 7 follicles); Young with Low AFC (YL; age 24 ± 2 years and 8 ± 2 follicles); Old with Low AFC (OL; age 34 ± 1 years and 7 ± 1 follicles). qPCR was performed to validate arrays.

MAIN RESULTS AND THE ROLE OF CHANCE

We identified a set of 30 differentially expressed mRNAs when comparing oocytes from women with different ages and AFC. In addition, 168 non-coding RNAs (ncRNAs) were differentially expressed in relation to age and/or AFC. Few mRNAs have been identified as differentially expressed transcripts, and among ncRNAs, a set of Piwi-interacting RNAs clusters (piRNAs-c) and precursor microRNAs (pre-miRNAs) were identified as increased in high AFC and old groups, respectively. Our results indicate that age and ovarian reserve are associated with specific ncRNA profiles, suggesting that oocyte quality might be mediated by ncRNA pathways.

LARGE SCALE DATA

Data can be found via GEO accession number GSE87201.

LIMITATIONS, REASONS FOR CAUTION

The oldest woman included in the study was 35 years old, thus our results cannot readily be extrapolated to women older than 35 or infertile women.

WIDER IMPLICATIONS OF THE FINDINGS

We show, for the first time, that several non-coding RNAs, usually regulating DNA transcription, are differentially expressed in relation to age and/or ovarian reserve. Interestingly, the mRNA transcriptome of in vivo matured oocytes remains remarkably stable across ages and ovarian reserve, suggesting the possibility that changes in the non-coding transcriptome might regulate some post-transcriptional/translational mechanisms which might, in turn, affect oocyte developmental competence.

STUDY FUNDING AND COMPETING INTEREST(S)

This work was supported by intramural funding of Clinica EUGIN and by the Secretary for Universities and Research of the Ministry of Economy and Knowledge of the Government of Catalonia. J.H. and A.S. are employees of Affymetrix, otherwise there are no competing interests.

Efficacy and safety of follitropin alfa/lutropin alfa in ART: a randomized controlled trial in poor ovarian responders

STUDY QUESTION

How does the efficacy and safety of a fixed-ratio combination of recombinant human FSH plus recombinant human LH (follitropin alfa plus lutropin alfa; r-hFSH/r-hLH) compare with that of r-hFSH monotherapy for controlled ovarian stimulation (COS) in patients with poor ovarian response (POR)?

SUMMARY ANSWER

The primary and secondary efficacy endpoints were comparable between treatment groups and the safety profile of both treatment regimens was favourable.

WHAT IS KNOWN ALREADY

Although meta-analyses of clinical trials have suggested some beneficial effect on reproductive outcomes with r-hLH supplementation in patients with POR, the definitions of POR were heterogeneous and limit the comparability across studies.

STUDY DESIGN, SIZE, DURATION

Phase III, single-blind, active-comparator, randomized, parallel-group clinical trial. Patients were followed for a single ART cycle. A total of 939 women were randomized (1:1) to receive either r-hFSH/r-hLH or r-hFSH. Randomization, stratified by study site and participant age, was conducted via an interactive voice response system.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women classified as having POR, based on criteria incorporating the ESHRE Bologna criteria, were down-regulated with a long GnRH agonist protocol and following successful down-regulation were randomized (1:1) to COS with r-hFSH/r-hLH or r-hFSH alone. The primary efficacy endpoint was the number of oocytes retrieved following COS. Safety endpoints included the incidence of adverse events, including ovarian hyperstimulation syndrome (OHSS). Post hoc analyses investigated safety outcomes and correlations between live birth and baseline characteristics (age and number of oocytes retrieved in previous ART treatment cycles or serum anti-Müllerian hormone (AMH)). The significance of the treatment effect was tested by generalized linear models (Poisson regression for counts and logistic regression for binary endpoints) adjusting for age and country.

MAIN RESULTS AND THE ROLE OF CHANCE

Of 949 subjects achieving down-regulation, 939 were randomized to r-hFSH/r-hLH (n = 477) or r-hFSH (n = 462) and received treatment.

Efficacy assessment: In the intention-to-treat (ITT) population, the mean (SD) number of oocytes retrieved (primary endpoint) was 3.3 (2.71) in the r-hFSH/r-hLH group compared with 3.6 (2.82) in the r-hFSH group (between-group difference not statistically significant). The observed difference between treatment groups (r-hFSH/r-hLH and r-hFSH, respectively) for efficacy outcomes decreased over the course of pregnancy (biochemical pregnancy rate: 17.3% versus 23.9%; clinical pregnancy rate: 14.1% versus 16.8%; ongoing pregnancy rate: 11.0% versus 12.4%; and live birth rate: 10.6% versus 11.7%). An interaction (identified post hoc) between baseline characteristics related to POR and treatment effect was noted for live birth, with r-hFSH/r-hLH associated with a higher live birth rate for patients with moderate or severe POR, whereas r-hFSH was associated with a higher live birth rate for those with mild POR. A post hoc logistic regression analysis indicated that the incidence of total pregnancy outcome failure was lower in the r-hFSH/r-hLH group (6.7%) compared with the r-hFSH group (12.4%) with an odds ratio of 0.52 (95% CI 0.33, 0.82; P = 0.005).

Safety assessment: The overall proportion of patients with treatment-emergent adverse events (TEAEs) occurring during or after r-hFSH/r-hLH or r-hFSH use (stimulation or post-stimulation phase) was 19.9% and 26.8%, respectively. There was no consistent pattern of TEAEs associated with either treatment.

LIMITATIONS, REASONS FOR CAUTION

Despite using inclusion criteria for POR incorporating the ESHRE Bologna criteria, further investigation is needed to determine the impact of the heterogeneity of POR in the Bologna patient population. The observed correlation between baseline clinical characteristics related to POR and live birth rate, as well as the observed differences between groups regarding total pregnancy outcome failure were from post hoc analyses, and the study was not powered for these endpoints. In addition, the attrition rate for pregnancy outcomes in this trial may not reflect general medical practice. Furthermore, as the patient population was predominantly White these results might not be applicable to other ethnicities.

WIDER IMPLICATIONS OF THE FINDINGS

In the population of women with POR investigated in this study, although the number of oocytes retrieved was similar following stimulation with either a fixed-ratio combination of r-hFSH/r-hLH or r-hFSH monotherapy, post hoc analyses showed that there was a lower rate of total pregnancy outcome failure in patients receiving r-hFSH/r-hLH, in addition to a higher live birth rate in patients with moderate and severe POR. These findings are clinically relevant and require additional investigation. The benefit:risk balance of treatment with either r-hFSH/r-hLH or r-hFSH remains positive.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by Merck KGaA, Darmstadt, Germany. P.H. has received honoraria for lectures and unrestricted research grants from Ferring, Merck KGaA and MSD. D.R. is a former employee of EMD Serono, a business of Merck KGaA, Darmstadt, Germany. J.S., J.H. and W.C. are employees of EMD Serono Research and Development Institute, a business of Merck KGaA, Darmstadt, Germany. T.D.’H. and S.L. are employees of Merck KGaA, Darmstadt, Germany.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier: NCT02047227; EudraCT Number: 2013-003817-16.

TRIAL REGISTRATION DATE

ClinicalTrials.gov: 24 January 2014; EudraCT: 19 December 2013.

DATE OF FIRST PATIENT'S ENROLMENT

30 January 2014.

Prognostic significance of baseline fatigue for overall survival: A patient-level meta-analysis of 43 oncology clinical trials with 3915 patients

We have previously identified a single-item measure for baseline overall quality of life (QOL) as a strong prognostic factor for survival, and that fatigue was an important component of patient QOL. To explore whether patient-reported fatigue was supplemental or redundant to the prognostic information of overall QOL, we performed a patient-level pooled analysis of 43 North Central Cancer Treatment Group (NCCTG) and Mayo Clinic Cancer Center (MCCC) oncology clinical trials assessing the effect of baseline fatigue on overall survival (OS). 3,915 patients participating in 43 trials provided data at baseline for fatigue on a single-item 0-100 point scale. OS was tested for association with clinically deficient fatigue (CDF, score 0-50, n = 1,497) versus not clinically deficient fatigue (nCDF, score 51-100, n = 2,418). We explored whether fatigue contributed to overall survival in the presence of performance status and overall QOL. We used Cox proportional hazards models that adjusted for the effects of overall QOL, performance score, race, disease site, age and gender. Baseline fatigue was a strong predictor of OS for the entire patient cohort (CDF vs. nCDF: 31.5 months vs > 83.9 months, p < 0.0001). The effect sizes of fatigue on survival were more variable across different disease sites than was seen for overall QOL (GI, esophageal, head and neck, prostate, lung, breast and others). After controlling for covariates, including performance status and overall QOL, baseline fatigue remained a strong prognostic factor in multivariate models (CDF vs. nCDF: HR = 1.23, p = 0.02). Baseline fatigue is a strong and independent prognostic factor for OS over and above performance status (PS) and overall QOL in a wide variety of oncology patient populations. Single-item measures of overall QOL and fatigue can help to identify vulnerable subpopulations among cancer patients. We recommend these single-item measures for routine inclusion as a stratification factor or key covariate in the design and analysis of oncology treatment trials.

Impact of model perfumes on surfactant and mixed surfactant self-assembly

The impact of some model perfumes on surfactant self-assembly has been investigated, using small-angle neutron scattering. A range of different model perfumes, with differing degrees of hydrophilicity/hydrophobicity, have been explored, and in order of increasing hydrophobicity include phenyl ethanol (PE), rose oxide (RO), limonene (LM), linalool (LL), and dihydrogen mercenol (DHM). The effect of their solubilization on the nonionic surfactant micelles of dodecaethylene monododecyl ether (C12EO12) and on the mixed surfactant aggregates of C12EO12 and the cationic dialkyl chain surfactant dihexadecyl dimethyl ammonium bromide (DHDAB) has been quantified. For PE and LL the effect of their solubilization on the micelle, mixed micelle/lamellar and lamellar regimes of the C12EO12/DHDAB mixtures, has also been determined. For the C12EO12 and mixed DHDAB/C12EO12 micelles PE is solubilized predominantly at the hydrophilic/hydrophobic interface, whereas the more hydrophobic perfumes, from RO to DHM, are solubilized predominantly in the hydrophobic core of the micelles. For the C12EO12 micelles, with increasing perfume concentration, the more hydrophobic perfumes (RO to DHM) promote micellar growth. Relatively modest growth is observed for RO and LM, whereas substantial growth is observed for LL and DHM. In contrast, for the addition of PE the C12EO12 micelles remain as relatively small globular micelles, with no significant growth. For the C12EO12/DHDAB mixed micelles, the pattern of behavior with the addition of perfume is broadly similar, except that the micellar growth with increasing perfume concentration for the more hydrophobic perfumes is less pronounced. In the Lbeta (Lv) region of the DHDAB-rich C12EO12/DHDAB phase diagram, the addition of PE results in a less structured (less rigid) lamellar phase, and ultimately a shift toward a structure more consistent with a sponge or bicontinuous phase. In the mixed L1/Lbeta region of the phase diagram PE induces a slight shift in the coexistence from Lbeta toward L1. The addition of LL to the Lbeta (Lv) region of the DHDAB-rich C12EO12/DHDAB phase diagram also results in a reduction in the lamellar structure (less rigid lamellae), and a shift toward a structure more consistent with a sponge or bicontinuous phase, or a coexisting phase of small vesicles. For the mixed L1/Lbeta region of the phase diagram LL induces a shift toward a greater L beta component.

The Microstructure of Di-alkyl Chain Cationic/Nonionic Surfactant Mixtures: Observation of Coexisting Lamellar and Micellar Phases and Depletion Induced Phase Separation

The evolution of the microstructure and composition occurring in the aqueous solutions of di-alkyl chain cationic/nonionic surfactant mixtures has been studied in detail using small angle neutron scattering, SANS. For all the systems studied we observe an evolution from a predominantly lamellar phase, for solutions rich in di-alkyl chain cationic surfactant, to mixed cationic/nonionic micelles, for solutions rich in the nonionic surfactant. At intermediate solution compositions there is a region of coexistence of lamellar and micellar phases, where the relative amounts change with solution composition. A number of different di-alkyl chain cationic surfactants, DHDAB, 2HT, DHTAC, DHTA methyl sulfate, and DISDA methyl sulfate, and nonionic surfactants, C12E12 and C12E23, are investigated. For these systems the differences in phase behavior is discussed, and for the mixture DHDAB/C12E12 a direct comparison with theoretical predictions of phase behavior is made. It is shown that the phase separation that can occur in these mixed systems is induced by a depletion force arising from the micellar component, and that the size and volume fraction of the micelles are critical factors.

All radial scars/complex sclerosing lesions seen on breast screening mammograms should be excised

AIM

To determine the incidence of pre-malignant and malignant conditions in radial scars identified from screening mammograms in women taking part in the UK NHS breast cancer screening programme.

METHODS

All women in our screening population from 1988 to 2002 with a radiological diagnosis of radial scar or complex sclerosing lesion confirmed on subsequent histopathology were included in this study. Patients were investigated with fine needle aspiration cytology then localisation biopsy (n=46) or straight to localisation biopsy (n=78). Patients where divided into two groups, one with pure RS/CSL with no associated epithelial features and the second with associated ADH, DCIS or invasive cancer.

RESULTS

One hundred and twenty-four lesions were confirmed histologically as radial scar or complex sclerosing lesions. The median age was 58 years. Of the 124 patients, 82 were pure RS/CSL. Forty-two had associated epithelial lesions, 22 patients had ADH and 20 patients had either in situ or invasive carcinoma. Where FNA was performed (n=46), mammograms had shown three lesions suspicious of cancer, which were not proven histologically. Mammograms picked up five malignancies out of the nine RS/CSL with associated cancers. Of these, FNA confirmed malignancy in only two patients. Where FNA was not done (n=78), mammogram had read five pure RS/CSL as cancers. It picked up only four cancers in RS lesions with DCIS/Ca out of 11.

CONCLUSION

All screen-detected stellate lesions should be excised due to their association with pre-malignant and malignant conditions.

Hématome cervical spontané secondaire à une hémorragie extracapsulaire d’un adénome parathyroïdien : à propos de 2 cas

The usual clinical manifestations of a parathyroid adenoma are due, in most of the cases, to hypercalcemia. The development of a spontaneous cervical or cervicomediastinal haematoma is a rare form of presentation. In case of a spontaneous cervical haematoma associated with dysphagia: measurement of serum calcium, phosphate and parathyroid hormone allows the diagnosis of haematoma due to extracapsular haemorrhage from a parathyroid adenoma. We report herein 2 cases.

[Video-assisted parathyroidectomy in the management of patients with primary hyperparathyroidism]

INTRODUCTION

In recent years, different minimally invasive techniques of parathyroidectomy have been described. We performed a retrospective study to evaluate the indications and results of video-assisted parathyroidectomy (Vap) in the management of our patients with primary hyperparathyroidism (PHPT).

MATERIALS AND METHODS

During the last 5 years (1998-2002), we operated on 528 patients with PHPT. Vap was proposed for patients with sporadic PHPT, without associated goiter and without previous neck surgery, in whom a single adenoma was localized by means of sonography and/or sestamibi scanning. Vap was performed by lateral approach with insufflation for patients with adenoma located deeply in the neck and by gasless midline approach for patients with adenoma located anteriorly. A quick parathyroid (qPTH) assay was used during the surgical procedures. Calcemia, phosphoremia and PTH were systematically evaluated in patients on days 1 and 8, 1 month and 1 year after surgery. All patients underwent pre-operative and postoperative investigations of vocal cord movements.

RESULTS

Among 528 patients with PHPT, 228 (43%) were not eligible for Vap: associated nodular goiter (99 cases), previous neck surgery (42 cases), suspicion of multiglandular disease (25 cases), lack of pre-operative localization (48 cases), and miscellaneous causes (14 cases). Vap was performed in 300 patients with sporadic PHPT: 282 lateral access, 17 midline access and 1 thoracoscopy. Median operative time was 50 min (20-130 min). Conversion to conventional parathyroidectomy was required in 42 patients (14%): missed adenomas (11 cases), difficulties of dissection (7 cases), multiglandular disease correctly predicted by qPTH (10 cases); qPTH assay false negative results (3 cases), sestamibi scan false positive results (10 cases) and 1 sonography false positive result. One patient presented definitive recurrent nerve palsy. One patient had a persistent PHPT and one other patient had a recurrent PHPT.

CONCLUSION

Vap can be proposed for more than half of patients with PHPT. In our experience Vap and conventional parathyroidectomy are complementary. Immediate results of Vap are similar to those obtained with conventional parathyroidectomy but no conclusions can be drawn in terms of influence of Vap on the outcome of the patients operated for PHPT.

Identification of patients with a non-recurrent inferior laryngeal nerve by duplex ultrasound of the brachiocephalic artery

A non-recurrent inferior laryngeal nerve (NRILN) is a rare anomaly that may increase the risk of injury during thyroid surgery. A NRILN results from an embryologic developmental abnormality of the aortic arches, demonstrated by the absence of the brachiocephalic artery and the presence of an aberrant subclavian artery (arteria lusoria). In our experience 100% of 104 patients with a NRILN were shown to have these abnormalities. We postulated that duplex scanning of the brachiocephalic artery could identify patients at risk of a NRILN. Twelve patients with an operative diagnosis of a right NRILN and associated vascular abnormalities underwent postoperative duplex scanning of the brachiocephalic artery. The examination was performed using a 7.5 or 3.5 MHz transducer. The average duration of assessment was 5 min. The absence of the brachiocephalic artery and the direct origin of the right common carotid artery from the arch of the aorta were demonstrated in each patient. Duplex scanning is a simple noninvasive method of identifying patients with the arterial abnormalities responsible for a NRILN. This may be used in the preoperative assessment of selected patients.

[Lessons learned from 274 laparoscopic adrenalectomies]

AIMS

To define the role of minimally invasive video-assisted surgery in the surgical management of adrenal disease and discuss the respective indications of the trans and retroperitoneal video assisted approaches.

MATERIALS AND METHODS

During the last 8 years (1994-2001), 330 adrenalectomies were performed in 305 patients: 274 (83%) laparoscopic approaches and 56 (17%) open approach. Open surgery was reserved for patients presenting with large or malignant tumours (29 cases), multiple and/or extraadrenal phaeochromocytomas (13 cases), previous intraabdominal intestinal surgery (10 cases), and in those requiring concomitant intraabdominal surgery (4 cases). Laparoscopic adrenalectomy was performed using the lateral transperitoneal approach for 89 Conn's syndrome, 67 Cushing's syndrome, 2 virilizing tumours, 51 phaeochromocytomas and 65 non secretory tumours greater than 4 cm in diameter. Nineteen patients underwent bilateral adrenalectomy.

RESULTS

There were no deaths. Twenty patients (7.3%) had a complication. Eleven cases required open conversion (4%) because of difficulties with dissection (8 cases), preoperative suspicion of malignancy (2 cases), and one pneumothorax. The average size of tumours was 34 mm (7-110 mm). There were 18 malignant tumours (6.5%): 8 adrenocortical carcinomas, 1 leiomyosarcoma, and 9 metastases. All patients with hormonally secreting tumours were cured of their endocrinopathy. There was 1 death secondary to hepatic metastases in a patient with an adrenocortical carcinoma.

CONCLUSION

Most adrenal tumours are suitable for video assisted excision. The only absolute contraindication is an invasive carcinoma requiring an extended excision. The lateral, transperitoneal approach is the most suitable for tumours greater than 5-6 cm in diameter. Both the transperitoneal or retroperitoneal approaches are suitable for smaller tumours depending on operator choice and experience. However in the presence of a large right lobe of liver or previous intraabdominal surgery the retroperitoneal approach may be preferable.