Robotic assisted orbital surgery for resection of advanced periocular tumours - a case series report on the feasibility, safety and outcome

PURPOSE

Orbital surgery benefits from well-designed instrumentation that offers gentle tissue manipulation, high manoeuvrability and control. Nevertheless, in confined spaces, tissue manipulation must be accomplished with exceptionally high accuracy and precision. This is where robotic surgery offers an advantage. We aimed to evaluate a robotic-assisted surgical system's feasibility, safety and outcome in assisting tumour clearance.

PATIENTS AND METHODS

A case series of patients with advanced periocular tumours undergoing robotic-assisted globe-sparing resection was performed using the DaVinci XI system (Intuitive Surgical, Inc). Institutional ethics and multidisciplinary approval were sought in all cases.

RESULTS

Four patients with advanced periocular tumours underwent robotic-assisted orbital surgery at a mean age of 63 years (range 42-86). Two patients were diagnosed with squamous cell carcinoma, and two had basal cell carcinoma. One patient was found to have positive lymph nodes at the time of surgery and underwent simultaneous parotidectomy and lymph node clearance. Clear resection of the primary tumour was achieved in all patients; three patients underwent further resection due to narrow margins prior to reconstruction. Patients were follow-up for at least one year, and three remained disease-free. One patient with pre-existing extra-orbital disease developed metastatic disease four months post-op. All patients preserved vision peri-operatively, with no complaints of diplopia. Moderate ocular surface disease was noted in two patients.

CONCLUSION

Our series highlights the potential advantage of three-dimensional optics, multi-directional instrumentation and motion scaling technology to achieve globe-sparing tumour resection in advanced periocular tumours. However, further robotic instrumentation development is required for orbital surgery.

Prospective development study of the Versius Surgical System for use in transoral robotic surgery: an IDEAL stage 1/2a first in human and initial case series experience

PURPOSE

Transoral robotic surgery is well established in the treatment paradigm of oropharyngeal pathology. The Versius Surgical System (CMR Surgical) is a robotic platform in clinical use in multiple specialities but is currently untested in the head and neck. This study utilises the IDEAL framework of surgical innovation to prospectively evaluate and report a first in human clinical experience and single centre case series of transoral robotic surgery (TORS) with Versius.

METHODS

Following IDEAL framework stages 1 and 2a, the study evaluated Versius to perform first in human TORS before transitioning from benign to malignant cases. Iterative adjustments were made to system setup, instrumentation, and technique, recorded in accordance with IDEAL recommendations. Evaluation criteria included successful procedure completion, setup time, operative time, complications, and subjective impressions. Further evaluation of the system to perform four-arm surgery was conducted.

RESULTS

30 TORS procedures were successfully completed (15 benign, 15 malignant) without intraoperative complication or conversion to open surgery. Setup time significantly decreased over the study period. Instrumentation challenges were identified, urging the need for TORS-specific instruments. The study introduced four-arm surgery, showcasing Versius' unique capabilities, although limitations in distal access were observed.

CONCLUSIONS

TORS is feasible with the Versius Surgical System. The development of TORS-specific instruments would benefit performance and wider adoption of the system. 4-arm surgery is possible however further evaluation is required. Multicentre evaluation (IDEAL stage 2b) is recommended.

New robotic platform for transoral robotic surgery: an IDEAL stage 0 study

Objectives

This study aims to assess the feasibility to perform transoral robotic surgery (TORS) with a new robotic platform, the Versius Surgical System (CMR Surgical, UK) in a preclinical cadaveric setting in accordance to stage 0 of the IDEAL-D framework.

Design

IDEAL stage 0 preclinical assessment of the Versius Robotic System in TORS in human cadavers.

Setting

All procedures were performed in a simulated operating theatre environment at a UK surgical training centre.

Participants

11 consultant head and neck surgeons from the UK, mainland Europe and the USA took part in TORS procedures on six human cadavers.

Interventions

3 key index procedures were assessed that represent the core surgical workload of TORS: lateral oropharyngectomy, tongue base resection and partial supraglottic laryngectomy.

Main outcome measures

The primary outcome was the successful completion of each surgical procedure. Secondary outcomes included the optimisation of system setup, instrumentation and surgeon-reported outcomes for feasibility of each component procedural step.

Results

33 cadaveric procedures were performed and 32 were successfully completed. One supraglottic laryngectomy was not fully completed due to issues dividing the epiglottic cartilage with available instrumentation. Surgeon-reported outcomes met the minimal level of feasibility in all procedures and a consensus that it is feasible to perform TORS with Versius was reached. Available instrumentation was not representative of other robotic platforms used in TORS and further instrument optimisation is recommended before wider dissemination.

Conclusions

It is feasible to perform TORS with the Versius Surgical System (CMR Surgical) within a pre-clinical cadaveric setting. Clinical evaluation is needed and appropriate with the system. Further instrument development and optimisation is desirable.

Soft Tissue Robotic Assisted Orbital Surgery Using da Vinci SP: A Cadaveric Experience

PURPOSE

Robotic surgical techniques have transformed many surgical specialties however robotic techniques and applications have been much more limited in ophthalmology. This study aims to evaluate the feasibility of robotic assisted orbital surgery using a single-port novel robotic platform, the da Vinci SP.

METHODS

A series of orbital procedures were performed in cadaveric specimens utilizing the da Vinci SP robotic system. The procedures performed included lacrimal gland dissection and biopsy, medial and lateral orbital wall dissections, enucleation, and lid-sparing orbital exenteration. Successful completion of each procedure was defined by the operating surgeon and was considered the primary outcome and marker of feasibility.

RESULTS

Seven cadaveric procedures were performed in 3 cadaveric specimens. All 7 procedures were completed successfully without complication. Setup optimization occurred throughout the study and setup and operative times were acceptable. Three instrument arms and 1 endoscope were utilized throughout the study allowing 3 arm operating and dynamic retraction. Instrument size was found to limit surgical access and precision particular at the orbital apex.

CONCLUSIONS

This preclinical study demonstrates that the da Vinci SP can be utilized within the orbit and is feasible for several applications. Robotic surgical systems offer significant advantages over conventional techniques and should be embraced. However, current commercially available robotic platforms are not optimized for the orbit and have their limitations although they may be suitable for some clinical applications.

Health risk factors in Australian Stroke Survivors: A latent class analysis

ISSUES ADDRESSED

To (i) determine the prevalence of health risk factors (physical activity, diet, alcohol, smoking, blood pressure medication use and mental health) in community-dwelling stroke survivors; and (ii) examine how these health risk factors cluster, and identify associations with physical functioning, independent living, or sociodemographic factors.

METHODS

A secondary analysis of data obtained during a national randomised controlled trial. Participants had experienced stroke and completed a baseline telephone survey on demographic and stroke characteristics, health risk factors, physical functioning and independence in activities of daily living. A latent class analysis was performed to determine health risk profiles. Univariate logistic regressions were performed to identify if participant characteristics were associated with resulting classes.

RESULTS

Data analysed from 399 participants. Two classes of health risk factors were identified: Low Mood, Food & Moves Risk (16% of participants) and Alcohol Use Risk (84% of participants). The Low Mood, Food & Moves Risk group had poorer diet quality, lower physical activity levels and higher levels of depression and anxiety. Lower levels of independence and physical functioning were predictor variables for this group. In contrast, the Alcohol Use Risk group had better physical activity and diet scores, significantly lower probability of depression and anxiety, but a higher probability of risky drinking.

CONCLUSIONS

We identified two distinct health risk factor groups in our population. SO WHAT?: Future interventions may benefit from targeting the specific needs and requirements of people who have experienced stroke based on their distinct risk group. Alcohol consumption in poststroke populations requires further attention.

Accessibility and applicability of physical activity guidelines and recommendations for adults living with long term conditions during COVID-19

To review the applicability and accessibility of physical activity guidelines for adults living with long-term conditions whilst shielding during the COVID-19. A narrative review with systematic methodology was conducted between 2015 and 2021, with two stages: 1) Search of electronic databases PubMed/Medline, Web of Science, PsycInfo, and Cinahl; 2) search of long-term condition organisations. Sixty-five articles were identified, where nine included specific guidelines during the COVID-19, 28 specific guidelines to individuals living with long-term conditions and 7 identified the utilization of online resources. Twenty-one long-term condition organizations websites were reviewed where all of them included a section regarding physical activity guidelines and seven referred to online and offline accessible resources during COVID-19. Accessibility and applicability were variable across academic databases and long-term conditions organisation websites. Findings could inform long-term condition policy and guidelines development to better and more relevant support people living with long-term conditions to be physically active.

Uncertainty in phosphorus fluxes and budgets across the U.S. long-term agroecosystem research network

Phosphorus (P) budgets can be useful tools for understanding nutrient cycling and quantifying the effectiveness of nutrient management planning and policies; however, uncertainties in agricultural nutrient budgets are not often quantitatively assessed. The objective of this study was to evaluate uncertainty in P fluxes (fertilizer/manure application, atmospheric deposition, irrigation, crop removal, surface runoff, leachate) and the propagation of these uncertainties to annual P budgets. Data from 56 cropping systems in the P-FLUX database, which spans diverse rotations and landscapes across the U.S. and Canada, were evaluated. Results showed that across cropping systems, average annual P budget was 22.4 kg P ha^-1 (range = -32.7 to 340.6 kg P ha^-1 ), with an average uncertainty of 13.1 kg P ha^-1 (range = 1.0 to 87.1 kg P ha^-1 ). Fertilizer/manure application and crop removal were the largest P fluxes across cropping systems and, as a result, accounted for the largest fraction of uncertainty in annual budgets (61 and 37%, respectively). Remaining fluxes individually accounted for <2% of the budget uncertainty. Uncertainties were large enough that determining whether P was increasing, decreasing, or not changing was inconclusive in 39% of the budgets evaluated. Findings indicate that more careful and/or direct measurements of inputs, outputs, and stocks are needed. Recommendations for minimizing uncertainty in P budgets based on the results of the study were developed. Quantifying, communicating, and constraining uncertainty in budgets among production systems and multiple geographies is critical for engaging stakeholders, developing local and national strategies for P reduction, and informing policy. This article is protected by copyright. All rights reserved.

A systematic review of the effectiveness of community interventions to improve parent health literacy

Background

Many community-based interventions have been developed to increase parent/caregiver health literacy, yet no systematic review of their effectiveness has been published. Therefore, the aim of this systematic review was to examine the effectiveness of community-based health literacy interventions in improving the health literacy of parents/caregivers.

Methods

A systematic review of six databases; MEDLINE, PsycINFO, CINAHL, Cochrane Library, Embase, and Education Source were conducted to identify relevant articles. Risk of bias were assessed using version two of the Cochrane risk of bias tool for randomised controlled trials or the Cochrane Collaboration Risk of Bias in Non-Randomised Studies of Interventions. The study findings were grouped and synthesised following the Synthesis Without Meta-analysis framework.

Results

Eleven community-based health literacy interventions for parents/caregivers were identified. Study design included randomised controlled trials (n = 4), non-randomised studies with comparison group (n = 4), and non-randomised studies without a comparison group (n = 3). Interventions were delivered digitally, in person or a combination of the two. The main findings of the studies showed some potential for both in person and digital interventions to increase parental health literacy. The risk of bias was high in over half the studies (n = 7) Studies were heterogeneous preventing a meta-analysis.

Discussion

Although no definitive conclusion of the effectiveness of community-based interventions can be drawn there are suggestions of improvement in many of the studies included in this review. The review has brought into question whether the health literacy measurement tools used met the needs of assessing the interventions outcomes. When comparing the cost and resources needed for digital with in person interventions, the findings of this review have implications for both practise and research.

Key messages

Neck Dissection Timing in Transoral Robotic or Laser Microsurgery in Oropharyngeal Cancer: A Systematic Review

Objective

This review assesses the effect on intra- and postoperative patient outcomes of the timing of neck dissection in relation to transoral surgery. Outcome measures include postoperative bleeding, intra- and postoperative fistula formation, and disease-specific and overall survival.

Data Sources

A search was conducted across the MEDLINE, Embase, US National Library of Medicine, and Cochrane databases with search terms in July 2021.

Review Methods

Articles that conformed with specified inclusion criteria were included. Included articles were scanned for bias with the ROBINS-I tool.

Results

Nineteen articles were selected for qualitative analysis, including 546 patients who had neck dissection in conjunction with transoral robotic surgery/transoral laser microsurgery (TORS/TLM). Seventy-one (18%) patients had neck dissection prior to TORS/TLM, 39 (10%) had neck dissection performed after TORS/TLM, and 281 (72%) had concurrent procedures. In patients with neck dissection before TORS/TLM, 3% experienced major postoperative bleeding, and fistula rates were 0%. In the cohort with neck dissection after TORS/TLM, 3% experienced minor postoperative hemorrhage, and 8% had intraoperative fistulae. In the concurrent cohort of patients, 1% had major postoperative bleeds and 0.3% had minor bleeds, while 4% developed intraoperative fistulas and 0.3% developed postoperative fistulas.

Conclusion

Current evidence indicated that there appears to be no correlation between timing of neck dissection and complications. This systematic review found insufficient data to comment on whether the timing of neck dissection in relation to TORS/TLM affects the outcomes of patients.

P-FLUX: A phosphorus budget dataset spanning diverse agricultural production systems in the United States and Canada

Quantifying spatial and temporal fluxes of phosphorus (P) within and among agricultural production systems is critical for sustaining agricultural production while minimizing environmental impacts. To better understand P fluxes in agricultural landscapes, P-FLUX, a detailed and harmonized dataset of P inputs, outputs, and budgets, as well as estimated uncertainties for each P flux and budget, was developed. Data were collected from 24 research sites and 61 production systems through the Long-term Agroecosystem Research (LTAR) network and partner organizations spanning 22 U.S. states and 2 Canadian provinces. The objectives of this paper are to (a) present and provide a description of the P-FLUX dataset, (b) provide summary analyses of the agricultural production systems included in the dataset and the variability in P inputs and outputs across systems, and (c) provide details for accessing the dataset, dataset limitations, and an example of future use. P-FLUX includes information on select site characteristics (area, soil series), crop rotation, P inputs (P application rate, source, timing, placement, P in irrigation water, atmospheric deposition), P outputs (crop removal, hydrologic losses), P budgets (agronomic budget, overall budget), uncertainties associated with each flux and budget, and data sources. Phosphorus fluxes and budgets vary across agricultural production systems and are useful resources to improve P use efficiency and develop management strategies to mitigate environmental impacts of agricultural systems. P-FLUX is available for download through the USDA Ag Data Commons (https://doi.org/10.15482/USDA.ADC/1523365).

Generation of cardio-protective antibodies after pneumococcal polysaccharide vaccine: Early results from a randomised controlled trial

BACKGROUND AND AIMS

Observational studies have demonstrated that the pneumococcal polysaccharide vaccine (PPV) is associated with reduced risk of cardiovascular events. This may be mediated through IgM antibodies to OxLDL, which have previously been associated with cardioprotective effects. The Australian Study for the Prevention through Immunisation of Cardiovascular Events (AUSPICE) is a double-blind, randomised controlled trial (RCT) of PPV in preventing ischaemic events. Participants received PPV or placebo once at baseline and are being followed-up for incident fatal and non-fatal myocardial infarction or stroke over 6 years.

METHODS

A subgroup of participants at one centre (Canberra; n = 1,001) were evaluated at 1 month and 2 years post immunisation for changes in surrogate markers of atherosclerosis, as pre-specified secondary outcomes: high-sensitive C-reactive protein (CRP), pulse wave velocity (PWV), and carotid intima-media thickness (CIMT). In addition, 100 participants were randomly selected in each of the intervention and control groups for measurement of anti-pneumococcal antibodies (IgG, IgG2, IgM) as well as anti-OxLDL antibodies (IgG and IgM to CuOxLDL, MDA-LDL, and PC-KLH).

RESULTS

Concentrations of anti-pneumococcal IgG and IgG2 increased and remained high at 2 years in the PPV group compared to the placebo group, while IgM increased and then declined, but remained detectable, at 2 years. There were statistically significant increases in all anti-OxLDL IgM antibodies at 1 month, which were no longer detectable at 2 years; there was no increase in anti-OxLDL IgG antibodies. There were no significant changes in CRP, PWV or CIMT between the treatment groups at the 2-year follow-up.

CONCLUSIONS

PPV engenders a long-lasting increase in anti-pneumococcal IgG, and to a lesser extent, IgM titres, as well as a transient increase in anti-OxLDL IgM antibodies. However, there were no detectable changes in surrogate markers of atherosclerosis at the 2-year follow-up. Long-term, prospective follow-up of clinical outcomes is continuing to assess if PPV reduces CVD events.

61 Use of Ketamine Sedation for the Treatment of Minor Plastic Surgery Procedures in the Paediatric Emergency Department

Aim

To determine if ketamine sedation is a safe and cost-effective way of treating paediatric patients presenting with minor injuries, requiring plastic surgery procedures, in the emergency department.

Method

A retrospective cohort study was carried out over a 9-month period in children between ages 18 months and 16 years old, presenting to the paediatric emergency department at Chelsea and Westminster Hospital with minor injuries requiring plastic surgery input. The data collected included previously validated co-primary outcome measures of surgical site infection at 7 days and cosmetic appearance summary score at a minimum of 4 months. Parental satisfaction surveys were completed at 4 months to assess perceived quality of treatment. A cost analysis comparison against procedures completed under general anaesthetic was also undertaken.

Results

During the 9-month period of study, 24 minor procedures were performed under ketamine in the paediatric emergency department. There were no serious adverse events recorded. Three cases exceeded the recommended 20-minute maximum procedure duration, but there was no associated adverse outcome. No cases required further procedures under general anaesthesia and there were no cases of surgical site infections at 7 days. Parents reported extremely favourable outcomes using this technique, with an average overall satisfaction score of 9.2 (assessed over a number of parameters, where 10 is complete satisfaction).

Conclusions

Ketamine procedural sedation in the paediatric population is a safe and cost-effective method for the treatment of minor plastic surgery procedures, with low risk for surgical site infection post-operatively, and high parent satisfaction rates

1079 Analysis of Human Papilloma Virus (HPV) Status in Metastatic Oropharyngeal Squamous Cell Carcinoma (OPSCC)

Introduction

OPSCC often (80%) presents with ipsilateral neck metastasis. Presentation may be as carcinoma of unknown primary (CUP). Sampling via ultrasound guided Fine Needle Aspiration Cytology (FNAC) and/or Core Biopsy (CB) from nodal metastases is required for diagnosis, comparison with primary tumour and to assess human papilloma virus (HPV) status. HPV positive biopsy from CUP may indicate oropharynx primary. HPV positive OPSCC has better prognosis. HPV association is ascertained by p16 immunocytochemistry (p16- IHC) and HPV DNA in situ hybridization (HPV-ISH). In a cohort of OPSCC patients from a single referral centre 68% had metastatic disease. Core biopsy was optimal for HPV testing.

Method

Retrospective review of records from Transoral Robotic Surgery (TORS) patients treated for OPSCC between December 2017-2019 was conducted. Cohort included patients undergoing TORS for diagnostic purposes and with curative intent.

Results

Data was available from 23 patients who had TORS for OPSCC. 47.8% (n = 11) presented with lymphadenopathy. 82.6% (n = 19) underwent FNAC. 68.4% (n = 13) were diagnosed with metastatic OPSCC and 56.5% (n = 13) underwent neck dissections. 52.2% (n = 12) had confirmed HPV positive metastases, 75% (n = 9) had 1 node positive, 25% (n = 3) had &gt;1 node positive. FNAC yielded enough tissue for p16 IHC and HPV-ISH in 10.5% (n = 2). CB yielded sufficient tissue for analysis in all cases 39.1% (n = 9).

Conclusions

The study confirms high incidence of neck metastases in HPV associated OPSCC patients. Needle core biopsy appears superior to FNAC for tissue sampling to assess HPV status in tumours metastatic to neck.

Sputum mast cell/basophil gene expression relates to inflammatory and clinical features of severe asthma

BACKGROUND

Mast cells (MCs) and basophils are important in asthma pathophysiology, however direct measurement is difficult, and clinical and inflammatory associations in severe asthma are poorly understood. Transcriptomic hallmarks of MCs/basophils may allow their measurement in sputum using gene expression.

OBJECTIVES

This study sought to develop and validate a sputum MC/basophil gene signature and investigate its relationship to inflammatory and clinical characteristics of severe asthma.

METHODS

A total of 134 candidate MC/basophil genes (identified by the Immunological Genome Project Consortium) were screened in sputum microarray for differential expression among control subjects (n = 18), patients with eosinophilic (n = 29), and patients with noneosinophilic asthma (n = 30). Candidate genes were validated by confirming correlation of gene expression with flow cytometry-quantified sputum MCs and basophils in a separate asthma cohort (n = 20). The validated gene signature was measured in a severe asthma cohort (n = 81), and inflammatory and clinical associations were tested.

RESULTS

Through microarray screening and subsequent validation, we found quantitative PCR gene expression of 8 targets correlated with sputum MCs/basophils: TPSAB1/TPSB2, CPA3, ENO2, GATA2, KIT, GPR56, HDC, SOCS2. In severe asthma, MC/basophil genes were associated with eosinophilic airway inflammation (GATA2, TPSB2, CPA3, GPR56, HDC, SOCS2), blood eosinophils (TPSB2, CPA3, GATA2, SOCS2, FCER1A, HDC), fractional exhaled NO (GATA2, SOCS2), decreased lung function (KIT, ENO2), and moderate exacerbation history (GATA2, SOCS2).

CONCLUSIONS

Quantitative PCR-based measures reflect varying sputum MC/basophil abundance, demonstrating associations of MCs/basophils with eosinophilic inflammation, spirometry and exacerbation history in severe asthma.

A rare case report of an ilio-psoas abscess due to entero-retroperitoneal fistula from gallstones post cholecystectomy

•

Ilio-psoas abscess due to gallstone entero-retroperitoneal fistulation post-cholecystectomy has not been reported previously.

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De-novo stone formation in the CBD can occur post-cholecystectomy and can lead to complications.

•

Surgeons should consider gallstones as a differential in small bowel fistulation.

Introduction and importance

This is a novel case of a 50-year-old female presenting with several months of left iliac fossa pain, on a background of a cholecystectomy 5 years prior. The aetiology of her pain was an ilio-psoas abscess secondary to an entero-retroperitoneal gallstone fistula, a condition not previously reported in the literature.

Case presentation

CT imaging revealed an abscess superior to the left psoas muscle, with a clear fistula to the small bowel and two calcified stones at the site of the fistula.

The patient was managed operatively, with the fistula disconnected and a 5 cm section of small bowel disconnected.

Clinical discussion

This is a novel case whereby a left sided iliopsoas abscess occurred due to entero-retroperitoneal fistulation of gallstones several years after the patient underwent laparoscopic cholecystectomy. Gallstone fistulation from within the small bowel does not appear to have previously been documented and the exact pathogenesis is unknown.

Conclusion

Gallstones should remain an important, albeit rare, differential diagnosis of small bowel fistulation and abscess formation following cholecystectomy.

Coblation® intracapsular tonsillectomy in children with recurrent tonsillitis: Initial experience

OBJECTIVES

The use of Coblation® intracapsular tonsillectomy for the treatment of sleep disordered breathing (SDB)/obstructive sleep apnoea (OSA) has an increasing evidence base. However, the results for tonsillitis as the predominant indication for surgery are not as clear. We present our initial results from 80 paediatric cases undergoing Coblation® intracapsular tonsillectomy for infective indications.

METHODS

Prospective case series within the secondary care environment, January 2016-July 2018, all with completed follow-up. We utilised the validated T14 tonsil symptom questionnaire pre- and postoperatively and also collected data regarding postoperative complications.

RESULTS

80 consecutive patients (age range 2-16 years and mean 7.2 years) undergoing Coblation® intracapsular tonsillectomy (with or without adenoidectomy) predominantly for infective reasons although some also had concomitant adenoidectomy for snoring/sleep disordered breathing were included. Mean follow-up was at 13 months postoperatively. 38 children had tonsillitis (with or without snoring) and 42 children had SDB in combination with tonsillitis. The mean over-all total T14 score was 32.7 preoperatively and 2.7 postoperatively (p < 0.0001). The mean infective score was 22.1 preoperatively and 1.5 postoperatively (p < 0.0001). The mean SDB score was 10.6 preoperatively and 1.5 postoperatively (p < 0.0001). There were no cases of haemorrhage, re-admission or regrowth noted.

CONCLUSION

Coblation® intracapsular tonsillectomy is a safe and effective technique for treating children with recurrent tonsillitis. Future studies should incorporate longer term follow-up.

Multiple concurrent atypical parathyroid adenomas: a rare occurrence

We present a case of an 80-year-old patient with three concurrent multiple atypical parathyroid adenomas. The patient was managed with bilateral parathyroid exploration and concurrent parathyroidectomy. Postoperative recovery was uneventful. Atypical parathyroid adenomas are a rare entity that are clinically difficult to distinguish from parathyroid carcinoma. Histological characteristics are similar however atypical adenomas lack complete capsular or vascular invasion and cannot be considered malignant. All reported cases of atypical parathyroid adenoma are solitary lesions. We present the first case of multiple concurrent atypical parathyroid adenomas.

A UK reported case of Graves' disease with thyroid hemiagenesis

We present a rare case of a 31-year-old patient with Graves' disease with agenesis of the left thyroid lobe. The patient was managed with a right hemithyroidectomy and isthmusectomy as definitively treatment of Graves' disease. The patient had an uneventful postoperative outcome and the histology was benign and consistent with Graves' disease. This is a rare case in the literature of Graves' disease with unilateral thyroid agenesis, and to our knowledge is the first reported case from the UK.

Mortality within 30 days of immunotherapy (checkpoint inhibitors) in metastatic cancer patients treated at Australian tertiary cancer center

6600

Background: Cancer treatment has evolved rapidly since the advent of immunotherapy (checkpoint inhibitors). As compared to chemotherapy, immunotherapy is associated with a more favourable but distinct side effect profile. Mortality within 30 days of chemotherapy in cancer patients has been accepted as a clinical indicator of preventable harm and used as an auditing tool for clinical practice and improving quality of life. This should be investigated in the current era of immunotherapy, as it has been the standard treatment for advanced melanoma, lung cancer, renal cell cancer and others. Methods: We conducted a retrospective study on patients with advanced cancer treated with immunotherapy and died within 30 days of treatment. Clinical data on patients treated with immunotherapy at Calvary Mater Newcastle between 2006 and 2018 was collected. Data were compared with 30-day mortality statistics of chemotherapy. Results: A total of 601 metastatic cancer patients received immunotherapy agents (Pembrolizumab, Nivolumab, Ipilimumab, Atezolizumab, Tislelizumab and MSB0011359C) on 5022 occasions. Seventy-six (12.6%) patients died within 30 days of receiving immunotherapy. Median age was 68 years (35-90). Melanoma was the most prevalent cancer type (63%) followed by lung (20%). Forty-seven (47%) of patients received immunotherapy as first-line treatment and 39% as second-line. Patients died within 30 days received an average 2 (1-16) immunotherapy doses. A quarter of patients had ECOG 3 and ECOG 4 before last dose. Majority of deaths were related to disease (86%). Nearly 80% of patients died in hospital. One patient died due to treatment-related pneumonitis. In univariate analysis, there was no association between mortality and patients’ demographic variables such as age, sex, BMI, cancer type, ECOG performance status, immunotherapy agent and prior treatment. Conclusions: To our knowledge, this is the first ever real-world data on 30-day mortality after immunotherapy in advanced cancer. Thirty-day mortality rates were comparable to published data on patients treated with chemotherapy. Results emphasise significance of careful selection of advanced cancer patient for immunotherapy. Due to small sample size, the power to detect a significant association between patients demographics and survival is reduced.

Measurement of exclusive Υ photoproduction from protons in p Pb collisions at s NN = 5.02 TeV

The exclusive photoproduction of Υ ( nS ) meson states from protons, γ p → Υ ( nS ) p (with n = 1 , 2 , 3 ), is studied in ultraperipheral p Pb collisions at a centre-of-mass energy per nucleon pair ofs NN = 5.02 TeV . The measurement is performed using the Υ ( nS ) → μ + μ - decay mode, with data collected by the CMS experiment corresponding to an integrated luminosity of 32.6nb - 1 . Differential cross sections as functions of the Υ ( nS ) transverse momentum squared p T 2 , and rapidity y, are presented. The Υ ( 1 S ) photoproduction cross section is extracted in the rapidity range | y | < 2.2 , which corresponds to photon-proton centre-of-mass energies in the range 91 < W γ p < 826 GeV . The data are compared to theoretical predictions based on perturbative quantum chromodynamics and to previous measurements.

Search for the Higgs Boson Decaying to Two Muons in Proton-Proton Collisions at sqrt[s]=13 TeV

A search for the Higgs boson decaying to two oppositely charged muons is presented using data recorded by the CMS experiment at the CERN LHC in 2016 at a center-of-mass energy sqrt[s]=13  TeV, corresponding to an integrated luminosity of 35.9  fb^{-1}. Data are found to be compatible with the predicted background. For a Higgs boson with a mass of 125.09 GeV, the 95% confidence level observed (background-only expected) upper limit on the production cross section times the branching fraction to a pair of muons is found to be 3.0 (2.5) times the standard model expectation. In combination with data recorded at center-of-mass energies sqrt[s]=7 and 8 TeV, the background-only expected upper limit improves to 2.2 times the standard model value with a standard model expected significance of 1.0 standard deviation. The corresponding observed upper limit is 2.9 with an observed significance of 0.9 standard deviation. This corresponds to an observed upper limit on the standard model Higgs boson branching fraction to muons of 6.4×10^{-4} and to an observed signal strength of 1.0±1.0(stat)±0.1(syst).

The effects of 4 weeks normobaric hypoxia training on microvascular responses in the forearm flexor

Intermittent exposure to hypoxia can lead to improved endurance performance. Currently, it is unclear whether peripheral adaptions play a role in improving oxygen delivery and utilization following both training and detraining. This study aimed to characterize skeletal muscle blood flow (mBF), oxygen consumption (mV̇O₂), and perfusion adaptations to i) 4-weeks handgrip training in hypoxic and normoxic conditions, and ii) following 4-weeks detraining. Using a randomised crossover design, 9 males completed 30-min handgrip training four times a week in hypoxic (14% FiO₂ ~ 3250m altitude) and normoxic conditions. mBF, mV̇O₂ and perfusion were assessed pre, post 4-weeks training, and following 4-weeks detraining. Hierarchical linear modelling found that mV̇O₂ increased at a significantly faster rate (58%) with hypoxic training (0.09 mlO₂·min^-1 · 100g^-1 per week); perfusion increased at a significantly (69%) faster rate with hypoxic training (3.72 μM per week). mBF did not significantly change for the normoxic condition, but there was a significant increase of 0.38 ml· min^-1 · 100ml^-1 per week (95% CI: 0.35, 0.40) for the hypoxic condition. During 4-weeks detraining, mV̇O₂ and perfusion significantly declined at similar rates for both conditions, whereas mBF decreased significantly faster following hypoxic training. Four weeks hypoxic training increases the delivery and utilisation of oxygen in the periphery.

Observation of Medium-Induced Modifications of Jet Fragmentation in Pb-Pb Collisions at sqrt[s_{NN}]=5.02 TeV Using Isolated Photon-Tagged Jets

Measurements of fragmentation functions for jets associated with an isolated photon are presented for the first time in pp and Pb-Pb collisions. The analysis uses data collected with the CMS detector at the CERN LHC at a nucleon-nucleon center-of-mass energy of 5.02 TeV. Fragmentation functions are obtained for jets with p_{T}^{jet}>30  GeV/c in events containing an isolated photon with p_{T}^{γ}>60  GeV/c, using charged tracks with transverse momentum p_{T}^{trk}>1  GeV/c in a cone around the jet axis. The association with an isolated photon constrains the initial p_{T} and azimuthal angle of the parton whose shower produced the jet. For central Pb-Pb collisions, modifications of the jet fragmentation functions are observed when compared to those measured in pp collisions, while no significant differences are found in the 50% most peripheral collisions. Jets in central Pb-Pb events show an excess (depletion) of low (high) p_{T} particles, with a transition around 3  GeV/c. This measurement shows for the first time the in-medium shower modifications of partons (quark dominated) with well-defined initial kinematics. It constitutes a new well-controlled reference for testing theoretical models of the parton passage through the quark-gluon plasma.

Measurement of differential cross sections for Z boson production in association with jets in proton-proton collisions at s = 13 TeV

The production of a Z boson, decaying to two charged leptons, in association with jets in proton-proton collisions at a centre-of-mass energy of 13TeV is measured. Data recorded with the CMS detector at the LHC are used that correspond to an integrated luminosity of 2.19fb -1 . The cross section is measured as a function of the jet multiplicity and its dependence on the transverse momentum of the Z boson, the jet kinematic variables (transverse momentum and rapidity), the scalar sum of the jet momenta, which quantifies the hadronic activity, and the balance in transverse momentum between the reconstructed jet recoil and the Z boson. The measurements are compared with predictions from four different calculations. The first two merge matrix elements with different parton multiplicities in the final state and parton showering, one of which includes one-loop corrections. The third is a fixed-order calculation with next-to-next-to-leading order accuracy for the process with a Z boson and one parton in the final state. The fourth combines the fully differential next-to-next-to-leading order calculation of the process with no parton in the final state with next-to-next-to-leading logarithm resummation and parton showering.

Measurement of the top quark mass with lepton+jets final states using p p collisions at s = 13 TeV

The mass of the top quark is measured using a sample of t t ¯ events collected by the CMS detector using proton-proton collisions ats = 13 TeV at the CERN LHC. Events are selected with one isolated muon or electron and at least four jets from data corresponding to an integrated luminosity of 35.9fb - 1 . For each event the mass is reconstructed from a kinematic fit of the decay products to a t t ¯ hypothesis. Using the ideogram method, the top quark mass is determined simultaneously with an overall jet energy scale factor (JSF), constrained by the mass of the W boson in q q ¯ ' decays. The measurement is calibrated on samples simulated at next-to-leading order matched to a leading-order parton shower. The top quark mass is found to be 172.25 ± 0.08 (stat+JSF) ± 0.62 (syst) GeV . The dependence of this result on the kinematic properties of the event is studied and compared to predictions of different models of t t ¯ production, and no indications of a bias in the measurements are observed.

Search for new physics in dijet angular distributions using proton-proton collisions at s = 13 TeV and constraints on dark matter and other models

A search is presented for physics beyond the standard model, based on measurements of dijet angular distributions in proton-proton collisions ats = 13 TeV . The data collected with the CMS detector at the LHC correspond to an integrated luminosity of 35.9fb - 1 . The observed distributions, corrected to particle level, are found to be in agreement with predictions from perturbative quantum chromodynamics that include electroweak corrections. Constraints are placed on models containing quark contact interactions, extra spatial dimensions, quantum black holes, or dark matter, using the detector-level distributions. In a benchmark model where only left-handed quarks participate, contact interactions are excluded at the 95% confidence level up to a scale of 12.8 or 17.5TeV, for destructive or constructive interference, respectively. The most stringent lower limits to date are set on the ultraviolet cutoff in the Arkani-Hamed-Dimopoulos-Dvali model of extra dimensions. In the Giudice-Rattazzi-Wells convention, the cutoff scale is excluded up to 10.1TeV. The production of quantum black holes is excluded for masses below 5.9 and 8.2TeV, depending on the model. For the first time, lower limits between 2.0 and 4.6TeVare set on the mass of a dark matter mediator for (axial-)vector mediators, for the universal quark couplingg q = 1.0 .

Measurement of the Z / γ ∗ → τ τ cross section in pp collisions at s = 13 TeV and validation of τ lepton analysis techniques

A measurement is presented of the Z / γ ∗ → τ τ cross section in pp collisions ats = 13 TeV , using data recorded by the CMS experiment at the LHC, corresponding to an integrated luminosity of 2.3 fb - 1 . The product of the inclusive cross section and branching fraction is measured to be σ ( pp → Z / γ ∗ +X ) B ( Z / γ ∗ → τ τ ) = 1848 ± 12 ( stat ) ± 67 (syst \,+\,lumi) pb , in agreement with the standard model expectation, computed at next-to-next-to-leading order accuracy in perturbative quantum chromodynamics. The measurement is used to validate new analysis techniques relevant for future measurements of τ lepton production. The measurement also provides the reconstruction efficiency and energy scale for τ decays to hadrons+ ν τ final states, determined with respective relative uncertainties of 2.2 and 0.9%.

Search for third-generation scalar leptoquarks decaying to a top quark and a τ lepton at s = 13 Te

A search for pair production of heavy scalar leptoquarks (LQs), each decaying into a top quark and a τ lepton, is presented. The search considers final states with an electron or a muon, one or two τ leptons that decayed to hadrons, and additional jets. The data were collected in 2016 in proton-proton collisions ats = 13 Te with the CMS detector at the LHC, and correspond to an integrated luminosity of 35.9fb - 1 . No evidence for pair production of LQs is found. Assuming a branching fraction of unity for the decay LQ → t τ , upper limits on the production cross section are set as a function of LQ mass, excluding masses below 900Ge at 95% confidence level. These results provide the most stringent limits to date on the production of scalar LQs that decay to a top quark and a τ lepton.

Measurement of prompt and nonprompt charmonium suppression in PbPb collisions at 5.02 TeV

The nuclear modification factors of J / ψ and ψ (2S) mesons are measured in PbPb collisions at a centre-of-mass energy per nucleon pair of s NN = 5.02 TeV . The analysis is based on PbPb and p p data samples collected by CMS at the LHC in 2015, corresponding to integrated luminosities of 464 μ b - 1 and 28 pb -1 , respectively. The measurements are performed in the dimuon rapidity range of | y | < 2.4 as a function of centrality, rapidity, and transverse momentum ( p T ) from p T = 3 GeV / c in the most forward region and up to 50 GeV / c . Both prompt and nonprompt (coming from b hadron decays) J / ψ mesons are observed to be increasingly suppressed with centrality, with a magnitude similar to the one observed at s NN = 2.76 TeV for the two J / ψ meson components. No dependence on rapidity is observed for either prompt or nonprompt J / ψ mesons. An indication of a lower prompt J / ψ meson suppression at p T > 25 GeV / c is seen with respect to that observed at intermediate p T . The prompt ψ (2S) meson yield is found to be more suppressed than that of the prompt J / ψ mesons in the entire p T range.

Search for Physics Beyond the Standard Model in Events with High-Momentum Higgs Bosons and Missing Transverse Momentum in Proton-Proton Collisions at 13 TeV

A search for physics beyond the standard model in events with one or more high-momentum Higgs bosons, H, decaying to pairs of b quarks in association with missing transverse momentum is presented. The data, corresponding to an integrated luminosity of 35.9  fb^{-1}, were collected with the CMS detector at the LHC in proton-proton collisions at the center-of-mass energy sqrt[s]=13  TeV. The analysis utilizes a new b quark tagging technique based on jet substructure to identify jets from H→bb[over ¯]. Events are categorized by the multiplicity of H-tagged jets, jet mass, and the missing transverse momentum. No significant deviation from standard model expectations is observed. In the context of supersymmetry (SUSY), limits on the cross sections of pair-produced gluinos are set, assuming that gluinos decay to quark pairs, H (or Z), and the lightest SUSY particle, LSP, through an intermediate next-to-lightest SUSY particle, NLSP. With large mass splitting between the NLSP and LSP, and 100% NLSP branching fraction to H, the lower limit on the gluino mass is found to be 2010 GeV.

Measurement of b hadron lifetimes in pp collisions at s = 8 TeV

Measurements are presented of the lifetimes of theB 0 ,B s 0 , Λ b 0 , and B c + hadrons using the decay channelsB 0 → J / ψ K ∗ ( 892 ) 0 ,B 0 → J / ψ K S 0 ,B s 0 → J / ψ π + π - ,B s 0 → J / ψ ϕ ( 1020 ) ,Λ b 0 → J / ψ Λ 0 , andB c + → J / ψ π + . The data sample, corresponding to an integrated luminosity of 19.7fb -1 , was collected by the CMS detector at the LHC in proton-proton collisions ats = 8 TeV . TheB 0 lifetime is measured to be 453.0 ± 1.6 (stat) ± 1.8 (syst) μ m in J / ψ K ∗ ( 892 ) 0 and 457.8 ± 2.7 (stat) ± 2.8 (syst) μ m in J / ψ K S 0 , which results in a combined measurement of c τ B 0 = 454.1 ± 1.4 (stat) ± 1.7 (syst) μ m . The effective lifetime of theB s 0 meson is measured in two decay modes, with contributions from different amounts of the heavy and light eigenstates. This results in two different measured lifetimes: c τ B s 0 → J / ψ π + π - = 502.7 ± 10.2 (stat) ± 3.4 (syst) μ m and c τ B s 0 → J / ψ ϕ ( 1020 ) = 443.9 ± 2.0 (stat) ± 1.5 (syst) μ m . The Λ b 0 lifetime is found to be 442.9 ± 8.2 (stat) ± 2.8 (syst) μ m . The precision from each of these channels is as good as or better than previous measurements. The B c + lifetime, measured with respect to theB + to reduce the systematic uncertainty, is 162.3 ± 7.8 (stat) ± 4.2 (syst) ± 0.1 ( τ B + ) μ m . All results are in agreement with current world-average values.

Search for Heavy Neutral Leptons in Events with Three Charged Leptons in Proton-Proton Collisions at sqrt[s]=13 TeV

A search for a heavy neutral lepton N of Majorana nature decaying into a W boson and a charged lepton is performed using the CMS detector at the LHC. The targeted signature consists of three prompt charged leptons in any flavor combination of electrons and muons. The data were collected in proton-proton collisions at a center-of-mass energy of 13 TeV, with an integrated luminosity of 35.9  fb^{-1}. The search is performed in the N mass range between 1 GeV and 1.2 TeV. The data are found to be consistent with the expected standard model background. Upper limits are set on the values of |V_{eN}|^{2} and |V_{μN}|^{2}, where V_{ℓN} is the matrix element describing the mixing of N with the standard model neutrino of flavor ℓ. These are the first direct limits for N masses above 500 GeV and the first limits obtained at a hadron collider for N masses below 40 GeV.

Measurement of Prompt D^{0} Meson Azimuthal Anisotropy in Pb-Pb Collisions at sqrt[s_{NN}]=5.02 TeV

The prompt D^{0} meson azimuthal anisotropy coefficients, v_{2} and v_{3}, are measured at midrapidity (|y|<1.0) in Pb-Pb collisions at a center-of-mass energy sqrt[s_{NN}]=5.02  TeV per nucleon pair with data collected by the CMS experiment. The measurement is performed in the transverse momentum (p_{T}) range of 1 to 40  GeV/c, for central and midcentral collisions. The v_{2} coefficient is found to be positive throughout the p_{T} range studied. The first measurement of the prompt D^{0} meson v_{3} coefficient is performed, and values up to 0.07 are observed for p_{T} around 4  GeV/c. Compared to measurements of charged particles, a similar p_{T} dependence, but smaller magnitude for p_{T}<6  GeV/c, is found for prompt D^{0} meson v_{2} and v_{3} coefficients. The results are consistent with the presence of collective motion of charm quarks at low p_{T} and a path length dependence of charm quark energy loss at high p_{T}, thereby providing new constraints on the theoretical description of the interactions between charm quarks and the quark-gluon plasma.

Search for the X(5568) State Decaying into B_{s}^{0}π^{±} in Proton-Proton Collisions at sqrt[s]=8 TeV

A search for resonancelike structures in the B_{s}^{0}π^{±} invariant mass spectrum is performed using proton-proton collision data collected by the CMS experiment at the LHC at sqrt[s]=8  TeV, corresponding to an integrated luminosity of 19.7  fb^{-1}. The B_{s}^{0} mesons are reconstructed in the decay chain B_{s}^{0}→J/ψϕ, with J/ψ→μ^{+}μ^{-} and ϕ→K^{+}K^{-}. The B_{s}^{0}π^{±} invariant mass distribution shows no statistically significant peaks for different selection requirements on the reconstructed B_{s}^{0} and π^{±} candidates. Upper limits are set on the relative production rates of the X(5568) and B_{s}^{0} states times the branching fraction of the decay X(5568)^{±}→B_{s}^{0}π^{±}. In addition, upper limits are obtained as a function of the mass and the natural width of possible exotic states decaying into B_{s}^{0}π^{±}.

Search for Narrow Resonances in the b-Tagged Dijet Mass Spectrum in Proton-Proton Collisions at sqrt[s]=8 TeV

A search for narrow resonances decaying to bottom quark-antiquark pairs is presented, using a data sample of proton-proton collisions at sqrt[s]=8  TeV corresponding to an integrated luminosity of 19.7  fb^{-1}. The search is extended to masses lower than those reached in typical searches for resonances decaying into jet pairs at the LHC, by taking advantage of triggers that identify jets originating from bottom quarks. No significant excess of events is observed above the background predictions. Limits are set on the product of cross section and branching fraction to bottom quarks for spin 0, 1, and 2 resonances in the mass range of 325-1200 GeV. These results improve on the limits for resonances decaying into jet pairs in the 325-500 GeV mass range.

Search for new physics in events with a leptonically decaying Z boson and a large transverse momentum imbalance in proton-proton collisions at s = 13 TeV

A search for new physics in events with a Z boson produced in association with large missing transverse momentum at the LHC is presented. The search is based on the 2016 data sample of proton-proton collisions recorded with the CMS experiment ats = 13 TeV , corresponding to an integrated luminosity of 35.9fb - 1 . The results of this search are interpreted in terms of a simplified model of dark matter production via spin-0 or spin-1 mediators, a scenario with a standard-model-like Higgs boson produced in association with the Z boson and decaying invisibly, a model of unparticle production, and a model with large extra spatial dimensions. No significant deviations from the background expectations are found, and limits are set on relevant model parameters, significantly extending the results previously achieved in this channel.