Patient-Specific Segmentation-Based Treatment Planning vs. NovoTAL for TTFields Therapy in Glioblastoma

PURPOSE/OBJECTIVE(S)

Patients treated with Tumor Treating Fields (TTFields) therapy for glioblastoma (GBM) have array layouts planned by NovoTAL. NovoTAL requires morphometric inputs and maximizes field intensity at the tumor. Patient-specific segmentation-based treatment planning (SBTP) software uses segmentation-based plans to maximize power density at defined regions of interest (ROIs). This technical analysis compared expected local minimum power density (LMiPD; mW/cm3) and local minimum field intensity (LMiFI; V/cm) delivered to ROIs with array layouts planned with SBTP vs NovoTAL. We hypothesized that SBTP has the potential to increase LMiPD and LMiFI to ROIs vs NovoTal.

MATERIALS/METHODS

37 patients from 5 sites who received TTFields therapy for GBM using NovoTAL were included. Treatment plans using the prescribed/treated NovoTAL layouts were created with SBTP. De novo SBTP layouts were also created. Three ROIs representing the original treated GBM (CTV), high risk margin around the GBM (CTV-2), and recurrent GBM (CTV-R) were created. Plans were optimized to CTV. SBTP vs NovoTAL LMiPD and LMiFI volumetrics to ROIs were evaluated. LMiPD and LMiFI were normalized with the delivered current from the treated NovoTAL layout. Layout rankings based on LMiPD and LMiFI, average LMiPD and LMiFI, D95, D5, DVHs, and voxel-by-voxel LMiPD and LMiFI for SBTP derived from NovoTAL layouts were compared to de novo SBTP layouts (paired t-tests).

RESULTS

Average LMiPD (1.551 vs 1.194) and LMiFI (1.115 vs 0.978) to CTV were significantly higher with SBTP vs NovoTAL (P < 0.0001 for each). Average LMiPD (1.445 vs 1.164) and LMiFI (1.197 vs 1.077) to CTV-2 were also higher (P < 0.0001 for each). There was a positive trend to higher average LMiPD (1.203 vs 1.157; P = 0.212) and LMiFI (1.103 vs 1.090; P = 0.311) to CTV-R. Top ranked overall layouts by LMiPD to CTV were SBTP layouts (97%; n = 36). Percent ratio ([SBTP-NovoTAL]/NovoTAL*100) D95 for LMiPD was 34% (to CTV), 24% (to CTV-2), and 5% (to CTV-R) and for LMiFI was 16%, 12%, and 2% respectively. Percent ratio D5 for LMiPD was 31%, 24%, and 3% and for LMiFI was 14%, 9%, and 0%, respectively. For a given percent CTV volume, minimum LMiPD and LMiFI were higher with SBTP (95%, n = 35; DVH curves shifted to right). SBTP yielded higher LMiPD and LMiFI to the majority of voxels within the CTV (95%, n = 35). With SBTP, LMiPD to CTV was significantly higher than to CTV-R (P < 0.001).

CONCLUSION

Overall, these data demonstrate that SBTP compared to NovoTAL yielded higher expected average LMiPD and LMiFI, D95, D5, and percent voxel LMiPD and LMiFI to defined ROIs. Higher LMiPD and LMiFI delivered to CTV vs CTV-R with SBTP suggests a benefit to re-planning if the GBM recurs. Given previous reports showing that higher LMiPD and LMiFI are positively correlated with improved overall and progression free survival, patient-specific SBTP may lead to improved clinical outcomes for GBM patients vs NovoTAL.

Acute angioedema in Cape Town emergency centres and a suggested algorithm to simplify and improve management

BACKGROUND

Angioedema is the most common acute allergic presentation to emergency centres (EC), with hospitalisation rates increasing in high-income countries. Angioedema can complicate with life-threatening laryngeal obstruction. There are no local data; therefore, we aimed to characterise acute angioedema cases presenting to ECs and develop a simple management algorithm.

OBJECTIVE

To characterise the clinical presentation, management and outcomes of acute angioedema cases presenting to ECs. Based on these findings, we developed a management algorithm for acute angioedema to improve the care of acute angioedema in South Africa (SA).

METHODS

We conducted a retrospective folder review of all patients admitted to Groote Schuur Hospital (tertiary) and Mitchells Plain District Hospital (secondary) ECs from 1  June 2018 to 31  June 2020. Using ICD-10 coding, folders of adults ≥18 years with possible angioedema presenting to the ECs were screened. An allergist extracted demographics, medical history, management and outcome data for each angioedema event.

RESULTS

A total of 142 acute angioedema episodes were included, with a median (interquartile range) age of 42 (28 - 58) years, and 62% of patients were female. The majority (124/142, 87%) of acute angioedema EC presentations involved swelling above the shoulders, with airway involvement in 20 (14%) patients, with two patients requiring intubation. Nineteen (13%) patients required admission, with five (26%) admitted to high care/intensive care. Drug-induced angioedema was the most common cause, with 64/142 (45%) linked to a known offending drug, 42/64 (65.6%) being angiotensin-converting enzyme inhibitor (ACE-I). Critical information to guide angioedema management, including past personal/family allergy history, and duration of angioedema prior to EC visit, was not recorded in 64.7% and 37.8% of EC records, respectively. Unnecessary treatment with corticosteroids or antihistamines occurred in 19/53 (36%) and 16/53 (30%) cases with bradykinin-mediated angioedema ACE-I angioedema and hereditary angioedema). Overall, only 36/142 (25%) of angioedema patients were connected to allergy care.

CONCLUSION

Angioedema is the most common allergy presentation to two ECs in Cape Town, SA. Bradykinin-mediated angioedema secondary to ACE-I therapy is the single most common offender, and was not appropriately managed in more than a third of cases. Based on these findings, we have developed a management algorithm that easily stratifies patients into bradykinin or mast cell-mediated angioedema with a step-by-step management approach that is applicable to the SA context. Ongoing awareness and education on allergy emergencies are required to ensure accurate diagnosis of less common causes of angioedema (particularly bradykinin-mediated angioedema) and linkage to allergy specialist care.

Long-term HIV and tuberculosis outcomes in patients hospitalised with severe cutaneous adverse reactions

Background

Treatment-limiting severe cutaneous adverse reactions (SCAR) occur more commonly amongst persons with HIV-associated tuberculosis (TB). The impact of SCAR on long-term HIV/TB outcomes is unknown.

Methods

Patients with TB and/or HIV admitted to Groote Schuur Hospital, Cape Town, South Africa with SCAR between 1/10/2018 and 30/09/2021 were eligible. Follow-up data was collected for 6- and 12-month outcomes: mortality, TB and antiretroviral therapy (ART) regimen changes, TB treatment completion, and CD4 count recovery.

Results

Forty-eight SCAR admissions included: 34, 11, and 3 HIV-associated TB, HIV-only and TB-only patients with 32, 13 and 3 cases of drug reaction with eosinophilia and systemic symptoms, Stevens-Johnson syndrome/toxic epidermal necrolysis and generalised bullous fixed-drug eruption respectively. Nine (19%), all HIV-positive (eight co-infected with TB), were deceased at 12-months, and 12(25%) were lost to follow-up. Amongst TB-SCAR patients, seven (21%) were discharged on all four first-line anti-TB drugs (FLTD), while 12(33%) had regimens with no FLTDs; 24/37(65%) completed TB treatment. Amongst HIV-SCAR patients, 10/31(32%) changed ART regimen. If retained in care (24/36), median (IQR) CD4 counts increased at 12-months post-SCAR (115(62-175) vs. 319(134-439) cells/uL).

Conclusion

SCAR admission amongst patients with HIV-associated TB results in substantial mortality, and considerable treatment complexity. However, if retained in care, TB regimens are successfully completed, and immune recovery is good despite SCAR.

Self-reported beta-lactam allergy in government and private hospitals in Cape Town, South Africa

BACKGROUND

Up to a quarter of inpatients in high-income countries (HICs) self-report beta-lactam allergy (BLA), which if incorrect,increases the use of alternative antibiotics, worsening individual health outcomes and driving bacterial resistance. In HICs, up to 95% ofself-reported BLAs are incorrect. The epidemiology of BLA in low- and middle-income African countries is unknown.

OBJECTIVES

To describe the epidemiology and de-labelling outcomes of self-reported BLA in hospitalised South African (SA) patients.

METHODS

Point-prevalence surveys were conducted at seven hospitals (adult, paediatric, government and privately funded, district andtertiary level) in Cape Town, SA, between April 2019 and June 2021. Ward prescription records and in-person interviews were conductedto identify and risk-stratify BLA patients using the validated PEN-FAST tool. De-labelling was attempted at the tertiary allergy clinic atGroote Schuur Hospital.

RESULTS

A total of 1 486 hospital inpatients were surveyed (1 166 adults and 320 children). Only 48 patients (3.2%) self-reported a BLA,with a higher rate in private than in government-funded hospitals (6.3% v. 2.8%; p=0.014). Using the PEN-FAST tool, only 10.4% (n=5/48)of self-reported BLA patients were classified as high risk for true penicillin hypersensitivity. Antibiotics were prescribed to 70.8% (n=34/48)of self-reported BLA patients, with 64.7% (n=22/34) receiving a beta-lactam. Despite three attempts to contact patients for de-labelling atthe allergy clinic, only 3/36 underwent in vivo testing, with no positive results, and 1 patient proceeded to a negative oral challenge.

CONCLUSION

Unlike HICs, self-reported BLA is low among inpatients in SA. The majority of those who self-reported BLA were low risk fortype 1 hypersensitivity, but outpatient de-labelling efforts were largely unsuccessful.

Sustainable and equivalent improvements in symptoms and functional well-being following viral cure from ledipasvir/sofosbuvir versus elbasvir/grazoprevir for chronic hepatitis C infection: Findings from the randomized PRIORITIZE trial

The PRIORITIZE trial (clinicaltrials.gov: NCT02786537) was the first comparative effectiveness study to directly compare ledipasvir/sofosbuvir (LDV/SOF) and elbasvir/grazoprevir (EBR/GZR) for the treatment of chronic hepatitis C virus (HCV). A secondary aim of this study was to compare LDV/SOF and EBR/GZR on sustainable changes in several HCV-associated symptoms and functional well-being in patients who achieved sustained virological response (SVR). PRIORITIZE, a randomized controlled trial conducted between 2016 and 2020, evaluated change in six PROMIS® symptom scores (fatigue, sleep disturbance, cognitive disturbance, nausea, diarrhoea, abdominal pain) and functional well-being using the disease-specific HCV-PRO instrument. Survey assessments were administered at baseline, early post-treatment (median = 6 months) and late post-treatment (median = 21 months). Constrained longitudinal linear mixed-effects models were used to evaluate within-treatment change and between-treatment differences. Data from 793 participants (average 55 years old, 57% male, 44% black, 17% with cirrhosis) were analysed. From baseline to early post-treatment, 5 out of 6 symptoms and functional well-being significantly improved (all p's < .05). In the LDV/SOF arm, mean changes ranged from -3.73 for nausea to -6.41 for fatigue and in the EBR/GZR, mean changes ranged from -2.19 for cognitive impairment to -4.67 for fatigue. Change of >3 points was consider clinically meaningful. Improvements in most symptoms slightly favoured LDV/SOF, although the magnitude of differences between the regimens were small. Both regimens demonstrated significant improvements in symptoms and functional well-being that were sustained during the late post-treatment phase. EBR/GZR and LDV/SOF regimens had clinically equivalent and durable improvements in HCV symptoms and functional well-being up to two years after SVR.

Rhino-orbito-cerebral mucormycosis: patient characteristics in pre-COVID-19 and COVID-19 period

Background: Rhino-orbito-cerebral-mucormycosis (ROCM), a rare and potentially fatal disease was seen in increasing numbers during the COVID-19 pandemic. This study describes and compares the patient characteristics and outcomes in COVID-19 associated mucormycosis (CAM) and non-COVID-19 mucormycosis (non-CAM). Methodology: CAM patients (24 cases) were recruited from the COVID-19 period and non-CAM (24 controls) from the pre-COVID-19 period. Clinical data of the CAM group was collected retrospectively with 3 month outcomes prospectively. The non-CAM group data was collected retrospectively. Patient characteristics were compared and risk factors for mortality in ROCM were assessed. Results: Orbital symptoms [altered vision, restricted eye movements, ptosis] and intracranial involvement were higher in CAM patients on presentation. Similarly, the radiological involvement of orbit (orbital apex, superior orbital fissure) and intracranial cavity (intracranial thrombosis, cavernous sinus) was also higher in CAM patients. Newly detected diabetes was found only in CAM patients (29.2%). Although univariate analysis suggested an increased mortality risk in ROCM patients with orbital involvement, the multivariate analysis showed no increased risk with any of the parameters assessed, including COVID-19 positivity. Conclusions: Compared to the non-CAM, the disease presentation was severe in CAM with higher frequency of orbital and intracranial involvement. However, with early detection and treatment, the short term survival was comparable in both groups.

Machine learning algorithms for predicting direct-acting antiviral treatment failure in chronic hepatitis C: An HCV-TARGET analysis

BACKGROUND AND AIMS

We aimed to develop and validate machine learning algorithms to predict direct-acting antiviral (DAA) treatment failure among patients with HCV infection.

APPROACH AND RESULTS

We used HCV-TARGET registry data to identify HCV-infected adults receiving all-oral DAA treatment and having virologic outcome. Potential pretreatment predictors (n = 179) included sociodemographic, clinical characteristics, and virologic data. We applied multivariable logistic regression as well as elastic net, random forest, gradient boosting machine (GBM), and feedforward neural network machine learning algorithms to predict DAA treatment failure. Training (n = 4894) and validation (n = 1631) patient samples had similar sociodemographic and clinical characteristics (mean age, 57 years; 60% male; 66% White; 36% with cirrhosis). Of 6525 HCV-infected adults, 95.3% achieved sustained virologic response, whereas 4.7% experienced DAA treatment failure. In the validation sample, machine learning approaches performed similarly in predicting DAA treatment failure (C statistic [95% CI]: GBM, 0.69 [0.64-0.74]; random forest, 0.68 [0.63-0.73]; feedforward neural network, 0.66 [0.60-0.71]; elastic net, 0.64 [0.59-0.70]), and all four outperformed multivariable logistic regression (0.51 [0.46-0.57]). Using the Youden index to identify the balanced risk score threshold, GBM had 66.2% sensitivity and 65.1% specificity, and 12 individuals were needed to evaluate to identify 1 DAA treatment failure. Over 55% of patients with treatment failure were classified by the GBM in the top three risk decile subgroups (positive predictive value: 6%-14%). The top 10 GBM-identified predictors included albumin, liver enzymes (aspartate aminotransferase, alkaline phosphatase), total bilirubin levels, sex, HCV viral loads, sodium level, HCC, platelet levels, and tobacco use.

CONCLUSIONS

Machine learning algorithms performed effectively for risk prediction and stratification of DAA treatment failure.

A Pragmatic, Randomized Controlled Trial of Oral Antivirals for the Treatment of Chronic Hepatitis C: The PRIORITIZE Study

BACKGROUND AND AIMS

Multiple direct-acting antiviral (DAA) regimens are available to treat HCV genotype 1 infection. However, comparative effectiveness from randomized controlled trials of DAA regimens is unavailable.

APPROACH AND RESULTS

We conducted a pragmatic randomized controlled trial (NCT02786537) to compare the effectiveness of DAAs for HCV genotype 1a or 1b on viral response, safety, tolerability, and medication nonadherence. Adults with compensated liver disease, HCV genotype 1, not pregnant or breastfeeding, and with health insurance likely to cover ledipasvir/sofosbuvir (LDV/SOF) were recruited from 34 US viral hepatitis clinics. Participants were randomized (± ribavirin) to LDV/SOF, elbasvir/grazoprevir (EBR/GZR), and paritaprevir/ritonavir/ombitasvir+dasabuvir (PrOD; treatment arm stopped early). Primary outcomes included sustained viral response at 12 weeks (SVR12), clinician-recorded adverse events, patient-reported symptoms, and medication nonadherence. Between June 2016 and March 2018, 1,609 participants were randomized. Among 1,128 participants who received ≥1 dose of EBR/GZR or LDV/SOF (± ribavirin), SVR12 was 95.2% (95% CI, 92.8%-97.6%) and 97.4% (95% CI, 95.5%-99.2%), respectively, with a difference estimate of 2.2% (-0.5% to 4.7%), falling within the "equivalence" interval (-5% to 5%). While most (56%) participants experienced adverse events, few were serious (4.2%) or severe (1.8%). In the absence of ribavirin, discontinuations due to adverse events were rare. Patient-reported symptoms and medication nonadherence were similar. Study limitations were dropout due to insurance denial and loss to follow-up after treatment, limiting the ability to measure SVR12.

CONCLUSIONS

This pragmatic trial demonstrated high SVR12 for participants treated with EBR/GZR and LDV/SOF with few adverse effects. Overall, the two regimens were equivalent in effectiveness. The results support current HCV guidelines that do not distinguish between ribavirin-free EBR/GZR and LDV/SOF.

Frontal increase of beta modulation during the practice of a motor task is enhanced by visuomotor learning

Movement is accompanied by beta power changes over frontal and sensorimotor regions: a decrease during movement (event-related desynchronization, ERD), followed by an increase (event-related synchronization, ERS) after the movement end. We previously found that enhancements of beta modulation (from ERD to ERS) during a reaching test (mov) occur over frontal and left sensorimotor regions after practice in a visuo-motor adaptation task (ROT) but not after visual learning practice. Thus, these enhancements may reflect local cumulative effects of motor learning. Here we verified whether they are triggered by the learning component inherent in ROT or simply by motor practice in a reaching task without such learning (MOT). We found that beta modulation during mov increased over frontal and left areas after three-hour practice of either ROT or MOT. However, the frontal increase was greater after ROT, while the increase over the left area was similar after the two tasks. These findings confirm that motor practice leaves local traces in beta power during a subsequent motor test. As they occur after motor tasks with and without learning, these traces likely express the cost of processes necessary for both usage and engagement of long-term potentiation mechanisms necessary for the learning required by ROT.

COVID-19 vaccination: Recommendations for management of patients with allergy or immune-based diseases

As South Africa continues to battle the second wave of SARS-CoV-2 infections, the imminent arrival of vaccines against COVID-19 offers hope. Vaccine roll-out has been accompanied by heightened media coverage that has created both excitement and anxiety, reporting on the shortened timeline of vaccine trials and approvals, as well as the recent series of anaphylaxis cases associated with the two approved mRNA COVID-19 vaccines. Patients with allergic and other immune-based diseases are subgroups especially concerned about vaccine safety and efficacy. This practice guideline offers broad recommendations for COVID-19 vaccination in various subgroups of allergic and immunebased disease, highlighting risk/benefit evaluation, and where and how routine vaccination should be altered.

Durability and stability of antimicrobial coated surfaces

Antimicrobial surface coating of i.e. medical devices could contribute to infection prevention and reduction of hospital acquired infections (HAI). Recent studies showed a significant reduction in the microbial contamination of antimicrobial coated surfaces in clinical setups. Nevertheless, there are only few publications available that deal with the durability and stability of these coatings under routine clinical conditions. In this work different antimicrobial coating compositions were tested on different surfaces for their durability and remaining antimicrobial activity. Our results show that the durability and stability of a subsequent applied antimicrobial coating is strongly dependent on the chemical formulation of the coating and also the underlying surface condition. Whereas we could still detect remaining antimicrobial coating and activity on some samples after repeated abrasion testing, some other samples lost their coating and activity after only a few abrasion cycles. Interestingly the integrated antimicrobial substance in the 3-D printed samples showed strong antimicrobial activity even after rough treatment of the surfaces (brushing, scratching).

COVID-19 antibody testing: From hype to immunological reality

The potential role for serological tests in the current COVID-19 pandemic has generated very considerable recent interest across many sectors worldwide, inter alia pathologists seeking additional weapons for their armoury of diagnostic tests; epidemiologists seeking tools to gain seroprevalence data that will inform improved models of the spread of disease; research scientists seeking tools to study the natural history of COVID-19 disease; vaccine developers seeking tools to assess vaccine efficacy in clinical trials; and companies and governments seeking tools to aid return-to-work decision-making. However, much of the local debate to date has centred on questions surrounding whether regulatory approval processes are limiting access to serological tests, and has not paused to consider the intrinsically limiting impact of underlying fundamental biology and immunology on where and how different COVID-19 serological tests can usefully be deployed in the response to the current pandemic. We review, from an immunological perspective, recent experimental evidence on the time-dependency of adaptive immune responses following SARS-CoV-2 infection and the impact of this on the sensitivity and specificity of COVID-19 antibody tests made at different time points post infection. We interpret this scientific evidence in terms of mooted clinical applications for current COVID-19 antibody tests in identifying acute infections, in confirming recent or past infections at the individual and population level, and in detecting re-infection and protective immunity. We conclude with guidance on where current COVID-19 antibody tests can make a genuine impact in the pandemic.

Chronic rhinitis in South Africa - more than just allergy!

Chronic rhinitis is a troublesome condition for sufferers. It is tempting to label all patients with chronic nasal symptoms as having allergic rhinitis (AR), but many such patients have other causes of chronic rhinitis that need a specific diagnosis and management strategy. Even when the patient fully fits the definition of AR, their condition will be best served by combining medication with ongoing patient education.

Prevalence and outcome of delirium among acute general medical inpatients in Cape Town, South Africa

BACKGROUND

Delirium is a common, serious, underdiagnosed condition in medical and surgical inpatients with acute conditions. It is associated with increased risk of mortality and morbidity. Data of geriatric cohorts are largely limited to developed countries.

OBJECTIVES

To describe prevalence, risk factors and outcomes of delirium among general medical patients admitted to two hospitals in Cape Town, South Africa.

METHODS

This was a prospective cohort study of patients with acute conditions admitted to a general medical inpatient service in secondary- and tertiary-level public hospitals in the Metro West area of Cape Town. Patients ≥18 years of age were recruited daily from all acute medical admissions. Patients were excluded if they were aphasic or their Glasgow coma scale was &lt;8/15. Delirium was diagnosed using the validated confusion assessment method (CAM) tool and performed by trained neuropsychologists. Demographic data were collected by a clinical team and short- and long-term mortality data were obtained using linkage analysis of hospitalised patients and routinely collected provincial death certification records.

RESULTS

The median age of inpatients was 51 (interquartile range 36 - 65) years, 29% were HIV-infected and the overall prevalence of delirium was 12.3%. Multivariate predictors of delirium included the presence of an indwelling urinary catheter (odds ratio (OR) 4.47; confidence interval (CI) 2.43 - 8.23), admission with a central nervous system disease (OR 4.34; CI 2.79 - 7.90), pre-existing cognitive impairment (OR 3.02; CI 1.22 - 7.43) and immobility (OR 1.88; CI 1.01 - 3.51). HIV infection was not associated with increased risk of delirium. Delirium was associated with an increased risk of inhospital (delirium v. no delirium: 29% v. 12%; p&lt;0.01) and 12-month (30% v. 20%; p&lt;0.01) mortality, as well as increased length of hospital stay (7 days v. 5 days; p&lt;0.01).

CONCLUSIONS

In this cohort of medical inpatients (relatively young and with a high HIV prevalence) 1 of 8 (12.3%) patients was delirious. Delirium was associated with adverse outcomes. Delirium risk factors in this young cohort were similar to those in geriatric cohorts in developed countries, and neither HIV nor opportunistic infections increased risk.

[Interrater reliability and clinical impact of the Post-Ureteroscopic Lesion Scale (PULS) grading system for ureteral lesions after ureteroscopy : Results of the German prospective multicenter BUSTER project]

BACKGROUND

The Post-ureteroscopic Lesion Scale (PULS) was designed as a standardized classification system for ureteral lesions after uretero(reno)scopy (URS). This study evaluates its routine use and a possible clinical impact based on a representative patient cohort.

MATERIALS AND METHODS

Data of 307 patients in 14 German centers within the BUSTER project were used to test 3 hypotheses (H): PULS score shows a high interrater reliability (IRR) after independent assessment by urologic surgeon and assistance personnel (H1); PULS score is correlated with the frequency of postoperative complications during hospital stay (H2); post-URS stenting of the ureter is associated with higher PULS scores (H3).

RESULTS

Median age of patients was 54.4 years (interquartile range [IQR] 44.4-65.8; 65.5% male). Median diameter of index stones was 6 mm (IQR 4-8) with 117 (38.4%) pyelo-caliceal and 188 (61.6%) ureteral stones. Overall, 70 and 82.4% of patients had pre-stenting and post-URS stenting, respectively. Stone-free status was achieved in 68.7% after one URS procedure with a complication rate of 10.8% (mostly grade 1-2 according to Clavien-Dindo). PULS scores 0, 1, 2 and 3 were assessed in 40%, 52.1%, 6.9% and 1% of patients, respectively, when estimated by urologic surgeons. PULS score showed a high IRR between the urologic surgeon and assistance personnel (κ = 0.883, p < 0.001), but was not significantly correlated with complications (ρ = 0.09, p = 0.881). In contrast, a significant positive correlation was found between PULS score and post-URS stenting (ρ = 0.287, p < 0.001). A PULS score of 1 multiplied the likelihood of post-URS stenting by 3.24 (95% confidence interval 1.43-7.34; p = 0.005) as opposed to PULS score 0.

CONCLUSIONS

Removal of upper urinary tract stones using URS is safe and efficacious. Real-world data provided by this study confirm a high IRR of the PULS score and its clinical impact on the indication for post-URS stenting. A future prospective randomized trial should evaluate a possible standardization of post-URS stenting based on PULS score assessment.

Prevalence and impact of baseline resistance-associated substitutions on the efficacy of ledipasvir/sofosbuvir or simeprevir/sofosbuvir against GT1 HCV infection

Baseline resistance-associated substitutions (RASs) have variable impacts in clinical trials but their prevalence and impact in real-world patients remains unclear. We performed baseline resistance testing using a commercial assay (10% cutoff) for 486 patients treated with LDV/SOF or SMV/SOF, with or without ribavirin, in the multi-center, observational HCV-TARGET cohort. Linkage of RASs was evaluated in selected samples using a novel quantitative single variant sequencing assay. Our results showed that the prevalence of NS3, NS5A, NS5B RASs was 45%, 13%, and 8%, respectively, and 10% of patients harbored RASs in 2 or more drug classes. Baseline LDV RASs in GT1a, TE, and cirrhosis LDV/SOF subgroup was associated with 2–4% lower SVR12 rates. SMV RASs was associated with lower SVR12 rates in GT1a, treatment-experienced, cirrhotics SMV/SOF subgroup. Pooled analysis of all patients with baseline RASs revealed that SVR12 was 100% (19/19) in patients treated for longer than 98 days but was 87% (81/93) in patients treated for shorter than 98 days. These results demonstrate that RASs prevalence and their impact in real world practice are in general agreement with registration trials, and suggest that longer treatment duration may overcome the negative impact of baseline RASs on SVR12 rates in clinical practice.

Primary Stenting for Acute Myocardial Infarction

Primary stenting for acute MI has been shown to be an improvement over PTCA alone. As with primary PTCA however there is an obligate delay in restoration of TIMI flow due to the time necessary for mobilization of the cath lab team. It is possible that a hybrid approach using partial thrombolysis plus early IIB/IIIA inhibitor administration followed by urgent angiography and stenting of the culprit lesion will be the ideal approach.

Ankyrin-rich membrane spanning protein as a novel modulator of transient receptor potential vanilloid 1-function in nociceptive neurons

BACKGROUND

The ion channel TRPV1 is mainly expressed in small diameter dorsal root ganglion (DRG) neurons, which are involved in the sensation of acute noxious thermal and chemical stimuli. Direct modifications of the channel by diverse signalling events have been intensively investigated, but little is known about the composition of modulating macromolecular TRPV1 signalling complexes. Here, we hypothesize that the novel adaptor protein ankyrin-rich membrane spanning protein/kinase D interacting substrate (ARMS) interacts with TRPV1 and modulates its function in rodent DRG neurons.

METHODS

We used immunohistochemistry, electrophysiology, microfluorimetry and immunoprecipitation experiments to investigate TRPV1 and ARMS interactions in DRG neurons and transfected cells.

RESULTS

We found that TRPV1 and ARMS are co-expressed in a subpopulation of DRG neurons. ARMS sensitizes TRPV1 towards capsaicin in transfected HEK 293 cells and in mouse DRG neurons in a PKA-dependent manner. Using a combination of functional imaging and immunocytochemistry, we show that the magnitude of the capsaicin response in DRG neurons depends not only on TRPV1 expression, but on the co-expression of ARMS alongside TRPV1.

CONCLUSION

These data indicate that ARMS is an important component of the signalling complex regulating the sensitivity of TRPV1.

SIGNIFICANCE

The study identifies ARMS as an important component of the signalling complex regulating the sensitivity of excitatory ion channels (TRPV1) in peripheral sensory neurons (DRG neurons) and transfected cells.

Hepatitis C virus: how to provide the best treatment with what I have

The therapeutic landscape for the treatment of chronic hepatitis C virus infection has been rapidly evolving, and by 2016 there will be six approved, all-oral regimens for use in patients in the USA and most of Western Europe. However, as many as patient populations will have limited access to new direct acting antiviral regimens, patients and physicians are often faced with the challenge of selecting the best regimen available, as opposed to the optimal treatment. In this paper, the challenges and opportunities in developing a high cure regimen for different patient populations will be discussed and highlighted through case-based scenarios.

Optimal interferon-free therapy in treatment-experienced chronic hepatitis C patients

Over the past year, interferon (IFN) free dosing regimens have become available to treat chronic hepatitis C. Offering high rates of sustained virological response (SVR), short treatment and improved tolerability, IFN-free treatment now represents the paradigm for both treatment-naïve and -experienced patients. Patients with prior treatment failure, in particular those with cirrhosis, still represent some of the most difficult to treat, but the availability of multiple agents that can interrupt several steps of the HCV lifecycle affords providers and patients with options that can be combined and individually tailored to each patient's unique needs to obtain high rates of SVR.

[Influence of body mass index on histopathological and intraoperative criteria in a consecutive series of patients after robotic-assisted radical prostatectomy]

BACKGROUND

In various studies it has been shown that obesity enhances the risk for a unfavorable pathological tumour stages, higher Gleason scores (GS), positive surgical margins (PSM), and certain perioperative parameters (higher blood loss, higher length of surgery, higher complication rates) after radical prostatectomy. However, for robot-assisted radical prostatectomy (RARP) there are only a few studies addressing this topic with partially conflicting results. Furthermore, none of these studies actually represents the clinical practice pattern as performed in a European centre.

MATERIAL AND METHODS

Beside further clinical and histopathological parameters, also body mass index (BMI) of patients undergoing RARP was recorded. The following categories were registered: BMI of < 25 kg/m², ≥ 25-29.9 kg/m², and ≥ 30 kg/m² defined as normal weight, overweight, and obesity, respectively. The potential correlation between BMI on the one hand and various criteria of aggressive tumour biology and specific perioperative parameters on the other hand has been examined on univariate and multivariable analyses.

RESULTS

22.8% (n=79), 59% (n=204), and 18.2% (n=63) of patients of the study group presented with normal weight, overweight, and obesity, respectively. Based on the results of various multivariable regression models there was no significant influence of obesity on pathological tumour stage, pN category, undifferentiated tumour growth (≥ GS7b), upgrading, or PSM rates. Furthermore, obese patients showed a significantly higher intraoperative blood loss and a higher length of surgery, which, however, did not result in a higher rate of grade 3a/b complications according to Clavien-Dindo classification after 90 days.

CONCLUSIONS

In the present series of consecutive patients undergoing RARP there was no evidence for a more aggressive tumour biology or a higher complication rate in obese patients.

Evaluation of the effects of manuka honey on salivary levels of mutans streptococci in children: a pilot study

BACKGROUND

There has been much debate in the past about whether honey is harmful to the teeth, mostly as part of the debate about raw sugar versus refined sugar and the results have been equivocal. However, what has not been taken into account is that honey varies markedly in the potency of its antibacterial activity. Manuka (Leptospermum scoparium) honey from New Zealand has been found to have substantial levels of non-peroxide antibacterial activity associated with an unidentified phytochemical component, denoted as Unique Manuka Factor (UMF).

AIMS

Considering the potential antimicrobial effects of manuka honey, the present study attempted to investigate effects of twice daily use of manuka honey with UMF 19.5 on salivary levels of Mutans streptococci in children.

STUDY DESIGN

The investigation was a stratified comparison of two parallel groups of children who either used manuka honey with regular tooth brushing regimen or continued only with regular tooth brushing regimen twice daily under professional supervision for a 21-day period. A total of three salivary samples were taken from each individual at baseline, day 10, and day 21; colony counts of Streptococcus mutans (S. mutans) were determined. All data was subjected to paired T-test and Wilcoxon's signed ranks sum for intra- and intergroup comparisons respectively.

RESULTS

Children using manuka honey showed statistically significant reductions in salivary S. mutans after 10 and 21 days.

CONCLUSION

Manuka honey with UMF 19.5 may be considered as an effective adjunctive oral hygiene measure for reducing colony counts in children.

A Simple Goniometer for Use Intraoperatively in Total Knee Arthroplasty

Intraoperative range of motion (ROM) assessment can be challenging during total knee arthroplasty (TKA) surgery. As computer assisted surgery is costly and not readily available to many surgeons, we have developed a simple, cost-effective intraoperative device to precisely measure knee flexion and extension. A simple knee goniometer system was constructed consisting of a digital level mounted to a base that rigidly attaches two standard needles. The needles are pushed through the overlying soft tissue of the distal femur. The device is then applied to the proximal tibia, where an angle measurement of the knee is registered. A validation study for this device was conducted on two pairs of intact cadaveric lower limbs at 0 deg, 10 deg, 15 deg, 20 deg, 25 deg, and 30 deg. Two orthopedic surgeons experienced with the system performed three measurements at each angle. Systematic error, defined as the goniometer reading at 0 deg flexion anatomically as determined by the navigation system, ranged from −9.1 deg to 3.0 deg, consistent for each operator on every case. Measurement error, defined as the variability in repeated, fixed angle measurements made with the goniometer, was 1.5 ± 1.0 deg across all surgeons, cases, and prescribed flexion angles. For both surgeons and all imposed flexion angles, measurement errors were below the 4 deg clinical threshold. The simple knee goniometer system generated accurate, repeatable measures of changes in flexion angle intraoperatively with measurement error comparable to errors obtained using the commercial navigation system (1 deg–2 deg). However, the knee goniometer is less complex, less time intensive, and less costly than currently available computer assistive devices. Taken together, our results are very promising for the continued development of this device.

[A very uncommon reason for chest pain]

A 25-year old female immigrant from Kosovo living in Switzerland for three years complained of intermittent atypical chest pain and shortness of breath for three months. The patient was febrile (38.4 °C) and had a regular tachycardia of 120/min and a blood pressure of 105/65 mmHg. The ECG showed deep symmetric negative T-waves on the leads V1 - V6. The conventional chest X-ray revealed a small bulge of the left cardiac outline. Leucocytes and differential count were normal but the C-reactive protein was markedly elevated (118mg/L). Computed tomography of the chest revealed several pleural and paramediastinal cystic masses on the left side. One of these cystic lesions covered a small defect of the aortic wall appearing as a pseudoaneurysm at the beginning of the descending aorta. Echocardiography showed pericardial cysts on the left ventricle and a small pericardial effusion. Serological tests for Echinococcus granulosus were strongly positive. Thus, the patient was diagnosed with cystic echinococcosis with pericardial, pleural and mediastinal involvement with a pseudoaneurysm of the descending aorta.

Mutations in LPL, APOC2, APOA5, GPIHBP1 and LMF1 in patients with severe hypertriglyceridaemia

OBJECTIVES

The severe forms of hypertriglyceridaemia (HTG) are caused by mutations in genes that lead to the loss of function of lipoprotein lipase (LPL). In most patients with severe HTG (TG > 10 mmol L(-1) ), it is a challenge to define the underlying cause. We investigated the molecular basis of severe HTG in patients referred to the Lipid Clinic at the Academic Medical Center Amsterdam.

METHODS

The coding regions of LPL, APOC2, APOA5 and two novel genes, lipase maturation factor 1 (LMF1) and GPI-anchored high-density lipoprotein (HDL)-binding protein 1 (GPIHBP1), were sequenced in 86 patients with type 1 and type 5 HTG and 327 controls.

RESULTS

In 46 patients (54%), rare DNA sequence variants were identified, comprising variants in LPL (n = 19), APOC2 (n = 1), APOA5 (n = 2), GPIHBP1 (n = 3) and LMF1 (n = 8). In 22 patients (26%), only common variants in LPL (p.Asp36Asn, p.Asn318Ser and p.Ser474Ter) and APOA5 (p.Ser19Trp) could be identified, whereas no mutations were found in 18 patients (21%). In vitro validation revealed that the mutations in LMF1 were not associated with compromised LPL function. Consistent with this, five of the eight LMF1 variants were also found in controls and therefore cannot account for the observed phenotype.

CONCLUSIONS

The prevalence of mutations in LPL was 34% and mostly restricted to patients with type 1 HTG. Mutations in GPIHBP1 (n = 3), APOC2 (n = 1) and APOA5 (n = 2) were rare but the associated clinical phenotype was severe. Routine sequencing of candidate genes in severe HTG has improved our understanding of the molecular basis of this phenotype associated with acute pancreatitis and may help to guide future individualized therapeutic strategies.