Gender differences in workplace violence against physicians and nurses in Latin America: a survey from the Interamerican Society of Cardiology

OBJECTIVES

To evaluate gender differences in workplace violence (WPV) against physicians and nurses in Latin America.

STUDY DESIGN

Cross-sectional study.

METHODS

A cross-sectional electronic survey was conducted between January 11 and February 28, 2022. A prespecified gender analysis was performed.

RESULTS

Among the 3056 responses to the electronic survey, 57% were women, 81.6% were physicians, and 18.4% were nurses. At least one act of violence was experienced by 59.2% of respondents, with verbal violence being the most common (97.5%). Women experienced more WPV than men (65.8% vs 50.4%; P < 0.001; odds ratio [OR]: 1.89; 95% confidence interval [CI]: 1.63-2.19). Women were more likely to report at least one episode of WPV per week (19.2% vs 11.9%, P < 0.001), to request for psychological help (14.5% vs 9%, P = 0.001) and to experience more psychosomatic symptoms. In addition, women were more likely to report having considered changing their job after an aggression (57.6% vs 51.3%, P = 0.011) and even leaving their job (33% vs 25.7%, P = 0.001). In a multivariate analysis, being a woman (OR: 1.76), working in emergency departments (OR: 1.99), and with COVID-19 patients (OR: 3.3) were independently associated with more aggressive interactions, while older age (OR: 0.95) and working in a private setting (OR: 0.62) implied lower risk.

CONCLUSIONS

Women are more likely to experience WPV and to report more psychosomatic symptoms after the event. Preventive measures are urgently needed, with a special focus on high-risk groups such as women.

Anal Canal Adenocarcinomas: Prognostic Factors and Outcomes at a Single Institution

PURPOSE/OBJECTIVE(S)

Adenocarcinomas of the anal canal (AAC) represent a rarity among cancers of the digestive tract. Data guiding management is limited to retrospective studies and optimal treatment paradigms of AAC are still evolving. Here, we aim to investigate their prognostic factors and outcomes.

MATERIALS/METHODS

We reviewed anorectal adenocarcinoma patients who underwent curative-intent neo/adjuvant therapy +/- surgery at a single institution from 2015-2019. AAC were defined as tumor epicenters ≤ 2 cm from the dentate line. Our primary outcome was 5-year overall survival (OS). We also analyzed 5-year local recurrence, distant metastasis, and disease-free survival (DFS), defined as the interval after treatment completion to the first occurrence of local, regional, distant recurrence, or death. All tumors were staged according to the Rectal Cancer paradigm per AJCC 7th Staging. Kaplan-Meier and Cox-Proportional Hazards Model were used for survival analyses.

RESULTS

In our cohort, 57 patients met inclusion criteria. Median follow-up time was 54 months. The median age was 64 years; 35% of the cohort was female. The majority of tumors were adenocarcinomas (77%), with a minority of mucinous (12%) and signet ring cell (11%) histologies. The median tumor size was 4 cm, located 1 cm from the anal verge. Most tumors (63%) were grade 2, 77% had T3 disease, and 53% had clinical nodal involvement. Most patients completed neoadjuvant chemoradiation, total mesorectal excision, and adjuvant chemotherapy (54%). Fifty-four percent underwent abdominopelvic resection. Of those who received neoadjuvant therapy, 11% achieved a pathologic complete response. Seventy percent of patients completed chemotherapy, either in the neoadjuvant or adjuvant setting. At 5 years, local recurrence was 9%, regional pelvic recurrence was 12%, inguinal nodal recurrence was 2%, and distant recurrence was 25%. Five-year DFS was 63% and 5-year OS was 70%. Multivariate analysis demonstrated age, female gender, CEA, grade 3 disease, mucinous histology, and nodal involvement to be prognostic of lower OS. Receipt of neo/adjuvant chemotherapy was found to be prognostic of higher OS (HR 0.13, p<0.05).

CONCLUSION

In this cohort, the majority of whom received surgical management, we show numerically similar or higher overall survival in comparison with prior studies. This study is limited by its retrospective nature and sample sizes of an exceedingly rare entity. Receipt of neo/adjuvant chemotherapy appears to have an impact on survival. Further investigation is needed to explore the role of total neoadjuvant therapy in improving outcomes in this patient population.

Immune checkpoint blockade in pancreatic cancer: Trudging through the immune desert

Pancreatic cancer (PC) has exceptionally high mortality due to ineffective treatment strategies. Immunotherapy, which mobilizes the immune system to fight against cancer, has been proven successful in multiple cancers; however, its application in PC has met with limited success. In this review, we articulated that the pancreatic tumor microenvironment is immuno-suppressive with extensive infiltration by M2-macrophages and myeloid-derived suppressive cells but low numbers of cytotoxic T-cells. In addition, low mutational load and poor antigen processing, presentation, and recognition contribute to the limited response to immunotherapy in PC. Immune checkpoints, the critical targets for immunotherapy, have high expression in PC and stromal cells, regulated by tumor microenvironmental milieu (cytokine and metabolites) and cell-intrinsic mechanisms (epigenetic regulation, oncogenic signaling, and post-translational modifications). Combining immunotherapy with modulators of the tumor microenvironment may facilitate the development of novel therapeutic regimens to manage PC.

Regulation of pancreatic cancer therapy resistance by chemokines

Pancreatic ductal adenocarcinoma (PDAC) is a highly lethal malignancy characterized by high resistance and poor response to chemotherapy. In addition, the poorly immunogenic pancreatic tumors constitute an immunosuppressive tumor microenvironment (TME) that render immunotherapy-based approaches ineffective. Understanding the mechanisms of therapy resistance, identifying new targets, and developing effective strategies to overcome resistance can significantly impact the management of PDAC patients. Chemokines are small soluble factors that are significantly deregulated during PDAC pathogenesis, contributing to tumor growth, metastasis, immune cell trafficking, and therapy resistance. Thus far, different chemokine pathways have been explored as therapeutic targets in PDAC, with some promising results in recent clinical trials. Particularly, immunotherapies such as immune check point blockade therapies and CAR-T cell therapies have shown promising results when combined with chemokine targeted therapies. Considering the emerging pathological and clinical significance of chemokines in PDAC, we reviewed major chemokine-regulated pathways leading to therapy resistance and the ongoing endeavors to target chemokine signaling in PDAC. This review discusses the role of chemokines in regulating therapy resistance in PDAC and highlights the continuing efforts to target chemokine-regulated pathways to improve the efficacy of various treatment modalities.

The Impact of Living with INOCA

Background

There is limited literature available on the impact of myocardial ischemia but no obstructive coronary arteries (INOCA) on patients' lives.

Purpose

We sought to determine how INOCA impacts the physical, social, and mental health of persons with this diagnosis.

Methods

A survey was made available to all members of the patient support group from INOCA International over a 3-month time period. Fitness was estimated using the Duke Activity Status Index (DASI), assessing levels of activities performed prior to the onset of INOCA symptoms, and after the diagnosis of INOCA. The formula to estimate fitness in metabolic equivalents (METs) = 0.43 × DASI + 9.6 / 3.5

Results

A total of 297 patients with INOCA responded to the survey; 91.2% were women. The most common diagnosis was coronary microvascular dysfunction (64.3%) and coronary artery spasm (50.5%) (Table 1). 34.4% reported living with symptoms for ≥3 years before their diagnosis of INOCA was made. 77.8% who had been told their symptoms were not cardiac. The symptoms the respondents experienced were numerous, but 92.9% reported symptoms of chest pain, pressure, or discomfort. Fitness levels prior to the onset of INOCA symptoms were significantly higher compared to after diagnosed with INOCA (8.6±1.8 METs vs 5.6±1.8 METs; P&lt;0.0001). Most respondents reported an adverse impact on their home life (80.5%), social life (80.1%), mental health (70.4%), outlook on life (69.7%), sex life (55.9%), and their partner/spouse relationship (53.9%). Work life was also affected once living with INOCA: approximately three-quarters had reduced their work hours or stopping work completely, 47.5% retired early, and 38.4% applied for disability. While living with INOCA, for each 1-MET decrease in fitness, there was a loss of 3.0±0.6 days/months of physical health, 1.8±0.6 days/month of mental health, and 2.9±0.7 days/months of inability to perform recreational activities (p&lt;0.0001) (Figure 1).

Conclusions

Living with INOCA has significant impact on physical, mental and social health. Significant physical fitness declines are seen in those living with INOCA and are lower in those experiencing any adverse impact of living with INOCA. Additionally, the impact of INOCA on the ability to work has important economic consequences to both the patient and society. Increased recognition of the impact of INOCA on these aspects of health need to be recognized and further work is needed to better diagnosis and treat the symptoms of INOCA to improve the quality of life, cardiovascular outcomes, and overall health of this frequently encountered cardiovascular disorder.

Funding Acknowledgement

Type of funding sources: None.

Endothelin-axis antagonism enhances tumor perfusion in pancreatic cancer

Delivery of therapeutic agents in pancreatic cancer (PC) is impaired due to its hypovascular and desmoplastic tumor microenvironment. The Endothelin (ET)-axis is the major regulator of vasomotor tone under physiological conditions and is highly upregulated in multiple cancers. We investigated the effect of dual endothelin receptor antagonist bosentan on perfusion and macromolecular transport in a PC cell-fibroblast co-implantation tumor model using Dynamic Contrast-Enhanced Magnetic Resonance Imaging (DCE-MRI). Following bosentan treatment, the contrast enhancement ratio and wash-in rates in tumors were two- and nine times higher, respectively, compared to the controls, whereas the time to peak was significantly shorter (7.29 ± 1.29 min v/s 22.08 ± 5.88 min; p = 0.04). Importantly, these effects were tumor selective as the magnitudes of change for these parameters were much lower in muscles. Bosentan treatment also reduced desmoplasia and improved intratumoral distribution of high molecular weight FITC-dextran. Overall, these findings support that targeting the ET-axis can serve as a potential strategy to selectively enhance tumor perfusion and improve the delivery of therapeutic agents in pancreatic tumors.

Preferential binding of DAP-PGs by major peptidoglycan recognition proteins found in cell-free hemolymph of Manduca sexta

Peptidoglycan recognition proteins (PGRPs) detect invading bacteria to trigger or modulate immune responses in insects. While these roles are established in Drosophila, functional studies are not yet achieved at the PGRP family level in other insects. To attain this goal, we selected Manduca sexta PGRP12 and five of the nine secreted PGRPs for recombinant expression and biochemical characterization. We cloned PGRP2-5, 12 and 13 cDNAs, produced the proteins in full (PGRP2-5, 13) or in part (PGRP3s, 12e, 13N, 13C) in Sf9 cells, and tested their bindings of two muramyl pentapeptides by surface plasmon resonance, two soluble peptidoglycans by competitive ELISA, and four insoluble peptidoglycans and eight whole bacteria by a pull-down assay. Preferential binding of meso-diaminopimelic acid-peptidoglycans (DAP-PGs) was observed in all the proteins containing a peptidoglycan binding domain and, since PGRP6, 7 and 9 proteins were hardly detected in cell-free hemolymph, the reportoire of PGRPs (including PGRP1 published previously) in M. sexta hemolymph is likely adapted to mainly detect Gram-negative bacteria and certain Gram-positive bacteria with DAP-PGs located on their surface. After incubation with plasma from naïve larvae, PGRP2, 3f, 4, 5, 13f and 13N considerably stimulated prophenoloxidase activation in the absence of a bacterial elicitor. PGRP3s and 12e had much smaller effects. Inclusion of the full-length PGRPs and their regions in the plasma also led to proHP8 activation, supporting their connections to the Toll pathway, since HP8 is a Spӓtzle-1 processing enzyme in M. sexta. Together, these findings raised concerns on the common belief that the Toll-pathway is specific for Gram-positive bacteria in insects.

AB0980 Hand Osteoarthritis: investigating Pain Effects in a randomised placebo-controlled feasibility study of estrogen-containing therapy (HOPE-e): report on the primary feasibility outcomes

Background

There is an unmet need for new treatments for hand osteoarthritis (OA). Symptomatic hand OA is more common in women and its incidence increases round the age of menopause. Pre-clinical, epidemiological and post hoc studies in Hormone Replacement Therapy (HRT) trials implicate estrogen deficiency as of likely importance in OA aetiopathogenesis. No clinical trials of HRT have been carried out in hand OA to date. The licensed HRT Duavive (conjugated estrogens + SERM bazedoxifene) was selected on its potential for efficacy and tolerability.

Objectives

We set out to determine the feasibility and acceptability of this form of HRT in post-menopausal women with hand OA, to generate proof of concept data and refine methods for a full study.

Methods

ISRCTN12196200. Females aged 40-65 yrs and 1-10yrs after final menstrual period with hand OA fulfilling ACR criteria and 2+ painful hand joints were recruited. Eligibility incorporated best practice for HRT prescription but did not require menopausal symptoms. Recruitment was at 3 sites in primary/secondary care, including directly from the community. Design was parallel group, double-blind 1:1 randomisation of Duavive or placebo, orally once daily for 24 weeks, then weaning for 4 weeks before stopping. Routes and rates of recruitment and the acceptability of randomisation, medication (compliance, retention), and proposed outcomes were measured, and the likelihood of unblinding. Measures related to hand pain and function, menopause symptoms and joint appearance. Patient and Public Involvement actively informed study rationale, design and materials. An end of study questionnaire and 2 participant focus groups provided further acceptability data.

Results

Recruitment was for 12/possible 18 months, interrupted due to COVID-19. Some study procedures were modified to allow reopening whilst collecting all primary outcomes. 434 enquiries/referrals were received, leading to 96 telephone pre-screens, of which 33 gave written informed consent and attended face to face screening. 28/33 screened (85%) were eligible and randomised. The highest number of randomisations was from study web presence (n=7) followed by SMS text from GP surgeries (n=5). Of 401 not proceeding, 250 (62%) were ineligible, most commonly due to contraindicated medication, followed by medical contraindication, whilst 55 (14%) decided not to take part, for reasons including not wanting to take a hormone-based drug or difficulty attending study visits. Retention and compliance were excellent. All 28 participants completed all study follow ups, with only 3 withdrawals from treatment due to AEs, 2 of these at week 24 and all in the placebo arm. There were no serious AEs. High levels of completeness of all study outcome measures were achieved. Bang’s blinding index suggested that participants/investigators were well blinded. There were overall high/good levels of satisfaction with taking part in the study. 26/28 (92%) would recommend taking part to others with hand OA (irrespective of study arm). Many found the flexibility offered by a combination of remote and face to face visits (due to the pandemic) attractive. Additional insights from focus groups were to include hand stiffness as well as pain measures but to reduce the overall number of questions.

Conclusion

Despite COVID-19 and a reduced recruitment period, this study recruited sufficient numbers to assess feasibility outcomes. Randomisation of eligible people and retention rates were high. A mixture of remote and face to face visits due to COVID-19 probably improved recruitment and retention and was supported by participants, who were generally satisfied with the study design and medication. The study provided useful insight and improvements that would be incorporated into a future study. Overall, this feasibility study showed that with clear messaging on eligibility and a defined recruitment strategy, recruitment and retention to a study testing this treatment is possible.

Acknowledgements

This research was funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0416-20023). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The study team thank the sites and the participants who made this research possible.

Disclosure of Interests

Jennifer A.E. Williams: None declared, Mae Chester-Jones: None declared, Anne Francis: None declared, Ioana Marian: None declared, Megan Goff: None declared, Gretchen Brewer: None declared, Malvika Gulati: None declared, Lucy Eldridge: None declared, Patrick Julier: None declared, Catherine Minns Lowe: None declared, Vicki Barber: None declared, Victoria Glover: None declared, Charles Mackworth-Young: None declared, Tonia Vincent Consultant of: Pfizer, Grant/research support from: Grant support from Fidia, Biosplice, Novartis, Pfizer as part of their contribution to an international consortium., Sarah E Lamb: None declared, Katy Vincent: None declared, Susan J Dutton: None declared, Fiona E Watt Consultant of: Pfizer, Grant/research support from: Pfizer and from Astellas Pharma (> 3 years ago)

Polyanhydride based nanovaccine promotes long term humoral and cellular response to PDAC associated protein MUC4β

Patients diagnosed with pancreatic ductal adenocarcinoma (PDAC) have an unrelentingly poor prognosis, in part because of the lack of neoantigen targets associated with PDAC tumors. However, another approach would be to take advantage of differentially expressed antigens on PDAC tumor cells. It has been demonstrated that mucin 4 (MUC4) is overexpressed on the tumor cells of many PDAC patients and is considered a promising antigenic target for PC immunotherapy. Previous work by our lab has demonstrated that poly-anhydride (PA) nanovaccines based on 20:80 1,8-bis(p-carboxyphenoxy)-3,6-dioxaoctane (CPTEG) and 1,6-bis(p-carboxyphenoxy)hexane (CPH) nanoparticles (NPs) both induced a humoral immune response to the beta subunit of MUC4 (MUC4β) and an anti-tumor response against OVA in an EG-7 tumor model. In these studies, we show that both a PA-based nanovaccine formulation and a PLGA-based nanovaccine induced MUC4β-specific T cell response. Results demonstrated that restimulation of LN and splenic lymphocytes 40 days after initial vaccination induced both CD4+ and CD8+ MUC4β-specific T cells. The MUC4ß-specific T cells could be detected for at least 180 days post-vaccination. Cytokine secretions from the antigen specific T cells included IL-2, INFγ, and TNF-α; in addition, tetramer analysis detected MUC4ß-specific CD8+ T cells using the MUCβ peptide FTPVFYSQL. Collectively, these results demonstrate that a PA nanovaccine can function as an effective vaccine platform for induction of MUC4ß-specific cellular immunity, and lays the ground work for forthcoming studies in MUC4β-expressing tumor model systems.

Supported by the National Institute of Health (U01 CA213862) and the Iowa State University Nanovaccine Institute. B. N. is grateful to the Vlasta Klima Balloun Faculty Chair.

Nanocarriers for pancreatic cancer imaging, treatments, and immunotherapies

Pancreatic tumors are highly desmoplastic and immunosuppressive. Delivery and distribution of drugs within pancreatic tumors are compromised due to intrinsic physical and biochemical stresses that lead to increased interstitial fluid pressure, vascular compression, and hypoxia. Immunotherapy-based approaches, including therapeutic vaccines, immune checkpoint inhibition, CAR-T cell therapy, and adoptive T cell therapies, are challenged by an immunosuppressive tumor microenvironment. Together, extensive fibrosis and immunosuppression present major challenges to developing treatments for pancreatic cancer. In this context, nanoparticles have been extensively studied as delivery platforms and adjuvants for cancer and other disease therapies. Recent advances in nanotechnology have led to the development of multiple nanocarrier-based formulations that not only improve drug delivery but also enhance immunotherapy-based approaches for pancreatic cancer. This review discusses and critically analyzes the novel nanoscale strategies that have been used for drug delivery and immunomodulation to improve treatment efficacy, including newly emerging immunotherapy-based approaches. This review also presents important perspectives on future research directions that will guide the rational design of novel and robust nanoscale platforms to treat pancreatic tumors, particularly with respect to targeted therapies and immunotherapies. These insights will inform the next generation of clinical treatments to help patients manage this debilitating disease and enhance survival rates.

Characterization of recombinant β subunit of human MUC4 mucin (rMUC4β)

MUC4 is a transmembrane mucin expressed on various epithelial surfaces, including respiratory and gastrointestinal tracts, and helps in their lubrication and protection. MUC4 is also aberrantly overexpressed in various epithelial malignancies and functionally contributes to cancer development and progression. MUC4 is putatively cleaved at the GDPH site into a mucin-like α-subunit and a membrane-tethered growth factor-like β-subunit. Due to the presence of several functional domains, the characterization of MUC4β is critical for understanding MUC4 biology. We developed a method to produce and purify multi-milligram amounts of recombinant MUC4β (rMUC4β). Purified rMUC4β was characterized by Far-UV CD and I-TASSER-based protein structure prediction analyses, and its ability to interact with cellular proteins was determined by the affinity pull-down assay. Two of the three EGF-like domains exhibited typical β-fold, while the third EGF-like domain and vWD domain were predominantly random coils. We observed that rMUC4β physically interacts with Ezrin and EGFR family members. Overall, this study describes an efficient and simple strategy for the purification of biologically-active rMUC4β that can serve as a valuable reagent for a variety of biochemical and functional studies to elucidate MUC4 function and generating domain-specific antibodies and vaccines for cancer immunotherapy.

Polyanhydride nanoparticles stabilize pancreatic cancer antigen MUC4β

Pancreatic cancer (PC) is one of the most lethal malignancies and represents an increasing and challenging threat, especially with an aging population. The identification of immunogenic PC-specific upregulated antigens and an enhanced understanding of the immunosuppressive tumor microenvironment have provided opportunities to enable the immune system to recognize cancer cells. Due to its differential upregulation and functional role in PC, the transmembrane mucin MUC4 is an attractive target for immunotherapy. In the current study we characterized the antigen stability, antigenicity and release kinetics of a MUC4β-nanovaccine to guide further optimization and, in vivo evaluation. Amphiphilic polyanhydride copolymers based on 20 mol % 1,8-bis(p-carboxyphenoxy)-3,6-dioxaoctane and 80 mol % 1,6-bis(p-carboxyphenoxy)hexane were used to synthesize nanoparticles. Structurally stable MUC4β protein was released from the particles in a sustained manner and characterized by gel electrophoresis and fluorescence spectroscopy. Modest levels of protein degradation were observed upon release. The released protein was also analyzed by MUC4β-specific monoclonal antibodies using ELISA and showed no significant loss of epitope availability. Further, mice immunized with multiple formulations of combination vaccines containing MUC4β-loaded nanoparticles generated MUC4β-specific antibody responses. These results indicate that polyanhydride nanoparticles are viable MUC4β vaccine carriers, laying the foundation for evaluation of this platform for PC immunotherapy.

Hypertensive disorders of pregnancy and impact on in-hospital cardio-obstetric outcomes

Introduction

Hypertensive disorders of pregnancy (HDP) are a major cause of maternal morbidity. However, short-term outcomes of HDP subgroups remain unknown.

Methods

Using the United States National Inpatient Sample database, all delivery hospitalizations between 2004 and 2014 with or without HDP (preeclampsia/eclampsia, chronic hypertension, superimposed preeclampsia on chronic hypertension and gestational hypertension) were analysed to examine the association between HDP and adverse in-hospital outcomes.

Results

We identified &gt;44 million delivery hospitalizations, within which the prevalence of HDP increased from 8% to 11% over a decade with increasing comorbidity burden. Women with chronic hypertension have higher risks of myocardial infarction, peripartum cardiomyopathy, arrhythmia and stillbirth compared to women with preeclampsia. Out of all HDP subgroups, the superimposed preeclampsia population had the highest risk of stroke (OR 7.83, 95% CI 6.25, 9.80), myocardial infarction (OR 5.20, 95% CI 3.11, 8.69), peripartum cardiomyopathy (OR 4.37, 95% CI 3.64, 5.26), preterm birth (OR 4.65, 95% CI 4.48, 4.83), placental abruption (OR 2.22, 95% CI 2.09, 2.36), and stillbirth (OR 1.78, 95% CI 1.66, 1.92) compared to women without HDP. In conclusion, we are the first to evaluate chronic SH without superimposed preeclampsia as a distinct subgroup in HDP and show that women with chronic SH are at even higher risk of some adverse outcomes compared to women with preeclampsia.

Conclusion

The chronic hypertension population, with and without superimposed preeclampsia, is a particularly high risk group and may benefit from increased antenatal surveillance and the use of a prognostic risk assessment model incorporating HDP to stratify intrapartum care.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): NIHR

Acute myocardial infarction in several mental illness: a nationwide analysis of prevalence, management strategies and outcomes

Background

Severe mental illness (SMI) is associated with an increased risk of cardiovascular disease and mortality. However, it is unclear whether SMI patients are just as likely to receive guideline-recommended therapy for AMI as those without mental illness.

Purpose

To examine national-level estimates of the prevalence, management strategies and in-hospital clinical outcomes of SMI patients presenting with AMI.

Methods

All AMI hospitalisations from the United States National Inpatient Sample were included, stratified by mental health status in to 5 groups: no-SMI, Schizophrenia, “Other non-organic psychoses” (ONOP), Bipolar Disorder and Major Depression. Multivariable logistic regression modelling was performed to examine the association between SMI subtypes and receipt of invasive management and subsequent in-hospital clinical outcomes, expressed as adjusted odds ratios (aOR) and 95% confidence intervals (CI).

Results

Out of 6,968,777 AMI hospitalisations between 2004 and 2014, a total of 439,544 (6.5%) had an SMI diagnosis. The prevalence of SMI amongst the ACS population doubled over the study period (from 4.5% in 2004 to 9.5% in 2014), primarily due to an increase in Major Depression and Bipolar Disorder diagnoses. All SMI subtypes were less likely to receive coronary angiography and PCI, with the Schizophrenia group being at least odds of either procedure (aOR 0.46 95% CI 0.45, 0.48 and aOR 0.57 95% CI 0.55, 0.59, respectively). Although patients with Schizophrenia and ONOP experienced higher crude rates of in-hospital mortality and stroke compared to those without SMI, only Schizophrenia patients were associated with increased odds of mortality (aOR 1.10 95% CI 1.04, 1.16), while ONOP were the only group at increased odds of stroke (aOR 1.53 95% CI 1.42,1.65) following multivariate adjustment. Patients with ONOP were the only group associated with increased odds of in-hospital bleeding compared to those without SMI (aOR 1.11 95% CI 1.04,1.17).

Conclusion

Patients with SMI are less likely to receive invasive management for AMI, with women and schizophrenia diagnosis being the strongest predictors of conservative management. Schizophrenia and “other non-organic psychoses” are the only SMI subtypes associated with adverse clinical outcomes after AMI. A multidisciplinary approach between psychiatrists and cardiologists could improve outcomes of this high-risk population.

Odds of management and clinical outcomes

Funding Acknowledgement

Type of funding source: None

Irreversible and sustained upregulation of endothelin axis during oncogene-associated pancreatic inflammation and cancer

Endothelin-1 (ET-1) and its two receptors, endothelin receptor A (ETAR) and endothelin receptor B (ETBR) exhibit deregulated overexprerssion in pancreatic ductal adenocarcinoma (PDAC) and pancreatitis. We examined the expression pattern of endothelin (ET) axis components in the murine models of chronic and acute inflammation in the presence or absence of oncogenic K-ras. While the expression of endothelin converting enzyme-1 (ECE-1), ET-1, ETAR and ETBR in the normal pancreas is restricted predominantly to the islet cells, progressive increase of ET receptors in ductal cells and stromal compartment is observed in the KC model (Pdx-1 Cre; K-rasG12D) of PDAC. In the murine pancreas harboring K-rasG12D mutation (KC mice), following acute inflammation induced by cerulein, increased ETAR and ETBR expression is observed in the amylase and CK19 double positive cells that represent cells undergoing pancreatic acinar to ductal metaplasia (ADM). As compared to the wild type (WT) mice, cerulein treatment in KC mice resulted in significantly higher levels of ECE-1, ET-1, ETAR and ETBR, transcripts in the pancreas. Similarly, in response to cigarette smoke-induced chronic inflammation, the expression of ET axis components is significantly upregulated in the pancreas of KC mice as compared to the WT mice. In addition to the expression in the precursor pancreatic intraepithelial neoplasm (PanIN lesions) in cigarette smoke-exposure model and metaplastic ducts in cerulein-treatment model, ETAR and ETBR expression is also observed in infiltrating F4/80 positive macrophages and α-SMA positive fibroblasts and high co-localization was seen in the presence of oncogenic K-ras. In conclusion, both chronic and acute pancreatic inflammation in the presence of oncogenic K-ras contribute to sustained upregulation of ET axis components in the ductal and stromal cells suggesting a potential role of ET axis in the initiation and progression of PDAC.

P681Acute Myocardial Infarction in patients with Leukaemia: A national analysis of prevalence, predictors and outcomes in United States hospitalisations (2004 to 2014)

Background

Patients with leukaemia are at increased risk of cardiovascular events. There is limited outcomes data for patients with a history of leukaemia who present with an acute myocardial infarction (AMI).

Purpose

To examine the prevalence and clinical characteristics of patients with leukaemia presenting with AMI, and evaluate differences in clinical outcomes according to the subtype of leukaemia in comparison to patients without leukaemia.

Methods

We analysed the Nationwide Inpatient Sample (2004–2014) for patients with a primary discharge diagnosis of AMI and concomitant leukaemia, and further stratified according to the subtype of leukaemia into 4 groups; AML; ALL; CML; and CLL. Multiple logistic regression was conducted to identify the association between leukaemia and major acute cardiovascular and cerebrovascular events (MACCE; composite of mortality, stroke and cardiac complications) and bleeding.

Results

Out of 6,750,927 AMI admissions, a total of 21,694 patients had a leukaemia diagnosis. The leukaemia group experienced higher rates of MACCE (11.8% vs. 7.8%), mortality (10.3% vs. 5.8%) and bleeding (5.6% vs. 5.3%). Following adjustments, leukaemia was independently associated with increased odds of MACCE (OR 1.26 [1.20,1.31]) and mortality (OR 1.43 [1.37,1.50]) without an increased risk of bleeding (OR 0.86 [0.81,0.92]). Acute myeloid leukaemia (AML) was associated with approximately three-fold risk of MACCE (RR 2.81 [2.51, 3.13]) and a four-fold risk of mortality (RR 3.75 [3.34, 4.22]) (Figure 1). Patients with leukaemia were less likely to undergo coronary angiography (CA) (48.5% vs. 64.5%) and percutaneous coronary intervention (PCI) (28.2% vs. 42.9%) compared to those without leukaemia.

Figure 1.Relative risk of adverse events

Conclusion

Patients with leukaemia, especially those with AML, are associated with poor clinical outcomes after AMI, and are less likely to receive CA and PCI compared to those without leukaemia. A multi-disciplinary approach between cardiologists and haematology oncologists may improve the outcomes of patients with leukaemia after AMI.

Comparison of Laryngeal Mask Airway with Tracheal Tube for Ophthalmic Surgery in Paediatric Patients

This study of sixty ASA grade 1 or 2 children, aged 1 to 12 years, undergoing elective ophthalmic procedures, compared the use of the laryngeal mask airway (LMA) with that of an endotracheal tube. Changes in intraocular pressure and haemodynamic parameters, and intraoperative and postoperative complications were measured. Patients were randomly allocated into two groups of 30 patients. In group 1, the airway was secured with an LMA and in group 2 with an endotracheal tube. A standard technique of general anaesthesia incorporating positive pressure ventilation was used in both groups. The changes in intraocular pressure, heart rate (HR) and mean arterial pressure (MAP) were observed before and after insertion of the airway device, two minutes after insertion, and pre and post removal of the device. The incidence of airway complications was also noted. There was no significant change in mean intraocular pressure after insertion of the LMA, but removal caused a significant increase to 19.3± 7.6 mmHg (from a baseline of 13.9±4.3 mmHg). In the endotracheal tube group, intubation increased the mean intraocular pressure significantly to 19.9±7.3 mmHg (from a baseline of 13.1±4.0 mmHg) and extubation caused an increase to 24.6±10.4 mmHg which was clinically as well as statistically significant. The incidence of postoperative coughing was lower in the LMA group, but the incidence of vomiting higher. Two patients had displacement of the LMA during the procedure. We conclude that the use of an LMA is associated with less increase in intraocular pressure than the use of an endotracheal tube in children.

Serine protease-related proteins in the malaria mosquito, Anopheles gambiae

Insect serine proteases (SPs) and serine protease homologs (SPHs) participate in digestion, defense, development, and other physiological processes. In mosquitoes, some clip-domain SPs and SPHs (i.e. CLIPs) have been investigated for possible roles in antiparasitic responses. In a recent test aimed at improving quality of gene models in the Anopheles gambiae genome using RNA-seq data, we observed various discrepancies between gene models in AgamP4.5 and corresponding sequences selected from those modeled by Cufflinks, Trinity and Bridger. Here we report a comparative analysis of the 337 SP-related proteins in A. gambiae by examining their domain structures, sequence diversity, chromosomal locations, and expression patterns. One hundred and ten CLIPs contain 1 to 5 clip domains in addition to their protease domains (PDs) or non-catalytic, protease-like domains (PLDs). They are divided into five subgroups: CLIPAs (22) are clip_1-5-PLD; CLIPBs (29), CLIPCs (12) and CLIPDs (14) are mainly clip-PD; most CLIPEs (33) have a domain structure of PD/PLD-PLD-clip-PLD_0-1. While expression of the CLIP genes in group-1 is generally low and detected in various tissue- and stage-specific RNA-seq libraries, some putative GPs/GPHs (i.e. single domain gut SPs/SPHs) in group-2 are highly expressed in midgut, whole larva or whole adult libraries. In comparison, 46 SPs, 26 SPHs, and 37 multi-domain SPs/SPHs (i.e. PD/PLD-PLD_≥1) in group-3 do not seem to be specifically expressed in digestive tract. There are 16 SPs and 2 SPH containing other types of putative regulatory domains (e.g. LDLa, CUB, Gd). Of the 337 SP and SPH genes, 159 were sorted into 46 groups (2-8 members/group) based on similar phylogenetic tree position, chromosomal location, and expression profile. This information and analysis, including improved gene models and protein sequences, constitute a solid foundation for functional analysis of the SP-related proteins in A. gambiae.

Imaging of esophageal tuberculosis: A review of 23 cases

Purpose: To evaluate the various radiological abnormalities in patients with proven esophageal tuberculosis.

Material and Methods: The case records of 23 patients with proven esophageal tuberculosis were evaluated retrospectively for various radiological abnormalities. Twenty-two patients had secondary involvement of esophagus in the form of direct extension of mediastinal and pulmonary tuberculosis or spinal tuberculosis. Only 1 patient had primary involvement of the esophagus with no evidence of disease elsewhere. The diagnosis was confirmed by endoscopic and CT-guided biopsy/aspiration cytology in 7 and 6 cases, respectively. Diagnosis was made on the basis of surgical biopsy of lymph node and autopsy in 1 patient each. In the remaining 8 patients the diagnosis was based on radiological and endoscopic findings and the response to antituberculous treatment.

Results: Chest radiography (CXR) was abnormal in 65% patients. While the findings were non-conclusive for esophageal tuberculosis, characteristic lesions of tuberculosis in lungs or spine were suggestive of tuberculous etiology. In 15 patients, CT of the chest confirmed the corresponding CXR findings and also showed additional findings of mediastinal lymphadenopathy when CXR was normal. Fourteen patients showed mediastinal lymphadenopathy on CT of the chest. In all these patients, more than one group of lymph nodes was involved. The characteristic hypodense center of lymph nodes suggestive of tuberculosis was seen in 12 patients. Radiological abnormalities seen in barium swallow examination were extrinsic compression, traction diverticula, strictures, sinus/fistulous tracts, kinking and pseudotumor mass of esophagus in decreasing order of frequency. The middle third of the esophagus was found to be the most frequent site of involvement.

Evaluation of gall bladder carcinoma with dynamic magnetic resonance imaging and magnetic resonance cholangiopancreatography

The objective of this study is to evaluate the efficacy of dynamic MRI with magnetic resonance cholangiopancreatography (MRCP) in the preoperative assessment of gall bladder carcinoma. Magnetic resonance imaging and MRCP were carried out in 15 patients with gall bladder carcinoma before surgery and the imaging findings correlated with surgical and pathological findings. Gall bladder carcinoma manifested as focal or diffuse wall thickening in 73% (11/15) and as a mass replacing the gall bladder in 27% (4/15). All tumours showed enhancement in the early phase, which persisted into the delayed phase. The sensitivity and specificity of MRI with MRCP in detecting hepatic invasion, lymph node metastasis and bile duct invasion was 87.5 and 86%, 60 and 90%, and 80 and 100%, respectively. Magnetic resonance imaging correctly diagnosed duodenal invasion in only 50% and in none of the two patients with peritoneal metastasis. In conclusion, dynamic MRI with MRCP is an accurate and a reliable method of showing gall bladder carcinoma and in assessing its local and regional extent as part of preoperative assessment.

Clinical profile, diagnosis and management of patients presenting with symptomatic pulmonary embolism

OBJECTIVE

To study the clinical profile and diagnostic methods in patients with symptomatic pulmonary embolism (PE).

METHODS

Prospective assessment of clinical features, radiology and outcome of patients presenting with symptomatic PE over an 18-month period.

RESULTS

During study period, 24 patients with a mean age of 39 +/- 12.1 years were diagnosed to have symptomatic pulmonary embolism. Dyspnoea (91.7%) and cough (58.3%) were the predominant complaints. Spiral computed tomographic pulmonary angiography (CTPA) was performed in 21 (87.5%) patients and perfusion scans in 14 (58.4%) patients. Echocardiography performed in all patients revealed evidence of pulmonary artery hypertension and right ventricular dyskinesia in 20 (83.3%) and 15 (62.5%) patients, respectively. Thrombolysis with streptokinase was performed in 14 (58.3%) patients. All patients received low molecular weight heparin followed by warfarin. Of the 24 patients, 20 (83.3%) were discharged and are under regular follow-up; four patients died.

CONCLUSIONS

Pulmonary embolism is a common problem and can be easily diagnosed provided it is clinically suspected. Early diagnosis and aggressive management is the key to successful outcome.

Comparison of efficacy of spironolactone with metformin in the management of polycystic ovary syndrome: an open-labeled study

We compared the efficacy of spironolactone (50 mg/d) with metformin (1000 mg/d) after random allocation in 82 adolescent and young women with polycystic ovary syndrome (PCOS) on body mass index (BMI), waist-to-hip ratio, blood pressure, menstrual cyclicity, hirsutism, hormonal levels, glycemia, and insulin sensitivity at baseline and at the 3rd and 6th months of treatment. Sixty-nine women who completed the follow-up had a mean age of 22.6 +/- 5.0 yr and mean BMI of 26.8 +/- 4.0 kg/m2. The number of menstrual cycles in the spironolactone and metformin groups increased from 6.6 +/- 2.1 and 5.7 +/- 2.3 at baseline to 9.0 +/- 1.9 and 7.4 +/- 2.6 at 3rd month and to 10.2 +/- 1.9 and 9.1 +/- 2.0/ year at the 6th month (P = 0.0037), respectively. The hirsutism score decreased from 12.9 +/- 3.2 and 12.5 +/- 4.9 at baseline to 10.1 +/- 3.1 and 11.4 +/- 4.1 at the 3rd month and to 8.7 +/- 1.9 and 10.0 +/- 3.3 at the 6th month, respectively. Both groups showed improvement in glucose tolerance and insulin sensitivity, although the metformin effect was significant in the latter. Serum LH/FSH and testosterone decreased in both groups. BMI, waist-to-hip ratio, and blood pressure did not change with either drug. We conclude that both drugs are effective in the management of PCOS. Spironolactone appears better than metformin in the treatment of hirsutism, menstrual cycle frequency, and hormonal derangements and is associated with fewer adverse events.

In vivo proton magnetic resonance spectroscopy (MRS) and single photon emission computerized tomography (SPECT) in systemic lupus erythematosus (SLE)

Neuropsychiatric involvement in SLE (NP-SLE) may not be picked up by routine neuroimaging procedures like computerized tomography (CT) or magnetic resonance imaging (MRI). We prospectively studied the role of single photon emission computerized tomography (SPECT) and magnetic resonance spectroscopy (MRS) in detection of NP-SLE in 20 patients with lupus (10 with clinical NP involvement and 10 without) and 9 healthy controls. MRI abnormalities were seen in 5/10 patients with NP-SLE while the MRI was normal in all the lupus patients without clinical NP involvement. Perfusion defects on SPECT were seen in as many as 8/10 patients with NP-SLE while only 1/10 lupus patients without clinical NP involvement and none of the healthy controls demonstrated perfusion defects. MRS revealed abnormal metabolite ratios in all patients with NP-SLE and as many as 8 lupus patients without clinical NP features. Normal metabolite ratios were observed in healthy controls. SPECT and MRS can help detect changes not evident on MRI and may serve as useful supplements to existing neuroimaging techniques in the diagnosis of NP-SLE. The precise significance of alterations in regional cerebral blood flow on SPECT and neurometabolite ratios on MRS needs larger, longitudinal studies.

Contrast-free unilateral endoscopic palliation in malignant hilar biliary obstruction: new method

BACKGROUND

Bilateral endoscopic drainage is difficult in malignant hilar biliary obstruction. Recently, unilateral drainage in malignant hilar biliary obstruction has been shown to be equally effective. However, contrast injection leads to cholangitis. There have been no reported studies on contrast-free metal stenting in malignant hilar biliary obstruction. The present study was undertaken to evaluate the results of contrast-free unilateral metal stenting in type II malignant hilar biliary obstruction.

METHODS

We prospectively studied the results of unilateral metal stenting in type II malignant hilar biliary obstruction without contrast injection in 18 patients.

RESULTS

A successful endoscopic drainage was achieved in 100% (18/18) of patients with hilar strictures. Cholangitis and 30-day mortality occurred in none.

CONCLUSIONS

Unilateral endoscopic metal stenting without contrast in type II malignant hilar biliary obstruction is a safe and effective method of palliation.

A prospective study of the incidence and open-label treatment of interferon-induced major depressive disorder in patients with hepatitis C

Interferon (IFN) therapy has been associated with the development of Major Depressive Disorder (MDD) when given to patients with hepatitis C (HCV). The incidence, time course, risk factors, and treatment of IFN-induced MDD are poorly understood. The objectives of the present study were to determine the incidence of IFN-induced MDD, as well as to determine the efficacy of open-label antidepressant treatment, in particular selective serotonin reuptake inhibitors (SSRIs) for IFN-induced MDD. Thirty-nine HCV patients on IFN therapy were monitored weekly using the Beck Depression Inventory (BDI). Those who became depressed were treated with citalopram, a SSRI antidepressant. Main outcome measures included the incidence of IFN-induced MDD, as well as response rates to antidepressants in those patients who developed IFN-induced MDD. Our results showed that 13 of 39 patients (33%) developed IFN-induced MDD. There were no differences in age, gender, past history of MDD, or substance use between those who became depressed and those who did not. However, there were significantly fewer African American patients in the depressed group. Patients who developed IFN-induced MDD were on IFN therapy for an average of 12.1 weeks prior to the development of MDD. Eleven of 13 patients (85%) were responsive to antidepressant treatment. We conclude that IFN-induced MDD is common in HCV patients. Health care providers should follow IFN-treated HCV patients for the development of MDD, particularly between the 2nd and 5th months of IFN therapy. SSRIs, in particular citalopram, are an effective treatment for IFN-induced depression in HCV patients.

Imaging of esophageal tuberculosis: a review of 23 cases

PURPOSE

To evaluate the various radiological abnormalities in patients with proven esophageal tuberculosis.

MATERIAL AND METHODS

The case records of 23 patients with proven esophageal tuberculosis were evaluated retrospectively for various radiological abnormalities. Twenty-two patients had secondary involvement of esophagus in the form of direct extension of mediastinal and pulmonary tuberculosis or spinal tuberculosis. Only 1 patient had primary involvement of the esophagus with no evidence of disease elsewhere. The diagnosis was confirmed by endoscopic and CT-guided biopsy/aspiration cytology in 7 and 6 cases, respectively. Diagnosis was made on the basis of surgical biopsy of lymph node and autopsy in 1 patient each. In the remaining 8 patients the diagnosis was based on radiological and endoscopic findings and the response to antituberculous treatment.

RESULTS

Chest radiography (CXR) was abnormal in 65% patients. While the findings were non-conclusive for esophageal tuberculosis, characteristic lesions of tuberculosis in lungs or spine were suggestive of tuberculous etiology. In 15 patients, CT of the chest confirmed the corresponding CXR findings and also showed additional findings of mediastinal lymphadenopathy when CXR was normal. Fourteen patients showed mediastinal lymphadenopathy on CT of the chest. In all these patients, more than one group of lymph nodes was involved. The characteristic hypodense center of lymph nodes suggestive of tuberculosis was seen in 12 patients. Radiological abnormalities seen in barium swallow examination were extrinsic compression, traction diverticula, strictures, sinus/fistulous tracts, kinking and pseudotumor mass of esophagus in decreasing order of frequency. The middle third of the esophagus was found to be the most frequent site of involvement.

Mucoepidermoid carcinoma of the bronchus: is conservative surgery always justified?

A case of mucoepidermoid carcinoma of the bronchus in a 7-year-old boy is reported. The patient underwent right pneumonectomy. Histologically, the tumor was a low-grade muco-epidermoid carcinoma arising from the bronchus with lymph node metastasis in the drainage area. Presence of lymph node metastasis in this low-grade tumor suggests the possibility of early progression of disease in what has until now been considered a very slow growing tumor. Aggressive surgery may be necessary in these situations.

Cerebrospinal fluid pseudocyst of the breast

Cerebrospinal fluid pseudocyst of the breast is a rare complication of ventriculoperitoneal shunt placement. Two cases of cerebrospinal pseudocyst of the breast are reported here. The mammography and ultrasound findings in these two cases are described.

Thrombolytic therapy of a left-sided prosthetic valve thrombosis without hemodynamic obstruction: a case report

We report a case of a 38-year-old woman with a prosthetic mitral valve who presented with multiple embolic events. Transesophageal echocardiography was used to diagnose nonobstructive thrombi on the prosthetic valve. She underwent successful thrombolytic therapy. The patient was discovered to be in a hypercoagulable state, which probably was caused by the concomitant use of phenytoin. We review the literature for diagnosis and treatment of nonobstructive prosthetic valve thrombosis.

Ultrasound guided fine needle aspiration biopsy in mediastinal tuberculosis

SETTING

Diagnosis of mediastinal tuberculosis (TB) is difficult due to non-specific clinical features and lack of characteristic radiographic features. Histopathological confirmation has often required computed tomography guided fine needle aspiration biopsy (FNAB) or even invasive procedures such as mediastinoscopy or open/surgical biopsy. FNAB under ultrasound (US) guidance can also be performed in this clinical setting.

OBJECTIVE

To define the role of percutaneous US guided FNAB in the diagnosis of mediastinal tuberculosis.

DESIGN

Twenty-six patients with a proven diagnosis of mediastinal TB formed the study group. Chest radiographs and sputum examination were negative. FNAB was performed via suprasternal (n = 20) and parasternal (n = 6) route under sonographic guidance using 22G spinal needle. Aspirates were considered positive for TB when epithelioid cell granuloma with caseation necrosis and/or the presence of Mycobacterium tuberculosis by acid-fast bacilli (AFB) or culture was demonstrated, indeterminate when epithelioid cell granulomas were seen but without caseation necrosis or AFB, and negative when aspirate contained non-representative material.

RESULTS

A total of 30 biopsies were performed in the 26 patients, including repeat biopsy and biopsy of different sites in two patients each. FNAB was positive for TB in 20 of the 26 patients. In four, AFB were demonstrated, and in seven culture was positive for M. tuberculosis; in the remaining six patients, cytologic diagnosis was indeterminate in four and negative in two. No procedure related complications were noted.

CONCLUSION

Ultrasound guided FNAB is a safe, effective technique in the diagnosis of mediastinal TB.

Ultrasound-guided transthoracic co-axial biopsy of thoracic mass lesions

PURPOSE

To compare the diagnostic yield of fine-needle aspiration biopsy (FNAB) and cutting needle biopsy in thoracic lesions.

MATERIAL AND METHODS

Thirty patients with thoracic mass lesions were subjected to ultrasound-guided co-axial FNAB and cutting needle biopsy using 0.7 mm aspirating and 1.0-mm cutting needles, respectively. The diagnostic yield of the individual modalities was compared with the combined yield.

RESULTS

A conclusive diagnosis was obtained in 76.6% (n=23) of patients by FNAB and in 66.6% (n=20) by cutting needle biopsy. The combined diagnostic yield of FNAB and cutting needle biopsy was 93.3% (n=28) with a significant statistical difference (p<0.03) as compared to cutting biopsy alone. Of the patients, 23.2% (n=7) had benign and 76.6% (n=23) malignant aetiologies. The diagnostic yield of FNAB versus cutting needle biopsy in benign lesions was 57.1% (n=4) and 100% (n=7), respectively. The diagnostic yield of FNAB versus cutting needle biopsy in malignant lesions was 82.6% (n=19) and 56.5%, (n=13). Two patients remained undiagnosed by either modality. There were no complications.

CONCLUSION

FNAB and cutting needle biopsy are complementary to each other and attempts should be made to obtain small tissue cores in addition to routine cytologic specimens in diagnosing thoracic lesions, especially in benign pathologies. US provides a safe guidance modality for lesions abutting the chest wall.

Protein energey malnutrition and skeletal muscle wasting in childhood acute lymphoblastic lukemia

OBJECTIVE

To determine the nutritional status and the extent of skeletal muscle wasting in children with acute lymphoblastic leukemia (ALL) at the time of diagnosis and after induction chemotherapy.

DESIGN

Prospective observational study.

SETTING

Tertiary care teaching hospital.

METHODS

25 new cases of ALL underwent somatometric measurements and ultrasonographic evaluation of skeletal muscle and subcutaneous fat at initial presentation and after completion of induction therapy.

RESULTS

Malnutrition (weight for age < 80percnt) was evident in 13 cases (52percnt), but cumulative incidence of malnutrition (weight for age < 80percnt, weight for height < 90percnt, height for age < 95percnt, skin fold thickness < 5th centile, midarm muscle circumference < 5th centile) was 88percnt. Nine children lost weight during induction (range: 0.2 to 5.8 kg; means +/- SD: 1.9 plusmn 1.8 kg). All these cases had a complicated course during induction chemotherapy. Fourteen children (56percnt) had skeletal muscle wasting during induction chemotherapy. All those children who had lost weight also had skeletal muscle wasting. Subcutaneous fat, in contrast increased in 24 cases (96percnt).

CONCLUSION

Malnutrition exists in a significant proportion of children with ALL. If induction chemotherapy is complicated, children lose significant weight and have significant muscle wasting. Increase in subcutaneous fat occurs in almost all children, which is probably a consequence of therapy with oral steroids

Image-guided percutaneous drainage of thoracic empyema: can sonography predict the outcome?

The aim of this study was to assess the safety and efficacy of image-guided percutaneous catheter drainage (IGPCD) of thoracic empyemas, and to correlate the outcome of IGPCD with the pre-procedural sonographic appearance. One hundred three patients (74 males and 29 females) with thoracic empyema (age range 1 month to 70 years, median age 28 years) underwent IGPCD. In 63 (61.17%) patients, IGPCD was the primary treatment modality; in 40 (38.84%) patients it was used after unsuccessful intercostal chest tube drainage (ICTD). Ultrasound was the main modality used for guidance; CT guidance was used in only 7 patients (6.8%). Eight- to 12-F pigtail catheters or 10- to 14-F Malecot catheters were used. The outcome was correlated with the pre-procedural US appearance (anechoic, complex non-septated or complex septated) of the empyema. The IGPCD technique was successful in 80 of 102 patients. Based on the US appearance, IGPCD was successful in 12 of 13 (92.3%) patients with anechoic empyemas; 53 of 65 (81.54%) patients with complex non-septated empyemas, and in 15 of 24 (62.5%) patients with complex septated empyemas. A statistically significant difference (p < 0.01) was seen in the outcome of IGPCD in the three categories. Twenty-two patients required further treatment: ICTD (n = 9; 2 of them later also underwent surgery); and surgery (n = 15). The duration of catheter drainage ranged from 2-60 days. No major complications were encountered. Percutaneous catheter drainage of thoracic empyemas with imaging guidance ensures accurate catheter placement with a high success and a low complication rate. Pre-procedural US can predict the likelihood of success of IGPCD.

High-resolution CT in renal transplant patients with suspected pulmonary infections

OBJECTIVE

This prospective study was carried out to assess the usefulness of high-resolution CT (HRCT) of the chest in immunocompromised renal transplant patients with suspected pulmonary infections.

MATERIAL AND METHODS

Twenty-one consecutive renal transplant patients with clinically suspected pulmonary infections underwent chest radiography, HRCT and other tests including bronchoalveolar lavage (BAL). HRCT was performed using a high spatial frequency algorithm with 2-mm-thick sections at 10-mm intervals from apices to domes of the diaphragm. The findings on chest radiography and HRCT were interpreted by two thoracic radiologists and the usefulness of HRCT was evaluated. The images were interpreted independently by two radiologists, who were blinded to the findings of other imaging modalities and the final diagnosis. Any differences regarding the imaging findings were resolved through consensus.

RESULTS

Final diagnosis was obtained in 17 patients, and no cause for symptomatology was established in 4 patients. The spectrum of infections included pulmonary tuberculosis (TB) in 11 patients, cytomegalovirus pneumonia (CMV) in 2 patients, cryptococcal and streptococcal pneumonia, pulmonary aspergillosis and esophageal candidiasis in 1 patient each. Compared to chest radiography, HRCT revealed additional findings in 11 patients. HRCT findings were suggestive of underlying infection in 11 patients. The final diagnosis coincided with HRCT diagnosis in all but 1 patient. HRCT findings were non-specific in 3 patients and normal in 7. The findings were concordant in 19 cases. The results were not in agreement in only 2 cases.

CONCLUSION

HRCT can provide useful information and suggest the diagnosis in a significant proportion of renal transplant patients with pulmonary infection.

Effects of MPEG compression on the quality and diagnostic accuracy of digital echocardiography studies

The advantages of digital echocardiography studies include ease of retrieval, review, comparison, duplication, and quantitation as well as the potential for moving studies over networks. However, the large amounts of data associated with digital echocardiography studies have posed new problems. Reduction of the amount of data can be accomplished with image compression, in particular MPEG-1 (Moving Pictures Expert Group), which is designed for dynamic image sequences. However the effects of different levels of compression on the quality and diagnostic content of echocardiographic images need to be established. Digital sequences of single cardiac cycles were acquired in 40 consecutive patients, MPEG-1-compressed at different effective ratios (60:1, 80:1, 120:1, 200:1, 300:1, 370:1, 500:1), reviewed, and scored for endocardial visualization. The overall visualization scores and percentages of nonvisualized segments in the compressed images were not different from the uncompressed images up to a compression ratio of 200:1. Differential effects of compression were noted on a segmental basis and also varied with baseline image quality. The ability to correctly identify regional wall motion abnormalities did not decrease until compression ratios of 1:200 or higher were used. Digital echocardiography loops, MPEG-1-compressed at an effective ratio of 200:1, demonstrate no degradation in endocardial visualization quality or diagnostic content. Compression at this ratio has the potential to reduce the storage size of digital echocardiography studies to less than 1% of their current size.

Orbital mass lesions: US-guided fine-needle aspiration biopsy--experience in 37 patients

PURPOSE

To evaluate the safety and effectiveness of using ultrasonographic (US) guidance for performing fine-needle aspiration biopsies of orbital mass lesions.

MATERIALS AND METHODS

Thirty-seven patients with mass lesions in the orbit underwent US-guided fine-needle aspiration biopsy. Computed tomographic scans were available in all patients. In 19 patients, the lesions were located in posterior orbit, whereas in 18 patients the lesions were located in (n = 3) or extended up to (n = 15) the anterior compartment. Fine-needle aspiration biopsy was performed with 22-25-gauge needles and use of the freehand technique.

RESULTS

Needle biopsies were performed safely and easily, and real-time US monitoring of the needle position was used to avoid injury to the eyeball. No major complications were encountered. Diagnostic specimens were obtained in 29 (78%) of the 37 patients, and 19 benign and 10 malignant disease processes were diagnosed. In eight patients (22%), an appropriate diagnosis could not be made, as aspiration samples yielded insufficient tissue.

CONCLUSION

US provides safe and effective guidance for performing fine-needle aspiration biopsy in orbital mass lesions and is especially useful in deep-seated nonpalpable retrobulbar lesions.