Fractionated stereotactic radiotherapy of intracranial postoperative cavities after resection of brain metastases - Clinical outcome and prognostic factors

Background and Purpose

After surgical resection of brain metastases (BM), radiotherapy (RT) is indicated. Postoperative stereotactic radiosurgery (SRS) reduces the risk of local progression and neurocognitive decline compared to whole brain radiotherapy (WBRT). Aside from the optimal dose and fractionation, little is known about the combination of systemic therapy and postoperative fractionated stereotactic radiotherapy (fSRT), especially regarding tumour control and toxicity.

Methods

In this study, 105 patients receiving postoperative fSRT with 35 Gy in 7 fractions performed with Cyberknife were retrospectively reviewed. Overall survival (OS), local control (LC) and total intracranial brain control (TIBC) were analysed via Kaplan-Meier method. Cox proportional hazards models were used to identify prognostic factors.

Results

Median follow-up was 20.8 months. One-year TIBC was 61.6% and one-year LC was 98.6%. Median OS was 28.7 (95%-CI: 16.9-40.5) months. In total, local progression (median time not reached) occurred in 2.0% and in 20.4% radiation-induced contrast enhancements (RICE) of the cavity (after median of 14.3 months) were diagnosed. Absence of extracranial metastases was identified as an independent prognostic factor for superior OS (p = <0.001) in multivariate analyses, while a higher Karnofsky performance score (KPS) was predictive for longer OS in univariate analysis (p = 0.041). Leptomeningeal disease (LMD) developed in 13% of patients.

Conclusion

FSRT after surgical resection of BM is an effective and safe treatment approach with excellent local control and acceptable toxicity. Further prospective randomized trials are needed to establish standardized therapeutic guidelines.

Psychological factors and long-term tinnitus handicap in vestibular schwannoma patients after retrosigmoid microsurgery - a cross-sectional study

OBJECTIVE

This study aimed to investigate the connection between psychological factors and postoperative tinnitus in vestibular schwannoma (VS) patients following retrosigmoid microsurgery.

DESIGN

Cross-sectional study.

STUDY SAMPLE

Ninety-three VS patients participated, completing questionnaires on demographics, tinnitus severity (THI-12), personality traits (TIPI-G), dizziness impact (DHI), perceived health benefits (GBI), somatisation tendencies (SOMS-2), and psychological distress (HADS-D). Our analysis involved Mann-Whitney U-tests, Spearman's rank-order correlations, and false discovery rate correction.

RESULTS

Most participants reported postoperative tinnitus (77/93), with 41 experiencing it preoperatively. Emotional stability correlated negatively with tinnitus presence, while tinnitus severity was associated with emotional distress. Preoperative somatisation tendencies were also positively linked to tinnitus severity. Postoperative Tinnitus was further linked to reduced perceived health benefits and increased anxiety and depression levels. Notably, age and gender showed no significant associations.

CONCLUSION

This study uncovers the interplay between postoperative tinnitus and psychological factors in VS patients, highlighting emotional and cognitive dimensions. Tailored psychological interventions addressing tinnitus's psychosomatic impact may enhance patients quality of life.

American Indian and Alaska Native violence prevention efforts: a systematic review, 1980 to 2018

BACKGROUND

Violence is a serious public health concern disproportionately experienced by American Indian and Alaska Native (AIAN) people. While the burden and impact of violence may be explained by the presence of risk factors among this group, AIAN communities benefit from unique protective factors and universal strategies which may be tailored with tribal adaptations. We sought to identify and explore violence prevention strategies specific to AIAN populations.

METHODS

A review was conducted to systematically identify violence prevention programs, policies, and practices implemented in AIAN communities. We searched nine electronic databases and relevant gray literature released between January 1980 and June 2018. We included intervention-focused records targeting at least one violence topic area (child abuse/neglect, elder abuse, intimate partner violence, sexual violence, youth violence, and suicide) in a majority (> 50%) AIAN population.

RESULTS

A total of 5220 non-duplicate records were screened, yielding 318 full-text records. After applying exclusion criteria, 57 records describing 60 program, policy, or practice implementations of 43 unique interventions were identified. All six violence types were represented, although more than half (58%; n = 25/43) focused on suicide prevention. Among suicide prevention programs, the most common strategies were identifying and supporting people at risk (80%; n = 20), teaching coping and problem-solving skills (56%; n = 14), and promoting connectedness (48%; n = 12). Two-thirds of the implementations (67%; n = 40/60) were in fully (100%) AIAN communities. Programs were implemented across many settings, though schools were the most common (35%, n = 21/60) setting. Of the 60 total implementations, a majority (80%; n = 48) were new approaches developed by and for AIAN communities, while the remainder were AIAN adaptations of programs previously created for non-AIAN populations. Most implementations (60%; n = 36/60) provided some evaluation data although less than half (45%; n = 27/60) reported evaluation results.

CONCLUSIONS

This review identified many violence prevention strategies specific to AIAN populations. While programs developed in one tribe may not be completely generalizable to others, shared tribal risk and protective factors suggest programs could be successful across diverse communities. Findings indicate there is a need to develop and evaluate violence prevention programs, policies and practices for AIAN populations.

Parameterized absorptive electron scattering factors

In electron diffraction, thermal atomic motion produces incoherent scattering over a relatively wide angular range, which appears as a diffuse background that is usually subtracted from measurements of Bragg spot intensities in structure solution methods. The transfer of electron flux from Bragg spots to diffuse scatter is modelled using complex scattering factors f + if' in the Bloch wave methodology. In a two-beam Einstein model the imaginary `absorptive' scattering factor f' can be obtained by the evaluation of an integral containing f over all possible scattering angles. While more sophisticated models of diffuse scatter are widely used in the electron microscopy community, it is argued in this paper that this simple model is appropriate for current structure solution and refinement methods. The two-beam model is a straightforward numerical calculation, but even this simplistic approach can become time consuming for simulations of materials with large numbers of atoms in the unit cell and/or many incident beam orientations. Here, a parameterized form of f' is provided for 103 elements as neutral, spherical atoms that reduces calculation time considerably.

Reduced fertility in an adenomyosis mouse model is associated with an altered immune profile in the uterus during the implantation period

STUDY QUESTION

Does a reduction in fertility and/or systemic immune cell change occur during the early implantation period in a mouse model of adenomyosis?

SUMMARY ANSWER

A reduction in fertility was observed in mice with adenomyosis, coinciding with local and systemic immune changes observed during the implantation period.

WHAT IS KNOWN ALREADY

Adenomyosis is a pathology responsible for impaired fertility in humans, with a still unclear pathophysiology. One hypothesis is that changes in immune cells observed in adenomyosis-affected uteri may alter fertility, notably the physiological immune environment necessary for successful implantation and a healthy pregnancy.

STUDY DESIGN, SIZE, DURATION

Randomly selected CD-1 female neonatal pups were orally dosed by administration of tamoxifen to induce adenomyosis (TAM group), while others received solvent only (control group). From 6 weeks of life, CD-1 mice of both groups were mated to study impaired fertility and related local and/or systemic immune cell changes during the early implantation period.

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

To evaluate fertility and pregnancy outcomes, ultrasound imaging was performed at E (embryonic day) 7.5 and E11.5 to count the number of gestational sacs and the number of resorptions in eight mice of the TAM group and 16 mice of the control group. The mice were sacrificed at E18.5, and morphometric, functional (quantitative reverse transcription PCR; RT-qPCR), and histological analyses were performed on the placentas. To identify local and/or systemic immune changes during the early implantation period, 8 mice of the TAM group and 12 mice of the control group were sacrificed at E4.5. Uterine horns and spleens were collected for flow cytometry and RT-qPCR analyses to study the immune cell populations. To investigate the profile of the cytokines secreted during the early implantation period at the systemic level, supernatants from stimulated spleen cells were analyzed by multiplex immunoassay analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

By ultrasound imaging, we observed a lower number of implantation sites (P < 0.005) and a higher number of resorptions (P < 0.001) in the TAM group, leading to smaller litters (average number of fetuses per litter: 1.00 [0.00; 5.25] in the TAM group versus 12.00 [9.50; 13.75] in the control group (P < 0.001). Histological and morphometric analyses of the placentas at E18.5 showed a higher junctional/labyrinthine area ratio in the TAM group (P = 0.005). The expression levels of genes that play a role in vascularization and placental growth (Vegf (P < 0.001), Plgf (P < 0.005), Pecam (P < 0.0001), and Igf2 (P = 0.002)) were reduced in the TAM group. In the TAM group, the percentages of macrophages, natural killer (NK) cells, and dendritic cells (DC) were significantly decreased in the uterus around the implantation period. However, the number of M1 macrophages was increased. Both macrophages and DC had an increased activation profile (higher expression of MCHII, P = 0.012; CD80, P = 0.015; CCR7, P = 0.043 for macrophages, and higher expression of CD206, P = 0.018; CXCR4, P = 0.010; CCR7, P = 0.006, MCHII, P = 0.010; and CD80, P = 0.012 for DC). In spleen, an increase in the activation of macrophages (CCR7, P = 0.002; MCHII, P = 0.001; and CD80, P = 0.034) and DC was observed in the TAM group (CCR7, P = 0.001; MCHII, P = 0.001; Ly6C, P = 0.015). In the uteri and the spleen, we observed increased percentages of CD4+ T lymphocytes (P = 0.0237 and P = 0.0136, respectively) in the TAM group and, in the uteri, an increased number of regulatory T cells (P = 0.036) compared with the controls.

LARGE SCALE DATA

Not applicable.

LIMITATIONS, REASONS FOR CAUTION

This study is limited by the use of an animal model and the lack of intervention.

WIDER IMPLICATIONS OF THE FINDINGS

These data support involvement of innate and adaptive immune cells in the implantation failure and the increased rate of resorption observed in the mouse model of adenomyosis. This substantiates the need for additional research in this domain, with the goal of addressing fertility challenges in women affected by this condition.

STUDY FUNDING/COMPETING INTEREST(S)

None.

Multiparametric MRI characteristics of prostatitis and atrophy in the peripheral zone in men without prostate cancer

PURPOSE

To analyse multiparametric magnetic resonance imaging (mpMRI) characteristics and appearance of histopathologically proven non-cancerous intraprostatic findings focussing on quantity of prostatitis and atrophy in the peripheral zone.

METHOD

In this retrospective analysis consecutive patients with mpMRI followed by MRI/TRUS-fusion biopsy comprising targeted (TB) and systematic biopsy (SB) cores without prostate cancer (PC) at histopathology were included. Subgroup analysis was performed in younger men (≤50 years). The proportions of prostatitis and atrophy were quantified for each biopsy core based on histopathology. MRI findings in the peripheral zone (PZ) and index lesions (IL, most suspicious/representative lesion) were characterized regarding changes in T2w, ADC value, and enhancement of dynamic contrast enhancement (DCE) and correlated with quantity of prostatitis and atrophy.

RESULTS

Seventy-two patients were analysed. The median baseline characteristics were PSA 5.4 ng/ml (4.0-7.9), PI-RADS classification 3 (2-4), prostate volume 43 ml (33-57), and PSA density 0.13 ng/ml2 (0.10-0.19). Prostatitis was found in 44 % (n = 32) and atrophy in 65 % (n = 47) of cases. The quantity of atrophy demonstrated a significant correlation to T2w changes, ADC increase and DCE enhancement (p = 0.05, p = 0.05, p = 0.01), whereas quantity of prostatitis did not show any significant correlation to the MRI changes (p = 0.68, p = 0.58, p = 0.95). Quantity of prostatitis and atrophy increased with PI-RADS classification. Younger men had lower PSA (4.4 vs. 7.8 ml/ng; p < 0.001), smaller prostate volume (40 vs. 59 ml; p = 0.001), and lower PI-RADS classification (2-3 vs. 3-4; p = 0.005) and prostatitis and atrophy were less frequently observed (p ≤ 0.01, p = 0.03).

CONCLUSIONS

Quantity of atrophy and prostatitis had different influence on MRI characteristics and increased within higher PI-RADS classification. Younger men had diffuse hypointense changes at T2w images, but less quantity of prostatitis and atrophy.

Impact and outcomes after lymphaticovenous anastomosis for 150 cases of lymphoedema followed up over 24 months

BACKGROUND

Lymphoedema is a chronic condition affecting daily activities of life, causing significant alterations and adjustments. Since 2015, lymphaticovenous anastomosis (LVA) has been available on the National Health Service for people with lymphoedema in Wales, United Kingdom. This study aimed to explore the impact and outcomes after LVA over a 24-month follow-up.

METHODS

Data were prospectively captured before and after LVA surgery on 150 patients with unilateral upper or lower limb lymphoedema. The same team (three lymphoedema specialists and two plastic surgeons) assessed/operated on all patients. Data captured included a quality of life tool (EQ5D5L), circumferential measurements (tape measure/perometer), compression garment usage, occurrence of cellulitis and a range of patient-reported outcome measures.

RESULTS

People who underwent LVA surgery had predominantly cancer-related lymphoedema (n = 118). Reviewing baseline data and 24-months after LVA, quality of life statistically improved (p = <0.005), as well as pain, heaviness, anxiety, impact on hobbies, work, purchasing clothes and intimacy/desirability. Mean perometer and circumferential measurements did not reduce over the 24 months. Number of days per week and hours that the patient wore compression garments did lessen and was statistically significant (p = <0.001). The quantity of cellulitis episodes captured from two years before and two years after LVA decreased from 4.22 to 0.10 (p = <0.001). Significant results (p = <0.001) were also found in a reduction in patients taking days off work due to cellulitis (5.81 to 0.16).

CONCLUSION

LVA resulted in significant improvements in patient-reported outcome measures, cellulitis episodes and reduced need for compression garments. Limb circumference via tape measure/perometer did not alter, yet the patient's quality of life considerably improved.

The development of the relationship between auditory and visual neural sensitivity and autonomic arousal from 6 m to 12 m

The differential sensitivity hypothesis argues that environmental sensitivity has the bivalent effect of predisposing individuals to both the risk-inducing and development-enhancing influences of early social environments. However, the hypothesis requires that this variation in environmental sensitivity be general across domains. In this study, we focused on neural sensitivity and autonomic arousal to test domain generality. Neural sensitivity can be assessed by correlating measures of perceptual sensitivity, as indexed by event-related potentials (ERP) in electrophysiology. The sensitivity of autonomic arousal can be tested via heart rate changes. Domain generality was tested by comparing associations in perceptual sensitivity across auditory and visual domains, and associations between sensitivity in sensory domains and heart rate. We contrasted ERP components in auditory (P3) and visual (P1, N290 and P4) detection-of-difference tasks for N = 68 infants longitudinally at 6 and 12 months of age. Domain generality should produce correlated individual differences in sensitivity across the two modalities, with higher levels of autonomic arousal associating with increased perceptual sensitivity. Having controlled for multiple comparisons, at 6 months of age, the difference in amplitude of the P3 component evoked in response to standard and deviant tones correlated with the difference in amplitude of the P1 N290 and P4 face-sensitive components evoked in response to fearful and neutral faces. However, this correlation was not found at 12 months of age. Similarly, autonomic arousal correlated with neural sensitivity at 6 months but not at 12 months. The results suggest bottom-up neural perceptual sensitivity is domain-general across auditory and visual domains and is related to autonomic arousal at 6 months but not at 12 months of age. We interpret the development of the association of these markers of ES within a neuroconstructivist framework and with respect to the concept of interactive specialisation. By 12 months of age, more experience of visual processing may have led to top-down endogenous attention mechanisms that process visual information in a way that no longer associates with automatic auditory perceptual sensitivity.

Tritium Beta Spectrum Measurement and Neutrino Mass Limit from Cyclotron Radiation Emission Spectroscopy

The absolute scale of the neutrino mass plays a critical role in physics at every scale, from the subatomic to the cosmological. Measurements of the tritium end-point spectrum have provided the most precise direct limit on the neutrino mass scale. In this Letter, we present advances by Project 8 to the cyclotron radiation emission spectroscopy (CRES) technique culminating in the first frequency-based neutrino mass limit. With only a cm^{3}-scale physical detection volume, a limit of m_{β}<155  eV/c^{2} (152  eV/c^{2}) is extracted from the background-free measurement of the continuous tritium beta spectrum in a Bayesian (frequentist) analysis. Using ^{83m}Kr calibration data, a resolution of 1.66±0.19  eV (FWHM) is measured, the detector response model is validated, and the efficiency is characterized over the multi-keV tritium analysis window. These measurements establish the potential of CRES for a high-sensitivity next-generation direct neutrino mass experiment featuring low background and high resolution.

Delivery Models and Health Economics of Supportive Care Services in England: A Multicentre Analysis

AIMS

Improvements in cancer treatment have led to more people living with and beyond cancer. These patients have symptom and support needs unmet by current services. The development of enhanced supportive care (ESC) services may meet the longitudinal care needs of these patients, including at the end of life. This study aimed to determine the impact and health economic benefits of ESC for patients living with treatable but not curable cancer.

MATERIALS AND METHODS

A prospective observational evaluation was undertaken over 12 months across eight cancer centres in England. ESC service design and costs were recorded. Data relating to patients' symptom burden were collected using the Integrated Palliative Care Outcome Scale (IPOS). For patients in the last year of life, secondary care use was compared against an NHS England published benchmark.

RESULTS

In total, 4594 patients were seen by ESC services, of whom 1061 died during follow-up. Mean IPOS scores improved across all tumour groups. In total, £1,676,044 was spent delivering ESC across the eight centres. Reductions in secondary care usage for the 1061 patients who died saved a total of £8,490,581.

CONCLUSIONS

People living with cancer suffer with complex and unmet needs. ESC services appear to be effective at supporting these vulnerable people and significantly reduce the costs of their care.

Effect of feeding a Saccharomyces cerevisiae fermentation product to Holstein cows exposed to high temperature and humidity conditions on milk production performance and efficiency-A pen-level trial

The objective of this study was to evaluate the effect of feeding a Saccharomyces cerevisiae fermentation product (SCFP) on milk production efficiency of Holstein cows naturally exposed to high temperature and humidity conditions. The study was conducted in 2 commercial farms in Mexico from July to October 2020 and included 1 wk covariate period, 3 wk adaptation, and 12 wk data collection. Cows [n = 1,843; ≥21 d in milk (DIM) and <100 d carried calf] were enrolled and assigned to the study pens (n = 10) balanced for parity, milk yield, and DIM. Pens were fed a total mixed ration diet either without (CTRL) or with SCFP (19 g/d, NutriTek, Diamond V). Milk yield, energy-corrected milk (ECM), milk components, linear somatic cell score, dry matter intake (DMI), feed efficiency (FE; Milk/DMI and ECM/DMI), body condition score, and the incidence of clinical mastitis, pneumonia, and culling were monitored. Statistical analyses included mixed linear and logistic models accounting for repeated measures (when applicable; multiple measurements per cow within treated pens) with pen as the experimental unit and treatment, time (week of study), parity (1 vs. 2+), and their interactions as fixed and pen nested within farm and treatment as random effect. Parity 2+ cows within pens fed SCFP produced more milk than cows within CTRL pens (42.1 vs. 41.2 kg/d); there were no production differences between groups of primiparous groups. Cows within SCFP pens had lower DMI (25.2 vs. 26.0 kg/d) and greater FE (1.59 vs. 1.53) and ECM FE (1.73 vs. 1.68) than cows within CTRL pens. Milk components, linear somatic cell score, health events, and culling were not different between groups. At the end of the study (245 ± 54 DIM), SCFP cows had greater body condition score than CTRL (3.33 vs. 3.23 in the first parity; 3.11 vs. 3.04 in 2+ parity cows). Feeding Saccharomyces cerevisiae fermentation products to lactating cows exposed to high temperature and humidity conditions improved FE.

The influence of frailty on outcomes for older adults admitted to hospital with benign biliary disease: a single-centre, observational cohort study

INTRODUCTION

The prevalence and complications of biliary disease increase with age. Frailty has been associated with adverse outcomes in the hospital setting. We describe the prevalence of frailty in older patients hospitalised with benign biliary disease and its association with duration of hospital stay, and 90-day and 1-year mortality.

METHODS

We performed a retrospective cohort study of patients aged 75 years and over admitted with acute biliary disease between 17 September 2014 and 20 March 2017. Clinical Frailty Scale (CFS) score was recorded on admission.

RESULTS

We included 200 patients with a median age of 82 (75-99) years, 60% were female; 154 (77%) were independent for personal activities of daily living (ADLs) and 99 (49.5%) for instrumental ADLs. Cholecystitis was the most common diagnosis (43%) followed by cholangitis (36%) and pancreatitis (21%). Ninety-nine patients were non frail (NF; CFS 1-4) and 101 were frail (F; CFS 5-9). Some 104 patients received medical treatment only. Surgery was more common in NF patients (11% vs F 2%), percutaneous drainage more frequently performed in F patients (15% vs NF 5%) and endoscopic cholangiopancreatography was similar in both groups (F 32% vs NF 31%). Frailty was associated with worse clinical outcomes in F vs NF: functional deconditioning (34% vs 11%), increased care level (19% vs 3%), length of stay (12 vs 7 days), 90-day mortality (8% vs 3%) and 1-year mortality (48% vs 24%).

CONCLUSIONS

Half of patients in our cohort were frail and spent longer in hospital, were less likely to undergo surgery and were less likely to remain alive at 1 year after discharge.

The value of performing cerebrovascular CT angiography in major trauma patients: a 5-year retrospective review

AIM

To assess whether routine cerebrovascular imaging is required in all major trauma (MT) patients.

MATERIALS AND METHODS

All MT patients with cerebrovascular imaging between January 2015 and December 2020 were included in the study. Data were collated regarding the type of indication for computed tomography (CT) angiography imaging, time interval from the initial trauma, relevant trauma diagnoses on initial trauma imaging, and CT angiography. Findings, such as aneurysms, vascular malformations, luminal thrombus, venous sinus thrombosis, or vascular injury, were collated. Subsequent treatment with anti-coagulants/anti-platelets or surgical/radiological intervention was noted. Follow-up imaging was assessed for residual injury or complications.

RESULTS

Two hundred and fifty of the 6,251 MT patients underwent dedicated cerebrovascular imaging and were included in the study. Of these 41 (16.4%) had cervical artery or venous sinus injury. Further positive vascular findings were identified in 25/250 patients who presented with an incidental stroke or a vascular abnormality and were mislabelled as MT patients at presentation. One patient with a carotid injury subsequently died following a large infarction. Another patient with vertebral artery injury suffered a non-lethal stroke. No patients underwent surgery or intervention.

CONCLUSION

The present study showed that the overall incidence of detected blunt cerebrovascular injuries was very low (0.6%) and even lower for symptomatic vascular injury (0.03%). Routine cerebrovascular imaging is not recommended in all MT trauma patients, but instead, a continued case-by-case basis should be considered.

Rhinitis associated with asthma is distinct from rhinitis alone: The ARIA-MeDALL hypothesis

Asthma, rhinitis and atopic dermatitis (AD) are interrelated clinical phenotypes that partly overlap in the human interactome. The concept of "one-airway-one-disease", coined over 20 years ago, is a simplistic approach of the links between upper- and lower-airway allergic diseases. With new data, it is time to reassess the concept. This article reviews (i) the clinical observations that led to Allergic Rhinitis and its Impact on Asthma (ARIA), (ii) new insights into polysensitisation and multimorbidity, (iii) advances in mHealth for novel phenotype definition, (iv) confirmation in canonical epidemiologic studies, (v) genomic findings, (vi) treatment approaches and (vii) novel concepts on the onset of rhinitis and multimorbidity. One recent concept, bringing together upper- and lower-airway allergic diseases with skin, gut and neuropsychiatric multimorbidities, is the "Epithelial Barrier Hypothesis". This review determined that the "one-airway-one-disease" concept does not always hold true and that several phenotypes of disease can be defined. These phenotypes include an extreme "allergic" (asthma) phenotype combining asthma, rhinitis and conjunctivitis. Rhinitis alone and rhinitis and asthma multimorbidity represent two distinct diseases with the following differences: (i) genomic and transcriptomic background (Toll-Like Receptors and IL-17 for rhinitis alone as a local disease; IL-33 and IL-5 for allergic and non-allergic multimorbidity as a systemic disease), (ii) allergen sensitisation patterns (mono- or pauci-sensitisation versus polysensitisation), (iii) severity of symptoms and (iv) treatment response. In conclusion, rhinitis alone (local disease) and rhinitis with asthma multimorbidity (systemic disease) should be considered as two distinct diseases, possibly modulated by the microbiome, and may be a model for understanding the epidemics of chronic and auto-immune diseases.

Cross-Linked Gel Electrolytes with Self-Healing Functionalities for Smart Lithium Batteries

Next-generation Li-ion batteries must guarantee improved durability, quality, reliability, and safety to satisfy the stringent technical requirements of crucial sectors such as e-mobility. One breakthrough strategy to overcome the degradation phenomena affecting the battery performance is the development of advanced materials integrating smart functionalities, such as self-healing units. Herein, we propose a gel electrolyte based on a uniform and highly cross-linked network, hosting a high amount of liquid electrolyte, with multiple advantages: (i) autonomous, fast self-healing, and a promising PF₅-scavenging role; (ii) solid-like mechanical stability despite the large fraction of entrapped liquid; and (iii) good Li⁺ transport. It is shown that such a gel electrolyte has very good conductivity (>1.0 mS cm^-1 at 40 °C) with low activation energy (0.25 eV) for the ion transport. The transport properties are easily restored in the case of physical damages, thanks to the outstanding capability of the polymer to intrinsically repair severe cracks or fractures. The good elastic modulus of the cross-linked network, combined with the high fraction of anions immobilized within the polymer backbone, guarantees stable Li electrodeposition, disfavoring the formation of mossy dendrites with the Li metal anode. We demonstrate the electrolyte performance in a full-cell configuration with a LiNi_0.8Mn_0.1Co_0.1O₂ (NMC811) cathode, obtaining good cycling performance and stability.

The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

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.

Search for Subsolar-Mass Binaries in the First Half of Advanced LIGO's and Advanced Virgo's Third Observing Run

We report on a search for compact binary coalescences where at least one binary component has a mass between 0.2  M_{⊙} and 1.0  M_{⊙} in Advanced LIGO and Advanced Virgo data collected between 1 April 2019 1500 UTC and 1 October 2019 1500 UTC. We extend our previous analyses in two main ways: we include data from the Virgo detector and we allow for more unequal mass systems, with mass ratio q≥0.1. We do not report any gravitational-wave candidates. The most significant trigger has a false alarm rate of 0.14  yr^{-1}. This implies an upper limit on the merger rate of subsolar binaries in the range [220-24200]  Gpc^{-3} yr^{-1}, depending on the chirp mass of the binary. We use this upper limit to derive astrophysical constraints on two phenomenological models that could produce subsolar-mass compact objects. One is an isotropic distribution of equal-mass primordial black holes. Using this model, we find that the fraction of dark matter in primordial black holes in the mass range 0.2  M_{⊙}<m_{PBH}<1.0  M_{⊙} is f_{PBH}≡Ω_{PBH}/Ω_{DM}≲6%. This improves existing constraints on primordial black hole abundance by a factor of ∼3. The other is a dissipative dark matter model, in which fermionic dark matter can collapse and form black holes. The upper limit on the fraction of dark matter black holes depends on the minimum mass of the black holes that can be formed: the most constraining result is obtained at M_{min}=1  M_{⊙}, where f_{DBH}≡Ω_{DBH}/Ω_{DM}≲0.003%. These are the first constraints placed on dissipative dark models by subsolar-mass analyses.

Imaging Features of Craniofacial Giant Cell Granulomas: A Large Retrospective Analysis from a Tertiary Care Center

BACKGROUND AND PURPOSE

Craniofacial giant cell granulomas are rare lesions with varied appearances on imaging. We aimed to describe the imaging features of giant cell granulomas of the craniofacial bones.

MATERIALS AND METHODS

A retrospective analysis of the clinical features and imaging findings of 20 histopathology-proved cases of craniofacial giant cell granulomas, dating from 2006 to 2022, was performed.

RESULTS

Of the 20 cases, 10 each were seen in men and women. The epicenter of the lesions varied in location: in the maxilla in 8 patients, in the mandible in 5, in the temporal bone in 3, in the sphenoid/clivus in 3, and in the orbit in 1 patient. On the radiographs, the lesions appeared well-circumscribed, expansile, and lytic. On CT, the lesions were predominantly multiloculated, with thin septa, a soft-tissue component, and with expansion and remodeling of the underlying bone. On MR imaging, the solid component of the lesions was isointense on T1WI and hypointense on T2WI, with heterogeneous enhancement of the solid component and rim enhancement of the locules. Fluid-fluid levels were present in 3 patients.

CONCLUSIONS

Giant cell granulomas commonly present as locally aggressive, expansile, multiloculated lytic lesions, with solid as well as cystic areas. The solid component is typically hypointense on T2WI. Certain key imaging features of giant cell granulomas can aid the radiologist in narrowing the differential diagnosis.

959 OPTIMISING MEDICAL CARE IN OLDER EMERGENCY UROLOGY PATIENTS USING A GERIATRICIAN-LED PERI-OPERATIVE SERVICE

Introduction

Older and frail patients account for a large proportion of urology service use (Drch GW, Griebling TL., JAGS, 2003; 51: S355–8). Frail patients are at higher risk of complications and readmissions (Suskind A et al., BJUI, 2016; 117:836–42). Emergency patients may not be optimised before admission, leading to further increased risk and time restraints on care planning. Therefore, a geriatrician-led Perioperative Care for Older People Undergoing Surgery (POPS) service was established within the urology department at a District General Hospital to improve older emergency urology inpatients’ outcomes. We reviewed the impact on medical management, readmissions, and care planning.

Method

Retrospective documentation review of emergency urology patients aged over 65 admitted in the 3 months before the POPS service implementation, compared to those reviewed by POPS in the 3 months following. Median clinical frailty score of the POPS group was 6. The Comprehensive Geriatric Assessment based inpatient perioperative service was created using co-design and staff questionnaires were completed post-implementation.

Results

100% of staff (n = 26) would recommend POPS to other surgical wards and comments on improvements focused on expansion (9/15).

Conclusion

The POPS service significantly improved the recognition and management of medical conditions and reduced medical readmissions. Increased end of life recognition and planning allowed patients’ wishes to be acted on. This service was successfully implemented with high staff acceptance.

POS1230 INCREASED ANTIBODY RESPONSE AFTER SARS-CoV-2 mRNA-BASED VACCINATION IN RITUXIMAB-TREATED PATIENTS WITH PREVIOUS COVID-19 INFECTION

Background

Rituximab (RTX) is associated with reduced humoral response to SARS-CoV-2 mRNA-based vaccine (1, 2). A recent study has shown that, despite their immunosuppression burden, kidney transplant recipients with previous exposure to SARS-CoV-2 showed a marked increase in antibody titer, even after a single dose of vaccine (3).

Objectives

To describe the results of immunization after 1 to 3 doses of mRNA SARS-CoV-2 vaccine in RTX-treated patients with previous symptomatic COVID-19 infection.

Methods

Observational prospective usual care study including consecutive patients with inflammatory rheumatic diseases in maintenance therapy with RTX. All patients received a 1 to 3-dose regimen of mRNA-based COVID-19 vaccination (BNT162b2 Pfizer/BioNTech or mRNA-1273, Moderna). Serum IgG antibody levels against SARS-CoV-2 spike proteins were measured at the time of the new RTX infusion. The SARS-CoV-2 S1/S2 IgG immunoassay (DiaSorin) was used for the quantitative determination of antibodies to the receptor-binding domain of the viral spike (S) protein. Seropositivity was defined by anti-S antibodies >15 UA/mL.

Results

We included 69 patients (60 females, mean age 60±13 years) on maintenance therapy with RTX including 13 with previous symptomatic COVID-19, all proven by RT-PCR (10 females, mean age 58±12 years) (Table 1). SymptomaticCOVID-19 occurred between March 2020 and May 2021. The mean interval between the infection and vaccination was 8±3 months and the serological response was assessed after a mean of 74±58 days from the last dose of vaccination (3rd dose for 3 patients, 2nd dose for 6 patients and 1st dose for 4 patients). The 56 patients with no history of symptomatic COVID-19 infection all received 3 doses of vaccine and the serological response was assessed after a mean of 63±27 days from the 3rd dose of vaccination. The seropositivity rate was significantly higher in RTX-treated patients with previous symptomatic COVID-19 infection (11/13, 85% vs.15/56, 27%, p<0.001). Anti-S antibody titles were also markedly increased in patients with previous symptomatic COVID-19 infection (median 119 AU/mL, 95% CI 16-400 AU/mL vs. 3.80 AU/mL, 95% CI 3.80-4.81 AU/mL p<0.0001) (Figure 1). Antibody titles were not different according to the severity of previous COVID-19, the number of doses of vaccine, the underlying disease, and B-cell counts.

Table 1.

Study population

Patients with previous symptomatic COVID-19 (n=13)Patients without symptomatic COVID-19 (n=56)Age (years), mean ± SD58±1260±11Females, n (%)10 (77)50 (89)Underlying disease: Rheumatoid arthritis10 (77)45 (80) Systemic sclerosis2 (15)5 (9) Systemic lupus erythematosus1 (8)1 (2) Sjögren syndrome0 (0)3 (5) Mixed connective tissue disease0 (0)2 (4)Disease duration (years), mean ± SD17±920±10Associated Methotrexate, n (%)9 (69)36 (64)Current treatment with corticosteroids, n (%)5 (38)21 (38)Corticosteroid dose >10 mg/day, n (%)0 (0)0 (0)CD19+ (/µL) (100-600), mean ± SD65±10645±51CD19 <18/µL, n (%)7 (54)33 (58)Figure 1.

Distribution of SARS-CoV-2 spike antibody levels according to the history of proven symptomatic COVID-19. **** p<0.0001 by Mann Whitney test. Dotted red line corresponds to the seropositivity threshold

Conclusion

RTX-treated patients with previous proven COVID-19 showed increased seropositivity and antibody titers after SARS-CoV-2 vaccination, even after a single-dose of vaccine. This response is strikingly different from that observed for SARS-CoV-2-naïve RTX treated patients who received 3 doses of SARS-CoV-2 mRNA-based vaccination. An “antigen dose phenomenon” may account for these discrepancies. A potential clinical implication might be to increase antibody response with an additional dose of vaccine following an exposure to SARS-CoV-2 in RTX-treated patients with absent or insufficient postvaccination antibody response.

References

[1]Avouac et al, Rheumatology 2021

[2]Jyssum et al, Lancet Rheumatol 2021

[3]Benotmane et al, Am J Transplant 2021

Disclosure of Interests

None declared

The black summer bushfires: impacts and risk factors for livestock bushfire injury in south-eastern Australia

Background

The 2019/2020 Australian bushfires were the largest bushfire event in modern Australian history. While actions to mitigate risk to homes from bushfires are well reported, there is very little research reported on the impacts of bushfires on livestock. With an increasing incidence of bushfires predicted, there is an urgent need to identify how farmers can best protect their livestock.

Objectives

Compare bushfire affected farms with and without injured livestock to identify associations between risk factors and bushfire injury. Infer management approaches that can be used to reduce bushfire injury in livestock.

Method

A case‐control study using a structured interview questionnaire, delivered in late 2020 to cattle and sheep farmers in south‐eastern Australia (New South Wales and Victoria) whose farmland was burnt in the 2019/2020 Australian bushfires. Case farms were farms with bushfires injured or killed livestock. Control farms were farms that had no bushfire injured livestock but that still had fire present on the farm. Interview responses were summarised and information theoretical approaches were used to identify potential risk factors for livestock bushfire injury and protective actions that could inform future fire‐preparation recommendations.

Results and discussion

Of 46 farms in the case‐control study, 21 (46%) reported bushfire injured or killed livestock. Apparent protective factors identified included: preparation (having a bushfire plan and more than two farm bushfire fighting units), backburning and receiving assistance from fire authorities. Combined beef and sheep grazing enterprises appeared to have an increased risk of bushfire injury to livestock.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.