Concurrent nonavalent human papillomavirus (HPV) vaccination and immune stimulation with imiquimod to treat recalcitrant HPV-associated high grade vaginal intra-epithelial neoplasia

This is the first report describing detailed T cell responses to viral-like proteins contained in an HPV specific vaccine given in combination with Imiquimod for treatment of persistent VAIN2/3. We postulate that stimulation of the innate immune system with Imiquimod and the specific CD4 and CD8T cell responses following HPV vaccination with Gardasil9@ combined to induce clinical remission in a woman with treatment-refractory disease.

Profiling cognitive-motor interference in a large sample of persons with progressive multiple sclerosis and impaired processing speed: results from the CogEx study

BACKGROUND

Performing cognitive-motor dual tasks (DTs) may result in reduced walking speed and cognitive performance. The effect in persons with progressive multiple sclerosis (pwPMS) having cognitive dysfunction is unknown.

OBJECTIVE

To profile DT-performance during walking in cognitively impaired pwPMS and examine DT-performance by disability level.

METHODS

Secondary analyses were conducted on baseline data from the CogEx-study. Participants, enrolled with Symbol Digit Modalities Test 1.282 standard deviations below normative value, performed a cognitive single task ([ST], alternating alphabet), motor ST (walking) and DT (both). Outcomes were number of correct answers on the alternating alphabet task, walking speed, and DT-cost (DTC: decline in performance relative to the ST). Outcomes were compared between EDSS subgroups (≤ 4, 4.5-5.5, ≥ 6). Spearman correlations were conducted between the DTCmotor with clinical measures. Adjusted significance level was 0.01.

RESULTS

Overall, participants (n = 307) walked slower and had fewer correct answers on the DT versus ST (both p < 0.001), with a DTCmotor of 15.8% and DTCcognitive of 2.7%. All three subgroups walked slower during the DT versus ST, with DTCmotor different from zero (p's < 0.001). Only the EDSS ≥ 6 group had fewer correct answers on the DT versus ST (p < 0.001), but the DTCcognitive did not differ from zero for any of the groups (p ≥ 0.039).

CONCLUSION

Dual tasking substantially affects walking performance in cognitively impaired pwPMS, to a similar degree for EDSS subgroups.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) for ovarian cancer in an Australian institution: lessons from 20 years' experience

Objectives

We report the 20-year experience of the largest Australian unit performing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for ovarian cancer and reflect on learning opportunities.

Methods

A retrospective review of all cases of CRS for ovarian cancer at St George Peritonectomy Unit from Jan 1998 to Jan 2018 was performed. Prospectively collected data include age, stage, histology, disease extent (PCI), completeness of cytoreduction (CC score), HIPEC regime, 30-day surgical morbidity, disease recurrence, and death. Survival was computed using Kaplan–Meier method and analysed using log-rank tests and Cox-proportional hazards models.

Results

Forty-one women with advanced ovarian cancer (11 primary stage III/IV, 30 recurrent) underwent CRS, 29 (71%) with HIPEC. Most (68%) had high-volume disease (PCI > 15). In 98%, CC0/CC1 (residual < 2.5 mm) was achieved. Fourteen (34%) had grade 3/4 complications, 1 patient (2%) died within 30 days and 2 patients (5%) died within 90 days. Progression-free and median overall survival was 30.0 and 67.0 months for primary cancer, and 6.7 and 18.1 months for recurrent cancer. Survival was associated with platinum-sensitivity, PCI ≤ 15, and CC score 0, but not HIPEC.

Conclusion

This study reports outcomes for patients with advanced ovarian cancer patients treated in an Australian centre offering CRS and HIPEC. Whilst survival and morbidity outcomes were good for primary disease, they were poorer than predicted from the literature for cases of recurrent disease. The incorporation of evidence-based predictors of survival and multidisciplinary input are essential to achieve the best survival outcomes.

Case Report: Caveolin‐1 Associated with Severe (Pediatric‐onset) Presentation of Pulmonary Arterial Hypertension

There has been a growing interest in the role that genetic factors influence pediatric pulmonary vascular disease. In fact, data suggests that genetic factors contribute to ~42% of pediatric‐onset pulmonary hypertension. Although animal and human studies suggest that aberrations in Caveolin1 (CAV1) signaling participate in the development of pulmonary vascular disorders, limited reports of CAV1‐associated heritable pulmonary arterial hypertension (HPAH) exist. This is a case report of a 2‐year‐old female with late recognition of HPAH due to a CAV1 pathogenic variant: c.474del, (p.Leu159Serfs*22)(NM_001753.5). The pedigree demonstrates autosomal dominant transmission with reduced penetrance of PAH, suggestive that additional genetic or environmental factors modify PAH development. Genetic testing and the discovery of rare genetic alterations in PAH during infancy and childhood may aid in identifying disease etiologies, guide therapeutic decisions, and ultimately identify novel therapeutic targets. Moreover, CAV1 genetics implicate variable expressivity and incomplete penetrance for HPAH and underscores the utility of predictive genetic testing for unaffected family members no matter their age.

Evaluation of the cognitive benefits of intrathecal baclofen pump implantation in people with intractable multiple sclerosis related spasticity

BACKGROUND

Spasticity is a common problematic symptom in Multiple Sclerosis with over one third of patients failing first line therapies. Intrathecal baclofen is a safe and efficacious option for treatment resistant spasticity. Anecdotally patients report improved concentration/cognitive performance when switching to intrathecal baclofen (ITB) from systemic medications.

AIM

To explore whether subjects who proceed with ITB pump implantation for spasticity management and reduce oral anti-spasticity agents will have improved cognitive function.

METHODS

Subjects were admitted for trial of ITB via lumbar puncture and subsequent pump implantation. Spasticity and cognitive measures before ITB trial and 3 months post implant were recorded. Paired t-test or Wilcoxon Signed Ranks test was used for within subject change and effect sizes (Cohen's d_z) were calculated. Subgroup analysis of those on ≥2, or ≤ 1 spasticity medications at baseline was performed.

RESULTS

27 subjects with MS completed per protocol. Mean age 46 years [26 - 56], disease duration 15 years [6 - 26], RRMS = 3, SPMS = 17 and PPMS=7. The majority were on multiple spasticity medications. Spasticity scores significantly improved post pump implant. Mean ITB dose at 3 months was 143 mcg / day and 19 discontinued all other treatments for spasticity. There was no deterioration on any cognitive or mood measure. An improvement of moderate effect size was found in Backwards Digit Span (d=0.41, p=0.059) and HADS - anxiety (d=0.37, p=0.097). Fatigue Severity Scale score decreased substantially (d=0.81, p=0.005). Small improvements in Symbol Digit Modalities Test score (d=0.24) and Sustained Attention to Response Task response time (d=0.23) were non-significant. Performance on other measures did not change. Effect sizes were larger in subgroup on ≥2 oral spasticity medications at baseline, compared to the group on ≤1 medication (SDMT, d=0.42 vs d=0.07; Backwards digit span 0.45 vs 0.28; HADS-anxiety 0.39 vs 0.32; HADS-depression d=0.32 vs 0.05 and FSS, d= 1.14 vs 0.42).

CONCLUSIONS

In a pilot study exploring the impact of ITB on cognition, spasticity scores improved universally and beneficial effects on some measures of fatigue, anxiety, auditory attention and verbal working memory were found. Improvement of speed of processing in those withdrawing higher doses of oral medication was also demonstrated suggesting that switching to ITB has added cognitive and psychological benefits for people with MS.

WP1-12 Reducing infection rates in an intrathecal baclofen service; closing the audit cycle

Objectives

Intrathecal baclofen (ITB) is a recognised treatment strategy for the management of spasticity. We have 30 years of experience, and 160 patients currently receiving treatment.

Design

An audit (Jan 13 – Jul 15) demonstrated complication rates of 4.4% (infection) and 4.92% (catheter). After this we recommended 1 vancomycin wash of the pump pocket, 2 occlusive dressing of pressure sores, 3 timely MRSA pre-screening, and this was introduced June-August 2016. We present a re-audit of the service.

Subjects

All patients admitted for ITB pump surgery between June 2016 and June 2018.

Methods

The database of patients was used, from which the patient notes were reviewed with information relating to each surgical procedure recorded.

Results

There were 92 surgical procedures and 78 patients (M 30, F 48). 12 patients had complications, requiring 18 surgical procedures. Out of 18 surgical procedures, 10 were catheter- and 7 pump-related). Our infection rate was lower at 1% of all surgeries (compared with 4.4%), or 0.6% of all ITB pump patients per year (compared with 3.4%), and our catheter complication rate was 6.25% of all patients per year. Our annual incidence rate of all complications was 5.6% in both groups.

Conclusions

The infection risk is lower and complication rate remains stable. We will discuss factors which may influence the risk of complication, and consider recommendations for the future.

Use of outpatient parenteral antimicrobial therapy for transrectal ultrasound-guided prostate biopsy prophylaxis in the setting of community-associated multidrug-resistant Escherichia coli rectal colonization

OBJECTIVE

To study the use of ertapenem delivered in an outpatient parenteral antimicrobial therapy (OPAT) hospital-based unit setting for targeted transrectal ultrasound-guided prostate biopsy (TRUSPBx) prophylaxis in the setting of multidrug-resistant (MDR) Escherichia coli rectal colonization. E coli is the pathogen most commonly associated with post-TRUSPBx complications, and there is increasing prevalence of community-associated MDR E coli.

METHODS

Prospective data analysis of all patients admitted to the OPAT unit for administration of intravenous antibiotics for prophylaxis for TRUSPBx over 18-month period was performed. Patients had identification of MDR E coli in rectal swab cultures and/or intolerance to available oral agents. Microbiologic data and tolerability of administered antibiotics and outcome after TRUSPBx were tabulated.

RESULTS

Nine patients (median age 74 years) were referred because of antibiotic-resistant E coli from rectal swabs (all fluoroquinolone resistant, 7 MDR). All patients received ertapenem 1 g intravenously 1 day before TRUSPBx and the day of the procedure before TRUSPBx. None of the patients experienced infectious complications immediately after TRUSPBx or several weeks or months later, and no patient was lost to urologic follow-up.

CONCLUSION

Increasing worldwide reports of prostatitis, urinary tract infections, and septicemia after TRUSPBx because of MDR E coli suggest rectal screening before procedure may be useful in decreasing complications. Targeted prophylaxis in these instances is necessary. Although carbapenems are used for treatment, they are not routinely used for prophylaxis. We report successful use of ertapenem delivered in a hospital-based OPAT unit for TRUSPBx prophylaxis.

Betabox: a beta particle imaging system based on a position sensitive avalanche photodiode

A beta camera has been developed that allows planar imaging of the spatial and temporal distribution of beta particles using a 14 × 14 mm(2) position sensitive avalanche photodiode (PSAPD). This camera system, which we call Betabox, can be directly coupled to microfluidic chips designed for cell incubation or other biological applications. Betabox allows for imaging the cellular uptake of molecular imaging probes labeled with charged particle emitters such as (18)F inside these chips. In this work, we investigate the quantitative imaging capabilities of Betabox for (18)F beta particles, in terms of background rate, efficiency, spatial resolution, and count rate. Measurements of background and spatial resolution are considered both at room temperature (21 °C ± 1 °C) and at an elevated operating temperature (37 °C ± 1 °C), as is often required for biological assays. The background rate measured with a 4 keV energy cutoff is below 2 cph mm(-2) at both 21 and 37 °C. The absolute efficiency of Betabox for the detection of (18)F positron sources in contact with a PSAPD with the surface passivated from ambient light and damage is 46% ± 1%. The lower detection limit is estimated using the Rose Criterion to be 0.2 cps mm(-2) for 1 min acquisitions and a 62 × 62 µm(2) pixel size. The upper detection limit is approximately 21 000 cps. The spatial resolution at both 21 and 37 °C ranges from 0.4 mm FWHM at the center of the field of view (FOV), and degrades to 1 mm at a distance of 5 mm away from center yielding a useful FOV of approximately 10 × 10 mm(2). We also investigate the effects on spatial resolution and sensitivity that result from the use of a polymer based microfluidic chip. For these studies we place varying layers of low-density polyethylene (LDPE) between the detector and the source and find that the spatial resolution degrades by ∼180 µm for every 100 µm of LDPE film. Sensitivity is reduced by half with the inclusion of ∼200 µm of additional LDPE film. Lastly, we demonstrate the practical utilization of Betabox, with an imaging test of its linearity, when coupled to a polydimethylsiloxane microfluidic chip designed for cell based assays.

Safety trial of Floseal(®) haemostatic agent in head and neck surgery

INTRODUCTION

Floseal® (Baxter, Hayward, CA, US) can be of value in reducing blood loss and haematoma rates. The manufacturer’s warnings include allergic reaction, poor wound healing and intravascular thrombosis. We aimed to determine whether Floseal® is safe to use in various head and neck surgery (HNS) procedures.

METHODS

A prospective trial was conducted using Floseal® in 42 various consecutive head and neck surgery procedures. Adverse incidents were used as the main outcome measure, including allergic reaction, wound breakdown, wound infection and thrombosis. Secondary outcome measures included haematoma formation, hospital stay, drain times and output.

RESULTS

No adverse incidents were recorded in the trial period. Two patients developed haematomas and required surgical exploration where a bleeding vessel was identified and dealt with.

CONCLUSIONS

Floseal® is safe to be used in head and neck surgery with no adverse effects. A larger number and a control group are required to ascertain its value in reducing blood loss, haematoma formation, drain usage and hospital stay.

Response of large area avalanche photodiodes to low energy x rays

For an experiment to study neutron radiative beta-decay, we operated large area avalanche photodiodes (APDs) near liquid nitrogen temperature to detect x rays with energies between 0.2 keV and 20 keV. Whereas there are numerous reports of x ray spectrometry using APDs at energies above 1 keV, operation near liquid nitrogen temperature allowed us to reach a nominal threshold of 0.1 keV. However, due to the short penetration depth of x rays below 1 keV, the pulse height spectrum of the APD become complex. We studied the response using monochromatic x ray beams and employed phenomenological fits of the pulse height spectrum to model the measurement of a continuum spectrum from a synchrotron. In addition, the measured pulse height spectrum was modelled using a profile for the variation in efficiency of collection of photoelectrons with depth into the APD. The best results are obtained with the collection efficiency model.

18F-fluorodeoxyglucose positron emission tomography/computed tomography in the assessment of occult primary head and neck cancers--an audit and review of published studies

AIMS

To assess the value of 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in patients with squamous cell and undifferentiated cancer neck nodes and no primary site on conventional assessment.

MATERIALS AND METHODS

Seventy-eight patients with neck nodal metastases from an unknown primary cancer were studied. PET/CT was carried out in all patients, 1h after FDG injection.

RESULTS

Uptake suspicious of an occult primary cancer was found in 46/78 (59.0%) patients. Subsequent investigations confirmed a primary site in the base of the tongue in 14, pharyngeal palatine tonsil in 14, post cricoid in one, lung in one. PET/CT diagnosed primary cancers in 30/78 patients (38.5%); sensitivity, specificity, positive predictive value, negative predictive value: 30/30 (100.0%), 32/48 (66.7%), 30/46 (65.2%), 32/32 (100.0%), respectively. PET/CT detected additional disease in four patients: contralateral nodal disease in two, mediastinal nodal disease in one and liver metastases in one.

CONCLUSIONS

FDG PET/CT is of value in the assessment of patients with occult head and neck primary cancers. However, false-positive results remain a limitation of the investigation.

P2-13-03: Comparative Assessment of 636 Women at Risk for Hereditary Breast Cancer within 3 Public Hospitals: The Consortium of Underserved BRCA Testers

Background: Underserved women at risk for Hereditary Breast and Ovarian Cancer (HBOC) are confronted with many unique challenges, such as barriers to accessing appropriate genetic testing and counseling services and decreased resources, that place them at increased cancer risk. It is unclear whether these high-risk women are appropriately referred for genetic counseling and what their genetic test results demonstrate due to minimal practice-based evidence. To study this population, and to establish an infrastructure to further explore long-term outcomes, we formed the Consortium of Underserved BRCA testers in October 2010 from: San Francisco General Hospital (SF), Stroger Hospital of Cook County (Chicago), and Grady Memorial Hospital (Atlanta).

Methods: Using common clinical and research protocols and mixed methods analysis, we examined and compared referral patterns, demographics, and BRCA test results between sites. We used chart reviews and common data collection instruments to gather and pool data. Using descriptive and comparative statistics, we examined similarities and differences between Consortium sites.

Results: SF's program began 9 years ago, Chicago's began 6 years ago, and Atlanta's began 3 years ago. Medicaid funding for BRCA testing has been available in SF since 2011, in Chicago since 2009, and is not yet available in Atlanta. P values were all &lt;0.05 for comparing referral sources between sites. Each site uses unique referral tools and systems. For example, in SF, a family history screening questionnaire is administered during mammography; in Chicago, an extensive primary care network has been educated to provide appropriate referrals; in Atlanta, a pedigree assessment tool is employed by referring clinics.

Pseudo-lyre sign

Carotid body tumours cause characteristic splaying of the internal and external carotid arteries, known as ‘Lyre Sign’. Vagal paragangliomas are rare tumours that arise from glomus cells along the length of the vagus nerve. We present a case in which a vagal paraganglioma has arisen from the vagus nerve at the carotid bifurcation, and has mimicked the ‘Lyre Sign’ of a carotid body tumour.

Systematic review of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for ovarian peritoneal carcinomatosis: A more efficacious way of delivering intraperitoneal chemotherapy

5524

Background: Advanced and recurrent ovarian cancer results in extensive dissemination of tumor within the peritoneal cavity. The current evidence suggests that cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) may be a feasible option with potential benefits compared to the current standard of care in the treatment of peritoneal carcinomatosis from ovarian cancer. Methods: A systematic review of relevant studies before August 2008 was undertaken to document and report its efficacy. Each study was appraised using a predetermined protocol. The quality of studies was assessed. The patient characteristics, protocol of treatment, perioperative morbidity and mortality, and treatment outcomes were synthesized through a narrative review with full tabulation of results of all included studies. Results: In total, 15 non-randomized, observational studies were reviewed, comprising of 512 patients. All patients received HIPEC as part of the combined treatment with cytoreductive surgery. Cisplatin was the most common chemoperfusate. The mortality associated with the treatment ranged from 0 to 10%. The rates of severe morbidity ranged from 0 to 40%. The median time of follow up ranged from 14 to 64 months, the median disease-free survival ranged from 10 to 57 months and the overall median survival ranged from 22 to 64 months. In patients who had an optimal cytoreduction, the median survival ranged from 29 to 66 months, with a 3- and 5-year survival rate that ranged from 35 to 63% and 12 to 66%, respectively. Conclusions: The future for cytoreductive surgery and HIPEC in ovarian cancer is promising. More studies are called for to validate the efficacy of this treatment. For it to become generally accepted, the oncology community must commit to a randomized trial. Before this, the current treatment of cytoreductive surgery combined with adjuvant intraperitoneal and intravenous chemotherapy should remain the mainstay of treatment.

No significant financial relationships to disclose.

Hypothermia therapy after pediatric cardiac arrest

BACKGROUND

Hypothermia therapy improves mortality and functional outcome after cardiac arrest and birth asphyxia in adults and newborns. The effect of hypothermia therapy in infants and children with cardiac arrest is unknown.

METHODS AND RESULTS

A 2-year, retrospective, 5-center study was conducted, and 222 patients with cardiac arrest were identified. Seventy-nine (35.6%) of these patients met eligibility criteria for the study (age >40 weeks postconception and <18 years, cardiac arrest >3 minutes in duration, survival for > or = 12 hours after return of circulation, and no birth asphyxia). Twenty-nine (36.7%) of these 79 patients received hypothermia therapy and were cooled to 33.7+/-1.3 degrees C for 20.8+/-11.9 hours. Hypothermia therapy was associated with higher mortality (P=0.009), greater duration of cardiac arrest (P=0.005), more resuscitative interventions (P<0.001), higher postresuscitation lactate levels (P<0.001), and use of extracorporeal membrane oxygenation (P<0.001). When adjustment was made for duration of cardiac arrest, use of extracorporeal membrane oxygenation, and propensity scores by use of a logistic regression model, no statistically significant differences in mortality were found (P=0.502) between patients treated with hypothermia therapy and those treated with normothermia. Also, no differences in hypothermia-related adverse events were found between groups.

CONCLUSIONS

Hypothermia therapy was used in resuscitation scenarios that are associated with greater risk of poor outcome. In an adjusted analysis, the effectiveness of hypothermia therapy was neither supported nor refuted. A randomized controlled trial is needed to rigorously evaluate the benefits and harms of hypothermia therapy after pediatric cardiac arrest.

Neutralizing anti-interferon beta antibodies are associated with reduced side effects and delayed impact on efficacy of Interferon-beta

Interferon-beta (IFNbeta) is a biological therapy which is immunogenic, inducing anti-IFN-beta neutralizing antibodies (Nabs) in some subjects. The frequency of Nabs varies depending on IFN-beta product and the Nab assay used.

OBJECTIVE

Assess frequency of Nabs using novel Luciferase assay, evaluate association with relapses, frequency of side effects and to compare results with published data.

METHODS

Serum samples at 12 and 24 months and a follow up sample were tested for binding and Nabs. Titre >20 NU was considered positive. Charts were reviewed retrospectively for clinical data.

RESULTS

Out of 327 subjects included, 130 subjects (40%) were binding antibody positive, 89 (27%) were Nab +ve at anytime. Risk at 12 months for being Nab +ve: Avonex 8%, Betaferon 39%, Rebif 33%, P < 10(-5); at 24 months 8, 31 and 27% respectively, P = 0.002. Nab titres were highest in Rebif Nab +ve subjects - 50% >320 NU. Annualized relapse rate was 1.53 pre-treatment, after treatment relapse rate was higher in Nab +ve group 0.67 (95% CI 0.38-0.97) versus 0.5 (0.38-0.61) Nab -ve P = 0.04. Nab status at 12 and 24 months was significantly associated with risk of subsequent relapse, risk being greatest in those with highest titres. Side effects were also significantly associated with Nab -ve status.

How we do it: Changes in thyroid and salivary gland surgery since 1989: who's doing it and what are they doing?

Keypoints * The aim of this study was to identify changes in the provision of parotid, submandibular and thyroid gland surgery between surgical specialties since 1989, as well as changes in surgical practice. * Data from the Department of Health's Hospital Episode Statistics (HES) was extracted from 1989/1990 and 2003/2004 records by operation and surgical specialty in England. * The data reveals a considerable decline in the amount of parotid and submandibular surgery performed by General surgeons; with the majority of this surgery currently being performed by ENT surgeons, and to a lesser extent, Oral and Maxillo-Facial surgeons. * Thyroid surgery has undergone less radical change, with General surgeons continuing to perform the majority of cases; however, an increasing proportion is now provided by ENT surgeons. * There also seems to be changes in the types of thyroid operation being performed; with large increases in total thyroidectomy and reductions in subtotal thyroidectomies.

Simple keel fixation technique for endoscopic repair of anterior glottic stenosis

The use of keels in the treatment of anterior glottic stenosis is well established. A variety of methods for keel fixation have previously been documented. We describe a simple technique of securing a Silastic keel, placed endoscopically, with a simple percutaneous suture, after laser vaporization of an anterior commissure web.

Clinically important venous thromboembolism in pediatric critical care: a Canadian survey

PURPOSE

Pediatric venous thromboembolism (VTE) is becoming an increasingly recognized morbidity associated with critical illness. The objective of this survey is to identify the patient factors and radiological features that pediatric intensivists consider more or less likely to make a venous thrombosis (VTE) clinically important in their patients.

MATERIALS AND METHODS

Our definition of clinically important VTE was a VTE likely to result in short- or long-term morbidity or mortality if left untreated. We asked respondents to rate the likelihood that patient factors and radiological features make a venous thrombosis clinically important using a 5-point scale (1 = much less likely to 5 = much more likely).

RESULTS

The 38 (58.5%) of 65 pediatric intensivists responding rated 4 patient factors as most likely to make a VTE clinically important: clinical suspicion of pulmonary embolism (mean score, 4.8), symptoms (mean, 4.5), detection by physical exam (mean, 4.4), and the presence of an acute or chronic cardiopulmonary comorbidity that might limit a patient's ability to tolerate pulmonary embolism (mean, 4.3). Of the radiological features, the 2 considered most important were VTE involving the vena cava extending into the right atrium (mean, 5) and central veins (mean, 4.5).

CONCLUSIONS

When labeling a VTE as clinically important, pediatric intensivists rely on several specific patient factors and thrombus characteristics.

Clinicopathologic review of malignant polyps in stage 1A carcinoma of the endometrium

OBJECTIVES

The aims of this study were to determine the incidence of malignant polyps in stage 1A endometrial cancer, to define the pathological features of such cancers, and to assess whether clinical outcome differs from similar cancers without a malignant polyp.

METHODS

We performed a retrospective pathological review of 107 cases of stage 1A endometrial cancer treated at two centers in New South Wales between January 1988 and July 2003. The presence of a malignant polyp was determined and a pathological description made of the tumor. Clinical data were collected, including prior tamoxifen usage, tumor recurrence and survival. The outcome of the malignant polyp group was compared to the same histological subtype not involving a malignant polyp.

RESULTS

The incidence of malignant polyps in our series was 32%. Malignant polyps occurred in all 8 cases involving a serous subtype. Precursor lesions of endometrial cancer were identified within malignant polyps. Three out of the four recurrences occurred in high-grade tumor subtypes and all four had a large primary tumor (size > or = 4 cm). When comparing the same subtype of tumor with and without a malignant polyp, there was no significant difference in clinical outcome.

CONCLUSIONS

Approximately one-third of stage 1A endometrial cancers are associated with a malignant polyp. Serous carcinoma commonly arises within an otherwise benign endometrial polyp. Malignant polyps offer an opportunity to identify precursors of endometrial carcinoma. Clinical outcome of stage 1A endometrial carcinoma was related to the histological subtype and the size of the tumor rather than the presence of a malignant polyp.

Performance measurements of a depth-encoding PET detector module based on position-sensitive avalanche photodiode read-out

We are developing a high-resolution, high-efficiency positron emission tomography (PET) detector module with depth of interaction (DOI) capability based on a lutetium oxyorthosilicate (LSO) scintillator array coupled at both ends to position-sensitive avalanche photodiodes (PSAPDs). In this paper we present the DOI resolution, energy resolution and timing resolution results for complete detector modules. The detector module consists of a 7 x 7 matrix of LSO scintillator crystals (1 x 1 x 20 mm3 in dimension) coupled to 8 x 8 mm2 PSAPDs at both ends. Flood histograms were acquired and used to generate crystal look-up tables. The DOI resolution was measured for individual crystals within the array by using the ratio of the signal amplitudes from the two PSAPDs on an event-by-event basis. A measure of the total scintillation light produced was obtained by summing the signal amplitudes from the two PSAPDs. This summed signal was used to measure the energy resolution. The DOI resolution was measured to be 3-4 mm FWHM irrespective of the position of the crystal within the array, or the interaction location along the length of the crystal. The total light signal and energy resolution was almost independent of the depth of interaction. The measured energy resolution averaged 14% FWHM. The coincidence timing resolution measured using a pair of identical detector modules was 4.5 ns FWHM. These results are consistent with the design goals and the performance required of a compact, high-resolution and high-efficiency PET detector module for small animal and breast imaging applications.

Environmental enrichment enhances recovery of function but exacerbates ischemic cell death

Prior exposure to brief 'conditioning' episodes of ischemia protects hippocampal CA1 neurons against a subsequent more severe ischemic insult. However, protected cells exhibit abnormal function and as survival times are extended this ischemic tolerance dissipates and cells begin to die. In this study, we sought to determine whether environmental enrichment could alter the above pattern of delayed cell death and functional impairment in a gerbil model of ischemic tolerance. Gerbils received either ischemic preconditioning, 5 min of ischemia without preconditioning or sham surgery. Three days after ischemia, gerbils were placed in either an enriched environment or standard laboratory housing. Open field habituation was assessed 3, 7, 10, 30 and 60 days after ischemia. Subsequently, animals were trained in two versions (win-shift and win-stay) of a T-maze task. Following behavioral testing, extracellular CA1 field potential amplitudes and CA1 cell counts were determined. Initial open field activity was significantly higher in all experimental groups compared to sham animals (P<0.001). By 60 days, enriched ischemic preconditioned and enriched ischemic gerbils were not different than shams whereas non-enriched, ischemic preconditioned and ischemic gerbils continued to have higher activity scores (P<0.05). Preconditioned and enriched ischemic animals learned the win-shift T-maze problem as quickly as shams while non-enriched ischemic gerbils were severely impaired compared with all other groups (P<0.001). Only the sham and enriched preconditioned groups readily acquired the win-stay paradigm. CA1 field potential amplitudes were lower (P<0.05) in ischemic than sham gerbils irrespective of treatment. Surprisingly, CA1 cell counts were significantly lower (P<0.01) in enriched versus non-enriched ischemic preconditioned animals. These data demonstrate that early, intensive intervention after ischemia can improve functional outcome but that this is accompanied by increased brain damage. Careful consideration needs to be given to the timing of rehabilitation after stroke and related types of brain injury.

Brain site variations in effects of morphine on electrical self-stimulation

Pairs of bipolar electrodes were stereotaxically aimed at two of three sites: the locus coeruleus (LC), the substantia nigra, pars compacta (SNC), and the median forebrain bundle (MFB). Rats were shaped to bar-press for trains of intracranial electrical stimulation presented as pairs of monophasic pulses. The first pulse of a pair (the C, conditioning pulse) was followed by a second pulse (the T, test pulse) after a parametrically varied interval. The effects of chronic morphine administration were tested in a paradigm of 7 days saline, 7 days morphine, 1 day morphine+naloxone, and 6 days post-drug saline. High doses of morphine (5 mg/kg) depressed response rates for intracranial self-stimulation (ICSS). LC placements and those just lateral or ventral to the LC showed large increases in ICSS rates under morphine (2.5 mg/kg). This area was delimited on either side by tips that showed response rate depressions under morphine. MFB placements yielded response rate facilitations under morphine. Sites medial to the MFB and ventral within the MFB showed rate depressions under morphine. Dorsal substantia nigra placements showed facilitated rates, whereas placements ventral within the SNC and substantia nigra, pars reticulata (SNR) produced more variable results, with rates tending to be depressed by morphine. The ICSS procedure may be a useful animal model for detecting the abuse potential of drugs.