A systematic review of the relationship between housing environmental factors and bovine respiratory disease in preweaned calves - Part 1: Ammonia, air microbial count, particulate matter and endotoxins

Bovine respiratory disease (BRD) is one of the leading causes of mortality and morbidity in calves across diverse management systems. Despite expert opinion often citing the influence of housing environment on the level of respiratory disease in calf groups, there have been few reviews of environmental factors that predispose to BRD. This systematic review was undertaken to identify the measurable environmental variables associated with respiratory disease in housed preweaned calves. To achieve this Pubmed, CAB Direct and Scopus databases were searched. To be considered for inclusion, publications had to be fully published in English, published before 24 November, 2022 and include at least one measurable/ manipulated environmental variable and a standardized method of BRD detection. Twelve publications were included in this review. These examined a wide range of risk factors including air microbial count (four publications), air particulate matter (one publication); air endotoxins (one publication) and air ammonia (four publications). From the included publications, a statistically significant relationship to BRD was identified in 2/4 examining air microbial count, 1/1 examining air particulate matter, 1/1 examining air endotoxins and 2/4 examining air ammonia. This review indicated a paucity of evidence from the peer-review literature demonstrating a significant association between the many investigated exposure factors and BRD occurrence. An optimal environment for housed calves could not be clearly identified in this review.

A systematic review of the relationship between housing environmental factors and bovine respiratory disease in preweaned calves - Part 2: Temperature, relative humidity and bedding

Bovine respiratory disease (BRD) is a challenge in all housed farming systems that raise calves. Farm to farm variation in BRD prevalence can be partially attributed to variation in host immunity, pathogens and housing environment. Unlike host immunity and BRD pathogens, housing environment has not been well investigated. The objective of this systematic review was to identify the measurable environmental variables associated with BRD in housed preweaned calves. Pubmed, CAB Direct and Scopus databases were searched. To be considered for inclusion publications had to be published in English, before 24 November, 2022 and include at least one measurable/ manipulated environmental variable and a standardized method of BRD detection. In total 12 publications were included in this review. In this second part of the systematic review the environmental variables identified were; temperature (9 publications); relative humidity (8 publications); bedding (5 publications); ventilation (1 publication); air CO2 concentration (1 publication) and air velocity (4 publications). Of the publications that were examined a statistically significant relationship to BRD was identified in 4/9 publications examining temperature, 3/8 examining relative humidity, 2/4 examining air velocity, 2/5 examining bedding, 0/1 examining ventilation rates and 0/1 examining CO2 concentration. From this review it is clear high airspeed at calf level should be avoided as should deep, wet pack bedding. The relationship between BRD prevalence and both high and low temperature requires more investigation to identify temperature thresholds associated with increased risk of BRD as well as the most influential modifiers. An optimal environment for housed calves could not be clearly identified in this review.

Does Inclusion of Emergency Medicine (EM) Residents in ECG Screening for STEMI Change the Time to Catheterization Lab Activation?

BACKGROUND

Emergency medicine physicians must rapidly obtain and interpret an electrocardiogram (ECG) to quickly identify life-threatening cardiac emergencies such as ST-elevation myocardial infarction (STEMI). Although ECG interpretation is a critical component of residency education, few high-powered studies exploring the accuracy of resident ECG interpretation exist.

OBJECTIVES

This study aims to evaluate whether or not the inclusion of Third Year Emergency Medicine Resident ECG interpretations is noninferior to attending-only ECG interpretations in regard to time to STEMI activation.

METHODS

This was a retrospective noninferiority study of STEMI activation times before and after the inclusion of Third Year Emergency Medicine Resident resident ECG interpretations into the workflow at an academic, urban tertiary care center between November 2020 and April 2022, excluding prehospital activations. The primary outcome was the proportion of successful STEMI activations initiated within 5 minutes of ECG completion. An absolute decrease of 10% between groups was chosen as the noninferiority margin.

RESULTS

In the attending-only group, 26 (66.7%) cases resulted in successful STEMI activations compared to 31 cases (77.5%) in the combined group. The proportion of successful STEMI activations did not differ with resident screening, X 2 = 1.15, P = 0.28. The absolute difference between groups' successful activations was an increase of 11%, which lies within the noninferiority margin (+11%, 95% confidence interval, -8.68% to 30.7%). Average times to STEMI activation in the attending-only and combined groups were 7.59 minutes (Standard Deviation [SD], 10.19) and 5.13 minutes (SD, 6.95), respectively. Average door-to-balloon times for those undergoing Percutaneous Coronary Intervention were 72.74 minutes (SD, 20.76) in the attending-only group and 89.90 minutes (SD, 67.74) in the combination group. Two sample t-test showed no statistically significant difference between the 2 groups for average time to STEMI activation (difference = 2.46 minutes, 95% CI, -1.46 to 6.38) and average door-to-balloon time (difference = 17.16, 95% CI, -39.73 to 5.41).

CONCLUSION

The inclusion of emergency medicine PGY-3 residents in the ECG screening workflow is noninferior to attending-only interpretation of ECGs with regard to STEMI activation time.

Stability of a delayed SARS-CoV-2 reactivation model with logistic growth and adaptive immune response

This paper develops and analyzes a SARS-CoV-2 dynamics model with logistic growth of healthy epithelial cells, CTL immune and humoral (antibody) immune responses. The model is incorporated with four mixed (distributed/discrete) time delays, delay in the formation of latent infected epithelial cells, delay in the formation of active infected epithelial cells, delay in the activation of latent infected epithelial cells, and maturation delay of new SARS-CoV-2 particles. We establish that the model's solutions are non-negative and ultimately bounded. We deduce that the model has five steady states and their existence and stability are perfectly determined by four threshold parameters. We study the global stability of the model's steady states using Lyapunov method. The analytical results are enhanced by numerical simulations. The impact of intracellular time delays on the dynamical behavior of the SARS-CoV-2 is addressed. We noted that increasing the time delay period can suppress the viral replication and control the infection. This could be helpful to create new drugs that extend the delay time period.

Pubertal consumption of R. badensis subspecies acadiensis modulates LPS-induced immune responses and gut microbiome dysbiosis in a sex-specific manner

Puberty is a critical period of development characterized by significant brain remodeling and increased vulnerability to immune challenges. Exposure to an immune challenge such as LPS during puberty can result in inflammation and gut dysbiosis which may lead to altered brain functioning and psychiatric illnesses later in life. However, treatment with probiotics during puberty has been found to mitigate LPS-induced peripheral and central inflammation, prevent LPS-induced changes to the gut microbiota and protect against enduring behavioural disorders in a sex-specific manner. Recent findings from our laboratory revealed that pubertal R. badensis subspecies acadiensis (R. badensis subsp. acadiensis) treatment prevents LPS-induced depression-like behavior and alterations in 5HT1A receptor expression in a sex-specific manner. However, the underlying mechanism remains unclear. Thus, the aim of this study was to gain mechanistic insights and to investigate the ability of R. badensis subsp. acadiensis consumption during puberty to mitigate the effects of LPS treatment on the immune system and the gut microbiome. Our results revealed that pubertal treatment with R. badensis subsp. acadiensis reduced sickness behaviors in females more than males in a time-specific manner. It also mitigated LPS-induced increases in pro-inflammatory cytokines in the blood and in TNFα mRNA expression in the prefrontal cortex and the hippocampus of female mice. There were sex-dependent differences in microbiome composition that persisted after LPS injection or R. badensis subsp. acadiensis consumption. R. badensis subsp. acadiensis had greater impact on the microbiota of male mice but female microbiota's were more responsive to LPS treatment. This suggested that female mice microbiota's may be more prone to modulation by this probiotic. These findings emphasize the sex-specific effects of probiotic use during puberty on the structure of the gut microbiome and the immune system and highlight the critical role of gut colonization with probiotics during adolescence on immunomodulation and prevention of the enduring effects of infections.

Health services access, utilization, and barriers for Arabic-speaking refugees resettled in Connecticut, USA

BACKGROUND

Arabic-speaking refugees are the largest group of refugees arriving in the United States since 2008, yet little is known about their rates of healthcare access, utilization, and satisfaction after the end of the Refugee Medical Assistance (RMA) period.

METHODS

This study was a cross-sectional observational study. From January to December 2019, a household survey was conducted of newly arrived Arabic-speaking refugees in Connecticut between 2016 and 2018. Households were interviewed in Arabic either in person or over the phone by one of five researchers. Descriptive statistics were generated for information collected on demographics, prevalence of chronic conditions, patterns of health seeking behavior, insurance status and patient satisfaction using the Patient Satisfaction Questionnaire (PSQ-18).

RESULTS

Sixty-five households responded to the survey representing 295 Arabic-speaking refugees - of which 141 (48%) were children. Forty-seven households (72%) reported 142 chronic medical conditions among 295 individuals, 62 persons (21%) needed daily medication, 285 (97%) persons were insured. Median patient satisfaction was > 4.0 out of 5 for 6 of 7 domains of the PSQ-18 but wide variation (scores from 1.0 - 5.0).

CONCLUSION

Arabic-speaking refugees in Connecticut participating in this study were young. The majority remained insured after their Refugee Medical Assistance lapsed. They expressed median high satisfaction with health services but with wide variation. Inaccessibility of health services in Arabic and difficulty obtaining medications remain areas in need of improvement.

The socioeconomic impact of multiple sclerosis in France: Results from the PETALS study

Background

Multiple sclerosis (MS) places a considerable financial burden on the society. However, data quantifying the contemporary cost burden in France are lacking.

Objective

This cost-of-illness study aimed to estimate the direct and indirect costs associated with MS in France.

Methods

Between October 2020-November 2020, 208 French adults with a confirmed diagnosis of MS were recruited via MSCopilot^® (a new MS self-assessment digital solution) and several MS patient networks. Indirect costs were estimated using a combination of top-down and bottom-up approaches. Direct costs were retrieved from Assurance Maladie (i.e. national system of health insurance) publications. Out-of-pocket expenses (OOPEs) incurred by MS patients were also reported. All costs were expressed in €2020. Data from the survey were extrapolated to the overall French MS population.

Results

MS exerted an annual cost burden of €2.7 billion on the French society (indirect costs: €1.3 billion; direct costs: €1.4 billion). Mean annual costs were €27,164.7 per-patient, with indirect and direct costs accounting for 48.1% and 51.9% of the total annual costs, respectively. OOPEs contributed over €90 million to the total annual costs.

Conclusions

MS imposes a substantial cost burden on the French society, with approximately half of the total annual costs driven by indirect costs.

Ventricular mechanics in adolescents with Fontan circulation: comparison to healthy controls

Funding Acknowledgements

Type of funding sources: None.

Background

While preserved torsion was demonstrated in very young patients with single ventricle (SV) physiology immediately post Fontan completion, there is very limited data about the changes in univentricular mechanics during adolescence and its association with outcomes.

Objective

We aimed to a) examine changes in ventricular strain and torsion in adolescents and young adults with SV in comparison to healthy controls, and b. examine its association with markers of myocardial fibrosis on cardiac magnetic resonance (CMR).

Methods

This is a retrospective single center study of adolescents with Fontan circulation in comparison with controls. Speckle-tracking echocardiography was used to assess ventricular strain, torsion, and untwist. Torsion was measured as difference between apical and basal rotations. CMR volumetric and T1 relaxometry data closest to echocardiograms were obtained. Patients were compared to controls in 1:2 match.

Results

50 SV patients (27 LV, 17 RV, and 6 co-dominant) were compared to 100 controls. Demographics, echocardiographic, and CMR measurements are shown in table 1. Median duration from Fontan completion was 13.8 (10.6-16.6) years. Compared to controls, adolescents with SV demonstrated reduced global longitudinal strain [-17.1% (-7.4 to -20.1) vs -20.1%(-12.3 to -24.5), p = 0.01], circumferential strain [-15.2% (-9.1 to – 20.3) vs -19.2% (-12.3 to -23.7), p = 0.007], and radial strain

[25.2% (15.8 to 54.3) vs 39.4% (25.7 to 62.1), p = 0.01].  Torsion was reduced in patients compared to controls [5.2˚/cm (-4.5 to 16.1) vs 9.2˚/cm (-6.8 to 17.4) vs, p = 0.01] with decreased apical rotation [3.9˚/cm (-10.2 to 14.8) vs 5.7˚/cm (1.6 to 15.6), p = 0.001] and basal rotation [-1.5˚/cm (-7.5 to 3.7) vs -3.9˚/cm (-0.3 to -8.5), p = 0.04], respectively. T1 values were higher in SV patients compared to controls [1009 ± 36ms vs 958 ± 40ms, p = 0.004] and correlated with worse circumferential strain (r = 0.59, p = 0.04) and inversely correlated with torsion (r=−0.71, p = 0.02).

Conclusion

Adolescents with SV demonstrated a significant decrease in ventricular torsion compared to controls. The increased T1 times and its association with decreased ventricular strain and torsion in SV patients highlights a potential role for myocardial fibrosis in impairment of ventricular mechanics of these patients. Abstract Figure.

Prenatal diagnosis of vascular ring: evaluation of fetal diagnosis and postnatal outcomes

Funding Acknowledgements

Type of funding sources: None.

Background

The performance of fetal echocardiogram in diagnosing vascular ring (VR) and its impact on postnatal outcomes has not been well examined.

Methods

We reviewed all patients with VR diagnosis from 2000-2020.

Results

50 patients with antenatal diagnosis of VR; 42(84%) with right aortic arch aberrant left subclavian artery and left-sided ductus arteriosus ((RAA-ALS) and 8(16%) with double aortic arch (DAA) were compared to 120 patients with postnatal diagnosis; 90(75%) with DAA, 22(18%) with RAA-ALS (Table 1). Prenatal diagnosis of VR increased over study period; 4 vs 31, 10 vs 29, 14 vs 25, 22 vs 35 between 2000-2005, 2005-2010, 2010-2015, and 2015-2020 respectively, p< 0.01. Prenatal diagnosis of VR was associated with less symptoms [26(52%) vs 72(60%), p < 0.003] and less cross-sectional imaging [22(44%) vs 82(69%), p = 0.0001]. Postnatal diagnosis of VR was associated with more surgical interventions (102(85%) vs 28(56%), p = 0.002), later surgical repair (22.9 ± 35 vs 12.6 ± 10.2 months, p < 0.01), more postoperative complications [8/102 (7.8%) vs 1/28 (3.5%), p = 0.04] and more residual symptoms (2/28(7%) vs 30/102(29%), p = 0.001 respectively].

Conclusion

Prenatal diagnosis of VR has evolved over time. RAA-ALS versus DAA were dominant in the prenatally and postnatally diagnosed cohorts respectively. Prenatal diagnosis of VR was associated less symptoms, less cross-sectional imaging, earlier age of surgical intervention and less residual symptoms.

Table 1 Prenatal Diagnosis (N = 50) Postnatal Diagnosis (N = 120) p-value Gestational Age (weeks) 39 ± 3 38 ± 2 0.9 Male (%) 31 (62%) 69(58%) 0.8 Subtype of vascular ring: Double aortic arch RAA-ALSA Others 8 (16%) 42 (80 %) 0 (0 %) 90 (72%) 22 (17%) 8 (11%) 0.002 0.01 Associated intracardiac CHD: VSD TOF DORV AVSD Coarctation of aorta Others 11 (22%) 1 1 3 0 3 3 24 (20%) 5 7 2 2 3 5 0.8 Associated genetic diagnosis: 22q11 deletion Trisomy 21 Others 9 (18%) 6 3 0 32 (26%) 29 3 0 0.1 Symptomatic presentation: Respiratory Gastrointestinal 26 (52 %) 15 11 72 (60 %) 57 15 <0.03 Age at first symptoms (month) 3.2 ± 2.8 21.6 ± 37 0.01 Diagnostic modalities: Fetal echocardiogram Postnatal echocardiogram Barium swallow Bronchoscopy CT scan MRI 50 (100%) 50 (100%) 2 (4%) 3 (6%) 18 (36 %) 4 (8%) 0 (0%) 120 (100%) 23 (25 %) 18 (15 %) 65 (54%) 7 (14%) Surgical repair 28 (56%) 102 (85%) 0.02 Age at surgical repair (month) 12.6 ± 10.2 22.9 ± 35 <0.01 Postoperative complications 1 (3%) 8 (7%) 0.03 Residual symptoms 2 (1%) 30 (25%) 0.001 Age at most recent follow up (mo) 26 ± 7 60 ± 7 0.02 Table 1: Comparison of patients with prenatal versus postnatal diagnosis of vascular ring

The Pivotal Role Of Coconut Oil Or Liquid Paraffin As Antidote Effective In Reducing Acute Aluminum Phosphide Poisoning In Cardiogenic Shock

Introduction/Objective

Aluminum phosphide (Alp) is a self-poisoning agent for raising the mortality rates in developing countries. Alp is known as “Rice-tablet” which is a cheap solid fumigant pesticide that is used for grain preservation which becomes a common mode of suicidal attempts in the rural community in Egypt. This study aims to identify the mechanism of salient features and management strategies were carried out on acute Alp-poisoned patients at Poison-Emergency-Unit, ElBehira-Hospitals. That was performed between Jan2018-Jun2019.

Methods

Patients were subjected to a full history evaluation of age, sex, Blood gases, and ECG, were demonstrated. Patients were grouped according to their outcome into survivors and non-survivors groups.

Results

The results demonstrated that (93%) of Alp-poisoning cases by oral-ingestion as suicidal attempts which were (54%) survived while (46%) non-survived. The blood-gases were showed that over 50% of the cases had metabolic acidosis with a highly-significant difference between survivors and non-survivors. PH and HCO3 values were significantly lower in non-survivors than those in the survivor group. Furthermore, SaO2 value was significantly higher in survivors than that of non-survivors. So the managing Alp-poisoning should be started for first 6hr since exposure. Treatment includes early gastric lavage with potassium-permanganate-(1:10,000), sodium-bicarbonate or coconut-oil/liquid-paraffin. The mechanism of Alp-poisoning explained that, phosphine gas inhibits 70% of mitochondrial cytochrome-c-oxidase in myocardial-tissue by the effect of free-radicals; electrolyte disturbance, and intracellular acidosis all cause a reduction in cardiac function, and multi-organ damage. These effects may cause arrhythmia and myocarditis which may be the cause of death.

Conclusion

It was concluded that myocardial depression with shock and metabolic acidosis may lead to respiratory failure due to acute Alp-poisoning. This case study reported that coconut oil play a pivotal role in managing acute Alp- poisoning even 6h post ingestion for reducing the oxidative outcomes of phosphine and recommended as antidote for acute Alp-intoxication.

Laparoscopic versus open ventral hernia repair in the elderly: a propensity score-matched analysis

BACKGROUND

Ventral hernia repair is common in the expanding aging population, but remains challenging due to their frequent comorbidities. The purpose of this study is to compare the surgical outcomes of open vs. laparoscopic ventral hernia repair in elderly patients.

METHODS

Patients ≥ 65 years of age that underwent elective open or laparoscopic ventral hernia repair were identified from the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database. To reduce potential selection bias, propensity scores were created for the likelihood of undergoing laparoscopic surgery based on patients' demographics and comorbidities. Patients were matched based on the logit of the propensity scores. Thirty-day surgical outcomes were compared after matching using Chi-square test for categorical variables and the Wilcoxon Rank-Sum test for continuous variables.

RESULTS

35,079 (71.1%) and 14,270 (28.9%) patients underwent open and laparoscopic ventral hernia repairs, respectively. Laparoscopic surgery was associated with a lower overall morbidity (5.9% vs. 9.1%; p < 0.001) compared to open repair. The incidence of surgical site infections (1.1% vs. 3.5%; p < 0.001), post-operative infections (2.7% vs. 3.6%; p < 0.001), and reoperation (1.7% vs. 2.1%; p = 0.009) were all lower after laparoscopic repair. All other major surgical outcomes were either better with laparoscopy or comparable between both treatment groups except for operative time.

CONCLUSION

Although open surgery remains the most prevalent in the elderly population, the results of this study suggest that laparoscopic surgery is safe and associated with a lower risk of overall morbidity, surgical site infections, and reoperation.

AB1146 REAL-LIFE PRACTICES IN MANAGEMENT OF REPRODUCTIVE HEALTH IN SLE AND APS BY OBSTETRICIANS AND RHEUMATOLOGISTS IN EGYPT. (AN ONLINE-BASED QUESTIONNAIRE)

Background:

Systemic lupus erythematosus (SLE) is an auto-immune disease that affect women in their reproductive age. Antiphospholipid syndrome (APS) is a hypercoagulable immune disease that occur as a primary condition or in assosiation with SLE.

The reproductive aspects as contraception, fertility, pregnancy are crucial to consider for proper management of SLE/APS.

Addressing these issues require collaboration between rheumatologists and obstetricians, improving their knowledge and ensuring that both are acquainted with the updated guidelines.

Objectives:

To assess the knowledge and practice of Egyptian obstetricians and rheumatologists in management of reproductive health issues in SLE and APS, and to detect common misconceptions.

Methods:

This research was conducted via google form online survey based on points discussed in EULAR recommendations for women’s health and the management of family planning, assisted reproduction, pregnancy and menopause in patients with SLE and/or APS.1It was sent to target obstetricians and rheumatologists by internet clouds like (Facebook, twitter, LinkedIn) from August to November 2019. It included five domains; demographic data, general knowledge and attitudes about pregnancy in SLE and APS, contraception, drugs, and assisted reproductive techniques (ART)

After submitting answers, respondents were shown a link directing them to the 2016 EULAR recommendations.1

Results:

This study was conducted on 254 physicians, 62% obstetricians and 38% rheumatologists. 64.6% were between the ages of 30-35 years.

For general knowledge, 52% of Obstetricians considered pregnancy in inactive SLE to be risky. (79.4%vs54.1%) of (rheumatologists and obstetricians) respectively test for aPL in SLE patients. More than 70% in both groups were well informed on the increased rate of fetal and maternal complications in both SLE and APS.

For fetal surveillance, 87% and 90% of obstetricians preformed first and second trimester U/S, and 79% preformed second trimester Doppler.

For contraception, (57.7%vs56.7%) discuss contraceptive choices with their patients. The majority considered it safe to use IUDs (73.9%vs76%) and condoms (84.7vs85.4%) in both SLE and APS patients. On the other hand, for hormonal contraception- Levonorgestrol IUD, Depoprovera, COCP, and POP- only 14.6%, 22.9%, 26.1%, 24.8% of rheumatologists and 18.5%, 27.2%, 29.9%, 26.8% of obstetricians considered them unsafe to use in APS.

Concerning treatment, the majority considered low dose presnidone to be safe during pregnancy (94.8 %vs80%) and breastfeeding (87.6%vs64.3%). The majority also agreed on avoidance of Methotrexate (94.8%vs84.1%) and Cyclophosphamide (89.7%vs66.2%). However, regarding Hydroxychloroquine and Azathioprine use in pregnancy there was a significant discrepancy between rheumatologists and obstetricians, (89.7 %vs42%) and (78.4%vs36.9%) believed them safe to use in pregnancy. For Mycophenolate Mofetil, (80.4%vs46.5%) said that it should be avoided in pregnancy. Regarding ART (45.4%vs71%) considered it safe to use in stable SLE/APS.

Conclusion:

The gaps in knowledge identified include the use of hormonal contraception in APS patients and the proper utilization of important medications to prevent and treat lupus flares. Initiation of shared Rheumatology/ obstetric clinics and focusing on the identified educational topics, would lessen the gap in knowledge and discrepancies in practice improve overall patient management.

References:

[1]Andreoli L et al. Ann Rheum Dis. 2017;76(3):476-85.

Disclosure of Interests:

None declared

P1488 Anomalous origin of left coronary artery from right pulmonary artery in association with scimitar syndrome

Clinical Presentation

A full-term neonate was referred to our institution because of respiratory distress. CXR was significant for right lung hypoplasia and mild cardiomegaly. ECG showed normal sinus rhythm, right atrial enlargement, and right ventricular hypertrophy with no signs of ischemia.

Imaging Findings

The initial echocardiogram demonstrated PAPVD with the right upper pulmonary vein draining into IVC/RA junction with flow acceleration (mean gradient= 7 mmHg), moderate ASD, small muscular VSD with left-right shunting, moderate PDA with bidirectional shunting. Forward flow was seen in the proximal part of left main coronary artery (LMCA). RV systolic pressure was supra-systemic with a qualitatively moderately reduced RV systolic function.

The patient was taken to the catheterization lab where MPA angiography revealed an antegrade flow from the RPA into LMCA supplying both the anterior descending and the circumflex arteries. A selective injection within the scimitar vein showed drainage of the right lung into a vertical vein connecting with stenosis to IVC.

A follow up echocardiogram to re-examine the coronary origin revealed an anomalous origin of LMCA from proximal RPA; 3 mm distal to branch pulmonary artery bifurcation with mainly antegrade low velocity flow into LMCA and LAD. (Image 1)

Role of Imaging in Patient Care

- Imaging of the coronary origin in patients with ALCAPA can be challenging especially if the LMCA originates from RPA. Also, the presence of pulmonary hypertension might contribute to maintain coronary perfusion and lead to misinterpretation of the antegrade flow in LMCA and its branches.

- In certain situations, cardiac catheterization is essential to make the diagnosis of ALCAPA which prevented a potentially catastrophic outcome. Catheter intervention with a series of balloon dilations of the stenotic scimitar vein was successful in relieving the stenosis.

Summary/Discussion Points:

- Extensive review of the available literature revealed only three cases of Scimitar syndrome associated with ALCAPA. In all of these cases, the LMCA originated from the posterior sinus of MPA. Our case is the first to report ALCAPA from RPA in association with Scimitar syndrome. This presentation might have led to the initial misinterpretation of the echocardiography images.

- The presence of pulmonary hypertension in our patient maintained an adequate antegrade flow across the LMCA preventing significant coronary steal and signs of myocardial ischemia.

- The report highlights the challenges in making the diagnosis of ALCAPA with echocardiograms. Moreover, we discuss the role of cross-sectional and invasive imaging to rule out potential coronary arteries anomalies in patients with Scimitar syndrome, as this a rare although a very significant association that may have important implications in their outcomes.

Abstract P1488 Figure. ALCAPA origin from RPA

Gut microbiota density influences host physiology and is shaped by host and microbial factors

To identify factors that regulate gut microbiota density and the impact of varied microbiota density on health, we assayed this fundamental ecosystem property in fecal samples across mammals, human disease, and therapeutic interventions. Physiologic features of the host (carrying capacity) and the fitness of the gut microbiota shape microbiota density. Therapeutic manipulation of microbiota density in mice altered host metabolic and immune homeostasis. In humans, gut microbiota density was reduced in Crohn's disease, ulcerative colitis, and ileal pouch-anal anastomosis. The gut microbiota in recurrent Clostridium difficile infection had lower density and reduced fitness that were restored by fecal microbiota transplantation. Understanding the interplay between microbiota and disease in terms of microbiota density, host carrying capacity, and microbiota fitness provide new insights into microbiome structure and microbiome targeted therapeutics.

Editorial note

This article has been through an editorial process in which the authors decide how to respond to the issues raised during peer review. The Reviewing Editor's assessment is that all the issues have been addressed (see decision letter).

Breast and Cervical Cancer Screening among US and non US Born African American Muslim Women in New York City

PURPOSE

Health disparities related to breast and cervical cancer among African American and African-born Muslim women in the United States have been identified in previous literature. Our study aimed at exploring the breast and cervical screening rates and factors that influence this population's disposition to adhere to cancer screening exams.

METHODS

Mixed methods were used to collect data with African American and African-born Muslim women in New York City. Data were collected from a total of 140 women; among them, 40 participated in four focus groups.

FINDINGS

Focus groups revealed nine themes: healthcare practices; lack of knowledge/misconceptions; negative perceptions and fear; time; modesty; role of religion; role of men; role of community; stigma and shame. Among 130 women who reported their cancer screening status, 72.3% of those age 21 and over were adherent to cervical cancer screening; 20.0% never had a Pap test. Among women age 40 and over, 80.2% reported adherence to recommended mammogram; 12.8% never had one. Among women under age 40, 52.2% had their last clinical breast exam (CBE) less than three years ago. Among women age 40 and over, 75.0% were adherent to yearly CBE.

CONCLUSIONS

While rates of screenings were above the national average and higher than expected, specific barriers and facilitators related to religious and health beliefs and attitudes that influence the decision to adhere to screening were revealed. These factors should be further explored and addressed to inform future research and strategies for promoting regular breast and cervical cancer screenings.

Primary retroperitoneal mucinous cystadenoma-A case study and review of the literature

INTRODUCTION

Primary retroperitoneal tumours of mucinous type are extremely rare and can be further sub-divided into benign, borderline or cystadenocarcinoma. Prompt diagnosis of retroperitoneal tumours is important as the majority are malignant.

PRESENTATION OF CASE

Our case describes a 30year old woman, presenting with a 3month history of intermittent right iliac fossa pain. Abdominal examination demonstrated a mass palpable in the right iliac fossa. Ultrasonography of the abdomen demonstrated a cystic mass with a magnetic resonance imaging (MRI) scan of the pelvis further defining the lesion. Laparoscopy was performed to further evaluate and ultimately remove the retroperitoneal mass. Macroscopic and microscopic examination reported mucinous epithelium of endocervical type with no evidence of invasion. Findings were consistent with primary retroperitoneal mucinous cystadenoma.

DISCUSSION

This is the 19th reported case of a benign primary retroperitoneal mucinous cystadenoma in the English literature. The origin of mucinous cystadenomas in the retroperitoneum is widely debated with multiple theories suggested. Diagnosis of retroperitoneal tumours is important but difficult as serological investigations, ultrasonography, computed topography and magnetic resonance imaging, although useful, cannot allow a confident diagnosis.

CONCLUSION

Primary retroperitoneal mucinous cystadenoma is a benign tumour, however because of the malignant nature of the majority of mucinous retroperitoneal tumours they should be considered in the differential of chronic abdominal pain despite their rarity.

Spatial distribution of bacterial colonies in a model cheese

In most ripened cheeses, bacteria are responsible for the ripening process. Immobilized in the cheese matrix, they grow as colonies. Therefore, their distribution as well as the distance between them are of major importance for ripening steps since metabolites diffuse within the cheese matrix. No data are available to date about the spatial distribution of bacterial colonies in cheese. This is the first study to model the distribution of bacterial colonies in a food-type matrix using nondestructive techniques. We compared (i) the mean theoretical three-dimensional (3D) distances between colonies calculated on the basis of inoculation levels and considering colony distribution to be random and (ii) experimental measurements using confocal microscopy photographs of fluorescent colonies of a Lactococcus lactis strain producing green fluorescent protein (GFP) inoculated, at different levels, into a model cheese made by ultrafiltration (UF). Enumerations showed that the final numbers of cells were identical whatever the inoculation level (10(4) to 10(7) CFU/g). Bacterial colonies were shown to be randomly distributed, fitting Poisson's model. The initial inoculation level strongly influenced the mean distances between colonies (from 25 μm to 250 μm) and also their mean diameters. The lower the inoculation level, the larger the colonies were and the further away from each other. Multiplying the inoculation level by 50 multiplied the interfacial area of exchange with the cheese matrix by 7 for the same cell biomass. We finally suggested that final cell numbers should be discussed together with inoculation levels to take into account the distribution and, consequently, the interfacial area of colonies, which can have a significant influence on the cheese-ripening process on a microscopic scale.

Interferon-gamma-dependent mechanisms of mycobacteria-induced pulmonary immunopathology: the role of angiostasis and CXCR3-targeted chemokines for granuloma necrosis

The mechanisms leading to granuloma caseation, a hallmark of tuberculosis (TB) in humans, are poorly understood. Lung histopathology of C57BL/6 (WT) mice 16 weeks after aerosol infection with Mycobacterium avium strain TMC724 is uniquely characterized by centrally necrotizing granulomas, strongly resembling human TB lesions. However, IFN-gamma-deficient (GKO) and IFN-gamma-receptor-deficient (GRKO) mice did not develop granuloma necrosis following M. avium infection. Comparison of differentially expressed genes in infected WT and GKO lungs by DNA microarray and RNase protection assays revealed that the angiostatic chemokines CXCL9-11 were significantly reduced in GKO mice. In contrast, angiogenic mediators such as angiopoietin and vascular endothelial growth factor, and angiogenic chemokines such as CXCL2, CCL3, and CCL4, remained unchanged or were expressed at higher levels than in infected WT mice, suggesting impaired neovascularization of the granuloma as a possible mechanism for caseation in WT mice. Granuloma vascularization was significantly decreased in central, but not peripheral, areas of granulomas of infected WT compared to GKO mice. In contrast to GRKO mice, WT mice showed signs of severe hypoxia in cells immediately surrounding the necrotic core of granulomas as measured immunohistochemically with a reagent detecting pimonidazole adducts. To test the hypothesis that CXCR3, the common receptor for the angiostatic chemokines CXCL9-11, is involved in granuloma caseation, histomorphology was assessed in M. avium-infected mice deficient for CXCR3 (CXCR3-KO). 16 weeks after infection, these mice developed caseating granulomas similar to WT mice. We conclude that IFN-gamma causes a dysbalance between angiostatic and angiogenic mediators and a concomitant reduction in granuloma vascularization, but that CXCR3-targeted chemokines are not sufficient to induce granuloma necrosis in a mouse model of mycobacteria-induced immunopathology.

Oxygen status of lung granulomas in Mycobacterium tuberculosis-infected mice

It is often assumed that Mycobacterium tuberculosis (Mtb)-induced granulomatous lesions, particularly those undergoing central caseation, are anoxic, and that the survival of Mtb in these lesions requires the integrity of its non-oxidative respiratory pathways. Using the hypoxia marker pimonidazole, we now provide immunohistochemical evidence that in the most frequently used animal model system of inbred mice Mtb-induced granulomas, even after more than one year of aerogenic infection, are not severely hypoxic. In contrast, chronic aerosol infection with M. avium strain TMC724 was associated with hypoxia surrounding necrotizing granuloma centres. Direct measurements of oxygen tension with a flexible microelectrode in mouse lungs chronically infected with Mtb disclosed a wide range of oxygen partial pressures in different parts of the lungs which, however, rarely approached the anoxic conditions consistently found in necrotizing tumours. We further show that an Mtb mutant, defective in nitrate reductase (narG) necessary for survival under anaerobic conditions in vitro, can persist in the lungs of chronically infected mice to a similar extent as wild-type Mtb. These findings have important implications for the use of the mouse model of Mtb infection in developing eradication chemotherapy and for evaluating putative mechanisms of chronic persistence and latency of Mtb.

Visceral nociceptive input to the area of the medullary lateral reticular nucleus ascends in the lateral spinal cord

In halothane-anesthetized rats, neurons stereotaxically located in the region of the medullary lateral reticular nucleus (LRN) and responsive to urinary bladder distension (UBD) were characterized using extracellular electrodes. Most neurons excited by UBD were also excited by noxious stimuli applied to bilateral receptive fields comprising at least half of the body surface. These bilateral nociceptive specific (bNS) neurons exhibited graded responses to graded intensities of UBD. Neuronal responses to noxious UBD were highly positively correlated with responses to noxious colorectal distension, suggesting a convergence of visceral sensory information in the area of LRN. Bilateral lateral mid-cervical spinal cord lesions virtually abolished activity of bNS neurons evoked by noxious UBD, while dorsal midline lesions had no significant effect. These data support a role for neurons in the region of the LRN in visceral nociception and implicate traditional lateral spinal cord pain pathways in the transmission of visceral information to caudal ventrolateral medullary structures.

Management of laparoscopic-related bowel injuries

BACKGROUND

Bowel injury is an uncommon but severely hazardous complication of various laparoscopic procedures.

METHODS

Twelve cases of bowel injuries complicating different laparoscopic procedures were diagnosed or received at Ain Shams University and Menofia University hospitals over the last 3 years. The mechanism of injury was analyzed, the diagnostic methods and surgical management scrutinized, and the prognosis studied.

RESULTS

The injuries were attributed to the inadvertant introduction of Veress needles or sharp-tipped trocars or forcible undue dissection. Failure of pneumoperitoneum was implicated in two cases. Faulty judgment of the extent and site of adhesions contributed to the damage in two cases. In four cases, the duodenum was injured. The colon was perforated in six cases, and the small bowel sustained damage in two cases. Three of the patients died, all of duodenal injury. The other nine patients survived by virtue of diagnosis and proper operative management.

CONCLUSION

Every measure should be taken to avoid the occurrence of bowel injury during laparoscopy. Intraoperative or early postoperative diagnosis and proper management of laparoscopic-induced bowel injuries can minimize morbidity and mortality and yield a better prognosis.

An objective characterization of atherosclerotic lesion: an alternative method to identify unstable plaque

BACKGROUND AND PURPOSE

The aim of this study was to evaluate a computer-assisted technique to characterize atherosclerotic plaque.

METHODS

In 9 subjects (7 men, 2 women; mean age 33 years), known anatomic areas (carotid, fat, muscle, iliotibial tract, and tibia) were scanned with an Acuson duplex ultrasound machine with 72 machine settings. The ultrasound images of these anatomic areas were recorded on magneto-optical disks. Echo amplitude statistics were obtained, and the mean pixel value (MPV) was used to assess the level of echogenicity. The ideal settings of this particular scanner for optimal discrimination between these tissues types were identified by the Heuristic Index of Discrimination. With these settings, carotid artery scanning was performed on 17 patients (15 men, 2 women; mean age 65 years), and the image analysis of their ultrasound carotid plaques was compared with their histological findings.

RESULTS

In this study, discrimination between the selected tissues was found to be optimal when the controls were set at log 40 dB, 0/2/0, and gain of -5 dB. The MPV of the carotid specimens scanned at this setting correlated significantly with the histological findings (Spearman correlation, P=0.002).

CONCLUSIONS

Computer-assisted image analysis to give the MPV is a technique that may be used to identify unstable atherosclerotic plaques reliably.

Feasibility of day case varicose vein surgery in a district general hospital

BACKGROUND

Day case surgery may reduce inpatient bed requirements, and varicose surgery may be an ideal operation to test the functioning of a day surgery service.

AIMS

To evaluate retrospectively the feasibility of day case varicose vein surgery in all-comers, and to identify the risk factors for admission.

METHODS

Over a three-year period from July 1995 to July 1998, all patients requiring varicose vein surgery had their procedure performed as a day case. A standard technique of sapheno-femoral ligation with below-knee stripping of the long saphenous vein and multiple stab avulsions of varicosities was performed. All limbs were dressed with wool in crepe bandage and were reviewed post-operatively at six weeks.

RESULTS

Five hundred and forty two patients underwent varicose vein surgery, of whom 26% had bilateral varicose veins, 88% had primary varicose veins and 22% had recurrent disease. The procedure was performed under general anaesthesia in 86% of cases and under spinal anaesthesia in the rest. There was no peri-operative mortality. Ten patients (1.9%) developed post-operative complications. Seventy two per cent of patients were discharged on the day of surgery, a further 25% required admission for one night due to minor anaesthetic complications and patient preference. Four per cent required admission for more than 24 hours. The need for overnight admission was associated with the age of the patients (p < 0.0001), bilateral varicose vein surgery (p < 0.005) and the use of spinal anaesthesia (p < 0.01).

CONCLUSION

Although varicose vein surgery is safe, acceptable and cost-effective as a day case procedure, if attempted in all-comers, overnight admission will be required in a significant proportion. Pre-operative selection is advised.

Inter-observer variation. An alternative method of assessing the role of ultrasonic imaging in clinical decision-making in lower limb arterial disease

BACKGROUND

The aim of the study is to determine the role of duplex scanning in deciding on the final treatment for patients with lower limb arterial disease compared to intra-arterial digital subtraction arteriography (IA DSA).

METHODS

Eighty-two patients (55 males, 27 females, mean age 68 years) with lower limb arterial disease had both duplex and arteriography performed. The findings of both modalities were reported by sonographer and radiologist in 164 anonymous reports. Five vascular surgeons (consultant grade) were asked to plan their treatment on the data provided in these reports. For the purposes of statistical analysis, the actual treatment the patient received was used as the reference standard. Both reports and treatment decisions were coded (double blinded).

RESULTS

The overall accuracy of duplex scanning to assess arterial disease of the lower limbs showed a sensitivity of 92%, and specificity of 99%. The accuracy of the decisions based on duplex was 84% and kappa with k of 0.62 (95% CI+0.14) compared to the reference standard, while the accuracy of the decision based on arteriography was 85% and kappa 0.63 (95% CI+0.14). The accuracy of decisions based on duplex compared to those based on arteriography (arteriography used as reference standard) was 91% and a kappa of 0.77 (95% CI+0.14).

CONCLUSIONS

Duplex scanning is an accurate diagnostic modality, and clinical decisions can be safely based on its findings.

Duplex scanning and effect of multisegmental arterial disease on its accuracy in lower limb arteries

AIM

To assess the accuracy of duplex in assessment of peripheral arterial disease and determine the effect of multisegmental disease on the accuracy duplex as opposed to single lesion.

PATIENTS AND METHODS

One hundred and seventy-seven lower limbs were examined in 90 patients who presented with lower limb arterial disease, (59 male, 31 female, median age 68 years--81 with intermittent claudication, eight rest pain, one ulceration). Patients were examined with duplex US, and arteriography (IA DSA). Two radiologists and two technologists were involved in this double-blind study. Patients were classified into five groups; groups with single stenotic lesions, single occlusions, multiple stenotic lesions or occlusions, and multiple mixed disease. Duplex accuracy was determined in each group.

RESULTS

Duplex was able to differentiate between normal and disease arterial segment with a sensitivity of 92%, specificity 99%, PPV 91%, and NPV 100% and Kappa 0.87. Sixty-six limbs were found to have single lesions, and 68 multisegmental disease. Duplex showed accuracy with a sensitivity of 87%, and specificity of 99%, for single stenotic lesion and 95%, 96% respectively for multisegmental. For single occlusions duplex accuracy showed sensitivity 92% and specificity 100%, and for multisegmental occlusions, sensitivity 97%, and specificity 99%. For mixed multisegmental pathology (stenosis and occlusion), sensitivity 94% and specificity 97%.

CONCLUSION

Duplex is an accurate tool in diagnosis of lower limb arterial disease and multisegmental pathology does not adversely effect this accuracy.

Comparison of duplex imaging and arteriography in the evaluation of lower limb arteries

BACKGROUND

The aim of this study was to assess the accuracy of duplex imaging, compared with arteriography, in detecting arterial disease distal to the renal arteries.

METHODS

Some 177 legs were studied in 90 patients (59 men, 31 women; median age 68 years) with peripheral arterial disease. Each patient had conventional intra-arterial angiography and duplex ultrasonography. Each leg was divided into 17 arterial segments, and the disease in each segment was quantified by measuring the peak systolic velocity ratio across any arterial lesion that was identified.

RESULTS

Compared with angiography, duplex imaging was able to detect arterial disease with an overall sensitivity of 92 per cent, specificity of 99 per cent, positive predictive value 91 per cent and negative predictive value 100 per cent, and with a kappa value of 0.87 (95 per cent confidence interval (c.i.) 0.81-0.93). Duplex was able to determine the length of the arterial lesion with a sensitivity of 89 per cent and a specificity of 98 per cent with a kappa value of 0.88 (95 per cent c.i. 0.86-0.90). When the surgeon's final management decision concerning each vascular lesion was used as the reference, duplex and arteriography were equivalent, with an accuracy of 84 per cent and 85 per cent respectively in identifying the management used.

CONCLUSION

Duplex ultrasonography is reliable in detecting arterial lesions in peripheral arteries and could be used routinely in the initial evaluation of patients with lower limb arterial disease.

Patch angioplasty following carotid endarterectomy using the ipsilateral superior thyroid artery

OBJECTIVES AND DESIGN

Synthetic and saphenous vein patches, when used in the carotid territory, are disadvantaged by complications. We tested the feasibility of using a locally harvested artery, the ipsilateral superior thyroid artery (STA), as a source of patching material following carotid endarterectomy (CEA).

MATERIALS AND METHODS

Twenty-two consecutive patients (15 male) with a median age of 70 (range 53-82) years underwent CEA with an intention to use the STA for patch angioplasty. The STA was harvested via a standard carotid incision and opened longitudinally to fashion a patch.

RESULTS

Of the 22 STAs harvested, only two were rejected due to small calibre. Mean harvesting time was 12 min and there were no immediate complications. Duplex scanning has not revealed restenosis (mean peak velocity = 0.78 [range 0.45-1.16] m/s) in any patient with a median follow-up of 13 (range 3-19) months.

CONCLUSIONS

This technique is quick, convenient and obviates many of the disadvantages associated with conventional patches. Follow-up has shown the technique to be both efficacious and durable in the medium term.