Approach to Acute Traumatic and Nontraumatic Diaphragmatic Abnormalities

Acute diaphragmatic abnormalities encompass a broad variety of relatively uncommon and underdiagnosed pathologic conditions, which can be subdivided into nontraumatic and traumatic entities. Nontraumatic abnormalities range from congenital hernia to spontaneous rupture, endometriosis-related disease, infection, paralysis, eventration, and thoracoabdominal fistula. Traumatic abnormalities comprise both blunt and penetrating injuries. Given the role of the diaphragm as the primary inspiratory muscle and the boundary dividing the thoracic and abdominal cavities, compromise to its integrity can yield devastating consequences. Yet, diagnosis can prove challenging, as symptoms may be vague and findings subtle. Imaging plays an essential role in investigation. Radiography is commonly used in emergency evaluation of a patient with a suspected thoracoabdominal process and may reveal evidence of diaphragmatic compromise, such as abdominal contents herniated into the thoracic cavity. CT is often superior, in particular when evaluating a trauma patient, as it allows rapid and more detailed evaluation and localization of pathologic conditions. Additional modalities including US, MRI, and scintigraphy may be required, depending on the clinical context. Developing a strong understanding of the acute pathologic conditions affecting the diaphragm and their characteristic imaging findings aids in efficient and accurate diagnosis. Additionally, understanding the appearance of diaphragmatic anatomy at imaging helps in differentiating acute pathologic conditions from normal variations. Ultimately, this knowledge guides management, which depends on the underlying cause, location, and severity of the abnormality, as well as patient factors. ©RSNA, 2024 Supplemental material is available for this article.

De novo urethral stricture disease in renal transplant recipients

INTRODUCTION

With routine catheterization and low urine output pre-transplant, renal transplant recipients (RTRs) may be at risk of urethral stricture disease post-transplant. The objective of this study was to characterize new urethral stricture disease in males following renal transplant.

METHODS

A retrospective chart review was carried out on all male RTRs at Vancouver General Hospital who developed urethral strictures from October 2009-2019. Descriptive analyses were conducted on patient characteristics. Comparative analyses against non-stricture RTRs were carried out.

RESULTS

Of 636 RTRs, 18 (2.8%) developed a postoperative urethral stricture. Median time from transplant to stricture discovery was 56 days (range 8-618 days). One-third of stricture patients had prior risk factors for stricture formation. Post-transplant, 77.8% presented symptomatically, with 61.1% requiring intervention. Overall graft survival rate was 88.9% among the RTR stricture group; 16.7% experienced acute rejection and 22.2% had delayed graft function (DGF). There was no significant association between developing postoperative urethral stricture and urinary tract infection (Chi-squared [X2]=0.04, p=0.84; odds ratio [OR ] 0.81, 95% confidence interval [CI] 0.1-6.21), DGF (X2=0.14, p=0.70; OR 0.8, CI 0.26-2.48), or acute rejection (X2=2.02, p=0.14; OR 2.55, CI 0.71-9.12).

CONCLUSIONS

De novo post-transplant urethral stricture rates appear to occur at a higher rate than the general population and contribute to patient morbidity. Stricture disease should be considered post-transplantation in patients with voiding dysfunction, even if they don't have prior risk factors. Multicenter studies should be considered to elucidate any relationship between urethral stricture and graft survival.

'I feel more part of the world': Participatory action research to develop post-diagnostic dementia support

Many people living with dementia are 'on the margins', not accessing services and support, despite policy and care advancements. The COVID-19 pandemic exacerbated this, with the closure of face-to-face support during lockdowns in the UK and globally. The aim of the 'Beyond the Margins' project was to develop, implement, and evaluate a face-face programme of support with, by and for people with direct experience of dementia who are on the margins of existing services and support. In March 2020 the project was interrupted by the outbreak of the COVID-19 pandemic and it changed to an online format. The three-phase participatory action research project included 40 people living with dementia, 26 care partners and 31 health and social care practitioners. A seven-week online personal development programme called Getting On with Life (GO) was developed, delivered, and evaluated. This paper focuses on the participatory approaches used to develop and implement the GO programme, and the resulting aspects of its approach to facilitation and content. Key features include the GO Programme's principles of providing a safe and a respectful space, and the programme's values of: Everyone who comes already knows things, can learn things and can teach things; Doing things 'with' each other, rather than 'for' or 'to' each other; Personalised goals-led by the needs of participants rather than an imposed agenda. A key finding was the importance of developing post-diagnostic programmes as a 'sandwich', providing a safe space for learning that is preceded by understanding pathways to access the programme and followed by explicit consideration of the next steps in increasing social engagement.

344 LONG-TERM OUTCOMES FOR HIP FRACTURE PATIENTS WHO HAVE RECEIVED A PERIOD OF INPATIENT REHABILITATION

Background

Twenty-eight percent of the 3,666 hip fractures reported by the Irish Hip Fracture Database (IHFD) in 2020 received a period of rehabilitation in an off-site facility nationally. Longer term outcomes for hip fracture patients are not yet included in the IHFD. This study aimed to describe recovery after hip fracture in patients admitted to a single inpatient rehabilitation facility.

Methods

Patients who experienced hip fracture between January 2020 and July 2020 were followed up for one year after their fracture. Baseline data was collected in relation to age, pre-fracture residence and New Mobility Score (NMS) and clinical frailty score. Residence, NMS and quality of life (EQ-5D-5L) were collected by a clinical physiotherapist at 30 days, 120 days and 1 year after hip fracture. Data was inputted and analysed using Microsoft Excel.

Results

Of 122 hip fracture patients admitted to rehabilitation,103 were followed up. The average age of patients was 79, 66% were female. The mortality rate was 9% (n=9) at 1 year follow up. Pre-fracture, n= 98 lived at home. Of these patients, 67%, 82% and 83% had returned home by 30 days, 120 days and 1 year. Pre-fracture 53% had high mobility levels (NMS>6). Of these patient 4%, 27% and 34% had returned to this level by 30 days, 120 and 1 year. 70% of patients had a low mobility score (0-6 on NMS) and 30 % had a high mobility score (7-9) at 1 year follow-up. 56% and 4% of patients reported no pain and severe pain at 1 year post op, respectively. 45% of patients had no issues performing their usual activities and 4% had severe issues/an inability to perform their usual activities at 1 year.

Conclusion

Our results show that recovery after hip fracture is slow with many not achieving baseline mobility or return to pre-fracture function within the first year.

Clinically relevant T cell expansion media activate distinct metabolic programs uncoupled from cellular function

Ex vivo expansion conditions used to generate T cells for immunotherapy are thought to adopt metabolic phenotypes that impede therapeutic efficacy in vivo. The comparison of five different culture media used for clinical T cell expansion revealed unique optima based on different output variables, including proliferation, differentiation, function, activation, and mitochondrial phenotypes. The extent of proliferation and function depended on the culture media rather than stimulation conditions. Moreover, the expanded T cell end products adapted their metabolism when switched to a different media formulation, as shown by glucose and glutamine uptake and patterns of glucose isotope labeling. However, adoption of these metabolic phenotypes was uncoupled to T cell function. Expanded T cell products cultured in ascites from ovarian cancer patients displayed suppressed mitochondrial activity and function irrespective of the ex vivo expansion media. Thus, ex vivo T cell expansion media have profound impacts on metabolism and function.

1-Methylnicotinamide is an immune regulatory metabolite in human ovarian cancer

Immune regulatory metabolites are key features of the tumor microenvironment (TME), yet with a few exceptions, their identities remain largely unknown. Here, we profiled tumor and T cells from tumor and ascites of patients with high-grade serous carcinoma (HGSC) to uncover the metabolomes of these distinct TME compartments. Cells within the ascites and tumor had pervasive metabolite differences, with a notable enrichment in 1-methylnicotinamide (MNA) in T cells infiltrating the tumor compared with ascites. Despite the elevated levels of MNA in T cells, the expression of nicotinamide N-methyltransferase, the enzyme that catalyzes the transfer of a methyl group from S-adenosylmethionine to nicotinamide, was restricted to fibroblasts and tumor cells. Functionally, MNA induces T cells to secrete the tumor-promoting cytokine tumor necrosis factor alpha. Thus, TME-derived MNA contributes to the immune modulation of T cells and represents a potential immunotherapy target to treat human cancer.

Multi-scale tissue architecture analysis of favorable-risk prostate cancer: Correlation with biochemical recurrence

Purpose

Prostate cancer (PCa) with biopsy-based grade group (GG) 1 or 2 characteristics has a favorable outcome, yet some cases still progress after radical prostatectomy and present with biochemical recurrence (BCR). We hypothesized that the multi-scale tissue architecture (MSTA) analysis score would correlate with the aggressive PCa phenotype and could be used as a tool for risk assessment to improve the management of patients with favorable-risk PCa.

Materials and Methods

MSTA was evaluated in needle-biopsy samples from 115 patients with favorable-risk PCa, as defined by GG1 and GG2, a prostate-specific antigen (PSA) level of <10 ng/mL, a clinical stage of cT1c to cT2b, and general Gleason GG (GGG) and expert pathologist-assessed GG (EGG). Algorithms based on Voronoi diagrams were applied to all Feulgen-thionin-stained diagnostic areas. One hundred tissue architecture features were calculated and an MSTA score, a linear combination of the most discriminant features, was generated. Correlation of MSTA score with BCR and other clinical variables was investigated.

Results

In a univariate regression model, EGG, clinical stage, and MSTA were significant predictors of BCR (respective p-values: 0.0016, 0.016, and 0.028). Survival analysis showed that patients with a high MSTA score were more likely to experience BCR than were patients with a low MSTA score (odds ratio, 2.9). Combining MSTA with GG assessment resulted in a significant stratification of risk for BCR.

Conclusions

MSTA score could be used as an objective adjunct risk stratification tool to pathologist assessments and could improve the management of patients with favorable-risk PCa.

Relational care and co-operative endeavour – Reshaping dementia care through participatory secondary data analysis

Dementia is emerging from the shadows of societal exclusion and stigma. The engagement within society for people who are marginalised is co-constructed through the everyday practices that take place between them and those around them. However, this is inherently political, positioning people as active and activist in the relationship of their lives with their communities. The research aimed to interrogate an existing qualitative dataset in partnership with people living with dementia to inform the development of a way of working with people with dementia that is empowering. In this qualitative secondary data analysis project, we (1) analysed data through two theoretical lenses: Douglas’ cultural theory of risk and Tronto’s Ethic of Care, and (2) co-analysed the data together with people living with dementia during 16 workshops. The design involved cycles of presenting, interpreting, representing and reinterpreting the data and findings between multiple stakeholders. We identified a granular understanding of the way relationships change for people with dementia and how subtle factors and nuanced behaviour contribute to social exclusion, or support social inclusion. The results support relational care through the co-operative endeavour (of co-operative communication, co-operative action and co-operative care) in promoting the inclusion of people living with dementia.

Quantification of large scale DNA organization for predicting prostate cancer recurrence

This study investigates whether Genomic Organization at Large Scales (which we propose to call GOALS) as quantified via nuclear phenotype characteristics and cell sociology features (describing cell organization within tissue) collected from prostate tissue microarrays (TMAs) can separate biochemical failure from biochemical nonevidence of disease (BNED) after radical prostatectomy (RP). Of the 78 prostate cancer tissue cores collected from patients treated with RP, 16 who developed biochemical relapse (failure group) and 16 who were BNED patients (nonfailure group) were included in the analyses (36 cores from 32 patients). A section from this TMA was stained stoichiometrically for DNA using the Feulgen-Thionin methodology, and scanned with a Pannoramic MIDI scanner. Approximately 110 nuclear phenotypic features, predominately quantifying large scale DNA organization (GOALS), were extracted from each segmented nuclei. In addition, the centers of these segmented nuclei defined a Voronoi tessellation and subsequent architectural analysis. Prostate TMA core classification as biochemical failure or BNED after RP using GOALS features was conducted (a) based on cell type and cell position within the epithelium (all cells, all epithelial cells, epithelial >2 cell layers away from basement membrane) from all cores, and (b) based on epithelial cells more than two cell layers from the basement membrane using a Classifier trained on Gleason 6, 8, 9 (16 cores) only and applied to a Test set consisting of the Gleason 7 cores (20 cores). Successful core classification as biochemical failure or BNED after RP by a linear classifier was 75% using all cells, 83% using all epithelial cells, and 86% using epithelial >2 layers. Overall success of predicted classification by the linear Classifier of (b) was 87.5% using the Training Set and 80% using the Test Set. Overall success of predicted progression using Gleason score alone was 75% for Gleason >7 as failures and 69% for Gleason >6 as failures. © 2017 International Society for Advancement of Cytometry.

von Willebrand factor arginine 1205 substitution results in accelerated macrophage-dependent clearance in vivo

BACKGROUND

Enhanced von Willebrand factor (VWF) clearance is important in the etiology of type 1 and type 2 von Willebrand disease (VWD). More than 20 different VWF point mutations have already been reported in patients with enhanced clearance. These include the VWD-Vicenza variant, which is characterized by an Arg1205His substitution in the VWF D3 domain. Critically, however, the molecular mechanisms through which single amino acid substitutions in VWF result in enhanced clearance of this complex multimeric glycoprotein have not been defined.

OBJECTIVES

In this study, we have investigated the biological basis underlying the enhanced clearance of the VWF-R1205H variant.

METHODS

Using VWF(-/-) mice, in vivo clearance rates were determined for a series of full-length and truncated recombinant VWF variants. In addition, the role of macrophages in modulating enhanced VWD-Vicenza clearance was investigated using clodronate liposome administration.

RESULTS

Our findings demonstrate that substitutions of R1205 with histidine, cysteine or serine all result in markedly reduced survival of full-length recombinant VWF. Importantly, D'A3 fragments containing these same R1205 substitutions also demonstrated significantly enhanced clearance. In contrast to the reduced in vivo survival observed with R1205H, clearance of R1204H was not enhanced. Recent studies have demonstrated that hepatic and splenic macrophages play key roles in regulating VWF clearance. Importantly, macrophage-depletion also served to markedly attenuate the enhanced clearance phenotypes associated with VWF-R1205H, VWF-R1205S and VWF-R1205C.

CONCLUSIONS

Collectively, these novel findings demonstrate a specific and critical role for the R1205 residue in modulating macrophage-mediated clearance of VWF in vivo.

PEG-hemoglobin: effects on tumor oxygenation and response to chemotherapy

BACKGROUND

The study was undertaken to determine whether administration of PEG-hemoglobin could improve the oxygenation of a solid tumor prior to and after chemotherapy and to determine whether administration of PEG-hemoglobin could enhance the efficacy of chemotherapy in a solid tumor.

MATERIALS AND METHODS

Rats bearing the 13762 mammary carcinoma were untreated or treated with cyclophosphamide, melphalan, taxol or cisplatin. Tumor oxygenation was determined 24 hrs. after chemotherapy with or without administration of PEG-hemoglobin while the animals breathed air, 28% oxygen or carbogen. Mice bearing the EMT-6 murine mammary carcinoma were treated with single doses of chemotherapy with or without co-administration of PEG-hemoglobin and tumor cell and bone marrow CFU-GM survivals were determined. Other EMT-6 tumor-bearing mice were treated with multiple doses of chemotherapy with or without PEG-hemoglobin and tumor growth delay was determined.

RESULTS

Administration of PEG-hemoglobin was effective in decreasing hypoxia in the 13762 mammary carcinoma both prior to and after chemotherapy administration. Increasing the level of inspired oxygen further decreased the tumor hypoxia most effectively when the level of tumor cell killing by the chemotherapy was high. Administration of PEG-hemoglobin along with air breathing to mice bearing the EMT-6 tumor increased tumor cell killing by cyclophosphamide, BCNU, adriamycin and taxol without increasing toxicity to the bone marrow CFU-GM. PEG-Hemoglobin given prior to each dose of chemotherapy increased the tumor growth delay produced by cyclophosphamide, adriamycin, 5-fluorouracil, BCNU and taxol in a manner with increased level of inspired oxygen and with a concomitant decreased in lung metastases.

CONCLUSIONS

Further investigation of PEG-hemoglobin as an oxygen delivery agent in oncology is warranted.

Interaction of interleukin-11 with cytotoxic therapies in vitro against CEM cells and in vivo against EMT-6 murine mammary carcinoma

Interleukin-11(rhIL-11) is a cytokine that has been shown to enhance the recovery of bone marrow and intestinal crypt cells after cytotoxic insult with radiation or anticancer drugs. The current study examined the effects of rhIL-11 on the response of CEM human lymphoblastic leukemia cells and on the EMT-6 murine mammary carcinoma in vivo to cytotoxic anticancer therapies. Exposure of CEM cells to rhIL-11 for 24 hr did not alter the cytotoxicity of melphalan or radiation, increased the cytotoxicity of CDDP (100 muM) and 4-hydroperoxycyclophosphamide (50 betaM) and decreased the cytotoxicity of 5-fluorouracil and ara-C toward the cells. Treatment of mice bearing the EMT-6 tumor with rhIL-11 twice daily for 4 days prior to and the day of cytotoxic therapy resulted in no significant change in the tumor cell killing or bone marrow CFU-GM killing by melphalan, cyclophosphamide, thiotepa, CDDP, radiation, 5-fluorouracil or ara-C. Administration of rhIL-11 twice per day on days 7-18 to EMT-6 tumor bearing animals receiving high dose chemotherapy (melphalan, thiotepa or cyclophosphamide) as a single dose on day 7 followed by mobilized peripheral blood cells on day 8 and rhG-CSF on days 8-20, tended to prolong the tumor growth delay produced by the drugs. This rhIL-11 treatment also resulted in a more rapid recovery of white blood cells and granulocytes in the animals. Furthermore, animals treated with rhIL-11 had improved survival rates compared with animals receiving all other normal tissue support without rhIL-11.

Longitudinally foretelling drug usage in adolescence: early childhood personality and environmental precursors

Drug usage in early adolescence (age 14) was related to concurrent and preschool personality characteristics for a sample of 54 girls and 51 boys. The personality concomitants and antecedents of drug use differed somewhat as a function of gender and the drug used. At age 14, for both sexes, the use of marijuana was related to ego undercontrol, while the use of harder drugs reflected an absence of ego-resiliency, with undercontrol also a contributing factor. At ages 3/4, subsequent adolescent drug usage in girls related to both undercontrol and lower ego-resiliency. In boys, adolescent drug usage related strongly, during their nursery school years, to undercontrol and with resiliency having no long-term implications. Early family environment related to adolescent drug usage in girls but not in boys. Drug usage in adolescent girls was related to homes earlier identified as unstructured and laissez-faire, where there was little pressure to achieve. Drug usage related to other substance use and, in boys, to IQ decline from age 11 to age 18. Implications of these results for contemporary views regarding adolescent drug usage are discussed.