KRT17High/CXCL8+ tumor cells display both classical and basal features and regulate myeloid infiltration in the pancreatic cancer microenvironment

PURPOSE

Pancreatic ductal adenocarcinoma (PDAC) is generally divided in two subtypes, classical and basal. Recently, single cell RNA sequencing has uncovered the co-existence of basal and classical cancer cells, as well as intermediary cancer cells, in individual tumors. The latter remains poorly understood; here, we sought to characterize them using a multimodal approach.

EXPERIMENTAL DESIGN

We performed subtyping on a single cell RNA sequencing dataset containing 18 human PDAC samples to identify multiple intermediary subtypes. We generated patient-derived PDAC organoids for functional studies. We compared single cell profiling of matched blood and tumor samples to measure changes in the local and systemic immune microenvironment. We then leveraged longitudinally patient-matched blood to follow individual patients over the course of chemotherapy.

RESULTS

We identified a cluster of KRT17-high intermediary cancer cells that uniquely express high levels of CXCL8 and other cytokines. The proportion of KRT17High/CXCL8+ cells in patient tumors correlated with intra-tumoral myeloid abundance, and, interestingly, high pro-tumor peripheral blood granulocytes, implicating local and systemic roles. Patient-derived organoids maintained KRT17High/CXCL8+cells and induced myeloid cell migration in an CXCL8-dependent manner. In our longitudinal studies, plasma CXCL8 decreased following chemotherapy in responsive patients, while CXCL8 persistence portended worse prognosis.

CONCLUSIONS

Through single cell analysis of PDAC samples we identified KRT17High/CXCL8+ cancer cells as an intermediary subtype, marked by a unique cytokine profile and capable of influencing myeloid cells in the tumor microenvironment and systemically. The abundance of this cell population should be considered for patient stratification in precision immunotherapy.

Four-Way Wada: SEEG-based mapping with electrical stimulation, high frequency activity, and phase amplitude coupling to complement traditional Wada and functional MRI prior to epilepsy surgery

Presurgical evaluation of refractory epilepsy involves functional investigations to minimize postoperative deficit. Assessing language and memory is conventionally undertaken using Wada and fMRI, and occasionally supplemented by data from invasive intracranial electroencephalography, such as electrical stimulation, corticortical evoked potentials, mapping of high frequency activity and phase amplitude coupling. We describe the comparative and complementary role of these methods to inform surgical decision-making and functional prognostication. We used Wada paradigm to standardize testing across all modalities. Postoperative neuropsychological testing confirmed deficit predicted based on these methods.

No difference in outcomes with 15 mm vs. 20 mm lumen-apposing metal stents for endoscopic ultrasound-guided gastroenterostomy for gastric outlet obstruction: a meta-analysis

BACKGROUND/AIMS

We compared outcomes between use of 15 vs. 20 mm lumen-apposing metal stents (LAMSs) in endoscopic ultrasound-guided gastroenterostomy (EUS-GE) for gastric outlet obstruction.

METHODS

Databases were queried for studies that used LAMS for EUS-GE to relieve gastric outlet obstruction, and a proportional meta-analysis was performed.

RESULTS

Thirteen studies were included. The 15 mm and 20 mm LAMS had pooled technical success rates of 93.2% (95% confidence interval [CI], 90.5%-95.2%) and 92.1% (95% CI, 68.4%-98.4%), clinical success rates of 88.6% (95% CI, 85.4%-91.1%) and 89.6% (95% CI, 79.0%-95.1%), adverse event rates of 11.4% (95% CI, 8.1%-15.9%) and 14.7% (95% CI, 4.4%-39.1%), and reintervention rates of 10.3% (95% CI, 6.7%-15.4%) and 3.5% (95% CI, 1.6%-7.6%), respectively. Subgroup analysis revealed no significant differences in technical success, clinical success, or adverse event rates. An increased need for reintervention was noted in the 15 mm stent group (pooled odds ratio, 3.59; 95% CI, 1.40-9.18; p=0.008).

CONCLUSION

No differences were observed in the technical, clinical, or adverse event rates between 15 and 20 mm LAMS use in EUS-GE. An increased need for reintervention is possible when using a 15 mm stent compared to when using a 20 mm stent.

Single-session EUS-guided gastrogastrostomy to facilitate cystgastrostomy in Roux-en-Y gastric bypass

Video 1Single-session EUS-guided gastrogastrostomy creation to facilitate cystgastrostomy in Roux-en-Y gastric bypass.

Intragastric Balloon Significantly Improves Metabolic Parameters at 6 Months: a Meta-Analysis

INTRODUCTION

It is estimated that by 2030, 38% of the world population will be overweight, and another 20% will be people with obesity. Intragastric balloons (IGBs) are an option in conjunction with lifestyle modification for the treatment of obesity. We sought to investigate the effects of IGB therapy on hemoglobin A1c (A1c), systolic and diastolic blood pressure (SBP, DBP), total cholesterol (TC), high-density lipoprotein (HDL), low-density lipoprotein (LDL), and triglycerides (TGs).

METHODS

PubMed, Embase, and Google Scholar were queried through November 2021 to identify studies that evaluated the effects of IGB therapy on selected variables at 6 months. A total of 17 studies and 1198 patients met inclusion criteria. Results were pooled using a random-effects model.

RESULTS

At 6-month post-IGB insertion, patients had a significant reduction in A1c (mean difference (MD): - 0.62, 95% confidence interval (CI): - 0.884 to - 0.355, p < 0.001), SBP (MD: - 8.39, 95% CI: - 11.39 to - 5.386, p < 0.001), DBP (MD: - 5.807, 95% CI: - 8.852 to - 2.76, p < 0.001), TC (MD: - 9.189, 95% CI: - 15.763 to - 2.616, p = 0.006), LDL (MD: - 5.20, 95% CI: - 9.05 to - 1.35, p = 0.008), and TGs (MD: - 25.35, 95% CI: - 40.30 to - 10.10, p = 0.001). There was no significant difference in HDL (MD: 1.245, 95% CI: - 0.11 to 2.60, p = 0.071).

CONCLUSIONS

Our meta-analysis suggests that IGB therapy is associated with improvements in insulin resistance, blood pressure, and dyslipidemia at 6 months. The results of this analysis suggest that IGB placement can be a viable treatment option to improve important metabolic parameters beyond weight loss alone.

Oncology clinical trial disruption during the COVID-19 pandemic: a COVID-19 and cancer outcomes study

Background

COVID-19 disproportionately impacted patients with cancer as a result of direct infection, and delays in diagnosis and therapy. Oncological clinical trials are resource-intensive endeavors that could be particularly susceptible to disruption by the pandemic, but few studies have evaluated the impact of the pandemic on clinical trial conduct.

Patients and methods

This prospective, multicenter study assesses the impact of the pandemic on therapeutic clinical trials at two large academic centers in the Northeastern United States between December 2019 and June 2021. The primary objective was to assess the enrollment on, accrual to, and activation of oncology therapeutic clinical trials during the pandemic using an institution-wide cohort of (i) new patient accruals to oncological trials, (ii) a manually curated cohort of patients with cancer, and (ii) a dataset of new trial activations.

Results

The institution-wide cohort included 4756 new patients enrolled to clinical trials from December 2019 to June 2021. A major decrease in the numbers of new patient accruals (−46%) was seen early in the pandemic, followed by a progressive recovery and return to higher-than-normal levels (+2.6%). A similar pattern (from −23.6% to +30.4%) was observed among 467 newly activated trials from June 2019 to June 2021. A more pronounced decline in new accruals was seen among academically sponsored trials (versus industry sponsored trials) (P < 0.05). In the manually curated cohort, which included 2361 patients with cancer, non-white patients tended to be more likely taken off trial in the early pandemic period (adjusted odds ratio: 2.60; 95% confidence interval 1.00-6.63), and substantial pandemic-related deviations were recorded.

Conclusions

Substantial disruptions in clinical trial activities were observed early during the pandemic, with a gradual recovery during ensuing time periods, both from an enrollment and an activation standpoint. The observed decline was more prominent among academically sponsored trials, and racial disparities were seen among people taken off trial.

EPIDEMIOLOGY AND SEASONAL VARIATION OF APPENDICITIS – A SINGLE CENTER RETROSPECTIVE STUDY FROM NORTH-EAST INDIA

Background. Acute appendicitis is the most common surgical emergency presenting in emergency department, and appendectomy is one of the most common surgeries. There is a wide variation in the incidence of acute appendicitis reported for different countries, different regions, race, sex, age and also seasons. Objective. The aim of this study was to understand the epidemiological trend and the seasonal variation of appendicitis in the northeast region of India. Methods. It was a retrospective hospital-based study conducted in Jan 2016 – Dec 2020 at a Tertiary Care Teaching Hospital in the northeast region of India. The patient data were obtained from the Medical Record Department of the hospital and the data regarding the weather was obtained from the Indian Meteorological Department (IMD) and the website www.worldweather.com. The statistical analysis was done using SPSS software version 24.0, and the seasonal variation was studied using Kruskal Wallis test. Results. Acute appendicitis affected both the sexes equally with a marginal higher incidence in males. It also had higher peak during the second and third decade of life in both the sexes. The incidence of acute appendicitis was high in the pre-monsoon and monsoon season with peak in the monsoon season. Conclusions. Acute appendicitis is more common during the pre-monsoon and monsoon season, a period known for humidity, high incidence of bacterial and viral infections.

Longitudinal neurodevelopmental profile of a pediatric patient with de novo SPTAN1, epilepsy, and left hippocampal sclerosis

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We present the first longitudinal study of neuropsychological functioning in a pediatric patient with SPTAN1.

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To our knowledge we report the first case of SPTAN1 heterozygosity in a patient with MTLE due to HS.

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This case is the first to show that lisdexamfetamine dimesylate improved attention, behavior, and school performance in a patient with heterozygous SPTAN1 variant.

Pathogenic variants in SPTAN1 result in abnormal neurodevelopment but limited information is available on the spectrum of neurodevelopmental profiles associated with variations in this gene. We present novel data collected at two time points over a three-year period in a nine-year-old patient with heterozygous de novo SPTAN1 variant, drug-resistant epilepsy, and left hippocampal sclerosis. Across evaluations, our patient’s performance was highly variable, ranging from below age expectation to within age-expected range. The patient exhibited relative cognitive strengths at both time points on verbal-expressive tasks. Weaknesses were seen in her attention, executive function, psychomotor processing speed, fine motor, visual-motor integration, and social skills. Memory findings were consistent those associated with left hippocampal sclerosis. Evaluations resulted in diagnoses including attention deficit hyperactivity disorder and autism spectrum disorder.

ADULT-ONSET CYSTIC HYGROMA IN AXILLA: A RARE CASE REPORT FROM INDIA AND LITERATURE REVIEW

Background. Cystic hygroma (CH), occurs in 1/6000 live births and in 90% of cases develops in age less than 2 years old. They are mainly located in cervicofacial region. Adult-onset CH is very rare. Objective. The aim of this study is to review literature to discuss the clinical presentation, diagnosis, and treatment of CH in adults through a case report of unilocular CH in the axillary region in an adult male from India. Methods. A first case report of unilocular CH in axillary region in an adult male from India is being investigated. Results. Here we report a case of unilocular CH in the axillary region in a 49-year-old male with a 14x16x8 cm cystic swelling in left axilla with a history of aspiration failure. Contrast-enhanced MRI (CEMRI) showed well-defined thin walled, unilocular cystic lesion which appeared hyperintense on T2 & STIR and hypointense on T1W1 and showed thin peripheral rim of enhancement on post contrast images. The patient underwent surgical excision and the diagnosis of a pathological CH was established. His postoperative recovery was uneventful and had no evidence of recurrence. Conclusion. Due to rarity of adult-onset unilocular CH in axilla, its evaluation for prompt diagnosis and definitive treatment to prevent recurrence and complications is urgent. Furthermore, this is the first reported case from India which has been successfully managed at a peripheral hospital in Northeast-India and our report of this case contributes to the evidences supporting the role of CH in a differential diagnosis for masses in the adult axilla, especially in acute phase with no predisposing factors.

Endoscopic ultrasound-guided gallbladder drainage as a rescue therapy for unresectable malignant biliary obstruction: a multicenter experience

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is often unsuccessful in patients with duodenal stenosis or malignant ampullary infiltration. While endoscopic ultrasound-guided biliary drainage (EUS-BD) has been proposed as an alternative, EUS-guided gallbladder drainage (EUS-GBD) is an attractive option when both approaches fail. We aimed to assess the effectiveness and safety of EUS-GBD as rescue therapy for malignant distal bile duct obstruction.

METHODS

A multicenter retrospective study was performed on patients with unresectable malignant distal bile duct obstruction who underwent EUS-GBD between 2014 and 2019 after unsuccessful ERCP and EUS-BD. Clinical success was defined as a decrease in serum bilirubin of > 50 % within 2 weeks.

RESULTS

28 patients were included, with a lumen-apposing metal stent used in 26 (93 %) and a self-expandable metal stent in two (7 %). The technical success rate was 100 %. The clinical success rate was 93 %, with an improvement in bilirubin (7.3 [SD 5.4] pre-procedure vs. 2.8 [SD 1.1] post-procedure; P = 0.001). Delayed adverse events included food impaction of the stent (n = 3), with a further two patients developing cholecystitis and bleeding.

CONCLUSION

This study demonstrates the feasibility of gallbladder drainage to relieve malignant distal bile duct obstruction in patients with failed ERCP and EUS-BD.

A seven-month-old with chronic intermittent biphasic stridor

Paediatric stridor can indicate serious pathology and requires prompt evaluation and management. Causes range from laryngomalacia to aerodigestive tract foreign bodies. We report on a chronic presentation of paediatric stridor, discuss the workup, management and lessons learned. A seven-month-old boy presented with chronic intermittent biphasic stridor for the previous five months. Diagnostic microlaryngoscopy and bronchoscopy revealed significant localised tracheomalacia. Urgent chest computed tomography was performed to investigate further. Radiological findings revealed an oesophageal foreign body prompting immediate rigid oesophagoscopy and removal of an embedded pistachio shell. The patient had an uneventful recovery. Foreign bodies in the airway and oesophagus are quite common in children, causing symptoms from the aerodigestive tract. It is uncommon for oesophageal foreign bodies to present with stridor in the absence of digestive tract symptoms. The otolaryngologist should consider this as a diagnosis, particularly in young children with an atypical presentation and symptoms.

Evidence of hepatitis A virus infection in the patients with acute encephalitis syndrome in Gorakhpur region, North India

The etiological agent remained unidentified in a large number of patients hospitalized for acute encephalitis syndrome (AES) in 2008-2009 in Uttar Pradesh and Bihar, north India. All patients were found to present with fever and altered sensorium, while 28%, 19% and 13% showed hepatomegaly, splenomegaly and meningeal signs, respectively. Involvement mostly of children with abnormal hepatic features prompted us to undertake an exploratory study on viral hepatitis A to determine its association, if any, with hepatic derangements. AES patients (n = 2515) and healthy children (n = 167) were investigated for the presence of serum anti-hepatitis A virus (anti-HAV) IgM and anti-Japanese encephalitis (anti-JE) virus IgM by ELISA. Cerebrospinal fluids (CSFs, n = 595) and rectal swabs (n = 182) were examined for anti-HAV IgM and/or HAV RNA. Anti-HAV IgM was detected in the sera of 14.6% patients as against 6.6% of healthy children (p = 0.0042). Anti-JE virus IgM positivity was Keywords: acute encephalitis syndrome; cerebrospinal fluid; hepatitis A virus; anti-HAV IgM; non-Japanese encephalitis.

Pleural tumours and tumour-like lesions

There are various neoplasms and tumour-like conditions of the pleura. Mesothelioma is perhaps the most widely recognised; however, there are many others that are more common and should be considered. Understanding the similarities and differences can be helpful in managing the patient with a newly found pleural lesion. We will discuss clinical symptoms at presentation and describe the imaging findings associated with these tumours, starting with conventional radiology, and correlating with computed tomography and combined positron-emission tomography (PET)/computed tomography (CT). Finally, imaging characteristics that help differentiation between the benign and malignant varieties will be reviewed.

Human epidermal growth factor receptor 2 expression in gastric carcinoma and its association with histopathological parameters in Indian population

INTRODUCTION

Gastric carcinoma is a leading cause of death worldwide with a five year survival of 10-15% even after curative resection. Trastuzumab has emerged as a potential targeted therapy in treatment of Her 2 positive gastric cancer. Her2 positivity ranges from 7-34% in studies across the world. There is a paucity of Indian studies hence a need for determination of Her2 expression in Indian population for better patient management. This study was carried out to determine the frequency of Her 2 expression in gastric carcinoma by immunohistochemistry (IHC) technique and to evaluate its association with histopathological parameters.

MATERIAL AND METHODS

A total of 110 cases of gastric adenocarcinoma diagnosed on histopathological examination from July 2013 to June 2015 were included. Of these, 40 cases were resection specimens and 70 were biopsies. Histological typing of gastric carcinoma was done on the basis of Lauren classification. IHC for Her2 was done in all 110 cases. Her 2 expression was correlated with various histopathological parameters.

RESULTS

Positive Her 2 expression (IHC 3+) was seen in 24.5% cases of gastric carcinoma. Patients in older age group(> 60 years) showed higher Her 2 positivity rate as compared to middle age (40-60 years) and younger population (<40 years). Higher percentage of Her 2 positivity was noted in male patients as compared to female patients. Her 2 positivity was seen more commonly in intestinal type of tumor as compared to diffuse and mixed types. Her 2 positivity was seen more in well differentiated carcinoma and higher stage tumors (pT3 and pT4). However, out of all, a statistically significant association of Her2 expression was found only with (intestinal) type of tumors (p= 0.005) and no significant association was seen with age, gender, site of tumor, tumor stage, lymph node status, lymphovascular, perineural and perinodal invasion or survival.

CONCLUSION

Inspired by promising results of Trastuzumab therapy in Her 2 positive gastric carcinoma worldwide, it is recommended to routinely test all cases of gastric carcinoma for Her 2 expression and to use the targeted therapy with curative intentions in Indian population.

Development of a high resolution plantar pressure monitoring pad based on fiber Bragg grating (FBG) sensors

BACKGROUND

High importance is given to plantar pressure monitoring in the field of biomedical engineering for the diagnosis of posture related ailments associated with diseases such as diabetes and gonarthrosis.

OBJECTIVE

This paper presents the proof-of-concept development of a new high resolution plantar pressure monitoring pad based on fiber Bragg grating (FBG) sensors.

METHODS

In the proposed configuration, the FBG sensors are embedded within layers of carbon composite material (CCM) in turn conforming to an arc shape. A total of four such arc shaped sensors are instrumented in the pad at the locations of the forefoot and the hind foot. As a test of the pad, static plantar pressure is monitored on normal subjects under various posture conditions. The pad is evaluated both as a standalone platform as well as a pad inserted inside a standard shoe.

RESULTS

An average pressure sensitivity of 1.2 pm/kPa and a resolution of approximately 0.8 kPa is obtained in this special configuration. The pad is found to be suitable in both configurations- stand-alone pad as well as an insert inside a standard shoe.

CONCLUSION

The proposed set up offers a cost-effective high resolution and accurate plantar pressure measurement system suitable for clinical deployment. The novelty of the developed pressure pad lies in its ability to be used both as platform type as well as inserted in-sole type sensor system.

Combined application of FBG and PZT sensors for plantar pressure monitoring at low and high speed walking

BACKGROUND

Clinical monitoring of planar pressure is vital in several pathological conditions, such as diabetes, where excess pressure might have serious repercussions on health of the patient, even to the extent of amputation.

OBJECTIVE

The main objective of this paper is to experimentally evaluate the combined application of the Fibre Bragg Grating (FBG) and the lead zirconate titanate (PZT) piezoceramic sensors for plantar pressure monitoring during walk at low and high speeds.

METHODS

For fabrication of the pressure sensors, the FBGs are embedded within layers of carbon composite material and stacked in an arc shape. From this embedding technique, average pressure sensitivity of 1.3 pm/kPa and resolution of nearly 0.8 kPa is obtained. These sensors are found to be suitable for measuring the static and the low-speed walk generated foot pressure. Simultaneously, PZT patches of size 10 × 10 × 0.3 mm were used as sensors, utilizing the d<formula>_{33}</formula> (thickness) coupling mode. A sensitivity of 7.06 mV/kPa and a pressure resolution of 0.14 kPa is obtained from these sensors, which are found to be suitable for foot pressure measurement during high speed walking and running. Both types of sensors are attached to the underside of the sole of commercially available shoes. In the experiments, a healthy male subject walks/runs over the treadmill wearing the fabricated shoes at various speeds and the peak pressure is measured using both the sensors. Commercially available low-cost hardware is used for interrogation of the two sensor types.

RESULTS

The test results clearly show the feasibility of the FBG and the PZT sensors for measurement of plantar pressure. The PZT sensors are more accurate for measurement of pressure during walking at high speeds. The FBG sensors, on the other hand, are found to be suitable for static and quasi-dynamic (slow walking) conditions. Typically, the measured pressure varied from 400 to 600 kPa below the forefoot and 100 to 1000 kPa below the heel as the walking speed varied from 1 kilometer per hour (kmph) to 7 kmph.

CONCLUSIONS

When instrumented in combination, the two sensors can enable measurements ranging from static to high speed conditions Both the sensor types are rugged, small sized and can be easily embedded in commercial shoes and enable plantar pressure measurement in a cost-effective manner. This research is expected to have application in the treatment of patients suffering from diabetes and gonarthrosis.

Safety of perioperative subcutaneous heparin for partial nephrectomy

INTRODUCTION

The development of deep venous thrombosis (DVT) or pulmonary embolism (PE) following urologic surgery is a life threatening, but largely preventable complication. Patients undergoing partial nephrectomy are at increased risk for the development of DVT or PE as they often possess multiple risk factors including malignancy, advanced age, and prolonged surgical time. This risk can be significantly reduced by administration of perioperative subcutaneous heparin (SQH), however many surgeons feel this is contraindicated due to potential blood loss and related complications.

MATERIALS AND METHODS

The medical records of 293 consecutive patients undergoing planned open, laparoscopic, or robotic assisted partial nephrectomy by a single surgeon over a 7 year period were reviewed. Approximately halfway through the period, the standard DVT prevention practice was changed from sequential compression stockings and early ambulation to include 5000 units of SQH administered 30-60 minutes prior to incision and continuing every 8 hours until discharge.

RESULTS

A total of 158 patients received perioperative SQH. There was no significant difference in surgical blood loss, transfusions, operative time, change in pre to postoperative hemoglobin or creatinine, conversion to radical nephrectomy, or duration of stay between the groups. There were no DVTs in either group. There was one PE in the group receiving SQH which was incidentally discovered.

CONCLUSIONS

Patients undergoing renal surgery for cancer are at increased risk for the development of DVT and PE. Prophylaxis against this serious complication with perioperative SQH is safe in patients undergoing partial nephrectomy despite common surgeon concerns regarding blood loss and related complications.

Distinct Alteration in Brain Endothelin A and B Receptor Characteristics Following Focal Cerebral Ischemia in Rats

Manipulation of the central endothelin (ET) system via either ETA antagonists or ETB agonists following experimental cerebral ischemia has been shown to be beneficial in previous experimental studies. In order to further explore the involvement of these receptors in cerebral ischemia, we determined changes in binding affinity (Kd) and density (Bmax) of ETA and ETB receptors in the rat brain at 24 h and 1 week following middle cerebral artery occlusion (MCAO). Rats subject to MCAO exhibited significant neurological and motor function deficit as well as large infarct volumes (126.41±40.12 and 152.82±21.67 mm(3) on days 1 and 7, respectively). Bmax increased (P<0.01) and Kd decreased (P<0.01) for ETA receptors in the infarcted right cerebral hemisphere compared to sham 24 h post MCAO. However, after 7 days of MCAO, Bmax of ETA receptors was similar, while Kd in the infarcted hemisphere increased (P<0.05) compared to sham. Binding characteristics for brain ETB receptors were not altered 24 h post MCAO. However, 7days following MCAO, there was a significant decrease (P<0.001) in Kd values and an increase (P<0.001) in Bmax values for ETB receptors in the ischemic cerebral hemisphere. The initial increase in ETA receptors is damaging and may be aggravating cerebral ischemia due to its vasoconstrictive actions. On the other hand, since ETB receptors have been shown to enhance brain angiogenesis, it is possible that an increase in binding characteristics of these receptors is part of a natural defense mechanism to repair the ischemic brain.

Does fluoroscopy with anterior hip arthroplasty decrease acetabular cup variability compared with a nonguided posterior approach?

BACKGROUND

The direct anterior approach for THA offers some advantages, but is associated with a significant learning curve. Some of the technical difficulties can be addressed by the use of intraoperative fluoroscopy which may improve the accuracy of acetabular component placement.

QUESTIONS/PURPOSES

The purposes of this study were to determine if (1) there is decreased variability of acetabular cup inclination and anteversion with the direct anterior approach using fluoroscopic guidance as compared with the posterior approach THA without radiographic guidance; (2) if there is a learning curve associated with achieving accuracy with the direct anterior approach THA. We also wanted (3) to assess the frequency of complications including dislocation with the anterior approach, which initially had a learning curve, and the posterior approach.

METHODS

This retrospective, comparative study of 825 THAs (372 posterior THAs without fluoroscopic guidance and 453 direct anterior THAs, performed by one surgeon, focused on a radiographic analysis to determine cup inclination and anteversion on standardized pelvic radiographs using specialized software. The first 100 direct anterior THAs performed while transitioning from the posterior approach to the direct anterior approach were included in the learning curve group. During this learning curve period, the direct anterior approach was used for all patients except those with conversion of previously fixed intertrochanteric or femoral neck fractures to THAs, gluteus medius tears, and obese patients with an immobile abdominal pannus (100 of 127 THAs). Variability of the acetabular component was compared among the posterior group, learning curve group, and direct anterior group.

RESULTS

Variances for cup inclination and anteversion were significantly lower in the direct anterior group (19 and 16 respectively, p < 0.01) as compared with the posterior group (50 and 79 respectively).Target inclination and anteversion were achieved better in the direct anterior group (98% and 97% respectively) as compared with the posterior group (86% and 77% respectively) (p < 0.01, OR for inclination = 9.1, 95% CI, 3.5 to 23.4; OR for anteversion = 8, 95% CI, 4 to 16). In the learning curve group, target anteversion achieved (91% of cases) was marginally lower than that of the direct anterior group (p = 0.03; OR = 2.9, 95% CI, 1.1 to 7.3) and target inclination (95%) was similar (p = 0.13). There was one posterior dislocation in the posterior group, two anterior dislocations in the learning curve group, and none in the direct anterior group.

CONCLUSIONS

Use of fluoroscopy with the patient in the supine position during direct anterior THA enables intraoperative assessment of cup orientation resulting in decreased variability of acetabular cup anteversion. However, there is a learning curve associated with achieving this accuracy. We could not discern whether this difference was the result of the approach or the use of fluoroscopy in the direct anterior group.

LEVEL OF EVIDENCE

Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

beta(1)-integrin mediates pressure-stimulated phagocytosis

BACKGROUND

Extracellular pressure alterations in infection, inflammation, or positive pressure ventilation may influence macrophage phagocytosis. We hypothesized that pressure modulates beta1-integrins to stimulate phagocytosis.

METHODS

We assayed fibroblast phagocytosis of fluorescent latex beads at ambient or 20 mm Hg increased pressure, and macrophage integrin phosphorylation by Western blot.

RESULTS

Pressure did not alter phagocytosis in beta(1)-integrin null GD25 fibroblasts, but stimulated phagocytosis in fibroblasts expressing wild-type beta(1)-integrin. In phorbol myristate acetate-differentiated THP-1 macrophages, pressure stimulated beta(1)-integrin T788/789 phosphorylation, but not S785 phosphorylation. Furthermore, pressure stimulated phagocytosis in cells expressing an inactivating S785A point mutation or a T788D substitution to mimic a constitutively phosphorylated threonine, but not in cells expressing an inactivating TT788/9AA mutation.

CONCLUSIONS

The effects of pressure on phagocytosis are not limited to macrophages but generalize to other phagocytic cells. These results suggest that pressure stimulates phagocytosis via increasing beta(1)-integrin T789 phosphorylation. Interventions that target beta(1)-integrin threonine 789 phosphorylation may modulate phagocytic function.

Retrospective analysis and chemotherapy results in extra-nodal NHL patients in a large super-speciality hospital in North India

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Background: We retrospectively analysed records of the Patients visiting the pathology department of Sir Ganga Ram Hospital, New Delhi a super-speciality hospital, between February 2007- February 2008. Out of a total of 16,500 cases, NHL was reported in 154 (0.93%)cases. The median age was 52 yrs and the no. of male patients were 104 and female were 50 making M:F = 2:1. The type of NHL was B-Cell type (CD-20+ve) in 132(85%) and T-Cell type (CD 3+ve) in 22 (15%) cases. Out of 154 patients, 77 were nodal and 77 were extra nodal. Additional features - HIV positivity in 2 patients, autoimmune haemolytic disease in 1 patient and thalessemia major in 1 patient. In extra-nodal group of NHL patients the no. Of male and female patients were 55 & 22 respectively (M:F=2.5:1). Out of 77 extra-nodal cases, 31(20%) were GIT NHL (Stomach -16, Colon-8, Ileum-4, and Duodenum-3) and out of the rest 46 extra-nodal cases the site of origin was - head & neck-14, skin n soft tissues -8, primary CNS-6, testicular-4, para-spinal- 3, breast mass-3, perinephric-2, bones-2 and 1 each in cervix, lung mass, liver and cervical plexus. Methods: A detailed analysis of 31 GIT NHL cases was carried out. 28 out of 31 were B-Cell type and 3 were T-Cell type. 26 out of 31 were diffuse large cell variety, 2 were mixed small & large cell variety and 1 MALT variety. In 2 patients the type of lymphoma could not be ascertained. Bone marrow infiltration was present in 2 out of 31 cases of GIT Lymphoma. Surgery was carried out in 15 of 31 GIT NHL cases and these were arising from Colon, Ileum and Duodenum. No surgery was performed in patients with stomach lymphoma. Results: Of all the extra-nodal cases chemotherapy was given to 39 patients - R-CHOP = 20 patients, CHOP = 13 patients, high dose MTX in primary CNS NHL = 6 patients. CR was achieved 16 out of 20 R-CHOP patients (80%), 8 out of 13 CHOP Patients (61 %) and 4 out of 6 high dose MTX patients (66%).

No significant financial relationships to disclose.

CT evaluation of shock viscera: a pictorial review

The purpose of this article is to review both the pathophysiology and the computed tomography features of the hypoperfusion complex and shock viscera. The main findings include dilated fluid-filled loops of bowel with hyperenhancing mucosa, intensely enhancing kidneys and mesenteric vasculature, and small caliber, dense aorta and collapsed, slit-like inferior vena cava. Variable features include increased enhancement of the adrenals, decreased enhancement of the spleen, and altered enhancement of the pancreas with both hypo- and hyperenhancement described. This complex of findings indicates a tenuous hemodynamic status and has been associated with a poor prognosis. In addition, it is important to discern this collection of findings from direct injury to the viscera to aid in appropriate triage and management of the patients' injuries.

To determine the cost-effectiveness of pemetrexed (PEM) compared to current standards of care in 2nd-line advanced non-small cell lung cancer (NSCLC) from the UK National Health Service (NHS) perspective

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Objective: To assess the clinical and cost-effectiveness of pemetrexed (PEM) compared with current standards of care (SOC) in 2nd-line advanced NSCLC from a UK perspective. The SOC selected for the evaluation were: (i) docetaxel (DOC) as it is the standard active therapy in the UK and is recommended by the National Institute for Health and Clinical Excellence (NICE) and (ii) best supportive care (BSC) as the majority patients in the UK who fail 1st-line therapy do not receive further chemotherapy. Methods: The analytic technique used was a cost-utility analysis (CUA) in the form of a Markov model. Utilities were generated from 100 members of the general public, considering tumor response status and toxicity, in accordance with the standard NICE appraisal methodology. Clinical inputs were derived from a pooled analysis phase III clinical trial data. Costs were taken from the British National Formulary and UK national databases. The incremental cost-effectiveness ratios (ICERs) are presented for both life-years gained (LYG) and quality-adjusted life- years (QALY) gained. Conclusions: The incremental cost per LY and cost per QALY for pemetrexed in 2nd-line NSCLC are below £20,000, compared to docetaxel and BSC. Based on its survival and toxicity benefits PEM is a cost-effective option in within the UK.

No significant financial relationships to disclose.

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Health state utility and toxicities in metastatic lung cancer: A qualitative study

16017

Background: In metastatic lung cancer, it is expected that quality of life is impacted both by the efficacy and toxicity of therapy. Previous research has reported health states either based on response to therapy or on toxicity, but not in combination. Using methodology applied in breast cancer (Narewska 2005), we developed health state descriptions for advanced non-small cell lung cancer (NSCLC) for use in cost-utility analyses. Methods: An interview discussion and content validation guide was produced based on literature review and clinical input. Response to therapy was described as responding disease, stable disease, or progressive disease. The most common toxicities were selected based on randomized clinical trials. Descriptions of health states were reviewed by clinical specialists. Final health states will be piloted and then used in a societal-based valuation study using standard gamble technique. The contributory effect of disease state and toxicity will be estimated using a mixed model analysis and compared with the data from the previous breast cancer utility study. Results: Eight toxicities were identified: alopecia and grade 3/4 neutropenia, febrile neutropenia, hand-foot syndrome, gastrointestinal (diarrhea/vomiting), rash, stomatitis and fatigue. These were combined with response to therapy to yield 19 health states: 9 responding disease (one with each toxicity plus one with no toxicity), 9 stable disease (one with each toxicity plus one with no toxicity) and one progressive disease (toxicity not included). These health states were reviewed by 6 pulmonary oncologists and 3 specialist nurses. Conclusions: Development of health states that combine both efficacy and toxicity will be useful in evaluating the relative value of therapies for advanced NSCLC and comparison with other diseases. Input by clinical experts has provided validation for the proposed health states. Evaluation of these health states by members of society will provide appropriate perspective for economic evaluations.

[Table: see text]

Health state utility and toxicities in metastatic lung and breast cancer: A qualitative study

16021

Background: In metastatic lung cancer, it is expected that quality of life is impacted both by the efficacy and toxicity. Previous research has reported health states either based on response to therapy or on toxicity, but not in combination. Using methodology applied in breast cancer (Narewska 2005), we developed health state descriptions for advanced non-small cell lung cancer (NSCLC) for use in cost-utility analyses. Methods: An interview discussion and content validation guide was produced based on literature review and clinical input. Response to therapy was described as responding disease, stable disease, or progressive disease. The most common toxicities were selected based on randomized clinical trials. Descriptions of health states were reviewed by clinical specialists. Final health states will be piloted and then used in a societal-based valuation study using standard gamble technique. The contributory effect of disease state and toxicity will be estimated using a mixed model analysis and compared with the data from the previous breast cancer utility study. Results: Eight toxicities were identified: alopecia and grade 3/4 neutropenia, febrile neutropenia, hand-foot syndrome, gastrointestinal (diarrhea/vomiting), rash, stomatitis and fatigue. These were combined with response to therapy to yield 19 health states: 9 responding disease (one with each toxicity plus one with no toxicity), 9 stable disease (one with each toxicity plus one with no toxicity) and one progressive disease (toxicity not included). These health states were reviewed by 6 pulmonary oncologists and 3 specialist nurses. Conclusion: Development of health states that combine both efficacy and toxicity will be useful in evaluating the relative value of therapies for advanced NSCLC and comparison with other diseases. Input by clinical experts has provided validation for the proposed health states. Evaluation of these health states by members of society will provide appropriate perspective for economic evaluations.

[Table: see text]