Breast Cancer Screening Referral Patterns and Compliance in Transgender Male Patients

Purpose

Screening guidelines for breast cancer (BC) in transgender male (TM) patients are not well defined. This study describes referral patterns and compliance with referral for BC screening among TM patients receiving care at a tertiary care center.

Methods

This was a retrospective cohort study of TM patients, 40-74 years of age, presenting for care between 2017 and 2020. The electronic medical record was queried for medical history and cancer screening data. Compliance with referral and screening was defined as occurring within 2 years of when screening would be expected.

Results

Of the 266 patients identified, 45 met inclusion criteria. One (2.2%) had a history of BC, 0 (0%) had hereditary BC risk, and 11 (24.4%) had a family history of BC. Of the patients, 18 (40%) were referred for BC screening, of whom 13 (72.2%) were compliant with screening. Ten (55.6%) were referred by a primary care provider, 2 (11.1%) were referred by a transgender medicine specialist, and 6 (33.3%) were referred by both. Of the cohort, 27 (60%) had undergone masculinizing mastectomy. Six (22.2%) of these patients were referred for screening, of whom 0 (0%) had pre-screening clinical findings indicating need for screening. Of the 18 (40%) patients who had not undergone masculinizing mastectomy, 12 (66.7%) were referred for BC screening.

Conclusions

There was heterogeneity in referral patterns for BC screening between TM patients who had undergone masculinizing mastectomy and those who had not. BC screening guidelines should be established for TM patients who have undergone masculinizing mastectomy.

Current Place of SGLT2i in the Management of Heart Failure: An Expert Opinion from India

Heart failure (HF) is a global health concern that is prevalent in India as well. HF is reported at a younger age in Indian patients with comorbidity of type 2 diabetes (T2DM) in approximately 50% of patients. Sodium-glucose cotransporter-2 inhibitors (SGLT2i), originally approved for T2DM, are new guideline-recommended and approved treatment strategies for HF. Extensive evidence highlights that SGLT2i exhibits profound cardiovascular (CV) benefits beyond glycemic control. SGLT2i, in conjunction with other guideline-directed medical therapies (GMDT), has additive effects in improving heart function and reducing adverse HF outcomes. The benefits of SGLT2i are across a spectrum of patients, with and without diabetes, suggesting their potential place in broader HF populations irrespective of ejection fraction (EF). This consensus builds on the updated evidence of the efficacy and safety of SGLT2i in HF and recommends its place in therapy with a focus on Indian patients with HF.

Role of Bisoprolol in Heart Failure Management: A Consensus Statement from India

In India, heart failure (HF) is an important health concern affecting younger age groups than the western population. A limited number of Indian patients receive guideline-directed medical therapy (GDMT). Selective β-1 blockers (BB) are one of the GDMTs in HF and play an important role by decreasing the sympathetic overdrive. The BB reduces heart rate (HR) reverse the adverse cardiac (both ventricular and atrial), vascular, and renovascular remodeling seen in HF. Bisoprolol, a β-1 blocker, has several advantages and can be used across a wide spectrum of HF presentations and in patients with HF and comorbid conditions such as coronary artery disease (CAD), atrial fibrillation (AF), post-myocardial infarction (MI), uncontrolled diabetes, uncontrolled hypertension, and renal impairment. Despite its advantages, bisoprolol is not optimally utilized for managing HF in India. This consensus builds on updated evidence on the efficacy and safety of bisoprolol in HF and recommends its place in therapy with a focus on Indian patients with HF.

Racial disparities in telehealth use during the coronavirus disease 2019 pandemic

OBJECTIVE

To investigate the impact of coronavirus disease 2019 on initial infertility consultations.

DESIGN

Retrospective cohort.

SETTING

Fertility practice in an academic medical center.

PATIENTS

Patients presenting for initial infertility consultation between January 2019 and June 2021 were randomly selected for prepandemic (n = 500) and pandemic (n = 500) cohorts.

EXPOSURE

Coronavirus disease 2019 pandemic.

MAIN OUTCOME MEASURES

The primary outcome was a change in the proportion of African American patients using telehealth after pandemic onset compared with all other patients. Secondary outcomes included presentation to an appointment vs. no-show or cancellation. Exploratory outcomes included appointment length and in vitro fertilization initiation.

RESULTS

The prepandemic cohort vs. the pandemic cohort had fewer patients with commercial insurance (64.4% vs. 72.80%) and more African American patients (33.0% vs. 27.0%), although the racial makeup did not differ significantly between the two cohorts. Rates of missed appointments did not differ between the cohorts, but the prepandemic cohort vs. the pandemic cohort was more likely to no-show (49.4% vs. 27.8%) and less likely to cancel (50.6% vs. 72.2%). African American patients, compared with all other patients, during the pandemic were less likely to use telehealth (57.0% vs. 66.8%). African American patients, compared with all other patients, were less likely to have commercial insurance (prepandemic: 41.2% vs. 75.8%; pandemic: 57.0% vs. 78.6%), present to their scheduled appointment (prepandemic: 52.7% vs. 73.7%; pandemic: 48.1% vs. 74.8%), and cancel vs. no-show (prepandemic: 30.8% vs. 68.2%, pandemic: 64.3% vs. 78.3%). On multivariable analysis, African American patients were less likely (odds ratio 0.37, 95% confidence interval 0.28-0.50) and telehealth users were more likely (odds ratio 1.54, 95% confidence interval 1.04-2.27) to present to their appointments vs. no-show or cancel when controlling for insurance type and timing relative to the onset of the pandemic.

CONCLUSION

Telehealth implementation during the coronavirus disease 2019 pandemic decreased the overall no-show rate, but this shift did not apply to African American patients. This analysis highlights disparities in insurance coverage, telehealth utilization, and presentation for an initial consultation in the African American population during the pandemic.

Standard-Dose Azithromycin in Class III Obese Patients Undergoing Unscheduled Cesarean Delivery

OBJECTIVE

 Perioperative antibiotic prophylaxis reduces cesarean wound complications. This study investigates whether integration of standard-dose (500 mg) azithromycin prophylaxis reduced wound complications in patients with class III obesity (body mass index [BMI] ≥ 40 kg/m2) undergoing unscheduled cesarean delivery.

STUDY DESIGN

 Retrospective cohort study of patients with class III obesity undergoing unscheduled cesarean delivery in single hospital system from January 1, 2017, to January 1, 2020. A standard dose (500 mg) of azithromycin was integrated into system order sets in 2018. Medical history and postoperative wound outcomes were compared in pre- and postintegration cohorts. Wound complication was defined as composite of wound seroma, hematoma, superficial or deep infection.

RESULTS

 A total of 1,273 patients met inclusion criteria, 303 patients in the preorder set group, and 970 patients in the postorder set group. Demographics were similar between the pre- and postintegration cohorts, including BMI (median: 44.4 kg/m2, p = 0.84) and weight at delivery (mean: 121.2 ± 17.8 kg, p = 0.57). Patients in the postintegration cohort had lower rates of composite postpartum wound complication (7.9 vs. 13.9%, p = 0.002), superficial infection or deep infection/abscess (6.7 vs. 10.2%, p = 0.042), and postpartum readmission or unscheduled visits (18.7 vs. 24.4%, p < 0.029). Rates of chorioamnionitis and endometritis were similar between the pre- and postintegration groups (8.6 vs. 6.9%, p = 0.33, and 1.7 vs. 1.9%, p = 0.81, respectively). Patients in the postintegration cohort had lower risk of postoperative composite wound complication (unadjusted odds ratio [OR]: 0.54, confidence interval [CI]: 0.36-0.80, p = 0.002) and lower rates of wound infection (unadjusted OR: 0.63, 95% CI: 0.40-0.99, p = 0.044). When comparing patients who received azithromycin at delivery and patients who did not, standard-dose azithromycin reduced risk of postoperative wound complication (unadjusted OR: 0.67, 95% CI: 0.46-0.99, p = 0.043).

CONCLUSION

 A standard dose of azithromycin provides adequate perioperative prophylaxis in class III obese patients, decreasing rates of postcesarean wound complications and unscheduled postpartum outpatient visits.

KEY POINTS

· Class III obese patients undergoing unscheduled cesarean have high rates of wound complications.. · Standard-dose azithromycin reduces risk of postcesarean wound infection in class III obese patients.. · Standard-dose azithromycin reduces readmission, unscheduled visits in class III obese patients..

Unrestricted Ketogenic Diet Feeding Enhances Epithelial Ovarian Cancer Growth In Vivo

The ketogenic diet (KD) is hypothesized to impact tumor progression by altering tumor metabolism. In this study, we assessed the impact of an unrestricted KD on epithelial ovarian cancer (EOC) tumor growth, gene expression, and metabolite concentration in a mouse model. ID8 EOC cells, which were syngeneic with C57Bl/6J mouse strain and transfected with luciferase (ID8-luc), were injectedand monitored for tumor development. Female mice were fed either a strict KD, a high fat/low carbohydrate (HF/LC) diet, or a low fat/high carbohydrate (LF/HC) diet (n = 10 mice per group) ad libitum. EOC tumor growth was monitored weekly, and tumor burden was determined based on luciferase fluorescence (photons/second). At the endpoint (42 days), tumors were collected and processed for RNA sequencing. Plasma and tumor metabolites were evaluated using LC-MS. The KD-fed mice exhibited a statistically significant increase in tumor progression in comparison to the HF/LC- and LF/HC-fed groups (9.1 vs. 2.0 vs. 3.1-fold, respectively, p < 0.001). The EOC tumors of the KD-fed mice exhibited significant enrichment of the peroxisome proliferator-activated receptor (PPAR) signaling and fatty acid metabolism pathways based on the RNA sequencing analysis when compared to the LF/HC- and HF/LC-fed mice. Thus, unrestricted KD diet enhanced tumor progression in our mouse EOC model. KD was associated with the upregulation of fatty acid metabolism and regulation pathways, as well as enrichment of fatty acid and glutamine metabolites.

Who Places High Value on the Uterus? A Cross-sectional Survey Study Evaluating Predictors for Uterine Preservation

STUDY OBJECTIVE

To determine predictors for placing high value on the uterus in patients who no longer desire fertility. The secondary objective was to identify reasons for placing high value on the uterus.

DESIGN

Cross-sectional survey study.

SETTING

Three hospitals within a large healthcare system in the United States.

PATIENTS

New patients ≥45 years old seeking care for benign gynecologic conditions, including abnormal uterine bleeding, uterine myomas, pelvic organ prolapse, endometriosis, or pelvic pain.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the summative score of the validated Value of Uterus (VALUS) instrument for measuring value placed on the uterus and the validated visual analog scale with the question "how important is it to you to keep your uterus when you have a gynecologic condition?" A total of 163 surveys were returned for analysis (79.2%). Using the VALUS cutoff, 64 patients (45.7%) were considered to have low value for their uterus (VALUS score <14), whereas 76 patients (54.3%) were considered to have high value for their uterus (VALUS score ≥14). The adjusted odds of placing high value for the uterus was 5.06 times higher among those who wanted to be sexually active in the future than those who do not desire to be sexually active (95% confidence interval, 1.55-16.52, p = .01). Patients who are sexually active have 3.94 higher adjusted odds of placing high value on the uterus than those who are not sexually active and do not desire to be (95% confidence interval, 1.36-11.43; p = .01). Race, religion, and personal history of cancer were not statistically significant.

CONCLUSION

Patients who highly value the uterus were highly motivated by the desire to be sexually active. Nonwhite race, religion, and personal history of cancer were not predictors for placing high value on uterine preservation.

Association between CT-based body composition assessment and patient outcomes during neoadjuvant chemotherapy for epithelial ovarian cancer

OBJECTIVE

The aim of this study was to characterize the body composition of patients undergoing neoadjuvant chemotherapy (NACT) for epithelial ovarian cancer (EOC), identify factors associated with sarcopenia at diagnosis, and evaluate the impact of pretreatment sarcopenia and changes in body composition parameters during therapy on perioperative and disease-related outcomes.

METHODS

Patients undergoing NACT for EOC between 2008 and 2020 were identified. Pre-treatment and post-treatment contrast-enhanced CT scans were reviewed to determine skeletal muscle index (SMI) and visceral adipose tissue (VAT) area at the mid-fourth lumbar vertebral level. SMI and VAT were analyzed for association with clinical and treatment variables.

RESULTS

174 patients were identified. Mean pretreatment SMI and VAT were 38.3 cm²/m² ± 7.9 and 51.2 cm²/m² ± 34.3, respectively. Comparatively, mean post-treatment SMI and VAT were 37.8 cm²/m² ± 7.9 and 43.7 cm²/m² ± 29.7, respectively. Most patients exhibited an overall decrease in SMI from pretreatment to posttreatment scans. Caucasian race, older age, and lower body mass index at diagnosis were associated with lower pretreatment SMI. Lower pre-treatment SMI was associated with lower surgical complexity scores (p < 0.001) and estimated blood loss (p = 0.029). Decrease in SMI after NACT was associated with increased rates of ICU admissions and length of stay. While there was no association between SMI and overall survival (OS) or progression-free survival (PFS), >2% decrease per 100 days in VAT was significantly associated with worse OS.

CONCLUSIONS

Patients with lower pretreatment SMI tend to undergo less complex surgery than those with higher SMI despite NACT. Decrease in VAT may be a potential indicator of worse OS. Information on body composition can aid in clinical decision making in patients with EOC.

Disruption of the Gut Microbiota Confers Cisplatin Resistance in Epithelial Ovarian Cancer

Epithelial ovarian cancer (EOC) is the leading cause of gynecologic cancer death. Despite initial responses to intervention, up to 80% of patient tumors recur and require additional treatment. Retrospective clinical analysis of patients with ovarian cancer indicates antibiotic use during chemotherapy treatment is associated with poor overall survival. Here, we assessed whether antibiotic (ABX) treatment would impact growth of EOC and sensitivity to cisplatin. Immunocompetent or immunocompromised mice were given untreated control or ABX-containing (metronidazole, ampicillin, vancomycin, and neomycin) water prior to intraperitoneal injection with EOC cells, and cisplatin therapy was administered biweekly until endpoint. Tumor-bearing ABX-treated mice exhibited accelerated tumor growth and resistance to cisplatin therapy compared with control treatment. ABX treatment led to reduced apoptosis, increased DNA damage repair, and enhanced angiogenesis in cisplatin-treated tumors, and tumors from ABX-treated mice contained a higher frequency of cisplatin-augmented cancer stem cells than control mice. Stool analysis indicated nonresistant gut microbial species were disrupted by ABX treatment. Cecal transplants of microbiota derived from control-treated mice was sufficient to ameliorate chemoresistance and prolong survival of ABX-treated mice, indicative of a gut-derived tumor suppressor. Metabolomics analyses identified circulating gut-derived metabolites that were altered by ABX treatment and restored by recolonization, providing candidate metabolites that mediate the cross-talk between the gut microbiome and ovarian cancer. Collectively, these findings indicate that an intact microbiome functions as a tumor suppressor in EOC, and perturbation of the gut microbiota with ABX treatment promotes tumor growth and suppresses cisplatin sensitivity.

SIGNIFICANCE

Restoration of the gut microbiome, which is disrupted following antibiotic treatment, may help overcome platinum resistance in patients with epithelial ovarian cancer. See related commentary by Hawkins and Nephew, p. 4511.

The impact of obesity and adipokines on breast and gynecologic malignancies

The link between obesity and multiple disease comorbidities is well established. In 2003, Calle and colleagues presented the relationship between obesity and several cancer types, including breast, ovarian, and endometrial malignancies. Nearly, 20% of cancer-related deaths in females can be accounted for by obesity. Identifying obesity as a risk factor for cancer led to a focus on the role of fat-secreted cytokines, known as adipokines, on carcinogenesis and tumor progression. Early studies indicated that the adipokine leptin increases cell proliferation, invasion, and inhibition of apoptosis in multiple cancer types. As a greater appreciation of the obesity-cancer link has amassed, we now know that additional adipokines can impact tumorigenesis. A deeper understanding of the adipokine-activated signaling in cancer may identify new treatment strategies irrespective of obesity. Moreover, adipokines may serve as disease biomarkers, harnessing the potential of obesity-associated factors to serve as indicators of treatment response and disease prognosis. As studies investigating obesity and women's cancers continue to expand, it has become evident that breast, ovarian, and uterine cancers are distinctly impacted by adipokines. While complex, these distinct interactions may provide insight into cancer progression in these organs and new opportunities for targeted therapies. This review aims to organize and present the literature from the last 5 years investigating the mechanisms and implications of adipokine signaling in breast, endometrial, and ovarian cancers with a special focus on leptin and adiponectin.

Sex-Specific Differences in Low Grade Glioma Presentation and Outcome

PURPOSE

In addition to established prognostic factors in low-grade glioma (LGG), studies suggest a sexual dimorphism with male sex portending worse prognosis. Our objective was to identify the impact of sex on presentation and outcomes in LGG.

METHODS

We conducted a retrospective cohort study of adults (aged ≥ 18 years) diagnosed with LGG (WHO 2016 grade 2 glioma). Patients with IDH wildtype tumors were excluded. Patients were matched between male and female sex by age, treatment, and surgery via propensity score matching. Patient, tumor, and treatment characteristics were analyzed by sex. Endpoints included overall survival (OS), next intervention free survival (NIFS), progression free survival (PFS), and malignant transformation free survival (MTFS). Kaplan Meier analyses and Cox proportional hazards regression multivariable analysis (MVA) with backwards elimination was completed.

RESULTS

Of the 532 patients identified, 258 (48%) were male. Males were more likely to present with seizure (69.38% vs. 56.57%, p = 0.002), but no other statistically significant differences between sexes at presentation were identified. 5-year OS was higher in females at 87% (95% CI 83%-91%) versus 78% (95% CI 73-84%) in males (p=0.0045). NIFS was significantly higher in female patients at 68% (95% CI 62-74%) versus 57% (95% CI 51%-64%) in males (p = 0.009). On MVA, female sex was independently associated with improved OS (HR 1.54, 95% CI 1.16-2.05; p= 0.002), NIFS (HR 1.42, 95% CI 1.42; p= 0.004), and MTFS (HR 1.62, 95% CI 1.24-2.12; p= 0.0004). In patients with molecularly defined LGG (IDH and 1p19q status) (n = 291), female sex remained independently associated with improved OS (HR 1.79, 95% CI 1.16-2.77; p = 0.008) and NIFS (HR 1.45, 95% CI 1.07-1.96; p = 0.016).

CONCLUSIONS

In this study, female sex was independently associated with improved outcomes. These findings support intrinsic sex-specific differences in LGG behavior, justifying further studies to optimize management and therapeutics based on sex.

Evaluation of Closure Technique on Incidence of Incisional Hernia Following Single Port Laparoscopy in Gynecologic Oncology Surgery

STUDY OBJECTIVE

To evaluate incidence and risk factors for incisional hernia in women undergoing single-port laparoscopy (SPL) for gynecologic oncology indications with a standardized fascia closure (SC) technique versus historical controls (HC).

DESIGN

Retrospective cohort study.

SETTING

Single academic institution.

PATIENTS

Women who underwent SPL from 6/1/2017-12/31/2019 for gynecologic oncology indications with SC were compared to HC who underwent SPL from 1/1/2009-12/31/2015.

INTERVENTIONS

Data was collected for patient demographics, postoperative outcomes, and incisional hernia development. Univariate analysis and multivariable regression models were built for predictors of incisional hernia.

MEASUREMENTS AND MAIN RESULTS

Of 1,163 patients, 242 (20.8%) patients had SC and 921 (79.2%) patients had HC. SC cohort had lower rates of diabetes versus HC (10.3% vs. 15.3%; p = .049) but no differences in hypertension (36.8% vs. 43.0% p = .081) and obesity (42.6% vs. 36.9%, p = .11). 1,123 (96.6%) patients did not undergo conversion to multi-port laparoscopy or laparotomy, of whom 7.2% (n=81) of patients developed an incisional hernia; there was no difference in incisional hernia development for SC with SPL (n= 237) versus HC with SPL (n= 886) (9.7% vs. 6.5%, p = .095). On multivariable analysis, increased BMI (OR 1.06; 95% CI 1.03-1.09, p < .001) and diabetes (OR 2.41; CI 1.34-4.32, p = .003) were associated with incisional hernia, but age (OR 1.00; CI .98-1.02, p = .92), length of surgery (OR 1.00; CI 1.00-1.01, p = .62), and hypertension (OR .89; CI .52-1.53, p = .68) were not. Patients with prior abdominal surgeries (OR 1.92; CI 1.14-3.26, p = .015) and hand-assist surgery (OR 3.17; CI 1.48-6.80, p = .003) were significantly associated with incisional hernia.

CONCLUSION

Implementation of a SC protocol did not decrease rate of incisional hernia versus HC during SPL. Risk of incisional hernia must be considered for SPL planning in patients with complex medical comorbidities and prior abdominal surgery.

Randomized comparison of proximal and distal radial access for coronary angiography and interventions

Funding Acknowledgements

Type of funding sources: None.

Introduction

Vascular access for coronary procedures is of paramount important not only for successful procedure but also to prevent complications. In comparison to femoral access, proximal radial artery (PRA) access at wrist is associated with decreased bleeding complications and mortality.  The most important complication of PRA access is radial artery occlusion Use of the proximal radial artery (PRA) approach at wrist has several limitations:  the need to supinate the hand, which can exacerbate chronic joint pain, the depth of the radial artery in large arms, which could make arterial puncture challenging even under ultrasound guidance, the risk of sporadic bleeding in the forearm, and the risk of radial artery occlusion. All above limitations can be overcome by distal radial artery (DRA) access in anatomical snuff box.  Randomized Studies are lacking for the comparison between DRA and PRA approach in coronary procedures.

Aims and objective

To compare safety, efficacy and feasibility between PRA and DRA approach in randomized fashion.

Material and methods

This was single center randomized controlled trial. 320 patients were randomized in PRA and DRA groups. PRA approach was in wrist and DRA approach was in anatomical snuff box. Primary endpoint was cannulation failure (failure to achieve radial access) and transradial failure (failure to complete procedure after successful access). Secondary safety outcome includes major (compartment syndrome, need for vascular surgery, hand dysfunction, nerve palsy ,arteriovenous fistula, hematoma requiring blood transfusion, proximal radial artery occlusion) and minor (radial artery spasm, hematoma not requiring transfusion or causing compartment syndrome, ecchymosis, local edema, paresthesia, pseudoaneurysm) complications; secondary efficacy outcome were puncture attempts, cannulation time, procedure time, radiation dose, hemostasis time  and quality of life endpoint  was pain score .

Results

 Each group was having 160 patients. In DRA group 73.9 % were CAG and 26.1 % were PCI; in PRA group and 75.7 were CAG and 24.3 were PCI. Cannulation failure was more in DRA group (7.5 % vs 2.5 %, P &lt; 0.001) without difference in transradial failure (n = 3 vs 4, p =0.764). There were no major complications in both groups except PRAO which was significantly less in DRA group (0 % vs 5.2 %, p= 0.007). Puncture attempts, cannulation time, pain score were more in DRA (1.65 vs 1.29, P &lt; 0.001;3.23 vs 2.62 minutes, p &lt; 0.001;25.5 vs 21.6 minutes, p = 0.039 respectively). There was no significant difference for minor complications in both groups.

Conclusion

DRA approach is as safe and feasible as PRA approach and causes significantly less PRAO. DRA approach may be advocated as default approach where radial access is chosen for coronary procedures. Abstract Figure. primary outcome  Abstract Figure. Procedural characteristic

Clinical significance of epicardial fat in suspected angina pectoris: an observational study

Funding Acknowledgements

Type of funding sources: None.

Background

Epicardial adipose tissue (EAT) is the visceral fat between pericardium and visceral epicardium and is the source of several endocrine and inflammatory mediators. It also has paracrine affects in the neighboring coronary arteries.

Objective

 To evaluate the association of EAT with subclinical atherosclerosis (carotid intima media thickness & flow mediated vasodilation), ultrasonic and anthropometric measures of abdominal fat, metabolic syndrome and coronary artery disease (CAD) concurrently.

Material and methods

Patients who underwent computed tomography (CT) coronary angiography for suspected CAD were prospectively included. All underwent anthropometric measurements, laboratory investigations, ultrasonic measurement of liver fat grade & B-mode hepatorenal ratio, carotid intima media thickness (CIMT), flow mediated vasodilation (FMD), CT measurement of epicardial fat thickness (EFT) & epicardial fat volume (EFV) along with CT coronary angiography. Study population was divided into 2 groups on the basis of presence or absence of CAD and were compared. The relationship between risk factors and presence of CAD was assessed by logistic regression analysis. To define EFT and EFV value predictive of the presence of significant CAD, the area under (AUC) the receiver operating characteristic (ROC) curve was calculated. Correlation between EFT as well as EFV with anthropometric and laboratory parameters, CIMT and FMD were assessed by Pearson correlation coefficient.

Results

Total 54 patients were included in study. Mean age was 54 years, 66% were diabetic and 33% were hypertensive. Mean CIMT, FMD, EFT and EFV were 0.70 + 0.27 cm; 5.64 + 2.64%; 5.51 + 2.50 mm and 60.6 + 28.6 cc, respectively. Total 34 (62.96%) patients were detected to have CAD. EFT as well as EFV were significantly higher in CAD group (3.31 + 2.34 vs 6.24 + 1.91mm; p= &lt;0.001, 72.5 + 22.3 vs 40.4 + 27.1cc; p= &lt;0.001); in patients with metabolic syndrome (83.3 + 18.4 vs 49.2 + 26.1cc; p &lt; 0.001, 7.13 + 1.49 vs 4.16 + 2.32mm; p &lt; 0.001). Both, EFV & EFT were significantly correlated with the abdominal fat, CIMT and FMD. Smoking, age and EFV were the independent predictors for CAD.  EFV &gt;31.65cc predicted the presence of CAD (sensitivity 91.25%, specificity 60%, AUC = 0.798, 95% CI = 0.665-0.930) and EFT &gt;2.85mm predicted the presence of CAD (sensitivity 94.1%, specificity 65%, AUC= 0.820, 95% CI= 0.687-0.953).

Conclusions

Epicardial fat is significantly associated with presence of CAD, metabolic syndrome, visceral fat, CIMT and FMD. CT measured epicardial fat may be included with CT based CAD lesion assessment and CT coronary calcium score to screen the patients of suspected angina pectoris. Abstract Figure. Epicardial adipose tissue  Abstract Figure. EFV and CAD

Distal radial access in the right anatomical snuffbox for coronary angiography and interventions: a prospective observational study

Background

Distal radial access in the anatomical snuffbox is a novel technique for vascular access. However, limited clinical data is available, mainly limited to the left distal radial access. In view of the paucity of data on right distal radial access; this study was conducted to assess the feasibility, efficacy and safety of the right distal radial approach as a default access route for transradial catheterization.

Methods

We enrolled 159 consecutive patients with a palpable right distal radial pulse prospectively at a single center. A detailed clinical evaluation, laboratory tests and echocardiographic examination was done. Doppler examination of distal radial artery for its patency and size was done before puncture attempt. The right distal radial artery was punctured using the back wall technique. Primary outcome was successful puncture of distal right radial artery. Secondary outcomes were number of puncture attempts, pain score, radial artery spasm, forearm and distal radial hematoma, proximal and distal radial artery occlusion, bleeding and other vascular complications, access site crossover due to distal radial access failure, contrast volume used, and radiation dose.

Results

Distal radial puncture was successful in 144/159 (90.1%) patients. The mean distal radial artery diameter was 2.2±0.25 mm. Mean pain score by visual analogue scale was 2.36±1.9. There were no bleeding events. Snuffbox hematoma was seen in 11 (7.6%) patients and forearm hematoma occurred in 5 (3.5%) patients. There were 9 (6.3%) cases of radial spasm, 4 (2.8%) cases of radial occlusion at distal access site and 1 (0.7%) forearm radial artery occlusion.

Conclusions

The right distal radial access is a feasible, safe and efficacious alternative approach for coronary angiogram and interventions.

Funding Acknowledgement

Type of funding sources: None.

The Microbiome and Gynecologic Cancer: Current Evidence and Future Opportunities

PURPOSE OF REVIEW

We review the emerging evidence regarding the relationship between the microbiota of the gastrointestinal and female reproductive tracts and gynecologic cancer.

RECENT FINDINGS

The microbiome has essential roles in maintaining health. In recent years, the microbiota of the gastrointestinal and female reproductive tracts have been linked to many diseases, including gynecologic cancer. Alterations to the bacterial populations in a microbiota, or dysbiosis, have been shown to favor a pro-carcinogenic state through altered immune responses, dysregulated hormone metabolism, and modulation of the cell cycle. Pre-clinical and clinical studies have emerged, demonstrating that specific bacteria or microbial communities may be associated with increased risk for uterine, ovarian, and cervical cancers. Notably, numerous studies have linked a non-Lactobacillus-dominant vaginal microbiota, composed of anaerobic bacteria, with HPV infection, persistence, and development of invasive cervical cancer. Similarly, next-generation high-throughput sequencing techniques have enabled the characterization of unique microbiotas in patients with malignant and benign gynecologic conditions, shedding light on new associations between bacterial species and gynecologic cancers. Harnessing the power of the microbiome for early diagnosis, therapeutic intervention and modulation creates tremendous potential to optimize gynecologic cancer outcomes in the future.

925 Is Routine Bloods Group and Save Required for Emergency Appendicectomy?

Introduction

Appendicectomy is commonly a safe and low bleeding risk procedure. However, some hospital guidelines stipulate a requirement for routine pre-operative blood group and save (G&S).We aim to determine if pre-operative G&S is required for appendicectomies by looking at the number of tests vs transfusion conducted.The cost of G&S is £4.14 per sample in our trust.

Method

A retrospective review was conducted over a 3-month period. Patient data and demographics were identified using the hospital coding, theatre records and transfusion departments.

Results

118 consecutive appendicectomies were identified. Of which, 99 laparoscopic vs 19 open (13 started open vs 6 converted to open) operations were performed. No patients required a blood transfusion during their admission. There was a total of 219 G&S conducted. Cross matching tests for these procedures cost a total of £906. We estimate a cost projection of £3624 for G&S tests over a year and £18120 over 3 years.

Conclusions

Bleeding complications requiring transfusion following appendicectomies are very uncommon. In our unit, 0% of patients identified required a transfusion during their admission. We suggest stopping routine pre-operative G&S for these patients would be clinically safe and would lead to financial savings and reduce pre-operative waiting time.

902 Too Hot to Handle? Acute Cholecystitis (‘Hot Gallbladder’) Management and Compliance with NICE Guidelines in A District General Hospital

Introduction

Current NICE guidelines recommend that patients with acute cholecystitis should be offered laparoscopic cholecystectomy within 1 week of diagnosis. However, the recommendation is often not met within our trust. We aim to investigate our compliance with these guidelines while outlining the complications and cost effects associated with delayed operation.

Method

A retrospective study identifying emergency patients presenting with image proven uncomplicated acute cholecystitis was performed. Hospital coding and finance departments were used to obtain this information.

Results

166 patients were identified within a 3-month period. Of which, 85 patients were diagnosed with acute uncomplicated cholecystitis and fulfilled the inclusion criteria. On average, patients waited 108 days for their cholecystectomies (range 14-281). No patients received a cholecystectomy within 1 week of diagnosis. 33 patients re-presented to hospital at least once and the total number of repeated admissions was 51. The average length of stay during readmissions was 6 days (range 1-27). The total cost incurred for those readmissions was £117,118.

Conclusion

Risk factors for ureteral obstruction and the diagnostic value of the "cysto-under-tension" technique at the time of uterosacral colpopexy

INTRODUCTION AND HYPOTHESIS

The objective is to determine the incidence of ureteral obstruction and delayed ureteral injury and to identify risk factors for ureteral obstruction following uterosacral colpopexy. The secondary objective is to evaluate the diagnostic value of the "cysto-under-tension" technique, when a cystoscopy is performed prior to vaginal cuff closure with the uterosacral sutures on tension.

METHODS

This was a retrospective review of patients undergoing uterosacral ligament colpopexy between 2007 and 2012 with a nested case-control analysis. Patients with documented ureteral obstruction on cystoscopy or a delayed ureteral injury were identified. Cases were defined as patients with a ureteral obstruction on cystoscopy and controls as those who did not; a multivariable regression analysis was performed.

RESULTS

A total of 551 patients underwent uterosacral ligament colpopexy. Twenty-four (4.3% [95% CI = 2.94-6.40]) patients had a ureteral obstruction on cystoscopy, and two (0.4% [95% CI = 0.09-1.31]) patients experienced a delayed ureteral injury. The "cysto-under-tension" technique was used in 40 (7.3%) cases, with a sensitivity of 50.0% (CI = 1.26-98.74) and specificity of 97.4% (CI = 86.2-99.9) to detect ureteral obstruction. On logistic regression for the case-control analysis, increased age remained associated with increased odds of ureteral obstruction (adjOR 1.06, 95% CI = 1.02-1.11) and a higher BMI had lower odds (adjOR 0.89, 95% CI = 0.79-0.98).

CONCLUSIONS

In this large cohort study, older age was associated with higher odds of obstruction at the time of colpopexy while a higher BMI might have been protective. The "cysto-under-tension" technique overall may not be that useful in detecting ureteral obstructions but has high negative predictive value.

NCOG-30. ADJUVANT VERSUS SALVAGE MANAGEMENT FOR IDH-MUTANT LOW GRADE GLIOMA

PURPOSE

Timing of postoperative treatment in low-grade glioma (LGG) remains controversial. We sought to evaluate outcomes between adjuvant versus salvage management among patients with IDH-mutant molecularly-defined LGG.

METHODS

We analyzed a single-institutional database of adults diagnosed with LGG (grade II) with an IDH-mutation and either 1p19q-codeletion (oligodendroglioma) or 1p19q-intact (astrocytoma). Cox multivariable analysis (MVA) accounting for age, sex, and extent-of-resection, was used to compare adjuvant versus salvage approaches on overall survival (OS), progression free survival (PFS), next-intervention free survival (NIFS, defined as intervention subsequent to either adjuvant or salvage treatment), and malignant-transformation free survival (MTFS). Adjuvant treatment was defined as immediate postoperative treatment with radiotherapy (RT) and/or temozolomide (TMZ) prior to progression. Salvage management was defined as postoperative observation followed by surgery or RT and/or TMZ at progression.

RESULTS

Of 162 patients with oligodendroglioma, median follow-up was 8.5 years (range, 0.03-25.7). Adjuvant treatment was given to 97 (59.9%) patients, with 65 (40.1%) undergoing a salvage approach. On MVA, adjuvant treatment was not associated with OS, PFS, NIFS, or MTFS (p &gt; 0.05 each). Among 82 patients with astrocytoma, median follow-up was 6.1 years (range, 0.5–25.7), and adjuvant treatment was administered to 41 (50.0%) patients, while 41 (50.0%) received salvage management. On MVA, adjuvant treatment was associated with improved PFS (HR 0.42, 95% CI 0.24-0.73, p &lt; 0.001) and NIFS (HR 0.35, 95% CI 0.18–0.65, p &lt; 0.001), but was not associated with OS or MTFS (p &gt; 0.05 each).

CONCLUSIONS

Among grade II, IDH-mutant oligodendrogliomas, initial postoperative observation followed by salvage treatment at progression may be appropriate, as immediate adjuvant therapy was not associated improved outcomes. However, a more individualized postoperative management approach is required for grade II, IDH-mutant astrocytomas, as adjuvant treatment was associated with improved PFS and NIFS, but not OS. Further validation and prospective studies are required.

The correlation between molecular characteristics and treatment outcomes in patients (pts) with grade 2-3 (G2-3) gliomas

e14551

Background: In a retrospective study, we investigated the correlation between the molecular characteristics and treatment outcomes in pts with G2-3 glioma. Methods: Pts with G2-3 glioma and known IDH mutation status who were diagnosed between 1994 and 2017 were analyzed. In most of the pts, IDH mutation was determined by immunohistochemistry only. Overall survival (OS) was defined as the date of biopsy/surgical resection to the date of last follow up or death. OS was estimated by Kaplan-Meier method and compared by log rank test. Results: 606 pts with G2 (81%) or G3 (19%) glioma were included. The median age at diagnosis was 38 years (Interquartile range 27-52), 55% of the pts were male, 83% were white, 47% had IDH-mt tumor and 67% underwent surgical resection. The median follow-up was 55.6 months (mo). The median OS (mOS) in pts with IDH mutated (mt) and IDH wild type (wt) tumor were 201 and 128 mo, respectively. The predictors of worse OS in pts with IDH-mt tumor included G3, receipt of chemotherapy or radiation therapy (RT), bilateral disease and lack of 1p/19q codeletion. The determinants of worse OS in pts with IDH-wt tumor included male gender, receipt of chemotherapy or RT, history of prior malignancy, smoking, G3, astrocytoma histology, no surgical resection, EGFR amplification, and lack of 1p/19q codeletion. The mOS by IDH, 1p/19q, and MGMT status is summarized in the table. RT and chemotherapy were more commonly used among pts who had G3 glioma and those who underwent biopsy only. Conclusions: Tumor grade continues to be a determinant of pt outcomes in the setting of molecularly defined gliomas. Presence of 1p/19q codeletion is a predictor of favorable OS in pts with G2-3 glioma. Surgical resection is a determinant of OS in pts with IDH-wt G2-3 gliomas, but not in pts with IDH-mt tumor. The worse OS in pts who were treated with RT or chemotherapy is likely due to the use of these treatment modalities in more aggressive tumors and in those who only had biopsy. [Table: see text]

Cardiological Society of India: Document on acute MI care during COVID-19

The unprecedented and rapidly spreading Coronavirus Disease-19 (COVID-19) pandemic has challenged public health care systems globally. Based on worldwide experience, India has initiated a nationwide lockdown to prevent the exponential surge of cases. During COVID-19, management of cardiovascular emergencies like acute Myocardial Infarction (MI) may be compromised. Cardiological Society of India (CSI) has ventured in this moment of crisis to evolve a consensus document for care of acute MI. However, this care should be individualized, based on local expertise and governmental advisories.

P41 Correlation of doppler ultrasound assessment of carotid femoral pulse wave velocity with coronary artery disease

Funding Acknowledgements

self

Background

Arterial stiffness is an important cardiovascular risk factor. Carotid femoral pulse wave velocity (cfPWV) is simple noninvasive  method to determine aortic stiffness. Arterial stiffness measures, cfPWV in particular,  have been found to be correlate with stroke and peripheral artery disease. Usually SphygmoCor or Complior are used to calculate cfPWV. Doppler ultrasound can serve as an alternative to these methods. 

Purpose

To assess cfPWV using doppler ultrasound and study its correlation with coronary artery disease and its severity. 

Methods

cfPWV was assessed by ultrasound Doppler in patient aged 20-70 years undergoing coronary angiography.  cfPWV was measured by sequential recordings of arterial pressure waveform at the carotid and femoral arteries with a Doppler ultrasound with ECG gating and calculated as the distance between the carotid and the femoral sampling site divided by the time interval. 

Result

Of the 358 subjects studied, 243 had coronary artery disease(CAD) (&gt;50% diameter stenosis) and were further divided into single, double or triple vessel disease groups. 115 patients  had mild CAD (&lt; 50% stenosis) or no CAD and served as controls. Baseline characteristics were similar except diabetes (more common in CAD group)(39.09% v/s 27.82%). cfPWV was found to increase with age in all groups. cfPWV was not significantly affected  by sex, diabetes, dyslipidemia, BMI, smoking or hypothyroidism. Mean cfPWV was significantly higher in patients with CAD (8.99 v/s 6.51 m/s, p &lt; 0.001) and hypertensives (8.71 v/s 7.83 m/s, p &lt; 0.001). Patients with triple vessel disease(TVD) had significantly higher cfPWV (10.12 m/s) than those with double(DVD)(8.84 m/s) or single vessel disease(SVD)(8.28m/s)(p &lt; 0.001). Multinomial logistic regression revealed an odds ratio of 2.00, 2.375 and 3.368 respectively for SVD, DVD and TVD groups in comparison to controls (p &lt; 0.001). cfPWV value &gt; 7.25 m/s predicted CAD with sensitivity 78.6 % and specificity 74.8% (AUC =0.848, P &lt; 0.001). 

Conclusion

Carotid femoral pulse wave velocity can be measured noninvasively by ultrasound Doppler. cfPWV increases with age and hypertension and has strong correlation with coronary artery disease and its severity. The cfPWV can be an independent risk factor and may be utilized for cardiovascular risk prediction.

Abstract P41 Figure. cfPWV in various subgroups.

The effect of an intraorifice barrier and base under coronal restorations on the healing of apical periodontitis: a randomized controlled trial

AIM

To evaluate the effect of intraorifice barriers and bases on the healing of apical periodontitis following root canal treatment in mandibular molars.

METHODOLOGY

A total of 120 permanent mandibular molars with necrotic pulps and periapical radiolucencies (PAI score ≥ 3) were recruited. Root canal treatment was performed in all teeth using a standard protocol, following which they were randomly allocated to one of the three treatment groups: intraorifice barrier group: coronal 3-mm gutta-percha was removed and replaced with glass-ionomer cement (GIC) barrier. The floor of the pulp chamber was then sealed with 2-mm-thick GIC base followed by final composite resin restoration; base group: received 2-mm-thick GIC base before placement of composite resin restoration; and control group: had pulp chamber entirely filled with composite resin only. Follow-up was done at 3, 6, 9 and 12 months. Combination of clinical and radiographic parameters were used to assess treatment outcome. The data were analysed using Kruskal-Wallis, chi-square and Wilcoxon signed-rank tests and logistic regression analysis.

RESULTS

At the end of 12 months, the base group had the most favourable healing (97.1%), whilst the control group had the least favourable healing (83.8%). The intraorifice barrier group had healing of 92.1%. However, there was no significant difference in healing between groups at the end of the follow-up period (P > 0.05). Additional subgroup analysis revealed a nonsignificant effect of periodontal status and root filling level on periapical healing.

CONCLUSION

The use of an additional barrier under permanent restorations did not significantly improve the outcome of primary root canal treatment in posterior teeth after 12 months. However, its influence in the long term requires further evaluation.

P1496Use of strain, strain rate, tissue velocity imaging and endothelial function for early detection of cardiovascular involvement in young diabetics

Background

Subtle structural and functional changes may precede the onset of overt global left ventricular dysfunction and obvious reduction of ejection fraction (EF), especially in young diabetics. Data pertaining to tissue velocity indices (TVI) and strain imaging to assess regional myocardial function and flow mediated vasodilatation is limited in young patients with diabetes.

Purpose

To evaluate conventional echocardiography parameters, tissue doppler indices, global and regional strain, carotid intimal medial thickness (CIMT), endothelial dependent (FMD) and independent function (NMD) of brachial artery in young patients (age <18 years) with type 1 diabetes and compare them with matched controls.

Methods

Conventional echocardiography parameters, tissue velocity indices (TVI) parameters along with strain (S), and strain rate (SR) in basal and mid left ventricular (LV) lateral wall, right ventricular (RV) lateral wall and septum were measured in 50 young diabetics (age 15.16±2.95 years, mean HBA1c 8.15±1.37 gm %) and 25 controls (age 15.60±2.51 years). Flow-mediated dilatation (FMD), nitrate mediated dilatation and carotid intimal media thickness (CIMT) were also estimated.

Results

Conventional echocardiography parameters were similar in patients and controls however deceleration time of the mitral inflow velocity (EDT) was significantly shorter in patients when compared with controls (149.06±31.66 vs. 184.56±19.27 ms, p<0.05). Lateral early diastolic myocardial velocity (LV-Em) was significantly lower (10.30±0.99 vs. 11.67±3.21, p<0.05) whereas lateral late diastolic myocardial velocity (LV-Am) was significantly higher than controls (11.73±1.44 vs. 8.82±1.69, p<0.05), thus a significantly lower ratio of early/late diastolic velocity at the basal segment of lateral LV (LV-Em/Am). Lower strain values at the basal lateral LV (21.39±4.12 vs. 23.78±2.02; p<0.05), mid lateral LV (21.43±4.27 vs. 23.17±1.92; p<0.05), basal septum (20.59±5.28 vs. 22.91±2.00; p<0.05), and mid septum (22.06±4.75 vs. 24.10±1.99; p<0.05) as compared to controls. SR at the basal and mid segments of the lateral LV wall and at the basal septum were also significantly lower in diabetic subjects. Strain rate (SR) in mid septal, basal and mid RV were lower than controls although not statistically significant. Patients also had significantly lower flow mediated dilatation (FMD) (8.36±4.27 vs. 10.57±4.12, p<0.05) implying endothelial dysfunction.

Strain rate in diabetic patient

Conclusion

Left ventricular strain indices are impaired in asymptomatic children and adolescents with type 1 DM despite absence of overt heart failure and normal ejection fraction. Early detection of subclinical regional myocardial dysfunction by deformation analysis including strain and strain rate may be useful in the asymptomatic diabetic population. In addition, evidence of endothelial dysfunction in the form of impaired flow mediated vasodilatation was observed in the diabetic children.

Acknowledgement/Funding

None

Clinical Effectiveness of a Resin-modified Glass Ionomer Cement and a Mild One-step Self-etch Adhesive Applied Actively and Passively in Noncarious Cervical Lesions: An 18-Month Clinical Trial

OBJECTIVES:

To evaluate the clinical effectiveness of two methods of application of a mild one-step self-etch adhesive and composite resin as compared with a resin-modified glass ionomer cement (RMGIC) control restoration in noncarious cervical lesions (NCCLs).

METHODS:

A total of 294 restorations were placed in 56 patients, 98 in each one of the following groups: 1) G-Bond active application combined with Solare-X composite resin (A-1SEA), 2) G-Bond passive application combined with Solare-X composite resin (P-1SEA), and 3) GC II LC RMGIC. The restorations were evaluated at baseline and after six, 12, and 18 months according to the FDI criteria for fractures/retention, marginal adaptation, marginal staining, postoperative sensitivity, and secondary caries. Cumulative failure rates were calculated for each criterion at each recall period. The effect of adhesive, method of application, and recall period were assessed. The Kruskal-Wallis test for intergroup comparison and Friedman and Wilcoxon signed ranks tests for intragroup comparison were used for each criterion ( α=0.05).

RESULTS:

The retention rates at 18 months were 93.26% for the A-1SEA group, 86.21% for the P-1SEA group, and 90.91% for the RMGIC group. The active application improved the retention rates compared with the passive application of mild one-step self-etch adhesive; however, no statistically significant difference was observed between the groups. Marginal staining was observed in 13 restorations (1 in A-1SEA, 4 in P-1SEA, and 8 in RMGIC) with no significant difference between the groups. The RMGIC group showed a significant increase in marginal staining at 12 and 18 months from the baseline. There was no significant difference between the groups for marginal adaptation, secondary caries, or postoperative sensitivity.

CONCLUSION:

Within the limitations of the study, we can conclude that mild one-step self-etch adhesive followed by a resin composite restoration can be an alternative to RMGIC with similar retention and improved esthetics in restoration of NCCLs. Agitation could possibly benefit the clinical performance of mild one-step self-etch adhesives, but this study did not confirm that the observed benefit was statistically significant.

World Health Organization

The World Health Organization, situated in Geneva, Switzerland, since its establishment on 7 April 1948, is working for the betterment of health and sanitary conditions across the globe through its six regional offices spanning the different continents. It has a well-laid network of trained personnel working in a transparent fashion for its various committees and projects for the eradication of epidemics such as malaria, cholera, and smallpox while providing both quantitative and qualitative data for the preparation of documents on technological, procedural, statistical, and developmental fronts on various health-related issues. It has extended help to the UN in achieving the Millennium Development Goals target and has shown prompt and efficient action against Ebola outbreak in West Africa in 2014 and is also involved in establishing food security and safety in African and South Asian subcontinent.

Attention Mediates the Effect of Context-Relevant Social

In everyday life we perceive events as having durations. Recent research suggests that the labeling of a stimulus influences the experience of its duration. Plausibly, the social meaning attributed to a stimulus impacts upon the amount of attention allocated to it, with greater attention resulting in better encoding and longer reproduction times. However, direct evidence for the role of attention in this effect of social meaning on duration reproduction is lacking. The present study addresses this issue directly. Eighty-four male Hindu pilgrims attending theKumbh Melain India listened to an ambiguous sound clip and reproduced its duration in a prospective timing task. The context-relevant social meaning of this sound clip was manipulated through attributing the sound to either the religious festival or busy city streets. Attentional load was manipulated by asking half the participants to perform a concurrent task. Reproduced durations were longer in the Mela compared to the City condition but only when participants completed a single task. The finding that mere labeling of the stimulus impacts duration judgments in a prospective paradigm in the single-task but not the dual-task conditions suggests that the effect of social meaning is indeed mediated through the deployment of attentional resources.

Cation Homeostasis in Red Cells From Patients With Sickle Cell Disease Heterologous for HbS and HbC (HbSC Genotype)

Sickle cell disease (SCD) in patients of HbSC genotype is considered similar, albeit milder, to that in homozygous HbSS individuals--but with little justification. In SCD, elevated red cell cation permeability is critical as increased solute loss causes dehydration and encourages sickling. Recently, we showed that the KCl cotransporter (KCC) activity in red cells from HbSC patients correlated significantly with disease severity, but that in HbSS patients did not. Two transporters involved in red cell dehydration, the conductive channels Psickle and the Gardos channel, behaved similarly in red cells from the two genotypes, but were significantly less active in HbSC patients. By contrast, KCC activity was quantitatively greater in HbSC red cells. Results suggest that KCC is likely to have greater involvement in red cell dehydration in HbSC patients, which could explain its association with disease severity in this genotype. This work supports the hypothesis that SCD in HbSC patients is a distinct disease entity to that in HbSS patients. Results suggest the possibility of designing specific treatments of particular benefit to HbSC patients and a rationale for the development of prognostic markers, to inform early treatment of children likely to develop more severe complications of the disease.

Effect of maintaining apical patency on endodontic pain in posterior teeth with pulp necrosis and apical periodontitis: a randomized controlled trial

AIM

To evaluate the association between apical patency and post-operative pain in posterior teeth with pulp necrosis and apical periodontitis.

METHODOLOGY

Sixty-eight patients requiring primary root canal treatment in mandibular first molars with necrotic pulps and apical periodontitis were included. The patients were randomly allocated to one of two groups: patency (n = 34) and nonpatency (n = 34). After administering local anaesthesia, root canal preparation was completed using ProTaper rotary instruments. A size 10 K-file was used as a patency file and carried 1 mm beyond the working length (WL) between each instrument change in the patency group, while it was carried up to WL in the nonpatency group. Patients were asked to record their pain experience on a pain chart daily for 7 days. Three patients (two in the patency group, one in the nonpatency group) did not return with completed pain charts on the subsequent visit, resulting in a total of 65 patients for the final analysis (patency, n = 32; nonpatency, n = 33). Data was analysed using Chi Square test, t-test, Mann-Whitney test and Wilcoxon Signed Ranks test.

RESULTS

Overall, 43% of the patients experienced post-operative pain. The patency group had less incidence of pain (34%) as compared to the nonpatency group (52%), but the difference was not significant (P = 0.163).

CONCLUSION

Maintenance of apical patency during chemomechanical preparation had no significant influence on post-operative pain in posterior teeth with necrotic pulps and apical periodontitis.