Burden of illness and costs in patients with myasthenia gravis currently receiving treatment in the United States.

INTRODUCTION/AIMS: If myasthenia gravis (MG) symptoms are inadequately controlled, patients may experience exacerbations or life-threatening myasthenic crises. Patients with inadequately controlled MG symptoms tend to be treated with chronic intravenous immunoglobulin (IVIg) therapy and/or multiple immunosuppressant therapies (ISTs). This study aimed to examine disease burden, healthcare resource utilization, and associated costs in these patients. METHODS: This was a retrospective observational study using a claims database. Patients with MG were classified into three cohorts based on treatment over a 1-y follow-up period: (a) treated with four or more IVIg episodes (chronic IVIg cohort); (b) received two or more non-steroidal ISTs (NSISTs) sequentially (multiple NSIST cohort); (c) received neither chronic IVIg nor multiple NSISTs (reference cohort). Incidences of crises and exacerbations and annual healthcare costs in each cohort were estimated. RESULTS: In total, 3516 patients with MG were included in the analysis. Compared with the reference cohort (n = 2992), the MG crisis rate was approximately twice as high in both the chronic IVIg (n = 324) and multiple NSIST (n = 291) cohorts (p < 0.001); and the MG exacerbation rate was approximately four-fold higher in the chronic IVIg cohort (p < 0.001) and three-fold higher in the multiple NSIST cohort (p < 0.001). Median annual MG-related inflation-adjusted total healthcare costs were higher in the chronic IVIg ($81,900) and multiple NSIST ($30,300) cohorts than in the reference cohort ($2540). DISCUSSION: The burden of crises/exacerbations was substantially higher and healthcare costs were considerably greater in patients with MG treated with chronic IVIg or multiple NSISTs than in patients not receiving these treatments.

TAp73 represses NF-κB-mediated recruitment of tumor-associated macrophages in breast cancer.

Infiltration of tumor-promoting immune cells is a strong driver of tumor progression. Especially the accumulation of macrophages in the tumor microenvironment is known to facilitate tumor growth and to correlate with poor prognosis in many tumor types. TAp73, a member of the p53/p63/p73 family, acts as a tumor suppressor and has been shown to suppress tumor angiogenesis. However, what role TAp73 has in regulating immune cell infiltration is unknown. Here, we report that low levels of TAp73 correlate with an increased NF-κB-regulated inflammatory signature in breast cancer. Furthermore, we show that loss of TAp73 results in NF-κB hyperactivation and secretion of Ccl2, a known NF-κB target and chemoattractant for monocytes and macrophages. Importantly, TAp73-deficient tumors display an increased accumulation of protumoral macrophages that express the mannose receptor (CD206) and scavenger receptor A (CD204) compared to controls. The relevance of TAp73 expression in human breast carcinoma was further accentuated by revealing that TAp73 expression correlates negatively with the accumulation of protumoral CD163+ macrophages in breast cancer patient samples. Taken together, our findings suggest that TAp73 regulates macrophage accumulation and phenotype in breast cancer through inhibition of the NF-κB pathway.

Selenium Deficiency as a Risk Factor for Peripartum Cardiomyopathy.

BACKGROUND: Peripartum cardiomyopathy (PPCM) is a multifactorial disease. Although the specific aetiology and pathogenesis of PPCM are unknown, several hypotheses have been proposed, including selenium deficiency. However, the risk of PPCM from selenium deficiency was not previously quantified. This posthoc analysis of peripartum cardiomyopathy in Nigeria (PEACE) registry data aimed to determine if selenium deficiency is an independent risk factor for PPCM. METHODS: Apparently healthy women who delivered within the previous 8 weeks and PPCM patients in Kano, Nigeria, were compared for selenium deficiency (<70µg/L) and other relevant socio-demographic and clinical characteristics. Selenium level was measured at recruitment for each subject. Independent predictors of PPCM were determined using logistic regression models. RESULTS: 159 PPCM patients and 90 age-matched controls were consecutively recruited. 84.9% of the patients and 3.3% of controls had selenium deficiency. Selenium deficiency independently increased the odds for PPCM by 167-fold while both unemployment and lack of formal education independently increased the odds by 3.4-fold. CONCLUSION: Selenium deficiency was highly prevalent among PPCM patients in Kano, Nigeria, and significantly increased the odds for PPCM. These results could justify screening of women in their reproductive years for selenium deficiency, particularly those living in regions with high incidence of PPCM. The results also call for the setting up of a definitive clinical trial of selenium supplementation in PPCM patients with selenium deficiency, to further define its benefits in the treatment of PPCM.

CONTEXTE: La cardiomyopathie péripartum (CMPP) est une maladie multifactorielle. Bien que l'étiologie spécifique et la pathogenèse de la CMPP soient inconnues, plusieurs hypothèses ont été proposées, notamment la carence en sélénium. Cependant, le risque de CMPP lié à la carence en sélénium n'a pas été précédemment quantifié. Cette analyse post-hoc des données du registre de la cardiomyopathie péripartum au Nigéria (PEACE) visait à déterminer si la carence en sélénium est un facteur de risque indépendant de la CMPP. MÉTHODES: Des femmes apparemment en bonne santé ayant accouché dans les 8 semaines précédentes et des patientes atteintes de CMPP à Kano, au Nigéria, ont été comparées pour la carence en sélénium (<70µg/L) et d'autres caractéristiques socio-démographiques et cliniques pertinentes. Le taux de sélénium a été mesuré au recrutement pour chaque sujet. Les prédicteurs indépendants de la CMPP ont été déterminés à l'aide de modèles de régression logistique. RÉSULTATS: 159 patientes atteintes de CMPP et 90 témoins appariés selon l'âge ont été recrutés consécutivement. 84,9% des patientes et 3,3% des témoins présentaient une carence en sélénium. La carence en sélénium augmentait indépendamment les chances de CMPP de 167 fois, tandis que le chômage et le manque d'éducation formelle augmentaient indépendamment les chances de 3,4 fois. CONCLUSION: La carence en sélénium était très répandue parmi les patientes atteintes de CMPP à Kano, au Nigéria, et augmentait significativement les chances de CMPP. Ces résultats pourraient justifier le dépistage de la carence en sélénium chez les femmes en âge de procréer, en particulier celles vivant dans des régions à forte incidence de CMPP. Les résultats appellent également à la mise en place d'un essai clinique définitif sur la supplémentation en sélénium chez les patientes atteintes de CMPP présentant une carence en sélénium, afin de définir davantage ses avantages dans le traitement de la CMPP. MOTS-CLÉS: Cardiomyopathie Péripartum; Carence en Sélénium; Facteur de Risque.

Risk factors for persistent pain after breast cancer surgery: a multicentre prospective cohort study.

Identifying factors associated with persistent pain after breast cancer surgery may facilitate risk stratification and individualised management. Single-population studies have limited generalisability as socio-economic and genetic factors contribute to persistent pain development. Therefore, this prospective multicentre cohort study aimed to develop a predictive model from a sample of Asian and American women. We enrolled women undergoing elective breast cancer surgery at KK Women's and Children's Hospital and Duke University Medical Center. Pre-operative patient and clinical characteristics and EQ-5D-3L health status were recorded. Pain catastrophising scale; central sensitisation inventory; coping strategies questionnaire-revised; brief symptom inventory-18; perceived stress scale; mechanical temporal summation; and pressure-pain threshold assessments were performed. Persistent pain was defined as pain score ≥ 3 or pain affecting activities of daily living 4 months after surgery. Univariate associations were generated using generalised estimating equations. Enrolment site was forced into the multivariable model, and risk factors with p < 0.2 in univariate analyses were considered for backwards selection. Of 210 patients, 135 (64.3%) developed persistent pain. The multivariable model attained AUC = 0.807, with five independent associations: age (OR 0.85 95%CI 0.74-0.98 per 5 years); diabetes (OR 4.68, 95%CI 1.03-21.22); pre-operative pain score at sites other than the breast (OR 1.48, 95%CI 1.11-1.96); previous mastitis (OR 4.90, 95%CI 1.31-18.34); and perceived stress scale (OR 1.35, 95%CI 1.01-1.80 per 5 points), after adjusting for: enrolment site; pre-operative pain score at the breast; pre-operative overall pain score at rest; postoperative non-steroidal anti-inflammatory drug use; and pain catastrophising scale. Future research should validate this model and evaluate pre-emptive interventions to reduce persistent pain risk.

Antibiotic Guidelines for Critically Ill Patients in Nigeria.

BACKGROUND: It is well documented that inappropriate use of antimicrobials is the major driver of antimicrobial resistance. To combat this, antibiotic stewardship has been demonstrated to reduce antibiotic usage, decrease the prevalence of resistance, lead to significant economic gains and better patients' outcomes. In Nigeria, antimicrobial guidelines for critically ill patients in intensive care units (ICUs), with infections are scarce. We set out to develop antimicrobial guidelines for this category of patients. METHODS: A committee of 12 experts, consisting of Clinical Microbiologists, Intensivists, Infectious Disease Physicians, Surgeons, and Anesthesiologists, collaborated to develop guidelines for managing infections in critically ill patients in Nigerian ICUs. The guidelines were based on evidence from published data and local prospective antibiograms from three ICUs in Lagos, Nigeria. The committee considered the availability of appropriate antimicrobial drugs in hospital formularies. Proposed recommendations were approved by consensus agreement among committee members. RESULTS: Candida albicans and Pseudomonas aeruginosa were the most common microorganisms isolated from the 3 ICUs, followed by Klebsiella pneumoniae, Acinetobacter baumannii, and Escherichia coli. Targeted therapy is recognized as the best approach in patient management. Based on various antibiograms and publications from different hospitals across the country, amikacin is recommended as the most effective empiric antibiotic against Enterobacterales and A. baumannii, while colistin and polymixin B showed high efficacy against all bacteria. Amoxicillin-clavulanate or ceftriaxone was recommended as the first-choice drug for community-acquired (CA) CA-pneumonia while piperacillin-tazobactam + amikacin was recommended as first choice for the treatment of healthcare-associated (HA) HA-pneumonia. For ventilatorassociated pneumonia (VAP), the consensus for the drug of first choice was agreed as meropenem. Amoxycillin-clavulanate +clindamycin was the consensus choice for CAskin and soft tissue infection (SSIS) and piperacillin-tazobactam + metronidazole ±vancomycin for HA-SSIS. Ceftriaxone-tazobactam or piperacillin-tazobactam + gentamicin was consensus for CA-blood stream infections (BSI) with first choice+regimen for HA-BSI being meropenem/piperacillin-tazobactam +amikacin +fluconazole. For community-acquired urinary tract infection (UTI), first choice antibiotic was ciprofloxacin or ceftriaxone with a catheter-associated UTI (CAUTI) regimen of first choice being meropenem + fluconazole. CONCLUSION: Data from a multicenter three ICU surveillance and antibiograms and publications from different hospitals in the country was used to produce this evidence-based Nigerian-specific antimicrobial treatment guidelines of critically ill patients in ICUs by a group of experts from different specialties in Nigeria. The implementation of this guideline will facilitate learning, continuous improvement of stewardship activities and provide a baseline for updating of guidelines to reflect evolving antibiotic needs.

CONTEXTE: Il est bien établi que l'utilisation inappropriée des antimicrobiens est le principal moteur de la résistance aux antimicrobiens. Pour lutter contre ce phénomène, il a été démontré que la bonne gestion des antibiotiques permettait de réduire l'utilisation des antibiotiques, de diminuer la prévalence de la résistance, de réaliser des gains économiques significatifs et d'améliorer les résultats pour les patients. Au Nigéria, les directives antimicrobiennes pour les patients gravement malades dans les unités de soins intensifs (USI), souffrant d'infections, sont rares. Nous avons entrepris d'élaborer des lignes directrices sur les antimicrobiens pour cette catégorie de patients. MÉTHODES UTILISÉES: Un comité de 12 experts, composé de microbiologistes cliniques, d'intensivistes, de médecins spécialistes des maladies infectieuses, de chirurgiens et d'anesthésistes, a collaboré à l'élaboration de lignes directrices pour la prise en charge des infections chez les patients gravement malades dans les unités de soins intensifs nigérianes. Les lignes directrices sont basées sur des données publiées et des antibiogrammes prospectifs locaux provenant de trois unités de soins intensifs de Lagos, au Nigeria. Le comité a pris en compte la disponibilité des médicaments antimicrobiens appropriés dans les formulaires des hôpitaux. Les recommandations proposées ont été approuvées par consensus entre les membres du comité. RÉSULTATS: Candida albicans et Pseudomonas aeruginosa étaient les microorganismes les plus fréquemment isolés dans les trois unités de soins intensifs, suivis par Klebsiella pneumoniae, Acinetobacter baumannii et Escherichia coli. La thérapie ciblée est reconnue comme la meilleure approche pour la prise en charge des patients. Sur la base de divers antibiogrammes et publications provenant de différents hôpitaux du pays, l'amikacine est recommandée comme l'antibiotique empirique le plus efficace contre les entérobactéries et A. baumannii, tandis que la colistine et la polymixine B se sont révélées très efficaces contre toutes les bactéries. L'amoxicilline-clavulanate ou la ceftriaxone ont été recommandées comme médicaments de premier choix pour les pneumonies communautaires, tandis que la pipéracilline-tazobactam + amikacine ont été recommandées comme médicaments de premier choix pour le traitement des pneumonies associées aux soins. Pour les pneumonies acquises sous ventilation mécanique (PAV), le consensus sur le médicament de premier choix est le méropénem. L'amoxycilline-clavulanate +clindamycine était le choix consensuel pour les infections de la peau et des tissus mous et la pipéracilline-tazobactam + métronidazole ±vancomycine pour les infections de la peau et des tissus mous. HA-SSIS. Ceftriaxone-tazobactam ou pipéracilline-tazobactam + gentamicine a fait l'objet d'un consensus pour les infections de la circulation sanguine de l'AC (BSI), le premier choix de régime pour les HA-BSI étant le méropénem/pipéracilline-tazobactam +amikacine +fluconazole. Pour les infections urinaires communautaires, l'antibiotique de premier choix était la ciprofloxacine ou la ceftriaxone, le régime de premier choix pour les infections urinaires associées à un cathéter étant le meropenem +fluconazole. CONCLUSION: Les données issues d'une surveillance multicentrique de trois unités de soins intensifs, d'antibiogrammes et de publications de différents hôpitaux du pays ont été utilisées par un groupe d'experts de différentes spécialités nigérianes pour élaborer ces lignes directrices sur le traitement antimicrobien des patients gravement malades dans les unités de soins intensifs, fondées sur des données probantes et spécifiques au Nigeria. La mise en œuvre de ces lignes directrices facilitera l'apprentissage, l'amélioration continue des activités de gestion et fournira une base de référence pour la mise à jour des lignes directrices afin de refléter l'évolution des besoins en antibiotiques. Mots clés: Antimicrobiens, Résistance aux antimicrobiens, Gestion des antibiotiques, Lignes directrices, Soins intensifs, Unité de soins intensifs, Infections associées aux soins de santé.

A 17-year-old boy with chest pain and transient ventricular wall thickening.

We describe the case of a 17-year-old boy who developed acute myopericarditis associated with transient ventricular wall thickening. This is a unique teaching case illustrating that acute myocarditis can be associated with significant oedema, secondary to inflammation, causing marked wall thickening that is apparent on echocardiography. This oedema resolves completely with anti-inflammatory drug treatment.

Phenotypic Characterisation of Staphylococcus aureus Isolated from Patients in Healthcare Institutions in Zaria Metropolis, Kaduna State, Nigeria.

BACKGROUND: Staphylococcus aureus is a cosmopolitan and pathogenic microorganism associated with various diseases spectra and antimicrobial resistance of public health importance. AIM: This study determined the phenotypic characteristics of S. aureus isolated from patients in healthcare institutions in Zaria metropolis. STUDY DESIGN: A cross-sectional hospital-based study was carried out in 5 healthcare institutions. Four hundred and twenty clinical samples were collected and analyzed. RESULTS: Majority of the patients (54.3%) were within the age range 21-40 years and mean age of 26.04 ± 12 years. Approximately, 70% of the respondents had history of antibiotic use prior to consultation in the hospitals and were self-prescribed, and 91.2% were outpatients. The most commonly abused antibiotics were ampicillin-cloxacillin (19.5%) and cotrimoxazole (10.0%), and the mean duration of their use was 3.5 ± 1.3 days. The detection rate for S. aureus was 10% and 5.2% for MRSA. The S. aureus isolates showed the highest frequency of resistance against ampicillin 42 (100%), followed by penicillin G 39 (92.9%) and least was to gentamicin 5 (11.9%). The frequency of resistance for the MRSA were ampicillin 22 (100%), penicillin G 21(95.5%) and least was to gentamicin 2 (9.1%). The minimum inhibitory concentrations of oxacillin were greater than 128 µg /ml. CONCLUSION: The detection rate of S. aureus and MRSA strains are of great public health concern which requires continuous health education on rational use of antibiotics among others.

CONTEXTE: Staphylococcus aureus est un micro-organisme cosmopolite et pathogène associé à divers spectres de maladies et à une résistance aux antimicrobiens d'importance pour la santé publique. OBJECTIF: Cette étude a permis de déterminer les caractéristiques phénotypiques de S. aureus isolé chez des patients dans des établissements de santé de la métropole de Zaria. PLAN DE L'ÉTUDE: Une étude transversale en milieu hospitalier a été menée dans 5 établissements de santé. Quatre cent vingt échantillons cliniques ont été recueillis et analysés. RÉSULTATS: La majorité des patients (54,3 %) étaient âgés de 21 à 40 ans et l'âge moyen était de 26,04 ± 12 ans. Environ 70 % des répondants avaient des antécédents d'utilisation d'antibiotiques avant la consultation dans les hôpitaux et étaient auto-prescrits, et 91,2 % étaient des patients externes. Les antibiotiques les plus fréquemment utilisés étaient l'ampicillinecloxacilline (19,5 %) et le cotrimoxazole (10,0 %), et la durée moyenne de leur utilisation était de 3,5 ± 1,3 jours. Le taux de détection de S. aureus était de 10 % et de 5,2 % pour le SARM. Les isolats de S. aureus ont montré la plus grande fréquence de résistance à l'ampicilline 42 (100%), suivie de la pénicilline G 39 (92,9%) et la plus faible à la gentamicine 5 (11,9%). La fréquence de résistance pour le SARM était de 22 (100%) pour l'ampicilline, 21 (95,5%) pour la pénicilline G et 2 (9,1%) pour la gentamicine. Les concentrations minimales inhibitrices de l'oxacilline étaient supérieures à 128 µg /ml. CONCLUSION: Le taux de détection des souches de S. aureus et de SARM est un grand problème de santé publique qui nécessite une éducation sanitaire continue sur l'utilisation rationnelle des antibiotiques entre autres. Mots clés: S. aureus, MRSA, phénotype, résistance aux antimicrobiens, patients d'hôpitaux, Nigeria.

Performance of the AUB-HAS2 Cardiovascular Risk Index in vascular surgery patients.

The American University of Beirut (AUB)-HAS2 risk index is a recently published tool for preoperative cardiovascular evaluation. It is based on six data elements: history of Heart disease, symptoms of Heart disease (angina or dyspnea), Age ⩾ 75 years, Anemia (hemoglobin < 12 mg/dL), emergency Surgery, and vascular Surgery. This study analyzes the performance of a modified AUB-HAS2 index (excluding the vascular surgery element) in a broad spectrum of vascular surgery procedures. The study population consisted of 90,476 vascular surgeries registered in the American College of Surgeons National Surgical Quality Improvement Program database. The performance of the AUB-HAS2 index was studied in seven groups: carotid endarterectomy (CEA), open abdominal aortic aneurysm surgical repair (OAAA), endovascular aortic aneurysm repair, supra-inguinal bypass, infra-inguinal bypass, lower extremity thrombo-endarterectomy, and lower extremity angioplasty. The outcome measure was death, myocardial infarction, or stroke at 30 days after surgery. Each patient was given an AUB-HAS2 score of 0, 1, 2, or > 2 depending on the number of data elements s/he has. The AUB-HAS2 index was able to stratify risk in the majority of patients into low (< 3%, score 0), intermediate (3-10%, score 1-2), and high (> 10%, score > 2) (p < 0.0001). The receiver operating curve had an area of 0.71 in the overall group and it ranged from 0.60 in CEA patients to 0.75 in OAAA patients. In conclusion, the AUB-HAS2 index is a simple tool that can quickly and effectively stratify the risk of patients undergoing a broad spectrum of vascular surgeries into low, intermediate, and high.

Obesity in women: anaesthetic implications for peri-operative and peripartum management.

The prevalence, healthcare and socio-economic impact of obesity (defined as having a body mass index of ≥ 30 kg.m-2 ) are disproportionately higher in women than men. A combination of biological and social factors, including the adaptation of energy homeostasis to the increased demands of pregnancy and lactation and poor access to healthy foods or exercise facilities, contribute to the increasing prevalence of obesity in women. Obesity-related physiological changes stem from mass loading and increased metabolism of adipose tissue, as well as secretion of bioactive substances from adipocytes leading to chronic low-grade inflammation. As a result, obesity is associated with increased risks of: infertility; malignancy; sleep-disordered breathing; cardiovascular disease; diabetes; and thromboembolism. Hence, obese women are at markedly increased risk of peri-operative morbidity and mortality and require comprehensive evaluation and targeted comorbidity optimisation by a multidisciplinary team. In addition to routine obstetric challenges, pregnancy in women with obesity further exacerbates the above risks, making multidisciplinary management starting at pre-conception even more important. Weight loss, lifestyle management and optimisation of comorbidity are the cornerstone of reducing obesity-related risks. The anaesthetist plays a vital role within the multidisciplinary team by emphasising weight loss as part of pre-operative comorbidity optimisation, formulation of individualised peri-operative management plans, supervising postoperative care in the high dependency or intensive care settings and providing safe labour analgesia and careful peripartum management for obese parturients.

Cryopreservation Studies on Silver Carp (Hypophthalmichthys molitrix) Embryos.

BACKGROUND: Cryopreservation is an effective tool for the preservation of live biological materials. OBJECTIVE: This study examined the suitability of cryopreservation protocols and the effectiveness of ultrasound for silver carp embryos. MATERIALS AND METHODS: Embryos at three developmental stages were exposed to 10, 15, 20, and 25% of five cryoprotectants (CPAs), namely propylene glycol (PG), dimethylformamide (DFA), DMSO, MeOH, and ethylene glycol (EG) for 20 min. Embryos were exposed to twelve vitrification solutions (VSs) for 10 (five steps of 2 min), 15 (five steps of 3 min), 20 (five steps of 4 min) min. Embryos were also exposed to ultrasound in VSs prior to cooling for cryopreservation. RESULTS: Hatching rates decreased with increasing CPA concentrations while toxicity varied in the order of PG < DMSO < EG < MeOH < DFA. Tail elongation stage was more tolerant to CPA than 6-somites and morula stages. The survival of embryos exposed to ultrasound in VS was remarkably lower than in water. Embryos exposed to ultrasound in VSs under the best conditions did not response well after attempted vitrification. CONCLUSION: Ultrasound-mediated CPA impregnation could be effective but other innovative methods may be needed to attain successful cryopreservation.

Supplemental peri-operative intravenous crystalloids for postoperative nausea and vomiting: an abridged Cochrane systematic review.

We conducted a Cochrane systematic review on the effectiveness of supplemental intravenous crystalloid administration in preventing postoperative nausea and vomiting. We included randomised controlled trials of patients undergoing surgery under general anaesthesia and given supplemental peri-operative intravenous crystalloid. Our primary outcomes were the risk of postoperative nausea and the risk of postoperative vomiting. We assessed the risk of bias for each included study and applied the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework for the certainty of evidence. We included 41 studies. We found that the intervention probably reduces the overall risk of postoperative nausea, the risk ratio (95%CI) being 0.62 (0.51-0.75) (I2  = 57%, p < 0.00001, 18 studies; 1766 participants; moderate-certainty evidence). It also probably reduces the risk of postoperative nausea within 6 h of surgery, with a risk ratio (95%CI) of 0.67 (0.58 to 0.78) (I2  = 9%, p < 0.00001, 20 studies; 2310 participants; moderate-certainty evidence) and by around 24 h, the risk ratio (95%CI) being 0.47 (0.32-0.69) (I2  = 38%, p = 0.0001, 17 studies; 1682 participants; moderate-certainty evidence). Supplemental intravenous crystalloid probably also reduces the overall risk of postoperative vomiting, with a risk ratio (95%CI) of 0.50 (0.40-0.63) (I2  = 31%, p < 0.00001, 20 studies; 1970 participants; moderate-certainty evidence). The beneficial effect on vomiting was seen both within 6 h and by around 24 h postoperatively.

Epidermal Carcinoma of the Conchal Bowl: Creation of a Multidisciplinary Pathway Approach.

BACKGROUND: Malignant neoplasms of the auricle make up 6% of all skin cancers. Management of cutaneous neoplasms of the conchal bowl presents a unique challenge in visualizing and defining margins that may extend into the external auditory canal (EAC). OBJECTIVES: The objective of this study was to create a multidisciplinary pathway for cutaneous carcinoma of the conchal bowl extending into the EAC. METHODS: We present a series of patients that were referred to dermatology or otolaryngology, with cutaneous neoplasms arising in the conchal bowl. A consensus approach from otolaryngology and dermatology, for evaluation and treatment, was created based on evaluation of these cases, and review of the otolaryngology and dermatology literature, in collaboration between the two specialties. RESULTS: Initial evaluation should be done by both dermatology and otolaryngology, with otomicroscopic evaluation of the canal. Imaging is recommended for lesions that approach the EAC, for bony and soft tissue spread. Excision of the tumor with Mohs micrographic surgery to achieve clearance in the conchal bowl should be performed initially. If extension into the external auditory meatus is present, otolaryngology would proceed with en bloc resection. Repair is dictated by the defect, with both specialties involved in follow-up. CONCLUSIONS: In collaboration between dermatology and otolaryngology, and following review of the literature, a pathway was created to manage skin cancer of the conchal bowl. This resulted in a stepwise approach for evaluation and management, ensuring that patients have a streamlined pathway for the treatment of these lesions.

Advanced schemes for underdense plasma photocathode wakefield accelerators: pathways towards ultrahigh brightness electron beams.

The 'Trojan Horse' underdense plasma photocathode scheme applied to electron beam-driven plasma wakefield acceleration has opened up a path which promises high controllability and tunability and to reach extremely good quality as regards emittance and five-dimensional beam brightness. This combination has the potential to improve the state-of-the-art in accelerator technology significantly. In this paper, we review the basic concepts of the Trojan Horse scheme and present advanced methods for tailoring both the injector laser pulses and the witness electron bunches and combine them with the Trojan Horse scheme. These new approaches will further enhance the beam qualities, such as transverse emittance and longitudinal energy spread, and may allow, for the first time, to produce ultrahigh six-dimensional brightness electron bunches, which is a necessary requirement for driving advanced radiation sources. This article is part of the Theo Murphy meeting issue 'Directions in particle beam-driven plasma wakefield acceleration'.

Social media for dissemination and public engagement in neurosurgery-the example of Brainbook.

BACKGROUND: Public engagement has become one of the most effective tools in gaining feedback and perspectives from members of the public, involving patients with decisions, and inspiring young people to carry the medical profession forwards. Brainbook is a multi-platform, social media-based resource that was created specifically to enhance public engagement in neurosurgery and results from one of its case discussions will be reported in this paper. METHODS: A Brainbook case was created in collaboration with the NIHR Global Health Research Group on Neurotrauma and presented over 3 days (23-25 February 2018). YouTube videos were created depicting the management of an acute subdural haematoma using patient interviews, medical illustration, consultant-led discussion and operative footage. Content was shared across all Brainbook social media platforms and analytics were gathered through social media applications. RESULTS: Over a 72-hour time period, and across multiple social media accounts, 101,418 impressions were achieved (defined as penetrance onto individual media feeds and total views of the content), with active discussion on social media. CONCLUSIONS: Neurosurgical content published across multiple social media outlets represents an encouraging and exciting potential for global engagement across multiple audiences. Social media can be an effective method of not only disseminating neurosurgical knowledge, but activating and engaging the public, allied healthcare professionals, medical students and neurosurgeons.

Mohs Micrographic Surgery Dermatopathology Concordance in Canada: A Single-Institution Experience.

BACKGROUND:: Mohs micrographic surgery (MMS) is a surgical modality that achieves high cure rates of nonmelanoma skin cancers but is dependent on accurate histologic examination of surgical margins. Therefore, quality assurance is essential to ongoing assessment of histological margins. OBJECTIVES:: To prospectively determine the concordance rate between a Mohs surgeon (MS) and dermatopathologist (DP) with respect to tumour status (ie, present or absent) and tumour type. Secondary end points were to determine the relationship between discordant interpretations and slide quality and to assess the feasibility of using an electronic webform for data collection. METHODS:: Ten percent (10%) of the planned MMS cases between January 2015 and March 2016 were randomly selected by a histotechnologist at the start of each month. The MS and DP were blinded to the chosen cases, and slides were reviewed independently at the beginning of the following month. Data were collected using an online webform. A blinded third party determined if there were discrepancies in interpretation, and any discordant slides were reviewed together and a consensus was reached. RESULTS:: A total of 270 slides from 54 total cases were reviewed. The overall tumour status concordance rate was 93.6%. Cohen's κ was 0.86. Tumour type concordance was 98.9%. No discrepancy required a change in patient care. All discrepant slides were from cases that required multiple stages. CONCLUSIONS:: This is the first study looking at MS-DP concordance in Canada, and our findings support the MS acting as his or her own pathologist.

Progression of a Buschke-Lowenstein tumor into invasive squamous cell carcinoma.

Buschke-Lowenstein tumors primarily are slow-growing giant condylomata accuminata of the anogenital region. They are locally destructive with a low rate of metastasis. Sexually transmitted oncogenic human papillomavirus type 6 and 11 are the greatest risk factors for Buschke-Lowenstein tumors or verrucous carcinomas, a type of squamous cell cancer. Grossly, the tumor appears as a large fungating, erythematous, cauliflower-like mass. Radical surgical excision of the tumor is the treatment of choice and close follow-up for recurrence is essential. The use of radiation or chemotherapy as adjunct treatments is controversial. This case report describes a patient with this rare condition.

A cross-sectional study of cytomegalovirus retinitis in HIV-1 infected adults in Nigeria.

BACKGROUND: Cytomegalovirus (CMV) retinitis is one of the most important opportunistic infections in HIV-infected patients in developing countries before the introduction of highly active antiretroviral therapy. In Nigerian and African HIV populations, CMV retinitis is under-reported. PATIENTS AND METHODS: In a cross-sectional study, 250 HIV-infected adults ≥18 years were recruited by systematic random sampling from March to August 2013. Using a structured questionnaire, information was obtained on socio-demographic characteristics and symptoms of visual impairment. HIV disease was staged according to the WHO clinical staging, and CD4+ T-lymphocyte count was measured. Participants with symptoms of impaired vision and/or CD4+ T-lymphocyte count <50 cells/µL had indirect ophthalmoscopic examination of the retina to detect CMV related eye lesions. RESULTS: Two hundred and fifty adults were HIV-infected, out of which 114 (46%) were males and 136 (54%) were females. The mean age of study participants was 35 years. History of impaired vision was reported by 21 (8.4%) of participants. The right eye was involved in 7 (33%), the left eye in 4 (19%), and both eyes in 10 (48%) of participants. The predominant symptoms were blurred vision 9 (43%), floaters 9 (43%), and blindness 3 (14%). Among participants who had indirect ophthalmoscopy, 3 (1.2%) had characteristic retinal changes suggestive of CMV retinitis. Two (67%) of patients with CMV retinitis were females and 1 (33%) was male. Mean CD4+ count was 25.33 ± 14.19 and all were WHO HIV clinical stage 4 with death occurring within 6 months of diagnosis. CONCLUSION: CMV retinitis though rare is associated with advanced HIV disease and attendant morbidity and mortality. We recommend integration of CMV diagnostic services and ophthalmological services as routine in HIV care and treatment programs in Nigeria targeted toward high-risk patients.

Variations in the referral patterns to pharmacologic and exercise myocardial perfusion imaging.

BACKGROUND: Myocardial perfusion imaging (MPI) is commonly utilized for the non-invasive evaluation of patients with suspected coronary artery disease (CAD). It is either performed with exercise or pharmacologic stress. The objective of this study is to compare the referral patterns and diagnostic findings in patients referred for pharmacologic vs exercise MPI. METHODS AND RESULTS: This was a prospective study of 429 consecutive patients who were referred for MPI at the American University of Beirut Medical Center (23% had pharmacologic stress with dipyridamole and 77% had exercise stress testing). Patients referred to pharmacologic stress were older, had a higher percentage of women, and a higher prevalence of diabetes and hypertension. There were more abnormal scans in the pharmacologic stress group (38% vs 20%, P < 0.001), as well as a higher prevalence of ischemia (21% vs 13%, P < 0.001) and impaired left ventricular function with an ejection fraction < 50% (19% vs 7.9%, P < 0.001). The significant predictors for referral to pharmacologic stress by multivariable logistic regression analysis were older age (OR = 2.01 (1.57-2.57), P < 0.001) and diabetes (OR = 2.04 (1.19-3.49), P = 0.009). CONCLUSION: Patients referred for pharmacologic stress MPI are at a higher risk than those referred for exercise stress MPI with more CAD risk factors, older age, and a higher prevalence of abnormal MPI findings.