Impact of COVID-19 severity on health-related quality of life among Saudi adult patients.

COVID-19 patients may experience varying degrees of symptom severity, significantly impacting the health-related quality of life. As a result, the current study examines the impact of symptom severity on health-related quality of life among Saudi adult COVID- 19 patients. In this cross-sectional study 310 adult COVID-19 patients were recruited through a snowball technique in Saudi Arabia. We used a questionnaire (SF-12 RAND tool questionnaire) that included three parts: sociodemographic factors, perception of degree severity of COVID-19 symptoms, and health-related quality of life (HRQoL). Out of 310 COVID-19 adult patients, 200 (64.5%) were female, 110 (35.5%) were between 30-49 years old. The mean scores of the HRQoL, physical components summary (PCS), and mental components summary (MCS) were 58.11±17.02, 71.32±23.72, and 44.91±17.94, respectively. Patients with very severe symptoms had the lowest HRQoL mean rank (120.39, P=0.023). There was a strong positive correlation between HRQoL and PCS (0.852) and HRQoL and MCS (0.730). However, PCS and MCS had a weak positive correlation (0.292). The severity of COVID-19 symptoms had a significant impact on HRQoL. Thus, it is essential to enhance the uptake of vaccines to decrease the risk of infections and avoid impact on quality of life.

Public knowledge, attitude and practice towards antibiotics use and antimicrobial resistance in Saudi Arabia: A web-based cross-sectional survey.

BACKGROUND: Antimicrobial resistance is a global issue that causes significant morbidity and mortality. Therefore, this study aims to assess knowledge, attitudes, and practices (KAP) of the general Saudi populations toward antibiotics use. DESIGN AND METHODS: A cross-sectional, anonymous online survey was conducted from January 1 to May 11, 2020, across five major regions of Saudi Arabia. Participants (aged ≥18 years) were invited through social media to complete an online self-structured questionnaire. All data were analyzed by Statistical Package (SPSS v.25). Descriptive statistics, Pearson's Chi-squared, t-tests, one-way analysis of variance (ANOVA), and Pearson correlation analyses were conducted. RESULTS: Out of 443 participants, the majority (n=309, 69.8%) were females, 294 (64.4%) were married, 176 (39.7%) were 25-34 years of age, 338 (76.3%) were living in the Eastern Province, 313 (70.7%) had college or higher education, 139 (31.4%) were not working, and 163 (36.8%) had a monthly income of USD 800-1330. Overall, most participants demonstrated good knowledge and practice (88% and 85.6%, respectively).  However, 76.8%had inadequate attitude score levels towards antibiotics use. Of all the respondents, 74.9% knew that not completing a full course of antibiotics may cause antibiotics resistance, 91.33% did not agree that antibiotics should be accessed without a prescription, and 94.04% will not hand over leftover antibiotics to family members. Factors associated with adequate knowledge were female, medical jobs, and higher income (p<0.05). CONCLUSIONS: Our findings revealed that while most participants were aware of antibiotics use and demonstrated good knowledge, good practices, they had negative attitudes towards antibiotics use.

Day-case approach to immediate breast reconstruction: pushing the boundaries of ambulatory breast surgery in the post-COVID-19 era.

INTRODUCTION: Day-case surgery is safe and efficacious for most breast surgical procedures. Limited data exist on its use in immediate breast reconstruction. We present our experience of day-case management of mastectomy with immediate pre-pectoral implant-based reconstruction (IBR). METHODS: Data were collected on 47 patients who underwent day-case skin-sparing (SSM) or nipple-sparing (NSM) mastectomy with pre-pectoral IBR between October 2017 and September 2019. Clinicopathological data were collected, including postoperative complications, re-admission and re-operation. The data were compared to published national standards. RESULTS: Median age was 52 years (range 37-74). Thirty-two patients (68%) had an SSM and 15 (32%) had an NSM. Two patients (4%) had risk-reducing mastectomies and 45 had treatment for invasive cancer or ductal carcinoma in situ (DCIS). Mean tumour size was 33.3mm (range 7-85mm). Forty-two (89%) patients went home on the day of surgery. No patients required re-operation in the first 48 hours. The median postoperative follow-up time was 11.4 months (range 1.8-22.7 months). During the first 90-day postoperative period, eight patients (17%) developed superficial skin necrosis, five patients (10.6%) developed postoperative infections and five patients (10.6%) suffered an implant loss. Eight patients (17%) were readmitted for re-operation. Compared to UK national standards set in the iBRA study, our cohort has demonstrated comparable postoperative infection, implant loss and re-operation and re-admission rates. CONCLUSION: We have demonstrated close to 90% day-case success rate for mastectomy with IBR. These early data suggest that immediate IBR can be carried out in a manner that is cost-efficient without impacting surgical outcomes.

Cucumis sativus and Cucurbita maxima extract attenuate diabetes-induced hepatic and pancreatic injury in a rat model.

Diabetes is usually associated with oxidative stress that causes hepatic and pancreatic tissue injury. This work was carried out to evaluate the effect of Cucumis sativus and Cucurbita maxima methanol extracts on the streptozotocin-induced diabetic hepatic and pancreatic injury in rats. Diabetes was induced in seven equal groups of rats by a single intraperitoneal injection of streptozotocin (40 mg/kg), in addition to the non-diabetic control group. Two diabetic groups were treated with Cucumis sativus methanol extract and two were treated with Cucurbita maxima, each at 200 and 400 mg/kg for 21 days after streptozotocin-induced diabetes. Another diabetic group was treated with both Cucumis sativus and Cucurbita maxima at 200 mg/kg of each. Another group was treated with metformin (200 mg/kg orally). The plant extracts normalized serum liver enzymes activities, oxidative stress markers, and restored serum proteins and lipid profile. They also significantly reduced blood sugar to values comparable to non-diabetic rats. The hypoglycemic effect is also confirmed by the improvement of the immunohistochemical expression of insulin in ß-cells of islets of Langerhans. Hepatic and pancreatic protection was also confirmed by the improvement of the histopathological picture as compared to STZ-diabetic rats. The GC-MS analysis revealed the presence of 35 and 34 compounds in the methanol extract of cucumber and pumpkin, respectively. Finally, the methanol extract of cucumber and pumpkin could be beneficial acting synergistically in the protection of the liver and pancreas against diabetes-induced tissue damage.

Outcomes of staged lingual mucosal graft urethroplasty for redo hypospadias repair.

BACKGROUND: The objective of this study was to present the outcomes for redo hypospadias repair using lingual mucosal graft (LMG). PATIENTS AND METHODS: Between June 2012 and February 2017, 47 patients underwent staged LMG urethroplasty for redo hypospadias repair. The inclusion criteria were previous failed hypospadias repair with a paucity of local skin that interferes with correction using skin flaps and demands graft urethroplasty. During the first stage, a well-vascularized bed on the tunica albuginea was created. Then, the harvested LMG was secured to the prepared bed. The second-stage urethroplasty was carried out after six months. In this stage, tubularization of the previously implanted LMG was performed. In four cases, tubularization was difficult owing to graft contracture. This difficulty was managed by using the dorsally degloved penile skin as the onlay island flap in three cases and the buccal mucosa onlay graft in the fourth case. In all cases, a second protective layer from the dartos or tunica vaginalis was developed to cover the neourethra. RESULTS: The median (interquartile range [IQR]) age of patients at the first stage was 5 (4-6) years, and the median (IQR) duration between both stages was 7 (6-8) months. The median (IQR) follow-up after the second stage was 15 (13-16) months. The median (IQR) number of previous operations was 2 (2-3). The median (IQR) length of the LMG was 3 (2.5-4) cm, and the median (IQR) width was 1 (1-2) cm. No donor-site major complications, but mild oral discomfort in the first week after graft harvesting, were reported in 39 (83%) patients. After the second stage, complications were reported in nine (19.2%) patients, meatal stenosis in five and fistula in four. The reported success rate was 80.9%. DISCUSSION: Reconstruction of previously failed hypospadias is a challenge owing to local tissue scarring and a paucity of adjacent healthy tissue. In this study, the LMG was used in two-stage redo hypospadias repair after previous repair failure. In the present study, a success rate of 80.9% was reported after the second stage. According to this study and the published series, harvesting the LMG is associated with minimal immediate donor-site complications and no long-term morbidity. Another advantage of the LMG is easy harvesting with effortlessly reachable tongue in comparison with the buccal mucosa that is deep and requires application of a mouth retractor. CONCLUSIONS: Two-stage LMG urethroplasty is a reliable procedure for salvage urethroplasty. Lingual mucosal graft harvesting is easy, with minor oral complications.

Awareness of disc herniation among general population in Aseer province, Saudi Arabia.

BACKGROUND: Herniated lumbar disc is a depositions of discs material (nucleus pulposus and annulus fibrosus) behind the intervertebral disk. Intervertebral disc connected the vertebral bodies together by pad of fibrocartilage. The major functions of intervertebral disc are mechanical, transferring load coming from the body weight and muscle contractions by spinal columns and letting the curving, flexion, and contortion. AIM: To assess the awareness of general population in Aseer region, southern of Saudi Arabia, regarding disc herniation and to identify the predictors for their awareness. METHODOLOGY: A descriptive cross-sectional approach was conducted through a questionnaire designed to examine the public herniated disc awareness and knowledge. The questionnaire given to individuals from general population visiting general public places in Aseer region. Content validity for the questionnaire was done as it was reviewed by three experts for any modification of corrections. RESULTS: The study included 1,044 participants aged between 15 and 70 years with mean age of 36.3 ± 11.2 years old. The majority of respondents were males (62.4%) and Saudi (98.9%). About 71% of the participants were university graduated. Generally, only 9% of the study participants recorded good awareness level regarding all aspects of disc herniation. CONCLUSION: This study showed that awareness regarding disc herniation among the general population was very poor for all domains.

Comparison between antral resection in laparoscopic sleeve gastrectomy and classical laparoscopic sleeve gastrectomy

Background: Laparoscopic sleeve gastrectomy (LSG) is essentially a restrictive bariatric operation. Weight loss is achieved by drastically reducing the gastric volume, which in turn leads to reduced food intake. In addition, a series of hormonal changes occurring postoperatively in bariatric patients, contribute to decreased appetite, reduced food intake and long-term weight loss. To date there is a lack of standardization regarding the surgical technique of LSG, which may affect the long-term outcome of the patients. Our study aimed to assess the difference in short and long- term weight loss and complications between antral resection in laparoscopic sleeve gastrectomy and classical laparoscopic sleeve gastrectomy with antral preservation. Patients and Methods: This is a controlled clinical trial held in Ain Shams University Hospital including 40 patients with BMI >30, of them 20 underwent antral resection in laparoscopic sleeve gastrectomy, and the other 20 patients underwent classical laparoscopic sleeve gastrectomy, with antral preservation. Results: Our study showed mild increase in weight loss and BMI reduction after 12 months in the antral resection group compared with the antral preservation group with mean weight loss 70.5kg in antral resection group versus 75.05kg in antral preservation group and mean BMI 27.7% in antral resection group versus 27.9% in antral preservation group, but did not reach statistical significant values. Conclusion: Our study showed that antral resection in laparoscopic sleeve gastrectomy resulted in non-significant better weight loss in the first postoperative year than classical laparoscopic sleeve gastrectomy

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Penile fasciocutaneous flap urethroplasty for the reconstruction of pediatric long anterior urethral stricture.

BACKGROUND: Though pediatric urethral stricture is an uncommon urological problem, it is a challenging urological one. The causative factors are iatrogenic, traumatic, and inflammatory. In the current study, the authors report their experience of the treatment of pediatric long anterior urethral stricture using penile circular fasciocutaneous flap. PATIENTS AND METHODS: The study included 23 pediatric patients who had long anterior urethral strictures, which were repaired using circular penile fasciocutaneous flap. The flap was elevated through a subcoronal circumferential incision and then it was split ventrally. The strictured portion of the urethra was sharply incised ventrally, extending to 1 cm into normal urethra. The flap was sutured to the urethral plate over silicone catheter of suitable size, which was removed after 3 weeks. The follow-up was scheduled every 3 months for the first year and then yearly thereafter. RESULTS: The urethroplasty was successful in 20 cases (86.96%). There were two cases complicated by stricture recurrence, which was managed by visual internal urethrotomy. Fistula formation was reported in one case and was repaired by simple excision and closure. Penile skin necrosis was reported in only one patient and was managed by frequent dressing. DISCUSSION: During the last five decades, there was a substantial advancement in the reconstruction of long or complex anterior strictures due to the use of grafts and flaps. During pediatric urethral stricture repair, particular attention must be paid to the differences between adults and children anatomy, e.g. the small urethral lumen and tissue delicateness. McAninch introduced the reconstruction of complex anterior urethral strictures utilizing circular penile fasciocutaneous flap. The technique of penile fasciocutaneous flap urethroplasty takes long time and requires meticulous dissection. Therefore, it should be restricted for long or complex anterior urethra strictures. Success rate in this study was 86.96%, which is in the same league as that reported in literature as regard adults penile fasciocutaneous flap urethroplasty. Whitson et al. reported success rates of 84% and 79% in the 5th and 10th years, respectively. In another study, Kim et al. revealed a success rate of 68.9%. In this study, complications incidence was 21.6%, which is consistent with reported incidence of complications of adults penile fasciocutaneous flap urethroplasty (8%-20%). CONCLUSION: According to the outcomes of this study, penile fasciocutaneous flap urethroplasty is a reasonable modality for the reconstruction of long anterior urethral stricture in pediatric patients especially after circumcision.

Gestational 3,3',4,4',5-pentachlorobiphenyl (PCB 126) exposure disrupts fetoplacental unit: Fetal thyroid-cytokines dysfunction.

Exposure to polychlorinated biphenyls (PCBs) is related to several endocrine disorders. This study examined the effect of maternal exposure of 3,3',4,4',5-pentachlorobiphenyl (PCB 126) on the fetoplacental unit and fetal thyroid-cytokine axis during the pregnancy. Pregnant albino rats received PCB 126 (20 or 40µg/kgb.wt.) by oral gavage from gestation day (GD) 1 to 20. Potential effects of PCB 126 were evaluated by following the histopathological changes in the placenta by Haematoxylin and Eosin (H&E) stain and measuring the maternofetal thyroid axis (ELIZA), maternofetal body weight, and fetal growth markers (ELIZA), and cytokines (ELIZA) at embryonic day (ED) 20. Placental tissues of both treated groups showed hyperemia, hemorrhage, degeneration and apoptosis in labyrinth layer and spiral artery at GD 20. Both administrations of PCB 126 elevated serum thyrotropin (TSH) concentration, and decreased free thyroxine (FT4) and free triiodothyronine (FT3) concentrations, resulting in a maternofetal hypothyroidism. The presence of hypothyroidism increased fetal serum concentration of transforming growth factor-ß (TGF-ß), leptin (LEP), tumor necrosis factor-α (TNF-α), interleukin-1ß (IL-1ß), and decreased the fetal serum insulin growth factor-I (IGF-I), IGF-II, insulin, adiponectin (ADP), and growth hormone (GH) in both treated groups at ED 20. However, the increase in resistin (RETN) and interferon-γ (IFN-γ) was non-significant in low-dose group and highly significant in high-dose group. Simultaneously, the reduction in body weight of the dams and fetuses was observed in both PCB 126 groups of examined day with respect to the control group. The maternal PCB 126 distorted the fetoplacental unit might disrupt the fetal thyroid-cytokines axis and prenatal development.

OC-09 - Microparticle-mediated transfer of TF hypercoagulability between cancer cells.

INTRODUCTION: Tissue Factor (TF) promotes apoptosis-resistance and facilitates haematogenous metastasis. Cancer cells release TF-bearing microparticles (TF-MP) which have pro-coagulant activity. TF-MPs from cancer cells induce increase in TF expression and procoagulant activity of recipient endothelial cells. Drug resistance microparticles transfer between cancer cells, resulting in induction of recipient cell drug resistance, however transfer of TF-MPs between cancer cells has not been demonstrated. AIM: To determine if microparticles isolated from TF expressing cancer cell lines can induced TF-mediated procoagulant activity in cell lines that do not express TF. MATERIALS AND METHODS: A7 cells (a melanoma cell line that does not express TF) were transformed to express TF with adenoviral transformation. In addition, the TF-expressing breast cancer cell line MDAMB231 was used. Media was collected from (1) wild-type A7 (A7-WT) cells, which acted as control (2) MDAMB231 cells, (3) A7 cells transformed with 'low' levels of TF-adenovirus and (4) A7 cells transformed with 'high' levels of TF-adenovirus. MPs were isolated from media by centrifugation using standard techniques. Isolated MPs were incubated with wild-type A7 (A7-WT) cells overnight. Pro-coagulant activity of A7-WT cells was assessed using a FXa generation assay. RESULTS: i) A7-WT cells incubated overnight with MDAMB231-derived MPs produced an almost 5 fold increase in procoagulant activity compared to control (Mean 3.5 mOD/min S.E 0.32 vs control 0.68 S.E. 0.05, p<0.01). ii) MPs released from A7-TF cells induced a dose-dependant increase in cell based procoagulant activity when incubated with A7-WTs compared to control:A7-WT cells incubated with control MPs (Control): mean mOD 0.83, S.E. 0.07A7-WT cells incubated with A7-TF derived MPs (low levels of TF-adenovirus): mean mOD 1.27, S.E. 0.06 (p=0.04 vs control)A7-WT cells incubated with A7-TF derived MPs (low levels of TF-adenovirus): mean mOD 2.77, S.E. 0.23 (p<0.01 vs control). CONCLUSIONS: These results demonstrate, for the first time, microparticle-mediated transfer of TF procoagulant activity between cancer cells. MPs shed by cancer cells in vivo have been implicated in cancer cell progression and hypercoagulability. The acquisition and spread of of MP-mediated TF activity has implications for cancer cell biology and cancer-induced hypercoagulability.

PO-09 - Incidence of pre-operative and post-operative deep vein thrombosis in colorectal cancer surgery. Interim results of a prospective clinical study.

INTRODUCTION: Venous thromboembolism (VTE) is a major cause of death in patients undergoing colorectal cancer surgery and usually arise from Deep Vein Thrombosis's (DVTs). In patients with cancer below knee and asymptomatic DVTs are at risk of propagating and result in a VTE. Retrospective, population based studies predating extended course venous thromboprophylaxis report an incidence of symptomatic VTE in colorectal cancer patients of approximately 5.5%. Clinical studies have suggested that pre-operative d-dimer may predict the development of post-operative DVTs. AIM: We undertook a multicentre prospective study to screen colorectal cancer patients pre- and post-operatively for the presence of DVTs. The aim of the study was to determine the incidence of DVTs in patients undergoing elective, curative surgery for colorectal cancer. The study also aimed to identify histological and clinical factors that pre-dispose to development of a DVT. The role of pre-operative d-dimer in predicting the development of post-operative DVTs was also analysed. MATERIALS AND METHODS: Patients at four hospitals undergoing elective curative surgery for colorectal cancer were recruited pre-operatively. Exclusion criteria were: previous VTE, previous malignancy, anti-coagulants. Bilateral full leg venous duplex was performed pre-operatively and at six weeks post-surgery. Plasma D-dimer was measured pre-operatively. RESULTS: Of 60 patients undergoing pre-operative duplex, five (8.3%) had below knee, asymptomatic DVTs. These patients were then excluded from further analysis. Of the remaining 55, 48 had post-operative duplex examination. Three (6.3%) developed post-operative DVTs all of which were asymptomatic and below knee. There were no symptomatic DVTs. Two of these patients had received extended course venous thromboprophylaxis and the other received inpatient thromboprophylaxis. Development of post op DVT was associated with lymph node positivity (p=0.02). There were no other histological, surgical or demographical factors that predicted the development of post-operative DVTs. Pre-operative D-dimer was higher in patients who developed a post-operative DVT compared to those who did not [1,275 ng/L (95%CI: 780 - 1770 ng/L) vs 805 ng/L (95% CI: 632 - 980 ng/L) p=0.03]. CONCLUSIONS: Of patients diagnosed with operable colorectal cancer, 8% have pre-operative asymptomatic DVT, and a further 6% develop DVT despite thromboprophylaxis. The subgroup of patients with lymph node involvement may benefit from more aggressive anticoagulation as they are at increased risk of DVT despite extended course anticoagulation. Pre-operative D-dimer may offer a predictive method to identify patients at risk of post-operative DVT.

PO-21 - Stromal fibroblasts in preinvasive breast cancer (ductal carcinoma in situ, DCIS) demonstrate a cancer-like procoagulant phenotypic switch that may facilitate invasion.

INTRODUCTION: Ductal carcinoma in-situ (DCIS) is a preinvasive breast cancer where cancer cells remain confined within the ductal basement membrane. However, genotypic changes have been identified in stroma surrounding DCIS, outside the basement membrane. Stromal fibroblasts undergo phenotypic change in cancer to promote tumour angiogenesis, proliferation, immunosuppression and metastasis and in vivo can induce invasion of DCIS. Phenotypic changes in DCIS stromal fibroblasts may potentially act as a precursor for invasion. AIM: To determine if stromal fibroblasts in DCIS have procoagulant changes similar to those seen in cancer-associated fibroblasts in invasive breast cancer. MATERIALS AND METHODS: As part of the prospective cohort study CHAMPion (Cancer induced Hypercoagulabulity as a Marker of Prognosis), patients with DCIS (n=72) and invasive breast cancer (n=292) were recruited. Stromal fibroblasts in tumour and corresponding normal breast tissue (distant from the cancer) were quantified (percentage IHC stained) for tissue factor (TF), thrombin, PAR1 and PAR2. Fibroblasts were identified morphologically, at a minimum distance of 0.2mm from ductal tissue, to avoid myoepithelial scoring. Scoring was performed in duplicate by two independent pathologists. RESULTS: Fibroblast TF expression was present in normal breast tissue (mean 43% ([SD 27%]) but markedly increased in DCIS (mean 62% [SD 27%], p=0.002). Fibroblast TF expression was further increased in invasive breast cancer (mean 74% [SD 23%], normal vs invasion, p<0.001; DCIS vs invasion, p=0.03). Fibroblast thrombin and PAR2, but not PAR1, expression was increased in DCIS compared to normal (thrombin: 60% vs 42%, p<0.001; PAR2: 58% vs 41%, p=0.002), however no further significant increase was seen in invasive cancer (thrombin 63%, PAR2 61%). Fibroblast tissue factor correlated with fibroblast thrombin expression (p<0.001, r=0.4) and fibroblast PAR2 expression (p<0.001, r=0.5), with thrombin and PAR2 expression also correlating (p<0.001, r=0.4). CONCLUSIONS: Procoagulant phenotypic changes, in terms of increased TF, thrombin and PAR2 expression, occur in stromal fibroblasts at the preinvasive stage. It needs to be determined if this change is functional and therefore a potential therapeutic target for preventing transition to invasion.

PO-32 - Patient, tumour and operative factors influencing perioperative hypercoagulability in colorectal cancer.

INTRODUCTION: Up to 6% of patients develop venous thromboembolism (VTE) following elective colorectal cancer surgery despite thromboprophylaxis. Clinical practices for perioperative thromboprophylaxis remains variable, particularly the use and duration of extended thromboprophylaxis. Identification of factors associated with a prolonged postoperative hypercoagulable state may allow the development of algorithms that allow more targeted thromboprophylaxis. AIM: To identify patient, tumour and surgical risk factors for prolonged (two and six weeks) hypercoagulability in colorectal cancer patients undergoing surgical resection. MATERIALS AND METHODS: In a prospective cohort study (Cancer-induced Hypercoagulability As a Marker of Prognosis [CHAMPion]), plasma d-dimer was measured at 2 and 6weeks post-operatively in patients undergoing elective, curative resection for colorectal cancer. Hypercoagulability (raised D-dimer) at 2 and 6weeks was correlated with patient, tumour and operative factors. RESULTS: Of the 62 patients recruited (median age 69years [range 39-90]), 37 were male. D-dimer was increased in females compared to males at six weeks (geometric mean (GM) 1,287ng/ml [95% CI 944 - 1,755 vs. 821ng/ml (95% CI 633 - 1064) p=0.03]. Age, smoking, hypertension, use of antiplatelet medication, BMI and WHO performance status were not associated with a prolonged hypercoagulable state. There were no tumour factors (including size/T stage/lymph node involvement/differentiation) associated with a prolonged hypercoagulable state. D-dimer was increased in patients undergoing open surgery (n=39) compared to laparoscopic surgery (n=23) at 2weeks (GM 2,337ng/ml [95% CI 1,806-3,023] vs. 1,212ng/ml [95% CI 898-1,629], p=0.001) and 6weeks (GM 1,162ng/ml [95% CI 818-1647] vs. 723ng/ml [95% CI 533-982]p=0.04). Operative time was not associated with prolonged hypercoagulability. D-dimer had a trend to be increased at 2weeks in patients receiving perioperative blood transfusions (n=8) compared to those that did not (n=54) (GM 2,618ng/ml [95% CI 1,525-4,536] vs. 1613ng/ml [95% CI 1,236 - 2,100] p=0.08). CONCLUSIONS: Even in this relatively small cohort of patients female gender, open surgery and receiving a blood transfusion are associated with on-going hypercoagulability up to six weeks post operation. This may represent a group where thromboprophylaxis should be targeted.

PO-51 - Expression of proteins of the tissue factor thrombin pathway is upregulated in the stroma and epithelium of colorectal cancer.

INTRODUCTION: Colorectal cancer expression of Tissue Factor (TF), PAR1 and PAR2 is associated with a poor prognosis. Their stromal, rather than epithelial, expression has prognostic significance in other cancers, this has not been explored in colorectal cancer. AIM: We aimed to determine the expression patterns of Tissue Factor (TF), PAR1 and PAR2 and thrombin in colorectal cancer and normal tissue. MATERIALS AND METHODS: Cancer and distant normal tissue were sampled from 37 patients. Expression of TF, Thrombin, PAR1 and PAR2 were determined by immunohistochemistry. Two observers scored expression level (0-3) in individual cells. Percentage of cells having each level of expression was determined and an H-score calculated which are given with 95% CI. RESULTS: Normal epithelium did not express TF, but it was expressed by cancer epithelium (36.5 (95% CI 17.6 - 55.4) p<0.001). Thrombin expression was increased in cancer vs normal epithelium (126.2 (95% CI 110.6 - 141.7) vs 101.6 (95% CI 92.5-110.8) p=0.01) as was PAR2 (172.4 (95% CI 152.9-191.8) vs 123.4 (95% CI 107.8-139.0) p<0.001). The increase in cancer epithelium PAR1 expression compared to normal (105.4 (95%CI 84.3-126.5) vs 89.0 (95% CI 80.4-97.6)) was not significant. Normal stroma did not express TF or thrombin however both were expressed by cancer stroma (TF 46.3 (95% CI 24.6-68.0) p<0.001, thrombin 11.4 (95% CI 6.2-16.7) p<0.001). PAR1 and PAR2 were both expressed in normal stroma but demonstrated increased expression in cancer stroma (cancer vs normal; PAR 1: 130.7 (95% CI 112.2-149.2) vs 19.5 (95% CI 11.24-27.7) p<0.001; PAR2: 21.5 (95% CI 12.9-30.1) vs 2.21 (95% CI 0.49-3.92) p<0.001). CONCLUSIONS: Upregulated expression of tissue thrombin pathway proteins is seen in colorectal cancer in both epithelial and stromal cells. Procoagulant tumour cells and tumour microenvironment may provide a novel therapeutic target for treatment in colorecal cancer.

The significance of circulating tumour cells in breast cancer: a review.

Haematogenous spread of circulating tumour cells (CTCs) is the principle mechanism for development of metastases. Research into the enumeration and characterisation of CTCs, particularly in the last decade, has allowed the introduction of semi-automated CTC assessment in the clinical setting. In breast cancer, CTC enumeration is being used as a prognostic biomarker, a predictive biomarker of treatment response and is being assessed to guide treatment in both the early and metastatic setting. CTC characterisation has the potential to direct targeted therapies, such as HER2 therapies in HER2 negative primary breast tumour patients. However, CTC assessment has considerable challenges. Capture and identification of these very rare cells is currently largely dependent on a presumed homogeneity of phenotype. In addition, high throughput assays are lacking. The clinical significance of CTCs is incompletely understood. A large proportion of CTC positive patients have no evidence of metastases, raising the issue of either inconsequential tumour dormancy or non-viable CTCs. CTCs may have additional clinical sequelae such as promoting venous thrombosis. However CTCs provide a real-time liquid biopsy of the tumour and represent an exciting, minimally invasive method of assessing disease status and also a novel therapeutic target for malignancy.

An ontological case base engineering methodology for diabetes management.

Ontology engineering covers issues related to ontology development and use. In Case Based Reasoning (CBR) system, ontology plays two main roles; the first as case base and the second as domain ontology. However, the ontology engineering literature does not provide adequate guidance on how to build, evaluate, and maintain ontologies. This paper proposes an ontology engineering methodology to generate case bases in the medical domain. It mainly focuses on the research of case representation in the form of ontology to support the case semantic retrieval and enhance all knowledge intensive CBR processes. A case study on diabetes diagnosis case base will be provided to evaluate the proposed methodology.

The impact of systemic fungal infection in patients with perforated oesophagus.

INTRODUCTION: Perforated oesophagus is a surgical emergency with significant morbidity and mortality. Systemic fungal infection represents a poor response to the magnitude of the insult, which adds significantly to the risk of morbidity and mortality in these patients. We reviewed our experience with this group of patients over a six-year period in a tertiary referral centre. METHODS: A retrospective clinical review was conducted of patients who were admitted following a ruptured oesophagus over a period of six years (January 2002 - January 2008). RESULTS: We had 27 admissions (18 men and 9 women) following an isolated perforated oesophagus to our unit. The median patient age was 65 years (range: 22-87 years). The majority (n=24, 89%) presented with spontaneous perforations (Boerhaave's syndrome) and three (11%) were iatrogenic. Fungal organisms, predominantly Candida albicans, were positively cultured in pleural or blood samples in 16 (59%) of the 27 patients. Fourteen patients grew yeasts within the first seven days while two showed a delayed growth after ten days. Overall mortality was 5 out of 27 patients (19%). There was no mortality among the group that did not grow yeasts in their blood/pleural fluid while mortality was 31% (5/16) in the group with systemic fungal infection (p<0.001). A positive fungal culture was also associated with increase ventilation time, intensive care unit stay and inpatient hospital stay but not an increased rate of complications. CONCLUSIONS: Systemic fungal infection in patients with a ruptured oesophagus affects a significant proportion of these patients and carries a poor prognosis despite advanced critical care interventions. It may represent a general marker of poor host response to a major insult but can add to mortality and morbidity. It is worth considering adding antifungal therapy empirically at an early stage to antimicrobials in patients with an established diagnosis of a perforated oesophagus.

Cross-matched blood in colorectal surgery: a clinical waste?

AIM: This study was carried out to determine the rate of perioperative blood transfusion and to create an evidence-based approach to requesting blood for elective colorectal surgery. METHOD: A comparative cohort study was carried out of 164 patients (107 men, 57 women, median age 68 years) who underwent major colorectal surgery. Details obtained included demographic and operative information, the number of units of blood cross-matched, units used, the reasons for transfusion and patient suitability for electronic issue (EI). The cross-match to transfusion ratio (C:T ratio) was calculated for each procedure and for the whole group of colorectal procedures. RESULTS: Some 162 units of blood were cross-matched for 76 (46%) patients, with the remaining 88 (54%) being grouped with serum saved. Twenty-one (13%) were transfused with a total of 48 units of blood. The C:T ratio for all procedures was 3.4/1. The commonest indication for transfusion was anaemia. One patient required an emergency transfusion. The majority (78%) of patients were suitable for EI. There were no significant differences between the transfused and nontransfused groups with regard to age, diagnosis (malignant vs benign) and laparoscopic or open colorectal procedure. CONCLUSION: Only a small proportion of patients undergoing elective major colorectal surgery require perioperative blood transfusions, most of which are nonurgent. Blood should not be routinely cross-matched in patients who are suitable for EI.

A simple strategy for breakpoint fragment determination in chronic myeloid leukemia.

Molecular characterization is considered a part of the routine work-up of chronic myeloid leukemia (CML) cases. Southern blot analysis using the universal BCR (UBCR) probe on BglII-digested DNA samples is the most commonly used technique, while employing the human 3' bcr probe (PR-1) is usually considered a complementary tool. In this study, we tried to develop a simple and economic strategy for molecular characterization of CML using the 3' probe as it has been shown to be the one capable of locating the breakpoint site. Seventy-eight cases of CML were studied. Molecular analysis was performed using the Southern blot technique. DNA was digested with Bam HI, BglII, EcoRI, and XbaI. Hybridization was performed using the human 3' bcr (PR-1) probe. BamHI and BglII could differentiate fragment 1 (F1) showing rearrangement (R) with Bam HI and germline configuration (G) with BglII; F2/3 showing R with both, and F4 showing R with BamHI and G with BglII. F2/3 cases were further divided by HindIII enzyme into F2 showing (G) and F3 showing (R). Fragment 0 showed G with both, but R with EcoRI and/or XbaI, while 3' deletion gave G with all four enzymes. Our results showed a relative incidence of 6.4% for F0, 20.5% for F1, 32.1% for F2, 19.2% for F3, 15.4% for F4, and 6.4% for 3' deletion. Sixty cases were evaluated clinically and hematologically and were followed up for disease evolution and survival. They included 32 cases in early chronic phase, 24 in late chronic phase, two in acceleration, and two in blastic crisis. No significant correlation was encountered between the breakpoint site and any of the clinical and hematological data except those patients with 3' deletion who showed a very short survival. The study emphasizes Southern blotting as the method of choice for molecular characterization of CML and offers a simple and economic strategy for diagnosis and determination of breakpoint fragment.