Abstract Background Surgical-site infection increases morbidity, mortality and financial burden. The preferred topical antiseptic agent (chlorhexidine or povidone–iodine) for preoperative skin cleansing is unclear. Methods A meta-analysis of clinical trials was conducted to determine whether preoperative antisepsis with chlorhexidine or povidone–iodine reduced surgical-site infection in clean-contaminated surgery. Results The systematic review identified six eligible studies, containing 5031 patients. Chlorhexidine reduced postoperative surgical-site infection compared with povidone–iodine (pooled odds ratio 0·68, 95 per cent confidence interval 0·50 to 0·94; P = 0·019). Conclusion Chlorhexidine should be used preferentially for preoperative antisepsis in clean-contaminated surgery.
Abstract The following abstracts are from papers presented at the 44th annual scientific meeting of the Vascular Society of Great Britain and Ireland, held in Liverpool 18–20 November 2009. The President of the Society, Mr P. Taylor, was in the Chair. The BJS Prize was won by Dr R. Aggarwal from the University of Leeds, and the Founder's Prize was won by Mr R. Sharpe from Leicester Royal Infirmary.
A BSTRACT Due to the high morbidity and mortality of the coronavirus disease 2019 (COVID-19) in patients with malignancy, the necessity of vaccination in this group of patients became particularly important. Although a large number of studies have reported the safety of COVID-19 vaccination in multiple myeloma (MM) patients, the effect of the COVID-19 vaccine on MM relapse has not yet been reported. Here, we report a case of a possible association between relapse of MM and COVID-19 vaccination with Sinopharm ® , an inactivated virus vaccine, in a patient with MM who has remained in complete remission for about 4 years. The MM relapse in the patient was diagnosed by both clinical findings and laboratory workup including serum protein electrophoresis, bone marrow aspiration, and biopsy. Despite this possible association between COVID-19 vaccination and MM relapse in the patient, given its importance in reducing mortality and having an acceptable safety profile, the COVID-19 vaccine should be administered to all cancer patients. However, careful monitoring and follow-up are recommended in patients with MM after COVID-19 vaccination.
MRI is a well-tolerated, short procedure that would provide an early, accurate and cost effective diagnosis in elderly patients with negative plain films and persistent post-traumatic hip pain, thereby facilitating their correct management. It is 100% sensitive and specific to occult hip fractures and does not involve ionising radiation. Fractured necks of femur in the elderly population are common. This group of patients are responsible for a significant proportion of health care costs and efforts today. The diagnosis of hip fractures is not always clear-cut and plain radiographs may not show an undisplaced fracture. The management of this patient group is dependant upon the correct diagnosis via imaging and treatment decisions are based on these findings. If these fractures are missed, there is a significant chance of displacement and avascular necrosis presenting at a later date. This would complicate matters and result in more complex surgery. This also increases health care costs due to an extra admission, more expensive and difficult surgery with longer rehabilitation and after care. In our study, the management of the patients reviewed was significantly altered due to the imaging process used. We performed MRI scans on thirty-six patients who had post-traumatic hip pain and negative plain radiographs (reported as normal or equivocal). Twenty-three (64%) of the patients sustained a fracture, of which sixteen (44%) involved the neck of the femur, all of whom were above the age of 71 years. 100% of the elderly age group scanned were positive for a femoral neck fracture and eleven (31%) received operative intervention. The five patients who did not undergo operative management were deemed too unwell for surgery. Only three patients’ scans were negative. These results confirm that MRI (in the 71 years and above age group), is indicated in order to diagnose an undisplaced fractured neck of femur not recognised on plain radiographs, which requires operative intervention in the form of dynamic hip screw or cannulated hip screws to prevent further deterioration or displacement.
Contrast induced nephropathy (CIN) is the commonest cause of iatrogenic renal injury and its incidence has increased with the advent of complex endovascular procedures. Evidence suggests that ascorbic acid (AA) has a nephroprotective effect in percutaneous coronary interventions when contrast media are used. A variety of biomarkers (NGAL, NGAL:creatinine, mononuclear cell infiltration, apoptosis and RBP-4) in both the urine and kidney were assayed using a mouse model of CIN in order to determine whether AA can reduce the incidence and/or severity of renal injury. Twenty-four BALB/c mice were divided into 4 groups. Three groups were exposed to high doses of contrast media (omnipaque) in a well-established model of CIN, and then treated with low or high dose AA or placebo (saline). CIN severity was determined by measurement of urinary neutrophil gelatinase-associated lipocalin (NGAL):creatinine at specific time intervals. Histological analysis was performed to determine the level of mononuclear inflammatory infiltration as well as immunohistochemistry to determine apoptosis in the glomeruli by staining for activated caspase-3 and DNA nicking (TUNEL assays). Reverse transcriptase PCR (rtPCR) of mRNA transcripts prepared from mRNA extracted from mouse kidneys was also performed for both lipocalin-2 (Lcn2) encoding NGAL and retinol binding protein-6 (RBP4) genes. NGAL protein expression was also confirmed by ELISA analysis of kidney lysates. Urinary NGAL:creatinine ratio was significantly lower at 48 h with a 44% and 62% (204.3μg/mmol versus 533.6μg/mmol, p = 0.049) reduction in the low and high dose AA groups, respectively. The reduced urinary NGAL:creatinine ratio remained low throughout the time period assessed (up to 96 h) in the high dose AA group. In support of the urinary analysis ELISA analysis of NGAL in kidney lysates also showed a 57% reduction (12,576 ng/ml versus 29,393 ng/ml) reduction in the low dose AA group. Immunohistochemistry for apoptosis demonstrated decreased TUNEL and caspase-3 expression in both low and high dose AA groups. Ascorbic acid reduced the frequency and severity of renal injury in this murine model of CIN. Further work is required to establish whether AA can reduce the incidence of CIN in humans undergoing endovascular procedures.
The evolution of metastatic oesophageal adenocarcinoma (OAC) is poorly understood. Whole genome sequencing (WGS) across multiple metastatic sites provides the unique opportunity to study clonal evolution of OAC.
Method
2 cases of junctional OAC were extensively sampled at autopsy within 4 h of death. At presentation case 1 was palliative, case 2 had potentially curative disease but progressed during treatment. 20 fresh frozen tumour samples from primary tumour and multiple metastases (adrenal, liver, pancreas, station 102, left gastric and para-aortic lymph nodes) underwent WGS. Clonal analysis involved estimating copy number status and tumour purity, followed by point mutation clustering based on allele frequency (proportion of tumour cells harbouring a mutation); clusters were referred to as clones and were annotated with driver events of clonal progression (single nucleotide variants (SNVs) and copy number events).
Results
11 clones spanned all samples in case 1 compared to 5 in case 2. Median SNVs per clone were 5885 in case 1 (range 1091–29883) and 2149 (range 424–27031) in case 2. The founding clone in both cases contained the bulk of the SNVs and key potential drivers of carcinogenesis (case 1:KRAS and GATA4 amplification, case 2:TP53 mutation). Metastases in case 1 had a branching pattern of evolution; 6 clones were unique to individual metastases and only 1 was shared across sites. Clones were on average 9363 (+/-5827) SNVs distant from the founder clone demonstrating continuing evolution in metastases. Para-aortic nodal metastasis preceded local lymph node metastasis. In contrast case 2 demonstrated linear evolution with just 2 metastatic clones that were on average 1286 (+/-1219) SNVs distinct from the primary tumour; 1 was only in the adrenal, the second was shared across multiple sites suggestive of an embolic pattern of tumour seeding. The liver metastasis was identical to the primary founder clone demonstrating that metastasis to the liver was the initial event, even prior to local lymph node metastasis.
Conclusion
Metastases can result from contrasting patterns of clonal evolution. Both cases demonstrate the striking phenomenon of early distant metastases, prior to the development of local lymph node metastases thus challenging our traditional algorithms of tumour staging and prognostication. Additional cases are being analysed to support our findings.
'%3e%3cpath fill='%23012169' d='M0 0v30h60V0z'/%3e%3cpath stroke='%23fff' stroke-width='6' d='m0 0 60 30m0-30L0 30'/%3e%3cpath stroke='%23C8102E' stroke-width='4' d='m0 0 60 30m0-30L0 30' clip-path='url(%23b)'/%3e%3cpath stroke='%23fff' stroke-width='10' d='M30 0v30M0 15h60'/%3e%3cpath stroke='%23C8102E' stroke-width='6' d='M30 0v30M0 15h60'/%3e%3c/g%3e%3c/svg%3e)