High Positive Incidence Research Articles

Detection of Aspergillus flavus in Figs by Means of Hyperspectral Images and Deep Learning Algorithms

Plant diseases cause economic losses and health risks, such as aflatoxins linked to liver cancer. These toxins, produced by fungi like Aspergillus flavus in figs, are often detected late through invasive methods or visual inspection. Since Spain, particularly Extremadura, is a key fig producer, alternative detection methods are essential to preventing aflatoxins in the food chain. The aim of this research is the early detection of Aspergillus flavus fungus using non-invasive techniques with hyperspectral imaging and applying artificial intelligence techniques, in particular deep learning. The images were taken after inoculation of the microtoxin using 3 different concentrations, related to three different classes and healthy figs (healthy controls). The analysis of the hyperspectral images was performed at the pixel level. Firstly, a fully connected neural network was used to analyze the spectral signature associated with each pixel; secondly, the wavelet transform was applied to each spectral signature. The resulting images were fed to a convolutional neural network. The hyperparameters of the proposed models were adjusted based on the parameter tuning process that was performed. The results are promising, with 83% accuracy, 82.75% recall, and 83.25% F1-measure for the fully connected neural network. The high F1-measure demonstrates that the model’s performance is good. The model has a low incidence of false positives for samples that contain aflatoxin, while a higher number of false positives appears in healthy controls. Due to the presence of false negatives, this class also has a high recall. The convolutional neural network results, accuracy, recall, and F1 are 77.25%, indicating moderate model performance. Only class 3, with higher aflatoxin concentration, achieves high precision and low false positive incidence. Healthy controls exhibit a high presence of false negatives. In conclusion, we demonstrate the effectiveness of pixel-level analysis in identifying the presence of the fungus and the viability of the non-invasive techniques applied in improving food safety. Although further research is needed, in this study, the fully connected neural network model shows good performance with lower energy consumption.

Are the Reference Values for the Provocative Concentration of Methacholine Appropriate for Children?

Background: Preliminary data in a randomly selected pediatric cohort study in 8-year-olds suggested a rate of positivity to a methacholine challenge test that was unexpectedly high, roughly 30%. The current recommendation for a negative methacholine test is a 20% decrease in the forced expiratory volume in one second at a dose greater than 400 μg. This was derived from studies in adults using the obsolete English Wright nebulizer. One explanation for the high incidence of positivity in the study in 8-year-olds could be that children deposit more methacholine on a μg/kg basis than adults, due to differences in their breathing patterns. The purpose of this study was to determine if pediatric breathing patterns could result in a higher dose of methacholine depositing in the lungs of children based on μg/kg body weight compared with adults. Methods: An AeroEclipse Breath Actuated nebulizer delivered methacholine aerosol, generated from a 16 mg/mL solution, for one minute, using age-appropriate breathing patterns for a 70 kg adult and a 30 and 50 kg child produced by a breathing simulator. Predicted lung deposition was calculated from the collected dose of methacholine on a filter placed at the nebulizer outport, multiplied by the fraction of the aerosol mass contained in particles ≤5 μm. The dose of methacholine on the inspiratory filter was assayed by high performance liquid chromatography (HPLC). Particle size was measured using laser diffraction technology. Results: The mean (95% confidence intervals) predicted pulmonary dose of methacholine was 46.1 (45.4, 46.8), 48.6 (45.3, 51.9), and 36.1 (34.2, 37.9) μg/kg body weight for the 30 kg child, 50 kg child, and 70 kg adult, respectively. Conclusions: On a μg/kg body weight, the predicted pulmonary dose of methacholine was greater with the pediatric breathing patterns than with the adult pattern.

Long-term clinical outcomes of male breast cancer patients treated with curative intent by trimodality therapy at an academic university hospital in India.

Male breast cancer is rare and accounts for less than 1% of all breast cancer cases worldwide. This retrospective cohort study included all patients of invasive male breast cancer treated with curative intent by a trimodality approach via a multidisciplinary team at an academic university hospital in India between 2009 and 2023. Records were identified from a prospectively maintained database. Clinicopathological parameters, treatment details and survival were recorded and analysed. Thirty-four patients were included. The median (IQR) age was 55(44-63) years. Most patients were overall stage III (74%) and node positive (79%) with Scarff-Bloom-Richardson grade II (50%). Twenty-five patients (73%) were oestrogen receptor (ER) positive. Lymphovascular space invasion (LVSI) and perineural invasion (PNI) were present in 62% and 21% of patients, respectively. The most common chemotherapy timing was adjuvant (53%) followed by neoadjuvant (41%), and the most commonly used regimen consisted of a combination of doxorubicin-cyclophosphamide followed by a taxane (53%). Most (85%) patients underwent a mastectomy, five patients underwent breast conservation. All patients received radiotherapy to a dose of 42.6 Gy in 16 fractions, followed by a tumour bed boost for those undergoing breast conservation. At a median follow-up of 70 months (range 10-159 months), the five and ten-year overall survival was 91% and 58%, and the five-year disease-free survival (DFS) was 67%. The median DFS was 72 months. On univariate analysis, the tumour sub-type (Luminal versus TNBC) significantly predicted DFS (P = 0.03 log-rank). Breast cancer in males has a high incidence of node positivity, ER positivity and LVSI. Even with advanced stages at presentation, trimodality therapy in a multidisciplinary setting offers good long-term outcomes.

A data-driven robust design optimization method and its application in compressor blade

The probability-based robust optimization methods require a large amount of sample data to build probability distribution models of uncertain parameters. However, it is a common situation that only scarce sampled data are available in practice due to expensive tests. This study proposes a data-driven robust optimization framework by embedding a novel uncertainty quantification (UQ) method, which can quantify the uncertainty based on the statistical moments of scarce input data. The computational robustness and accuracy of the developed UQ methods are validated. Then, the data-driven multi-objective optimization framework is applied to improve the mean performance and aerodynamic robustness of a two-dimensional compressor blade with real stagger angle errors. Uncertainty analysis shows that there is a probability of 47.55% to deviate from the nominal total pressure loss coefficient by more than 1% for the actual performance values at high positive incidence i=7° condition. In the optimization process, the total pressure loss coefficient is selected as the objective function, while the static pressure ratio is used as a constraint. The Gaussian process regression model is trained to improve the robust optimization efficiency. The robust optimization is conducted under the most sensitive conditions. Optimized results indicate that compared with the nominal blade, the mean performance of the selected robust blades is increased by 10.9%, 8.56%, and 0.83%; the performance dispersion is decreased by 19.0%, 24.8%, and 35.3%, respectively. The optimized results can provide useful references for the robust design of compressor blades.

A Systematic Review and Meta-Analysis of Malaria Test Positivity Outcomes and Programme Interventions in Low Transmission Settings in Southern Africa, 2000-2021.

Malaria is one of the most significant causes of mortality and morbidity globally, especially in sub-Saharan Africa (SSA) countries. It harmfully disturbs the public’s health and the economic growth of many developing countries. Despite the massive effect of malaria transmission, the overall pooled proportion of malaria positivity rate in Southern Africa is still elusive. Therefore, the objective of this systematic review and meta-analysis is to pool estimates of the incidence of the malaria positivity rate, which is the first of its kind in South African countries. A literature search is performed to identify all published articles reporting the incidence of malaria positivity in Southern Africa. Out of the 3359 articles identified, 17 studies meet the inclusion for systematic review and meta-analysis. In addition, because substantial heterogeneity is expected due to the studies being extracted from the universal population, random-effects meta-analyses are carried out to pool the incidence of the malaria positivity rate from diverse diagnostic methods. The result reveals that between-study variability is high (τ2 = 0.003; heterogeneity I2 = 99.91% with heterogeneity chi-square χ2 = 18,143.95, degree of freedom = 16 and a p-value < 0.0001) with the overall random pooled incidence of 10% (95%CI: 8–13%, I2 = 99.91%) in the malaria positivity rate. According to the diagnostic method called pooled incidence estimate, the rapid diagnostic test (RDT) is the leading diagnostic method (17%, 95%CI: 11–24%, I2 = 99.95%), followed by RDT and qPCR and RDT and loop mediated isothermal amplification (LAMP), respectively, found to be (3%, 95%CI: 2–3%, I2 = 0%) and (2%, 95%CI: 1–3%, I2 = 97.94%).Findings of the present study suggest high malaria positive incidence in the region. This implies that malaria control and elimination programmes towards malaria elimination could be negatively impacted and cause delays in actualising malaria elimination set dates. Further studies consisting of larger samples and continuous evaluation of malaria control programmes are recommended.

Hepatitis C Epidemiology in a Large Urban Jail: A Changing Demographic.

Nearly 1 in 3 people with hepatitis C virus (HCV) infection pass through the criminal justice system annually; the system is a crucial location for HCV screening, education, and linkage to care. We aimed to (1) determine the prevalence and incidence of HCV antibody positivity and (2) evaluate the demographic characteristics of people with HCV in a large urban jail. We offered universal opt-out HCV testing to any person undergoing a routine blood test at the Dallas County Jail from June 2015 through December 2019 (N = 14 490). We extracted data on demographic characteristics from the electronic medical record and collected data on risk factors from people with HCV antibody positivity. We performed univariate and multivariate analyses. The prevalence of HCV antibody positivity was 16.7%; the incidence was 13.5 cases per 1000 person-years. HCV antibody positivity was significantly associated with older age (P < .001), female sex (P = .004), non-Hispanic White race versus non-Hispanic Black race (P < .001), and being released to prison versus not (P < .001). Among people born after 1965, those who were HCV antibody-positive were more frequently non-Hispanic White and Hispanic women, whereas among those born in 1965 or before, those who were HCV antibody-positive were more frequently non-Hispanic Black men. The high prevalence and incidence of HCV antibody positivity in a large county jail argue for routine, universal HCV testing and prevention counseling in criminal justice settings. Changing demographic characteristics mirror those of the national injection drug use epidemic and shed insight into designing interventions for risk reduction, education, linkage to care, and treatment.

DOP26 COVID-19 vaccine effectiveness in Inflammatory Bowel Disease patients on tumor-necrosis factor inhibitors: Real world data from a mass-vaccination campaign

BackgroundSome studies have shown decreased serological response to vaccination in patients on anti-tumor necrosis factor (TNF) medications. While the large majority of these patients do seroconvert after vaccination, titers have generally been lower and one study showed reduced neutralizing and inhibitory functions. One real-world population-based study compared found no increased infection rate in anti-TNF treated patients, but infection rates were low. The low event rate mandates exploration in longer-term population-based data. We used the epi-Israeli IBD Research Nucleus (IIRN) database to explore the effectiveness of COVID-19 vaccination in IBD patients in Israel.MethodsWe included all IBD patients insured in two of the four Israeli HMOs, covering 35% of the population, by validated algorithms, and selected those who received two doses of Pfizer BNT162b2 vaccine. These were matched by date of vaccination ±3 days and demographic variables to non-IBD controls. The primary outcome was incidence of positive COVID-19 PCR following vaccination between December, 2020 to June, 2021.Results12,640 IBD patients received two vaccine doses; the matched cohort included 4,946 matched pairs (total 9,892 subjects). Mean age was 50.5±16.1 years and median follow-up was 22 weeks (range 4.1–24.4). Fifteen (0.3%) vaccinated IBD patients tested positive compared with 15 (0.3%) vaccinated non-IBD controls (OR=1 [95%CI 0.49–2.05], p=1.0). Patients on anti-TNF and/or corticosteroids did not have a higher incidence of positivity – neither compared to the entire group nor to IBD patients treated with vedolizumab/ustekinumab, even after precise matching for demographics, underlying diseases and IBD severity.ConclusionIn a large population-based cohort of IBD patients in Israel, vaccine effectiveness was equivalent to non-IBD controls and was not influenced by treatment with anti-TNF or corticosteroids. Notwithstanding previous findings of impaired serological response in anti-TNF treated IBD patients, this real-world large-scale study shows that vaccine protection is robust in IBD patients, including those on immunosuppressive medications.

Clarifying the Role of Observation in the Management of Poorly Differentiated Pancreatic Neuroendocrine Tumors

Introduction: The management of pancreatic neuroendocrine tumors (PNET) varies between observation (O), pancreatic resection (PR) and enucleation (E). Currently, size, grade and location are used to determine which treatment strategy may be employed. We sought to evaluate each strategy and further clarify the role for surgery with regards to patients with poorly differentiated (PD) PNET. Method: Utilizing the National Cancer Database we identified patients with poorly differentiated PNET and stratified based upon size and management. Pearson’s Chi-square test was used to compare categorical variables. Survival analyses were performed using the Kaplan-Meier method. Multivariate analysis (MVA) was performed to identify predictors of survival. A p-value of <0.05 was considered significant. Results: We identified 3,187 patients diagnosed with poorly differentiated pancreatic neuroendocrine tumors. The median age of the cohort was 61 (18-90). Patients with tumors > 2cm demonstrated a higher incidence of node positivity compared to other cohorts p=0.01. Patients with <2cm tumors demonstrated a 5-year survival of 65% in those undergoing surgery vs 16% in those who did not, p<0.001. There was no difference in survival in those patients undergoing pancreatic enucleation vs those undergoing pancreatic resection, (median survival 102.2 months PR, vs 107.9 months PE, p=0.16). Multivariate analysis revealed age, tumor location, size, surgery, and clinical stage were predictors of survival. Conclusions: Poorly differentiated pancreatic neuroendocrine tumors exhibit high incidence of node positivity. Surgery improves survival in all patients with poorly differentiated PNET. Thus, observation has no role in the management of PD PNET.

Evaluation of the current treatment strategies for poorly differentiated pancreatic neuroendocrine tumors

Presenter: Jamie Glasser MS | Sarasota Memorial Cancer Institute Background: The management of pancreatic neuroendocrine tumors (PNET) varies between observation (O), pancreatic resection (PR) and enucleation (E). Currently, size, grade and location are used to determine which treatment strategy may be employed. We sought to evaluate each strategy and further clarify the role for surgery with regards to patients with poorly differentiated (PD) PNET. Methods: Utilizing the National Cancer Database we identified patients with poorly differentiated pancreatic neuroendocrine tumors and stratified based upon size and management. Mann-Whitney U and Kruskal were used to compare continuous variables and Pearson’s Chi-square test was used to compare categorical variables. Unadjusted survival analyses were performed using the Kaplan-Meier method. Multivariate analysis (MVA) was performed to identify predictors of survival. All statistical tests were two-sided and p<0.05 was considered significant. Results: We identified 3,187 patients with PD PNET with a median age of 61 (18-90). There were 84 (2.6%) patients with tumors 2 cm. There were more males than females p2cm demonstrated a higher incidence of node positivity compared to other cohorts, p2cm, p=0.01. Patients with tumors 2cm tumors, 5-year survival was 65% in those undergoing surgery vs 16% in those who did not, p<0.001. There was no difference in survival in those patients undergoing pancreatic enucleation vs those undergoing pancreatic resection, (median survival 102.2 months PR, vs 107.9 months PE, p=0.16). Multivariate analysis revealed age, tumor location, size, surgery, and clinical stage were predictors of survival. Conclusion: Poorly differentiated pancreatic neuroendocrine tumors exhibit high incidence of node positivity, even in patients with tumors < 1cm. Surgery improves survival in all patients with poorly differentiated PNET. Thus, observation has no role in the management of PD PNET.

Functional correlates of left atrial volume dilatation during vasodilator stress echocardiography

Abstract Background Exercise and dobutamine stress may induce acute left atrial volume index (LAVI) dilatation in 1 out 10 patients. The effect of vasodilator stress in LAVI remains unknown. Purpose To assess the feasibility and functional correlates of LAVI change during dipyridamole stress echocardiography (SE). Methods We studied 149 patients (99 male, age 66±10 years, ejection fraction 59±8%, 64 with previous myocardial infarction), who underwent dipyridamole ABCDE-SE. LAVI was measured with the biplane disk summation method at rest and peak stress: LAVI-dilators were defined as those with stress-rest increase ≥6.8 ml/m2. Criteria for abnormal response of ABCDE-SE were: stress-induced changes in regional wall motion abnormalities (RWMA) for step A; B-lines at peak stress ≥2 for step B (4-site simplified scan, each site scored from 0= A-lines or black lung to 10= white lung for coalescing B-lines); reduced left ventricular contractile reserve (LVCR, peak/ rest based on force) ≤1.1 for step C; abnormal coronary flow velocity reserve (CFVR) ≤2.0, assessed by pulsed wave Doppler sampling in left anterior descending coronary artery for step D; abnormal heart rate reserve (HRR, peak/rest heart rate) ≤1.22 for step E. Results LAVI dilation occurred in 13 patients (9%). The positivity was for step A: RWMA in 6 pts (4%); step B: presence of peak B-lines in 12 pts (8%); step C: abnormal LCVR in 14 pts (9%); step D: reduced CFVR in 17 pts (11%) and step E: abnormal HRR in 46 pts (31%). LAVI dilators showed significantly higher incidence of positivity of steps A-B-C-D (see figure) compared to patients without LAVI dilatation. Conclusion Evaluation of LAVI change during vasodilator SE is feasible, and LAVI dilatation is more frequently found with ischemic (step A), wet (step B), weak (step C) and cold (step D) heart. Figure 1 Funding Acknowledgement Type of funding source: None

Infections Caused by Carbapenemase-Producing Klebsiella pneumoniae: Microbiological Characteristics and Risk Factors.

The spread of carbapenemase-producing Klebsiella pneumoniae (CPKP) worldwide is a serious problem. This retrospective, matched case–control, parallel study in a tertiary teaching hospital analyzed the microbiological and clinical characteristics of CPKP infection, focusing on the risk factors for carbapenem resistance and patient mortality. The hospital department with the highest incidence of CPKP infections was the intensive care unit. All CPKP strains examined were positive for blakpc-2, and 84.8% of CPKP were ST11. Hypervirulent phenotype was identified in 22.7% of the patients with CPKP, with these strains displaying a high incidence of positivity for entB, ybtS, and iutA. Multivariate conditional logistic regression analysis demonstrated that Pitt bacteremia score >4, prior stomach tube, continuous renal replacement therapy (CRRT), and previous carbapenem exposure were associated with CPKP infection. Higher albumin concentration and use of cephalosporins after diagnosis were strong prognostic factors for crude 28-day mortality. Further, high APACHE II score, CRRT, use of carbapenems after diagnosis, and bacteremia were risk factors for crude in-hospital mortality. CPKP isolates showed clonal spread and were resistant to most antibiotics, resulting in higher financial burden. Critical illness was associated with increased mortality.

Numerical loss analysis in a compressor cascade with leading edge tubercles

A numerical analysis of loss has been carried out to explore the loss mechanism of leading edge tubercles in a high speed compressor cascade. Taking the lead from flippers of the humpback whale, tubercles are passive structures of a blade for flow control. Evaluation of the overall performance in terms of entropy increase shows that the loss reduction is achieved both at high negative and high positive incidence angles, while a rise in the loss is obtained near the design point. And a smaller wave number as well as a smaller amplitude results in lower additional losses at the design point. Spanwise and streamwise distributions of pitchwise-averaged entropy increase combined with flow details have been presented to survey the loss development and, subsequently, to interpret the loss mechanism. The tubercle geometry results in the deflection flow and the consequent spanwise pressure gradient. This pressure gradient induces formation of counter-rotating streamwise vortices, transports away the low-momentum fluid near wall from crests towards troughs and leads to local high loss regions behind troughs as well as loss reduction behind the crests in comparison to the baseline. The interaction between these vortices and flow separation by momentum transfer leads to separation delay and the consequent loss reduction at the outlet.

PD-L1 Is Frequently Expressed in Acute Myeloid Leukemia Patients with Leukocytosis

Background: The immune response is probably important for the long-term outcome of patients with tumours, including leukemias. However, its efficiency is often modulated by various immunosuppressive mechanisms, such as the expression of inhibitory receptors on the surface of the immune cells and of their ligands on tumor cells. The introduction of blocking antibodies against these receptors and ligands has gained considerable interest in the past several years and renewed the relevance of the stimulation of anti-tumor immune responses in the treatment of cancers. The significance of PD-1/PD-L1 expression in leukemias is not yet well established, although monoclonal antibodies targeting either PD-1 or PD-L1 are currently in clinical trials also for hematologic malignancies.Aim and methods: We have recently shown that the surface expression of PD-L1 protein correlates with the ratio of two PD-L1 transcript variants (v1/v2) in hematopoietic cells (Brodská et al., submitted to Cancer Immunotherapy Research). This finding has enabled a retrospective examination of PD-L1 expression in frozen cDNA samples obtained from the peripheral blood of AML patients at diagnosis. A total of 55 patients with high leukocyte counts were selected for this analysis as their samples were presumed to be predominantly composed of leukemic cells. As our previous findings suggested the existence of anti-nucleophosmin immune response in vivo, the patients were divided into two groups according to the nucleophosmin mutation status.Results: The majority of the tested samples were PD-L1-positive (Fig. 1). The positivity was of 65% in patients with nucleophosmin mutations (NPM1mut, N = 31) and of 88% in patients with wild-type nucleophosmin (NPM1wt, N = 24). A better overall survival for PD-L1-low patients was observed in NPM1mut patient group, although the difference was not statistically significant (p = 0.21, Fig.2). The cutoff value for v1/v2 transcript levels was of 8.25.Conclusions: Although PD-L1 expression in AML patients at diagnosis is usually low, we found very high incidence of PD-L1 positivity among patients with leukocytosis. Therefore, a high diagnostic leukocyte count may be associated with immune response failure in AML.Acknowledgment: The work was supported by the Ministry of Health of the Czech Republic (grant No 16-30268A and the project for conceptual development of the research organization No 00023736). [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Mucinous carcinoma of breast in a 30-year-old female: A rare case report and discussion

Mucinous carcinoma (MC) (colloid carcinoma) is a particular, rare type of breast carcinoma. It is characterized by the presence of extracellular mucin. MC of the breast generally presents as a lobulated, moderately well-circumscribed mass on mammography, sonography, and magnetic resonance imaging. It has a favorable prognosis due to the low incidence of axillary lymph node metastasis and poor adherence to bottom fascia and poor infiltration of overlying skin. It has high incidence of estrogen receptor and progesterone receptor positivity. The incidence of MC in females under 35 years of age is only 1%. Here, we report a case of MC of right breast in a 30-year-old female.

OP130: Clinico-pathological correlation of advanced gingivo-buccal complex cancer with nodal status

Objective (a) To elucidate the pathological significance of clinical and radiological lymph node enlargement in cases with T3/T4 cancer of the gingivo-buccal complex. (b) To elucidate the prognostic impact of pathological lymph node metastasis in T3/T4 cancer of the gingivo-buccal complex. Methods 90 cases of gingivo-buccal complex cancer were surgically treated at a single institute (All India Institute Of Medical Sciences, New Delhi) from year 2007 to 2010. All data was collected prospectively. 78 cases were evaluable; 12 cases were excluded for inadequacy of data recording. All cases had excision of primary supplemented with a neck dissection (selective neck dissection 35, comprehensive neck dissection 43). All cases had post- operative radiotherapy. Clinical and radiological N stages were compared with final pathological N stage and subsequent follow-up status. Cases were followed-up for a period ranging from 3 months to 24 months. Results 33 cases were clinically staged as N0 and only 2 of these 33 were noted to have lymph node metastasis on pathological evaluation of the neck dissection. However, 52 cases were N+ on clinical evaluation. Final pathology confirmed disease in 26/52 and 26/52 did not manifest pathological metastasis in the clinically enlarged nodes. The pN0 group had a significantly better treatment outcome (76.1% disease -free in follow-up) as compared to pN + group ( 20% disease-free in follow-up) ( p Conclusions (a) Selective neck dissection may not be necessary in clinical and radiological N0 neck as incidence of occult metastasis is low. (b) Clinically N+ neck has high incidence of false positivity (50%). (c) Pathologically N+ neck has poor treatment outcome as compared to pN0 neck.

Thyroid cancer and Delphian node

The manuscript published in this volume of the European Archives of Otolaryngology discusses the incidence and impact of pre-laryngeal nodal metastasis in thyroid cancer [1]. The authors have used the title pre-laryngeal synonymous to Delphian nodes. The subject of Delphian node metastasis in thyroid cancer is well described for a number of years however interestingly there is very little original data published on the incidence of Delphian node metastasis in thyroid cancer except in the recent literature. The Australian group (Isaacs et al. [2, 3]) published their experience of large number of patients in whom Delphian nodes were removed and the incidence of metastasis was noted to be approximately 21 %. Our group at Memorial Sloan-Kettering Cancer Center looked at more than 100 patients with incidence of metastatic disease to be 25 % [4]. The authors in the present manuscript have reviewed their prospective experience of 67 patients undergoing prelaryngeal (Delphian node biopsy) with a metastatic incidence of 19.4 %. The authors have done a good job on correlating the incidence of metastatic disease to the highrisk thyroid cancer features such as size of tumor, extrathyroidal extension and isthmus involvement. These prognostic factors are extremely well defined both in terms of overall prognosis in patients with thyroid cancer and the incidence of nodal metastasis, be that to the Delphian node or the paratracheal or lateral jugular nodes. The authors have clearly reported higher incidence of paratracheal nodal metastasis in patients with positive Delphian node. Some of us who routinely look for the Delphian node are amazed that the node is generally hidden under the fascia covering the crico-thyroid muscle and extending between the cricoid and thyroid cartilages. Unless one opens this fascia, the node may not be apparent. Occasionally, the node may be misrecognized as a pyramidal lobe of thyroid. It is important to explore this area. There is always a small vein crossing the cricoid cartilage which needs to be carefully secured to avoid intraoperative bleeding or postoperative development of hematoma. Clearly, the authors have added their own series to the recent few publications with high incidence of Delphian node positivity. The more you look for the Delphian node, the more one is likely to find the node and approximately 20–25 % of the patients will have positive Delphian nodes. Clearly, the patients with positive Delphian node are more likely to have other central compartment positive nodes however it is quite clear that this nodal metastasis probably does not have a major impact on the overall prognosis in patients with well-differentiated thyroid cancer. Its impact in patients with medullary thyroid cancer remains unclear as the experience is quite minimal in medullary thyroid cancer, however, we have noted some of the recurrences in medullary thyroid cancer especially in the Delphian area. The recent publication from the American Thyroid Association has described the central compartment as the area extending between the hyoid to the innominate vessels and from carotid to carotid laterally [5]. Interestingly, there are hardly any lymph nodes above the superior pole of the thyroid requiring extensive dissection between the hyoid to the superior pole of the thyroid however, the Delphian node removal should be a part of the proper central compartment clearance. We have used frozen section generously to evaluate the Delphian node. It is unlikely the positive frozen section would change the surgical procedure however if the Delphian node is positive, we are more A. R. Shaha (&) Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA e-mail: shahaa@mskcc.org

Curative effect observation of patients with primary systemic amyloidosis treated by the combination of bortezomib with dexamethasone and cyclophosphamide

To analyze the efficacy and side effects of the combination regimen containing bortezomib, cyclophosphamide and dexamethasone(BCD) in the treatment of primary systemic amyloidosis (PSA). The clinical manifestation, efficacy and side effects of 22 PSA patients after treatment were retrospectively analyzed. Of the 22 PSA patients, 9 were newly diagnosed cases and 13 relapsed cases, 20(90.9%) had symptomatic cardiac involvement and 20 (90.9%) had 2 or more organs involved. The median free light chain were 140 mg/L. There were no specific abnormality was found by G-banding and FISH. RQ-PCR-MAGE C1/CT7/ABL had high positive incidence in amyloidosis and can be observed ahead of the flow cytometry and morphology examination. Hematological response occurred in 88.9% in newly diagnosed patients, with 55.6% organ response, 2 patients occured sudden death during BCD interval. For relapsed patients, the hematological response was 46.2%, with 30.7% organ response. Ten of the 22 PSA patients developed peripheral neurophathy, 1 liver dysfunction, 1 severe infection after intra-tracheal stent. BCD produces rapid and high hematological responses in the PSA patients especially in newly diagnosed patients. It is well tolerated with few side effects. MAGE C1/CT7 might be helpful in the early detection of the clonal plasma cell.

Performance and flow fields of a supersonic axial turbine at off-design conditions

The increasing demand of energy efficiency and the utilisation of small-scale energy sources require efficient, small and versatile turbines. Supersonic turbines have a high power density and therefore small size and fewer stages than the subsonic ones. However, the performance of a supersonic turbine can decrease rapidly when operating at off-design conditions. This raises a need for the improvement of the turbine off-design performance. In this article, a supersonic axial flow turbine is studied numerically to find the causes of efficiency decrement. This article presents the most thorough study so far about the reasons that lead to the decreased off-design performance with supersonic axial flow turbines and explains the loss sources individually for the stator and the rotor. Three operating conditions are studied, and it is suggested that at the lower than design pressure ratios, the shock losses of the stator decrease while simultaneously the stator secondary losses increase. The high positive incidence at the lowest modelled pressure ratio, mass flow and rotational speed caused a significant decrease in the rotor and stage performance. This highlights the importance of incidence even in shock-driven supersonic turbine flows.

Differences in metastatic potential in HER2 positive and triple negative inflammatory breast cancer

Background: Inflammatory breast cancer (IBC) presents the most aggressive form of breast cancer with high metastatic potential. It is initially inoperable form of BC, so the standard treatment is induction chemotherapy (iCT) but is known by low rate of complete remission (CR). High incidence of HER2 positivity has been reported, up to 38%. The aim of this retrospective analysis is to evaluate the metastatic potential, comparatively in groups of HER2 positive (HER2+) and triple negative (TN) IBC patients. Methods: We evaluated 84 medical records of female patients with diagnosed IBC, without distant metastases, registered at Institute for oncology and radiology of Serbia, in period 2008- 2010. IBC is defined as BC with typical clinical signs of cancer-mastitis, with or without pathologically confirmed dermal lymphatic invasion (DLI) and with or without underlying tumor. Responses to iCT have been evaluated clinically and by mammography after 4 cycles of iCT and depending of the registered response, treatment was continued, changed to second line CT or complemented with radiotherapy or surgery. In follow-up period (median 23 months, range 4-42), all first metastatic sites were recorded. Time to progression was calculated from date of diagnosis to date of relapse. Results: The incidence of HER2+ IBC was 47,6% (40/84 patients) and TN IBC 20,2% (17/84 patients). Median age at diagnosis was 57,6 and 54,8 years, respectively. DLI was confirmed in 19/40 patients (47,5%) of HER2+ and 3/17 (17,6%) of TN patients. Response rate (RR) to iCT was observed in 77,5% (31/40 patients) of HER2+ and 70,6% (12/17) of TN patients. In HER2+ group, 9/40 patients (22,5%) experienced disease progression (PD), with average time to progression 14,7 months. Even 4/40 patients (10%) developed CNS metastases. Other metastatic sites were: local recurrence, bones and lung, detected in 2 patients each, and contralateral breast in one patient. Two patients died (5%). In TN group, 7/17 patients (41,2%) had PD, with average time to progression 12,5 months. Most common were liver metastasis, seen in 4 patients (23,5%), local recurrence was seen in 3 patients while lung and CNS were affected in one patient each. Three patients died (17,6%). Conclusion: In this study we showed that triple negative is more aggressive form of inflammatory breast cancer than HER2+ IBC, with lower response rate to iCT, shorter time to disease progression and higher mortality. Interestingly, patients with HER2+ IBC have higher chance to develop CNS metastases. Although the number of patients analyzed in this paper is relatively small and follow up is quite short, we are strongly convinced that this analysis can contribute to the knowledge about IBC at least in the term of its metastatic potential.

Robotic Cylindrical Abdominoperineal Resection With Transabdominal Levator Transection

The extralevator approach to abdominoperineal resection is an emerging surgical option for patients with low rectal cancer. This technique involves a wide excision of the levator muscles that could reduce the high incidence of circumferential margin positivity associated with conventional abdominoperineal resections. We present our technique of robotic cylindrical abdominoperineal resection where the daVinci robot is used to perform a controlled transection of the levator muscles transabdominally under direct visualization. Five patients with rectal adenocarcinoma within 5 cm of the anal verge underwent robot-assisted cylindrical abdominoperineal resection. Safety, feasibility, immediate postoperative outcomes, and pathological adequacy of the specimen were assessed. The procedure was successfully completed in all 5 patients without any intraoperative complications, robot-associated morbidity, or conversion to the open approach. The mean operative time and length of hospital stay were 343 minutes and 5.8 days. An intact mesorectal envelope and negative circumferential margin was achieved in all cases. All specimens had a cylindrical shape. Robotic assistance enables the transabdominal transection of the levator muscles in cylindrical abdominoperineal resection, with acceptable perioperative and pathological outcomes. Further studies are essential to objectively define the safety, efficacy, and long-term results of this new technique.