North American Series Research Articles

Diversity of Late Blight Resistance Genes in the VIR Potato Collection

Late blight (LB) caused by the oomycete Phytophthora infestans (Mont.) de Bary is the greatest threat to potato production worldwide. Current potato breeding for LB resistance heavily depends on the introduction of new genes for resistance to P. infestans (Rpi genes). Such genes have been discovered in highly diverse wild, primitive, and cultivated species of tuber-bearing potatoes (Solanum L. section Petota Dumort.) and introgressed into the elite potato cultivars by hybridization and transgenic complementation. Unfortunately, even the most resistant potato varieties have been overcome by LB due to the arrival of new pathogen strains and their rapid evolution. Therefore, novel sources for germplasm enhancement comprising the broad-spectrum Rpi genes are in high demand with breeders who aim to provide durable LB resistance. The Genbank of the N.I. Vavilov Institute of Plant Genetic Resources (VIR) in St. Petersburg harbors one of the world's largest collections of potato and potato relatives. In this study, LB resistance was evaluated in a core selection representing 20 species of seven Petota series according to the Hawkes (1990) classification: Bulbocastana (Rydb.) Hawkes, Demissa Buk., Longipedicellata Buk., Maglia Bitt., Pinnatisecta (Rydb.) Hawkes, Tuberosa (Rydb.) Hawkes (wild and cultivated species), and Yungasensa Corr. LB resistance was assessed in 96 accessions representing 18 species in the laboratory test with detached leaves using a highly virulent and aggressive isolate of P. infestans. The Petota species notably differed in their LB resistance: S. bulbocastanum Dun., S. demissum Lindl., S. cardiophyllum Lindl., and S. berthaultii Hawkes stood out at a high frequency of resistant accessions (7-9 points on a 9-point scale). Well-established specific SCAR markers of ten Rpi genes-Rpi-R1, Rpi-R2/Rpi-blb3, Rpi-R3a, Rpi-R3b, Rpi-R8, Rpi-blb1/Rpi-sto1, Rpi-blb2, and Rpi-vnt1-were used to mine 117 accessions representing 20 species from seven Petota series. In particular, our evidence confirmed the diverse Rpi gene location in two American continents. The structural homologs of the Rpi-R2, Rpi-R3a, Rpi-R3b, and Rpi-R8 genes were found in the North American species other than S. demissum, the species that was the original source of these genes for early potato breeding, and in some cases, in the South American Tuberosa species. The Rpi-blb1/Rpi-sto1 orthologs from S. bulbocastanum and S. stoloniferum Schlechtd et Bché were restricted to genome B in the Mesoamerican series Bulbocastana, Pinnatisecta, and Longipedicellata. The structural homologs of the Rpi-vnt1 gene that were initially identified in the South American species S. venturii Hawkes and Hjert. were reported, for the first time, in the North American series of Petota species.

Pathological characterization and clinical outcome of penile intraepithelial neoplasia variants: a North American series

AbstractPenile intraepithelial neoplasia (PeIN) is classified as human papillomavirus (HPV)- and non-HPV-related. This classification is associated with distinct morphologic subtypes. The natural history and prognosis of PeIN subtypes are not well known. This study aims to evaluate clinicopathological features, HPV status, and outcome of PeIN subtypes. Eighty-two lesions from 64 patients with isolated PeIN were retrospectively reviewed. Mean age was 59 years. Lesions were multicentric in 34% of patients and affected glans (33%), shaft (26%), and foreskin (20%). Histologically, 22% of patients had coexisting lesions, classified as hybrid and mixed. HPV-related PeIN (97%) included basaloid (59%), warty (8%), warty-basaloid (8%), hybrid (19%) and mixed (3%) types. P16 and HPV positivity occurred in 99% and 82% of lesions, respectively. HPV 16 was more common in basaloid PeIN. Multiple genotypes were detected in 35%, more commonly in hybrid PeIN (P = 0.051). Positive margins occurred in 63% of excisions. PeIN recurred in 48% of excisions and 30% of overall repeated procedures, and progression to invasive carcinoma occurred in 2%. At follow-up, 86% of patients had no evidence of disease and 12% were alive with disease. Lichen sclerosus occurred in non-HPV and HPV-related PeIN (100% and 47%).In conclusion, HPV-related and, more specifically basaloid PeIN were the predominant types and preferentially associated with HPV 16. While PeIN had a high recurrence rate, there was a slow and infrequent progression to invasive or metastatic carcinoma with multimodal treatments. Additional studies are needed to understand biology and natural history of PeIN.

Minimum 10-Year Survivorship of Mobile-Bearing Unicompartmental Arthroplasty: Single Surgeon, North American Non-Designer Consecutive Series.

Mobile-bearing unicompartmental knee arthroplasty (UKA) provides a durable option for the surgical treatment of monocompartmental knee arthritis. Despite its availability in the United States since 2004, there is only 1 published North American series reporting on the minimum 10-year results of mobile-bearing UKA. The purpose of this study is to determine the survivorship, reasons for failure, and patient-reported outcomes of the Oxford mobile-bearing UKA at minimum 10-year follow-up. One hundred fifty-seven knees were eligible for inclusion in this study based on the date of their index surgery allowing for a minimum 10-year follow-up. The mean follow-up from implantation was 11.4 years (range 10.0-13.8). Failures were reviewed for potential etiologic factors. Survivorship free of reoperation for any reason and free of revision was determined using Kaplan-Meier curves. Functional outcomes were assessed using the Knee Society Knee and Function scores. There were 17 revisions (10.6%). Six were secondary to progression of lateral compartment arthritis, 5 for persistent pain, 3 for femoral component aseptic loosening, 2 polyethylene dislocations, and 1 deep infection. The mean time to revision was 4 years (range 0.1-11). The survivorship free from revision at minimum 10-year follow-up was 85%. At final follow-up, the mean Knee Society Knee Score was 93 (range 66-100) and the mean functional score was 80 (range 30-100). This single surgeon series demonstrated a survivorship of 85% at minimum 10-year follow-up. These results are comparable to published data from North America, but survivorship is lower than European series.

Splenic Abscess in the New Millennium: A Descriptive, Retrospective Case Series.

BackgroundSplenic abscess is a rare infection often resulting from hematogenous spread. Immunocompromised states are commonly comorbid, and the microbiology is heterogeneous.MethodsWe conducted a retrospective review of 33 cases identified by convenience sampling. Cases were treated in our institution’s hospital system between May 2012 and February 2021 and classified as proven or probable based on predetermined criteria.ResultsThe median age was 57 years, and 58% were men. Common underlying diseases included diabetes mellitus (30%), pancreatic disease (30%), and hematological malignancy (15%). The most common mechanism of pathogenesis was hematogenous spread (n = 13). Escherichia coli, enterococcal spp., and anaerobes were frequently implicated. One case was discovered at autopsy and excluded from subsequent analyses. The median duration of antimicrobial therapy (range) was 45 (5–525) days, and the median length of index hospitalization was 20 days. Percutaneous drainage by interventional radiology was common (17 of 32; 53%), and 6 patients underwent splenectomy. Treatment success was achieved in 14 of 32 cases (44%), with clinical stability in 3 of 32 cases (9%). Failures occurred in 13 of 32 (41%) cases, 2 of whom died from splenic abscesses. Two patients (2 of 32) were lost to follow-up.ConclusionsTo our knowledge, this is the largest North American series since the turn of the century and the first to distinguish between proven and probable cases. As reflected in our series, patients with splenic abscess may require prolonged hospitalizations and courses of antimicrobial therapy. Improvements in management are needed.

Highly Selective Partial Neurectomies for Spasticity: A Single-Center Experience.

Sedating antispastic medications and focal therapies like botulinum toxin are the most common therapies for spasticity but are temporary and must be performed continuously for a principally static neurological insult. Alternatively, highly selective partial neurectomies (HSPNs) may reduce focal spasticity more permanently. To quantify the change in spasticity after HSPN and assess patient satisfaction. We retrospectively reviewed the records of patients with upper- and/or lower-extremity spasticity treated with HSPN from 2014 to 2018. Only cases with a modified Ashworth scale (MAS) score independently determined by a physical therapist were included. Pre- and postoperative MAS, complications, and patient satisfaction were evaluated. The 38 patients identified (24 male, 14 female; mean age 49 yr) underwent a total of 88 procedures for focal spasticity (73% upper extremity, 27% lower extremity). MAS scores were adjusted to a 6-point scale for evaluation. The mean preoperative and final postoperative follow-up adjusted MAS scores were 3.6 and 1.7, respectively (P<.001), which represents average MAS less than 1+. Positive, neutral, and worse results were described by 91%, 6%, and 3% of patients, respectively. Four patients requested revision surgery. No perioperative complications were encountered. This is the first North American series to analyze HSPN for spasticity and the only series based on independent evaluation results. HSPN surgery demonstrated objective short- and long-term reduction in spasticity with minimal morbidity and excellent patient satisfaction.

Application of measurement methods for solid discharge in the Ribeirão Jordão stream and tributaries in UPGRH PN-1

The Brazilian fluviometric potential guarantees the presence of hydroelectric plants in several locations. The dam construction generates changes in the transportation and sediment deposition processes, which can lead to different types of operational along with environmental impacts. The present study aims at measuring the liquid flow, analyzing the sediments and quantifying the solid discharge of the Jordão stream, located in the vicinity of the city of Araguari-MG, in order to enable the minimization and remediation of these impacts. For the measurement of the liquid flow, the equipment ADCP (Acoustic Doppler Current Profiler) and the fluviometric windlass were used. For the collection of suspended sediment samples, a North American series integrator U.S – DH 48 was used, and a Model Petersen collector for bed sediments, while in the laboratory, granulometric analyzes were carried out to prepare the granulometric curves. The data obtained in field work were used in the determination of solid flows through 7 methods found in the literature with the following results per section, being in the results from Station Pissarão 1 ranged from 5.42 to 258.36 T / day, while at Station Pissarão 2 from 0.01 to 81.83 T / day, at Station Bom Jardim between 9.55 to 770.86 T / day, from Station Jordão 1 between 0.02 to 35.96 T / day and from Station Jordão Foz 5.48 to 37.08 T / day. The same data were applied in the HEC-RAS program in order to determine, in the temporal scale, the behavior of the mass eroded or deposited in the stations in the period from September 1, 2018 to May 31, 2019, whose seasonality is from the flood period and considering at the end of the period, it was found that in the Pissarão stream there was a removal of sediment at the source in 29,455 T and a deposit with Station 01 with a positive balance of 8,225 T, and removal of sediment at the Pissarão 02 and Foz Stations, respectively, of 34,774 and 18,555 T. In the Bom Jardim stream, approximately 39,544 T were removed at the source and 43,050 and 9,984 T, respectively, in the Bom Jardim and Bom Jardim Foz Stations, while after the confluence between these streams in the Jordão stream, approximately 34,013 was respectively removed; 152,246 and 74,011 T at the point of the eastern Jordão stream, and at the Jordão 01 and Jordão Foz Stations.

Australia and New Zealand (ANZ) outcomes of high-dose chemotherapy and stem cell transplantation for relapsed or refractory germ cell tumors (GCT) from 1999 to 2019: Multicenter registry-based study with ABMTRR.

382 Background: High dose chemotherapy (HDCT) with autologous stem-cell transplant (ASCT) is effective in advanced germ cell tumours (GCT) that are refractory to, or progress after, first-line therapies. Five-year overall survival in North American and European series range from 48-60%1,2,3. This study aimed to assess ANZ outcomes for quality assurance. Methods: Retrospective multi-centre audit of all male patients with GCT who underwent HDCT and ASCT from 1999-2019. Patients were identified from the Australasian Bone Marrow Transplant Recipient Registry. Primary outcomes included overall and progression- free survival (OS, PFS). Results: 111 patients were identified at 13 centres, each treating a median (range) of 7 (1-27) patients. Median (range) age was 30 (14-68) years. 88 (79%) had testicular primary. 16% were pure seminoma. Median time from first diagnosis to first stem cell cycle was 11 months (range 3 months-38 years). Prior to ASCT, 35% had primary refractory disease and 65% had relapsed. IPFSG risk score was very low in 5%, low in 13%, intermediate in 36%, high in 25%, and very high in 21%. HDCT regimen was CE in 78% (as part of TI-CE regimen in 38%), Carbop-EC-T in 6%, ICE in 6%, CEC in 5% and other in 4%. 89% completed all planned HDCT and ASCT cycles. Five treatment related deaths occurred. Progressive disease on treatment occurred in 14%. At median follow-up time 4.4 years (95% CI: 2.9 to 6.0), 51% were disease-free, 13% alive with disease, 34% deceased. 3 patients displayed late progression over 2 years after ASCT. The estimated 1, 2 and 5-year PFS rates were 62%, 57% and 52% respectively and OS rates were 73%, 65% and 61%. Survival by IPFSG and IGCCG risk categories are displayed in the table below. Conclusions: This is the first registry-based audit of HDCT for metastatic GCT from ANZ, which has demonstrated our outcomes are comparable with best international practice.

Pediatric Critical Care and COVID-19.

* Abbreviations: ARDS — : acute respiratory distress syndrome COVID-19 — : coronavirus disease 2019 GI — : gastrointestinal HFNC — : high-flow nasal cannula IMV — : invasive mechanical ventilation IVIg — : intravenous immunoglobulin NIV — : noninvasive ventilation Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, disproportionally affects adults (children <5% in most reports).1 Adult critical illness is characterized by acute hypoxemia, multiorgan failure, and high mortality.2,3 Reported risk factors for severe illness include age, cardiorespiratory comorbidities, obesity, and laboratory findings (lymphopenia and elevated D-dimer).2,4 Pediatric reports describe low infection rates and infrequent PICU admission.5,6 The largest PICU report consists of 48 North American children.7 It describes treatments and outcomes but not with … Address correspondence to Sebastian Gonzalez-Dambrauskas, MD, Red Colaborativa Pediatrica de Latinoamerica and Cuidados Intensivos Pediatricos Especializados, Casa de Galicia, Montevideo, Uruguay. E-mail: sgdambrauskas{at}gmail.com

Risk adapted approach: How to treat splenic marginal zone lymphoma in resource-poor settings? - The real-life experience of a Brazilian cancer treatment center

BackgroundSplenic marginal zone lymphoma (SMZL) is a rare lymphoid B-cell malignant neoplasm with primary involvement of the spleen. It is a chronic disease, of indolent behavior and prolonged survival. However, 25% of cases have higher biological aggressiveness, propensity for histological transformation to high grade B-cell non-Hodgkin lymphoma and shortened survival. Recognition of these cases of reserved outcome is important for selecting a risk-adapted therapeutic approach in a resource-poor settings.MethodsWe described clinical and epidemiological characteristics, survival analysis and prognostic factors in a retrospective cohort of 39 SMZL patients, treated in Latin America.ResultsWe observed a predominance of female (71.8%), median age of 63 years and higher incidence of B symptoms (56.4%) and extra-splenic involvement (87.1%) than in European and North-American series. With a median follow-up of 8.7 years (0.6-20.2 years), estimated 5-year overall survival (OS) and progression-free survival (PFS) were 76.9% and 63.7%, respectively. Factors with adverse prognostic impact on OS and PFS were Hb < 100 g/L, platelet count < 100 x 109/L, albumin < 3.5 g/dL, LDH > 480 U/L and high-risk Arcaini and SMZL/WG scores. Despite a relative low number of patients, no superiority was observed among the therapeutic regimens used including rituximab monotherapy, splenectomy and cytotoxic chemotherapy.ConclusionTherefore, in resource-poor settings, where access to immunotherapy is not universal for all SMZL patients, we suggest that first-line should consist on rituximab therapy for elderly patients or with high surgical risk or with at least 1 risk factor identified in our study. Remainders can be safely managed with splenectomy.

Transoral Endoscopic Parathyroidectomy: Early Outcomes from a North American Series

Razavi, Christopher R. MD; Shaear, Mohammad MD; Ranganath, Rohit MD; Russell, Jonathon O. MD; Tufano, Ralph P. MD, MBA, FACS Author Information

Association of ATXN2 intermediate-length CAG repeats with amyotrophic lateral sclerosis correlates with the distributions of normal CAG repeat alleles among individual ethnic populations.

Intermediate-length CAG repeats in ATXN2 have been widely shown to be a risk factor for sporadic amyotrophic lateral sclerosis (SALS). To evaluate the association of ATXN2 intermediate-length CAG repeat alleles with an increased risk of SALS, we investigated distributions of CAG repeat alleles in 394 patients with SALS and 490 control individuals in the Japanese population. In the intermediate-length repeat units of 29 or more, we identified one SALS patient with 31 repeat units and two control individuals with 30 repeat units. Thus, no significant differences in the carrier frequency of intermediate-length CAG repeat alleles were detected between patients with SALS and control individuals. When we investigated the distribution of "large normal alleles" defined as ATXN2 CAG repeats ranging from 24 up to 33 in the Japanese population compared with those in other populations in previous studies, the frequency of large normal alleles was significantly higher in the European and North American series than in the Japanese series. Moreover, these frequencies in the Turkish, Chinese, Korean, and Brazilian (Latin American) series were also higher than that in the Japanese series. These results raise the possibility that the frequencies of large normal alleles in individual populations underlie the frequencies of ALS risk alleles in the corresponding populations.

Comparte, copia y mejora: La piratería como medio de desarrollo tecnológico y cultural

Se parte de una visión de la piratería no tanto como amenaza al sistema, sino como la manera más eficaz de desarrollo tecnológico y cultural. Partiremos de los ejemplos mencionados en The Pirate Book (Maigret &amp; Roszkowska 2015). Primero, el caso de la industria shanzhai en China, cuya deficiencia educativa de los trabajadores les ha llevado a aprender por sí solos los conocimientos técnicos que compiten con la industria tecnológica occidental. El trabajo para las compañías internacionales les permite reproducir a la perfección estos productos y ponerlos en circulación. Luego, el caso de El Paquete, el principal medio de difusión cubano; una carpeta repleta de material audiovisual que puedes descargar en un pendrive en establecimientos físicos. Este material suele estar prohibido por el gobierno de Cuba, que lo tacha de inmoral (series americanas, últimos estrenos, libros, música reggaetón, software e incluso una versión offline de Wikipedia que se refresca con cada actualización semanal del Paquete). Por último, el caso de la industria cinematográfica llamada Mollywood, ubicada en una ciudad pobre de la India llamada Malegaon. Partiremos de un documental que sigue el rodaje de una versión de Superman realizada con recursos muy escasos.

Aplastic anaemia in pregnancy - a single centre, North American series.

Aplastic anaemia (AA) is infrequently observed in pregnancy. We describe 19 pregnancies in 9 women at a tertiary care centre over a period of 30years. Spontaneous resolution of AA did not occur postpartum in the five pregnancies where AA was first diagnosed in pregnancy. In the remaining pregnancies, although haematological indices declined and transfusion support was needed in 35% of pregnancies, relapses were not observed. There were no deaths, but complications occurred in 79% of pregnancies. Preterm delivery and postpartum haemorrhage were observed in 21% and 26% of pregnancies, respectively.

Characteristics and incidence of transfusion-associated necrotizing enterocolitis in the UK

Background and aims: The etiology of necrotizing enterocolitis (NEC) is unclear and postulated as being multifactorial. It has been suggested that one causative factor is the transfusion of packed red blood cells (PRBCs) leading to the disease entity commonly referred to as transfusion-associated NEC (TANEC). TANEC has been reported in North America but its incidence has not been formally investigated in the UK. Our aims were to identify the incidence of NEC and TANEC in tertiary-level UK neonatal units and to describe characteristics of TANEC cases.Materials and methods: Using strict case definitions for NEC and TANEC, we undertook a retrospective review to estimate the incidence of TANEC cases occurring in four UK tertiary-level centers during a 38-month period.Results: Of 8007 consecutive neonatal admissions of all gestations to the four centers, 68 babies went on to develop NEC and all affected infants were of very low birth weight (VLBW); 34 of these had previously received a transfusion of PRBCs but did not fit the diagnostic criteria for TANEC, whereas 15 (22%) of the 68 babies with NEC qualified as TANEC cases. UK cases occurred at an earlier postnatal age than cases reported in multiple large North American series and were of a lower birth weight.Conclusions: We have confirmed the presence of TANEC in the UK VLBW neonatal population. Its incidence lies within the wide range described in previous reports of this phenomenon globally, though with some local variation in characteristics. Further work is needed to clarify causation, pathophysiology, and possible mechanisms of prevention of TANEC.

Resection of gallbladder remnants after subtotal cholecystectomy: presentation and management

BackgroundSubtotal cholecystectomy (SC) involves removal of a portion of the gallbladder typically due to hazardous inflammation. While this technique reliably prevents common bile duct (CBD) injury, future procedures can be required if the gallbladder remnant becomes symptomatic. The morbidity associated with resection of gallbladder remnants in patients that previously underwent SC is reviewed. MethodsRecords for patients having undergone redo cholecystectomy for symptomatic gallbladder remnants in a tertiary care system from 2013 to 2017 were retrospectively reviewed. ResultsFourteen patients underwent repeat cholecystectomy. Five surgeons dictated the initial procedure as a subtotal cholecystectomy. All patients returned with symptomatic cholelithiasis between zero months and seven years after the index cholecystectomy. Redo cholecystectomy was attempted laparoscopically in two patients but ultimately required an open approach in all. One patient had a recognized CBD injury requiring a hepaticojejunostomy, and a second patient had a minor wound infection. Symptoms resolved in 13/14 patients. ConclusionsRedocholecystectomy (RC) for gallbladder remnants has been detailed in case reports, but no sizable North American series have been presented. These results illustrate a drawback to the reconstituting technique of SC. RC effectively resolves symptoms but requires adherence to safe principles of cholecystectomy and is one indication for an open approach.

Postoperative D-dimer predicts venous thromboembolism in patients undergoing urologic tumor surgery

PurposeWe examined the incidence of pulmonary thromboembolism (PE) and deep venous thromboembolism (DVT) in patients who underwent urologic tumor surgery. The aim of this study was to investigate the postoperative D-dimer for prediction of venous thromboembolism events (VTE), as well as to identify other risk factors associated with the occurrence of thromboembolisms. Patients and methodsThis was a prospective observational cohort study, which included 1,269 patients who underwent major urologic tumor surgery, from August 2015 to February 2017, at our center. Data comprising age, sex, body mass index, Charlson comorbidity index, type of surgery, Caprini score, postoperative D-dimer levels, and other laboratory tests were collected for analyses. Lower limb venous ultrasound was performed before surgery and the day before hospital discharge to measure DVT. Computerized tomography or ventilation/perfusion lung scan was applied to detect PE. ResultsThe overall incidence of VTE was 2.4% (31 cases) in 1,269 patients, consisting of 23 PE events and 9 DVT events. Patients undergoing radical cystectomy were most likely to suffer VTE (4.3%). The optimal cutoff value for postoperative D-dimer was 0.98μg/ml, according to the receiver operating characteristic curve analysis, with a sensitivity of 83.9%, and a specificity of 80.0%. On multivariate analysis, hypertension (odds ratio, OR = 2.5, 95% CI: 1.1–5.7; P = 0.026), Charlson comorbidity index ≥ 2 (OR = 5.6, 95% CI: 2.2–14.6; P<0.001), and D-dimer lever ≥ 1μg/ml on postoperative day 1 (OR = 12.52, 95% CI: 4.6–35.2; P<0.001) were independently associated with VTE after urologic tumor surgery. ConclusionsThe overall incidence of urologic-tumor-surgery-associated VTE in an Asian population is similar to those reported in European and North American series. Elevated D-dimer early after operation is an independent predictor of VTE in patients undergoing urologic tumor surgery. In addition, hypertension and the Charlson comorbidity index are both important clinical risk factors. The Caprini score recommended by the guideline is inadequate in this study population. The postoperative D-dimer plasma level is a more reliable marker for identifying patients at high-risk of developing venous thromboembolisms.

Applying the Keystone Design Perforator Island Flap Concept in a Variety of Anatomic Locations: A Review of 60 Consecutive Cases by a Single Surgeon.

The keystone design perforator island flap has been gaining popularity for reconstruction of cutaneous defects. Published experience of this technique in North America is limited predominantly to the trunk and extremities; our study aims to demonstrate expanding applications. Retrospective chart review was conducted on all patients who underwent keystone flap reconstruction by a single surgeon. Outcomes of interest were wound healing complications (WHC) and surgical site infections (SSI). Mean follow up time was 24.4 months. Sixty consecutive flaps were performed with an overall WHC rate of 26.7% and SSI rate of 11.7%. Reconstructed sites included 25 lower extremity, 20 trunk, 5 upper extremity, and 10 head and neck. Flap size averaged 405.6 cm (range 16-2303). Wound healing complications were associated with coronary artery disease (P = 0.04) and traumatic defects (P = 0.043). Surgical site infections were associated with coronary artery disease (P = 0.02) and flap size of 251 to 500 cm (P = 0.039), although this association was not seen among flaps greater than 500 cm. Although more common in lower extremity reconstructions, no statistically significant associations between flap location and WHC (P = 0.055) or SSI (P = 0.29) were identified. There were no reconstructive failures and no patients required reoperation. This series demonstrates the versatility of the keystone flap in a wide variety of anatomic locations, with similar complication rates to those previously reported and no reoperations. Flap design was frequently modified based on the anatomical topography and adjacent subunits. To our knowledge, this is the largest and most diverse North American series of keystone flap reconstructions to date.

Transoral thyroidectomy and parathyroidectomy – A North American series of robotic and endoscopic transoral approaches to the central neck

ObjectiveMost thyroid surgery in North America is completed via a cervical incision, which leaves a permanent scar. Approaches without cutaneous incisions offer aesthetic advantages. This series represents the largest series of transoral vestibular approaches to the central neck in North America, and the first published reports of robotic transoral vestibular thyroidectomy for thyroid carcinoma. Materials and methodsData was prospectively collected for patients that underwent transoral vestibular approach thyroidectomy and/or parathyroidectomy between April 2016 and February 2017. ResultsFifteen patients underwent the procedure for removal of the thyroid (n=12), parathyroid (n=2) or both thyroid and parathyroid glands (n=1). The first case was converted to an open procedure. Fourteen were completed through these remote access incisions, including patients with a body mass index as high as 44. There were no permanent complications. The postoperative median Dermatology Life Quality Index score was 3, which indicates a small effect on quality of life. ConclusionThe transoral vestibular approach to the central neck is a promising technique for patients who desire to optimize aesthetics.

Topical immunotherapy with diphencyprone (DPCP) for in-transit and unresectable cutaneous melanoma lesions: an inaugural Canadian series

ABSTRACTBackground: Diphencycprone (DPCP) is an immune contact sensitizer applied to melanoma lesions. Early studies show favorable efficacy. We present the first North-American series of patients treated with DPCP.Methods: A single center retrospective study of patients with in-transit or unresectable melanoma lesions treated with DPCP from December 1,2014 to December 31,2015 was completed. Primary objectives were response rate and toxicity. Secondary objective was health-related quality of life assessment with the Functional Assessment of Cancer Therapy-Melanoma (FACT-M) questionnaire.Results: Fifteen consecutive patients were identified with median age of 78 (range 43–92). 73% of patients had prior treatment. Two patients (13%) had a complete response after 25 and 32 weeks, respectively. Four patients (27%) had a partial response with a mean treatment time of 30 weeks (range 6–51 weeks). Six (40%) had stable disease. Six patients stopped DPCP – three from systemic progression and three from toxicity. The most common toxicity was blisters; one patient had significant skin ulceration that resolved on stopping DPCP. Median FACT-M score was 142.95 (possible total 172). Mean overall follow-up time was 22.7 weeks.Conclusion: DPCP is a feasible option for in-transit and other melanoma cutaneous lesions ineligible/refractory to surgery and may delay need for systemic therapy.

Spectrum of paediatric rheumatic diseases in Nigeria

BackgroundPaediatric rheumatology service in Sub-Sahara African is virtually not available as there is a shortage of paediatric rheumatologists and other rheumatology health professionals. We aim to describe the clinical spectrum and the frequencies of paediatric rheumatic diseases (PRDs) in Lagos State University Teaching Hospital (LASUTH), Lagos, Nigeria.MethodsThis is a retrospective review of patients with PRDs seen over a five year period (March 2010 to February 2016) at the rheumatology clinic and children ward of LASUTH. We reviewed the folders of 57 patients from our records. The demographics, baseline laboratory features, clinical diagnosis, treatment patterns and patient outcomes were extracted and analyzed. Clinical and laboratory characteristics between patients with Juvenile idiopathic arthritis (JIA) and patients with juvenile connective tissue diseases (JCTD) were compared using Fisher’s exact test.ResultsFifty seven patients were studied with a female to male ratio of 3 to 1 (Female: 43; M: 14). The mean age at presentation in years was 14 ± 4.4 years (range: 1.5–22 years). The mean duration of symptoms before diagnosis was 18.4 ± .9 months (range: 2–60 months). The diagnostic types of PRDs included 28(49.1%) cases of JIA. These were made up of 14 cases of polyarticular JIA, nine cases of oligoarticular JIA and 5 cases of systemic onset JIA. Others were 18 (24.6%) cases of juvenile systemic lupus erythematosus (JSLE), 3 (5.3%) cases of joint hypermobility syndrome, 2 (3.5%) cases of juvenile systemic sclerosis, 2 (3.5%) cases of fibromyalgia, 2 (3.5%) cases of plantar fasciitis, 1 (1.6%) case of juvenile dermatomyositis (JDM), 1 (1.6%) case of juvenile polymyositis-systemic lupus erythematosus (PM-SLE) overlap, 1 (1.6%) case of secondary bilateral knee osteoarthritis from Blount disease, 1 (1.6%) case of secondary osteoporosis from childhood leukemia and 1 (1.6%) case of Osgood-Schlatter’s disease. Constitutional symptoms and extra-articular diseases were significantly more frequent among JCTD cases than among the JIA cases (Constitutional symptoms: 100% vs 83.3%, p = 0.003; extra-articular disease: 100% vs 10.7%, p = 0.001). The percentage mortality in this study was 10.5% while 20 (35.1%) of the patients were lost to clinic follow up.ConclusionThe pattern of PRDs observed in this study is similar to that described in South African and North American series but it differs from patterns reported in Asian series. Although hitherto largely unrecognized, PRDs may constitute a substantial cause of morbidity and mortality in black Africans.