Surgical Confirmation Research Articles

Study of mucormycosis in COVID-19 patients in a tertiary care center, Raichur Institute of Medical Sciences, Raichur.

Coronavirus disease-2019 (COVID-19), caused by severe acute respiratory syndrome (SARS-CoV-2), has become an emergency global public health issue. Disease pattern of COVID-19 ranges from mild to life-threatening pneumonia with associated bacterial and fungal coinfections. Due to associated comorbidities (e.g., diabetes mellitus and chronic obstructive pulmonary disease) and immunocompromised conditions (e.g., corticosteroid therapy), these patients are prone to develop severe opportunistic infections. The aim of this study was to investigate the incidence of fungal coinfection of hospitalized patients with COVID-19 infection (SARS-CoV-2) in RIMS, Raichur. Our study included 94 patients with invasive fungal infection who presented with either COVID-19 infection or had recovered from COVID-19 infection. Tissue samples from suspected sites were received in formalin for histopathological examination, and these were stained stains with hematoxylin and eosin and with periodic acid-Schiff/Gomori's methenamine silver wherever required. A total of 94 biopsies were received with clinical suspicion of mucormycosis. Out of these, 52 (55.3%) were positive for mucormycosis and 42 (44.7%) were negative. Out of 52 positive cases, 46 (88.4%) were males and 6 (11.6%) were females. The highest number of cases was seen in age group of 51-60 years (26.92%). Out of the 52 positive cases, KOH mount was positive for fungal elements in 8 cases and negative for fungal elements in 29 cases. Uncontrolled diabetes and overzealous use of steroids are two of the main factors aggravating the incidence of mucormycosis in COVID-19 patients. Early surgical intervention, histopathological confirmation and rapid and judicious intravenous antifungal treatment should be initiated for better patient outcomes.

Accuracy of MRI Pelvis in the Diagnosis of Ovarian Endometrioma: Using Histopathology as Gold Standard.

BackgroundEndometriosis is defined as the ectopic presence of endometrial mucosa at locations other than the uterine cavity. It results in significant morbidity and is a leading cause of infertility as well. Magnetic resonance imaging (MRI) is establishing its role in the diagnosis of endometriosis and its complications. The objective of this study was to assess the accuracy of MRI in the diagnosis of ovarian endometriosis using histopathology as the gold standard.Materials and methodsAll patients presenting with clinical complaints and suspicion of endometriosis, undergoing MRI followed by surgical resection and confirmation by histopathology, were included in the study. Data were analyzed on a predefined proforma and parameters of accuracy were calculated.Results A total of 170 patients were included in this study, having a mean age of 36.8 years with a standard deviation of 10.4 years. The mean parity for included subjects was 2.25, with a standard deviation of 1.3. Overall, the sensitivity of MRI was 86.7% and the specificity was 81.9%. The positive predictive value (PPV) of MRI was 83.3%, while the negative predictive value (NPV) was 81.9%. Overall, the diagnostic accuracy of MRI was 84.7%.ConclusionThe accuracy of MRI in the diagnosis of endometriosis was found to be acceptable and comparable to most of the worldwide published literature. The routine use of MRI for diagnosis and preoperative planning is justified by the results of this study.

A Rare Case of Nasopharyngeal Glial Heterotopia in a Neonate

Nasopharyngeal glial heterotopias is an extremely rare, nonhereditary, developmental malformation manifesting as a mass composed of mature neural tissue with no intracranial continuity. Glial heterotopia is a rare, non-neoplastic, extracranial midline malformation. Nasal glioma is the most frequently encountered entity among congenital nasal masses. Cases which are associated with intracranial extension are termed as encephalocele. It must be considered in the differential diagnosis of airway obstruction in neonates. Magnetic resonance imaging is mandatory to rule out intracranial extension. We report a rare case of heterotopic brain tissue in nasopharynx with no intracranial extension to attract attention to the diagnostic workup of nasopharyngeal obstruction in a neonate with respiratory distress. Clinical examination and radiological studies are diagnostic while early surgical excision and histopathological confirmation is the gold standard. This baby underwent complete intranasal endoscopic excision of mass on day 20 of life. The postoperative course was uneventful and the baby is growing well on follow-up. This case would be one of the few cases reported from India.

P–305 The expression of innate immune factors in the eutopic endometrium of women with endometriosis

Abstract Study question Is the expression of IL–17A and antimicrobial peptides (AMPs) altered in endometriosis? Summary answer IL–17A protein levels were similar in the endometrium of women with and without endometriosis but the expression of several AMPs was reduced in endometriosis. What is known already Chronic inflammation and aberrant immune signalling in the eutopic endometrium underlies the pathophysiology of endometriosis. Endometrial IL–17 levels have previously been shown by our group to be negatively correlated with successful pregnancy. IL–17 has also been associated with endometriosis. Among its immunomodulatory functions, IL–17 regulates the expression of several antimicrobial peptides (AMPs), highly conserved proteins that are involved in the innate immune response. Despite the well accepted paradigm of immune dysregulation in endometriosis, surprisingly little is known about the relationship between endometrial IL–17, AMPs and endometriosis, particularly in the context of infertility. Study design, size, duration This was a prospective cohort study. Endometrial biopsy samples were collected at the time of endometrial scratch testing, or during elective laparoscopy, over a 15-month period. The aim was to evaluate and compare IL–17A protein levels and the expression of specific AMPs (SLPI, elafin, beta-defensin 1, S100A7, S100A8, S100A9) [MW1] , in the endometrium of patients with endometriosis, and those without the disease. Participants/materials, setting, methods Thirty-two patients were recruited for the study, with 26 included in the final analysis. Biopsies were obtained at the time of planned endometrial scratch (mid-luteal phase) prior to ART (n = 7), or at the time of laparoscopy (n = 19). RNA was extracted and Q-PCR analysis for AMP transcript levels was performed. ELISA was carried out to quantify levels of IL–17A in endometrial tissue in a subgroup (n = 17). Main results and the role of chance: In our cohort IL–17A protein levels were not significantly different in the endometrium of patients with disease compared to those without (p = 0.3636). The expression of the AMPs elafin, SLPI, BD1 and S100A9, as measured by a Q-PCR transcript profiling approach, were found to be significantly reduced in the eutopic endometrium in cases of endometriosis as compared to cases without endometriosis. There was no significant difference in AMP expression between disease stages. No demonstrable difference in IL–17A protein levels, or AMP expression was detected between the proliferative and secretory phases of the menstrual cycle. Limitations, reasons for caution Numbers may not have been large enough to fully evaluate the impact of endometriosis stage or the effect of cycle phase. While all patients with endometriosis had surgical confirmation of disease, not all patients in the control cohort had a laparoscopy, though they had no clinical features suggestive of endometriosis. Wider implications of the findings: Our findings indicate that the innate immune environment of the eutopic endometrium is altered in endometriosis. Endometrial expression of AMPs was diminished in endometriosis, independent of disease stage. This work supports the model of dysregulated innate immune system in endometriosis, and reveals AMPs as novel immune players in disease pathogenesis. Trial registration number Not applicable

ANÁLISE DA SENSIBILIDADE NÃO CELÍACA AO GLÚTEN EM PACIENTES COM ENDOMETRIOSE

Overview and Aims: Identify patients with surgically confirmed endometriosis and with gastrointestinal symptomatology by assessing whether there is clinical improvement of these from the adoption of gluten-free diet (GFD). Study design: They were invited to participate in the study by the researchers through telephone calls and instant messaging applications after selection in the clinics of attending physicians. Population: Through the GSRS (Gastrointestinal Symptom Rating Scale) questionnaire, the relationship of GFD adherence to symptomatology attenuation and benefit in the quality of life of 48 patients was analyzed. Methods: Inclusion criteria: female patients with surgical confirmation of endometriosis who agreed to participate in the study in accordance with the Informed Consent Form (ICF). Exclusion criteria: patients who already performed GFD, patients diagnosed with celiac disease, gluten allergy or non-celiac sensitivity to gluten, presence of gastrointestinal comorbidities, severe diseases or cognitive alterations that prevented the study from being performed. The patients who obtained the top 20 scores were invited to adopt GFD for one month, among those selected, only 12 proposed to participate in the diet. However, three of these presented personal complications that prevented the continuation of the same. After this period, a new questionnaire was applied to measure the impact of the diet on quality of life. Results: Nine patients finished the proposed period for the diet, with the average score obtained in the pre-diet questionnaire reducing from 57.2 to 36 in the post-diet. Conclusion: There was an improvement in gastrointestinal complaints of most patients and consequently in quality of life with GFD.

Clinical usefulness of 18F-FDG PET in patients with hepatocellular carcinoma undergoing surgical resection

The diagnosis and staging hepatocellular carcinoma (HCC) is important because of the different treatment methods and the prognosis. [18F]fludeoxyglucose positron emission tomography/computed tomography ([18F]FDG-PET/CT) has been suggested as a diagnostic modality in HCC. The aim of this study is to evaluate the accuracy of [18F]FDG-PET for staging of HCC after surgical resection and histological confirmation. We retrospectively collected data of 56 patients who underwent [18F]FDG-PET before surgical resection for HCC from March 2011 to May 2017. All of whom were suitable for resection by conventional HCC staging. The results of maximal standardized uptake value (SUVmax) was compared with histological confirmation. A larger tumor size was related with a higher SUV (≥ 4.9) and also serum alpha-feto protein was associated with SUV. The recurrence rate was higher in patients with a higher SUV and the patients with lower SUV had better survival rate. HCC, [18F]fludeoxyglucose positron emission tomography, standardized uptake value (SUV).

Rare Case of Childhood Lipoblastoma presenting as Tongue Mass

Introduction Lipoblastoma is a rare benign tumour arising from embryonic white fat been commonly noted in limbs and trunk, but tongue involvement is rare and has not yet been reported. Case Report A child with tongue lipoblastoma is reported, whose imaging reported an encapsulated, well-delineated, fat-containing tumour. Surgical excision was performed with no post-operative morbidities. Discussion Lipoblastoma is an uncommon childhood tumour, which rarely affects the tongue. It presents as a progressive painless swelling, rarely causing any symptom. MRI is helpful to assess the precise location and extent of the lesion. Although the ratio of fat to myxocollagenous tissue in the tumour is variable, the diagnosis can be suggested in most cases based on the imaging characteristics. Recommended treatment is complete surgical excision and confirmation of diagnosis by histopathological examination.

Endoscopically Assisted Marginal Mandibulectomy Using an Intraoral Approach Alone for Squamous Cell Carcinoma of the Posterior Mandibular Gingiva: A Technical Note.

Technical note. Marginal mandibulectomy is a surgical procedure for treatment of mandibular gingival tumors. The intraoral approach to the posterior region of the mandible for marginal mandibulectomy is difficult due to limited access and operating field visibility; the conventional surgical procedure may require some skin incisions. This report discusses the effectiveness of endoscopic assistance in marginal mandibulectomy. This article describes endoscopically assisted marginal mandibulectomy using an intraoral approach alone for squamous cell carcinoma of the posterior mandibular gingiva. The advantages of this surgical method are twofold: (1) superior visibility to the lower edge of the mandible without any skin incision; and (2) safe surgical confirmation of important anatomy on the buccolingual side (e.g., mental foramen, lingual nerve, mandibular foramen, and neurovascular bundle). This minimally invasive approach without any skin incision, as well as the superior visibility of the operating field, are important advantages of endoscopically assisted marginal mandibulectomy that cannot be obtained by other surgical methods. Endoscopically assisted marginal mandibulectomy using an intraoral approach alone may be useful because it avoids damage to facial skin and improves safety by employing an enlarged bright field.

Ovotesticular Disorder of Sex Development in Korean Children: A Single-Center Analysis over a 30-Year Period.

To present clinical features that characterize ovotesticular disorder of sex development (OT-DSD) in the Korean population. Among the patient cohort who were initially suspected to have OT-DSD, the actual OT-DSD patients and those of other disorder of sex development were compared. Retrospective medical chart review of patients who were initially suspected to have OT-DSD from 1984 to 2018 on the basis of clinical examination. Tertiary care university hospital. Of 26 patients with initial diagnosis of OT-DSD, 3 were excluded because of incomplete records, and finally, 23 patients were subjected to analysis. Various examinations were performed before the surgical confirmation of gonad histopathology. Medical records were reviewed for clinical, anatomical, biochemical, and cytogenic characteristics, gender assignment, medical treatment, and histopathologic diagnosis. Characteristics of OT-DSD in a Korean population. Among 23 patients suspected to have OT-DSD, 13/23 (56.5%) were diagnosed as OT-DSD after histopathologic confirmation. Of the remaining 10 patients, 5/23 (21.7%) were diagnosed with mixed gonadal dysgenesis, 3 with Turner variant, 1 with 46,XX disorder of sex development, and 1 with Mayer-Rokitansky-Küster-Hauser syndrome. Among the 13 OT-DSD cases, 9 patients presented with the 46,XX karyotype, 1 with the 46,XY, and 3 with the 46,XX/XY karyotype. Nine patients were assigned as male and 4 as female at birth. The most common gonad histology was ovotestis 10/26 (38%), followed by ovary and testis. OT-DSD is one of the rarest disorders with various clinical presentations. A patient with ambiguous genitalia must be examined with a multidisciplinary approach with clinical suspicion for OT-DSD. Standardized procedure of evaluation and treatment is crucial.

Test Characteristics of Abdominal Computed Tomography for the Diagnosis of Gastro-gastric Fistula in Patients with Roux-en-Y Gastric Bypass.

Gastrogastric fistulae (GGF) occur in 1-6% of Roux-en-Y gastric bypass (RYGB) patients. Many patients undergo abdominal computed tomography (CT) as an initial test owing to its wide availability; however, CT diagnostic accuracy for GGF is unclear. Our aim was to evaluate test characteristics of abdominal CT compared to upper gastrointestinal series (UGI) and esophagogastroduodenoscopy (EGD) for diagnosing GGF using surgery as a gold standard. Retrospective review of RYGB patients who underwent abdominal CT with oral contrast within 1 year. Demographics, weight parameters, and symptoms were collected. Surgery within 1 year of the diagnostic tests was included as the gold standard comparison. Primary outcomes included CT sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy (DA) for GGF. One hundred thirty-seven patients were included, where 42 (30.1%) had positive CT and 95 (69.3%) had negative CT for GGF. Compared to surgical confirmation, CT abdomen with PO contrast had sensitivity of 73.1% (59-84.4), specificity of 95.2% (88.3-98.7), PPV 90.5% (77.4-97.3), NPV of 85.1% (76.3-91.2), and DA 89.7%. UGI series had sensitivity of 58.5% (42.1-73.7), specificity of 98.8% (93.5-99.9), PPV of 96% (79.7-99.9), NPV of 82.8% (73.9-89.7), and diagnostic accuracy (DA) of 85.4%. EGD had sensitivity of 78.3% (63.6-89.1), specificity of 98.8% (93.5-99.9), PPV 97.3 (85.8-99.9), and DA 91.5%. There were no significant differences in diagnostic test characteristics among modalities. Abdominal CT with oral contrast has similar diagnostic test characteristics to UGI and EGD at detecting GGF when using surgical diagnosis as a gold standard.

Ultrasound features of traumatic digital nerve injuries of the hand with surgical confirmation.

Characterize the appearance of digital nerve injuries in different ultrasound planes and correlate the presence and size of neuromas with time from injury. Surgically confirmed nerve injuries were retrospectively evaluated. Appearances of the nerve injury in the available imaging planes were reviewed by two readers. Associations between presence and size of neuroma with time from injury were analyzed. Injuries of 29 digital nerves (3 incomplete lacerations, 17 complete lacerations, 6 with 7 stump neuromas, 3 neuromas-in-continuity) noted on ultrasound were surgically confirmed. Among the 20 lacerations, long-axis images were obtained in 15, of which 10 depicted the injury and 4 did not. Among the 10 depicting the injury in long axis, 2 showed a discrete gap, and 7 showed the nerve obscured by laceration tissue without a gap. In short axis, the nerve injury was visible in all 20, and nerve laceration was seen as a discrete gap in 2, and obscuration by laceration tissue in 14. Neuromas were hypoechoic and well-defined. There was a positive association between time and presence of neuroma (OR = 1.3, p = 0.002). Correlations between time and cross-sectional area (rs = 0.45) and volume (rs = 0.57) of neuromas were moderately positive. Ultrasound long axis may be less useful, and those short axis may be more reliable for assessing digital nerve injuries than previously reported. Neuromas are hypoechoic and well-defined, and their size can vary based on time from injury.

Different types of bullae of limbs with necrotizing fasciitis predict different outcome: a prospective study

Study objectiveNecrotizing fasciitis (NF) is an uncommon life-threatening necrotizing skin and soft tissue infection. Bullae are special skin manifestations of NF. This study was conducted to analyze the differences between different types of bullae of limbs with NF for providing the information to emergency treatment.MethodsFrom April 2015 to August 2018, patients were initially enrolled based on surgical confirmation of limbs with NF. According to the presence of different bullae types, patients were divided into no bullae group (Group N), serous-filled bullae group (Group S), and hemorrhagic bullae group (Group H). Data such as demographics, clinical outcomes, microbiological results, presenting symptoms/signs, and laboratory findings were compared among these groups.ResultsIn total, 187 patients were collected, with 111 (59.4%) patients in Group N, 35 (18.7%) in Group S, and 41 (21.9%) in Group H. Group H had the highest incidence of amputation, required intensive care unit care, and most patients infected with Vibrio species. In Group N, more patients were infected with Staphylococcus spp. than Group H. In Group S, more patients were infected with β-hemolytic Streptococcus than Group H. Patients with bacteremia, shock, skin necrosis, anemia, and longer prothrombin time constituted higher proportions in Group H and S than in Group N.ConclusionsIn southern Taiwan, patients with NF accompanied by hemorrhagic bullae appear to have more bacteremia, Vibrio infection, septic shock, and risk for amputation. If the physicians at the emergency department can detect for the early signs of NF as soon as possible, and more patient’s life and limbs may be saved.

Estimation of the Endometriosis Fertility Index prior to operative laparoscopy.

Can the Endometriosis Fertility Index (EFI) be estimated accurately before surgery? The EFI can be estimated accurately based on mere clinical/ultrasound information, with some improvement after adding data from diagnostic laparoscopy. The EFI is a validated clinical instrument predicting the probability of pregnancy after endometriosis surgery without the use of ART. Being an end-of-surgery-score, it implies the decision for operative laparoscopy to be made in advance-hence, its role in the pre-surgical decision-making process remains to be established. Single-cohort prospective observational study in 82 patients undergoing complete endometriosis excision (between June and December 2016). Two methods were used to estimate the final EFI: type A based on non-surgical clinical/ultrasound findings only, and type B based on the combination of non-surgical clinical/ultrasound findings and diagnostic laparoscopy data. To calculate EFI type A, an algorithm was created to translate non-surgical clinical/imaging information into rASRM (revised American Society of Reproductive Medicine)-and EFI points. EFI type A and type B estimates were assessed for their clinical and numerical agreement with the final EFI score. Agreement was defined as clinical if EFI scores were within the same range (0-4, 5-6, 7-10), and numerical if their difference was ≤1. All 82 patients underwent complete laparoscopic CO2-laser excision of any rASRM stage of endometriosis in the Leuven University Fertility Centre (LUFC) of University Hospitals Leuven, a tertiary referral centre for both endometriosis and infertility. An anonymized clinical research file was created. For each patient, three different data sets were created, in order to allow the estimation of the (surgical part) EFI and of the rASRM scores, defined as follows: 'Estimated type A' contained only non-surgical clinical/imaging data, 'Estimated type B' included type A information plus the information of the diagnostic laparoscopy and 'Final EFI' included information of type A, type B and all intra-operative information required to calculate the final EFI. To calculate EFI type A without surgical information, a set of rules was used to translate pre-surgical clinical/imaging information into (rASRM and EFI points). Scoring was done by one person (C.T.), with a time interval of 4 weeks between sessions for each EFI type. Next to the EFI, also rASRM score and stage were calculated. Agreement rate between estimated EFI type A and final EFI was high for both the clinical (0.915; 95% CI 0.832-0.965) and numerical definition (0.878; 95% CI 0.787-0.940). Agreement rates between estimated EFI type B and final EFI were even higher (clinical (0.988; 95% CI 0.934-1.000), numerical (0.963; 95% CI 0.897-0.992)). Type A estimation is dependent on high-level gynaecological ultrasound expertise, which may not be available in all clinics. A small number of patients had no prior clinical, ultrasound (hard markers) or surgical confirmation of the diagnosis of endometriosis. When applying the estimated EFI type A in clinical practice, a priori assumptions of the presence or absence of endometriosis will need to be made in adjunct to the estimation of the estimated type A EFI when counselling patients on the potential benefit of an (at least diagnostic) laparoscopy. The level of agreement for type A or B should also be taken into account when counselling patients on the type of efforts undertaken to attempt to diagnose or rule out endometriosis. As this study reports, the EFI can be estimated accurately based on clinical/ultrasound data only without the need for any surgical data. This means that the EFI could be used as an instrument to guide joint physician-patient decision-making between surgery, ART or other fertility management options for the individualized treatment of women with endometriosis-related infertility. During this study period, C.T. was supported by FWO (Research Fund Flanders, Grant number 1700816N) and UZ Leuven KOF (University Hospitals Leuven, Klinisch Onderzoeksfonds).The LUFC received unrestricted research grants from Ferring Pharmaceuticals and Merck SA. Gedeon Richter and MSD sponsored travel to and attendance at scientific meetings. C.M. received consultancy fees from Lumenis (paid to KU Leuven, no private revenue). T.D. has been vice-president and head of global medical affairs infertility for the multinational pharmaceutical company Merck (Darmstadt, Germany) since 1 October 2015. He continues his academic appointment on a part-time basis as Professor of Reproductive Medicine at the University of Leuven (KU Leuven). T.D. has been vice-president and head of global medical affairs infertility for the multinational pharmaceutical company Merck (Darmstadt, Germany) since October 2015. He is also a Guest Professor in Reproductive Medicine and Biology at the Department of Development and Regeneration, Group Biomedical Sciences, KU Leuven (University of Leuven), Belgium, and an Adjunct Professor at the Department of Obstetrics and Gynecology in the University of Yale, New Haven, USA. This work was initiated before he joined Merck KGaA in October 2015, and completed during the subsequent years. study registration number at UZ Leuven Clinical Trial Centre: S59221.

Ultrasonographic Diagnosis of Placenta Accreta Spectrum (PAS) Disorder: Ideation of an Ultrasonographic Score and Correlation with Surgical and Neonatal Outcomes

The objective of this study was to evaluate a novel ultrasonographic scoring system for the diagnosis of PAS and the prediction of maternal and neonatal outcomes. In this retrospective study, 138 patients with at least one previous caesarean section (CS) and placenta previa were included. They were divided into four groups ranging from Group 0 (Non PAS) to Group 3 (Placenta Percreta) according to the histological or surgical confirmation. Their ultrasound examinations during pregnancy were reviewed according to the nine different ultrasound signs reported by the European Working Group on Abnormally Invasive Placenta. For each parameter, 0 to 2 points were assigned. The sum of the points reflects the severity of PAS with a maximum score of 20. The scoring system revealed good performances in evaluation metrics, with an overall accuracy of 94%. In addition to this, patients’ characteristics and surgical and neonatal outcomes were analyzed with an evidence of higher incidence of complications in severe forms. Our study suggests that antenatal ultrasonographic diagnosis of PAS is feasible with sufficient level of accuracy. This will be important in identifying high-risk patients and implementing preventive strategy.

Correlation of Multi-Detector Computed Tomography and Intraoperative Variations of the Celiac Trunk and Hepatic Artery in Resectable Hepatobiliary Pancreatic Cancers.

IntroductionKnowledge of celiac artery variations is imperative to perform complex hepato-biliary pancreatic surgical procedures to avoid inadvertent complications. Multi-detector computed tomographic (MDCT) angiography aids in detecting these variations preoperatively. Surgical confirmation is considered the gold standard.Aims and objectivesPreoperative assessment of celiac artery variations by MDCT angiography and surgical confirmation intraoperatively in resectable hepato-biliary pancreatic cancers.Patients and methodsMDCT angiography was performed in 40 patients with clinical evidence of resectable hepato-biliary-pancreatic cancers. Three dimensional (3D) reconstructions were performed to confirm the celiac artery variations. Surgery was performed as per the institute’s protocol in all these patients for resection of tumor and confirmation of celiac artery anatomy. Variations were confirmed surgically that were identified through imaging.ResultsMDCT angiography identified normal trifurcated celiac artery anatomy in 33 (82.5%) patients and variant anatomy in seven (17.5%) patients. The most common variation was a replaced right hepatic artery (r-RHA) from the superior mesenteric artery (SMA) in four (10%) of patients. A replaced left hepatic artery (r-LHA) from the celiac trunk, a common hepatic artery (CHA) from the abdominal aorta, and an accessory right hepatic artery (ac-RHA) from the proper hepatic artery itself were identified in one (2.5%) patient each, respectively. All these findings were confirmed intraoperatively. There was a 100% statistical correlation between imaging and surgical findings.ConclusionSurgical confirmation of radiological data of celiac artery variations is the gold standard to avoid disastrous complications such as inadvertent vascular bleeds, biliary injuries, and hepatic necrosis. Since the presence of variations warrants the preservation or excision of the arterial system without oncological compromise and minimizing surgical complications.

Intussusception after Rotavirus Vaccine Introduction in India

BackgroundA three-dose, oral rotavirus vaccine (Rotavac) was introduced in the universal immunization program in India in 2016. A prelicensure trial involving 6799 infants was not large enough to detect a small increased risk of intussusception. Postmarketing surveillance data would be useful in assessing whether the risk of intussusception would be similar to the risk seen with different rotavirus vaccines used in other countries.MethodsWe conducted a multicenter, hospital-based, active surveillance study at 27 hospitals in India. Infants meeting the Brighton level 1 criteria of radiologic or surgical confirmation of intussusception were enrolled, and rotavirus vaccination was ascertained by means of vaccination records. The relative incidence (incidence during the risk window vs. all other times) of intussusception among infants 28 to 365 days of age within risk windows of 1 to 7 days, 8 to 21 days, and 1 to 21 days after vaccination was evaluated by means of a self-controlled case-series analysis. For a subgroup of patients, a matched case–control analysis was performed, with matching for age, sex, and location.ResultsFrom April 2016 through June 2019, a total of 970 infants with intussusception were enrolled, and 589 infants who were 28 to 365 days of age were included in the self-controlled case-series analysis. The relative incidence of intussusception after the first dose was 0.83 (95% confidence interval [CI], 0.00 to 3.00) in the 1-to-7-day risk window and 0.35 (95% CI, 0.00 to 1.09) in the 8-to-21-day risk window. Similar results were observed after the second dose (relative incidence, 0.86 [95% CI, 0.20 to 2.15] and 1.23 [95% CI, 0.60 to 2.10] in the respective risk windows) and after the third dose (relative incidence, 1.65 [95% CI, 0.82 to 2.64] and 1.08 [95% CI, 0.69 to 1.73], respectively). No increase in intussusception risk was found in the case–control analysis.ConclusionsThe rotavirus vaccine produced in India that we evaluated was not associated with intussusception in Indian infants. (Funded by the Bill and Melinda Gates Foundation and others.)

Linking biomarkersof environmental chemical exposure and endometriosis: integrating the exposome and metabolome in the ENDOXOMICS-b Study

Background/Aim Endometriosis is a gynaecological disease impacting a staggering 5-15% of women with dramatic socio-economic impacts, aggravated by long diagnostic delays of 8-10 years between symptom onset and surgical confirmation. Previous studies suggest a relationship between exposure to some persistent organic pollutants (POPs) and endometriosis, but its aetiology remains uncertain. In this study, we developed a comprehensive analytical framework based in mass spectrometry (MS) and advanced computational approaches to characterise exposure and metabolic profiles to identify potential biomarkers of exposure and effect related to endometriosis. Methods The ENDOXOMICS-β study comprises women seeking obstetric intervention for endometriosis, infertility, and other gynaecologic issues at University Hospital of Nantes. Endometriosis phenotype was determined histologically. 140 serum samples (92 cases, 48 controls) were analysed for POPs using ultra-trace methods based on liquid and gas chromatography coupled to high-resolution MS (LC- and GC-HRMS). Lipid and metabolite profiling was performed using the Biocrates MxP® Quant 500 Kit and targeted flow injection analysis (FIA-MS/MS) and LC-MS/MS. Data analyses included a battery of algorithms for single-block (elastic-net, neural networks, support vector machine) and multiblock (partial-least-square) variable selection. Multivariate logistic regression (MLR) was used to validate the associations, adjusting for covariates. Results Preliminary targeted metabolomics analyses quantified over 600 metabolites, including a number of functional/structural families (acylcarnitines, ceramides, glycerophospolipids, phosphatidylcholines, sphingolipids). 80 lipids were found associated with endometriosis (p<0.05) with elevated adjusted odds-ratios. Several organochlorine pesticides, polychlorobiphenyls and perfluoroalkyl substances were also identified. Multiblock models appear a powerful approach to integrate highly correlated, multidimensional data to identify potential exposure and effect biomarkers. Conclusion To our knowledge, this is the first application of quantitative MS-based metabolomics and exposomics in serum to identify potential biomarkers associated with endometriosis. Integrative multiblock methods offer promising potential for the discovery of biomarkers of exposure and effect with large applications in etiological and clinical research.

Severe Dysmenorrhea Is the Primary Contributor to Low Physical Quality of Life in Canadian Women with Endometriosis

Study Objective (1) To compare quality of life (QoL) in women presenting for endometriosis care at a Canadian tertiary care centre to the general population and (2) to identify significant factors associated with reduced physical and mental QoL. Design Prospective observational questionnaire study. Setting Tertiary academic hospital. Patients or Participants Women with clinically suspected or surgically confirmed endometriosis. Interventions Participants were recruited at the time of consultation and completed the Medical Outcome Survey (SF-36) and the Endometriosis Phenome and Biobanking Harmonization Project Minimum Clinical Questionnaire prior to treatment. SF-36 scores were compared to the Canadian normative data for women aged 35-44 years. Logistic regressions (controlled for co-morbidities) were performed for patient reported demographics, endometriosis related symptomology, endometriosis type, treatment history and diagnostic delay with high and low physical (PCS) and mental (MCS) component summary scores as the outcome. Significant factors (p Measurements and Main Results Ninety participants completed the questionnaires. Sixty-two (69%) patients presented with deep, 8 (9%) with ovarian, and 18 (20%) with superficial endometriosis. Two (2%) participants were excluded after surgical confirmation of no endometriosis. Endometriosis participants scored significantly less in all SF-36 subdomains than the Canadian women normative data (mean% difference=16-47%). Significant factors associated with the low PCS scores were age dysmenorrhea began (OR=0.92, 95%CI=0.85-0.99), severe dysmenorrhea (OR=4.85, 95%CI=1.58-14.89), dyspareunia (OR=10.26, 95%CI=1.26-86.47), dysuria (OR=4.39, 95%CI=1.47-13.01), non-cyclic pelvic pain (OR=4.05, 95%CI=1.36-12.06), and number of endometriosis symptoms (OR=2.02, 95%CI=1.29-3.18). In the final model, only severe dysmenorrhea remained significantly associated with low PCS score (OR=5.27, 95%CI=1.06-33.73). No factors were significantly associated with MCS scores. Conclusion Endometriosis negatively impacts women's QoL with scores up to 47% less than the general population. Severe dysmenorrhea was the primary contributor to poor physical quality of life, highlighting the importance of treating endometriosis-associated menstrual pain as a primary outcome in this patient population.

187. Compared to gold standard bone SPECT/CT showed superior accuracy in detecting pseudarthrosis

BACKGROUND CONTEXT Pseudarthrosis remains the primary cause of persistent pain postoperatively after spinal fusion surgery, leading to failed back surgery syndrome. The utility of the integrated single-photon emission computed tomography and computed tomography (SPECT/CT) in a bone scan as a problem-solving tool in evaluating patients with suspected pseudarthrosis, hardware failure and adjacent level disease has been previously reported. A number of studies have been done showing its benefits and limitations when compared to other imaging techniques. Direct comparison against the gold standard of surgical pseudarthrosis confirmation is limited. PURPOSE The purpose of this study is to evaluate the diagnostic accuracy of SPECT/CT, computed tomography (CT) and magnetic resonance imaging (MRI) scans in preoperatively identifying pseudarthrosis with verification by intraoperative findings. STUDY DESIGN/SETTING Retrospective study. PATIENT SAMPLE Patients undergoing revision spinal surgery. OUTCOME MEASURES Imaging comparison to gold standard. METHODS After obtaining IRB approval, a retrospective study of patients who underwent revision spinal fusion was completed. The surgeries were performed by a single orthopedic spine surgeon over a 12-month period. Patients included in the study had SPECT/CT imaging done prior to surgery, and had either MRI or CT scan or both. All available preoperative imaging results (SPECT/CT, CT and MRI) and operative reports were collected, verified and compared. Estimates of sensitivity, specificity, likelihood ratios (LRs), positive predictive value (PPV) and negative predictive value (NPV) were all calculated to evaluate the diagnostic accuracy. RESULTS A total of 60 surgical patients (62% female, mean age 58 years), including 19 cervical fusion (32%), five thoracolumbar fusion (8%) and 36 lumbar fusion (60%), were included in this series. Prior to spinal surgery, average time to imaging of 60 patients who underwent SPECT/CT, 31 patients who underwent CT, and 33 patients who underwent MRI was around 5 months, respectively. Results of diagnostic accuracy show that when compared to lower sensitivity studies like CT (11%) and MRI (6%), SPECT/CT sensitivity was high at 91% (95% CI 75-98%) leading a significant negative likelihood ratio at -LR 0.1 (95% CI 0.04-0.36) and a PPV of 83% (95% CI 70-91%); specificity was moderate at 79% (95% CI 59-92%) with a moderate positive likelihood ratio of +LR 4 (95% CI 2-9) and a NPV of 88% (95% CI 71-96%). CONCLUSIONS SPECT/CT scan was found to demonstrate excellent criterion validity to rule-out a diagnosis of pseudarthrosis when a negative result was observed; however, further validation is warranted. DISCUSSION Pseudarthrosis can be challenging to diagnose as it can also occur with other postoperative complications such as adjacent level disease and/or hardware failure, SPECT/CT scan should be integrated into routine clinical practice as a diagnostic tool in patients with persistent postoperative pain. A negative SPECT-CT virtually rules out pseudarthrosis. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Direct and indirect CT imaging features of esophago-airway fistula in adults.

BackgroundEsophago-airway fistula (EAF) is an abnormal connection between the esophagus and the trachea or a major bronchus. While contrast esophagography remains the primary radiographic tool for the diagnosis of EAF, computed tomography (CT) is often employed in its evaluation. A systematic analysis of CT findings of EAF in adults has not been previously published. The goal of our study is to determine the direct and indirect CT findings of EAF in adults.MethodsWe identified patients with EAF detected on CT at our institution between January 1, 2001 and December 31, 2019, with endoscopic or surgical confirmation. We collected patient clinicopathologic characteristics and assessed CTs for direct and indirect imaging features of EAF in these patients.ResultsTwenty-six patients (median age: 56 years; range, 25–79 years; F=13, 50% and M=13, 50%) with confirmed EAF were identified. Half of the patients had an underlying malignancy. On CT, a direct connection between the esophagus and the airway was identified in most cases (22/26; 85%). Common indirect CT findings of EAF included esophageal wall thickening (21/26, 81%), mediastinal fatty stranding (21/26, 81%), airway wall thickening (20/26, 77%), fluid or debris within the airways (17/26, 65%), and focal or diffuse esophageal dilation with air (17/26, 65%). Mediastinal fluid collections were infrequently seen (4/26, 15%), but findings of aspiration or other pneumonia were common (19/26, 73%).ConclusionsCT plays an essential role in both the primary and secondary evaluation of adult EAF resulting from both malignant and benign etiologies. CT may be the first diagnostic exam to suggest and detect the presence of EAF and may precede clinical suspicion, and it can detect a subset of fistulas not demonstrated on esophagography. There are several direct and indirect imaging findings on CT that can help in the detection of EAF.