COVID-19: mobilising CT as a frontline management tool

As the COVID-19 pandemic has spread across the globe, questions have arisen about the approach healthcare systems should adopt in order to optimally manage patient influx. With a focus on the impact of COVID-19 on the NHS, we describe the frontline experience of a severely affected hospital in close proximity to London. We highlight a protocol-driven approach, incorporating the use of CT in the rapid triage, assessment and cohorting of patients, in an environment where there was a lack of readily available, onsite RT-PCR testing facilities. Furthermore, the effects of the protocol on the effective streamlining of patient flow within the hospital are discussed, as are the resultant improvements in clinical management decisions within the acute care service. This model may help other healthcare systems in managing this pandemic whilst assessing their own needs and resources.     

Efficacy of Targeted Narrowband Ultraviolet B Therapy in Vitiligo

Background:

Phototherapy is one of the most effective treatment options in vitiligo. Targeted phototherapy devices are becoming more popular as they offer a lot of advantages over the conventional whole-body phototherapy units.

Aims and Objectives:

The present study was conducted to assess the efficacy and safety of a targeted narrowband ultraviolet B (NBUVB) device in vitiligo.

Materials and Methods:

A total of 40 patients of vitiligo were treated with a targeted NBUVB device twice-weekly for a maximum of 30 sessions or until 100% repigmentation, whichever was reached first. The extent of repigmentation achieved was assessed and adverse effects, if any, were also noted down.

Results:

There were 31 responders (77.5%) who achieved repigmentation ranging from 50% to 100%. The onset of repigmentation was seen as early as the 3^rd dose in some cases and by the 10^th dose in all responders. A total of 97 lesions were treated out of which 45 lesions (46.6%) achieved 90-100% repigmentation. Lesions showing 75% and 50% repigmentation were 14 and 15 in number respectively. 23 lesions failed to show any significant repigmentation at the end of 30 doses. Best response was seen on the face and neck with 20 of the 31 lesions achieving 90-100% repigmentation in this area. Duration of vitiligo was seen to have no statistically significant impact on the repigmentation achieved.

Conclusion:

Targeted NBUVB phototherapy seems to be an effective treatment option in localized vitiligo with a rapid onset of repigmentation seen as early as 2^nd week of treatment.     

Closure of a bronchopleural fistula using glue

Bronchopleural fistula after pneumonectomy remains a challenge after lung cancer surgery. It is associated with high mortality, morbidity and prolonged hospital stay necessitating further thoracotomy. We describe a technique using intra-mucosal injection of glue to close a bronchopleural fistula via bronchoscopy.     

Inferiorly based thigh flap for reconstruction of defects around the knee joint

Background:

Soft-tissue defects around the knees are common in injured limbs and in the same injury the leg is often involved and the thigh is spared. Furthermore due to pliable and relatively lax skin, we have used inferiorly based thigh flap to reconstruct defects around knee joint.

Aims and Objectives:

The aim of this study is to evaluate the use of inferiorly based thigh flap to cover soft-tissue defects over the proximal one-third of the leg, patellar region, knee, and lower thigh.

Materials and Methods:

This study was conducted during the period between October 2011 and February 2013. Inferiorly based anteromedial thigh fasciocutaneous flap was performed on 12 patients and inferiorly based anterolateral thigh fasciocutaneous flap on four patients. The sites of the soft-tissue defects included patellar regions, infrapatellar region, upper one-third of leg, lower thigh, and over the knee joint.

Results:

Patients were evaluated post-operatively in terms of viability of flap, the matching of the flap with the recipient site, and donor site morbidity. All the flaps survived well except one which developed distal marginal flap loss, one in which wound dehiscence was noticed, and two in which mild venous congestion was observed. Venous congestion in two patients subsided on its own within 3 days. One patient with wound dehiscence achieved complete healing by secondary intention. Patient who developed distal flap loss required debridement and skin grafting. No appreciable donor site morbidity was encountered. Skin colour and texture of the flap matched well with the recipient site.

Conclusions:

The inferiorly based thigh flap is a reliable flap to cover the defect over proximal one-third of the leg, patellar region, knee, and lower thigh.KEY WORDS: Defect around the knee joint, inferiorly based thigh flap, perforator based flap     

Distally based posterior tibial artery perforator flap for coverage of defects around the ankle,heel and lower third of leg

Introduction

Reconstruction of distal leg region remained a difficult task. Free flaps had long been considered as a gold standard for these regions. However, due to various limitations of the free flap, a local fasciocutaneous flap could be considered as a good alternative. In this study, the use of a distally based posterior tibial artery perforator flap had been evaluated in the coverage of defects around the ankle, heel, and lower third of a leg. The study also outlined the donor-site morbidity and the technical details of the surgical procedure.

Methods

In this prospective study, a total of 42 patients with distal lower leg defects were included. The defects were located on the lower third of the leg (n?=?23), ankle (n?=?11), and heel (n?=?8). Reconstruction was performed using distally pedicled posterior tibial artery perforator flaps. Patients were evaluated in terms of viability of the flap, functional gain, and donor-site morbidity. The technical details of the operative procedure have also been outlined.

Results

All the flaps survived well, with the exception of one patient, who experienced complete flap loss. Minor complications were, however, noted in four other patients: One patient developed superficial epidermolysis; one developed postoperative venous congestion, which subsided within 3 days by conservative means, and in two patients, partial loss of the skin graft occurred at the donor site but healed completely with dressing and antibiotics. The patients were followed up for an average period of 6 months, ranging from 1 to 13 months. Donor-site morbidity was minimal.

Conclusions

It was concluded that the distally based pedicled posterior tibial artery perforator flap was a reliable, easy, less time-consuming, and versatile procedure for covering the defects around the ankle, heel, and lower third a leg. Level of Evidence: Level IV, therapeutic study     

Immune molecular profiling of whole blood drawn from a non‐human primate cardiac xenograft model treated with anti‐CD154 monoclonal antibodies

Most studies of xenografts have been carried out with complex immunosuppressive regimens to prevent immune rejection; however, such treatments may be fatal owing to unknown causes. Here, we performed immune molecular profiling following anti‐CD 154 monoclonal antibody (mA b) treatment in heterotopic abdominal cardiac xenografts from α‐1,3‐galactosyltransferase‐knockout pigs into cynomolgus monkeys to elucidate the mechanisms mediating the undesirable fatal side effects of immunosuppressive agents. Blood samples were collected from healthy monkeys as control and then at 2 days after xenograft transplantation and just before humane euthanasia; 94 genes related to the immune system were analyzed. The basic immunosuppressive regimen included cobra venom factor, anti‐thymocyte globulin, and rituximab, with and without anti‐CD 154 mA bs. The maintenance therapy was followed with tacrolimus, MMF , and methylprednisolone. The number of upregulated genes was initially decreased on Day 2 (?/+ anti‐CD 154 mA b, 22/13) and then increased before euthanasia in recipients treated with anti‐CD 154 mA bs (?/+ anti‐CD 154 mA b, 30/37). The number of downregulated genes was not affected by anti‐CD 154 mA b treatment. Additionally, the number of upregulated genes increased over time for both groups. Interestingly, treatment with anti‐CD 154 mA bs upregulated coagulation inducers (CCL 2/IL 6 ) before euthanasia. In conclusion, immunosuppressive regimens used for cardiac xenografting affected upregulation of 6 inflammation genes (CXCL 10, MPO , MYD 88, NLRP 3, TNF α, and TLR 1) and downregulation of 8 genes (CCR 4 , CCR 6 , CD 40 , CXCR 3 , FOXP 3 , GATA 3 , STAT 4 , and TBX21 ).     

Changing the paradigm of organ utilization from PHS increased‐risk donors: an opportunity whose time has come?

Approximately 8–11% of all organ donors are classified by Public Health Service (PHS) as increased‐risk. The proportion of PHS increased‐risk donors is on the rise. At the University of Washington Medical Center, in 2014, the proportion of transplants from PHS increased‐risk donors was 28% of liver transplants and 23% of kidney transplants. Nationally, transplant providers have been reluctant to use organs from PHS increased‐risk donors because of concern for transmission of HIV, HCV, or HBV. There is also patient apprehension when these organs are being offered, and thus the discard rate of these otherwise good quality organs is high. Because of the organ shortage, preventing underutilization of such organs is essential. We provide data and considerations that should be used to guide the use of organs from PHS increased‐risk donors.     

Automation of the ELISpot assay for high-throughput detection of antigen-specific T-cell responses

The enzyme linked immunospot (ELISpot) assay is a fundamental tool in cellular immunology, providing both quantitative and qualitative information on cellular cytokine responses to defined antigens. It enables the comprehensive screening of patient derived peripheral blood mononuclear cells to reveal the antigenic restriction of T-cell responses and is an emerging technique in clinical laboratory investigation of certain infectious diseases. As with all cellular-based assays, the final results of the assay are dependent on a number of technical variables that may impact precision if not highly standardised between operators. When studies that are large scale or using multiple antigens are set up manually, these assays may be labour intensive, have many manual handling steps, are subject to data and sample integrity failure and may show large inter-operator variability. Here we describe the successful automated performance of the interferon (IFN)-γ ELISpot assay from cell counting through to electronic capture of cytokine quantitation and present the results of a comparison between automated and manual performance of the ELISpot assay. The mean number of spot forming units enumerated by both methods for limiting dilutions of CMV, EBV and influenza (CEF)-derived peptides in six healthy individuals were highly correlated (r > 0.83, p < 0.05). The precision results from the automated system compared favourably with the manual ELISpot and further ensured electronic tracking, increased through-put and reduced turnaround time.