Intraoperative Near-infrared Spectroscopy Can Predict Skin Flap Necrosis.

Background: The study aimed to validate the previously identified capacity of near-infrared spectroscopy (NIRS) to detect clinically relevant differences in tissue perfusion intraoperatively. Methods: Consecutive patients undergoing oncologic resection requiring flap reconstruction were analyzed. Clinicians were blinded to tissue oxygen saturation (StO2) measurements taken intraoperatively. Measurements were taken at (1) control areas not affected by the procedure, (2) areas at risk of necrosis based on distal location, and (3) areas of skin flap necrosis (SFN) identified during the follow-up period. Mean StO2 values were compared using a single-sample t test and analysis of variance (ANOVA) to determine differences in oxygenation. Results: There were 102 patients included from April 2018 to May 2019. Reconstruction was undertaken following resection for breast cancer (46), melanoma (35), sarcoma (9), and other cutaneous malignancies (12). Breast reconstruction involved 38 alloplastic reconstructions and eight autologous free flaps. Other skin flap reconstruction involved 42 local/regional skin flaps, 13 pedicled flaps, and one free flap. Eighteen patients (17.6%) developed SFN. Mean intraoperative StO2 measurements for control areas, areas at risk, and areas of SFN were 74.8%, 70.9%, and 54.3%, respectively. StO2 values equal to or less than 60% were highly specific (96%) for SFN, whereas StO2 values above 85% were highly sensitive (96%) to rule out SFN. Conclusion: These results further support the use of NIRS to objectively assess variations in skin flap oxygenation and tissue perfusion that are correlated with the development of postoperative SFN.

Aplastic anemia secondary to nivolumab and ipilimumab in a patient with metastatic melanoma: a case report.

BACKGROUND: Immune checkpoint blockade (ICB) is becoming an increasingly prevalent strategy in the clinical realm of cancer therapeutics. With more patients being administered ICB for a host of tumor types, the scope of adverse events associated with these drugs will likely grow. Here we report a case of aplastic anemia (AA) in a patient with metastatic melanoma secondary to dual ICB therapy. To our knowledge, this is only the second case of AA secondary to dual ICB in the literature, and the first to have a positive patient outcome. CASE PRESENTATION: A 51-year old male with metastatic melanoma was started on dual immune checkpoint blockade, in the form ipilimumab (3 mg/kg) and nivolumab (1 mg/kg). Two weeks following the second cycle, he presented to the emergency department with profound polypipsia, polyuria and fatigue. The patient was diagnosed with diabetic ketoacidosis secondary to immune therapy induced type-1 diabetes and was admitted to the ICU. While in hospital the patient developed a symptomatic anemia and neutropenia. A bone marrow biopsy revealed a markedly hypocellular marrow with trinlineage hypoplasia with no evidence of myelodysplasia, neoplasm or excess blasts. Flow cytometry revealed an inverted CD4+:CD8+ ratio and an absence of hematogones. Taken together the presumed etiology was AA secondary to immunotherapy. The patient was subsequently started in IV methylprednisone 70 mg/day for 8 days, followed by a prednisone taper. This intervention rectified the bicytopenia and to date the patient has shown stable blood counts. CONCLUSION: With the use of ICBs becoming increasingly prevalent in the clinical arena, the number of patients presenting with immune-related adverse events will likely increase. The current case illustrates the need to be vigilant when managing cancer patients receiving ICB. The resolution of this patient's AA with corticosteroids highlights the value of early detection and appropriate treatment of these rare immune-mediated adverse events.

Detection of virus in water: sensitivity of the tentative standard method for drinking water.

The sensitivity of several microporous virus-adsorbent media for reliably detecting low levels of poliovirus from 380 and 1,900 liters of drinking water by use of the tentative standard method was investigated. The virus-adsorbent media tested were (i) nitrocellulose membrane filters, (ii) epoxy-fiber glass-asbestos filters, (iii) yarn-wound fiber glass depth filters, and (iv) epoxy-fiber glass filter tubes. Virus was adsorbed to the filter media at pH 3.5 and eluted with glycine buffer, pH 11.5. The results from 44 samples demonstrated that poliovirus was detected with a 95% reliability at mean virus input levels of 3 to 7 plaque-forming units/380 liters when 1,900 liters of water was sampled. At mean virus input levels of less than 1 to 2 plaque-forming units/380 liters, the detection reliability was 66% in 76 samples when 1,900 liters of water was sampled. No significant difference in virus detection sensitivity was observed among the various virus adsorbent media tested. Overall virus recovery efficiency ranged from 28 to 42%, with a grand average of 35%. Members of the coxsackievirus groups A and B, echovirus, and adenovirus were also detected when 380 and 1,900 liters of water were sampled. These experimental observations attest to the sensitivity of the tentative standard method for detecting low levels of virus in large volumes of drinking water.

Comparative study of four microporous filters for concentrating viruses from drinking water.

Four microporous virus-absorbent filter media for recovering low levels of virus from 380 liters of drinking water were compared. In addition two of the filter media were compared with 1,900 liters of drinking water. The filter media evaluated were MF nitrocellulose membranes (293 mm), AA Cox M-780 epoxy-fiberglass-asbestos disks (267 mm), K-27 yarn-wound fiberglass cartridges + AA Cox M-780 disks (127 mm), and Balston epoxy-fiberglass tubes (24.5 by 63.5 mm). The filters were used to concentrate seeded poliovirus from 380 liters of finished drinking water. Sodium thiosulfate was added to the drinking water to neutralize chlorine, and hydrochloric acid was added to adjust the pH to 3.5. Virus was eluted from the filters with glycine-NaOH buffer at pH 11.5. In terms of virus recovery efficiency, the filter media ranked Balston greater than Cox 267-mm greater than MF 293-mm congruent to K-27 + Cox 127-mm, but differences were slight. The Balston filters and holders were also superior to the other systems in terms of size, weight, cost, and handling factors. Experiments with 2- and 8-mum porosity Balston filters showed no statistically significant difference in virus recovery. Virus was readily detected by the Balston and the MF 293-mm systems at input levels of 12 to 22 PFU/1,900 liters. Preliminary experiments indicated that an elution pH lower than 11.5 may be satisfactory.

Epoxy-fiberglass adsorbent for concentrating viruses from large volumes of potable water.

A simple and compact virus-adsorbing unit for efficiently concentrating human enteric viruses from 100 gallons (about 380 liters) or more of potable water is described.

Apparatus for conditioning unlimited quantities of finished waters for enteric virus detection.

An apparatus has been developed, constructed, and tested for conditioning unlimited quantities of finished waters for enteric virus detection.

Recovery of poliovirus from turbid estuarine water on microporous filters by the use of celite.

The application of a new step for recovering poliovirus from moderately to highly turbid estuarine water by the filter virus-adsorption technique was investigated. The experiments were conducted under both (i) laboratory-based conditions (200-ml volumes) where the turbidity was controlled and (ii) simulated field conditions (15- to 100-gal volumes) where the turbidity varied depending upon the hydrology of the raw estuarine water. The new step consisted of adding Celite to the turbid water prior to sampling for virus. In the experiments, the pH of the water was first adjusted to 3.5 and then AlCl(3) was added to 0.0005 M. Celite was added to a concentration of 0.01% and mixed thoroughly. Either an HE Cox M-780 microfilter (Cox Instrument, Div. of Lynch Corp., Detroit, Mich.) or an MF-membrane filter (Millipore Corp., Bedford, Mass.) was used as the virus adsorbent. Virus was eluted from the Celite-filter complex in situ at pH 9 with 5x nutrient broth. In the laboratory-based experiments, when turbidity ranged from 5.0 to 30.0 Jackson turbidity units (JTU), virus recovery ranged from 66 to 89%. In the simulated field experiments, when the turbidity ranged from 8.5 to 80.0 JTU, virus recovery ranged from <1 to 74%, depending upon the multiplicity of virus input and the level of turbidity. The new step greatly improved the filtration-flux of turbid water and significantly reduced the premature clogging problem usually observed with microporous filters.

Virus in water. II. Evaluation of membrane cartridge filters for recovering low multiplicities of poliovirus from water.

The efficiency of a Millitube MF cartridge filter, a membrane filter, for recovery of poliovirus from 100-gal volumes of both fresh (tap) and estuarine water was determined. In the high multiplicity of virus input-output experiments, recovery of 97% or greater of input virus was achieved in both types of water when the final concentration of divalent cation as Mg(2+) was 1,200 mug/ml and the pH was 4.5. Virus was effectively eluted from the membrane cartridge with 5x nutrient broth in 0.05 M carbonate-bicarbonate buffer at pH 9.0. Four elutions of 250 ml each were used. In the low multiplicity of virus input-output experiments under the same cationic and pH conditions, up to 67% of the input virus was recovered when the virus was further concentrated from the eluates by the aqueous polymer two-phase separation technique. The volume reduction was 126,000-190,000 to 1. The use of the combined techniques, i.e., membrane adsorption followed by aqueous polymer two-phase separation, provided a highly sensitive, simple, and remarkably reliable sequential methodology for the quantitative recovery of poliovirus occurring at multiplicities as low as 1 to 2 plaque-forming units per 5 gal of water.

Ultraviolet devitalization of eight selected enteric viruses in estuarine water.

The effect of ultraviolet (UV) radiation on the devitalization of eight selected enteric viruses suspended in estuarine water was determined. The surviving fractions of each virus were calculated and then plotted against the UV exposure time for purposes of comparison. Analytical assessment of the survival data for each virus consisted of least squares regression analysis for determination of intercepts and slope functions. All data were examined for statistical significance. When the slope function of each virus was compared against the slope function of poliovirus type 1, the analytical findings indicated that poliovirus types 2 and 3, echovirus types 1 and 11, and coxsackievirus A-9 exhibited similar devitalization characteristics in that no statistically significant difference was found (P > 0.05). Conversely, the devitalization characteristics of coxsackievirus B-1 and reovirus type 1 were dissimilar from those of poliovirus type 1 in that a statistically significant difference was found between the slope functions (P < 0.05). This observed difference in devitalization of coxsackievirus B-1 and reovirus type 1 was attributed primarily to the frequency distribution of single and aggregate virions, the geometric configuration, the size of the aggregates, and the severity of aggregation. The devitalization curve of coxsackievirus B-1 was characteristic of a retardant die-away curve. The devitalization curve of reovirus type 1 was characteristic of a multihittype curve. The calculated devitalization half-life values for poliovirus types 1, 2, and 3; echovirus types 1 and 11; coxsackievirus types A-9 and B-1; and reovirus type 1 were 2.8, 3.1, 2.7, 2.8, 3.2, 3.1, 4.0, 4.0 sec, respectively. These basic data should facilitate an operative extrapolation of the findings to the applied situation. It was concluded that UV can be highly effective and provide a reliable safety factor in treating estuarine water.

Inactivation of poliovirus type 1 by the Kelly-Purdy ultraviolet seawater treatment unit.

Three experiments were conducted to determine the effect of ultraviolet (UV) radiation on poliovirus-contaminated seawater. In two of the experiments, the effectiveness of the Kelly-Purdy UV Seawater Treatment Unit to inactivate poliovirus type 1 (T(1)) suspended in continuously flowing seawater was determined. In experiment 1, the observed survival ratio of poliovirus T(1) was 2.3 x 10(-4) (99.98% reduction) in 15.7 sec. No virus was detected (<0.2 plaque-forming unit/ml) in 20.6 seconds. The calculated half-life value was 1.29 sec. In experiment 2, the observed survival ratio of poliovirus T(1) was 5.9 x 10(-4) (99.94% reduction) in 11.7 sec. No virus was detected in 15.7 sec. The calculated half-life value was 1.37 sec. In experiment 3, a laboratory-controlled UV experiment designed to closely simulate the geometry of the continuously flowing seawater system, the observed survival ratios of poliovirus T(1) were 9.7 x 10(-3) (99.03% reduction) and 3.6 x 10(-4) (99.96% reduction) in 15 and 30 sec, respectively; the calculated half-life value was 2.38 sec. A statistically significant difference was found between the inactivation rates of poliovirus T(1) in the two test systems. This rate difference was attributed primarily to UV dosage and stirring effects. The data indicated that UV radiation effectively inactivated poliovirus T(1) in flowing seawater. These results validate the efficacy of the Kelly-Purdy UV Seawater Treatment Unit for use in commercial depuration systems.

Survival of poliovirus in flowing turbid seawater treated with ultraviolet light.

The effectiveness of a model ultraviolet (UV) radiation unit for treating flowing turbid seawater contaminated with poliovirus was determined. At a turbidity of 70 ppm, the observed survival ratios ranged from 1.9 x 10(-3) (99.81% reduction) to 1.5 x 10(-4) (99.98% reduction) at flow rates ranging from 25 to 15 liters/min; no virus was recovered at flow rates of 10 and 5 liters/min. At a turbidity of 240 ppm, the observed survival ratios ranged from 3.2 x 10(-2) (96.80% reduction) to 2.1 x 10(-4) (99.98% reduction) at flow rates ranging from 25 to 5 liters/min. As expected, turbidity had an adverse influence on the effectiveness of UV radiation; however, by adjusting the flow rate of the seawater through the treatment unit, adequate disinfection was shown to be predictable.