Aggressive melanoma cells are able to form alternative routes for angiogenesis. The formation of extracellular matrix-rich vasculogenic-like networks [periodic acid Schiff (PAS) loops] and expression of endothelial-associated genes [allowing direct contact of erythrocytes (blood lakes)] are forms of vasculogenic mimicry (VM). The detection of these alternative routes may be used as an additional staging factor for cutaneous melanoma and predicts the route of metastasis in melanoma. We studied the association of the presence of VM with metastasis (lymphogenous and/or haematogenous) in patients diagnosed with cutaneous malignant melanoma in het Groene Hart Hospital, the Netherlands, between 1995 and 2000. Tumour tissue samples of 123 patients were assessed on PAS loops and blood lakes and correlated to clinical data. VM was detected in 42 (34%) and proven metastasis developed in 23 patients (18.7%). VM was associated with shorter survival (P<0.001). In 36 tumours, PAS loops were detected. PAS loops were correlated with the presence of lymphogenous as well as haematogenous metastasis (P=0.062 and 0.013). In 20 tumours, blood lakes were detected and correlated with haematogenous metastasis (P<0.001). In multivariate analyses, the detected blood lakes were significantly associated with haematogenous metastasis (P<0.001, adjusted odds ratio 6.8, 95% confidence interval 1.47-31). Blood lakes were strongly correlated with haematogenous metastasis of cutaneous melanoma and were an independent determinant for survival. These interesting findings need further investigation, although we believe that implementation of this detection can directly lead to better staging of cutaneous melanoma.

Aim Platelet inhibition induced by P2Y12 receptor antagonists in patients with ST-elevation myocardial infarction (STEMI) can be affected by concomitant use of opioids. The aim of this trial was to examine the effect of intravenous (iv) acetaminophen compared with iv fentanyl on P2Y12 receptor inhibition in patients with STEMI. Methods and Results The ON-TIME 3 trial randomised 195 STEMI patients who were scheduled to undergo primary percutaneous coronary intervention (PCI) and were pre-treated with crushed ticagrelor to iv acetaminophen (N = 98) or iv fentanyl (N = 97) in the ambulance. The primary endpoint, consisting of the level of platelet reactivity units (PRU) measured immediately after primary PCI, was not significantly different between the study arms (median PRU 104 [IQR 37-215] vs. 175 [63-228], P = 0.18). However, systemic levels of ticagrelor were significantly higher in the acetaminophen arm at the start of primary PCI (151 ng/mL [32-509] vs. 60 ng/mL [13-206], P = 0.007), immediately after primary PCI (326 ng/mL [94-791] vs. 115 ng/mL [38-326], P = 0.002) and at one-hour after primary PCI (488 ng/mL [281-974]) vs. 372 ng/mL [95-635], P = 0.002). Acetaminophen resulted in the same extent of pain relief as compared to fentanyl (reduction of 3 points on 10-step-pain scale before primary PCI [IQR 1-5] in both study arms (P = 0.67) and immediately after PCI (reduction of 5 points [3-7]; P = 0.96). Conclusion Iv acetaminophen in comparison with iv fentanyl was not associated with significantly lower platelet reactivity in STEMI patients, but resulted in significantly higher ticagrelor plasma levels and was effective in pain relief.

Mucocele of the appendix refers to an appendix that is distended by mucus and transformed in a mucus-filled sac. Appendicular torsion is rare. Primary and secondary forms of appendicular torsion are known. Our patient presented to the emergency department with complaints mimicking acute appendicitis. Imaging with computed tomography and ultrasound showed a cystic lesion most likely originating from the right ovary. The veriform appendix was located close to this lesion and seemed to be distended. During diagnostic laparoscopy, a torsion of the veriform appendix due to a mucocele was found and an appendectomy was performed. Histopathological analysis confirmed the diagnosis. Torsion of the vermiform appendix is most often diagnosed intra-operatively. Pre-operative radiologic imaging is often not useful in the detection of appendicular abnormalities other than acute appendicitis. The treatment consists of detorsion and appendectomy.

Abstract:In 2006, while admitted in our hospital for surgical treatment of recurrent diverticulitis, a 54-year-old man was found to have an adenocarcinoma arising within a colonic diverticulum. Computed tomography, during this episode of diverticulitis, showed a thickened wall of the sigmoid and infl ammatory induration of the pericolonic fat. Colonoscopy could be performed up to no more then 25 cm from the anus due to mucosal edema. A sigmoid resection was performed. Histopathological examination of the resected specimen showed an infl amed diverticulum with a submucosal adenocarcinoma of the intestinal type within its wall. The surrounding fl at colonic mucosa was not involved by the cancerous process. Due to lymph node involvement the patient received adjuvant chemotherapy and remained disease free during follow up.

Background In the region of South Limburg, the Netherlands, a shared ST-elevation myocardial infarction (STEMI) networking system (SLIM network) was implemented. During out-of-office hours, two percutaneous coronary intervention (PCI) centres—Maastricht University Medical Centre and Zuyderland Medical Centre—are supported by the same interventional cardiologist. The aim of this study was to analyse performance indicators within this network and to compare them with contemporary European Society of Cardiology guidelines. Methods Key time indicators for an all-comer STEMI population were registered by the emergency medical service and the PCI centres. The time measurements showed a non-Gaussian distribution; they are presented as median with 25th and 75th percentiles. Results Between 1 February 2018 and 31 March 2019, a total of 570 STEMI patients were admitted to the participating centres. The total system delay (from emergency call to needle time) was 65 min (53–77), with a prehospital system delay of 40 min (34–47) and a door-to-needle time of 22 min (15–34). Compared with in-office hours, out-of-office hours significantly lengthened system delays (55 (47–66) vs 70 min (62–81), p < 0.001), emergency medical service transport times (29 (24–34) vs 35 min (29–40), p < 0.001) and door-to-needle times (17 (14–26) vs 26 min (18–37), p < 0.001). Conclusions With its effective patient pathway management, the SLIM network was able to meet the quality criteria set by contemporary European revascularisation guidelines.