A case of disseminated cryptococcosis with abdominal involvement due to Cryptococcus neoformans species complex in a Ragdoll cat and false-negative cryptococcal antigen lateral flow tests due to the postzone phenomenon

Although cryptococcosis is the most common systemic fungal disease of cats, abdominal involvement is rarely reported. The pathogenesis of cryptococcosis usually involves sinonasal colonisation, followed by tissue invasion and sinonasal infection, with possible subsequent spread to the lungs and/or direct extension into the central nervous system (CNS), for example, via the cribriform plate. Further haematogenous spread can occur to any tissue, including skin and the CNS. This report describes a case of disseminated cryptococcosis due to Cryptococcus neoformans species complex in a 13-year-old cat, the fourth documented Australian feline case with abdominal involvement. The cat presented with a chronic history of upper respiratory disease that progressed to severe lethargy and anorexia. An autopsy revealed striking peritonitis with multifocal abdominal involvement affecting the liver, spleen, adrenal glands, kidneys, pancreas and mesentery. Cryptococcal organisms were also observed in organs within the thoracic cavity, sinonasal tissues and the CNS. Testing of abdominal fluid and serum for cryptococcal antigen using a commercially available lateral flow assay using neat fluid specimen initially tested false-negative. However, after dilution of the sample to 1:64, a positive result was obtained, confirming a postzone phenomenon. Taken together, the collective findings were indicative of widely disseminated cryptococcosis due to Cryptococcus neoformans with atypical involvement of the abdominal cavity.

Abstract P6-12-06: Nonsteroidal, tissue selective androgen receptor modulator (SARM), enobosarm, reduces growth of androgen receptor-positive breast cancer in patient-derived preclinical models

Introduction: In breast cancer the androgen receptor (AR) is the most abundantly expressed steroid receptor with 75-95% of estrogen receptor (ER)-positive and 40-70% of ER-negative breast cancers expressing the AR. Historically, advanced breast cancer has been treated with androgens, resulting in significant clinical response. However, the use of steroidal androgens fell from favor as a result of their virilizing side effects. Nonsteroidal, tissue selective androgen receptor modulators (SARMs) will provide a novel targeted approach to exploit the therapeutic benefits of androgens in breast cancer.

Aims: To test the effects of enobosarm (a first-in-class SARM) and enzalutamide (AR antagonist) on the growth of patient-derived breast cancer xenografts (PDX) and to discern the mechanism of action of AR-targeted therapies in AR-positive breast cancer.

Materials and Methods: AR-positive PDXs with varying receptor expression (ER, progesterone receptor (PR), and HER2) were implanted in immunecompromised mice. Mice carrying PDXs were treated with vehicle, 10 mg/kg/day (mpk) enobosarm (GTx, Inc., Memphis, TN), or 20 mpk enzalutamide (Medivation Inc.), orally. Tumor volume was measured twice or thrice weekly. Tumors that received enobosarm were further analyzed to determine the mechanism of action.

Results: Enobosarm significantly (p<0.01) inhibited the growth of ER-, PR-, and HER2- positive HCI-7 and ER- and PR- negative and HER2-positive HCI-12 PDX. While enobosarm inhibited the growth of HCI-12 by ~80% and HCI-7 by ~60%, enzalutamide failed to inhibit the growth of the HCI-7 PDX. In contrast, neither enobosarm nor enzalutamide inhibited the growth of ER- and PR-negative and HER2-positive HCI-9 PDX, consistent with the heterogeneity of AR-positive breast cancers. Growth of two triple-negative breast cancer (TNBC) PDXs were inhibited by 30-40% by enobosarm, but not by enzalutamide. These results were reproduced in xenografts developed with breast cancer cell lines, MCF-7 and MDA-MB-231 expressing the AR. Gene expression studies conducted with the HCI-12 tumors indicated that enobosarm inhibited the expression of various proliferative genes (MUC2, IL10RA, IGSF1, SLC6A4, and others) and increased the expression of growth inhibitory genes (CYP4F8, MYBPC1, and others). Ingenuity pathway analysis demonstrated that enobosarm inhibited genes that are downstream of HER2 signaling. Interestingly, miR-21-3p, which has been implicated in chemo-resistance, was consistently expressed at approximately 10-50-fold higher than miR-21-5p in PDXs. This imbalance was partially reversed by enobosarm.

Conclusion: These results indicate that AR-positive breast cancers are highly heterogeneous and that enobosarm has promise as novel targeted therapy to treat AR-positive breast cancer. Enobosarm is currently in phase II clinical trial in both ER-positive breast cancer and in TNBC patients.

Citation Format: Narayanan R, Ponnusamy S, Fan M, Yang CH, Grimes BL, Fleming MD, Pritchard EF, Berry MP, Oswaks RM, Fine RE, Loiseau J-C, Schwartzberg LS, Pfeffer LM. Nonsteroidal, tissue selective androgen receptor modulator (SARM), enobosarm, reduces growth of androgen receptor-positive breast cancer in patient-derived preclinical models [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-12-06.

An exploration of parents' and young people's perspectives of hospice support

BACKGROUND

Hospices are an important component of children's palliative care provision and increasing numbers of children/young people with life-limiting conditions mean that the demand placed on them for support is likely to increase. However, there has been a lack of published research examining how families experience the support provided by children's hospices.

METHODS

The aim of the study was to investigate parents' and young people's perceptions of hospice support and identify how support could be improved. A mixed-method approach was used involving a postal survey of families and in-depth qualitative interviews with a purposively sampled subsample of parents and young people.

RESULTS

A total of 108 (49.8% response rate) questionnaires were returned and interviews were conducted with 12 parents and seven young people. Families were highly satisfied with the support provided in terms of quality of care; interpersonal qualities of the staff; the individualized, family-focused approach; accessibility of support and involvement in decision making. Young people valued the opportunity to meet with other young people and take part in different activities. For parents the provision of a break from caring was the main way in which they were supported although they felt they wanted more of this form of support. A consistent theme in relation to support for young people and siblings was the need to develop facilities, activities and bereavement support specifically for teenagers/young people.

CONCLUSIONS

Parents value a model of care that provides holistic, family-focused support that is responsive to individual needs and which promotes control and active involvement in decision making. The key challenge now is to respond to increasing need and a changing population of users.

Gerontological nurse specialists

This article focuses on the development of a new role highlighted in The NHS Plan (DoH 2000a), nurse specialist for older people or gerontological nurse specialist.

Does optimal timing for spine fracture fixation exist?

OBJECTIVE

To evaluate the effect of timing of spine fracture fixation on outcome in multiply injured patients.

SUMMARY BACKGROUND DATA

There is little consensus regarding the optimal timing of spine fracture fixation after blunt trauma. Potential advantages of early fixation include earlier patient mobilization and fewer septic complications; disadvantages include compounded complications from associated injuries and inconvenience of surgical scheduling.

METHODS

Patients with spine fractures from blunt trauma admitted to an urban level 1 trauma center during a 42-month period who required surgical spine fracture fixation were identified from the registry. Patients were analyzed according to timing of fixation, level of spine injury, and impact of associated injuries (measured by injury severity score). Early fixation was defined as within 3 days of injury, and late fixation was after 3 days. Outcomes analyzed were intensive care unit and hospital stay, ventilator days, pneumonia, survival, and hospital charges.

RESULTS

Two hundred ninety-one patients had spine fracture fixation, 142 (49%) early and 149 (51%) late. Patients were clinically similar relative to age, admission blood pressure, injury severity score, and chest abbreviated injury scale score. The intensive care unit stay was shorter for patients with early fixation. The incidence of pneumonia was lower for patients with early fixation. Charges were lower for patients with early fixation. Patients were stratified by level of spine injury. There were 163 cervical (83 early, 80 late), 79 thoracic (30 early, 49 late), and 49 lumbar fractures (29 early, 20 late). There were no differences in injury severity between early and late groups for each fracture site. The most striking differences occurred in the thoracic fracture group. Early fixation was associated with a lower incidence of pneumonia, a shorter intensive care unit stay, fewer ventilator days, and lower charges. High-risk patients had lower pneumonia rates and less hospital resource utilization with early fixation.

CONCLUSIONS

Early spine fracture fixation is safely performed in multiply injured patients. Early fixation is preferred in patients with thoracic spine fractures because it allows earlier mobilization and reduces the incidence of pneumonia. Although delaying fixation in the less severely injured may be convenient for scheduling, it increases hospital resource utilization and patient complications.

Older people with dementia in acute settings

This article suggests that screening and assessing for dementia can be incorporated into nurses' roles, as can a range of strategies to address some of the common challenges that nurses face when working with older people with cognitive impairment in acute settings.

Intermittent and continuous ceftazidime infusion for critically ill trauma patients

BACKGROUND

The adequacy of intermittent and continuous infusion ceftazidime for the treatment of nosocomial pneumonia in critically ill trauma patients was assessed by analyzing ceftazidime pharmacokinetics in relation to the minimum inhibitory concentration (MIC) and treatment outcome.

METHODS

Serial blood samples were obtained during ceftazidime therapy in 31 trauma patients. Ceftazidime pharmacokinetics were compared with that of previously studied healthy volunteers. Ceftazidime pharmacokinetics were analyzed according to the time above the MIC and treatment outcome.

RESULTS

Critically ill trauma patients had a significantly increased volume of distribution and clearance (0.32 +/- 0.14 L/kg and 2.35 +/- 0.89 mL. min(-1). kg(-1), respectively) compared with healthy volunteers (0.21 +/- 0.03 and 1.58 +/- 0.23 mL. min(-1). kg(-1)). The time above the MIC was >/=92% of the dosing interval for all patients and treatment outcomes were similar between the two treatment groups.

CONCLUSIONS

Ceftazidime pharmacokinetics are significantly altered in critically ill trauma patients. Both intermittent and continuous ceftazidime regimens were equally effective for the treatment of nosocomial pneumonia caused by less virulent bacteria.

Screening for dementia and depression in older people

Nurses have a valuable role to play in screening for dementia and depression in older people but they must be confident, adequately trained and supported. The authors conclude that screening and assessment is vital for older people to gain access to specialist mental health services.

Dementia. Part 2: Person-centred assessment

A positive attitude towards people with dementia will enable the nurse to ascertain their strengths and abilities. Person-centred assessment can enhance the patient's experience and lead to more accurate information. Nurses should also consider the needs and role of the patient's carer.

Risk of abdominal septic complications after feeding jejunostomy placement in patients undergoing splenectomy for trauma

Compared with total parenteral nutrition, enteral feeding via jejunostomy reduces septic complications in patients with severe trauma. However, violation of the bowel with insertion of a jejunostomy tube may increase the risk of intra-abdominal abscess (IAA), particularly if no simultaneous gastrointestinal tract injury exists. The records of 123 patients requiring splenectomy for trauma at a level I trauma center during a 6-year period (1986 to 1992) were reviewed to examine the incidence of IAA in patients with and without simultaneous jejunostomy placement in the presence and absence of gastrointestinal tract injuries. Thirty patients had jejunostomies placed (J), and 93 did not (NoJ). There were no significant differences between the groups in age, Abdominal Trauma Index, Injury Severity Score, or transfusion requirements. The incidence of IAA was not significantly different between the J and NoJ groups in the presence or absence of gastrointestinal tract injuries. Thus, jejunostomy placement does not increase the incidence of IAA after splenectomy regardless of the presence of a gastrointestinal tract injury.

Surgical resection of a solitary liver metastasis in a 46-year-old patient with a malignant thymoma

Clinical history, surgical treatment, and pathologic findings of a solitary liver metastasis of a malignant thymoma in a 46-year-old female are reported. An extensive literature review has revealed no record of surgical resection of liver metastasis in a patient with invasive thymoma.

Combined high-performance liquid chromatographic procedure for measuring 4-hydroxypropranolol and propranolol in plasma: pharmacokinetic measurements following conventional and slow-release propranolol administration

An assay is described for the simultaneous determination of propranolol and its active metabolite, 4-hydroxypropranolol, in human plasma. Both compounds were separated from an ethereal extract by high-performance liquid chromatography employing a C18 bonded-phase column. Detection of the effluent was by fluorescence. Suitable fluorescent spectrometers and wavelength settings that allow optimum detection of both compounds have been described. The limit of sensitivity was 2 ng/ml for both propranolol and 4-hydroxypropranolol. Mean peak plasma levels of propranolol and 4-hydroxypropranolol in six patients receiving a single dose of a slow-release 160-mg formulation of propranolol were 28 and 6 ng/ml, respectively. These levels were about one-tenth the level obtained following a single conventionally prepared dose of propranolol (160 mg). Peak levels were delayed and plasma levels of propranolol persisted for a longer period with the slow-release formulation. Area under the curve estimates suggested that the bioavailability of the slow-release formulation following single-dose administration was about one-third that of the conventional preparation.

Congenital Malformation of the Neck. (Klippel-Feil's Disease or Web-Neck)

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The Union of Fractures of Long Bones in Newborn Infants, without Surgical Treatment: (Section for the Study of Disease in Children)

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