Pancreatic Gangliocytic Praganglioma: A Rare Case and Literature Review

Introduction/Objective

Gangliocytic paraganglioma, GP is a morphologically distinct tumor first reported by Dahl in 1957, most often in second portion of duodenum near ampulla of Vater. GP mostly present as single tumors, but occasionally may be multiple, when seen in association with Von Recklinghausen disease and carcinoid tumors. Rare cases have been reported at other sites in gastrointestinal tract including esophagus, pylorus, jejunum and extra- gastrointestinal tract in the nasopharynx, thymus, lung and ovary. Pancreatic GP is extremely rare with five cases reported till date.

Methods/Case Report

A 42- year- old male presented with abdominal pain. Physical exam showed no abnormalities. The significant findings on labs were raised amylase levels in the range of 1262 U and mild hyperglycemia with blood glucose of 178mg/dl. CA 19-9 was found to be 8.0 U/ml. Coronal CT Abdomen showed hypodense well circumscribed nodule 1.5 cm in body of pancreas. Gross specimen of pancreas showed a circumscribed 1.5 cm nodule in body of Pancreas.The microscopic sections of pancreatic mass show epithelioid appearing neuroendocrine cells in nests, with spindle shaped schwann cells or sustentacular cells in periphery, and scattered ganglion cells. The immunohistochemical staining positive for synaptophysin in epithelioid cells, S100 in spindled schwann cells and CK in epithelioid cells and Ganglion cells. Based on the microscopic findings, a diagnosis of Gangliocytic Paraganglioma, GP arising in Pancreas was made.

Results (if a Case Study enter NA)

NA

Conclusion

Pancreatic GP, are often misdiagnosed as Pancreatic Neuro endocrine tumors, Grade1. The accurate differentiation and precise diagnosis is crucial for appropriate clinical management. WHO classification of 2010, classifies gangliocytic paragangliomas as benign. Duodenal GP has a benign behavior with lymph node metastasis in only 5-7% cases, and no evidence of distant metastasis. In comparison, Pancreatic GP show an more aggressive behavior with lymph node metastasis observed in 2/6 cases and one case with sternal bone metastasis, emphasizing the importance of the primary location of origin of GP as prognostic factor. Our understanding is limited due to the scarcity of literature; more published data shall be instrumental in further explaining the clinical behavior of this rare entity.

Staphylococcus caledonicus sp. nov. and Staphylococcus canis sp. nov. isolated from healthy domestic dogs

Two strains, H8/1^T and H16/1A^T, of Gram-stain-positive, coagulase-negative staphylococci were isolated from separate healthy domestic dogs in Scotland. Both strains were genome sequenced and their inferred DNA–DNA hybridisation indicates that H8/1^T and H16/1A^T represent two novel species of the genus Staphylococcus. On the basis of the results of genome sequence analysis (genome blast distance phylogeny and single nucleotide polymorphism analysis) H8/1^T is most closely related to Staphylococcus devriesei and H16/1A^T most closely related to Staphylococcus felis. Also, average nucleotide identity distinguished H8/1^T and H16/1A^T from S. devriesei and S. felis as did minor phenotypic differences. On the basis of these results, it is proposed that H8/1^T and H16/1A^T represent novel species with the respective names Staphylococcus caledonicus and Staphylococcus canis. The type strain of S. caledonicus is H8/1^T (=NCTC 14452^T=CCUG 74789^T). The type strain of S. canis is H16/1A^T (=NCTC 14451^T=CCUG 74790^T)

AB0288 SAFETY OF BELIMUMAB IN PATIENTS WITH ACTIVE SYSTEMIC LUPUS ERYTHEMATOSUS: YEAR 2 FOLLOW-UP OF A LARGE PHASE 4, RANDOMISED, DOUBLE-BLIND, PLACEBO-CONTROLLED STUDY

Background:

Belimumab (BEL), a recombinant human monoclonal antibody that inhibits B-lymphocyte stimulator (BLyS), is approved for the treatment of systemic lupus erythematosus (SLE). Clinical studies have yielded varying incidence rates of mortality and adverse events of special interest, such as malignancies, thereby necessitating large-scale, long-term assessment following BEL exposure.

Objectives:

To assess all-cause mortality and new primary malignancies during post-treatment Year 2 follow-up in adult patients with active, autoantibody-positive SLE who received intravenous (IV) BEL or placebo (PBO), plus standard therapy in the 52-week double-blind treatment period of the ongoing BASE trial.1

Methods:

This was a post-treatment follow-up of the Phase 4, double-blind study (BASE1; GSK Study BEL115467; NCT01705977), which randomised 4019 adults with active SLE and receiving standard therapy to BEL (10 mg/kg IV) or PBO on Days 0, 14, 28, and monthly thereafter until Week 48. All patients (including those who discontinued BEL before the end-of-treatment phase) were contacted by phone annually (+/-30-day time window). Rates of mortality and new primary malignancy are summarised for Year 2 follow-up, presented by the treatment received during the 52-week double-blind treatment period (Year 1).

Results:

Baseline patient characteristics and disease activity collected at the start of the study, evaluated in patients with Year 2 follow-up were similar to the overall Year 1 study population. Cumulatively by Year 2 follow-up, 10.7% and 9.5% of patients had been exposed to commercial BEL in the BEL and PBO groups, respectively. Cumulative follow-up adjusted mortality and malignancy rates (per 100 patient years) were lower in the BEL vs PBO Year 1 treatment group (Table 1).

Conclusion:

Year 2 follow-up results of BASE, the largest clinical trial of SLE to date,1 provide continued support for the BEL safety profile. No new BEL safety concerns were identified in patients with active, autoantibody-positive SLE receiving standard therapy.

Funding: GSK

References:

[1]Sheikh SZ, et al. Lancet Rheum. 2020 (ePub ahead of print) doi.org/10.1016/S2665-9913(20)30355-6

Table 1.

Year 2 post-treatment* follow-up mortality and new primary malignancy rates by study treatment during Year 1

BELPBOTotalYear 1 as-treated populationN=2002N=2001N=4003Year 1 deaths, n (%)13 (0.65)22 (1.10)35 (0.87)Year 1 new primary malignancies, n (%)9 (0.45)10 (0.50)19 (0.47)Year 2 (as-treated in Year 1) populationN=1681N=1666N=3347Year 2 deaths by MedDRA SOC, n (%)9 (0.54)21 (1.26)30 (0.90)Cardiac disorders2 (0.12)6 (0.36)8 (0.24)Infections and infestations4 (0.24)2 (0.12)6 (0.18)Uncoded1 (0.06)3 (0.18)4 (0.12)General disorders/administration site conditions1 (0.06)2 (0.12)3 (0.09)Gastrointestinal disorders1 (0.06)1 (0.06)2 (0.06)Neoplasms02 (0.12)2 (0.06)Other05 (0.30)†5 (0.15)Cumulative deaths by Year 2 follow-up, n (%)22 (1.10)43 (2.15)65 (1.62)Incidence rate per 100 patient years0.601.180.89Year 2 new primary malignancies by MedDRA SOC, n (%)3 (0.18)4 (0.24)7 (0.21)Neoplasms2 (0.12)4 (0.24)6 (0.18)Hepatobiliary disorders1 (0.06)01 (0.03)Cumulative malignancies by Year 2 follow-up, n (%)12 (0.60)14 (0.70)26 (0.65)Patient incidence rate per 100 patient years0.340.400.37

*Patients in the post-treatment follow-up period are no longer receiving study treatment; †1 event/patient: blood/lymphatic system, musculoskeletal/connective tissue, nervous system, psychiatric, and renal/urinary disorders.

MedDRA, Medical Dictionary for Regulatory Activities; SOC, system organ class.

Acknowledgements:

Medical writing assistance was provided by Katalin Bartus, PhD, Fishawack Indicia Ltd., UK, part of Fishawack Health, and was funded by GSK.

Disclosure of Interests:

Saira Sheikh Grant/research support from: Pfizer, Morton Scheinberg Consultant of: GSK, Pfizer, Alnylam, AbbVie, PTC Therapeutics, James Cheng-Chung Wei Consultant of: TSH Biopharm, AbbVie, BMS, Celgene, Chugai, Eisai, Janssen, Novartis, Pfizer, Sanofi-Aventis and UCB pharma, Grant/research support from: AbbVie, Amgen, Astellas, BMS, Celgene, Eli Lilly, Gilead, Janssen, Novartis, Pfizer Sun and UCB, Dana Tegzová: None declared, William Stohl Consultant of: GSK, Grant/research support from: GSK, Pfizer, Gilead, Tamara Mucenic Speakers bureau: Novartis, Janssen, BMS, AbbVie, Pfizer, Roche, Grant/research support from: GSK, Janssen, Roche, Eli Lilly, Gilead, UCB, Raj Punwaney Shareholder of: GSK, Employee of: GSK, Regina Kurrasch Shareholder of: GSK, Employee of: GSK, Julia Harris Shareholder of: GSK, Employee of: GSK, Saima Muzaffar Shareholder of: GSK, Employee of: GSK, Sofia Fernandes Shareholder of: GSK, Employee of: GSK, Norma Lynn Fox Shareholder of: GSK, Employee of: GSK, Andrew Liu Shareholder of: GSK, Employee of: GSK, Holly Quasny Shareholder of: GSK, Employee of: GSK, David Roth Shareholder of: GSK, Employee of: GSK

Calibrating a chief complaint list for low resource settings: a methodologic case study

BACKGROUND

The chief or presenting complaint is the reason for seeking health care, often in the patient's own words. In limited resource settings, a diagnosis-based approach to quantifying burden of disease is not possible, partly due to limited availability of an established lexicon or coding system. Our group worked with colleagues from the African Federation of Emergency Medicine building on the existing literature to create a pilot symptom list representing an attempt to standardize undifferentiated chief complaints in emergency and acute care settings. An ideal list for any setting is one that strikes a balance between ease of use and length, while covering the vast majority of diseases with enough detail to permit epidemiologic surveillance and make informed decisions about resource needs.

METHODS

This study was incorporated as a part of a larger prospective observational study on human immunodeficiency virus testing in Emergency Departments in South Africa. The pilot symptom list was used for chief complaint coding in three Emergency Departments. Data was collected on 3357 patients using paper case report forms. Chief complaint terms were reviewed by two study team members to determine the frequency of concordance between the coded chief complaint term and the selected symptom(s) from the pilot symptom list.

RESULTS

Overall, 3537 patients' chief complaints were reviewed, of which 640 were identified as 'potential mismatches.' When considering the 191 confirmed mismatches (29.8%), the Delphi process identified 6 (3.1%) false mismatches and 185 (96.9%) true mismatches. Significant chief-complaint clustering was identified with 9 sets of complaints frequently selected together for the same patient. "Pain" was used 2076 times for 58.7% of all patients. A combination of user feedback and expert-panel modified Delphi analysis of mismatched complaints and clustered complaints resulted in several substantial changes to the pilot symptom list.

CONCLUSIONS

This study presented a systematic methodology for calibrating a chief complaint list for the local context. Our revised list removed/reworded symptoms that frequently clustered together or were misinterpreted by health professionals. Recommendations for additions, modifications, and/or deletions from the pilot chief complaint list we believe will improve the functionality of the list in low resource environments.

P10: LYMPH NODE YIELD IS NOT A RELIABLE PROGNOSTIC MARKER IN ANTERIOR RESECTION AND ABDOMINOPERINEAL RESECTION FOLLOWING NEOADJUVANT THERAPY FOR RECTAL CANCER

Introduction

International guidelines recommend a minimum lymph node yield (LNY) of ≥12 for oncological resection in colorectal cancer (CRC). Neoadjuvant chemoradiotherapy (NACRT) decreases LNY, which questions its ability to provide accurate prognostic information. The consensus of this significance remains undetermined. This study aimed to investigate the significance of LNY on recurrence and survival following anterior resection and abdominoperineal resection with or without NACRT for rectal cancer.

Method

Prospectively collected data on patients diagnosed with rectal cancer in a tertiary referral centre was interrogated retrospectively. Patients were divided into primary surgery and NACRT groups. Univariable analysis was performed using Fisher's exact test, t-test, and x2 test, while multivariable analysis utilised a multiple regression model. Disease recurrence and survival was analysed with logrank test for Kaplan-Meier curves.

Result

148 patients were included [56.1% (n=83) receiving NACRT]. The median LNY of the primary surgery group was 14 [interquartile range (IQR) 11-19] and for the NACRT group was 12 (IQR 8-14) (p <0.001). Disease recurrence was similar in both primary surgery and NACRT groups. There was a significant decrease in overall mortality in NACRT patients (p = 0.03), but there was no significant difference observed in recurrence or mortality amongst LNYs of <8, 8-11, and ≥12.

Conclusion

LNY less than 12 was not a negative prognostic indicator following NACRT and surgery for rectal cancer.

Take-home message

A lymph node yield of less than 12 is not a negative prognostic indicator in rectal cancer patients who receive neoadjuvant chemotherapy.

Development of a shared decision-making tool in vitiligo: an international study

BACKGROUND

Shared decision-making tools (SDMt) are visual tools developed to promote joint medical decisions between physicians and patients. There is a paucity of such tools in dermatology.

OBJECTIVES

To develop and validate a SDMt for use in specialized consultation for vitiligo.

METHODS

A prospective cross-sectional study was carried out from March 2019 to March 2020. We first conducted a qualitative study of topics discussed by patients and clinicians during therapeutic decision-making in the setting of a specialized consultation for vitiligo using an anchored-theory method, which allowed conceptualization of the SDMt. The usefulness of the SDMt was evaluated by a working group of multidisciplinary health workers and patients with vitiligo. Consensus on the final tool was obtained through an e-Delphi method.

RESULTS

We recruited 30 patients with vitiligo for the qualitative study, which identified 91 topics related to therapeutic decision-making. Hierarchical clustering analysis confirmed the distribution of these topics in two subgroups (general treatment goals and priorities, and topics specific to each treatment). The consensus of a multidisciplinary group was used to develop the SDMt. The tool was comprised of eight A5 cards, which addressed face repigmentation; body repigmentation (limited area); body repigmentation (extended area); partial or complete depigmentation; coping with the disease; stabilization of disease; maintaining repigmentation; and disease information. Cognitive interviews confirmed the satisfaction, readability and usefulness of the SDMt. The SDMt was then translated and culturally validated in English.

CONCLUSIONS

We developed a tool for shared decision-making in nonsegmental vitiligo, which we translated and cross-culturally validated in a US patient population with vitiligo to ensure its generalizability.

UK food and nutrition security during and after the COVID-19 pandemic

The COVID‐19 pandemic is a major shock to society in terms of health and economy that is affecting both UK and global food and nutrition security. It is adding to the ‘perfect storm’ of threats to society from climate change, biodiversity loss and ecosystem degradation, at a time of considerable change, rising nationalism and breakdown in international collaboration. In the UK, the situation is further complicated due to Brexit. The UK COVID‐19Food andNutritionSecurity project, lasting one year, is funded by the Economic and Social Research Council and is assessing the ongoing impact of COVID‐19 on the four pillars of food and nutrition security: access, availability, utilisation and stability. It examines the food system, how it is responding, and potential knock on effects on the UK’s food and nutrition security, both in terms of the cascading risks from the pandemic and other threats. The study provides an opportunity to place the initial lessons being learnt from the on‐going responses to the pandemic in respect of food and nutrition security in the context of other long‐term challenges such as climate change and biodiversity loss.

Characterisation and control of the biosolids storage environment: Implications for E. coli dynamics

E. coli survival in biosolids storage may present a risk of non-compliance with guidelines designed to ensure a quality product safe for agricultural use. The storage environment may affect E. coli survival but presently, storage characteristics are not well profiled. Typically biosolids storage environments are not actively controlled or monitored to support increased product quality or improved microbial compliance. This two-phased study aimed to identify the environmental factors that control bacterial concentrations through a long term, controlled monitoring study (phase 1) and a field-scale demonstration trial modifying precursors to bacterial growth (phase 2). Digested and dewatered biosolids were stored in operational-scale stockpiles to elucidate factors controlling E. coli dynamics. E. coli concentrations, stockpile dry solids, temperature, redox and ambient weather data were monitored. Results from ANCOVA analysis showed statistically significant (p < 0.05) E. coli reductions across storage periods with greater die-off in summer months. Stockpile temperature had a statistically significant effect on E. coli survival. A 4.5 Log reduction was measured in summer (maximum temperature 31 °C). In the phase 2 modification trials, covered stockpiles were able to maintain a temperature >25 °C for a 28 day period and achieved a 3.7 Log E. coli reduction. In winter months E. coli suppression was limited with concentrations >6 Log₁₀ CFU g^-1 DS maintained. The ANCOVA analysis has identified the significant role that physical environmental factors, such as stockpile temperature, has on E. coli dynamics and the opportunities for control.

Two-dimensional echocardiographic estimates of left ventricular volumes obtained in different views in dogs provide similar measurements but are not interchangeable

INTRODUCTION

Little information exists regarding the interchangeability of left ventricular volume estimates using a monoplane Simpson's Method of Discs on images obtained from the left apical four-chamber and right parasternal long axis four-chamber views. We examined if volume estimates obtained from these views were interchangeable.

ANIMALS

A total of 224 dogs: 86 healthy, 96 with mitral valve disease, 42 with various cardiac pathologies.

MATERIALS AND METHODS

Investigators obtained right parasternal long-axis and left apical four-chamber views from each dog and used manufacturer-supplied software to estimate left ventricular volumes in diastole and systole using Simpson's Method of Discs. Estimates based on linear measurements (diameter cubed, 0.67∗diameter cubed, and Teichholz) were also calculated. Reproducibility for each view, and agreement between the estimates obtained with each view, and those calculated from linear dimensions, were examined using Limits of Agreement. Reference intervals for volumes indexed to bodyweight and body surface area were calculated.

RESULTS

Neither method proved very reproducible. Although no bias was detected, the agreement between volumes indexed to bodyweight and body surface area was insufficient to recommend interchangeability. Estimates based on Teichholz and diameter cubed methods overestimated volumes; however, those based on 0.67∗diameter cubed performed reasonably.

CONCLUSIONS

Monoplane volume estimates from the left apical and right parasternal long axis four-chamber views are similar but not interchangeable. Clinicians can perform crude estimates of left ventricular volume using the equation 0.67∗diameter cubed.