Comprehensive mutational analysis of primary and relapse acute promyelocytic leukemia

Acute promyelocytic leukemia (APL) is a subtype of myeloid leukemia characterized by differentiation block at the promyelocyte stage. Besides the presence of chromosomal rearrangement t(15;17), leading to the formation of PML-RARA (promyelocytic leukemia-retinoic acid receptor alpha) fusion, other genetic alterations have also been implicated in APL. Here, we performed comprehensive mutational analysis of primary and relapse APL to identify somatic alterations, which cooperate with PML-RARA in the pathogenesis of APL. We explored the mutational landscape using whole-exome (n=12) and subsequent targeted sequencing of 398 genes in 153 primary and 69 relapse APL. Both primary and relapse APL harbored an average of eight non-silent somatic mutations per exome. We observed recurrent alterations of FLT3, WT1, NRAS and KRAS in the newly diagnosed APL, whereas mutations in other genes commonly mutated in myeloid leukemia were rarely detected. The molecular signature of APL relapse was characterized by emergence of frequent mutations in PML and RARA genes. Our sequencing data also demonstrates incidence of loss-of-function mutations in previously unidentified genes, ARID1B and ARID1A, both of which encode for key components of the SWI/SNF complex. We show that knockdown of ARID1B in APL cell line, NB4, results in large-scale activation of gene expression and reduced in vitro differentiation potential.

24: COCAINE-RELATED ACUTE CORONARY SYNDROME AND INCIDENCE OF HEART DISEASE

Purpose of Study

Cocaine-related chest discomfort is frequently encountered in urban emergency departments. Incidence of co-morbid illness and heart disease is not well defined in patients with cocaine-related ACS. Appropriate risk stratification in patients with cocaine-related ACS is not clearly defined.

Methods Used

231 consecutive patients meeting inclusion criteria were entered into a large ACS registry at an urban, inner-city acute-care facility. Comparisons in demographics, co-morbid conditions, left ventricular function and coronary disease were made between patients with cocaine-related ACS and those with non-cocaine ACS.

Summary of Results

44 (19%) of these patients either tested positive for cocaine by urine drug screen or had self-reported cocaine abuse. Compared to the non-cocaine ACS patients, these individuals were significantly younger, more likely to be male, unmarried, uninsured and also have history of alcohol and tobacco abuse (all p<0.05). The cocaine-users were less likely to have risk factors of diabetes (p<0.002) and hyperlipidemia (p<0.02). Ejection fraction mean was 51.3% (sd 15.4) in the cocaine-users vs. 48.1% (sd 14.0) in the non-cocaine users, with an incidence of EF</=40% of 28% vs. 31% respectively (p=ns). 50% (22/44) of the cocaine-users underwent a stress test evaluation, and 27% of these were positive for ischemia. Of the 41% (18/44) undergoing cardiac catheterization, 13/18 were diagnosed with significant CAD, 4/18 with non-ischemic cardiomyopathy, and one study was normal. A total of 24/44 (55%) had either a new or old diagnosis of documented CAD or NICM, compared to 94% of the non-cocaine ACS patients.

Conclusions

Cocaine-related chest pain leading to hospitalization is often associated with infarction or significant coronary artery disease. Although optimal evidence-based management is lacking in this population, ischemia evaluations and appropriate further risk stratification and modification may be warranted.

MP16: SCREENING FOR INFECTIVE ENDOCARDITIS AMONG PATIENTS IN AN INNER CITY HOSPITAL

Purpose of Study

Over the years, epidemiology of infective endocarditis (IE) has been changing with the change in population at risk. The aging of our population, better antibiotics for treatment of infections and changes in predisposing conditions have contributed to the changing prevalence patterns of this disease in different patient groups. At present little data is available on the prevalence of IE in selected patient groups such as the medically indigent. We studied the prevalence of IE in patients evaluated in an inner city hospital.

Methods Used

We screened the clinical, laboratory and echocardiographic data of 246 consecutive patients referred for echocardiographic evaluation, with suspected IE during the period 04/1996 to 05/ 2001. Using the New Duke criteria for diagnosing endocarditis, these patients were classified as having 1. Definite IE 2. Possible IE and 3. Diagnosis of IE rejected.

Summary of Results

Of the 246 patients screened, 72 (29%) fulfilled criteria for diagnosis of IE. Twenty of these patients (8%) were classified as “definite” IE and 52 (21%) as “possible” IE. Diagnosis of IE was “rejected” in 174 (71%) of the screened patients.

Conclusions

Screening for IE in this medically indigent patient population of an inner city hospital, confirmed definite endocarditis in only 8% of the patients referred with suspected endocarditis. This represents a very small proportion of the patients screened and is much lower than reported in other studies, in a different patient population. This could be due to a higher degree of suspicion for IE in this patient group. Further inquiry is needed to confirm the underlying mechanism responsible for this observation.

Metabolite pattern ofCysticercus cellulosaemetacestode from different predilection sites of swine using proton magnetic resonance spectroscopy

Cysticercosis due to Taenia solium is one of the most common public health problems in various regions of the world. We have performed prolon magnetic resonance spectroscopy (1H MRS) experiments of the fluid aspirated from cysticerci excised from skeletal muscle (n = 16) and brain (n = 9) of infected swine to compare the metabolite pattern of cysticerci in different predilection sites. Perchloric acid extract of cysticercus cysts excised from skeletal muscles (n = 16) was also prepared to ascertain water-soluble, low molecular weight metabolites using 1H MRS. Absolute quantification and statistical analysis of different metabolites was done to look for any significant differences in different locations of cysts. The metabolite pattern of cysticerci was found to be similar in the various predilection sites. Metabolites observed were leucine, valine, alanine, lysine, glycine, lipid contents, lactate, glutamate, acetate, succinate, creatine, choline, and glucose. Concentration of creatine in cysticercus fluid of cysts removed from the muscle was found to be significantly higher (p = 0.001) than the cysts located in the brain. We conclude that the metabolite pattern in the cysticerci is not influenced by the surrounding tissue location; however concentration of certain metabolites may depend upon the tissue location.

Composite endpoints in trials of type-2 diabetes

Composite endpoints (CEPs) are being used more frequently as outcomes for trials of drugs in type-2 diabetes. We reviewed the literature to determine how CEPs have been used to date in trials of drugs for type-2 diabetes. A systematic search was undertaken on Medline, Embase and Cochrane databases and Clinicaltrials.gov for randomized controlled trials of currently marketed agents including SGLT-2 inhibitors (dapagliflozin), GLP-1 agonists (exenatide, liraglutide) and DPP-4 inhibitors (linagliptin, saxagliptin, sitagliptin and vildagliptin). CEPs used were identified as well as numbers and percentages of patients achieving each. Thirty-six studies were identified that reported results on ≥1 CEP; 15 different CEPs were reported (7 with 2 components, 8 with 3 components). All CEPs addressed goals recommended by the American Diabetes Association (ADA). All included HbA1c<7%; other endpoints measured weight, blood pressure and hypoglycaemic events. Results were obtained for CEPs from 6 months to 2 years. Rates of achieving CEPs decreased with increasing numbers of components and outcomes assessed. CEPs are becoming used as indicators of clinical outcomes in type-2 diabetes trials, but are still not common. More research is required to identify optimal CEPs. Standardization of outcomes and their reporting is needed.

Histopathologic changes following neoadjuvant chemotherapy in locally advanced breast cancer

AIMS

To compare the clinical and pathologic assessment of response to neoadjuvant chemotherapy and describe the various histopathologic changes observed.

MATERIALS AND METHODS

We studied a group of 40 patients with locally advanced breast cancer who had their initial workup in the form of clinico-imaging assessment of the size and pretreatment biopsy from the lesion. All the patients received two to six cycles of neoadjuvant chemotherapy, either cyclophosphamide 50 to 60 mg/m 2 IV, doxorubicin 40 to 50 mg/m 2 IV and 5-fluorouracil 500 to 800 mg/m 2 IV (CAF) or cyclophosphamide, epirubicin, and 5-fluorouracil (CEF). Clinical and pathologic assessment of response to chemotherapy was done based on the UICC guidelines.

RESULT

Complete clinical response (cCR) was seen in 10% cases (4/40), thirty percent patients had (12/40) partial response and 60% (24/40) had stable disease after neoadjuvant chemotherapy. Pathologic complete response (pCR) with no evidence of viable tumor was observed in 20% patients (8/40). Fifteen patients (37.5%) showed partial response and 42.5% patients (17/40) had a stable disease. No patient progressed during the course of chemotherapy. Changes in the tumor type were observed following chemotherapy, most common being the mucinous change. Histologic changes like dyscohesion, shrinkage of tumor cells, elastosis, collagenization, necrosis, lymphocytic reaction, giant cell response are some of the common observations seen following treatment with neoadjuvant chemotherapy.

CONCLUSION

Pathologic assessment of response to neoadjuvant chemotherapy is a better predictor than the clinical response. The chemotherapy drugs can be modified based on the response observed after 1-2 cycles of neoadjuvant, the response being based on both tumor and patient's responsiveness.

Comparative physicochemical evaluation of a marketed herbomineral formulation: naga bhasma

In the practice of Ayurveda, where herbomineral formulations are said to be made biocompatible through specific processes like Shodhana and Marana, the western medical science on the contrary has raised the safety concerns of these formulations in the recent past. In the present study, comparative physico-chemical analysis of Naga bhasma, a herbo-mineral preparation having a reputation of miraculous drug commonly used to treat several health disorders, was carried out using five marketed formulations through analytical methods like differential scanning calorimetry, X-ray difraction, thermogravimetric analysis, Fourier Transform infrared spectroscopy and also subjected for particle size analysis and estimation of trace and heavy metals to access the safety of these formulation. The results revealed variable observations regarding particle size, metal form and content of lead. The presence of free lead in five different formulations indicated towards the possible risk of severe side effects to the consumer. Present findings certainly put doubt over the safety of this formulation but at the same time, variation in the results with all five formulations also indicated that these formulations were not prepared as per the mentioned Ayurvedic text. Hence, enforcement of strict regulatory guidelines is strongly warranted before launching into the market. Further, a series of biological studies need to be conducted before taking any final verdict on the safety of this formulation.

Selective estrogen receptor modulators for BPH: new factors on the ground

As the current management of BPH/lower urinary tract symptoms by traditionally involved pharmacological agents such as 5alpha-reductase inhibitors and α1-adrenoceptor antagonists is suboptimal, there is definite need of new therapeutic strategies. There is ample evidence in literature that suggests the role of estrogens in BPH development and management through the different tissue and cell-specific receptors. This article reviews the beneficial actions of selective estrogen receptor modulator (SERM) and ERβ-selective ligands, which have been demonstrated through in vitro studies using human prostate cell lines and in vivo animal studies. SERMs have anti-proliferative, anti-inflammatory and pro-apoptotic mechanisms in BPH, and also act by inhibiting various growth factors, and thus represent a unique and novel approach in BPH management directed at estrogen receptors or estrogen metabolism.

Long-term continence disturbance after lateral internal sphincterotomy for chronic anal fissure: a systematic review and meta-analysis

AIM

A systematic review was carried out to analyse continence at 2 years or more after lateral internal sphincterotomy (LIS) for chronic anal fissure (CAF).

METHOD

PubMed, MEDLINE, Scopus, Embase, Ovid, SCI, Cochrane Central Register of Controlled Trials (CENTRAL) and Google Scholar were used to search the literature from 1969-2012 for studies reporting a follow-up of more than 2 years after LIS for CAF. The primary outcome parameter analysed was continence. The secondary outcome parameters included success rate, recurrence, incidence of postoperative abscess and fistula formation and patient satisfaction.

RESULTS

Of 324 studies screened, 22 (n = 4512) were included. The mean follow-up period ranged from 24-124 months. The overall continence disturbance rate was 14% (95% CI 0.09-0.2). Weighted analysis showed flatus incontinence in 9% (95% CI 0.04-0.16), soilage/seepage in 6% (95% CI 0.03-0.1), accidental defaecation in 0.91% (95% CI 0.003-0.02), incontinence to liquid stool in 0.67% (95% CI 0.001-0.02) and incontinence to solid stool in 0.83% (95% CI 0.003-0.02) of patients.

CONCLUSION

The long-term risk of continence disturbance after lateral internal sphincterotomy is significant. Randomized controlled trials with a long follow-up are needed to substantiate these findings and to redefine its role in the treatment of chronic anal fissure.

Postoperative adhesive intestinal obstruction from gossypiboma

Retained foreign bodies after surgery is a rare condition which can have medico-legal consequences. Foreign bodies forgotten in the abdomen include towels, artery forceps, pieces of broken instruments or irrigation sets, and rubber tubes. The most common surgically retained foreign body is the laparotomy sponge. Such materials cause foreign body reaction in the surrounding tissue. The complications caused by these foreign bodies are well known, but cases are rarely published because of medico-legal implications. We report a case of 41-year-old female admitted with features of intestinal obstruction and had a previous history of hysterectomy performed 2 months back at another hospital. Pathologists must be aware of this entity and its proper reporting as the cases are liable to go to court. Surgeons must recognize the risk factors that lead to a gossypiboma and take measures to prevent it.