Management of epididymo-orchitis in three different clinical settings: Streamlining pathways and improving care

Objective:

This study represents the first direct comparison of management of epididymo-orchitis (EO) by Accident and Emergency (A&E), Urology and Genito-Urinary Medicine (GUM) departments in a large tertiary care centre, and their compliance with international guidelines.

Methods:

Case notes of patients with EO who attended A&E, Urology and GUM between January and June 2014 were analysed retrospectively.

Results:

A total of 127 men were seen (median age: 33, range: 15–79). Forty-four attended A&E (median age: 35), 30 Urology (median age: 37), and 53 GUM (median age: 31). MSU was sent in 17/44 (38.6%) of A&E, 11/30(36.7%) of Urology, and 35/53(66%) of GUM patients. Fifty-three of 53 (100%) of GUM, 14/44 (31.8%) of A&E and four of 30 (13.3%) of Urology patients had chlamydia and gonorrhoea NAAT testing. Of these, 90.9% of A&E, 93.3% of Urology and 100% of GUM patients were prescribed antibiotics. Twelve A&E and one Urology patient were referred to GUM. Conversely, only three of 11 A&E and zero of five GUM patients aged over 50 were referred for urological follow-up.

Conclusion:

The management of EO, especially in younger men at risk of STIs by A&E and Urology, and older men at risk of urological problems by GUM, is an area for significant improvement. Closer co-operation between departments, unifying local management protocols, abandoning the traditional demographic divide, and ensuring effective referral pathways are essential to improving care.

Recurrent life-threatening reactions to platelet transfusion in an aplastic anaemia patient with a paroxysmal nocturnal haemoglobinuria clone

A 60-year-old woman was diagnosed with non-severe aplastic anaemia when she presented with anaemia and thrombocytopenia. She developed recurrent life-threatening hypotensive reactions during transfusion of leukodepleted platelet concentrates, and washed platelet concentrates prevented the development of such reactions subsequently. A paroxysmal nocturnal haemoglobinuria clone was detected on investigating for aplastic anaemia, which has been speculated to play a role in the recurrent hypotensive reactions.

Malignant spinal cord compression: NICE guidance, improvements and challenges

BACKGROUND AND AIM

Malignant spinal cord compression (mSCC) is one of the most serious complications of cancer. Recent NICE guidance has aimed to improve patient pathways and outcomes for patients with mSCC. We have examined the current presentations, management and outcomes for patients with mSCC in West London following the implementation of the NICE guidance.

MATERIALS AND METHODS

The electronic records and clinical notes were reviewed for all patients assessed for confirmed or potential mSCC at Charing Cross Hospital in 2012. Details on the number of referrals, the proportion with confirmed mSCC, the cancer diagnosis, treatment and outcome were analysed.

RESULTS

191 patients were reviewed with 127 (66%) cases of confirmed mSCC. The commonest tumour types were prostate cancer (26 cases), lung cancer (26), breast cancer (21) and kidney cancer (15). 21% of the patients had no previous cancer diagnosis; mSCC was their presenting diagnostic event. Radiotherapy was the predominant management, 24% of the patients had first line surgical treatment. At presentation 62% of patients were either chair or bed bound. Treatment brought important mobility benefits to all patients groups with 20% of the initially chair or bed bound patients leaving the hospital with independent mobility.

CONCLUSION

Enhanced patients pathways with ease of access, rapid assessment and prompt treatment can improve outcomes. Despite these pathways many patients still present with gross motor impairment and over 20% have no previous diagnosis of cancer. Ongoing work to maintain awareness for patients and primary care of the diagnosis and emergency pathways is essential to optimize outcomes.

Interim estimates of 2013/14 influenza clinical severity and vaccine effectiveness in the prevention of laboratory-confirmed influenza-related hospitalisation, Canada, February 2014

Binary file ES_Abstracts_Final_ECDC.txt matches

Achilles tendinopathy following Kaletra (lopinavir/ritonavir) use

A multitude of rheumatologic manifestations have been associated with HIV infection and protease inhibitors use. We describe two cases that display a temporal relationship between initiating Kaletra and developing Achilles tendinopathy. Immediate and dramatic resolution of symptoms occurred on switching from Kaletra to an alternative agent. Clinicians may want to consider a trial of an alternative agent in individuals on Kaletra who experience Achilles tendinopathy. Adverse events must be formally reported so that our understanding of antiretrovirals may continually evolve and aid decisions about antiretroviral prescribing.

Discrimination of epimeric glycans and glycopeptides using IM-MS and its potential for carbohydrate sequencing

Mass spectrometry is the primary analytical technique used to characterize the complex oligosaccharides that decorate cell surfaces. Monosaccharide building blocks are often simple epimers, which when combined produce diastereomeric glycoconjugates indistinguishable by mass spectrometry. Structure elucidation frequently relies on assumptions that biosynthetic pathways are highly conserved. Here, we show that biosynthetic enzymes can display unexpected promiscuity, with human glycosyltransferase pp-α-GanT2 able to utilize both uridine diphosphate N-acetylglucosamine and uridine diphosphate N-acetylgalactosamine, leading to the synthesis of epimeric glycopeptides in vitro. Ion-mobility mass spectrometry (IM-MS) was used to separate these structures and, significantly, enabled characterization of the attached glycan based on the drift times of the monosaccharide product ions generated following collision-induced dissociation. Finally, ion-mobility mass spectrometry following fragmentation was used to determine the nature of both the reducing and non-reducing glycans of a series of epimeric disaccharides and the branched pentasaccharide Man3 glycan, demonstrating that this technique may prove useful for the sequencing of complex oligosaccharides.

Opt-out testing for HIV: perspectives from a high prevalence community in south-east England, UK

Peoples' perspectives and attitudes towards being offered opt-out HIV testing were explored in a geographical area of high HIV prevalence. Users (n = 31) of sexually transmitted infection (STI) testing services took part in community focus groups in the south-east of England, UK. There was broad support for opt-out HIV testing based on public health and individual health benefits. For this sample, opt-out HIV testing when registering with a general practice surgery and on elective or emergency admission to a general hospital was acceptable, although there were concerns about the rigour of informed consent. Heterosexual participants' criticism of people from higher prevalence groups for HIV declining tests, while maintaining their own right to opt-out, suggested that attitudes towards testing may be influenced by levels of perceived risk. Innovations in HIV testing policies to increase testing rates will benefit from an acknowledgement of the different meanings that testing has.

Abstract B114: Variation in glucose availability induces reactive oxygen species and increased P-gp mediated multi-drug resistance to chemotherapeutics

Background: Generally, many types of cancer develop resistance to the stress induced by chemotherapy. Moreover, within the tumor, there exists a considerable spatial and temporal gradient of glucose, rendering a significant portion of cancer cells exposed to a stressful micro-environment (Mol Syst Biol, 2012; 8; 589). Notably, hypoxia inducible factor-1 (HIF-1) is a major redox-sensitive transcription factor responsible for regulation of P-glycoprotein (P-gp), the most consistently over-expressed detoxification drug efflux transporter involved in the development of multi-drug resistant (MDR) cancers (Cancer Res 2002; 62; 3387-94). Considering that glucose deficiency is a common stress factor in tumors, this study investigated whether variations to glucose availability could increase drug resistance to the cytotoxic agent and P-gp substrate, doxorubicin (DOX).

Methods: Reactive oxygen species (ROS) were measured under incubation conditions with different concentrations of glucose by flow cytometry using the cellular and mitochondrial stress markers DCFH-DA and MitoSOX, respectively. Stress induced NF-κβ activation was determined by western blotting and immunofluorescent detection of p65. Regulation of HIF-1 and its downstream target genes were assessed by RT-PCR and western blotting. Cellular proliferation was determined via MTT assays.

Results: We demonstrated that changes in glucose availability critically enhanced cellular ROS signaling, thereby conferring P-gp-mediated drug resistance against clinically available chemotherapeutics. Both elevated (50 mM) and restricted (0 and 12.5mM) glucose availability significantly (p<0.001) induced mitochondrial superoxide production which both stabilized HIF-1 activity and also activated the cytosolic transcription factor, NF-κB, by de-phosphorylation of the functional p65 subunit. Following this, the p65 subunit was observed to translocate into the nucleus, resulting in enhanced HIF-1 transcription. The ROS-mediated increase in HIF-1 activity significantly (p<0.05) increased P-gp protein surface expression and function. Notably, the up-regulation of P-gp subsequently led to greater drug resistance to DOX in glucose restricted cells (IC50: 28.3±1.3 µM) compared with cells at basal glucose concentrations (25 mM; IC50: 3.6±0.6 µM). This resistant phenotype was reversible by addition of the specific P-gp inhibitor, Elacridar.

Conclusion: This study demonstrated that as tumor cells become increasingly glucose deprived or alternatively exposed to higher amounts of glucose, this increases stress and consequently leads to a more aggressive MDR phenotype via up-regulation of P-gp. These results reveal important insights into how changes in glucose availability elevate multi-drug resistance in tumors, which is critical for determining chemotherapeutic strategies.

Citation Information: Mol Cancer Ther 2013;12(11 Suppl):B114.

Citation Format: Nicole Seebacher, Des Richardson, Patric Jansson. Variation in glucose availability induces reactive oxygen species and increased P-gp mediated multi-drug resistance to chemotherapeutics. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2013 Oct 19-23; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2013;12(11 Suppl):Abstract nr B114.

Penile intraepithelial neoplasia: important lessons from a case series

Summary

Seven men presenting to our genitourinary (GU) medicine clinic over a period of 22 months had a histopathological diagnosis of penile intraepithelial neoplasia (PIN). Median duration of symptoms was eight months (range 2–216 months). Macroscopic appearances were different in all cases. All histology was reviewed locally and at a tertiary centre. Six of seven had severe dysplasia (PIN III). Interestingly, only one individual was HIV-positive and one, who was immunocompetent, had multifocal disease. These cases highlight the importance of a full anogenital examination and early biopsy in patients presenting with atypical or persistent penile lesions.

Cytosolic phospholipase A2α sustains pAKT, pERK and AR levels in PTEN-null/mutated prostate cancer cells

Constitutive phosphorylation of protein kinase B (AKT) is a common feature of cancer caused by genetic alteration in the phosphatase and tensin homolog (PTEN) gene and is associated with poor prognosis. This study determined the role of cytosolic phospholipase A2α (cPLA2α) in AKT, extracellular signal-regulated kinase (ERK) and androgen receptor (AR) signaling in PTEN-null/mutated prostate cancer cells. Doxycycline (Dox)-induced expression of cPLA2α led to an increase in pAKT, pGSK3β and cyclin D1 levels in LNCaP cells that possess a PTEN frame-shift mutation. In contrast, silencing cPLA2α expression with siRNA decreased pAKT, pGSK3β and cyclin D1 levels in both PC-3 (PTEN deletion) and LNCaP cells. Silencing of cPLA2α decreased pERK and AR protein levels. The inhibitory effect of cPLA2α siRNA on pAKT and AR protein levels was reduced by the addition of arachidonic acid (AA), whereas the stimulatory effect of AA on pAKT, pERK and AR levels was decreased by an inhibitor of 5-hydroxyeicosatetraenoic acid production. Pharmacological blockade of cPLA2α with Efipladib reduced pAKT and AR levels with a concomitant inhibition of PC-3 and LNCaP cell proliferation. These results demonstrate an important role for cPLA2α in sustaining AKT, ERK and AR signaling in PTEN-null/mutated prostate cancer cells and provide a potential molecular target for treating prostate cancer.