Clinical outcome and predictors of severity in scrub typhus patients at a tertiary care hospital in Chandigarh, India

BACKGROUND & OBJECTIVES

Scrub typhus is an under-reported rickettsial illness caused by Orientia tsutsugamushi which is transmitted by trombiculid mites. Serious complications are not uncommon and multiorgan dysfunction may develop leading to death. Paucity of data on the clinical spectrum and determinants of aftermath may be contributing to higher mortality in the region. A prospective study was done to describe the spectrum of organ dysfunction in serologically confirmed cases of scrub typhus and document predictors of adverse outcomes.

METHODS

This prospective study was carried out in patients diagnosed to have scrub typhus by IgM ELISA. The clinical features, investigations and complications among survivors were statistically compared to those in the deceased. Fisher's exact test, t-test and logistic regression have been applied where appropriate.

RESULTS

The study population comprised of 123 patients. Majority of patients (62%) had one or more organ dysfunction. Ten patients (8.1%) did not survive. Complications documented were acute kidney injury (AKI) in 35%, hepatitis in 29.2%, acute respiratory distress syndrome (ARDS) in 26%, shock in 13%, meningitis in 5.7%, disseminated intravascular coagulation (DIC) in 2.6%, pancreatitis in 2.6% and myocarditis in 1.6%. Certain clinical features, biochemical parameters and complications had statistically significant correlation with the outcome. The mean SOFA score was considerably higher in those who did not survive. Interpretation &conclusion: Patients developing hepatic dysfunction, acute kidney injury and respiratory distress should be identified early and intensively monitored. The SOFA score can be utilized to assess the severity at admission and rapidly triage the sicker patients.

Abstract P2-03-04: A novel druggable target upstream of Notch: MEK5/ERK5 signaling regulates Jagged-1 and Notch1 expression in triple negative breast cancer stem cells

Triple negative breast cancer (TNBC) is a molecularly heterogeneous, clinically aggressive disease group that is highly prevalent among African-Americans and younger patients. Standard chemo/radio therapy often produces clinical responses, but recurrence and metastasis are unfortunately common. Metastatic disease is generally incurable. Chemo/radiotherapy has been shown to induce EMT and enrich a chemo-resistant cancer stem-like cell (CSC) population in TNBC. CSCs are thought to drive disease recurrence. Notch signaling is critical for maintenance of TNBC CSC. Expression of Notch1 and its ligand Jagged1 are correlated with poor prognosis. Efforts to pharmacologically target Notch with Gamma Secretase Inhibitors (GSIs) have been impaired by the systemic toxicity of the GSIs, and by the fact that Notch1 also plays a key role in anti-tumor adaptive immunity. Therapeutic agents that indirectly and selectively target Notch signaling in breast cancer cells would be a potentially attractive strategy. However, no such agents have been identified to date. We have found that the MAPK5-ERK5 kinase pathway, which contains at least two druggable targets, functions as a master regulator of Notch signaling in TNBC cells. ERK5 knockout TNBC cells have dramatically decreased expression of Notch receptors, ligands and transcriptional targets. In vivo, these cells form barely detectable tumors that do not metastasize and express lower levels of Notch1 and its ligand Jagged1. Using in silico screening, we identified a class of compounds that selectively target MAP2K5 (MEK5) and decrease the phosphorylation of MAPK7 (ERK5). We selected compound SC-181 for further study. Consistent with ERK5KO cells, pharmacological suppression of ERK5 phosphorylation with SC-181 decreased Notch1 and Jagged1 mRNAs and proteins. SC-181 reversed EMT and reduced the CD44hi/CD24lo CSC population in TNBC cells, but had no effect on T-cell proliferation. SC-181 decreased the number and size of mammospheres in a concentration-dependent manner. Overexpression of the Notch1 intracellular domain (N1IC) in ERK5KO cells rescues their phenotype, dramatically increasing the CSC fraction and promoting EMT. Our results suggest that targeting the MEK5-ERK5 pathway is a promising new strategy to selectively modulate Notch signaling in TNBC CSC without compromising tumor immunity.

Citation Format: Ucar DA, Matossian MD, Hoang-Barnes VT, Hossain FM, Gupta M, Burks HE, Wright TD, Cavanaugh J, Flaherty P, Burow ME, Miele L. A novel druggable target upstream of Notch: MEK5/ERK5 signaling regulates Jagged-1 and Notch1 expression in triple negative breast cancer stem cells [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-03-04.

Abstract P5-08-07: Study of diphenylamine analogs as inducers of mesenchymal to epithelial transition in breast cancer

The organization of cell cytoskeleton is altered in events of epithelial to mesenchymal transition (EMT), promotion of cell motility, and cancer metastases. EMT is associated with decreased cell-cell adhesion, downregulation of epithelial markers like E-Cadherin, cytokeratins, and occludins, and upregulation of mesenchymal markers such as N-cadherin, vimentin, and various transcription factors such as slug and ZEB. Epithelial to mesenchymal transition is also a consequence of drug resistance and is responsible for cancer metastases. Triple negative breast cancer is highly aggressive cancer and patients show poor prognosis and disease-free survival due to the lack of targeted therapy. Mitogen activated protein kinase pathway, including extracellular activated kinase ERK1/2 and ERK5, and phosphoinositide 3-kinase (PI3K) pathway are known to alter the cytoskeleton through the downstream activation of oncogenes such as FRA-1 and loss of focal adhesions. Of these pathways, the MEK5-ERK5 pathway is understudied in triple negative breast cancer TNBC, and there are few research tools available to selectively inhibit this pathway. The diphenylamine analogs were derived from the parent molecule Mekinist, a FDA approved MEK1/2 inhibitor for melanoma, and modified to gain selectivity towards MEK5. SC-1-151, a type-III allosteric inhibitor of MEK5 is a dual MEK1/2 (98.6%) and MEK5 (59%) inhibitor; the molecule inhibits cell viability and colony formation, and attenuates tumor growth.

SC-1-151 was serendipitously identified as a mesenchymal to epithelial transition activator in TNBC cell line MDA-MB-231. E-cadherin protein expression and cell morphology were examined to study MET after the treatment of MDA-MB-231 cells with different structural analogs of SC-1-151 after treatment for 5 days. The compound was further found to induce E-cadherin expression and epithelial phenotype in tamoxifen resistant estrogen positive MCF-7 cell line that underwent EMT. The compound is identified to promote this activity by targeting at least the ERK-FRA1-ZEB1 axis. Alkyl or N-Methyl piperazine substituents on the amide of ring 1 produced similar result as SC-1-151, and substituting the amide group with acid or ester also induced MET. In contrast, ortho-fluoro, para-iodo functional groups of the arene ring 2, when replaced with a meta-bromo substituent did not induce MET. We aim to test the compounds on EGF treated MDA-MB-468 cells to observe the attenuation of EGF induced EMT. Future studies will be performed to determine the specific protein interactions of the promising compounds.

Citation Format: Bhatt AB, Wright TD, Anna K, Gupta M, Chakrabarty S, Flaherty PT, Hoang V, Burow M, Cavanaugh JE. Study of diphenylamine analogs as inducers of mesenchymal to epithelial transition in breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-08-07.

Haemostatic functions and metabolic profile of subclinical hypothyroid and hypothyroid patients

Objectives: Both hypercoagulable and hypocoagulable states have been proposed for hypothyroidism, whether in overt or subclinical spectrum. The status of haemostatic functions, metabolic profile and their relationship in hypothyroid disorders need to be evaluated.Methods and Material: This prospective case control study was undertaken in 30- 50 years old female subclinical and hypothyroid patients. Haemostatic functions like bleeding time (BT), clotting time (CT), prothrombin time (PT), activated partial thromboplastin time (APTT), platelet count and metabolic parameters like plasma glucose and lipid levels and clinical variables like blood pressure and body mass index were noted and compared. In addition the strength of correlation of TSH, T4, T3, lipid profile with the haemostatic functions was evaluated.Results: Both groups of patients were obese, normotensive with normal haemostatic parameters. The platelet count correlated with TSH in subclinical hypothyroid patients and with T4 levels in hypothyroid patients. Although within normal range, total cholesterol and LDL cholesterol levels were higher and postprandial plasma glucose (PPPG) levels lower in hypothyroid patients compared to subclinical hypothyroid patients. A positive correlation was seen between TSH and LDL, PPPG levels, between fT3 and BMI, and also of antiTPO with total cholesterol, LDL, Fasting plasma glucose (FPG) in hypothyroid patients. The BMI was negatively associated with fT3 levels in subclinical hypothyroid patients.Conclusion: This study found normal haemostatic and metabolic functions in both subclinical and hypothyroid patients. Although within normal range, hypothyroid patients had higher total and LDL cholesterol. TSH and antiTPO levels correlated with LDL levels in these patients. Correlation of platelet count with TSH in subclinical hypothyroid and T4 levels in hypothyroid patients advocate a difference in mechanism involved. Therefore it can be connoted that thyroid status influences metabolic profile, and platelet count.Bangladesh Journal of Medical Science Vol.17(4) 2018 p.532-536

Interface induced magnetic properties of Gd/Co heterostructures

Antiferromagnetic coupling between rare-earth and transition metal ferromagnetic layers gives rise to various magnetic ground states in heterostructures of these materials. Interface structure and morphology tend to play important roles in magnetic properties of such systems. Interface induced magnetization in Gd/Co heterostructures has been studied using a combination of structural and magnetic characterization techniques. The interface morphology of the Gd/Co system was varied by growing Gd/Co multilayers using magnetron sputtering under different argon partial pressures. Interfacial properties were further modified by annealing the multilayers under high vacuum. The macroscopic magnetization measurements have been correlated with depth dependent structure and magnetic properties of multilayers studied using X-ray and polarized neutron reflectometry techniques. Secondary ion mass spectrometry measurements from both as-deposited and annealed samples also confirmed modification at the interfaces. It has been shown that the interface structure, together with roughness, leads to a unique low-temperature magnetic phase characterized by twisting of Gd and Co moments.

Early Results of Extreme Hypofractionation Using Stereotactic Body Radiation Therapy for High-risk, Very High-risk and Node-positive Prostate Cancer

AIMS

Stereotactic body radiotherapy (SBRT) in low- and intermediate-risk prostate cancer has shown encouraging results. However, its use in high-risk patients is limited due to lack of data regarding adequate radiotherapy dose, need for pelvic nodal treatment and androgen deprivation therapy. Herein we report our experience of SBRT in this subgroup.

MATERIALS AND METHODS

Analysis of a prospectively maintained database of 68 consecutive patients of the National Comprehensive Cancer Network (NCCN) high-risk, very high-risk and node-positive adenocarcinoma prostate treated with SBRT was undertaken. All patients were treated with rotational intensity-modulated radiotherapy with daily image guidance. The dose delivered to the prostate and gross node was 35-37.5 Gy in 5 alternate day fractions. Node-positive patients received 25 Gy to pelvic nodal regions until the common iliac nodes. Treatment was delivered in 7-10 days. All patients received long-term androgen deprivation therapy (79% medical and 21% surgical).

RESULTS

Most patients (65%) had a Gleason score ≥ 8. The median prostate-specific antigen was 42. Twenty patients were high risk (30%), 11 (16%) very high risk and 37 (54%) node positive. No acute Radiation Therapy Oncology Group grade ≥ 3 genitourinary or gastrointestinal toxicity was noted. Acute grade 2 genitourinary and gastrointestinal toxicity were 12% and 3%, respectively. Late grade 3 genitourinary and gastrointestinal toxicity was 3% and 0%, respectively. There was no increase in acute or late gastrointestinal toxicity with prophylactic pelvic nodal radiotherapy. Prior transurethral resection of prostate (n = 11) did not increase toxicity. At a median follow-up of 18 months, 97% patients were alive and 94% were biochemically controlled.

CONCLUSION

SBRT is safe in the treatment of high-risk, very high-risk and node-positive prostate cancer, even with prophylactic pelvic radiotherapy or prior transurethral resection of prostate. Longer follow-up is required to determine efficacy.

Risk of Vascular access Thrombosis in Patients with Systemic Lupus Erythematosus on Hemodialysis

Introduction

Anticardiolipin antibody is associated with increased risk of vascular access thrombosis (VAT) in hemodialysis (HD) patients. Systemic lupus erythematous (SLE) patients have a high prevalence of anticardiolipin antibodies, but it is not clear whether these patients are at high risk of developing vascular access thrombosis.

Methods

Thirty six SLE patients on HD, who had either an arterio-venous (AV) graft or AV fistula as vascular access, and were not on anticoagulation treatment, were retrospectively identified at Henry Ford Hospital. A similar number of patients without SLE, matched for age, sex, race and type of vascular access were selected as a control population. Vascular access thrombosis rate at one year was compared between two groups.

Results

Mean age at dialysis was 36±10 years in 36 SLE patients (28 females, 8 males) and was 38±6.4 years in 36 non-SLE patients (29 females, 7 males). Of all patients, 29/36 (80.5%) SLE and 27/36 (75%) non-SLE patients had AV grafts, whereas the rest had AV fistulas as vascular access (19.5% SLE and 25% non-SLE patients). Out of 36 SLE patients, 24 (66.6%) patients developed VAT at one year as compared to 14 (38.9%) patients in non-SLE group (p<0.05). The odds ratio of VAT in SLE patients was 3.1 (95% CI 1.2–8.2).

Conclusion

SLE patients on hemodialysis are more likely to develop vascular access thrombosis as compared to non-SLE patients.