Clostridium difficile infection after restorative proctocolectomy and ileal pouch anal anastomosis for ulcerative colitis

AIM

Clostridium difficile infection (CDI) of the ileal pouch following restorative proctocolectomy (RPC) is becoming increasingly recognized. We aimed to understand better (i) the associated risk factors, (ii) treatment practices and (iii) the pouch diversion and failure rate in patients who developed CDI of the pouch after RPC for ulcerative colitis (UC).

METHOD

Patients who tested positive for C. difficile of the pouch between 2007 and 2010 were included in the analysis. Data collected included patient demographics, time from RPC to documented CDI, the treatment of CDI and rate of excision of the pouch.

RESULTS

Of 2785 patients recorded in the hospital CDI database, 15 had had an RPC with ileal pouch anal anastomosis. The median age was 44 years and the median interval from RPC to first documented episode of CDI was 3 years. Thirteen (81%) patients had had multiple episodes of pouchitis before and after CDI infection, and all were symptomatic at the time of testing for CDI. Within 30 days of the diagnosis of CDI, six (40%) patients were taking immunosuppressive medication, seven (47%) were taking a proton pump inhibitor and 12 (80%) had received antibiotics. Five patients required hospitalization for CDI and four had severe infections characterized by a serum creatinine more than 1.5 times baseline (n = 3) and a white cell count above 15 000 (n = 1). Six patients who underwent endoscopy had severe inflammation of the pouch including the presence of a pseudomembrane in one case. Ten patients were treated with metronidazole alone and five with vancomycin. Two patients had recurrent CDI of the pouch during a median follow-up period of 2.9 years and one had CDI refractory to medical management. This patient required diversion of the pouch with an ileostomy for refractory CDI but no patient required excision of the pouch.

CONCLUSION

All 15 patients developing CDI of the pouch were successfully treated with antibiotics and only one required surgery in the form of an ileostomy.

Carcinoma in accessory axillary breast

We present a rare case of carcinoma developing in an accessory breast. The patient presented with a progressive lump in her right axilla for 1 year. On examination, there was a well-developed nipple areola complex in the right axilla overlying a hard, fixed 5 × 3 cm lump. On investigation, core biopsy revealed poorly differentiated carcinoma of the breast. Mammography also revealed features of a malignant lesion with skin and muscle infiltration. Neoadjuvant chemotherapy was administered followed by modified radical mastectomy after three cycles. Immunohistochemistry study showed positive status of oestrogen and progesterone receptors, and negative HER-2 neu. Three more cycles of chemotherapy along with 50 Gy radiotherapy were given in an adjuvant setting followed by hormone therapy.

Systematic review: colitis associated with anti-CTLA-4 therapy

BACKGROUND

Cytotoxic T-lymphocyte-associated protein-4 (CTLA-4) has an important role in T-cell regulation, proliferation and tolerance. Anti-CTLA-4 agents, such as ipilimumab and tremelimumab, have been shown to prolong overall survival in patients with metastatic melanoma, and their use is being investigated in the treatment of other malignancies. Their novel immunostimulatory mechanism, however, predisposes patients to immune-related adverse effects, of which gastrointestinal effects such as diarrhoea and colitis are the most common.

AIMS

To discuss the existing literature and summarise the epidemiology, pathogenesis and clinical features of anti-CTLA-4-associated colitis, and to present a management algorithm for it.

METHODS

We searched PubMed for studies published through October 2014 using the terms 'anti-CTLA,' 'ipilimumab,' 'tremelimumab,' 'colitis,' 'gastrointestinal,' 'immune-related adverse effect,' 'immunotherapy,' 'melanoma,' and 'diarrhoea.'

RESULTS

Watery diarrhoea is commonly associated with anti-CTLA-4 therapy (27-54%), and symptoms occur within a few days to weeks of therapy. Diffuse acute and chronic colitis are the most common findings on endoscopy (8-22%). Concomitant infectious causes of diarrhoea must be evaluated. Most cases may be successfully managed with discontinuation of anti-CTLA-4 and conservative therapy. Those with persistent grade 2 and grade 3/4 diarrhoea should undergo endoscopic evaluation and require corticosteroid therapy. Corticosteroid-resistant cases may respond to anti-tumour necrosis factor-alpha therapy such as infliximab. Surgery is reserved for patients with bowel perforation or failure of medical therapy.

CONCLUSION

Given the increasing use of anti-CTLA-4 therapy, clinicians must be aware of related adverse events and their management.

Association between biomarkers of oxidative stress, trace elements, and cell proliferation index in patients with benign and malignant breast diseases

OBJECTIVES

To understand the association between biomarkers of oxidative stress, antioxidants, trace elements, and cell proliferation index in relation to the disease progression in the pathophysiology of breast diseases.

DESIGN AND METHODS

Concentrations of markers of oxidative stress, antioxidants, trace elements, and cell proliferation index were evaluated in the patients with benign breast diseases, malignant breast diseases, and healthy volunteers as controls. Multinomial logistic regression analysis was used to identify the contribution of the selected indexes using odds ratio and associated confidence interval.

RESULTS

The level of markers of oxidative stress (malondialdehyde [MDA]) and cell proliferation index were found to be significantly higher with significantly depleted levels of antioxidants and trace elements in breast cancer patients compared with control subjects as well as benign breast disease patients. A similar pattern of changes were observed between benign and control subjects.

CONCLUSION

An inadequate amount of antioxidant enzymes and trace elements may be an important contributing factor associated with oxidative stress leading to elevated levels of MDA and cell proliferation index in relation to disease progression and clinical stage in the pathophysiology of breast diseases.

Acute small intestinal obstruction-an unusual complication of capsule endoscopy

We report a case of endoscopic capsule impaction causing acute small intestinal obstruction in a patient with Crohn's disease (CD), having obscure gastrointestinal bleeding. A 57-year old female presented with features of acute small bowel obstruction 2 days after capsule endoscopy elsewhere for the evaluation of intermittent bleeding per rectum and iron deficiency anemia. Patient underwent an exploratory laparotomy with right hemicolectomy for the diseased ileocecal region which mimicked malignancy. The capsule was found to be impacted in the strictured lumen of the terminal ileum. Post operative histopathological examination revealed it to be Crohn's disease.

Correlation of serum toll like receptor 9 and trace elements with lipid peroxidation in the patients of breast diseases

Toll-like receptors are recognized as redox sensitive receptor proteins and have been implicated in cellular response to oxidative stress. Altered pro-oxidant-antioxidant balance leads to an increased oxidative damage and consequently play an important role in breast diseases. The study was designed to access the oxidative stress status by quantification of byproducts generated during lipid peroxidation and inadequate trace elements during oxidative damage and its effects on the toll like receptor (TLR) activity in patients of breast diseases. Decreased levels of selenium, copper, zinc, magnesium and iron with elevated levels of malondialdehyde (marker of lipid peroxidation) were accompanied by decreased TLR activity in patients of benign breast diseases as well as breast carcinoma. A similar pattern was observed with the advancement of disease and its subsequent progression in breast carcinoma patients. Results of multinomial regression analysis suggest benign breast disease patients are at higher risk of developing breast cancer with high odds ratio of lipid damage.

NF-κB p65 subunit DNA-binding activity: association with depleted antioxidant levels in breast carcinoma patients

NF-κB is recognized as a redox-sensitive transcription factor and has been implicated in cellular response to oxidative stress. The study was designed to correlate the changes in antioxidant status with the levels of nuclear factor-κB (NF-κB) p65 subunit DNA-binding activity in relation to lymph node involvement, tumor size, and staging in breast carcinoma patients. Case control study comprised of 40 breast carcinoma patients along with 40 age- and sex-matched healthy subjects as controls. Levels of enzymatic/nonenzymatic antioxidants along with the trace elements were measured to study the antioxidant status in the study subjects. Levels of NF-κB p65 subunit DNA-binding activity was estimated by ELISA assay. The levels of enzymatic, nonenzymatic antioxidants, and trace elements were found to be significantly depleted in breast carcinoma patients in comparison to healthy controls suggesting significantly decreased levels of antioxidant activity in the breast carcinoma patients. Also, these results indicate that antioxidant levels decrease progressively with the advancement of stage and subsequent progression of disease. DNA-binding activity of NF-κB p65 subunit was higher in breast cancer patients in comparison to normal healthy controls, and the activity was found to increase with the advancement of disease. Significant correlation was observed between the DNA-binding activity of NF-κB p65 subunit and antioxidant status in the patients. The logistic regression analysis revealed decreased levels of antioxidants and increased level of DNA-binding activity of NF-κB p65 subunit were significantly associated with incidence of breast carcinoma. Depleted antioxidant status and increased level of DNA-binding activity of NF-κB p65 subunit thus point clearly of an association in relation to disease progression, clinical stage, and cytological grade in the pathophysiology of breast carcinoma.

Detection rate and outcome of colonic serrated epithelial changes in patients with ulcerative colitis or Crohn's colitis

BACKGROUND

Chronic ulcerative colitis (CUC) and colonic Crohn's disease (CD) increase colorectal neoplasia (CRN) risk. While sessile serrated polyp (SSP) is a known cancer precursor, serrated epithelial changes (SEC) are of uncertain prevalence and neoplastic risk.

AIM

To assess the serrated lesion detection rates in CUC and CD and documented incidence of subsequent CRN in a retrospective, single-centre cohort study.

METHODS

Patients were identified by a central diagnostic index and pathology review confirmed SEC, SSP, CUC and CD diagnoses from 2006-12. Matched controls were identified from among all CUC and CD patients having colonoscopy during the second half of the time period. All were followed for incident CRN, estimated by the Kaplan-Meier method.

RESULTS

Between 2006 and 2012, 79 SEC and 10 SSP cases were identified. Detection rates were estimated to be 10/1000 and 2/1000 patients, for SEC and SSP respectively, among 4208 unique CUC or CD patients having colonoscopy from 2010-12. With only 10 cases, SSP patients were not further analysed. Cumulative incidence of subsequent CRN at 1 and 3 years was 12% (95% CI, 0-30%) and 30% (3-57%), respectively, in SEC patients compared to 4% (0-12%) and 9% (0-23%), respectively, in CUC or CD controls (P = 0.047, log-rank). However, this statistical difference was not significant after patients were stratified for history of prior or synchronous dysplasia (P = 0.09).

CONCLUSIONS

Serrated epithelial changes and sessile serrated polyps are uncommonly detected by colonoscopy in chronic ulcerative colitis and Crohn's disease patients. Histology with changes of serrated epithelium may be associated with risk of subsequent colorectal neoplasia, however further studies are needed to explore this relationship.

Abstract P2-04-04: Breast cancer risk reduction in high risk women identified at the time of screening mammography. Integrating data from an established high risk clinic

Background: At the time of screening mammography, patient data can be collected and entered into a Modified Gail Model Risk Assessment Tool to identify patients at increased risk of invasive breast cancer. In turn, these patients can be referred to high risk centers where risk reduction strategies and chemoprophylaxis can be considered. The objective of this study is to establish how many women are at high risk of invasive breast cancer in a screening population who should be referred to a high risk center for counseling.

Methods: This is an observational prospective study evaluating 1,000 women at a single institution presenting for mammographic screening or diagnostic evaluation. At the time of mammography, these women routinely complete a standard intake questionnaire addressing breast cancer risk factors put forward by the institutional clinic. Modified Gail model risk scores were calculated from these data sheets. Women with a 5 year risk of invasive breast cancer of 1.7% or greater were identified as well as women at particularly high risk (≥3.4% or double the 5-year risk). At the time of analysis patients with a history of breast cancer or who underwent diagnostic mammography were excluded. Retrospective data from our institutional high risk clinic from January 2007 to December 2009 was analyzed in respect to patient age at referral, Gail Model Score, personal history of breast cancer, history of benign breast biopsies, and recommendation for and acceptance of chemoprophylaxis.

Results: Of 1,000 women screened in the prospective analysis, 366 had ≥1.7% 5-year risk of invasive breast cancer. 26% (96) of these women were under 60 years old while 74% (270) were ≥60 years old. Among the latter group, 19.6% (53) were found to have ≥ 3.4% of developing invasive cancer. In these women with double the 5-year risk, 96.2% had a family history of breast cancer and 69.8% had a prior biopsy. Similarly, in women under 60, greater than half were high risk secondary to a prior biopsy or family history. In the retrospective analysis of 600 patients evaluated in the high risk clinic, 38.8% were eligible for chemoprevention based on age >35, Gail model risk score, and no contraindications to treatment. 45.7% accepted recommendation for chemoprophylaxis as opposed 54.3% who had declined. Age was not found to be a predictor of acceptance of treatment.

Conclusions: 1/3 of patients who receive annual screening are at high risk for breast cancer. These patients can be identified from data routinely obtained at the time of screening mammography. These women should be referred for high-risk counseling and consideration of chemoprevention at the time of screening mammography. Further prospective studies may be warranted to determine if this is an effective way to provide risk reduction strategies for high risk women.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-04-04.

Variables affecting the performance of galactomannan assay in high-risk patients at a tertiary care centre in India

BACKGROUND

Diagnosis of invasive aspergillosis (IA) in immunocompromised patients using galactomannan ELISA (GM-ELISA) has shown variable sensitivity and specificity.

OBJECTIVES

To assess the diagnostic performance of GM-ELISA and analyze the effect of decreasing the cut off value, neutropenia, antifungals and piperacillin-tazobactam (PTZ). Prognostic value using 30 day all-cause mortality was also determined.

MATERIALS AND METHODS

Serum samples from 81 patients categorized into "proven," "probable," and "possible," categories based on revised EORTC/MSG definitions were tested by GM-ELISA.

RESULTS

Sensitivity of GM-ELISA in proven, probable and possible cases was 91.7%, 84.6% and 83.3% respectively. At an index cut-off value of 0.5 an increased sensitivity with minimal loss of specificity was observed. Use of antifungals demonstrated a decrease in sensitivity in proven and possible cases whereas it remained unaffected in probable category. Specificity increased from 75% to 100% with a positivity criterion of >2 consecutive samples. Although an increase in specificity was observed in patients not receiving PTZ, it was not statistically significant. Serial GM index values increased significantly in neutropenic patients and were associated with a poor prognosis.

CONCLUSIONS

GM-ELISA may be a useful diagnostic and prognostic modality for the detection of IA in high risk patients.

Oxidative damage markers as possible discriminatory biomarkers in breast carcinoma

The study was designed to evaluate the markers of oxidative damage and to establish their diagnostic utility in breast carcinoma patients. Levels of 8-hydroxy-2-deoxyguanosine (8-OH-dG), protein carbonyl (PC), and malondialdehyde (MDA) along with total antioxidant status (TAS) were measured in breast carcinoma patients and controls. Receiver operating characteristic (ROC) analysis was done to study the diagnostic potential of the oxidative damage markers. Significant increases in oxidative damage markers were observed in breast carcinoma patients compared with the normal controls, which were accompanied by significant decrease in TAS. The logistic regression analysis revealed higher levels of oxidative stress marker and reduced level of TAS were significantly associated with breast cancer. ROC curves analysis demonstrates that 8-OHdG and PC are better indicators for distinguishing cancer patients from controls, followed by MDA and TAS. Our results indicate increased oxidative damage is associated with malignancy in breast cancer patients. High accuracy of oxidative stress markers in indicating cancer presence can be used as discriminatory makers for efficient diagnosis.