Causes of mortality among inpatients with systemic lupus erythematosus in a tertiary care hospital in North India over a 10-year period

INTRODUCTION

Systemic lupus erythematosus (SLE) is a systemic autoimmune disorder with significant morbidity and mortality. The present study was undertaken to identify the causes of in-hospital mortality of patients with SLE.

METHODS

This was a retrospective study. The hospital records of patients with SLE who died between 1998 and 2007 were reviewed. Demographic details, organ involvement, treatment received and evidence of infection were recorded. Disease activity was calculated using the SLE Disease Activity Index. The cause of death of each patient was determined and this information was classified into either deaths caused primarily due to SLE, deaths caused due to infection or those that were multi-factorial.

RESULTS

Seventeen patients with SLE who were diagnosed according to the revised American College of Rheumatology criteria died between 1998 and 2007. Fifteen of these patients were female and two were male. The median age was 25 years. The average duration of hospital stay was 10.29 days. Seven patients (41%) died of active SLE (three from pulmonary hemorrhage, two had renal failure, one had myocarditis and one had severe thrombocytopenia with upper gastrointestinal bleed), three patients (18%) died from infections (one contracted Staphylococcal septicemia, another contracted tuberculous meningitis and the third patient had Pseudomonas septicemia) and in seven patients (41%) the etiology was multi-factorial (these showed both active SLE and evidence of infection). In total 10 patients had evidence of infection, two of these were community-acquired and the rest were hospital-acquired.

CONCLUSION

Active SLE and/or infection are the major causes of death in hospitalised patients with SLE. To reduce patient mortality improvements in supportive care for patients with active SLE and measures to prevent hospital-acquired infections are required.

Abstract PD05-09: Whole-genome progression of breast cancer from early neoplasia to invasive carcinoma

Cancer evolution involves cycles of genomic damage, epigenetic deregulation, and increased cellular proliferation that eventually culminate in the carcinoma phenotype. Early breast neoplasias include usual ductal hyperplasia, columnar cell lesions, and flat epithelial atypia and some are thought to represent precursor stages. To elucidate their role in cancer evolution we performed comparative whole genome sequencing of early neoplasias, matched normal tissue, and carcinomas from six patients. The identified somatic mutations served as lineage markers to build trees that relate the tissue samples. On the basis of the lineage trees we inferred the order, timing, and rates of mutational events. We find that in a subset of cases, the last common ancestor of an early neoplasm and a carcinoma was hypermutated and had several aneuploidies, and that evolution further accelerated in the carcinoma lineage. In contrast to highly advanced tumors that are the focus of much of current cancer genome sequencing, the early neoplasia genomes, and the carcinomas as well, harbor a striking paucity of potentially functional somatic point mutations. The earliest significant events we could detect, those changes that occurred in common ancestors of neoplastic and tumor cells, are aneuploidies. Several aneuploidies are recurrent, suggesting that they are among the earliest genomic events that predispose breast tissue to eventual development of invasive carcinoma.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD05-09.

Profile of presentation of human immunodeficiency virus infection in north India, 2003-2007

BACKGROUND

Clinico-epidemiological profile of the Human immunodeficiency virus (HIV) epidemic in India is varied and depends on multitude of factors including geographic location. We analyzed the characteristics of HIV-infected patients attending our Immunodeficiency Clinic to determine any changes in their profile over five years.

SETTINGS AND DESIGN

A retrospective observational study.

MATERIALS AND METHODS

The study sample included all patients with HIV infection from January 1, 2003 to December 31, 2007. Diagnosis of HIV was made according to National AIDS Control Organization guidelines.

RESULTS

Of 3 067 HIV-infected patients, 1 887 (61.5%) were male and 1 180 (38.5%) were female patients. Mean age of patients was 35.1 ± 9.0 years. Majority (91.8%) of patients were in the age group of 15 to 49 years. Progressively increasing proportion of female patients was noted from year 2004 onward. Median CD4 count at presentation in year 2003 was 197/μl (Interquartile range [IQR] = 82.5-373) while in year 2007 it was 186.5/μl (IQR = 86.3-336.8). Mean CD4 count of male patients was 203.7 ± 169.4/μl, significantly lower as compared with female patients, which was 284.8 ± 223.3/μl (P value ≤0.05). Every year, substantial proportions of patients presenting to clinic had CD4 count<200/μl indicating advanced disease. Predominant route of transmission was heterosexual in 2 507 (81.7%) patients. Tuberculosis and oropharyngeal candidiasis were the most common opportunistic infections (OIs). Cryptococcal meningitis was the most common central nervous infection. Our patients had comparatively lower median CD4 counts at the time of presentation with various OIs.

CONCLUSIONS

Patients had advanced stage of HIV infection at the time of presentation throughout five years. Females presented earlier during the course of HIV infection. There is need for early screening and increasing awareness in healthcare providers to make a diagnosis of HIV much sooner.

Prussian blue modified glassy carbon electrodes-study on operational stability and its application as a sucrose biosensor

Stabilisation of electrochemically deposited Prussian blue (PB) films on glassy carbon (GC) electrodes has been investigated and an enhancement in the stability of the PB films is reported if the electrodes are treated with tetrabutylammonium toluene-4-sulfonate (TTS) in the electrochemical activation step following the electrodeposition. A multi-enzyme PB based biosensor for sucrose detection was made in order to demonstrate that PB films can be coupled with an oxidase system. A tri-enzyme system, comprising glucose oxidase, mutarotase and invertase, was crosslinked with glutaraldehyde and bovine albumin serum on the PB modified glassy carbon electrode. The deposited PB operated as an electrocatalyst for electrochemical reduction of hydrogen peroxide, the final product of the enzyme reaction sequence. The electrochemical response was studied using flow injection analysis for the determination of sucrose, glucose and H(2)O(2). The optimal concentrations of the immobilisation mixture was standardised as 8U of glucose oxidase, 8U of mutarotase, 16U of invertase, 0.5% glutaraldehyde (0.025mul) and 0.5% BSA (0.025mg) in a final volume of 5mul applied at the electrode surface (0.066cm(2)). The biosensor exhibited a linear response for sucrose (4-800muM), glucose (2-800muM) and H(2)O(2) (1-800muM) and the detection limit was 4.5, 1.5 and 0.5muM for sucrose, glucose and H(2)O(2), respectively. The sample throughput was ca. 60 samples h(-1). An increase in the operational and storage stability of the sucrose biosensor was also noted when the PB modified electrodes were conditioned in phosphate buffer containing 0.05M TTS during the preparation of the PB films.

Steroid induced rare bipolar mood disorder

A patient with multiple psychosomatic disorder developed a steroid induced rare bipolar mood disorder (both mania and depression). The "unmasking effect" of steroids and a positive family history of psychiatric disorder as a possible risk factor, hitherto undocumented, is suggested in steroid induced psychosis.

Sarcomatoid carcinoma of the hand: a clinical case with an aggressive and uncommon presentation

Cutaneous sarcomatoid carcinoma is a high-grade malignancy. We describe a clinical case of an aggressive sarcomatoid carcinoma in an 87-year-old woman, who presented to the outpatients department with a haemorrhagic nodule on the dorsum of her right hand. By the time of excision 3 weeks later, the nodule had enlarged to 100 × 90 × 65 mm in size. On histological examination, a poorly differentiated carcinoma was seen, with both carcinomatous and sarcomatous elements, in keeping with a sarcomatoid carcinoma. The tumour was positive for cytokeratin, epithelial, smooth-muscle actin, and vimentin stains. Two months later, the patient presented with a recurrent growth on the excised scar along with numerous large right axillary lymph nodes. A right axillary dissection along with excision of the growth confirmed tumour recurrence with metastasis to lymph nodes. Soon after, the patient developed cerebral metastasis, which proved fatal. This case thus highlights the aggressive potential of sarcomatoid carcinoma.

Prevalence of hepatitis B virus infection in non-Hodgkin lymphoma: a systematic review and meta-analysis

BACKGROUND AND AIM

A recent meta-analysis has demonstrated an association between hepatitis C virus and non-Hodgkin lymphoma (NHL). There is also evidence on the association between hepatitis B virus (HBV) and NHL. The aim of this study was to evaluate this evidence using a meta-analytic approach.

METHODS

We searched the MEDLINE database from 1962 to 2008 for case-control studies that have reported the association of HBV with NHL. We calculated the odds ratio (OR) and 95% confidence intervals (CI) to assess the prevalence of HBV infection and pooled the results using three different statistical models.

RESULTS

Our search yielded 12 studies with 11 studies (3262 NHL patients, 1,523,205 controls) evaluating HBV infection in NHL and one study (3888 HBV-infected individuals, 205,203 controls) that had investigated for NHL in HBV infection. The OR of detecting HBV infection in NHL when compared with the control population was 2.56 (95% CI, 2.24-2.92) by the fixed effects model; 2.61 (95% CI, 2.29-2.98) by the exact method and 2.67 (95% CI, 2.04-3.49) by the random effects model suggesting a high prevalence of HBV carrier state in lymphoma. There was evidence of statistical heterogeneity which disappeared after exclusion of retrospective studies on sensitivity analysis.

CONCLUSIONS

The results of this study suggest a possible causal relation between HBV infection and NHL which needs to be confirmed by experimental and epidemiological studies. In countries where prevalence of HBV infection is 1% or more, it may be prudent to screen patients with NHL for occult HBV infection.

Prevalence of hepatitis B virus infection in non-Hodgkin lymphoma: a systematic review and meta-analysis

BACKGROUND AND AIM

A recent meta-analysis has demonstrated an association between hepatitis C virus and non-Hodgkin lymphoma (NHL). There is also evidence on the association between hepatitis B virus (HBV) and NHL. The aim of this study was to evaluate this evidence using a meta-analytic approach.

METHODS

We searched the MEDLINE database from 1962 to 2008 for case-control studies that have reported the association of HBV with NHL. We calculated the odds ratio (OR) and 95% confidence intervals (CI) to assess the prevalence of HBV infection and pooled the results using three different statistical models.

RESULTS

Our search yielded 12 studies with 11 studies (3262 NHL patients, 1,523,205 controls) evaluating HBV infection in NHL and one study (3888 HBV-infected individuals, 205,203 controls) that had investigated for NHL in HBV infection. The OR of detecting HBV infection in NHL when compared with the control population was 2.56 (95% CI, 2.24-2.92) by the fixed effects model; 2.61 (95% CI, 2.29-2.98) by the exact method and 2.67 (95% CI, 2.04-3.49) by the random effects model suggesting a high prevalence of HBV carrier state in lymphoma. There was evidence of statistical heterogeneity which disappeared after exclusion of retrospective studies on sensitivity analysis.

CONCLUSIONS

The results of this study suggest a possible causal relation between HBV infection and NHL which needs to be confirmed by experimental and epidemiological studies. In countries where prevalence of HBV infection is 1% or more, it may be prudent to screen patients with NHL for occult HBV infection.

Prevalence of hepatitis B virus infection in non-Hodgkin lymphoma: a systematic review and meta-analysis

BACKGROUND AND AIM

A recent meta-analysis has demonstrated an association between hepatitis C virus and non-Hodgkin lymphoma (NHL). There is also evidence on the association between hepatitis B virus (HBV) and NHL. The aim of this study was to evaluate this evidence using a meta-analytic approach.

METHODS

We searched the MEDLINE database from 1962 to 2008 for case-control studies that have reported the association of HBV with NHL. We calculated the odds ratio (OR) and 95% confidence intervals (CI) to assess the prevalence of HBV infection and pooled the results using three different statistical models.

RESULTS

Our search yielded 12 studies with 11 studies (3262 NHL patients, 1,523,205 controls) evaluating HBV infection in NHL and one study (3888 HBV-infected individuals, 205,203 controls) that had investigated for NHL in HBV infection. The OR of detecting HBV infection in NHL when compared with the control population was 2.56 (95% CI, 2.24-2.92) by the fixed effects model; 2.61 (95% CI, 2.29-2.98) by the exact method and 2.67 (95% CI, 2.04-3.49) by the random effects model suggesting a high prevalence of HBV carrier state in lymphoma. There was evidence of statistical heterogeneity which disappeared after exclusion of retrospective studies on sensitivity analysis.

CONCLUSIONS

The results of this study suggest a possible causal relation between HBV infection and NHL which needs to be confirmed by experimental and epidemiological studies. In countries where prevalence of HBV infection is 1% or more, it may be prudent to screen patients with NHL for occult HBV infection.

CD4 cell count recovery in HIV/TB co-infected patients versus TB uninfected HIV patients

BACKGROUND

There is lack of data comparing the improvement in CD4 count following antitubercular (ATT) and antiretroviral therapy (ART) in patients presenting with Human Immunodeficiency Virus/Tuberculosis (HIV/TB) dual infection compared with CD4 matched cohort of TB uninfected HIV patients initiated on ART. We sought to test the hypothesis; TB additionally contributes to reduction in CD4 count in HIV/TB co-infected patients and this would result in greater improvement in count following treatment compared with CD4 matched TB uninfected individuals.

MATERIALS AND METHODS

In a retrospective cohort study design we studied the change in CD4 cell counts in two groups of patients - those with CD4 cell count >100 cells / mm 3 (Group 1) and <100/mm 3 (Group 2) at presentation. In each group the change in CD4 cell count in dually infected patients following six-month ATT and ART was compared to cohorts of CD4 matched TB uninfected patients initiated on ART.

RESULTS

In Group 1 (52 patients) dually infected subjects' CD4 count improved from 150 cells/ mm 3 to 345 cells/mm 3 (P=0.001). In the control TB uninfected patients, the change was from 159 cells/mm 3 to 317 cells/mm 3 (P=0.001). Additional improvement in dually infected patients compared to the control group was not statistically significant (P=0.24). In Group 2 (65 patients) dually infected subjects count improved from 49 cells/mm3 to 249 cells/mm 3 (P=0.001) where as in control TB uninfected patients improvement was from 50 cells/ mm 3 to 205 cells/mm 3 (P=0.001), there being statistically significant additional improvement in dually infected subjects (P=0.01).

CONCLUSION

Greater increment in CD4 counts with ATT and ART in dually infected patients suggests that TB additionally influences the reduction of CD4 counts in HIV patients.

Abstract P2-06-11: Ramifications of HER2/ER/PR Guidelines from ASCO/CAP for Translational Cancer Research Using a Cohort from a Tertiary Care Centre in Ontario

Background: A transdisciplinary team from basic science, pathology, clinical and biostatistics was assembled to establish a framework with which to take novel laboratory biomarkers and targets to clinical validation. Human epidermal growth factor receptor (HER2), estrogen (ER) and progesterone (PR) receptor are of important prognostic and predictive value and drivers of systemic therapy for breast cancer (BC). As a first step, the current ASCO/CAP guidelines were used to re-assign centrally reviewed tumour specimens and compare to the clinically assigned scores for ER/PR and HER2.

Methods: With REB approval, a cohort of 62 cases of non-metastatic invasive BC with banked tumour specimens was assembled between 2005 and 2007. Clinico-pathological information for each case was retrospectively obtained from the medical file and entered into an anonymized database. Full section slides were originally stained by routine immunohistochemistry (IHC). Categorical clinical scores for ER/PR (negative-neg/weak/positive-pos) were compared to the continuous scores assigned in a blinded fashion using ASCO/CAP criteria (% pos/H-score). Categorical clinical scores obtained with duplicate IHC antibody staining of full sections for HER2 (neg/equivocal-eq/pos) were compared to those obtained from IHC assessments of triplicate 6mm cores in a tissue microarray (TMA) that were assigned to be neg/eq/pos using ASCO/CAP criteria. A senior breast pathologist adjudicated discordant specimens. Exact Fisher tests were used to compare the two sets of categorical assessments.

Results: Mean age was 43.5 years, (range 29-49). The majority of the cohort (59.7%) had N0 disease and received adjuvant chemotherapy (74.2%); 72.6% of the cohort was alive at the time of this analysis. Score means and ranges of ER/PR are displayed below. Two of 16 clinically ER neg cases (12.5%) were rescored as pos and 0/43 clinically ER pos cases were rescored as neg, P&lt;0.0001. Two of 13 clinically PR neg cases (15.4%) were rescored as pos and 4/46 clinically PR pos cases (8.7%) were rescored as neg, (P&lt;0.0001). HER2 status was reassessed for 51 cases, 41 of which (80%) had concordant scores (P&lt;0.0001). Thirty-nine (76%) cases were classified as HER2 neg on TMA, 7 of which (18%) were eq on routine IHC and neg by fluorescence in situ hybridization. In routine IHC, 15.7% of tumours were eq. Four TMA cases were eq (7.8%%); with routine IHC, one of these was neg, one eq, and two were pos. Eight patients were HER2 pos in both assessments.

ER/PR scores

Conclusions: Systemic therapy recommendations could be impacted in a small but substantive number of cases by the methodology used for biomarker assessment and scoring, particularly near threshold values. This study illustrates that the scoring criteria used may be an important contributor to variability in correlative biomarker studies. Consideration should be given to routine systematic reassessment with continuous scoring for biomarker data proposed for use in correlative science studies.

Direct measurement of the electron density of extended femtosecond laser pulse-induced filaments

We present direct time- and space-resolved measurements of the electron density of femtosecond laser pulse-induced plasma filaments. The dominant nonlinearity responsible for extended atmospheric filaments is shown to be field-induced rotation of air molecules.