O-006 Diagnosis debate – USG vs endoscopy

MULLERIAN ANOMAIES – DEBATE USG OR ENDOSCOPY

Mullerian duct anomalies are a complex spectrum of congenital anomalies resulting from defective fusion or canalization leading to different uterine anomalies. Early detection and proper diagnosis of uterine anomalies are paramount for proper management. Outflow obstruction defects like transvers septal defects or non canalised functional horn present early with complaint of pain while rest of patients present with amenorrhoea , infertility, repeated first-trimester abortion, fetal intrauterine growth restriction, and obstetric complications.The prevalence of uterine malformations is variable depending on the population studied , 0.4% , 4 % respectively in the general population and in infertile women while a high prevalence between 3 and 38% is reported in patients with repeated spontaneous miscarriages.

Imaging plays an important role in diagnosis and treatment planning in mullerian duct anomalies. There are different imaging and endoscopic modalities that can be used for the diagnosis and confirmation of uterine malformations. All modalities are having limitations and one need to select and combine various modalities depending on the clinical presentation of patient and pelvic examination. In younger patients or acute cases, trans abdominal ultrasonography (US) is the preferred method because it is readily available, inexpensive, and rapid and does not use ionizing radiation. However it may not give the complete picture because of poor demarcation especially in fatty patient and owing to complex nature of defects , Field-of-view restrictions with US, patient body habitus, and artefact from bowel gas. Pelvic magnetic resonance imaging (MRI) is an excellent tool in the diagnosis of Mullerian duct anomalies due to high soft tissue resolution. But it is more expensive and less available. 3D ultrasound may be a valid alternative to pelvic MRI as It is less expensive and better tolerated by patients however in doubtful cases of complex nature , hysteroscopy combined with laparoscopy may be considered to confirm the diagnosis. Another advantage of endoscopy is the opportunity to correct the defect in the same sitting in most of the cases.

Hysterosalpingography (HSG) and hysteroscopy are considered good modalities to assess the uterine cavity. Hysteroscopy provide the direct visualisation of the defect and considered as gold standard for cavity evaluation in doubtful cases of septate and bicornuate uterus and for simultaneous correction. However outer contour cannot be visualised so one need to use laparoscopy for complete evaluation which is a major drawback. Three-dimensional transvaginal sonography provides image quality like those provided by MRI and is being extensively used for diagnosis of all sorts of mullerian defects. it has got the advantage of realtime imaging which is helpful in distorted pelvic anatomy , visualisation of outer contour is possible ,which is considered very important to differentiate between bicornuate and septate uterus and unicornuate uterus with rudimentary horn. however it may not be possible in all cases to get a definitive diagnosis inspite of using a high end 3D machine specially in presence of artefacts , distorted contour and retroverted uterus. In such cases both modalities including MRI and endoscopy may be required to reach to a definitive diagnosis.

It can be concluded that primary imaging tool is still 2d ultrasound but 3D TVS should be included in all suspected anomalies along with complete careful pelvic examination to corroborate the findings of USG. In doubt ful or complex cases, MRI should be performed particularly for cervical and vaginal atresia and septum. endoscopy should be reserved for all doubtful cases for confirmation and for acute cases where a corrective surgery can also be planned to relieve the distress.

Increasing adherence to plotting e-partograph: a quality improvement project in a rural maternity hospital in India

Abnormal prolonged labour and its effects are important contributors to maternal and perinatal mortality and morbidity worldwide. E-partograph is a modern tool for real-time computerised recording of labour data which improves maternal and neonatal outcome. The aim was to improve the rates of e-partograph plotting in all eligible women in the labour room from existing 30% to achieve 90% in 6 months through a quality improvement (QI) process.A team of nurses, obstetricians, postgraduates and a data entry operator did a root cause analysis to identify the possible reasons for the drop in e-partograph plotting to 30%. The team used process flow mapping and fish bone analysis. Various change ideas were tested through sequential Plan-Do-Study-Act (PDSA) cycles to address the issues identified.The interventions included training labour room staff, identification of eligible women and providing an additional computer and internet facility for plotting and assigning responsibility of plotting e-partographs. We implemented these interventions in five PDSA cycles and observed outcomes by using control charts. A set of process, output and outcome indicators were used to track if the changes made were leading to improvement.The rate of e-partograph plotting increased from 30% to 93% over the study period of 6 months from August 2018 to January 2019. The result has been sustained since the last PDSA cycle. The maternal outcome included a decrease in obstructed and prolonged labour with its associated complications from 6.2% to 2.4%. The neonatal outcomes included a decrease in admissions in the neonatal intensive care unit for birth asphyxia from 8% to 3.4%. It can thus be concluded that a QI approach can help in improving adherence to e-partography plotting resulting in improved maternal health services in a rural maternity hospital in India.

Institution of an antibiotic stewardship programme for rationalising antibiotic usage: a quality improvement project in the NICU of a public teaching hospital in rural central India

Antibiotic misuse is the most common cause of antimicrobial resistance-a globally declared emergency. This necessitates the introduction of rational antibiotic usage management policy. The paediatrics department of a public teaching hospital with around 500 neonatal intensive care unit (NICU) admissions annually revealed 75% of NICU admission exposure to any antibiotics. The aim was to institute antibiotic stewardship programme (ASP) to optimise antibiotic usage from existing 75% to 40% in a 6-month period through a quality improvement (QI) project.A root cause analysis using fishbone diagram was performed to identify the possible reasons for the high antibiotic usage. Six Plan-Do-Study-Act cycles were conducted to implement the protocols for usage of antibiotics for well-defined indications; active laboratory engagement to decrease the turnaround time for blood culture results; a hard stop to all antibiotic orders after 72 hours; streamlining of antibiotic usage; strengthening universal aseptic practices; and confidence building of staff. The outcomes monitored were antibiotic exposure rates, average number of antibiotic days in all NICU admissions, sepsis rates and mortality.Institution of ASP had significantly reduced antibiotic exposure in NICU admissions, that is, from 75% in March to 41% in August 2018. Median (IQR) antibiotic days per infant in NICU went down from 3 to 0 (0-6). The per cent of NICU admission with culture-positive sepsis and all-cause mortality rate in NICU declined from 18% to 11.56% and 25% to 16%, respectively, over these 6 months.Thus, ASP for rationalising antibiotic usage was successfully instituted in NICU of a rural medical college in central India through QI, without any adverse effect on sepsis and mortality.

Bacille calmette-guérin: An ophthalmic perspective

Vaccines such as bacille Calmette-Guérin (BCG) are known for their heterologous effects mediated through a number of mechanisms, including trained immunity constituted by monocyte-macrophage based innate immunity. Other events such as direct hematogenous spread and induction of autoimmunity are also described. There has been a resurgent interest in harnessing some of the benefits of trained immunity in the management of COVID-19, even as several specific vaccines have been approved. We summarize the current knowledge of ocular effects of BCG. Potential effect of granulomatous inflammation on angiotensin converting enzyme activity and accentuation of cytokine storm that may result in undesirable ocular and systemic effects are also discussed.

Burden of congenital rubella syndrome (CRS) in India based on data from cross-sectional serosurveys, 2017 and 2019-20

Background

India has set a goal to eliminate measles and rubella/Congenital Rubella Syndrome (CRS) by 2023. Towards this goal, India conducted nationwide supplementary immunization activity (SIA) with measles-rubella containing vaccine (MRCV) targeting children aged between 9 months to <15 years and established a hospital-based sentinel surveillance for CRS. Reliable data about incidence of CRS is necessary to monitor progress towards the elimination goal.

Methods

We conducted serosurveys in 2019–20 among pregnant women attending antenatal clinics of 6 hospitals, which were also sentinel sites for CRS surveillance, to estimate the prevalence of IgG antibodies against rubella. We systematically sampled 1800 women attending antenatal clinics and tested their sera for IgG antibodies against rubella. We used rubella seroprevalence data from the current survey and the survey conducted in 2017 among antenatal women from another 6 CRS surveillance sites to construct a catalytic models to estimate the incidence and burden of CRS.

Result

The seroprevalence of rubella antibodies was 82.3% (95% CI: 80.4–84.0). Rubella seropositivity did not differ by age group and educational status. Based on the constant and age-dependent force of infection models, we estimated that the annual incidence of CRS in India was 225.58 per 100,000 live births (95% CI: 217.49–232.41) and 65.47 per 100,000 live births (95% CI: 41.60–104.16) respectively. This translated to an estimated 14,520 (95% CI: 9,225–23,100) and 50,028 (95% CI: 48,234–51,543) infants with CRS every year based on age-dependent and constant force of infection models respectively.

Conclusions

Our findings indicated that about one fifth of women in the reproductive age group in India were susceptible for rubella. The estimates of CRS incidence will serve as a baseline to monitor the impact of MRCV SIAs, as well progress towards the elimination goal of rubella/CRS.

Rubella infection during the first trimester of pregnancy can affect fetus, resulting in spontaneous abortion, stillbirth or birth of a baby with a combination of birth defects known as congenital rubella syndrome (CRS). Vaccination with rubella containing vaccine (RCV) is recommended as one of the strategies for eliminating rubella/CRS. The Southeast Asia region has set a target to eliminate rubella/CRS by 2023. Towards this goal, India completed nationwide immunization campaigns using measles-rubella vaccine during 2017–19, targeting children aged 9 months to <15 years. A case-based surveillance for CRS was initiated in five sentinel hospitals (Phase-1) in 2016 and later expanded to additional 6 sites (Phase-2) in 2019, to estimate burden of CRS and monitor its trend. As an adjunct to CRS surveillance, periodic serologic surveys were also planned to monitor the rubella seroprevalence among the pregnant women. A serosurvey conducted in 2017 indicated that 83.4% pregnant women attending antenatal clinics of Phase-1 sentinel hospitals had IgG antibodies against rubella. The second serosurvey conducted during 2019–20 in 6 Phase-2 sites indicated a comparable seroprevalence of 82.3%. Using seroprevalence data from these two serosurveys, we estimated that the annual incidence of CRS in India was 225.58 per 100,000 live births with constant force of infection and 65.47 per 100,000 live births with age-dependent force of infection models. This incidence rates translated to an estimated 14,520 to 50,028 infants with CRS every year. The estimates of CRS incidence will serve as a baseline to monitor the progress towards the elimination goal of rubella/CRS in India.

Identification of genomic imbalances (CNVs as well as LOH) in sertoli cell only syndrome cases through cytoscan microarray

Sertoli cell only syndrome (SCOS) is characterized by complete absence of germ cells in seminiferous tubules of testis. SCOS is multifactorial but genetic factors play a major role in pathogenesis of the disorder with idiopathic origin. Genetic factors majorly include sex chromosomal aneuploidy and Yq Microdeletion. But a large number of cases are still idiopathic. The study aimed to evaluate the genomic imbalances (CNVs and LOH) in idiopathic SCOS patients. The study is based on 28 apparent idiopathic SCOS cases and 10 controls. Molecular cytogenetic techniques viz., FISH, STS-Multiplex PCR and Affymetrix cytoscan microarray (750 K) were used. The microarray screened whole genomic imbalances in DNA from peripheral blood of 25 cases (excluded Klinefelter syndrome patients) and testicular FNAC sample of 2 cases. High FSH and low Inhibin B were observed in cases as compared to control controls groups. Four cases of sex chromosomal abnormality (i.e., three non-mosaic 47, XXY males and one non-mosaic 46, XX male) as well as four cases of Yq microdeletion (i.e., three cases with AZFc deletion and one case with complete AZFa, b and c deletion) were identified. Microarray detected unbalanced translocation of two segments of Y-chromosome i.e., Yp11.31-p11.2 (~4.o mb region, involving SRY) and Yp11.2 (~2.5 mb region) on X-chromosome in XX male. Also, loss of segment on same X-chromosome involving PAR1 region was identified. We have identified both autosomal and sex chromosomal CNVs (recurrent as well as private) involving candidate genes like SYCE1, ZFPM2, SRPK1, DAZ1, BPY2, HSFY1, VCY1 etc. All these CNVs are possibly associated with SCOS pathogenesis. CNVs identified in cases were already reported as pathogenic variant in clinical database DECIPHER. Microarray also detected many LOH (all autosomal, >3.0 mb size) that covered genes with spermatogenesis related function. The mechanism of action of LOH in pathogenesis of SCOS still remains unravelled. CNVs and LOH related to spermatogenesis identified from two different sample types (blood vs. testicular tissue) were discordant. This study should be extended for larger cohort of patients.

A retrospective multi-center experience of renal transplants from India during COVID-19 pandemic

INTRODUCTION

Coronavirus disease 2019 (COVID-19) pandemic led to a sudden drop in renal transplant numbers across India in the initial months of 2020. Although the transplant numbers increased with easing of lockdown, the outcome of these transplants remains unknown.

METHODS

This was a retrospective, observational, multi-center study done across eight different transplant centers in India. All the transplants done from January 30, 2020 to December 31, 2020 were included. The primary outcomes studied were patient and death censored graft survival as well as incidence of COVID-19 infection and its outcomes.

RESULTS

During the study period a total of 297 kidney transplants were done. After a median follow up of 265 days the patient and death censored graft survival was 95.3% and 97.6%, respectively. Forty-one patients (13.8%) developed COVID-19 post-transplant. Majority (58.5%) were asymptomatic to mildly symptomatic and the case fatality ratio was 14.6%. On multivariable logistic regression analysis older age was associated with higher likelihood of COVID-19 infection (odds ratio 1.038; CI 1.002-1.077).

CONCLUSIONS

Patient and graft outcome of kidney transplants done during the COVID-19 pandemic in India was acceptable. The incidence of COVID-19 was 13.8% with a high case fatality ratio.

A Multicenter Cohort Study From India of 75 Kidney Transplants in Recipients Recovered After COVID-19

BACKGROUND

There is limited current knowledge on feasibility and safety of kidney transplantation in coronavirus disease-19 (COVID-19) survivors.

METHODS

We present a retrospective cohort study of 75 kidney transplants in patients who recovered from polymerase chain reaction (PCR)-confirmed COVID-19 performed across 22 transplant centers in India from July 3, 2020, to January 31, 2021. We detail demographics, clinical manifestations, immunosuppression regimen, laboratory findings, treatment, and outcomes. Patients with a previous diagnosis of COVID-19 were accepted after documenting 2 negative severe acute respiratory syndrome coronavirus 2 PCR tests, normal chest imaging with complete resolution of symptom for at least 28 d and significant social distancing for 14 d before surgery.

RESULTS

Clinical severity in patients ranged from asymptomatic (n = 17, 22.7%), mild (n = 36.48%), moderate (n = 15.20%), and severe (n = 7.9.3%) disease. Median duration between PCR positive to transplant was 60 d (overall) and increased significantly from asymptomatic, mild, moderate, and severe disease (49, 57, 83, 94 d, P 0.019), respectively. All recipients and donors were asymptomatic with normal creatinine after surgery at a median (interquartile range) follow-up of 81 (56-117) d without any complications relating to surgery or COVID-19. Patient and graft survival was 100%, and acute rejection was reported in 6.6%.

CONCLUSIONS

Prospective kidney transplant recipients post-COVID-19 can be considered for transplantation after comprehensive donor and recipient screening before surgery using a combination of clinical, radiologic, and laboratory criteria, careful pretransplant evaluation, and individualized risk-benefit analysis. Further large-scale prospective studies with longer follow-up will better clarify our initial findings. To date, this remains the first and the largest study of kidney transplantation in COVID-19 survivors.

Development of a hub and spoke model for quality improvement in rural and urban healthcare settings in India: a pilot study

OBJECTIVE

Hub and spoke model has been used across industries to augment peripheral services by centralising key resources. This exercise evaluated the feasibility of whether such a model can be developed and implemented for quality improvement across rural and urban settings in India with support from a network for quality improvement.

METHODS

This model was implemented using support from the state and district administration. Medical colleges were designated as hubs and the secondary and primary care facilities as spokes. Training in quality improvement (QI) was done using WHO's point of care quality improvement methodology. Identified personnel from hubs were also trained as mentors. Both network mentors (from QI network) and hub-mentors (from medical colleges) undertook mentoring visits to their allotted facilities. Each of the participating facility completed their QI projects with support from mentors.

RESULTS

Two QI training workshops and two experience sharing sessions were conducted for implementing the model. A total of 34 mentoring visits were undertaken by network mentors instead of planned 14 visits and rural hub-mentors could undertake only four visits against planned 18 visits. Ten QI projects were successfully completed by teams, 80% of these projects started during the initial intensive phase of mentoring. The projects ranged from 3 to 10 months with median duration being 5 months.

DISCUSSION

Various components of a health system must work in synergy to sustain improvements in quality of care. Quality networks and collaboratives can play a significant role in creating this synergy. Active participation of district and state administration is a critical factor to produce a culture of quality in the health system.

Sex ratio trajectory in mouse

Skewing of the sex ratio towards males occurs in humans. The possible explanation for excess male births could be a preference for Y-bearing sperm at fertilization and/or selective elimination of female embryos during pregnancy. In this study, we have tested the sex ratio in the preimplantation embryo (2-3 cells stage/closest possible primary sex ratio), the post-implantation embryo (day E7.5), and at birth (secondary sex ratio) on a homogenous (genetic, environmental, and dietary) population of mice to ascertain the biological reason i.e., male preference at fertilization or female elimination during pregnancy or both. Primary sex ratio on early preimplantation embryos (2-3 cells stage) was studied on 598 embryos and secondary sex ratio (at birth) on 721 pups using PCR-based sexing (both X & Y chromosome-specific) besides sex ratio of 80 post-implantation embryos (day E7.5). We have also investigated whether the fat content (high & low) of the diet affects the sex ratio. We observed a skewed sex ratio (more female) in preimplantation embryos (0.436; 95 % CI 0.39, 0.48), and post-implantation embryos (0.462; 95 % CI 0.35, 0.57) but reverse skewing (more male) at birth (0.539; 95 % CI 0.5, 0.58). We also observed that high-fat diet promoted male sex ratio at birth (0.657; 95 % CI 0.57, 0.74) whereas a low-fat diet had the opposite effect (0.46; 95 % CI 0.36, 0.56) but no effect at fertilization (2-3 cells stage embryos). This indicates selective elimination of female embryo and fetus throughout pregnancy in mice, more so with a high-fat diet.

Integrin α9 regulates smooth muscle cell phenotype switching and vascular remodeling

Excessive proliferation of vascular smooth muscle cells (SMCs) remains a significant cause of in-stent restenosis. Integrins, which are heterodimeric transmembrane receptors, play a crucial role in SMC biology by binding to the extracellular matrix protein with the actin cytoskeleton within the SMC. Integrin α9 plays an important role in cell motility and autoimmune diseases; however, its role in SMC biology and remodeling remains unclear. Herein, we demonstrate that stimulated human coronary SMCs upregulate α9 expression. Targeting α9 in stimulated human coronary SMCs, using anti-integrin α9 antibody, suppresses synthetic phenotype and inhibits SMC proliferation and migration. To provide definitive evidence, we generated an SMC-specific α9-deficient mouse strain. Genetic ablation of α9 in SMCs suppressed synthetic phenotype and reduced proliferation and migration in vitro. Mechanistically, suppressed synthetic phenotype and reduced proliferation were associated with decreased focal adhesion kinase/steroid receptor coactivator signaling and downstream targets, including phosphorylated ERK, p38 MAPK, glycogen synthase kinase 3β, and nuclear β-catenin, with reduced transcriptional activation of β-catenin target genes. Following vascular injury, SMC-specific α9-deficient mice or wild-type mice treated with murine anti-integrin α9 antibody exhibited reduced injury-induced neointimal hyperplasia at day 28 by limiting SMC migration and proliferation. Our findings suggest that integrin α9 regulates SMC biology, suggesting its potential therapeutic application in vascular remodeling.

Spontaneous Time-Reversal Symmetry Breaking at Individual Grain Boundaries in Graphene

Graphene grain boundaries (GBs) have attracted interest for their ability to host nearly dispersionless electronic bands and magnetic instabilities. Here, we employ quantum transport and universal conductance fluctuation measurements to experimentally demonstrate a spontaneous breaking of time-reversal symmetry across individual GBs of chemical vapor deposited graphene. While quantum transport across the GBs indicate spin-scattering-induced dephasing and hence formation of local magnetic moments, below T≲4  K we observe complete lifting of time-reversal symmetry at high carrier densities (n≳5×10^{12}  cm^{-2}) and low temperature (T≲2  K). An unprecedented thirtyfold reduction in the universal conductance fluctuation magnitude with increasing doping density further supports the possibility of an emergent frozen magnetic state at the GBs. Our experimental results suggest that realistic GBs of graphene can be a promising resource for new electronic phases and spin-based applications.

Smooth Muscle Cell-Specific PKM2 (Pyruvate Kinase Muscle 2) Promotes Smooth Muscle Cell Phenotypic Switching and Neointimal Hyperplasia

[Figure: see text].

Expanded ATLAS™-identified neoantigen-specific peripheral T cells (NPTs) demonstrate considerable neoantigen breadth, polyfunctionality, and effector function

Adoptive T cell therapy using ex vivo expanded autologous tumor-infiltrating lymphocytes (TIL) has resulted in notable tumor regression across multiple solid tumor indications. Despite their success, TIL harvest requires invasive surgery and sterile isolation. In addition, extracted cells from an immunosuppressive tumor microenvironment (TME) often have impaired functions, low neoantigen-specificity and require high dose cytokine for expansion. All possible reasons for non-responders or post-treatment relapse. Generating T cell therapies specifically expanded against neoantigen targets and derived from peripheral blood lymphocytes may overcome these limitations.

The ATLAS bioassay identifies patient-specific neoantigen targets of T cells, and Inhibigens™, tumor antigens that are detrimental to protective immune responses. Using PLANET™, a robust and scalable closed manufacturing process, T cells specific for up to 30 ATLAS-identified neoantigens (excluding Inhibigens) are expanded, providing considerable breadth of tumor recognition and the potential to limit tumor escape. Use of peripheral T cells leverages robust cells not suppressed by the TME and eliminates the need for invasive tumor resection. Our data show that NPTs are specific for up to 89% of targeted neoantigens, consist of non-exhausted effector and central memory cells, and express proliferative and tissue homing markers. NPTs are highly polyfunctional, secreting multiple combinations of IFNγ, Granzyme B, TNFα, and MIP1α in response to specific neoantigens. Evaluation of markers for memory-progenitor stem-like features in NPTs are being explored and will be discussed. The TITAN™ clinical trial evaluating GEN-011 NPTs is ongoing (NCT04596033).

Acute glycemic and insulin response of Fossence™ alone, or when substituted or added to a carbohydrate challenge: A three-phase, acute, randomized, cross-over, double blind clinical trial

Short chain fructo-oligosaccharides (scFOS) are well-recognized prebiotic fibers. Fossence™ (FOSS) is a scFOS that has been produced from sucrose via a proprietary fermentation process and has not been tested for its digestibility or glucose/insulin response (GR and IR, respectively). The present randomized, controlled, cross-over study was conducted in 3 phases to explore GR and IR to ingestion of FOSS, when replaced by/added to available-carbohydrates (avCHO) among 25 healthy adults (40 ± 14years). In each phase GR and IR elicited by 3-4 test-meals were measured among the fasted recruited subjects. The interventional test meals were as follows: Phase-1, water alone or 10g FOSS or 10g Dextrose in 250ml water; Phase-2, 250ml water containing Dextrose:FOSS (g:g) in the content as 50:0 or 50:15 or 35:0 or 35:15; Phase-3 portions of white-bread (WB) containing avCHO:FOSS (g:g) in the content as 50:0 or 50:15 or 35:0 or 35:15. Blood samples (finger prick method) were collected at fasting and 15, 30, 45, 60, 90 and 120 min after start of test meal ingestion. Plasma glucose and serum insulin were analyzed utilizing standard methods. The primary endpoint was differences in glucose IAUC. All subjects provided their written consent to participate in the study (ClinicalTrials.gov: NCT03755232). The results demonstrated that FOSS, when consumed alone, showed no raise in glycaemia or insulinemia and was statistically equivalent to response of water alone. GR and IR elicited by dextrose:FOSS and WB:FOSS test-meals of Phase 2 and Phase 3, were statistically equivalent to the respective test-meals without FOSS. Result of the 3 phases support the hypothesis that FOSS is resistant to breakdown and is indigestible in the human small-intestine, and therefore can be classified as an unavailable carbohydrate that does not raise post prandial blood glucose or insulin. FOSS, being sweet to taste, may be an acceptable sugar replacer in beverages without compromising their taste and sensory qualities.

Massive pulmonary embolism and thrombus-in-transit via a patent foramen ovale: a case report of successful use of extracorporeal membrane oxygenation to manage post-embolectomy severe right ventricular dysfunction

Background

Pulmonary embolism with thrombus-in-transit through a patent foramen ovale is rare. It may present with neurological sequalae and rapid diagnosis is needed to prevent mortality and morbidity. The European Society of Cardiology (ESC) published guidelines in 2019 for diagnosis and management of acute pulmonary embolism which were useful in this case.

Case summary

A 32-year-old sedentary male presented with sudden onset shortness of breath, syncope, a probable seizure, and chest pain. Investigations showed an acute pulmonary embolism with mobile thrombus in the right atrium and right ventricle and also thrombus-in-transit passing through a patent foramen ovale into the left atrium. He was resuscitated and rapidly transferred to theatre where he underwent surgical thromboembolectomy. There was difficulty in separating him from cardiopulmonary bypass due to right ventricular failure and he was initiated on extracorporeal membrane oxygenator support. He recovered fully and was discharged home after 43 days.

Discussion

This case report highlights the presentation of this rare diagnosis and discusses the management of acute pulmonary embolism according to recent ESC guidelines.

Human telomerase RNA component (hTERC) gene expression and chromosome 7 ploidy correlate positively with histological grade of cervical intraepithelial neoplasia

OBJECTIVE

Cervical cancer screening by primary human papilloma virus detection and cytology is fraught with low specificity and variable sensitivity, respectively. Cytology-histology correlation remains modest. Biomarkers associated with early genetic events in cervical squamous carcinogenesis and detectable in cytology material are likely to be relevant. Human telomerase RNA component (hTERC) gene overexpression and aneuploidy are promising candidates in view of their reported early and consistent association with cervical squamous oncogenesis.

METHODS

We analysed hTERC gene expression and chromosome 7 ploidy by fluorescent in-situ hybridisation (FISH) in 50 women with cytological precursor squamous intraepithelial lesions and available histology outcomes. Results were expressed as percentages of cells showing ≥3 signals, mean signals/nucleus, and maximum amplitude across various cytology and histology categories. Proportions of positive cases were calculated from threshold values derived from 6 controls. Distribution of above indices with respect to ≥cervical intraepithelial neoplasia 2 (CIN2) was explored.

RESULTS

For both genetic aberrations, there was significant positive correlation (for all indices) between the proportion of positive cases and worsening cytological and histological outcomes (P < .05), with significant intergroup differences (P < .05). High-grade lesions (≥CIN2) had significantly higher results compared to <CIN2 lesions (P ≤ .001). In five discordant cases with ≥CIN2 under- or overdiagnosed on cytology, FISH supported the histological diagnosis.

CONCLUSIONS

HTERC gene amplification and chromosome 7 ploidy showed positive association with cervical squamous carcinogenesis and could be relevant in settings of discrepant cytology-histology correlation.