Smooth Muscle Proliferation in Hamartomatous Polyps Mimicking Prolapse in Pediatric Patients with PTEN Hamartoma Tumor Syndrome

Introduction/Objective

In the field of pediatric pathology, it is vital to find recognize cases that could be associated with cancer predisposition syndromes. PTEN hamartoma tumor syndrome (PHTS) is an inherited set of disorders caused by germline inactivating mutations of the PTEN tumor suppressor gene. In the GI tract, PHTS is associated with hamartomatous polyps that can display smooth muscle overgrowth. We therefore present a series of three cases of colonic polyps with smooth muscle overgrowth, mimicking prolapse, in pediatric patients with PTEN mutations.

Methods/Case Report

The first case is a 19-year-old male with PHTS who underwent colonoscopy due to hematochezia. Two pedunculated polyps were removed from the transverse and descending colon. Both polyps showed prominent smooth muscle and ganglion cells in the lamina propria. In the second case, a 9-year-old male with PHTS also underwent colonoscopy due to hematochezia. At least 20 sessile 2-4mm polyps were present in the colon. Histology showed smooth muscle proliferation and ganglion cells in the lamina propria. The third case is a 13-year-old male with undiagnosed PHTS, but a history of Chron’s disease, trichilemmoma, and plantar wart like lesions. He underwent upper and lower endoscopy for Chron’s disease assessment. Three polyps were removed from the descending colon. One was a juvenile polyp while the other two showed prominent smooth muscle proliferation and ganglion cells in the lamina propria.

Results (if a Case Study enter NA)

NA

Conclusion

Histologically, all hamartomatous polyps had smooth muscle overgrowth, confirmed by SMA immunostain, which could easily be confused with prolapse type changes such as in solitary rectal ulcer syndrome. The key in distinguishing between the two is by recognizing ganglion cells within the lamina propria, confirmed by S100 immunostain. Additional clues include identifying mucosal ganglion cells, disarray of crypt architecture, and fibromuscular proliferation as well as considering the location and number of polyps. It is vital for pathologists to recognize the differential diagnosis of polyps with smooth muscle proliferation, especially in pediatric populations where a diagnosis of cancer predisposition syndromes may not be established. Furthermore, is important to discuss pursuing PTEN genetic testing with clinical colleagues as it has immense medical implications and requires a thorough future medical following.

Skin Necrosis in a Patient with Protein S Deficiency, Warfarin Anticoagulation, and Acute COVID-19 Infection: A Case Report

Introduction/Objective

Although thrombotic complications from COVID are well documented, the pathophysiology remains poorly understood, especially in patients with comorbid hypercoagulable risk factors and anticoagulant medication use. COVID has several dermatologic manifestations that may occur due to alterations in hemostasis. We present a case of skin necrosis in a patient with protein S deficiency, warfarin anticoagulation, and acute COVID infection.

Methods/Case Report

A 48-year-old female, BMI >50, heterozygous Protein S (PS) deficiency, Factor V Leiden, and history of recurrent venous thromboembolic events on warfarin, tested positive for COVID. Her only symptom was fatigue. Several days later, the patient developed painful ecchymoses and erythematous blisters on her breast, arm, and abdomen. Laboratory results showed INR 3.6, fibrinogen 675-1054 gm/dL, WBC 15k with absolute neutrophilia, and D-dimer 2274 ug/L DDU. The patient confirmed compliance with her maintenance warfarin dose. Biopsy showed thrombotic vasculopathy without leukocytoclastic vasculitis. Wound cultures were negative.

Results (if a Case Study enter NA)

NA.

Conclusion

The patient’s history and presentation were concerning for warfarin induced skin necrosis. However, the patient had taken warfarin for > 20 years and had an INR of 3.6 which substantiated that warfarin was not discontinued or missed. A retrospective review of INR results during acute COVID infection showed a decrease in time in therapeutic range and an increase in supratherapeutic INRs, suggesting COIVD patients may require decreased warfarin doses. Additionally, PS levels decline in patients with COVID; a similar effect is seen with HIV and Varicella infections. It is theorized that this may be mediated by an increase in C4b binding protein, an acute phase reactant that regulates the complement cascade and binds PS. With an infectious source ruled out and the patients’ known comorbid conditions, an acute exacerbation of the patients underlying hypercoagulable state is the likely driver of the patient’s skin necrosis with COVID as the probable precipitator. In summary, inherited and acquired hypercoagulable risk factors should be included in the differential diagnosis as a cause of skin changes in patients with COVID infection. Although histology may be helpful in diagnosing the cause of skin changes with COVID, laboratory results and clinical correlation are key in identifying a etiology.

COST-EFFECTIVENESS OF BENRALIZUMAB VERSUS MEPOLIZUMAB AND DUPILUMAB IN PATIENTS WITH SEVERE UNCONTROLLED EOSINOPHILIC ASTHMA IN SPAIN

OBJECTIVE

To assess the cost-effectiveness of benralizumab (benra) vs. mepolizumab (mepo) and dupilumab (dupi) for the treatment of patients with severe uncontrolled asthma from the Spanish Health System perspective.

METHODS

Exacerbations avoided, quality-adjusted life years (QALYs) gained and costs in a 5-year period were estimated with a Markov model for a cohort of 1,000 patients in which, based on published evidence, 31% of the patients received biologics + oral corticosteroids (OCS) and 69% received only biologics. Efficacy data (exacerbation reduction and OCS elimination) were derived from a matching-adjusted indirect comparison. Published EQ-5D utilities per health state (biologic alone, biologic + OCS, standard of care + OCS, exacerbations, and post-exacerbations) were used for QALY estimation. Utility decrements associated with exacerbation management [-0.1 (OCS or emergency visits), -0.2 (hospitalization)] derived from the literature were applied. Costs (€, 2022) included drug acquisition (ex-factory price), administration and disease management. An expert panel (2 pneumologists and 1 pharmacist) validated all inputs.

RESULTS

Benra was more effective (52.21 QALYs) than mepo (51.39 QALYs) and dupi (51.30 QALYs). Benra avoided more exacerbations (2.87 exacerbations) compared to mepo (4.70 exacerbations) and dupi (5.11 exacerbations) for the 5-year horizon. Total costs/patient were €56,093.77 (benra), €59,280.45 (mepo) and €62,991.76 (dupi), resulting in benra dominating (more QALYs with lower costs) vs. mepo and dupi.

CONCLUSIONS

Benralizumab can be considered as a dominant treatment alternative vs. other biologic drugs for the treatment of uncontrolled severe eosinophilic asthma patients in Spain.

Raspberry Pi based photovoltaic I-V curve tracer

This paper details the design and implementation of a photovoltaic current - voltage (I-V) tracer. The I-V tracer employs a capacitive load controlled by a raspberry pi model 4B. The complete measurement system includes protections, capacitor charging/discharging power electronics and current, voltage, irradiance and temperature sensors. Results, which include maximum power point, open circuit voltage, short circuit current and module efficiency, are displayed on an LCD touch display. Detailed description of the required software and the graphical user interface is also presented. This measurement system is very useful for testing photovoltaic installations, allowing an immediate verification whether the panels fulfill with the specifications and detection of possible failures.

Characteristics and in-hospital outcomes among patients with type 2 myocardial infarction

Introduction

Type 2 myocardial infarction (T2MI) is one of the most common reasons for hospital admission in the United States (US). Despite its prevalence, it was only given its own ICD-10 code as recently as October 2017. Data are limited regarding the clinical characteristics and management of T2MI as compared with other types of myocardial infarction (MI). Epidemiological research involving large databases is crucial in laying the foundation for further investigation into disease characterization and management.

Purpose

To elucidate the clinical phenotype and prognostic implications of patients presenting with a T2MI by analyzing data from the largest inpatient database in the US.

Methods

The National Inpatient Sample Database was queried to identify patients admitted with T2MI using ICD-10 codes between October 2017 and December 2018. These were compared against control patients admitted for any other type of MI (ATMI) from January 2016 to December 2018. The chi-square test for univariate analysis and binary logistic regression were used to explore the association between T2MI, inpatient outcomes, and baseline characteristics when compared to the ATMI cohort.

Results

A total of 302,920 adults admitted with a diagnosis T2MI over a 15-month period were identified and compared against 3,243,669 admitted with ATMI over a 36-month period. Those admitted with T2MI tended to be older (mean ± SD, 71±14 vs. 69±14 years, p≤0.001) and had a relatively higher percentage of females (47.9% vs. 41.1%, p≤0.001). The African American cohort was the only racial group with a significantly higher percentage of T2MI (16% vs. 12.3%, p≤0.001).

Patients admitted with T2MI were more likely to have chronic comorbidities, especially heart failure (54.9% vs. 41.8%, p≤0.001), chronic kidney disease (CKD) (37.3% vs. 27.8%, p≤0.001), chronic lung disease (29.3% vs. 22.2%, p≤0.001), and atrial fibrillation/flutter (36.2% vs. 25.2%, p≤0.001). They were also more likely to be discharged to a skilled nursing or other facility (29.5% vs. 18.6%). Finally, they were less likely to receive a coronary stent (1.1% vs. 24.6%, p≤0.001) and more likely to undergo bypass grafting (37.3% vs. 27.6%, p≤0.001).

African Americans admitted with T2MI had the lowest risk of in-hospital mortality (adjusted odds ratio [aOR]: 0.606; 95% CI: 0.56–0.64, p≤0.001). Patients hospitalized with additional diagnoses of CKD (aOR: 2.59; 95% CI: 2.48–2.69, p≤0.001), right heart failure (aOR: 1.93; 95% CI: 1.68–2.19, p≤0.001), heart failure with bi-ventricular involvement (aOR: 1.82; 95% CI: 1.58–2.10), or atrial fibrillation or atrial flutter (aOR: 1.30; 95% CI: 1.26–1.33, p≤0.001) were at greatest risk for in-hospital mortality.

Conclusions

Patients admitted with T2MI represent a unique clinical phenotype compared with the broader ATMI population. They are more likely to be older, have more chronic comorbidities, and have a relatively higher percentage of females and African Americans.

Funding Acknowledgement

Type of funding sources: None.

Linezolid-resistant MRSA-CC398 carrying the cfr gene, and MRSA-CC9 isolates from pigs with signs of infection in Spain

AIMS

To perform the molecular characterization of 23 Staphylococcus aureus isolates from pigs with signs of infections recovered in Spanish farms during 2018-2019.

METHODS AND RESULTS

The antimicrobial resistance pattern and virulence profile were determined. The molecular typing was performed by different molecular techniques. The transferability of the cfr gene was assessed by conjugation and its genetic environment was determined by PCR mapping. In all, 21 isolates were methicillin-resistant S. aureus (MRSA) carrying the mecA gene (SCCmecV or non-typeable SCCmec), whereas the remaining two were methicillin-susceptible (MSSA). All but one MRSA isolates (n = 20) belonged to the CC398, being the spa t011 the most prevalent (n = 11). The remaining MRSA and the two MSSA isolates were ascribed to ST9/CC9. The S. aureus isolates exhibited resistance to (number of resistant isolates): β-lactamics (21), erythromycin and/or clindamycin (20), aminoglycosides (7), tetracycline (22), fluoroquinolones (14), chloramphenicol (5) and linezolid (1). The S. aureus isolates did not carry any of the virulence genes studied. One MRSA belonging to the CC398 showed linezolid resistance mediated by the cfr gene. The cfr gene was co-located with fexA in the Tn558 variant previously reported in the S. aureus plasmid pSCFS7.

CONCLUSIONS

Two major livestock-associated genetic lineages were detected among pigs with signs of infection in Spain. The presence of the cfr gene among LA-MRSA-CC398 is of great concern not only for veterinary medicine, but also for humans in close contact.

SIGNIFICANCE AND IMPACT OF THE STUDY

This work describes the molecular characterization of S. aureus isolates recovered from pigs with signs of infection and we report, as far as we know, the first description of MRSA-CC9 from pigs in Spain. Moreover, the detection of a MRSA-CC398 isolate carrying the multiresistance cfr gene highlights the need for continuous surveillance and awareness of LA-MRSA.

The Perplexity Surrounding Chiari Malformations - Are We Any Wiser Now?

Chiari malformations are a diverse group of abnormalities of the brain, craniovertebral junction, and the spine. Chiari 0, I, and 1.5 malformations, likely a spectrum of the same malformation with increasing severity, are due to the inadequacy of the para-axial mesoderm, which leads to insufficient development of occipital somites. Chiari II malformation is possibly due to nonclosure of the caudal end of the neuropore, with similar pathogenesis in the rostral end, which causes a Chiari III malformation. There have been significant developments in the understanding of this complex entity owing to insights into the pathogenesis and advancements in imaging modalities and neurosurgical techniques. This article aims to review the different types and pathophysiology of the Chiari malformations, along with a description of the various associated abnormalities. We also highlight the role of ante- and postnatal imaging, with a focus on the newer techniques in the presurgical evaluation, with a brief mention of the surgical procedures and the associated postsurgical complications.

Prognostic value of odor identification impairment in multiple sclerosis: 10-Years follow-up

BACKGROUND

Olfactory dysfunction has been linked to clinical severity variables in multiple MS populations. Though, its prognostic value is still unknown.

OBJECTIVE

The aim of this study was to explore the long-term outcome associated with Brief-Smell Identification Test (B-SIT) performance in a cohort of MS patients.

METHODS

A retrospective review of the clinical records was conducted in 149 patients who participated in a previous study, with a median follow-up of 121 months. Demographic and clinical data regarding the last clinical appointment with EDSS measurement were collected. Multiple Sclerosis Severity Scale (MSSS) and Age-Related Multiple Sclerosis Severity (ARMSS) scores were calculated. Date of the last clinical contact or death was recorded.

RESULTS

Among MS patients with progressive clinical course (n = 33), those with impaired B-SIT at baseline had greater change per month during follow-up (as measured by increases in MSSS and ARMSS scores) and a higher hazard of death. No significant associations were found among patients with relapsing and remitting MS (n = 116).

CONCLUSIONS

The study results demonstrate that odor identification impairment has prognostic value in progressive MS, suggesting that a brief odor identification measure can be a marker of neurodegeneration in progressive MS.

AB1180 THE EVOLUTION OF AN FLS IN SEARCH OF EXCELLENCE: THE EXPERIENCE OF GRAN CANARIA

Background:

The implementation of an FLS in the Spanish public health system is not an easy task since there are no official plans for the incorporation of personnel dedicated to the unit

Objectives:

To expose the consolidation and improvement of an FLS after its implementation as well as the problems that have arisen over time.

Methods:

The health program for secondary fracture prevention was implemented in 2012. Initially worked with the same staff assigned to the Rheumatology service, since 2016 we have a part-time support nurse. Patients are identified from the emergency registry and, more recently, from patients admitted for hip fracture and treated in a monographic osteoporosis clinic. The baseline visit consists of consultation with the nurse, DXA and bone metabolism analytics. Falling patients are referred to a fall prevention school. Most patients are referred to their primary care physician to start a treatment.

Results:

Of the 2,416 patients attended the baseline visit, 30% were forearm fractures, 27% hip, 20% humerus, 10% spine and 11% other fractures. In comparison to 2012, in 2019 the monthly average of patients has doubled, increased the number of hip and spine fractures, and increased the percentage of captured patients (Table). In spite of consolidating the unit, getting a support nurse for the admitted patients and establishing a solid alliance with primary care, it is pending the involvement of Primary Care Nurses and start first prescription at the hospital.

Table.

Comparison of the first year with the last year of implementation of our FLS.

20122019Mean monthly number of fractures, N2242Type of fracture: forearm/hip/spine, %37/20/628/40/11Captured patients of elegible, %5777Delay in weeks until first visit to FLS, median1412Patient origin: emergency list/inpatient/outpatient, %100/0/059/31/9DXA performed, %10061Referral to fall prevention school, %026Criteria to start a treatment, %6790*Referral to the osteoporosis clinic, %377

*We apply the 2019 recommendations of the Spanish Society of Rheumatology

Conclusion:

We present the achievements made by our FLS along 8 years and the difficulties within the Spanish public health system.

Disclosure of Interests:

Antonio Naranjo Grant/research support from: amgen, Consultant of: UCB, Speakers bureau: AMGEN, Amparo Molina Speakers bureau: AMGEN, STADA, Cristina Sepúlveda: None declared, Candelaria Torres: None declared, Fabiola Santana: None declared, Francisco Rubiño: None declared, Rubén López: None declared, Soledad Ojeda Speakers bureau: AMGEN, LILLY, GEBRO

Cannabinoid hyperemesis syndrome, a treatment discussion

Introduction

Cannabinoid hyperemesis syndrome (CHS), is characterized by recurrent episodes of severe nausea and intractable vomiting, preceded by chronic use of cannabis. A pathognomonic characteristic is compulsive bathing in hot water. The resolution of the problem occurs when cannabis use is stopped. However, patients are often reluctant to discontinue cannabis. Treatment with anti-emetic medication is ineffective. Case series suggested haloperidol as a potential treatment. Other antipsychotics as olanzapine has been used as anti-emetic treatment in chemotherapy.

Objectives

To describe three cases of patients with CHS whom showed a successful response to olanzapine, even when, haloperidol had failed.

Aims

To present an alternative treatment for CHS which can offer benefits over haloperidol.

Methods

We present three cases of patients who suffered from CHS and were admitted to emergency department. All patients were treated with olanzapine after conventional anti-hemetic treatment failure. One patient was also unsuccessfully treated with haloperidol.

Results

All three patients showed a good response to olanzapine treatment. Different presentations were effective: velotab and intramuscular. Their nausea, vomits and agitation were ameliorated. They could be discharge after maintained remission of symptoms.

Conclusions

Olanzapine should be considered as an adequate treatment for CHS. Its suitable receptorial profile, its availability in different routes of administration and its side effects profile could offer some benefits over haloperidol.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

206 Overexpression of germ cell genes DAZL, STRA8, and BOULE in bovine adipose tissue-derived mesenchymal stem cells for male germ cell derivation

Invitro gamete derivation from stem cells has potential applications as an alternative method for dissemination of elite animal genetics, production of transgenic animals, and conservation of endangered species. Mesenchymal stem cells (MSC) may be suitable candidates for invitro gamete derivation given their differentiation capacity and their potential for cell therapy. DAZL (deleted in azoospermia-like) and BOULE (also called BOLL) encode RNA-binding proteins that control differentiation of germ cells; STRA8 (stimulated by RA-8) encodes a protein required for meiosis. Considering the crucial roles of these factors, the aim of the present study was to evaluate co-overexpression of different combinations of DAZL, STRA8, and BOULE on germ cell gene expression profile in adipose tissue-derived MSC (AT-MSC). AT-MSC were harvested from abattoir-derived male bovine fetuses (n=9; 7-8 months of gestation). The optimal concentration of Lipofectamine 2000 (1, 1.5, 2, 1.5ng µL−1; Invitrogen) was analysed in AT-MSC transfected with plasmid pSIN-EF2-Puro containing DAZL, STRA8, and BOULE coding sequences (pSIN-EF2-DAZL-P2A-STRA8-T2A-BOULE-Puro). Then, AT-MSC were transfected either with plasmids containing DAZL, STRA8, and BOULE genes (pSIN-EF2-DAZL-P2A-STRA8-T2A-BOULE-Puro), DAZL and BOULE genes (pSIN-EF2-DAZL-P2A-STRA8-T2A-Puro), DAZL (pSIN-EF2-DAZL-P2A-T2A-Puro), or empty plasmid at a concentration of 1ng µL−1 of Lipofectamine. Cell samples were obtained from each plasmid treatment and analysed for expression of housekeeping genes ACTB and GAPDH and germ cell genes DAZL, PIWIl2, STRA8, and BOULE by quantitative-PCR using relative values (Quantity) through the ΔΔCT formula. AT-MSC transfected with pSIN-EF2-DAZL-P2A-STRA8-T2A-BOULE-Puro using 1ng µL−1 of Lipofectamine achieved higher (P<0.05) expression of DAZL (13.3-fold) compared with cells transfected with empty vector. Moreover, AT-MSC transfected with pSIN-EF2-DAZL-P2A-STRA8-T2A-BOULE-Puro had higher (P<0.05) levels of DAZL mRNA (3.8-fold) compared with empty vector. Messenger RNA levels of STRA8 (1.4-fold) were only detected in AT-MSC transfected with pSIN-EF2-DAZL-P2A-STRA8-T2A-Puro; PIWIl2 and BOULE were not detected in transfected or untransfected AT-MSC. In conclusion, bovine fetal AT-MSC are amenable for overexpression of germ cell markers DAZL and STRA8. Transfection with plasmid containing three germ cell genes (DAZL, STRA8, and BOULE) allowed overexpression of DAZL, whereas transfection with plasmid containing two germ cell genes (DAZL and STRA8) achieved overexpression of STRA8. This study was supported by Fondecyt grant 1191114, Government of Chile.

Determination of the fundamental absorption and optical bandgap of dielectric thin films from single optical transmittance measurements

In this work, we propose a method to retrieve the thickness and optical constants of dielectric thin films from single optical transmittance measurements. The method is based on the envelope method and requires a simple dispersion model for the real part of the refractive index with few fitting parameters, while the absorption coefficient can be determined without the aid of a dispersion model. The wavelength-dependent optical constants can be obtained even from spectra that exhibit few interference fringes. We have tested the method with simulated and real transmittance data from thin films in the spectral range covering the fundamental absorption. In order to assess the method's reliability to retrieve the optical constants and optical bandgap, a comparison is performed with the method by Chambouleyron, known as the Pointwise Unconstrained Minimization Approach, and a fit using the Cody-Lorentz dispersion model. We evaluate the methods' capability to retrieve the fundamental absorption and optical bandgap, and their compromise with film thickness accuracy. Finally, the methods are tested and contrasted using optical transmittance of three different semiconductor material thin films.

Lipid changes and tolerability in a cohort of adult HIV-infected patients who switched to rilpivirine/emtricitabine/tenofovir due to intolerance to previous combination ART: the PRO-STR study

Objectives

To analyse lipid changes and tolerability in a cohort of HIV-infected patients who switched their antiretroviral regimens to rilpivirine/emtricitabine/tenofovir (RPV/FTC/TDF) in a real-world setting.

Methods

PRO-STR is a 48 week prospective observational post-authorization study in 25 hospitals. Patients with a viral load <1000 copies/mL, receiving at least 12 months of combination ART (cART), with constant posology for at least the prior 3 months, were categorized according to previous treatment [NNRTI or ritonavir-boosted PI (PI/r)]. Analytical tests were performed at the baseline visit, between week 16 and week 32, and at week 48.

Results

A total of 303 patients were included (mean age 46.6 years; male 74.0%; previous treatment 74.7% NNRTI and 25.3% PI/r). Both groups exhibited significantly reduced lipid profiles, except for HDL cholesterol, for which a non-significant increase was observed. [NNRTI patients: total cholesterol (baseline: 195.5 ± 38.4 mg/dL; week 48: 171.0 ± 35.5 mg/dL), total cholesterol/HDL ratio (baseline: 4.2 ± 1.2; week 48: 4.0 ± 1.2), HDL (baseline: 49.1 ± 12.0 mg/dL; week 48: 49.2 ± 45.8 mg/dL), LDL (baseline: 119.2 ± 30.2 mg/dL; week 48: 114.2 ± 110.7 mg/dL), and triglycerides (baseline: 136.6 ± 86.8 mg/dL; week 48: 113.4 ± 67.8 mg/dL); PI/r patients: total cholesterol (baseline: 203.2 ± 48.8 mg/dL; week 48: 173.4 ± 36.9 mg/dL), total cholesterol/HDL ratio (baseline: 4.7 ± 1.6; week 48: 4.0 ± 1.2), HDL (baseline: 46.4 ± 12.5 mg/dL; week 48: 52.1 ± 54.4 mg/dL), LDL (baseline: 127.0 ± 36.3 mg/dL; week 48: 111.4 ± 35.8 mg/dL), and triglycerides (baseline: 167.6 ± 107.7 mg/dL; week 48: 122.7 ± 72.1 mg/dL)]. The most common intolerances were neuropsychiatric in the NNRTI patients and gastrointestinal and metabolic in the PI/r patients, and these intolerances were significantly reduced in both groups at week 48 [NNRTI: neuropsychiatric (baseline: 81.3%; week 48: 0.0%); PI/r: gastrointestinal (baseline: 48.7%; week 48: 0.0%) and metabolic (baseline: 42.1%; week 48: 0.0%)].

Conclusions

RPV/FTC/TDF improved the lipid profiles and reduced the intolerances after switching from NNRTI or PI-based regimens, in a cohort of HIV-infected patients.

A65 Characterization of endolysin gene of bacteriophages infecting Listeria spp. isolated from dairy industry wastewater

Bacteriophages and their endolysins, enzymes that degrade the cell walls of bacteria, are emerging as alternative tools to detect and inhibit growth of pathogen bacteria. Listeria monocytogenes is a foodborne pathogen that causes listeriosis, a serious invasive disease that affects both humans and a wide range of animals. Listeria spp. are ubiquitous in the dairy farm environment and could be present in dairy-processing plants and wastewater. All Listeria-specific bacteriophages found to date are members of the Caudovirales, of the Siphoviridae or Myoviridae families. Myophages infecting Listeria have been recently classified by the ICTV in the Spounavirinae subfamily, as well as in the P100 virus genus. The aim of this work was to isolate Listeria spp. bacteriophages and their endolysin codifying genes from wastewater of a dairy industry. Wastewater with and without treatment was sampled during the course of a year, and isolation of bacteriophages was performed after an enrichment step using as hosts L. innocua, L. ivanovii, and L. monocytogenes serotypes 1/2a, 1/2b, and 4b. Bacteriophages infecting L. innocua and L. ivanovii were isolated (n = 24) from 3 out of 12 samples. Bacteriophages were purified, and the host range was determined using spot test and EOP against five collection strains and several field isolates of Listeria spp. Two bacteriophages of narrow and broad host range, vB_Lino_VEfB7, and vB_Liva_VAfA18, were selected for further characterization. High titer stocks of bacteriophages were purified by centrifugation with ammonium acetate, and morphological information on the purified bacteriophages was obtained by negative staining and transmission electronic microscopy. Their morphology, size, and contractile tails indicated that these bacteriophages belonged to the Myoviridae family. Bacteriophage genomes were extracted using phenol-chloroform, followed by ethanol precipitation, and tested by digestion with RNAsa A and DNAse I. RFLP was performed, digesting genomes with restriction enzymes HindIII and NcoI. Consistent with the morphological findings, bacteriophages contained dsDNA genomes but showed different RFLP patterns. A PCR designed to amplify conserved domains of endolysins—PGRP and CwlA—was applied to characterize this gene. Another PCR was designed to amplify the complete endolysin gene, and the complete sequence of this gene was obtained and analyzed. Substitution model selection and a maximum likelihood phylogenetic tree of the endolysin gene was carried out using IQ-Tree software. The sequences of the endolysin gene indicated that the codified enzyme is an N-acetyl-muramoyl-L-alanine amidase, related to A511 and P100 species of the recently described P100virus genus. Further evolutionary analyses are needed to evaluate their belonging to this species or their taxonomy within this genus.

Diversity of Staphylococcus aureus clones in wild mammals in Aragon, Spain, with detection of MRSA ST130-mecC in wild rabbits

AIMS

To determine the Staphylococcus aureus carriage rate in wild mammals in Aragon, northern Spain, to analyse their antimicrobial resistance phenotype/genotype and to characterize the recovered isolates.

METHODS AND RESULTS

Nasal and rectal swabs of 103 mammals were collected in Aragón during the period 2012-2015. Antimicrobial susceptibility, the presence of antimicrobial resistance genes and virulence factors were investigated. Molecular characterization was carried out by spa, MLST, agr and SCCmec. Staphylococcus aureus were recovered from 23 animals (22%). Four of the 23 S. aureus were methicillin-resistant S. aureus (MRSA). Three MRSA were mecC-positive and were isolated from European rabbits and were typed as t843 (ascribed to CC130). The remaining MRSA was a mecA-carrying isolate from European hedgehog, typed as ST1-t386-SCCmecIVa-agrIII and it harboured the blaZ, erm(C), ant(6)-Ia and aph(3´)-IIIa resistance genes. A high diversity of spa-types was detected among the 19 methicillin-susceptible S. aureus isolates, which showed high susceptibility to the antimicrobials tested. The tst gene and different combinations of staphylococcal enterotoxins were found.

CONCLUSIONS

Staphylococcus aureus were detected in nasal and rectal samples of wild mammals. Wild rabbits could be a reservoir of mecC-MRSA.

SIGNIFICANCE AND IMPACT OF THE STUDY

This work provides information on the presence and characteristics of S. aureus from mammals in a defined geographic region in Spain.

Cost-effectiveness of Cladribine Tablets and fingolimod in the treatment of relapsing multiple sclerosis with high disease activity in Spain

OBJECTIVE

To estimate the cost-effectiveness of Cladribine Tablets in the treatment of relapsing multiple sclerosis (RMS) with high disease activity compared with fingolimod, from the perspective of the National Health System (NHS) in Spain.

METHODS

A Markov model was developed. The annual transition probabilities, were adjusted to patients with RMS with high disease activity. The effect of the treatments compared on the Expanded Disability Status Scale (EDSS) was modeled by hazard ratios for the confirmed progression of disability. The annual relapse rate and the probability of suffering adverse reactions were obtained from a meta-analysis and the literature. The derived costs were calculated from Spanish unit costs. The utilities were obtained from the CLARITY clinical trial and the literature. Deterministic and probabilistic sensitivity analyzes were performed.

RESULTS

Cladribine tablets was the dominant treatment: lower costs (-86,536 €) and more effective (+1.11 quality-adjusted life years - QALYs) compared to fingolimod. The probability that Cladribine Tablets was cost-effective compared to fingolimod ranged between 94.6% and 96.1% for willingness to pay from € 20,000 to € 30,000 per QALY gained.

CONCLUSIONS

Cladribine Tablets is a cost-effective treatment, compared to fingolimod, for the treatment of RMS with high disease activity.

EXPERT OPINION

According to the present study, compared to fingolimod, treatment with Cladribine Tablets of relapsing multiple sclerosis with high disease activity is an option that could generate savings for the Spanish National Health System, with a considerable gain in QALYs. Cladribine Tablets is considered cost-effective and dominant (less costs and more effectiveness) than fingolimod treatment option in this population.

[Growth hormone of dried blood spot for the diagnosis of growth hormone deficiency]

INTRODUCTION

The diagnosis of growth hormone deficiency (GHD) is difficult to determine, and could be associated with severe complications, especially in the neonatal period. The stimulation test of growth hormone (GH) secretion is considered the gold standard for diagnosis, but it has methodological complications and is associated with adverse effects. Neonates present physiological increased secretion of GH, representing a diagnostic window.

OBJECTIVE

To evaluate if the dried blood spot on filter paper obtained in the neonatal period, as part of a neonatal screening for con genital hypothyroidism and phenylketonuria, allows differentiating patients with GHD from those who do not have it.

PATIENTS AND METHOD

Study of cases and controls by measuring the GH concen tration in dried blood spot on filter paper obtained in the neonatal period, comparing controls with GHD with cases with discarded deficiency. The sample was extracted from the filter paper, obtaining two 0.125 inch discs per each patient from the center of the blood spot on the paper, for a highly sen sitive ELISA assay for human GH based on the use of polyclonal antibodies against 22 kDa recom binant human GH.

RESULTS

Seven cases of GHD and ten controls were obtained. The median GH concentration of the dried blood spot in the cases is 2.0 ng/ml (Interquartile range 3.6 ng/ml) and 2.05 ng/ml (Interquartile range 2.0 ng/ml) in the controls, Mann-Whitney U test 30.5 (p = 0.68). The two cases with multiple pituitary-hormone deficiency (MPHD) present concentrations lower than 1 ng/ml.

CONCLUSION

The dried blood spot sample did not differentiate GHD patients from control cases, although MPHD cases present much lower concentrations compared to isolated growth hor mone deficiency (IGHD).

Abstract P5-13-15: The value of patient navigation in breast cancer being tested in Rio de Janeiro, Brazil

OBJECTIVES: The main objective of this Patient Navigation Program in Rio de Janeiro (PNP Rio), Brazil, is to promote adherence to the "60 Day Law", which states that all patients with cancer within the public system should start treatment within 60 days after diagnosis of cancer. Thus, the objectives are: 1.) to establish feasibility of PNP in this setting; 2.) to identify barriers to compliance the Law of 60 days and 3.) to ensure that at least 70% of recruited breast cancer patients begin treatment within the mandated 60-day period. One report by FEMAMA states that only 30% of breast cancer patients in Rio de Janeiro to initiate treatment within the 60-day mandate.

METHODS: From August 2017 to May 2018, one hundred patients aged 33-81 years (mean age 59 years) were recruited for navigation at Rio Image - an advanced breast cancer diagnosis center administered by the state health secretary and located in the capital city of Rio de Janeiro, attending patients from the public system from all 92 municipalities in the state. Patient Navigator (PN), a trained social worker, starts navigation from diagnosis, administering questionnaires to collect: patient population data, dates and information of historical milestones, and patient satisfaction. Patients were followed up by phone, e-mail or text message to identify barriers to initiation of treatment.

RESULTS: Patients presented staging 0-I (17%), II-III (78%) and IV (5%). There were two deaths related to breast cancer in this group. All patients reported at least one barrier, ranging from 2 to 12 barriers (M=5). The barriers to compliance with the "Law of 60 days" were: Fear and fatalistic thoughts (99%), Financial problems (79%), Uncoordinated health care (76%), Health professionals ignore the Law of the 60 days (75%), Need to do staging exams again (52%), Concern about communicating with medical staff (52%), Transport (42%), Difficult in obtain surgical risk consultation (12%), Line of surgeries in hospitals (12%), Difficult of insertion in the regulation system in Primary Care(11%), Patient cannot express herself (5%), Social support(4%), Absent of the immunohistochemistry panel (4%), Cognitive problems (3%), Comorbidities (2%). The PNP had 100% patient satisfaction and in 60% of the cases it helped the patients to start treatment within the period established by law.

CONCLUSIONS: In summary, PNP Rio generated a positive experience for patients in the public health system because it is an intentional and proactive process of assisting the individual through the cancer system, accessing services and actively overcoming barriers to quality care. The PNP Rio did not achieve the success rate of 70% of compliance with the Law as intended (achieved 60%). However, the barriers that the PN can not overcome such as lack of human resources and medical supplies, were informed to health authorities and hospital administrators. This is an opportunity for discussion of reallocation of funds, focusing on the use of scarce resources in prevention and early treatment rather than late-stage disease. In the Brazilian context, PNP may represent an opportunity to implement existing legislation adequately, and as such, would have great potential for integration at the federal, state, and local health systems.

Citation Format: Gioia S, Torres C, Cavalcanti J, Brigagao L, Proencio T, Krush L, Goss P. The value of patient navigation in breast cancer being tested in Rio de Janeiro, Brazil [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 P5-13-15.

Brazil Needs Organized Breast Cancer Screening: Pilot Project in Rio De Janeiro

Background: In Rio de Janeiro there is only the opportunistic screening program for women with breast cancer who arrive at health facilities and with a 14% rate of mammography coverage. In countries that have implemented effective screening programs, with coverage of the target population, quality of screening, and adequate treatment, breast cancer mortality has declined. Evidence of the impact of screening on mortality by this neoplasm justifies its adoption as a public health policy, as recommended by WHO. 80% of the population use the public health system (Sistema Unico de Saude - SUS), provided by the government. This system mainly provides conventional mammography. The private insurance system covers the remaining 20%, who have access to modern technologies such as digital mammography or MRI. Aim: The breast cancer organized screening program in the community of the Andaraí, RJ is committed in assisting women asymptomatic 50-69 years from SUS. Methods: The program foresees the participation of these women for an indefinite period, free of charge, and the accomplishment of biennial digital mammography, going through the stages of early detection and diagnosis. In case of positivity for malignant disease, it will be treated properly. Results: Since April 2014 have been 350 women with an average age of 54 years. 100% of them were asymptomatic and 49% had never done before mammography. Only 1 woman presented clinical suspect aged 44 years. The screening program organized by breast cancer in the community of Andaraí, RJ presented a mammographic coverage rate of 70%. The program is contemplated in the healthcare plan of the SUS. Conclusion: Preliminary results of the study suggest that population based organized screening are feasible and age of onset mammography screening should be 50 years in Rio de Janeiro.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Abstract P4-04-19: Endocrine medical treatment in breast cancer, is that enough?

Endocrine treatment has been in the management of hormone receptor breast cancer for a few decades, but never as the first line of treatment. Now in the biomolecular era, we are able to select patients where endocrine treatment can be considered the first line of treatment.

Methods: During the months of May 2011 until June 2017, patients with ductal/lobular, in-situ and invasive cancer were treated medically with endocrine treatment as first choice of treatment (Tamoxifen/AI), due to medical morbidity or as requested by patients. The use of biomolecular assays helped to support the treatment decision. The infrastructure of ABC as a comprehensive center with all the modalities for diagnostic and interventional breast imaging center allow us to do all the follow up with the same health professionals. The assessments of the follow-ups were based on clinical, imaging (MRI, ultrasound and mammogram), and pathological responses.

We use the term "complete clinical response" on patients where the clinical history and the physical examination demonstrate complete improvement of the breast cancer. "Complete imaging response" is referred to those patients that before treatment had a breast MRI with enhancement lesions and in the follow-ups show no more enhancements. "Complete pathological response" refers to patients which had no residual cancer on the surgical specimen.

Results: We followed a total of 32 patients for an average period of 20.12 months (range=2-63 months), and an average age of 69.69 (range=45-86). Twenty-six of these patients (81.2 %) had Invasive Ductal Carcinoma, 6 patients (18.7%)had DCIS, 23 of the patients (71.88%), were only treated with endocrine treatment.Nine patients (28.13%) were treated with endocrine therapy plus surgery. The decision for surgery was a personal request of the patient, not a failure of the endocrine treatment.

The 32 patients (100%) had a complete clinical response. Twenty-five patients (78.13%) presented a complete imaging response.From the patients who had surgery,1 patient (11.11%) presented a complete pathological response, 6 patients (66.67%) presented down staging of the tumor, and 2 patients (22.22%) presented no change.

Twenty-nineof the 32 patients (90.63%) were able to obtain the recurrence score by Twenty-one Genes.Twenty-four of those had a low recurrence score, 4 had an intermediate score, and 1 patient had a high recurrence score.

Discussion: Even though this is a small group of patients, there was no failure of treatment, mortality or progress of the disease. It demonstrated that, on selective patients, the effectiveness of endocrine treatment is possible, and can be used as the first line treatment. The selection of those patients was supported with the use of the 21 genes.

Conclusion:Now days endocrine treatment, based on clinical and biomolecular assays, can be considered safe to use as first line of treatment for invasive and non-invasive breast cancer for those patients that refuse surgery or chemotherapy.

Citation Format: Rosario V, Torres C, Santiago CP. Endocrine medical treatment in breast cancer, is that enough? [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-04-19.

182 In Vitro Derivation of Male Germ Cells from Bovine Bone Marrow-Derived Mesenchymal Stem Cells

During the last few years, the in vitro derivation of germ cell lineages from stem cells has emerged as an exciting new strategy for obtaining mature gametes. In vitro gamete derivation technology has potential applications as an alternative method for dissemination of elite animal genetics, production of transgenic animals, and conservation of endangered species. Germ cell differentiation and gametogenesis is a complex process and potential of different stem cell donors (i.e. SSC, ESC, iPSC) for in vitro male germ cell derivation has been inconsistent. Mesenchymal stem cells (MSC) may be suitable candidates for in vitro gamete derivation considering their (1) plasticity that is not limited to mesodermal derivatives, (2) availability of abundant tissues sources for isolation, (3) high proliferative potential, (4) simple and inexpensive isolation, and (5) high potential for cell therapy, including autologous or allogenic transplantation. The present study aimed to induce differentiation of MSC isolated from bone marrow derived from bovine male fetuses (bfMSC) into the germ cell lineage using an in vitro approach based on the exogenous effect of retinoic acid (RA) and bone morphogenetic protein 4 (BMP4). Differentiation media consisted in control media (DMEM with high glucose plus 10% fetal bovine serum, 100 IU mL−1 penicillin, 100 μg mL−1 streptomycin, and 0.25 μg mL−1amphotericin B) supplemented with RA (0.01, 0.1, or 1 µM) or BMP4 (10, 50, or 100 ng mL−1). Cell samples were obtained from differentiating and control bfMSC cultures and analysed for expression of housekeeping genes β-ACTIN and GAPDH, pluripotent genes OCT4 and NANOG, germ cell genes FRAGILLIS, STELLA, and VASA, male germ cell genes DAZL, PIWIl2, and STRA8, and meiotic biomarker SCP3 by quantitative-PCR (Q-PCR). OCT4, NANOG, and DAZL were immunodetected in undifferentiated and differentiated bfMSC using flow-cytometry analysis. The mRNA expression of DAZL was activated by RA or BMP4 supplementation, although no differences (P > 0.05) were detected among different concentrations. DAZL and NANOG mRNA levels increased (P < 0.05) from Day 7 to Day 21 during supplementation of RA (0.1 μM). In comparison, DAZL mRNA levels increased (P < 0.05) at Day 14 during supplementation of BMP4 (100 ng). OCT4 and SCP3 mRNA levels were not affected by RA or BMP4 treatments. Transcripts of FRAGILLIS, STELLA, VASA, PIWIl2, and STRA8 were not detected in control or differentiated bfMSC. Higher (P < 0.05) percentages of undifferentiated bfMSC were positive for NANOG (80.6%) and OCT4 (83.4%). DAZL- and NANOG-positive cells were 2.1% and 2.9%, and 95.9% and 97.8% at Days 0 and 21 of RA treatment, respectively. Data indicated that expression of germ cell biomarker DAZL in bfMSC is activated and increased after in vitro supplementation of RA and BMP4. Moreover, NANOG mRNA levels were regulated by RA treatment. Similar levels of SCP3 mRNA expression suggest that differentiated bfMSC were not induced into meiosis. Thus, exposure of bfMSC to RA or BMP4 under in vitro conditions might induce an early stage of premeiotic germinal differentiation.

Diagnostic Accuracy of Centrally Restricted Diffusion in the Differentiation of Treatment-Related Necrosis from Tumor Recurrence in High-Grade Gliomas

BACKGROUND AND PURPOSE

Centrally restricted diffusion has been demonstrated in recurrent high-grade gliomas treated with bevacizumab. Our purpose was to assess the accuracy of centrally restricted diffusion in the diagnosis of radiation necrosis in high-grade gliomas not treated with bevacizumab.

MATERIALS AND METHODS

In this prospective study, we enrolled patients with high-grade gliomas who developed a new ring-enhancing necrotic lesion and who underwent re-resection. The presence of a centrally restricted diffusion within the ring-enhancing lesion was assessed visually on diffusion trace images and by ADC measurements on 3T preoperative diffusion tensor examination. The percentage of tumor recurrence and radiation necrosis in each surgical specimen was defined histopathologically. The association between centrally restricted diffusion and radiation necrosis was assessed using the Fisher exact test. Differences in ADC and the ADC ratio between the groups were assessed via the Mann-Whitney U test, and receiver operating characteristic curve analysis was performed.

RESULTS

Seventeen patients had re-resected ring-enhancing lesions: 8 cases of radiation necrosis and 9 cases of tumor recurrence. There was significant association between centrally restricted diffusion by visual assessment and radiation necrosis (P = .015) with a sensitivity of 75% and a specificity of 88.9%, a positive predictive value 85.7%, and a negative predictive value of 80% for the diagnosis of radiation necrosis. There was a statistically significant difference in the ADC and ADC ratio between radiation necrosis and tumor recurrence (P = .027).

CONCLUSIONS

The presence of centrally restricted diffusion in a new ring-enhancing lesion might indicate radiation necrosis rather than tumor recurrence in high-grade gliomas previously treated with standard chemoradiation without bevacizumab.

Antibiogramj: A tool for analysing images from disk diffusion tests

BACKGROUND AND OBJECTIVES

Disk diffusion testing, known as antibiogram, is widely applied in microbiology to determine the antimicrobial susceptibility of microorganisms. The measurement of the diameter of the zone of growth inhibition of microorganisms around the antimicrobial disks in the antibiogram is frequently performed manually by specialists using a ruler. This is a time-consuming and error-prone task that might be simplified using automated or semi-automated inhibition zone readers. However, most readers are usually expensive instruments with embedded software that require significant changes in laboratory design and workflow.

METHODS

Based on the workflow employed by specialists to determine the antimicrobial susceptibility of microorganisms, we have designed a software tool that, from images of disk diffusion tests, semi-automatises the process. Standard computer vision techniques are employed to achieve such an automatisation.

RESULTS

We present AntibiogramJ, a user-friendly and open-source software tool to semi-automatically determine, measure and categorise inhibition zones of images from disk diffusion tests. AntibiogramJ is implemented in Java and deals with images captured with any device that incorporates a camera, including digital cameras and mobile phones. The fully automatic procedure of AntibiogramJ for measuring inhibition zones achieves an overall agreement of 87% with an expert microbiologist; moreover, AntibiogramJ includes features to easily detect when the automatic reading is not correct and fix it manually to obtain the correct result.

CONCLUSIONS

AntibiogramJ is a user-friendly, platform-independent, open-source, and free tool that, up to the best of our knowledge, is the most complete software tool for antibiogram analysis without requiring any investment in new equipment or changes in the laboratory.

TGFβ engages MEK/ERK to differentially regulate benign and malignant pancreas cell function

While TGFβ signals are anti-proliferative in benign and well-differentiated pancreatic cells, TGFβ appears to promote the progression of advanced cancers. To better understand dysregulation of the TGFβ pathway, we first generated mouse models of neoplastic disease with TGFβ receptor deficiencies. These models displayed reduced levels of pERK irrespective of KRAS mutation. Furthermore, exogenous TGFβ led to rapid and sustained TGFBR1-dependent ERK phosphorylation in benign pancreatic duct cells. Similar to results that our group has published in colon cancer cells, inhibition of ERK phosphorylation in duct cells mitigated TGFβ-induced upregulation of growth suppressive pSMAD2 and p21, prevented downregulation of the pro-growth signal CDK2 and ablated TGFβ-induced EMT. These observations suggest that ERK is a key factor in growth suppressive TGFβ signals, yet may also contribute to detrimental TGFβ signaling such as EMT. In neoplastic PanIN cells, pERK was not necessary for either TGFβ-induced pSMAD2 phosphorylation or CDK2 repression, but was required for upregulation of p21 and EMT indicating a partial divergence between TGFβ and MEK/ERK in early carcinogenesis. In cancer cells, pERK had no effect on TGFβ-induced upregulation of pSMAD2 and p21, suggesting the two pathways have completely diverged with respect to the cell cycle. Furthermore, inhibition of pERK both reduced levels of CDK2 and prevented EMT independent of exogenous TGFβ, consistent with most observations identifying pERK as a tumor promoter. Combined, these data suggest that during carcinogenesis pERK initially facilitates and later antagonizes TGFβ-mediated cell cycle arrest, yet remains critical for the pathological, EMT-inducing arm of TGFβ signaling.

Clozapine induced diarrhea

Introduction

Clozapine (CZP) is the only antipsychotic approved for resistant schizophrenia 1. Due to its side effects, CZP is not the first therapeutic option in a psychotic episode. Its anticholinergic effects often cause constipation, however, diarrhea have also been described in literature.

Objectives

We describe a patient with two episodes of severe diarrhea after clozapine initiation, which lead to CZP discontinuation.

Aims

Discuss about the differential diagnosis of diarrhea in CZP patients and the needing of a further studies for clarify the more appropriate management in CZP induced diarrhea.

Methods

We present a case report of a 46 years man diagnosed with schizoaffective disorder who presented two episodes of severe diarrhea with fever, which forced his transfer to internal medicine and UCI after CZP initiation.

Results

At the first episode analytical, radiological and histological findings led to Crohn's disease diagnosis, which required budesonide and mesalazine treatment. In the second episode, the digestive team concluded that the episode was due to clozapine toxicity despite the controversial findings (clostridium toxin and Crohn's compatible biopsies)

Conclusions

Diarrhea caused by CZP has been controversial in the literature. However due to the severity of digestive episodes and the paucity of alternative treatments further studies for a better understanding of its physiopathology are warranted.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Polydipsia and intermittent hyponatremia

Introduction

Hyponatraemia occurs in 4% of schizophrenic patients. Dilutional hyponatraemia, due to inappropriate retention of water and excretion of sodium, occurs with different psychotropic medications and could lead to hippocampal dysfunction. This complication is usually asymptomatic but can cause severe problems, as lethargy and confusion, difficult to diagnose in mentally ill patients.

Objectives

To describe a case of a patient with psychotropic poli-therapy, admitted three times due to hyponatremia and the pharmacological changes that improved his condition.

Aims

To broadcast the intermittent hyponatraemia and polydipsia (PIP), a not rare condition, suffered by treated schizophrenic patients and discuss its physiopathology and treatment thorough a case report.

Methods

A 56-year schizophrenic male was admitted for presenting disorganized behavior, agitation, auditory hallucinations, disorientation, ataxia, vomits and urinary retention. He was on clomipramine, haloperidol and clotiapine (recently added), quetiapine, fluphenazine and clonazepam. After water restriction his symptoms improved and he was discharged. Twenty-five days later, he was readmitted for presenting the same symptoms and after water restriction, he was discharged. Five days later, he was again admitted and transferred to the psychiatric ward.

Results

Haloperidol, fluphenazine and clomipramine were replaced by clozapine. These changes lead him to normalize the hypoosmolality and reduce his water-voracity. Endocrinology team did not label this episode of SIADH due to its borderline blood and urine parameters.

Conclusions

Hyponatremia is frequent in schizophrenic patients and may have severe consequences. Therefore, a prompt recognition and treatment is warranted.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Clinical impact and prevalence of MRSA CC398 and differences between MRSA-TetR and MRSA-TetS in an area of Spain with a high density of pig farming: a prospective cohort study

OBJECTIVES

Tetracycline resistance (Tet^R) is a phenotypic marker of the livestock-associated methicillin-resistant Staphylococcus aureus (MRSA) CC398 clone. The aim of this study was to analyse the prevalence of MRSA CC398 in patients in contact with healthcare facilities and differences between patients with MRSA-Tet^R and MRSA tetracycline-susceptible (Tet^S) strains.

METHODS

Patients diagnosed with MRSA from January 2012 to December 2015 were divided into two groups, MRSA-Tet^R and MRSA-Tet^S. Epidemiologic and clinical data were evaluated. Molecular analysis was performed (multilocus sequence typing, spa typing) on MRSA-Tet^R strains.

RESULTS

Data from 288 MRSA patients were obtained, and 106 (36.8%) carried MRSA-Tet^R (93 typed as CC398 (87.7%); the remaining 13 isolates were ascribed to CC9, CC1, CC121, CC30, CC97, CC146 and CC152). The most frequent spa type was t011 (56.6%, 61/106). Detection of MRSA-Tet^R increased over the years (21.9%, 16/73, in 2012; 50.7%, 36/71, in 2015; p <0.001). Hospital acquisition was found in 16.7% (19/114) of MRSA-Tet^R patients vs. 83.3% (95/114) in MRSA-Tet^S patients (p <0.001). Frequency of MRSA-Tet^R patients in nursing homes was lower than in MRSA-Tet^S patients (4.7%, 5/106, vs. 27.5%, 50/182, p <0.001). MRSA-Tet^R as distinct from MRSA-Tet^S was associated with workers on pig farms (49.0%, 52/106, vs. 1.0%, 2/182; p <0.001), fewer admissions to hospital (46.2%, 49/106, vs. 68.1%, 124/182; p <0.001) and fewer comorbidities (81.1%, 86/106, vs. 59.9%, 109/182; p <0.001). Sixty cases of MRSA-CC398 infection were diagnosed, including, among others, endocarditis, septic arthritis, prosthetic joint infection, pneumonia and bacteraemia.

CONCLUSIONS

Prevalence of MRSA-Tet^R (especially CC398) at the hospital level in a Spanish region with intensive pig farming activity is high and is responsible for severe infections. Significant differences were detected in clinical and epidemiologic characteristics among MRSA-Tet^R and MRSA-Tet^S patients.

New intravascular contrast agent applied to dynamic contrast enhanced MR imaging of human breast cancer

Purpose: To evaluate the feasibility of using dynamic contrast-enhanced MR imaging with a new intravascular contrast agent in grading human breast cancer.

Material and Methods: 23 patients with 27 breast tumors (21 carcinomas and 6 fibroadenomas) were examined with dynamic MR imaging after administration of Clariscan, an iron oxide nanoparticle with large T1 relaxivity and a long plasma half life. A 3D T1-weighted gradient echo sequence with an acquisition time of 60 s was repeated at regular intervals of 3–5 min before and up to 1 h after injection of 2 mg/kg b.w. of Clariscan. The endothelial transfer constant, Kps, which reflects overall vascular permeability, and the fractional plasma volume, fPV, were estimated from time-intensity curves acquired from three separate regions of interest (ROIs): whole tumor, a permeability hot spot, and a blood volume hot spot. Kps and fPV were compared to the results of histologic tumor grading (Scarff-Bloom-Richardson, SBR) and microvascular density, MVD.

Results: A statistically significant correlation between the MR-derived Kps parameters and the SBR score was obtained for the whole tumor ROI ( R = 0.70), and for the permeability hot spot ROIs ( R = 0.67). A correlation between fPV and SBR was detected for the blood volume hot spot ROIs ( R = 0.48). There was no statistically significant correlation between Kps or fPV with MVD.

Conclusion: The results support the hypothesis that dynamic MR with the intravascular contrast agent Clariscan may be used for non-invasive tumor grading.

Diagnosis and outcome of childhood perineurioma

INTRODUCTION

Intraneural perineurioma is a rare peripheral nerve tumor of childhood and early adulthood. Patients demonstrate progressive muscle weakness and atrophy largely without sensory complaints.

CASE

We report two children with perineurioma affecting the radial and femoral nerves. Electromyography (EMG), ultrasound, and 3-T MR imaging were important tools for localizing perineurioma and permitting its differentiation from other nerve lesions. The first patient underwent surgical excision of the perineurioma and a traditional nerve graft. At 10 months post-operative follow-up, she demonstrated no meaningful recovery of muscle strength compared to her pre-operative assessment. EMG did confirm axonal continuity indicating that reinnervation had occurred via the nerve graft. The second patient underwent a two-staged surgical procedure that included an end-to-side nerve transfer. At 18 months post-operative follow-up, she demonstrated mild improvement in muscle strength and EMG evidence of ongoing reinnervation.

CONCLUSION

The surgical management of perineurioma remains controversial, and reports of clinical recovery after nerve grafts and nerve transfers vary. Nerve transfers have been reported to provide superior results to traditional nerve grafting in adults with post-traumatic plexus injuries. The modest gain in strength of our patient who underwent a nerve transfer raises the question if this may also apply to patients with perineurioma. Additional studies will be required, which must also take into consideration that features of long-standing neuropathy (i.e., limb length discrepancy) have the potential to reduce the likelihood of reinnervation and clinical recovery.