A biomarker for bacteremia in pregnant women with acute pyelonephritis: soluble suppressor of tumorigenicity 2 or sST2

Objective: Sepsis is a leading cause of maternal death, and its diagnosis during the golden hour is critical to improve survival. Acute pyelonephritis in pregnancy is a risk factor for obstetrical and medical complications, and it is a major cause of sepsis, as bacteremia complicates 15-20% of pyelonephritis episodes in pregnancy. The diagnosis of bacteremia currently relies on blood cultures, whereas a rapid test could allow timely management and improved outcomes. Soluble suppression of tumorigenicity 2 (sST2) was previously proposed as a biomarker for sepsis in non-pregnant adults and children. This study was designed to determine whether maternal plasma concentrations of sST2 in pregnant patients with pyelonephritis can help to identify those at risk for bacteremia.Study design: This cross-sectional study included women with normal pregnancy (n = 131) and pregnant women with acute pyelonephritis (n = 36). Acute pyelonephritis was diagnosed based on a combination of clinical findings and a positive urine culture. Patients were further classified according to the results of blood cultures into those with and without bacteremia. Plasma concentrations of sST2 were determined by a sensitive immunoassay. Non-parametric statistics were used for analysis.Results: The maternal plasma sST2 concentration increased with gestational age in normal pregnancies. Pregnant patients with acute pyelonephritis had a higher median (interquartile range) plasma sST2 concentration than those with a normal pregnancy [85 (47-239) ng/mL vs. 31 (14-52) ng/mL, p < .001]. Among patients with pyelonephritis, those with a positive blood culture had a median plasma concentration of sST2 higher than that of patients with a negative blood culture [258 (IQR: 75-305) ng/mL vs. 83 (IQR: 46-153) ng/mL; p = .03]. An elevated plasma concentration of sST2 ≥ 215 ng/mL had a sensitivity of 73% and a specificity of 95% (area under the receiver operating characteristic curve, 0.74; p = .003) with a positive likelihood ratio of 13.8 and a negative likelihood ratio of 0.3 for the identification of patients who had a positive blood culture.Conclusion: sST2 is a candidate biomarker to identify bacteremia in pregnant women with pyelonephritis. Rapid identification of these patients may optimize patient care.

Evaluation of the optimal sequence of adjuvant chemotherapy and radiation therapy in the treatment of advanced endometrial cancer

OBJECTIVE

The optimal sequence of adjuvant chemoradiation in the treatment of advanced endometrial carcinoma (EC) remains unclear. We sought to evaluate the outcomes of patients treated with chemoradiation in sandwich fashion (chemotherapy-radiotherapy-chemotherapy; CRC), versus those treated sequentially (chemotherapy-radiotherapy; CR) (radiotherapy-chemotherapy; RC), to determine if there is a survival advantaged associated with a particular treatment sequence.

METHODS

A multicenter retrospective analysis of patients with stage III and IV EC from 2000-2018 was conducted. Inclusion criteria were patients who had undergone comprehensive surgical staging/tumor debulking; followed by adjuvant chemoradiation. Differences in the frequencies of adverse events were evaluated using Pearson's χ² test. Progression free survival (PFS) and overall survival (OS) rates were calculated using Kaplan-Meier estimates.

RESULTS

Final analysis included 152 patients; 36.8% (n=56) CRC, 28.9% (n=44) CR, and 34.2% (n=52) RC. Histology included 44.0% endometrioid, 47.5% serous and 8.5% clear cell tumors. There was no difference in the frequency of histology (p=0.973), stage (p=0.143), cytoreduction status (p=0.932), or treatment delays (p=0.571) between adjuvant therapy sequences. The most frequent location of disease recurrence was abdomen. The median PFS favored CRC versus CR or RC (36-months vs. 22-months and 24-months, respectively) (p=0.038), as did the median OS (48-months vs. 28-months and 34-months, respectively) (p=0.003). CRC demonstrated superiority over CR and RC sequencing in terms 3-year PFS (55% vs. 34% and 37%, respectively) and 3-year OS (71% vs. 50% and 52%, respectively).

CONCLUSIONS

Adjuvant chemoradiation delivered in CRC sequence was associated with improvements in both PFS and OS compared to alternant therapy sequencing.

A clinicopathologic study of endometrial cancer metastatic to bone: Identification of microsatellite instability improves treatment strategies

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Metastasis of endometrial cancer (EC) to bone is rare, occurring in <1.0% of cases.

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The most common sites of bone metastasis in EC are the spine and hip.

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Diagnosis of bone metastasis is associated with widely metastatic disease and poor prognosis.

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The median overall survival following a diagnosis of bone metastasis was 11 months in our series.

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87.5% of patients with bone metastasis were found to have microsatellite instability.

Metastasis to bone (BM) is an uncommon manifestation of advanced endometrial cancer (EC). The present study will review the clinicopathologic features of a cohort of patients with EC and BM. We conducted a multi-center retrospective review of patients with EC and BM. Demographic and clinical information was extracted from the medical records. Survival outcomes were determined using Kaplan-Meier Curves. Final analysis included 10 patients. The median age was 65 years (range 31–71). 80% had FIGO stage III/IV disease. The most common site of BM was the spine (66%). All patients presented with extraosseous dissemination at the time of diagnosis of BM and 70% were found to have multiple sites of BM. 80% of patients were diagnosed with BM in the recurrent setting. The median time to diagnosis of bone recurrence was 14 months (range: 0–44). Median survival after diagnosis of BM was 11 months (range: 1–22 months). Patients with endometrioid histology and single site of bone metastasis experienced improved survival (p = 0.04 and p = 0.05, respectively). Eight patients had immunohistochemistry or molecular tumor profiles available for review. Seven of these patients (87.5%) were found to have microsatellite instability (MSI). The most common mutation was hypermethylation of MLH-1 (43%). To our knowledge, this is the first report demonstrating a correlation between MSI and metastasis to bone. The identification of BM in EC is uncommon, but will alter treatment strategies and dramatically impact prognosis. Molecular tumor profiling should be performed to identify targeted therapy options and optimize adjuvant treatment strategies.

Surgical Management of Underlying Biliary Disease in Refractory Hyperemesis Gravidarum

Hyperemesis gravidarum (HEG) is the most common cause of hospitalization during the first half of pregnancy. It affects approximately 0.3-3% of all pregnancies [1]. There is no one accepted definition or diagnostic criteria for HEG. The most commonly cited criteria include persistent vomiting not related to other causes, measure of acute starvation (most commonly ketonuria), and weight loss; most often loss of at least 5% of pre-pregnancy body weight [2]. Symptoms typically begin in the late first trimester and are rarely associated with abdominal pain. HEG is managed a stepwise fashion by adding pharmacotherapy sequentially until symptom resolution [3, 4]. Patients who present with classic signs and symptoms of HEG but are non-responsive to all levels of therapy present a therapeutic challenge. In these cases, the search for other causes of nausea and vomiting should be undertaken. In the current report, we review 10 cases of refractory HEG. Eight patients were incidentally diagnosed with biliary disease by abdominal ultrasound (US) during workup for refractory symptoms. These patients underwent surgical consultation and were subsequently offered laparoscopic cholecystectomy. Here, we review the pregnancy courses from initial presentation until delivery to explore the incidence of underlying biliary disease and role of cholecystectomy in refractory HEG.

'Caught in the middle'? Mental nurse training in England 1919-51

The early history of mental health nurse training is one that has only been partially researched. While some writers have discussed the content and impact of training on the development of mental health nursing, little has been written on the professional and institutional factors that influenced this development. The medical profession, psychiatry, was to play an important role in the development of training and regulation of nursing staff in the large Victorian asylums and was an important influence on the knowledge base of mental health nursing. Their professional organization, the Medico-Psychological Association (the Royal Medico-Psychological Association after 1926 when they acquired a royal prefix) produced the first textbook for asylum nurses in 1885 and established a national training scheme for them 4 years later. However, in 1919 the Nurses Registration Act established the General Nursing Council for England and Wales and this body was given statutory responsibility for the training and registration of nurses, including 'mental' nurses. They were soon to be in conflict with the Medico-Psychological Association. The two organizations continued to run their own rival training schemes for mental health nurses for over 30 years, the Royal Medico-Psychological Association finally relinquishing their role in 1951. The Royal Medico-Psychological Association scheme proved far more popular than the General Nursing Councils, with significantly more nurses participating in it. This paper discusses these organizational influences on the development of 'mental nurse' training and discusses the possible impact that they have had on the knowledge base of mental health nursing.

An interaction between the IL-4Ralpha gene and infection is associated with atopic eczema in young children

BACKGROUND

A gain of function mutation (Q551- > R) in the IL-4 receptor alpha-chain (IL-4Ralpha) has been found to be associated with atopy in some studies but not others. The different results may be explained by interactions between the IL-4Ralpha polymorphism and environmental factors.

OBJECTIVES

To identify interactions between the R551 mutation and environmental factors that are associated with atopy.

METHODS

DNA from the Children in Focus (CiF) cohort of the Avon Longitudinal Study of Parents and Children (ALSPAC) was genotyped by heteroduplex formation for the presence of the R551 polymorphism. The data were then analysed for associations with flexural eczema as an indicator of atopic eczema, skin prick tests to allergens and serum IgE levels, and for interactions with environmental factors.

RESULTS

A significant (P = 0.02) positive association was seen between the R551 polymorphism and flexural eczema in children up to 6 months of age who had not been given antibiotics, but not in children who had been given antibiotics. This association was maintained as a trend until 30 to 42 months of age but was no longer statistically significant. There was no significant association between the R551 polymorphism and positive skin prick tests or levels of serum IgE at 61 months of age, consistent with the effect of the R551 polymorphism being restricted to early life.

CONCLUSION

There is an association between the R551 polymorphism and flexural eczema in children at 6 months of age who have not had infection requiring treatment with antibiotics. Restriction of the R551 association with eczema to children who have not had antibiotics lends support to the 'hygiene hypothesis', which states that exposure to infection in childhood can protect against allergic disease.

Women in mental health nursing: angels or custodians?

Like other 'Cinderella' services mental health nursing has received much less attention from historians than general nursing. However a study of its history can illuminate such issues as the division of labour, gender, images of nursing, professionalisation and unionisation. Drawing on primary historical sources, including hospital archives and contemporaneous reports and journals, the author considers the role of women in mental health nursing, from its origins to the onset of the NHS in 1948. The development of mental health nursing differed substantially from general nursing. It could be argued that the tensions between the two were never more apparent than in the debate surrounding the registration of nursing in the early twentieth century. Female mental health nurses fighting with police in the Radcliff Strike in 1922 portrays a much less famous image in nursing's history than Florence Nightingale with her lamp. The dichotomy between the custodial nature of the Victorian asylum system and the caring ethos espoused by the advocates of 'moral management' created many tensions. Images of nurses as angels, responding to a calling or vocation, sat uneasily with the large numbers of men working in the asylums and the growth of trade unionism in this period, particularly after the foundation of the National Asylum Workers Union in 1910. The periods of industrial unrest in the mental hospitals of the inter-war years saw women members playing an important role; this has important ramifications for mental health nursing today.

Plasma chitotriosidase activity in Gaucher disease patients who have been treated either by bone marrow transplantation or by enzyme replacement therapy with alglucerase

A marked elevation in plasma chitotriosidase (chitinase) activity has recently been observed in patients with Gaucher disease (Hollak et al 1994). It has been suggested that this phenomenon may serve as a useful marker for the efficacy of treatment with enzyme replacement therapy. We report our findings on the comparison of plasma chitotriosidase levels in 8 patients treated with the modified human placental enzyme alglucerase and 8 patients treated by allogeneic bone marrow transplantation (BMT). Two years after transplantation the activity in the BMT patients had fallen by over 93% and has continued to fall. Now, 5-12 years post-BMT, 6 patients have normal levels of plasma chitotriosidase and 2 patients have activities slightly above the reference range. Patients have been treated with alglucerase for a considerably shorter time than the BMT patients. The chitotriosidase activities have fallen and are continuing to fall in 7 patients but at a slower rate than in the BMT group. In one patient there has been no appreciable change in activity over the last 6 months, which would suggest that she may be on too low a dosage.