Outcomes of 4-factor Prothrombin Complex Concentrate in Patients With Liver Disease and Nonvitamin K Antagonist-Related Coagulopathy: A Retrospective Study

The administration of 4-factor prothrombin complex concentrate (4F-PCC) has expanded beyond its Food and Drug Administration (FDA)-approved indication for the emergent reversal of vitamin K antagonists (VKAs). Therefore, this study aimed to evaluate the risks and benefits associated with the expanded use of 4F-PCC. We conducted a single-center retrospective review of 4F-PCC administrations at our university hospital. Of the 159 patients who received 4F-PCC, 76% (n = 121) and 24% (n = 38) received it for the FDA-approved indication in the vitamin K-related coagulopathy (VKA) group and for expanded use in the nonvitamin K-related coagulopathy (nVKA) group, respectively. The expanded use of 4F-PCC was associated with a less robust reduction in the international normalized ratio (INR) (INR of -0.7 ± 1.3 vs INR of -1.6 ± 1.8, P = .002), and fewer patients in the nVKA group achieved a postadministration INR of less than1.5 (11% vs 79%, P = .001) than those in the VKA group. Furthermore, the 30-day mortality rate was significantly higher in the nVKA cohort than in the VKA cohort (42% vs 20%, P = .04). Notably, based on our data, underlying differences in the patient's comorbidities, particularly advanced liver disease, may have contributed to the observed outcome variations, including mortality rate. Therefore, factors, including comorbidities and the underlying etiology of coagulopathy, should be considered when deciding on the expanded use of 4F-PCC. Further research is needed to better understand the potential risks and benefits of 4F-PCC in expanded use scenarios, and the clinical decision to use 4F-PCC outside its FDA-approved indication should be made carefully, considering this information.

An Undergraduate Surgery Interest Group: Introducing Premedical Students to the Practice of Surgery

PURPOSE

Early exposure and surgical mentorship can augment interest in surgery. We evaluate the effect and feasibility of offering education and mentorship opportunities in surgery to premedical students at our institution through an undergraduate surgery interest group (USIG).

MATERIALS AND METHODS

We conducted a 1-year assessment of our USIG and reviewed its organizational structure, funding resources, media promotion, and educational activities. Our USIG hosted introductory-level surgical skills workshops, guest lectures by surgeons, and various facility tours. To assess participants' interests, as well as the influences on them to pursue a surgical profession, we analyzed pre- and post-event questionnaires. Similar questionnaires were completed by medical students in our medical student surgery interest group to compare any differences in perception between premedical and medical students.

RESULTS

Our USIG currently has 378 undergraduate student members, with a higher proportion of women than in our medical student surgery interest group (P < 0.003). Neurosurgery was the most popular career choice among undergraduate participants. Participants reported the highest satisfaction with suturing and high-fidelity trauma surgery skills workshops. Undergraduate participants indicated that their intrinsic interest in the sciences is the highest motivation to pursue a surgical profession. Resident lifestyle and social obligations of a surgical career were actually positive influences for undergraduate participants; in contrast, medical students viewed those variables as negative factors.

CONCLUSION

Our USIG was met with enthusiasm by premedical students and faculty alike. Participation strengthened premedical students' interest in pursuing surgery and increased their understanding of the surgical profession. Early mentorship may positively influence premedical students' perception of surgical careers. USIG is economically feasible and time-efficient; we encourage other academic institutions and educators to consider investing in similar interest groups.

Abstract 5914: The porcine model for onocolytic adenovirus-based therapy

Oncolytic adenoviruses (Ad) are promising tools in the development of cancer therapeutics. A majority of Ad-based therapies utilize serotypes of species C, with Adenovirus type 5 (Ad5) being the most commonly employed. Previously, clinical trials have demonstrated the low efficiency of Ad5 vectors, mainly due to absence of the Ad5 primary receptor (Coxsackie Adenovirus Receptor, CAR) in cancer cells. Engineering Ad vectors utilizing the species B (Ad3, Ad35, Ad11) receptors have greatly improved the oncolytic potential of Ad-based therapies. However, the lack of a viable animal model has impeded clinical translation of these tropism-modified vectors. Mouse models are insufficient because Ad does not replicate in murine tissue. Non-human apes are not feasible due to availability and cost. Cotton rats and Syrian hamsters, although permissive of Ad5 replication, are not suitable for Ad3-, Ad35-, and Ad11-retargeted vectors due to the lack of species B primary receptors (CD46 and desmoglein 2) in rodent systems. In this study, we explored pigs as a model to study performance of the group B oncolytic adenoviruses by employing the fiber-modified Ad5/Ad3 chimeric vector. As a control, the Ad5 fiber-unmodified virus was used. First, we demonstrated the ability of swine cell lines to support replication of both Ad5 and Ad5/Ad3. Second, we analyzed binding, gene transfer, cytolytic, and replication ability of Ad5 and Ad5/Ad3 in various non-human cell lines (swine, hamster, murine, rat, bovine, canine). Our data confirmed that while hamster cell lines (HP1 and HapT1) were able to support binding and replication of Ad5-based vectors, they failed to support that with the Ad3-retargeted vectors. Additionally, we showed that among all tested cell lines, only porcine cells (PK15 and PTK75) were supportive of both binding and replication of the Ad3-retargeted virus. Of note, Ad5/Ad3 outperformed Ad5 in its cytolytic effect in porcine cell lines. These in vitro results prompted evaluation of the vectors in vivo. Immunocompetent Yorkshire pigs were systemically injected with a single dose of Ad5- and Ad5/3- expressing luciferase (Luc) from the Ad E3 region. Quantitative PCR analyses of the primary organs collected 7 days post-infection revealed Ad5 and Ad5/3 viral DNA in the lungs and spleen. Replication-dependent Luc expression was also observed in these tissue samples suggesting active viral replication. The quantity of viral DNA in other tissue such as the kidneys, liver, and pancreas was negligible. The results of these in vitro and in vivo studies indicate that pigs are a promising model to assess unmodified and tropism-modified adenoviral vectors.

Citation Format: Malavika Chandrashekar, Lisa Koodie, Michele Dunning, George Ruth, Richard Bianco, Masato Yamamoto, Julia Davydova. The porcine model for onocolytic adenovirus-based therapy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5914.

A comparative study of different modalities of treatment in nicotine dependence syndrome

There are different modalities for management of Nicotine dependence, but it is still inconclusive which is the best modality for the treatment of Nicotine dependence syndrome (NDS). In this background the present study was carried out to assess the efficacy and to compare different modalities for the treatment of NDS.

METHODS

Patients diagnosed as NDS as per ICD-10 were taken up for study. These patients were administered proforma to elicit sociodemographic details, Fagerstrom test for Nicotine Dependence, Questionnaire of Smoking Urges-Brief and breath analysis was done using carbon monoxide meter. Assessment was done at base line and at weekly follow-ups for 12 weeks. Patients were divided into six groups randomly. Group A received BUP at a dose of 150mg/day for 3 days; subsequently increased to 300mg/day, Group B: for initial 6 weeks Nicotine gum of 4mg every 1-2 hourly was used and next 6 weeks every 2-4 hourly was used, Group C: BI, Group D: BI+BUP, Group E: BI+NRT, Group F received BUP+NRT+BI.

RESULTS

The quit rates at end of the study were BUP-30%, NRT-26.66%, BI-23.33%, BI+BUP-43.33%, BI+NRT-33.33%, and BI+BUP+NRT-50%. BI+BUP+NRT had 2-3 times more quit rates than the individual modality treatment group.

CONCLUSION

There was no statistically significant difference between the study groups, but there was clinical difference in quit rates. Among the groups BI+BUP+NRT had higher quit rates compared to other groups. Combination modalities yield better quit rates than individual modalities.

Case report on anorexia nervosa

Anorexia nervosa is an eating disorder characterized by excessive restriction on food intake and irrational fear of gaining weight, often accompanied by a distorted body self-perception. It is clinically diagnosed more frequently in females, with type and severity varying with each case. The current report is a case of a 25-year-old female, married for 5 years, educated up to 10(th) standard, a homemaker, hailing from an upper social class Hindu (Marvadi) family, living with husband's family in Urban Bangalore; presented to our tertiary care centre with complaints of gradual loss of weight, recurrent episodes of vomiting, from a period of two years, menstrual irregularities from 1 year and amenorrhea since 6 months, with a probable precipitating factor being husband's critical comment on her weight. Diagnosis of atypical anorexia nervosa was made, with the body mass index (BMI) being 15.6. A multidisciplinary therapeutic approach was employed to facilitate remission. Through this case report the authors call for the attention of general practitioners and other medical practitioners to be aware of the symptomatology of eating disorders as most patients would overtly express somatic conditions similar to the reported case so as to facilitate early psychiatric intervention.

Evaluation of immuno efficiency of hemorrhagic septicemia vaccine strain (vaccine seed)

OBJECTIVE

To compared seed culture of hemorrhagic septicemia (HS) bacteria which was used to produce vaccine for its antibody induction efficiency before and after passaging in natural host (calf) using laboratory animals.

METHODS

Serial dilution of virulent bacteria was injected in to mice which were immunized with HS vaccine which was obtained from seed bacteria before and after back passaged in calf. Ratio of survived and dead was calculated by Reed-Meunch hypothesis and the LD50 value for each vaccine trial groups were calculated.

RESULTS

The immunological study revealed that vaccine prepared from back passaged seed culture showed greater improvement in its immunopotency than seed vaccine (before back passage). Around 200 mice were used to study the immuno efficiency of vaccine. Each mouse was from the same source, which were free from the Pastuerella infection previous to expose to trial infection. The same broth culture of HS was used to induce infection in mice in both trials (vaccine before back passage and vaccine after back passage). The 0.2 mL of broth dilution from 10(-1) to 10(-10) was used, as dilution increases, death rate decreases. It indicates the minimum load of bacterium is required to induced infection.

CONCLUSIONS

Obtained results revealed that back passaged vaccine seed HS bacteria in its natural host had provided better immune efficiency to the culture than laboratory stock culture, and this findings recommended that regular annual back passage was mandatory for the vaccine seed culture of Pastuerella multocida bacteria for better establishment of immune potent vaccines.

A comparison of early and delayed arthroscopically-assisted reconstruction of the anterior cruciate ligament using hamstring autograft

Delayed rather than early reconstruction of the anterior cruciate ligament is the current recommended treatment for injury to this ligament since it is thought to give a better functional outcome. We randomised 105 consecutive patients with injury associated with chondral lesions no more severe than grades 1 and 2 and/or meniscal tears which only required trimming, to early (< two weeks) or delayed (> four to six weeks) reconstruction of the anterior cruciate ligament using a quadrupled hamstring graft. All operations were performed by a single surgeon and a standard rehabilitation regime was followed in both groups. The outcomes were assessed using the Lysholm score, the Tegner score and measurement of the range of movement. Stability was assessed by clinical tests and measurements taken with the KT-1000 arthrometer, with all testing performed by a blinded uninvolved experienced observer. A total of six patients were lost to follow-up, with 48 patients assigned to the delayed group and 51 to the early group. None was a competitive athlete. The mean interval between injury and the surgery was seven days (2 to 14) in the early group and 32 days (29 to 42) in the delayed group. The mean follow-up was 32 months (26 to 36).

The results did not show a statistically significant difference for the Lysholm score (p = 0.86), Tegner activity score (p = 0.913) or the range of movement (p = 1). Similarly, no distinction could be made for stability testing by clinical examination (p = 0.56) and measurements with the KT-1000 arthrometer (p = 0.93).

Reconstruction of the anterior cruciate ligament gave a similar clinical and functional outcome whether performed early (< two weeks) or late at four to six weeks after injury.

Sacral chordomas: a 10-year study

A retrospective analysis of 14 cases of sacral chordoma seen between 1984 and 1993 at the Kidwai Memorial Institute of Oncology is reported. The mean patient age was 54 years, with 13 males and one female. Seventy-one per cent of patients presented with symptoms related to a painful sacral mass. Eight patients underwent radical surgery and two had adjuvant radiotherapy. One patient had a partial tumour resection. Three patients received radical radiotherapy. Two patients were offered only pain relief medication. The median follow-up was 33 months. The actuarial overall survival (OS) at 5 years was 48%. In the 12 patients in whom curative therapy was attempted, the 5-year OS was 56% and progression-free survival was 36%. Four patients developed local recurrence and three developed distant metastasis.

The scapular fasciocutaneous flap: a new flap for reconstruction of the posterior neck

The axial, myocutaneous and free flaps have made immediate reconstruction of head and neck defects possible. Notwithstanding this remarkable progress, defects of the posterior neck leave the reconstructive surgeon with very little choice. The scapular fasciocutaneous flap is easy to harvest, reliable and versatile, with functional and cosmetic results comparable to free flaps. We describe the anatomy and the technique of this new donor site, along with a case report.

Neoadjuvant Cis-DDP in esophageal cancers: an experience at a regional cancer centre, India

We are analysing the results of 80 patients who underwent surgery during 1983-84 for esophageal cancer. Forty patients who received pre-operative single agent Cis-DDP were grouped under "A" and 40 patients who went for surgery directly were grouped under "B". Twenty-two patients (55%) of Group A showed tumor necrosis. Both groups underwent resection and hand-sewn anastamosis of the esophagus. There were 10 post-operative deaths among 80 resected cases, 9 of them being from anastomatic leak. Cis-DDP has induced negligible side effects. A comparatively high survival rate during early years in patients who responded to Cis-DDP suggests that neoadjuvant chemotherapy might be of value.