Tocilizumab Associated With Survival in Patients Hospitalized for COVID-19 Acute Respiratory Distress Syndrome and Low Urine Output

BACKGROUND

Acute respiratory distress syndrome (ARDS) with oliguria is associated with increased mortality. Interleukin-6 (IL-6) plays an integral role in the pathophysiology of both disease processes. Patients who experience severe COVID-19 have demonstrated higher IL-6 levels compared to baseline, and use of tocilizumab has demonstrated efficacy in such cohorts. We set out to investigate the relationship between tocilizumab use, COVID-19 ARDS, low urine output, and mortality.

METHODS

Retrospective cohort review of adult patients aged ≥ 18 years with COVID-19 and moderate or severe ARDS, admitted to the intensive care unit (ICU) of a tertiary referral center in metropolitan Detroit. Patients were analyzed based on presence of oliguria (defined as ≤ 0.7 mL/kg/h) on the day of intubation and exposure to tocilizumab while inpatient. The primary outcome was inpatient mortality.

RESULTS

One hundred and twenty-eight patients were analyzed, 103 (80%) with low urine output, of whom 30 (29%) received tocilizumab. In patients with low urine output, risk factors associated with mortality on univariate analysis included Black race (P  =  .028), lower static compliance (P  =  .015), and tocilizumab administration (P  =  .002). Tocilizumab (odds ratio 0.245, 95% confidence interval 0.079-0.764, P  =  .015) was the only risk factor independently associated with survival on multivariate logistic regression analysis.

CONCLUSION

In this retrospective cohort review of patients hospitalized with COVID-19 and moderate or severe ARDS, tocilizumab administration was independently associated with survival in patients with low urine output ≤ 0.7 mL/kg/h on the day of intubation. Prospective studies are needed to investigate the impact of urine output on efficacy of interleukin-targeted therapies in the management of ARDS.

A Case of Acute Liver Failure Due to Artemisinin-Derived Herbal Supplements

A 49-year-old female presented with malaise, nausea, vomiting, and discolored urine. She was found to have an acute liver failure with labs significant for aspartate aminotransferase (AST) of 2164, alanine aminotransferase (ALT) of 2425, alkaline phosphatase (ALP) of 106, total bilirubin of 3.6, and lactate dehydrogenase (LDH) of 2269. The international normalized ratio (INR) was also elevated at 1.9. All workup for acute liver failure was negative and it was found that she had started taking a new supplement called "Gut Health", which contained artemisinin, for weight loss and menopausal symptoms. After discontinuing the supplements and symptomatically treating her for acute liver failure, her transaminitis resolved.

P–285 Controlling semi-invasive activity of human endometriotic stromal cells by inhibiting NF-kB signaling pathway using aloe-emodin or aspirin

Study question

Does inhibiting nuclear factor-kB (NF-kB) signaling by aloe-emodin (AE) or aspirin (Asp), as anti-inflammatory compounds, suppress the invasive activity of stage IV human endometriotic stromal cells?

Summary answer

Eutopic endometriotic stromal cells (EuESCs) seem to have a semi-invasive activity which is largely suppressed by AE or Asp.

What is known already

Inflammation and its master regulator, NF-kB, have been implicated in the development of endometriosis. Inhibition of NF-kB pathway using small molecules ameliorated disease progression and reduced the lesion size; nevertheless, underlying mechanism is not fully understood.

Study design, size, duration

In this cross-sectional study, a total of 8 infertile patients with proven endometriosis and 8 women without endometriosis (Control group) undergoing infertility treatment cycles, were enrolled between October 2018 and December 2019. The invasiveness of collected endometriotic stromal cells before and after treatment with AE or Asp, was analyzed and compared with the control group.

Participants/materials, setting, methods

The eutopic endometriotic and healthy endometrial biopsies were digested and the single cells were cultured. Gene and protein expression of proliferation, adhesion, and invasion markers of eutopic endometriotic stromal cells (EuESCs) with and without treatment with AE or Asp, as well as control endometrial stromal cells (CESCs) were analyzed using q-PCR and immunofluorescence staining, respectively. Cell migration capacity was assessed by wound closure assay.

Main results and the role of chance

We observed an association between NF-kB overexpression and higher proliferation/adhesion capacity in EuESCs. TNF-α, as a known NF-kB inducer, further potentiated this association. EuESCs at stage IV, displayed silent invasive and migratory behaviors. Pretreatment of EuESCs with AE or Asp significantly attenuated NF-kB expression and reduced proliferative, adhesive, invasive and migratory activity.

Limitations, reasons for caution

Due to some adverse effects observed following treatment with AE or Asp on the normal activity of EuESCs, more investigations on possible toxicity of the treatment, must be considered.

Wider implications of the findings: We suggest that both Asp and AE (as potent NF-kB inhibitors) may be useful as a supplement to conventional endometriosis treatments.

Trial registration number

Not applicable

Saccharomyces cerevisiae lysophospholipid acyltransferase, Lpt1, requires Asp146 and Glu297 for catalysis

The esterification of lysophospholipids contributes to phospholipid synthesis, remodeling, and scavenging. Acyl-CoA-dependent lysophospholipid acyltransferase activity with broad substrate use is mediated by Saccharomyces cerevisiae Lpt1p. We sought to identify Lpt1p active site amino acids besides the histidine conserved among homologs and repeatedly found to be required for catalysis. In vitro Lpt1p assays with amino acid modifying agents implicated aspartate, glutamate, and lysine as active site residues. Threonine and tyrosine were not ruled out. Aligning the primary structures of functionally characterized LPT1 homologs from fungi, plants, and animals identified 11 conserved aspartate, glutamate, lysine, threonine, and tyrosine residues. Site-directed mutagenesis of the respective codons showed that changing D146 and E297 abolished activity without abolishing protein expression. The mechanism of Lpt1p was further analyzed using monounsaturated acyl-CoA species with different double bond positions. Delta 6 species showed the highest catalytic efficiency. We propose that D146 and E297 act in conjunction with H382 as nucleophiles that attack the hydroxyl group in lysophospholipids in a general acid/base mechanism. This sequential mechanism provides a precedent for other members of the membrane bound O-acyltransferase family. Also, Lpt1p optimally orients acyl-CoA substrates with 7.5 Å between a double bond and the thioester bond.

Effect of therapeutic ultrasound on folliculogenesis, angiogenesis and apoptosis after heterotopic mouse ovarian transplantation

One of the challenges in ovarian transplantation is ischemia-reperfusion damage. When transitional tissue faces an acute and critical condition in terms of blood supply (immediately after organ transplantation), treatment with low-intensity pulsed ultrasound (LIPUS) seems to be very beneficial. The aim of this study was to evaluate the effects of ultrasound therapy on heterotopic transplanted mouse ovarian tissue. Adult female Naval Medical Research Institute mice were divided into three groups. In the experimental groups, the transplanted ovary was exposed 5 min daily to ultrasound with an intensity of 0.3 W/cm(2), frequency of 3 MHz and pulse mode of 1:4. The grafted ovaries were assessed with the usual histology and immunohistochemistry techniques. Results indicate that more CD31 angiogenic factor was expressed in irradiated animals than in control animals, and ultrasound therapy resulted in better follicular preservation, especially after 14 d. In conclusion, therapeutic ultrasound may accelerate and increase re-angiogenesis and can help to promote ovarian follicular growth.

Aeluropus littoralis NaCl-induced vacuolar H(+)-ATPase subunit c: molecular cloning and expression analysis

The vacuolar H(+)-ATPase (VHA) is a universal component of eukaryotic organisms that is responsible for establishing and maintaining intracellular pH gradients across specialized organellar membranes, and influences the transport of cations into the vacuoles of plant cells. A cDNA clone (AlVHA-c) encoding the c subunit of V-ATPase was isolated from the monocot halophyte Aeluropus littoralis. The DNA sequence of AlVHA-c showed significant homology with V-ATPase subunit c of millet, rice and Zea mays. The deduced amino acid sequence of AlVHA-c and other reported c subunits were compared, and sequence relationships have been drawn to know their genetic relatedness. Semi-quantitative RT-PCR analysis of salt-treated A. littoralis plants revealed that subunit c of V-ATPase is regulated by NaCl treatment at transcriptional level in a tissue-specific manner. The increased V-ATPase subunits amounts of A. littoralis provide the energy for the compartmentalization of sodium in response to salinity.

Routine computerized tomography scanning, groin ultrasound with or without fine needle aspiration cytology in the surgical management of primary squamous cell carcinoma of the vulva

We set out to study whether computerized tomography (CT) scanning of the vulva and the groin and groin ultrasound scanning (USS) alone or with fine needle aspiration cytology (FNAC) (USS/FNAC) influenced or could influence the surgical management of primary squamous cell carcinoma of the vulva (SCCaV). Forty-four patients underwent surgery for primary SCCaV following radiologic imaging by one or more modalities. Patient details included the clinical assessment of the carcinoma, radiologic findings, the operation performed, and whether the decision regarding the type and extent of surgery for the vulval carcinoma and, in particular, for the groin node dissection was or could be influenced by the radiologic findings. The age range was 38-87 years, with a median of 74 years. A total of 75 groin dissections were performed. Twenty-five of the 44 patients (56.8%) did not have groin node metastasis, 14 had unilateral metastasis (31.8%), and 5 (11.4%) had bilateral metastasis. All cases with histologically proven nodal status were analyzed to compare the preoperative imaging status with the histology. The calculated sensitivity, specificity, negative predictive value, and positive predictive value for CT were 58%, 75%, 75%, and 58%, for USS alone-87%, 69%, 94%, and 48%, and for USS-guided FNAC-80%, 100%, 93%, and 100%, respectively. There was no patient in whom surgical planning for the vulval carcinoma or the groin nodes was or could be altered by the CT findings. The data do not support the routine use of CT scanning in patients with primary SCCaV, either in assessment of the primary vulval carcinoma or in detecting groin nodal metastases. For the groin nodes, USS/FNAC is superior to CT in assessing disease status. In contrast to CT, USS/FNAC may have a useful clinical role in the management of the groin nodes in vulval carcinoma.

Factors predisposing to cavity margin positivity following conservation surgery for breast cancer

AIMS

Incomplete excision leads to local recurrence following breast conservation therapy (BCT). The aim of this study was to examine factors associated with cavity margin (CM) positivity and return to theatre rates.

METHODS

Breast conservation surgery with entire CM excision was the initial procedure in 301 patients with 303 breast cancers. Of these, 258 patients were treated successfully with breast conservation surgery and 43 patients subsequently required a mastectomy for persistent involved margins. The mean and median follow-up was 38 and 42 (range 6-78) months, respectively.

RESULTS

Positive CMs were found in 73 out of 303 tumours. Large tumour size (p<0.001) and tumour type (invasive lobular cancer and ductal carcinoma in-situ) (p=0.043) were significant predictors of CM positivity both by univariate and multivariate analysis. As a result of CM status in relation to initial margin (IM) status, 60 cancers treated that were IM positive but CM negative avoided return for further excision at a second operative procedure.

CONCLUSION

Complete CM excision should avoid the need for further re-excision surgery in most patients where initial specimen margin was positive.

Clinical presentation and long-term outcome of pure myoepithelial carcinoma of the breast

INTRODUCTION

Pure myoepithelial carcinoma of the breast is a rare tumour of controversial histogenesis. Little is known about its natural history and long-term outcome following treatment.

METHODS

All patients with pure myoepithelial carcinoma treated at our institution between 1970 and 2001 were studied with respect to pathological features, outcome and prognosis.

RESULTS

Six patients were identified. The median age was 60 (40-66) years and median follow-up was 34.5 months (range 14-76) months. Four tumours were T1 and one was T2 (one tumour size unknown). There were two moderately differentiated and three well-differentiated tumours (grade could not be assessed in one patient). Oestrogen and progesterone receptor could be assessed in five patients and all were negative. Primary treatment was wide local excision with clear radial margins. Lymph node assessment was negative in all patients. One patient received adjuvant radiotherapy. Three patients developed local recurrence at 15, 38 and 50 months and two patients developed distant metastasis at 30 and 79 months. The local recurrences were treated by further excision but two patients developed distant metastasis at intervals of 15 and 26 months, respectively. Two patients have died of the disease and four remain well. The 2-year and 5-year survival was 88% (SE, 6) and 55% (SE, 16), respectively. Large tumour size is a prognostic indicator of poor outcome.

CONCLUSION

Pure myoepithelial carcinoma of the breast adopts an aggressive clinical course with an outcome comparable to poorly differentiated adenocarcinoma of the breast.

Early changes in apoptosis and proliferation following primary chemotherapy for breast cancer

Patients undergoing primary chemotherapy for invasive breast cancer consented to a core biopsy of the invasive breast primary pre- and 24 h postchemotherapy. The resulting tissue was analysed for apoptosis, Ki67, ER and HER-2 using immunohistochemical techniques. These data were then used to evaluate the relationship between these biological markers and response to chemotherapy and overall survival. Response rate to chemotherapy in this group was 86%, 16 patients (25%) achieved a clinical complete response and 41 (63%) a partial response. Prechemotherapy there was a significant correlation between Ki67 and apoptotic index (AI), r=0.6, (P<0.001). A significant rise in AI (P<0.001), and fall in Ki67 (P=0.002) was seen 24 h following chemotherapy. No relationship was seen between pretreatment AI and clinical response, but higher Ki67 and growth index (Ki67/AI ratio, GI) did correlate with clinical response (both r=0.31, P<0.025). No correlation was seen between the change in AI or Ki67 at 24 h and clinical response or survival. Significant changes in apoptosis and proliferation can be demonstrated 24 h following chemotherapy, but these changes do not relate to clinical response or outcome in this study. Pretreatment proliferation and GI are however predictive of response to chemotherapy in breast cancer.

Squamous cell carcinoma of the breast: clinico-pathologic implications and outcome

AIMS

Pure squamous cell carcinoma (SCC) of the breast is a rare tumour and little is known about long-term outcome. We report our experience of a consecutive series of patients.

METHODS

All patients with SCC treated at our institution between 1970 and 2001 were included. The pathological features, outcome and prognosis were studied.

RESULTS

Eleven patients were identified. The median age was 55 (38-90) years and median follow-up was 62 (3-332) months. Four tumours were T1, three were T2 and three were T3 (one tumour size was unknown). There were seven poorly differentiated and three moderately differentiated SCC. Tumour grade could not be assessed in one patient. Primary treatment was mastectomy in six patients, wide local excision in four patients and radiotherapy in one patient. There was lymph node (LN) involvement in two patients. Oestrogen receptor status was assessed in seven patients and only one tumour was positive. Adjuvant chemotherapy was given to three patients and five patients received adjuvant radiotherapy. Two patients developed local recurrence at 5 and 12 months and three patients developed distant metastasis at 2, 36 and 306 months. Three patients were treated with chemotherapy at recurrence. Three patients have died of the disease, two are alive with disease and six remain well. The 2- and 5-year overall survival was 80% (SE=13%) and 67% (SE=16%) respectively. Large tumour size and positive LN status were prognostic indicators of poor outcome.

CONCLUSION

SCC of the breast adopts an aggressive course with outcome comparable to poorly differentiated breast adenocarcinoma.

The role of ultrasound-guided cytology of groin lymph nodes in the management of squamous cell carcinoma of the vulva: 5-year experience in 44 patients

AIM

To assess the accuracy of ultrasound combined with fine-needle aspiration cytology (FNAC) in the detection of lymph node metastasis in patients with squamous cell carcinoma of the vulva.

MATERIALS AND METHODS

The groin nodes of 44 consecutive patients with primary squamous cell carcinoma of the vulva undergoing groin node dissection were assessed with ultrasound and FNAC. The results were compared with histology from subsequent inguinofemoral lymph node dissection. Twenty-nine patients underwent bilateral groin node dissections and 15 unilateral providing comparable data for 73 groins.

RESULTS

Histology demonstrated metastatic disease in 28 groins and no evidence of metastatic disease in 45. Ultrasound agreed with the histology in 67 of the 73 groins (92%), with two false-positives, four false-negatives and two indeterminate appearances. Cytology agreed with the histology in 65 of 72 FNAC samples obtained (90%), with six false-negatives, and one indeterminate result. No false-positive cytology results were seen. Ultrasound and FNAC together failed to detect metastatic disease in four groins, one with an indeterminate ultrasound appearance, another with indeterminate cytology, the two others each having a single positive inguinal node despite a negative ultrasound and FNAC.

CONCLUSION

The combination of ultrasound and FNAC provides a sensitive and specific tool for pre-operative assessment and may prevent unnecessary groin dissection and the attendant morbidity in selected patients with vulval cancer.

Normal and SV40 transfected human peritoneal mesothelial cells produce IL-6 and IL-8: implication for gynaecological disease

High levels of interleukin-6 (IL-6) and interleukin-8 (IL-8) have been demonstrated in the peritoneal fluid of benign and malignant gynaecological disease. Peritoneal monocytes and macrophages, endometrial cells, endometrial and peritoneal stromal cells and tumour cells produce these cytokines in vitro. To investigate whether normal human peritoneal mesothelial cells (HPMC) produce IL-6 and IL-8, HPMC were isolated from omental biopsies. Primary HPMC (P-HPMC) were transfected with pSV3-neo encoding SV40 large T antigen (T-HPMC) to generate sufficient cells. T-HPMC preserved the characteristics of P-HPMC as assessed by phase contrast microscopy, electron microscopy, immunocytochemistry and flow cytometry (FACS) analysis. T-HPMC retained a stable phenotype up to passage 14-19, whereas P-HPMC proliferated poorly and became senescent by passage 4-6. T-HPMC and P-HPMC constitutively expressed IL-6 and IL-8 at both protein and mRNA level. IL-6 and IL-8 production was stimulated by recombinant human interleukin-1beta (hIL-1beta) or human tumour necrosis factor-alpha (hTNF-alpha) alone in a dose-dependent manner. Moreover, hIL-1beta or hTNF-alpha up-regulated IL-6 and IL-8 gene expression as determined by competitive PCR. In contrast, human interferon-gamma (hIFN-gamma) or lipopolysaccharide (LPS) showed no effect. These data indicate that (1) T-HPMC lines mimic the morphological and functional features of P-HPMC, (2) P-HPMC and T-HPMC constituitively produce IL-6 and IL-8, which is enhanced by hIL-1beta and hTNF-alpha and (3) HPMC in vivo may participate in the pathogenesis of benign and malignant gynaecological disease.

Outcome and predictive factors of local recurrence and distant metastases following primary surgical treatment of high-grade malignant phyllodes tumours of the breast

AIM

High-grade malignant phyllodes tumour (MPT) is a rare but aggressive breast malignancy and forms approximately 25% of all phyllodes tumours. The aim of the study was to determine parameters that influence outcome in high-grade MPT.

METHODS

This study consisted of 48 women diagnosed with high-grade MPT. All patients were treated primarily with surgery by local excision (LE, margins <1 cm), wide local excision (WLE, margins > or =1 cm) or mastectomy. Cox's regression was used for multivariate analysis of the data.

RESULTS

The mean patient age was 47 (range 21-85) years and the average tumour size was 7.8 (range 1.5-20) cm. Ten patients were treated with LE, 14 with WLE and 24 with mastectomy. The median follow-up was 9 years (range 5 months-28 years). Local recurrence (LR) occurred in 19 patients (40%) at mean time of 28 (range 5-84) months after primary treatment. Distant metastasis (DM) occurred in 13 (27%) patients at average time of 25.6 (range 6-120) months. LR, subsequent metastatic spread and survival following treatment of MPT were related to tumour size and excision margins, but not to other clinical or histopathological characteristics.

CONCLUSION

Tumour size and surgical margins were found to be the principal determinants of LR and DM. Complete surgical excision, by mastectomy if necessary, is important in the primary surgical treatment of high-grade MPT.

The basic pathology of human breast cancer

This article illustrates the most common benign and malignant lesions in the breast, and is intended for the biologist working in the area of breast cancer and breast biology, not for the practicing pathologist. The atlas covers benign proliferative lesions, atypical lesions, variants of in situ cancer, the main types of invasive cancers, spindle cell lesions, and examples of vascular and lymphatic spread. Some entities are included to illustrate a point of particular relevance to the biology and histogenesis of the lesions. Some controversial diagnostic areas are considered, along with the relative risk of developing breast cancer associated with some of the proliferative lesions. The content of this atlas should be read in conjunction with the companion article by Howard and Gusterson in this issue. Their article covers the cellular origin of epithelial and stromal tumors and presents a description of some of the common benign proliferative lesions that are considered to be components of the normal spectrum of changes seen at postmortem or in biopsies.

Nocardia asteroides: an unusual cause of breast abscess

A case of nocardial breast infection is presented and infection by nocardia organisms must be considered as a rare differential diagnosis of chronic inflammation of the breast.

Characteristics and growth patterns of human peritoneal mesothelial cells: comparison between advanced epithelial ovarian cancer and non-ovarian cancer sources

OBJECTIVE

To compare the characteristics and growth patterns of human peritoneal mesothelial cells (HPMCs) from advanced epithelial ovarian cancer (EOC) patients with those from non-EOC patients.

METHODS

Peritoneal and omental biopsies were obtained from treatment-naïve patients. Formalin-fixed biopsies and cytologic touch preparations were studied immunochemically. HPMCs were isolated from tissue biopsies or malignant ascites and cultured with or without growth factors. Cell growth was determined by the MTT assay. Cultured HPMCs were further characterised by flow cytometry analysis (FACS).

RESULTS

Peritoneal biopsies showed a continuous flat mesothelial cell layer in non-EOC patients, whereas in advanced EOC, the mesothelium was a discontinuous layer of rounded cells. In all peritoneal biopsies, the mesothelium expressed cytokeratin 8/18, vimentin, and the mesothelioma cell antigen but not E-cadherin. In touch preparations, expression of the putative fibroblast antigen ranged from negative to weakly positive. HPMC from non-EOC cases grew slowly in vitro except when exposed to L-cysteine (L-cys 30 micrograms/mL) during the initial 24 hours of culture. Conversely, cells from EOC sources grew more rapidly, especially when exposed to both epidermal growth factor (EGF 10 ng/mL) and hydrocortisone (HC 400 ng/mL). HPMC coexpressed cytokeratin 8/18 and vimentin in vitro, but the expression of the putative fibroblast antigen increased during primary culture, whereas that of the mesothelioma cell antigen decreased in successive passages. Furthermore, in FACS, cultured HPMC did not express CD14, CD16, or CD34.

CONCLUSION

In peritoneal biopsies from non-EOC and EOC patients, HPMCs showed different morphology but similar immunostaining characteristics, whereas cultured cells from different sources were similar in both morphology and phenotype. L-cysteine enhanced the growth of non-EOC but not of EOC-derived HPMCs, which had a maximal response to EGF and HC. The growth advantage of HPMCs from EOC in vitro suggests these cells are in a primed or activated state.

The role of high resolution ultrasound with guided cytology of groin lymph nodes in the management of squamous cell carcinoma of the vulva: a pilot study

The accuracy of high resolution ultrasound with guided fine needle aspiration cytology in detecting inguinal lymph node involvement was assessed in 24 women undergoing radical vulvectomy and groin node dissection for squamous cell vulval cancer. Of the 43 groins dissected, ultrasound correctly diagnosed the lymph node status in 36, with five false positive and two false negative results. Cytology in 40 groins showed no false positive and five false negative results. The sensitivity and specificity for the combined techniques were 83% and 82% respectively. Assessed together, the combined technique failed to detect metastatic disease in two groins; in both cases the extent of nodal metastatic involvement was a solitary focus < 3 mm in diameter. The ultrasound and fine needle aspiration procedure is safe and well tolerated and can be repeated as needed for surveillance. The authors suggest that this procedure should be evaluated further to determine whether a policy of individual selection for lymphadenectomy can be implemented based on this technique.