Tumor resistance to anti-mesothelin CAR-T cells caused by binding to shed mesothelin is overcome by targeting a juxtamembrane epitope

Despite many clinical trials, CAR-T cells are not yet approved for human solid tumor therapy. One popular target is mesothelin (MSLN) which is highly expressed on the surface of about 30% of cancers including mesothelioma and cancers of the ovary, pancreas, and lung. MSLN is shed by proteases that cleave near the C terminus, leaving a short peptide attached to the cell. Most anti-MSLN antibodies bind to shed MSLN, which can prevent their binding to target cells. To overcome this limitation, we developed an antibody (15B6) that binds next to the membrane at the protease-sensitive region, does not bind to shed MSLN, and makes CAR-T cells that have much higher anti-tumor activity than a CAR-T that binds to shed MSLN. We have now humanized the Fv (h15B6), so the CAR-T can be used to treat patients and show that h15B6 CAR-T produces complete regressions in a hard-to-treat pancreatic cancer patient derived xenograft model, whereas CAR-T targeting a shed epitope (SS1) have no anti-tumor activity. In these pancreatic cancers, the h15B6 CAR-T replicates and replaces the cancer cells, whereas there are no CAR-T cells in the tumors receiving SS1 CAR-T. To determine the mechanism accounting for high activity, we used an OVCAR-8 intraperitoneal model to show that poorly active SS1-CAR-T cells are bound to shed MSLN, whereas highly active h15B6 CAR-T do not contain bound MSLN enabling them to bind to and kill cancer cells.

Modifications to Hepatopancreatobiliary surgical services during COVID-19 partial lockdown in a hospital in northern Malaysia

Maintaining hepatopancreatobiliary (HPB) services during the initial phase of a pandemic in a state referral hospital for COVID-19 presents a few challenges, especially when a nationwide, government-issued partial lockdown is in enforcement. We describe the adaptations to our practice to maintain the services whilst ensuring safety of patients and staff, by postponing non-urgent clinic cases, grouping our staff to two mutually exclusive teams that work on alternate shifts and selecting HPB operative cases according to the modified Risk Urgency Decision Matrix.

POS1276 LONG TERM OUTCOME OF MULTIPLE ULTRASOUND GUIDED SUPRASCAPULAR NERVE BLOCK IN TREATMENT OF FROZEN SHOULDER IN DIABETIC PATIENTS

Background:

Frozen shoulder is prevalent among diabetic patients, and usually has aggressive course, with more tendency to be bilateral and resistant to treatment. Suprascapular nerve block (SSNB) is used with increasing frequency by anesthetists and rheumatologists in the management of frozen shoulder. We previously introduced a protocol of nine injections for SSNB with better short term outcome than single SSNB injection (1). Long term outcome of SSNB in management of frozen shoulder is still not detected.

Objectives:

To evaluate the long term effect of multiple (nine) ultrasound guided supra-scapular nerve block in treatment of diabetic frozen shoulder.

Methods:

A retrospective cohort study followed up 40 diabetic patients who received a course of ultrasound guided multiple supra-scapular nerve block (9 injections) on 2014. In this study we retrospectively assessed the patients from previously recorded data at a mean duration of 6 years after completing the 9 injection course SSNB clinically by measuring the shoulder active range of motion (using a goniometer in three planes: abduction, internal, and external rotation). Visual analogue scale and Functional assessment by shoulder pain and disability index (SPADI).

Results:

Thirty four patients (85% of original cohort) completed the long term follow up.

The patients were 19 (55.9%) females, 60.6 y mean age, and the mean of disease duration was 85.6 months. The majority of patients (33 patients 97.05%) continues improvement and gained within normal complete range of motions in all directions and excellent grades of shoulder function (Table 1).

Table 1.Clinical ParametersAt base lineAt 4 monthsLast follow up at (72months±4)**P valueSPADI pain score (100)(68.8 ± 0.5)a(10.3 ± 7.4)b(0.9±1.9)c0.00*SPADI disability score (100)(69.2 ± 7.7)a(6.25 ± 2.25)b(0.4±0.8)c0.00*SPADI total (100)(69.1 ± 8.5)a(8.15 ± 5.4)b(1.1±0.9)c0.00*Patient global assessment (100)(90.2 ± 8.2)a(8.2 ± 4.2)b(0.4±2.1)c0.00*Night pain (100)(55.4±10.2)a(10.3 ± 4.9)b(2.3±1.1)c0.00*Abduction (180°)(77.5 ± 4.7)a(170.3 ± 10.3)b(174.2±6.2)b0.00*External rotation (100 °)(46 ± 12.6)a(80.1 ± 10.2)b(86.4±10.3)b0.00*Internal rotation (70 °)(34.5 ± 2.4)a(55.4 ± 10.1)b(60.2±9.5)b0.00*

* P <0.05 there was a statistical significant difference

•A,b,c--- the alphabet of different symbols ---means a significant statistical difference between groups

SPADI: shoulder pain and disability index

Conclusion:

The multiple injection courses for supra-scapular nerve block has an excellent long term efficacy as treatment of diabetic frozen shoulder. This method should be the treatment of choice in patients of diabetic frozen shoulder who do not respond to physiotherapy.

References:

[1]Mortada, M. A., Ezzeldin, N., Abbas, S. F., Ammar, H. A. & Salama, N. A. Multiple versus single ultrasound guided suprascapular nerve block in treatment of frozen shoulder in diabetic patients. J. Back Musculoskelet. Rehabil. 30, 537–542 (2017).

Disclosure of Interests:

None declared

Emergency Laparotomy in a COVID-19 patient with acute abdomen

We describe here the first laparotomy involving a COVID-19 patient in Malaysia. A 60-year-old man screened positive for SARS-CoV-2 in March 2020 and developed acute abdomen in the ward in Hospital Sultanah Bahiyah, Kedah. He underwent laparotomy and cholecystectomy for gangrenous cholecystitis. All personnel adhered to infectious control precautions, donning full personal protective equipment (PPE) throughout the surgery. Post-operatively, due to raised septic parameters, he was carefully diagnosed with and treated empirically for superimposed bacterial sepsis instead of cytokine release syndrome, with confirmed blood culture of Klebsiella pneumoniae. Patient was discharged well later. None of the staff involved in his care developed COVID-19 infection.

Clinical implications of conventional cytogenetics, fluorescence in situ hybridization (FISH) and molecular testing in chronic myeloid leukaemia patients in the tyrosine kinase inhibitor era - A review

Chronic myeloid leukaemia (CML) provides an illustrative disease model for both molecular pathogenesis of cancer and rational drug therapy. Imatinib mesylate (IM), a BCR-ABL1 targeted tyrosine kinase inhibitor (TKI) drug, is the first line gold standard drug for CML treatment. Conventional cytogenetic analysis (CCA) can identify the standard and variant Philadelphia (Ph) chromosome, and any additional complex chromosome abnormalities at diagnosis as well as during treatment course. Fluorescence in situ hybridization (FISH) is especially important for cells of CML patients with inadequate or inferior quality metaphases or those with variant Ph translocations. CCA in conjunction with FISH can serve as powerful tools in all phases of CML including the diagnosis, prognosis, risk stratification and monitoring of cytogenetic responses to treatment. Molecular techniques such as reverse transcriptase-polymerase chain reaction (RT-PCR) is used for the detection of BCR-ABL1 transcripts at diagnosis whereas quantitative reverse transcriptase-polymerase chain reaction (qRTPCR) is used at the time of diagnosis as well as during TKI therapy for the quantitation of BCR-ABL1 transcripts to evaluate the molecular response and minimal residual disease (MRD). Despite the excellent treatment results obtained after the introduction of TKI drugs, especially Imatinib mesylate (IM), resistance to TKIs develops in approximately 35% - 40% of CML patients on TKI therapy. Since point mutations in BCR-ABL1 are a common cause of IM resistance, mutation analysis is important in IM resistant patients. Mutations are reliably detected by nested PCR amplification of the translocated ABL1 kinase domain followed by direct sequencing of the entire amplified kinase domain. The objective of this review is to highlight the importance of regular and timely CCA, FISH analysis and molecular testing in the diagnosis, prognosis, assessment of therapeutic efficacy, evaluation of MRD and in the detection of BCR-ABL1 kinase mutations which cause therapeutic resistance in adult CML patients.

AB0177 RHEUMATOID ARTHRITIS SAUDI DATABASE (RASD): A SINGLE CENTER EXPERIENCE

Background:

National Registries are essential to direct current practice and design appropriate management strategies1. Rheumatoid arthritis (RA) registries in the middle east and north Africa remain scarcely represented2.

Objectives:

Our objective is to describe the Saudi RA population and to compare the findings to internationally reported data.

Methods:

This is a cross sectional, analytical study that was conducted at Doctor Soliman Fakeeh Hospital (DSFH). The study ran from December of 2014 and concluded in December of 2018 using a pool of 433 patients. Inclusion criteria included adults older than 18 years of age who fulfilled the 2010 American College of Rheumatology criteria for diagnosis of RA3. Data were collected from patients and entered in a specially designed program for this registry. They included main demographic details,, lag times to final disease diagnosis. Disease Activity Score-28-C Reactive Protein (DAS-28-CRP) was calculated on presentation and on subsequent visits with intervals ranging from three to six months between them. Multiple regression model was used to assess the predictors of disease activity. We charted the lines of medications given, including conventional and biologic disease modifying antirheumatic drugs (DMARDs), following treat to target strategies4.

Results:

Out of 430 patients, 76.68% were female, while only 23.32% were male and the mean age was found to be 49.26 years with SD±11.

At initial presentation, 45.5% had demonstrated active disease (moderate or high disease activity) based on DAS-28-CRP scores while 54.5% were in remission or low disease activity. Out of the total number of clinic visitors, 330 had regular follow ups for more than 1 year while 103 patients were either irregularly visiting the rheumatology clinic or had lost follow up. The remission rates after 1 year had increased to 79.7% (263 patients), while 9.7% (32 patients) had low disease activity and no patients had sustained high disease activity at the end of follow up. It was also found that the female gender, higher Health Assessment Questionnaire-Disability Index (HAQ-DI) and a longer lag1/lag2 period were associated with higher disease activity in our population. Biologic medications had been used by 129 patients (29.7%) while conventional DMARDs were given to 304 patients (70.3%).

Conclusion:

We described a population of RA patients in a single center in SA. We detected higher remission rates at one year of follow up. This could be attributed to many factors, including good referral systems and treat to target strategies with easier access to biologic medications.

References:

[1]Singh JA, Saag KG, Bridges SL Jr, Akl EA, Bannuru RR, Sullivan MC, Vaysbrot E, McNaughton C, Osani M, Shmerling RH, Curtis JR, Furst DE, Parks D, Kavanaugh A, O’Dell J, King C, Leong A, Matteson EL, Schousboe JT, Drevlow B, Ginsberg S, Grober J, St Clair EW, Tindall E, Miller AS, McAlindon T. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis.Arthritis Rheumatol.2016 Jan;68(1):1-26.

[2]Smolen, Josef S., et al. “EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update.”Annals of the rheumatic diseases73.3 (2014): 492-509.

[3]Saag KG, Teng GG, Patkar NM, Anuntiyo J, Finney C, Curtis JR, et al. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis.Arthritis Rheum2008;59: 762–84.

[4]Hussain W, Noorwali A, Janoudi N. From symptoms to diagnosis: an observational study of the journey of rheumatoid arthritis patients in Saudi Arabia.Oman Med J.2016;31(1):29.

Disclosure of Interests:

Rola Hassan Grant/research support from: Pfizer pharmaceuticals, Mohamed Cheikh Grant/research support from: Pfizer pharmaceuticals, Hani Almoallim Grant/research support from: Pfizer pharmaceuticals, Hanan Faruqui Grant/research support from: Pfizer pharmaceuticals, Reem AlQuraa Grant/research support from: Pfizer pharmaceuticals, Ayman Eissa Grant/research support from: Pfizer pharmaceuticals, Aous Alhazmi Grant/research support from: Pfizer pharmaceuticals, Nahid Janoudi Grant/research support from: Pfizer pharmaceuticals

Is Procalcitonin more superior to hs-CRP in the diagnosis of infection in diabetic foot ulcer?

INTRODUCTION

Procalcitonin (PCT) has recently emerged as a marker for diagnosing infection. This study aimed to compare the performance of PCT and other infection markers in diagnosing infected diabetic foot ulcer (IDFU).

MATERIALS AND METHODS

A total of 128 diabetic patients with foot ulcers were recruited and divided into two groups, consisting of 73 patients in the IDFU group and 55 in the non-infected diabetic foot ulcer (NIDFU). The severity of infection in IDFU patients was graded based on the Infectious Disease Society of America-International Working Group on the Diabetic Foot classification. Blood samples from all the patients were collected for measurement of PCT, high sensitivity C-reactive protein (hs-CRP) and white cell count (WBC). The area under the receiver operating curves (AUC) were then constructed and analysed.

RESULTS

PCT, hs-CRP and WBC levels were significantly higher in the IDFU group compared to NIDFU with hs-CRP demonstrated the highest AUC (0.91; p <0.001) followed by PCT (0.814; p < 0.001) and lastly WBC (0.775; p < 0.001). The best cut off value, sensitivity and specificity for the presence of infection in diabetic foot, were 3.47 mg/dL, 80% and 89% for hs-CRP, 0.11 ng/ml, 70% and 87% for PCT and 11.8x109/L, 60% and 90% for WBC. All the infection markers showed significant positive correlations with infection severity of DFU.

CONCLUSION

This study showed that hs-CRP is a more sensitive marker for diagnosing IDFU. Although PCT is useful in differentiating IDFU from NIDFU, the use of PCT is not necessary as it adds little value to the current practice.

Jejunal metastasis of Merkel cell carcinoma: case report

Merkel cell carcinoma (MCC) of the skin is a rare but aggressive cutaneous neuroendocrine-derived malignancy that predominantly affects elderly white males. The presence of distant nodal metastases significantly impacts survival. Typical metastatic sites of MCC are liver, bone, brain and skin. Gastrointestinal metastases are uncommon and small bowel is the most common site followed by stomach. We report a case of symptomatic MCC jejunal metastasis.

Mirizzi syndrome: a challenging diagnosis. Case report

Mirizzi Syndrome (MS) is an uncommon complication of chronic gallstone disease defined as a common bile duct (CBD) obstruction secondary to gallstone impaction in the cystic duct or gallbladder neck. MS is still a challenging clinical situation: preoperative diagnosis of MS is complex and can be made in 18-62.5% of patients. Over 50% of patients with MS is diagnosed during surgery. In most of cases, laparotomy is the preferred surgical approach. We report the case of a 70-year-old woman with a history of asthenia, jaundice, abdominal pain and preoperative imaging that suggest the presence of biliary stones with a choledocal stenosis. Intraoperatively, a MS with cholecysto-biliary fistula involving less than two-thirds of the circumference of the bile duct was diagnosed and successfully treated.

Pseudomixoma peritonei associated with appendiceal cistoadenoma rupture: case report

Appendiceal mucocele represents specimen finding in 0.2-0.3% out of appendectomies. The rupture or perforation in peritoneal cavity might cause pseudomixoma peritonei (PMP), with multiple mucinous deposits in the abdominal cavity. We report a case of PMP caused by a perforated appendiceal cistoadeonoma.

Intrathecal administration of autologous bone marrow stromal cells improves neuropathic pain in patients with spinal cord injury

Neuropathic pain (NP) is highly disabling, responds poorly to pharmacological treatment, and represents a significant cause of decreased quality of life in patients suffering from spinal cord injury (SCI). In recent years, cell therapy with autologous mesenchymal stromal cells (MSCs) has been considered as a potential therapeutic weapon in this entity. Ten patients suffering chronic SCI received 100 million MSCs into subarachnoid space by lumbar puncture (month 1 of the study) and this procedure was repeated at months 4 and 7 until reaching a total doses of 300 million MSCs. Intensity of NP was measured by standard numerical rating scale (VAS) from 0 to 10, recording scores previous to the first MSCs administration and monthly, until month 10 of follow-up. Months 1, 4, 7 and 10 of the study were selected as time points in order to a statistical analysis by the nonparametric Wilcoxon rank test. Our results showed significant and progressive improvement in NP intensity after the first administration of MSCs (p: 0.003). This study supports the benefit of intrathecal administration of autologous MSCs for the treatment of NP in patients with SCI.

Potential use of cord blood for Hb E hemoglobinopathy screening programme using capillary electrophoresis

BACKGROUND

Thalassemia and hemoglobinopathies are inherited red blood cell disorders found worldwide. Hemoglobin (Hb) E disorder is one of the hemoglobinopathies known to have the high prevalence in South East Asia. Most of transfusion-dependent thalassemias were genotypically compound heterozygous Hb E/ β-thalassemia. In Malaysia, the national screening program for thalassemia was implemented for early pregnancy or secondary school girls; however many participants do not turn-up and missed the screening test. Screening for thalassemia using samples from cord blood is an alternative choice as it is a readily available source of blood and hence early detection of the disease. The purpose of this study was to determine the potential use of cord blood for the screening of HbE hemoglobinopathy by using capillary electrophoresis (CE).

METHODS

Cord blood samples were collected from 300 newborns of healthy mothers. Hematological parameters were determined and hemoglobin quantitation for all cord blood samples were performed using capillary electrophoresis system (CES) and high performance liquid chromatography (HPLC).

RESULTS

Majority of cord blood samples (63%) revealed Hb AF followed by Hb AFA2 (20%). Hb AFE was detected in 10.7% with the mean value of Hb E ranging from 2.3%-11.1%.

CONCLUSION

Hemoglobin E was detected in cord blood using capillary electrophoresis system. It can be recommended in areas where Hb E/β is prevalent. Implementation of a screening strategy using CE on cord blood sampling will identify the disease early. With regular follow-up on these patients, the status of their disease can be determined earlier and appropriate management implemented.

The burden of HPV associated cancers in two regions in Nigeria 2012-2014

INTRODUCTION

HPV attributable cancers are the second most common infection-related cancers worldwide, with much higher burden in less developed regions. There are currently no country-specific estimates of the burden of these cancers in Nigeria just like many other low and middle income countries.

METHODS

In this study, we quantified the proportion of the cancer burden in Nigeria that is attributable to HPV infection from 2012 to 2014 using HPV prevalence estimated from previous studies and data from two population based cancer registries (PBCR) in Nigeria. We considered cancer sites for which there is strong evidence of an association with HPV infection based on the International Agency for Research on Cancer (IARC) classification. We obtained age and sex-specific estimates of incident cancers and using the World Standard Population, we derived age standardized incidence (ASR) rates for each cancer type by categories of sex, and estimated the population attributable fractions (PAF).

RESULTS

The two PBCR reported 4336 new cancer cases from 2012 to 2014. Of these, 1627 (37.5%) were in males and 2709 (62.5%) in females. Some 11% (488/4336) of these cancers were HPV associated; 2% (38/1627) in men and 17% (450/2709) in women. Of the HPV associated cancers, 7.8% occurred in men and 92.2% in women. The ASRs for HPV associated cancers was 33.5 per 100,000; 2.3 and 31.2 per 100,000 in men and women respectively. The proportion of all cancers attributable to HPV infection ranged from 10.2 to 10.4% (442-453 of 4336) while the proportion of HPV associated cancers attributable to HPV infection ranged from 90.6% to 92.8% (442-453 of the 488 cases). In men, 55.3% to 68.4% of HPV associated cancers were attributable to HPV infection compared to 93.6% to 94.8% in women. The combined ASR for HPV attributable cancers ranged from 31.0 to 31.7 per 100,000. This was 1.4 to 1.7 per 100,000 in men and 29.6 to 30.0 per 100,000 in women. In women, cervical cancer (n=392, ASR 28.3 per 100,000) was the commonest HPV attributable cancer, while anal cancer (n=21, ASR 1.2 per 100,000) was the commonest in men.

CONCLUSIONS

HPV attributable cancers constitute a substantial cancer burden in Nigerian women, much less so in men. A significant proportion of cancers in Nigerian women would be prevented if strategies such as HPV DNA based screening and HPV vaccination are implemented.

Generation and characterisation of human umbilical cord derived mesenchymal stem cells by explant method

Mesenchymal stem cells (MSCs) derived from human umbilical cord (UC) have been considered as an important tool for treating various malignancies, tissue repair and organ regeneration. Umbilical cord-derived mesenchymal stem cells (UC-MSCs) are better alternative to MSCs that derived from bone marrow (BM-MSCs) as they are regarded as medical waste with little ethical concern for research and easily culture-expanded. In this present study, the foetal distal end of human UC was utilised to generate MSC by explant method. Upon in vitro culture, adherent cells with fibroblastic morphology were generated with rapid growth kinetics. Under the respective inductive conditions, these cells were capable of differentiating into adipocytes and osteocytes; express an array of standard MSC's surface markers CD29, CD73, CD90, CD106 and MHC-class I. Further assessment of immunosuppression activity revealed that MSCs generated from UC had profoundly inhibited the proliferation of mitogen-activated T lymphocytes in a dosedependent manner. The current laboratory findings have reinforced the application of explant method to generate UCMSCs thus, exploring an ideal platform to fulfil the increasing demand of MSCs for research and potential clinical use.

Risk factors for hospitalisation and associated costs among patients with hepatitis A associated with imported pomegranate arils, United States, 2013

OBJECTIVES

To assess hospitalisation risk factors and economic effects associated with a multistate hepatitis A outbreak in 2013.

STUDY DESIGN

Retrospective case series.

METHODS

Eligible outbreak-related cases confirmed by September 1, 2013, were defined as acute hepatitis symptoms and positive IgM anti-hepatitis A during March 15-August 12 among patients who consumed the food vehicle or had the outbreak genotype. We reviewed medical records, comparing demographic and clinical characteristics among hospitalized and non-hospitalized patients; we used logistic regression analysis to identify factors associated with hospitalization. We interviewed patients regarding symptom duration and healthcare usage and estimated per-patient and total costs. Health departments reported outbreak-related personnel hours.

RESULTS

Medical records were reviewed for 147/159 (92%) eligible patients; median age was 48 (range: 1-84) years, and 64 (44%) patients were hospitalized. Having any chronic medical condition was independently associated with hospitalisation (odds ratio, 3.80; 95% confidence interval, 1.68-8.62). Interviews were completed for 114 (72%) eligible patients; estimated per-patient cost of healthcare and productivity loss was $13,467 for hospitalized and $2138 for non-hospitalized patients and $1,304,648 for all 165 outbreak-related cases. State and local public health personnel expenditures included 82 h and $3221/outbreak-related case.

CONCLUSIONS

Hospitalisations in this outbreak were associated with chronic medical conditions and resulted in substantial healthcare usage and lost productivity. These data can be used to inform future evaluation of expansion of hepatitis A vaccination recommendations to include adults with chronic medical conditions.

Genetic aberrations in multiple myeloma characterized by cIg-FISH: a Brazilian context

Genetic abnormalities are critical prognostic factors for patients diagnosed with multiple myeloma (MM). This retrospective, multicenter study aimed to contribute with the genetic and clinical characterization of MM patients in a country with continental dimensions such as Brazil. Genetic abnormalities were assessed by cIg-fluorescent in situ hybridization (cIg-FISH) in a series of 152 MM patients (median age 55 years, 58.5% men). Overall, genetic abnormalities were detected in 52.7% (80/152) of patients. A 14q32 rearrangement was detected in 33.5% (n=51), including t(11;14), t(4;14) and t(14;16) in 18.4, 14.1, and 1% of cases, respectively. del(13q) was identified in 42.7% (n=65) of patients, of whom 49.2% (32/65) presented a concomitant 14q32 rearrangement. del(17p) had a frequency of 5.2% (n=8). del(13q) was associated with high plasma cell burden (≥50%, P=0.02), and del(17p) with advanced ISS stages (P=0.05) and extramedullary disease (P=0.03). t(4;14) was associated with advanced Durie-Salmon stages (P=0.008), renal insufficiency (P=0.01) and was more common in patients over 60 years old. This study reports similar frequencies of genetic abnormalities to most series worldwide, whereas the t(14;16) and del(17p), two high risk factors for newly diagnosed patients, exhibited lower frequencies. Our results expand the knowledge on the molecular features of MM in Brazil, a country where innovative therapies that could overcome a poor prognosis for some genetic abnormalities are not always available.

Abdominal cocoon

Background The abdominal cocoon syndrome was first described as a rare condition where part of or the whole small bowel is encased within a fibrous membrane. Idiopathic sclerosing encapsulating peritonitis (or abdominal cocoon) is a rare cause of small bowel obstruction, especially in adult population. Diagnosis is usually incidental at laparotomy. But preoperative diagnosis can be made. Case presentation This report is of a 27-year-old Bangladeshi male who presented with increasing abdominal pain and features of subacute intestinal obstruction. He had a history appendicectomy 2 months back through grid iron incision in a peripheral hospital. Pre-operative work-up did not reveal a sac like structure encasing small intestinal loops. At computed tomography of the abdomen and pelvis, a huge cystic structure was seen encasing loops of small bowel. At laparotomy, a fibrous capsule was revealed, in which small bowel loops were encased, with the presence of interloop adhesions. A diagnosis of primary abdominal cocoon was established and extensive adhesiolysis was performed. The patient had an uneventful recovery and follow-up. No evidence of Kochs noted in the abdomen or on histopathology of tissue sent for examination. Conclusion Abdominal cocoon is a rare cause of small bowel obstruction, but should be suspected especially in cases with attacks of non strangulating obstruction in the same individual. A high index of clinical suspicion may be generated by the recurrent character of small bowel obstruction. Clinicians must rigorously pursue a preoperative diagnosis. The overall prognosis is satisfactory. DOI: http://dx.doi.org/10.3329/pulse.v5i2.20269 Pulse Vol.5 July 2011 p.61-64

Detection of methicillin-resistant Staphylococcus aureus directly by loop-mediated isothermal amplification and direct cefoxitin disk diffusion tests

We evaluated the utility of 2 methods for detection of methicillin-resistant Staphylococcus aureus (MRSA) directly from signal-positive blood culture bottles: loop-mediated isothermal amplification (LAMP) assay, and direct cefoxitin disk diffusion (DCDD) test using a 30 μg cefoxitin disk. In parallel, standard microbiological identification and oxacillin susceptibility testing with MecA PCR was performed. Of 60 blood cultures positive for Gram-positive cocci in clusters, LAMP (via detection of the FemA and MecA genes) showed 100% sensitivity and specificity for identification of MRSA/MSSA. When coagulase-negative staphylococci were tested, sensitivity for detection of methicillin resistance was 91.7% and specificity was 100%. DCDD along with direct tube coagulase assay detected only 80.6% of MRSA/MSSA. LAMP showed higher diagnostic accuracy although DCDD was more cost-effective and did not require additional reagents or supplies.

Outcome of young age at diagnosis of breast cancer in South Egypt

BACKGROUND

Incidence of breast cancer in patients <40 years old accounts for 20% of the total breast cancer patients in Egypt which is quite higher than the incidence reported worldwide. This study was conducted to evaluate the differences in survival between age groups below and above the age of 40.

METHOD

170 patients <40 years and 500 patients ≥40 years were evaluated retrospectively to assess the differences in disease free survival (DFS) and overall survival (OS) between age groups after adjustment of other risk factors like stage, lymph node status, tumor size, and hormonal positivity.

RESULTS

After median follow up of 49 months, there was no significant difference between the 2 age groups with regards to DFS p= 0.6 and OS P=0.7 and there was no significant difference between the 2 groups when we stratified the patients according to stages, hormonal status and number of metastatic lymph nodes. However, we found significant increase in local recurrence after breast conserving surgery in patients <40 years compared to patients ≥40 years.

CONCLUSION

Patients <40 years exhibited more often at advanced stage and large tumors size compared to patients ≥ 40 years; However, there was no significant difference in DFS and OS when we adjusted other risk factors. Furthermore, our analysis revealed that age <40 years can be considered as an adverse prognostic factor for the locoregional failure after breast conserving surgery.

KEYWORDS

breast cancer, young age, <40 years old, locoregional failure, DFS.