Pan-cancer analyses suggest kindlin-associated global mechanochemical alterations

Kindlins serve as mechanosensitive adapters, transducing extracellular mechanical cues to intracellular biochemical signals and thus, their perturbations potentially lead to cancer progressions. Despite the kindlin involvement in tumor development, understanding their genetic and mechanochemical characteristics across different cancers remains elusive. Here, we thoroughly examined genetic alterations in kindlins across more than 10,000 patients with 33 cancer types. Our findings reveal cancer-specific alterations, particularly prevalent in advanced tumor stage and during metastatic onset. We observed a significant co-alteration between kindlins and mechanochemical proteome in various tumors through the activation of cancer-related pathways and adverse survival outcomes. Leveraging normal mode analysis, we predicted structural consequences of cancer-specific kindlin mutations, highlighting potential impacts on stability and downstream signaling pathways. Our study unraveled alterations in epithelial-mesenchymal transition markers associated with kindlin activity. This comprehensive analysis provides a resource for guiding future mechanistic investigations and therapeutic strategies targeting the roles of kindlins in cancer treatment.

Spongy Scalp Swelling in a Middle-Aged Female: A Case Report of Lipedematous Scalp

Lipedematous scalp is a rare cutaneous disorder, characterized by subtle but conspicuous scalp swelling, usually associated with dysesthesia. The chronic recalcitrant nature of this condition can be extremely debilitating for the patient. We report a case of boggy scalp swelling and dysesthesia in a 37‑year‑old female present for five years. Magnetic resonance imaging (MRI) brain showed thickening of subcutaneous tissue of the scalp. Histopathological examination revealed thickened and edematous subcutaneous tissue, reaching up to the upper dermis. A diagnosis of lipedematous scalp was made. The patient was reassured about the benign nature of the disease and given symptomatic treatment for dysesthesia. Herein we discuss the approach to a case of boggy dysesthetic scalp swelling and the available treatment options.

Prevalence and Clinical Significance of Electrocardiographic Complete Right Bundle Branch Block in Young Individuals

BACKGROUND AND AIMS

There is limited information on the clinical significance of complete right bundle branch block (CRBBB) in young individuals. The aim of this study was to determine the prevalence and significance of CRBBB in a large cohort of young individuals aged 14-35 years old.

METHODS

From 2008 to 2018, 104,369 consecutive individuals underwent a cardiovascular assessment with a health questionnaire, electrocardiogram, clinical consultation, and selective echocardiography. Follow-up was obtained via direct telephone consultations. Mean follow-up was 7.3 ± 2.7 years.

RESULTS

CRBBB was identified in 154 (0.1%) individuals and was more prevalent in males compared with females (0.20% vs. 0.06%; p<0.05) and in athletes compared with non-athletes (0.25% vs. 0.14%; p<0.05). CRBBB-related cardiac conditions were identified in 7 (5%) individuals (4 with atrial septal defect, 1 with Brugada syndrome, 1 with progressive cardiac conduction disease and 1 with atrial fibrillation). Pathology was more frequently identified in individuals with non-isolated CRBBB compared with individuals with isolated CRBBB (14% vs 1%; p < 0.05) and in individuals with a QRS duration of ≥130 milliseconds (ms) compared with individuals with a QRS of <130ms (10% vs 1%; p<0.05).

CONCLUSION

The prevalence of CRBBB in young individuals was 0.1% and was more prevalent in males and athletes. CRBBB-related conditions were identified in 5% of individuals and were more common in individuals with non-isolated CRBBB and more pronounced intraventricular conduction delay (QRS duration of ≥130ms). Secondary evaluation should be considered for young individuals with CRBBB with symptoms, concerning family history, additional electrocardiographic anomalies or significant QRS prolongation (≥130ms).

Systemic treatments in Parthenium dermatitis: A systematic review and meta-analysis

Parthenium dermatitis is the commonest form of plant dermatitis in India, caused by the plant Parthenium hysterophorus. Systemic immunosuppressives are commonly employed in its treatment. However, there is a relative lack of comparative head-to-head trials. This study was done to assess the relative efficacy and safety of systemic treatments in Parthenium dermatitis. We systematically reviewed all the published studies investigating the safety and efficacy of systemic treatments for Parthenium dermatitis in the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and clinical trial registries. Treatment benefit data were tabulated based on outcome measures of scoring systems. The quality of evidence for each outcome was assessed by Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria for meta-analysis. The pooled Standardized mean difference (SMD) for case series and comparative studies based on clinical severity score (CSS) for azathioprine was 4.007 (95% CI (Confidence interval): 3.141, 4.873) and 0.746 (95% CI: 0.139, 1.352), respectively. About 88.8% (95% CI: 76.8%, 100.8%, p = 0.076) of the patients had excellent or a good response to azathioprine. Our meta-analysis shows that azathioprine has the highest level of evidence in the treatment of Parthenium dermatitis.

Outcomes of Brain Metastases with Suspicious Imaging Undergoing Resection to Evaluate for Radionecrosis vs. Tumor Progression

PURPOSE/OBJECTIVE(S)

In patients treated with stereotactic radiosurgery (SRS) for brain metastases, radiographic changes on surveillance imaging may result from treatment effect/radionecrosis (RN) or tumor progression. Distinguishing between these processes is critical to appropriate management. We report long-term outcomes for a cohort of patients who demonstrated radiographic progression on serial imaging after initial radiation and ultimately underwent resection to inform further management.

MATERIALS/METHODS

A retrospective chart review identified 76 patients with an associated 82 brain lesions between 2009 and 2022 that were initially treated with SRS, then demonstrated suspicious imaging changes developing through at least two scan time points that led to pathologic confirmation of either tumor or RN. We report clinical outcomes and details of further treatments.

RESULTS

Of the 82 lesions, 55 (67.1%) were found to be pathologically-confirmed viable tumor and were treated with repeat radiation and 27 (32.9%) were found to be strictly RN and conservatively managed. Over half of the lesions (14/27) ultimately found to be radionecrotic required use of steroids pre-operatively due to neurologic symptoms. Among the 27 that were found to be RN, the most common histology was melanoma (33.3%, n = 9). The most common dose fractionation regimen was 20 Gy in 1 fx (n = 11, 40.7%; range: 16-20 Gy x 1Fx), and the median BED (10) was 50.4 Gy (IQR 41.6 - 50 Gy). None of these lesions required further intervention with median post-surgery follow up of 24.4 months (range 1-104 months). There were 55 instances (in 51 patients) of pathologically-confirmed recurrent/progressive tumor who were consequently treated with repeat radiation with either Cs-131 brachytherapy (12 (21.8%)) or SRS (43 (78.2%)). The most common histology was NSCLC (37.2%, n = 19). The most common fractionation for repeat irradiation with SRS was 8 Gy x 3 fx (n = 15, 27.3%), followed by 5 Gy x 5 fx (n = 10, 18.2%), and 4 Gy x 5 fx (n = 8, 14.6%). Four individuals each had two lesions that were re-irradiated for local recurrence. Among patients treated with re-irradiation, the median follow-up to local failure was 15.2 months (95% CI 7.3-26.6 months). Radionecrosis was confirmed on pathology in 4/55 (7.2%) of lesions. The median follow-up from date of SRS2 to local failure was 14.1 months (95% CI 7.6-24.3 months). The 2-yr local control rate was 74.8% (95% CI 61.7-90.7%).

CONCLUSION

We recommend cautious monitoring of possible progression after radiosurgery, with consideration of resection for continuous progression, as a significant proportion of radiographic progression are ultimately pure RN. Management determined by pathology (observation for RN; additional radiation for confirmed tumor) leads to excellent control.

Trends in the Use of Hypofractionation in Treatment of Breast Cancer in Botswana

PURPOSE/OBJECTIVE(S)

Clinical trials have shown that moderate hypofractionation (HF) is clinically effective as adjuvant treatment to breast conserving surgery or following mastectomy with advanced disease. ASTRO issued updated guidelines in 2018, expanding the population eligible to receive HF to all patients, regardless of age and tumor stage. Use of HF can promote efficient resource utilization for over-burdened health care systems; however, global adoption of HF has been previously only reported via ESTRO survey of individual physicians. These data note that HF following lumpectomy is 40% in Africa vs. >90% in North America, with limited data on the uptake of HF within individual African countries. In this study, we characterize temporal trends and clinical, socio-demographic factors associated with the use of HF in breast cancer in Botswana.

MATERIALS/METHODS

We retrospectively analyzed a cohort of breast cancer patients receiving curative intent radiation between 2015 and 2022 at the only radiation clinic in Botswana. We compared patients' characteristics between those who received HF vs. standard fractionation (SF) and report chi-square statistics when appropriate. We fit a multilevel mixed-effects logistic regression model with a random intercept for district while adjusting for fixed effects such as HIV infection status, laterality, hormone receptor status, and marital status.

RESULTS

A total of 234 patients were prescribed curative intent radiation between 2015 and 2022 in Gaborone, Botswana. Median age at diagnosis was 51 years old, and the majority of patients presented with stage III disease (61.9%, 109/234). 26.9% of this population were women living with HIV (WLWH), and 71% lived >100km from the hospital. HF was utilized overall in 59.4% (139/234) of patients. Most common fractionation patterns included: 4005cGy/15fx and 4267cG/16fx. One patient received ultra-HF (2600cGy/5fx). In unadjusted chi-square analysis, a higher proportion of HF was seen in right vs left-sided breast cancer (65.8% vs. 50.9%, p = 0.02), increasing year of diagnosis from 2015 - 2022 (p<0.001), and among patients >/ = 40 years of age vs. those <40 years of age (62.8% vs 42.1%, p = 0.017). Temporal trends show a significant increase in the utilization of HF starting from 23.8% (5/21) in 2015, to 61.5% (32/52) in 2018, and finally 100% (11/11) of cases in 2022. Our regression analysis shows that there is no statistically significant between-district variance or patient-level factors that associate with the uptake of HF. The overall utilization rate for HF between 2015-2022 was 59.4% (95% CI: 53.0%-65.5%).

CONCLUSION

Based on recent survey results the uptake of HF among African countries is lower than that of North America. To our knowledge, this is the first quantitative analysis of the utilization of HF over 5 years in an African country. Further analysis on factors related to physician prescription of hypofractionation is warranted, including influence of breast laterality, age, and primary surgery type.

Impact of Consolidative Radiation on Overall and Progression Free Survival in Pediatric, Adolescent and Young Adult Metastatic Sarcoma

PURPOSE/OBJECTIVE(S)

To determine the association between consolidative radiation and survival in pediatric, adolescent, and young adult (AYA) metastatic sarcoma MATERIALS/METHODS: Eligible patients included those diagnosed with metastatic bone or soft tissue sarcoma at ≤39 years of age. Patients whose cancer progressed prior to the time of local control were excluded. Consolidative radiation (RT) was defined as RT to all sites of metastatic disease. Kaplan Meier method was used to estimate overall survival (OS) and progression-free survival (PFS). Cox proportional hazards was used to account for confounding variables. To adjust for immortal time bias (ITB), end of local control was chosen as a landmark time.

RESULTS

Patients (n = 77) had a median age at diagnosis of 14.5 years (range: 1.7-29.7 years). The most common histology was Ewing sarcoma (49%), followed by rhabdomyosarcoma (30%). Median follow up was 28.5 months, without significant difference between patients treated with and without consolidative RT (23.7 vs. 21.5 months, p = 0.270). Median time to completion of consolidative RT from diagnosis was 8.5 months. Ewing sarcoma was more likely to be treated with consolidative RT compared to other histologies (p<0.001). Consolidative RT was associated with improved OS (2yr OS: 81.9% vs. 57.9%, p = 0.009) and PFS (2yr PFS: 71.2% vs. 30%, p = 0.001). On multivariate analysis, after accounting for age, histology, number, and type of metastases (lung, bone or other), consolidative RT remained independently associated with improved OS (hazard ratio (HR):0.36, 95% confidence interval [CI]: 0.17, 0.78, p = 0.010) and improved PFS (HR = 0.34, 95% CI = 0.16, 0.73, p = 0.006). The OS benefit for consolidative RT persisted after adjusting for ITB (1yr OS post-local control: 80.9% vs. 89.7%, p = 0.016). The effect of consolidative RT was validated in a dataset consisting of patients who were diagnosed with localized disease but had metastatic progression (n = 30). In this metachronous population, consolidative RT remained independently associated with improved OS (HR = 0.11, 95% CI = 0.03, 0.51, p = 0.004) after accounting for age.

CONCLUSION

ConsolidativeRT was independently associated with improved OS and PFS in pediatric and AYA patients with metastatic sarcoma at diagnosis. The OS benefit extended to those who underwent consolidative RT for metastatic progression. Future work should evaluate biomarkers to optimize patient selection and timing and dose of consolidative RT.

Patterns of Failure in Pediatric and Young Adult Rhabdomyosarcoma

PURPOSE/OBJECTIVE(S)

To characterize patterns of failure in pediatric and young adult patients with rhabdomyosarcoma (RMS) from a single institution with over 20 years of experience.

MATERIALS/METHODS

Patients diagnosed with RMS from 2000 to 2022 were identified retrospectively. Time to failure was calculated from diagnosis. Local only failure was defined as first failure at the primary site without distant failure. Distant failure was defined as first failure outside of the primary site with or without local failure. Cumulative incidence (CI) of failure was calculated using death as a competing risk. Fine-Gray regression was used to evaluate impact of prognostic factors.

RESULTS

Ninety-five patients were eligible. Median age was 7.28 years (range 0 - 35 years), 41% of patients were >10 years old. Median follow up was 33.3 months. Approximately half (n = 47, 49.5%) of the tumors demonstrated alveolar histology. FOXO1 fusion status was available in 76 (80%) patients, of which 7 out of 37 alveolar tumors (18.9%) were FOXO1 fusion negative. The majority of tumors presented with unfavorable primary site (n = 72, 75.8%) and advanced stage (Stage III and IV, n = 72, 75.8%). The 5-yr CI of local only failure and distant failure for the entire cohort was 19.0% (95% CI 11.3, 28.3) and 34.6% (24.0, 45.5%), respectively. The predominant pattern of failure by Group was: Groups 1&2: Local only (5yr CI 14.8%), Group 3: Distant (5yr CI: 25.9%), Group 4: Distant (5yr CI: 67.6%). CI of distant failure by primary site was higher in perianal/gluteal (n = 2/5, 5yr CI 60.0%) and extremity (n = 8/19, 5yr CI 45.9%) sites. Of the 28 distant failures, 10 (36%) also had a local failure component. CI of local only failure by primary site was higher in parameningeal head and neck (n = 6/25, 5yr CI 30%) and bladder/prostate (n = 2/12, 5yr CI 23%) sites. The following were associated with an increased CI of distant failures: increasing age (HR 1.08, p<0.01), alveolar vs. embryonal histology (HR 3.01, p = 0.0095), FOXO1 fusion positive vs. negative (HR 2.8, p = 0.02) and Group IV vs. Groups I/II (HR 7.7, p = 0.0007). FOXO1 fusion and alveolar histology were associated with older age and Group IV, both of which were independently associated with increased distant failure on multivariate analysis.

CONCLUSION

Failures were predominantly distant in older patients and patients with Group IV RMS, both of which were associated with FOXO1 fusion and alveolar histology, highlighting the need to improve therapies in this population. Local only failures were highest in parameningeal head and neck and bladder/prostate primaries, highlighting the need to improve local control strategies at these sites.

SCCAg as a Biomarker of Advanced Stage and OS in Limited Resource Setting for Cervical Cancer

PURPOSE/OBJECTIVE(S)

Elevated serum squamous cell antigen (SCCAg) has been previously correlated with poor survival, extensive tumor involvement, and recurrence for cervical cancer. Failure of serum SCCAg to normalize after treatment completion has also been studied as a poor prognostic indicator. This is the first study describing the association of SCCAg with stage and outcomes in patients diagnosed with cervical cancer in Botswana, in a population with a majority of women who are living with HIV (WLWH).

MATERIALS/METHODS

Patients with histologically confirmed cervical cancer were enrolled in a prospective observational study between August 2016 and April 2020 in Botswana. Among all patients undergoing definitive chemoradiation, serum SCCAg was determined at pre-treatment baseline, end of treatment (EOT), and 3-month follow-up (normal reference range 0.3 -1.9 ng/ml). Normalization of SCCAg was defined as return to the reference range after treatment (SCCAg response), and was measured first at EOT; if EOT values were not available, 3-month values were utilized. Patients were staged according to FIGO 2009 criteria, early stage was defined as Stage I-II; while advanced stage was defined as Stage III-IV. Median follow-up was 44 months. A significant cut-off point for baseline and SCCAg response correlated with overall survival (OS) was calculated utilizing a log-rank test RESULTS: Among 234 patients who were diagnosed with histologically confirmed cervical cancer, 73.5% were WLWH (mean CD4 count 466 cells/mL). 92.9% of all cancers were squamous cell carcinoma. 68.8% of patients had elevated SCCAg at time of diagnosis. There was no significant difference in mean baseline SCCAg between WLWH (13.3 ng/mL) and women living without HIV (9.07 ng/mL), p = 0.1052. There was a significant difference seen in mean SCCAg between early (7.9 ng/mL ± SD 13.4) and advanced (18.9 ng/mL, ± SD 29.8) stage disease at diagnosis, p < 0.0001. Baseline SCCAg > 7.9 ng/mL was found to be associated with worse OS (p < 0.001). 5-year OS was significantly different among patients with SCCAg response < = 2.8 (5-year OS 66.2%), vs. SCCAg >2.8 ng/mL (5-year OS 42.4%). There was no significant difference in average SCCAg values between EOT (p = 0.68) and 3-month follow-up (p = 0.24). There was no difference in the proportion of patients who experienced normalized SCCAg by HIV status (p = 0.67).

CONCLUSION

There was no significant difference in SCCAg among WLWH and women living without HIV. Among patients with elevated SCCAg above normal at baseline, SCCAg was associated with early vs. advanced stage disease. Additionally, there was a significant difference seen in overall survival by two measurement points: baseline SCCAg >7.9 ng/mL and response SCCAg >2.8 ng/mL. SCCAg may be utilized as a biomarker in low-resource settings to refine prognosis. Further studies will be needed to determine utility and validation in predicting recurrence risk and/or lymph node metastases.

The Voice of the Lost Toe: Pseudo-Ainhum Beyond Skin

An 11-year-old boy presented with serial autoamputations of the right 4th and 5th toes during the past 6 years. This was associated with sensory loss on the right leg and development of constriction bands around the right 2nd and 3rd digits for the past 5 months. For a year, the patient had been treated with paucibacillary, multi-drug therapy (PB-MDT) with a presumptive diagnosis of leprosy. He was born from a nonconsanguinous marriage and the birth was uneventful. The developmental milestones were normal, and no family history of any congenital anomalies was reported.

Rescue treatment with intravenous immunoglobulin and amniotic membrane dressing in refractory paediatric pemphigus vulgaris with sepsis

We report a case of refractory paediatric pemphigus vulgaris with sepsis, treated successfully with intravenous immunoglobulin (IVIG) and amniotic membrane dressing. The patient was initially started on oral prednisolone (1 mg/kg/day) and dapsone 50 mg once daily. Azathioprine 50 mg orally was then used in place of dapsone due to rapid disease progression with extensive skin involvement. However, the patient developed sepsis and azathioprine had to be discontinued. Because of rapidly progressive disease and sepsis, the patient was put on IVIG at a dose of 2 g/kg in divided doses over 3 days along with amniotic membrane dressing. There was marked improvement after 2 weeks of follow-up.

Prevalence and diagnostic significance of novel 12-lead ECG patterns following COVID-19 infection in elite soccer players

Background

Identification of athletes with cardiac inflammation following COVID-19 can prevent exercise fatalities. The efficacy of pre and post COVID-19 infection electrocardiograms (ECGs) for detecting athletes with myopericarditis has never been reported. We aimed to assess the prevalence and diagnostic significance of novel 12-lead ECG patterns following COVID-19 infection in elite soccer players.

Methods

We conducted a multicentre study over a 2-year period involving 5 centres and 34 clubs and compared pre COVID and post COVID ECG changes in 455 consecutive athletes. ECGs were reported in accordance with the International recommendations for ECG interpretation in athletes. The following patterns were considered abnormal if they were not detected on the pre COVID-19 infection ECG: (a) biphasic T-waves; (b) reduction in T-wave amplitude by 50% in contiguous leads; (c) ST-segment depression; (d) J-point and ST-segment elevation &gt;0.2 mV in the precordial leads and &gt;0.1 mV in the limb leads; (e) tall T-waves ≥1.0 mV (f) low QRS-amplitude in &gt;3 limb leads and (g) complete right bundle branch block. Athletes exhibiting novel ECG changes underwent cardiovascular magnetic resonance (CMR) scans. One club mandated CMR scans for all 28 (6%) athletes, despite the absence of cardiac symptoms or ECG changes.

Results

Athletes were aged 22±5 years (89% male and 57% white). 65 (14%) athletes reported cardiac symptoms. The mean duration of illness was 3±4 days. The post COVID ECG was performed 14±16 days following a positive PCR. 440 (97%) athletes had an unchanged post COVID-19 ECG. Of these, 3 (0.6%) had cardiac symptoms and CMRs resulted in a diagnosis of pericarditis. 15 (3%) athletes demonstrated novel ECG changes following COVID-19 infection. Among athletes who demonstrated novel ECG changes, 10 (67%) reported cardiac symptoms. 13 (87%) athletes with novel ECG changes were diagnosed with inflammatory cardiac sequelae; pericarditis (n=6), healed myocarditis (n=3), definitive myocarditis (n=2), and possible/probable myocarditis (n=2). The overall prevalence of inflammatory cardiac sequelae based on novel ECG changes was 2.8%. None of the 28 (6%) athletes, who underwent a CMR, in the absence of cardiac symptoms or novel ECG changes revealed any abnormalities. Athletes revealing novel ECG changes, had a higher prevalence of cardiac symptoms (67% v 12% p&lt;0.0001) and longer symptom duration (8±8 days v 2±4 days; p&lt;0.0001) compared with athletes without novel ECG changes. Among athletes without cardiac symptoms, the additional yield of novel ECG changes to detect cardiac inflammation was 20% (n=3).

Conclusions

3% of elite soccer players demonstrated novel ECG changes post COVID-19 infection, of which almost 90% were diagnosed with cardiac inflammation during subsequent investigation. Most athletes with novel ECG changes exhibited cardiac symptoms. Novel ECGs changes contributed to a diagnosis of cardiac inflammation in 20% of athletes without cardiac symptoms.

Funding Acknowledgement

Type of funding sources: None.

Mitral valve abnormalities in decedents of sudden cardiac death due to hypertrophic cardiomyopathy and idiopathic left ventricular hypertrophy

Background

The sole identification of left ventricular hypertrophy (LVH) in a young individual that died suddenly may often lead to an erroneous diagnosis of hypertrophic cardiomyopathy (HCM). Emerging data suggests that idiopathic LVH (ILVH) and HCM may be separate entities.

Aim

We aimed to report on the prevalence and nature of mitral valve (MV) abnormalities, in a cohort of sudden cardiac death (SCD) victims with a post-mortem examination consistent with HCM and ILVH.

Methods

We reviewed 6860 consecutive cases of SCD referred to our specialist cardiac pathology centre between 1994 and 2020. SCD was defined as death from a cardiovascular cause within 12 hours of apparent well-being. HCM was defined by the presence of LVH, in the absence of abnormal loading conditions and characterised by myocyte disarray at histology. ILVH was defined as unexplained LVH (heart weight &gt;500 g in males and &gt;400 g in females) and left ventricular (LV) wall thickness &gt;15mm, in the absence of myocardial disarray or secondary causes of LVH. The MV was examined for patency, circumference, thickening, nodularity, ballooning, bulging between cords, perforation, and the presence of impact lesions in the LV outflow tract (LVOT) and aortic outlet.

Results

Of the total cases of SCD, 264 (4%) were due to HCM (mean age 41±18 years, 78% males, LV maximal wall thickness 19±6 mm) (Figure 1). Ante-mortem symptoms were reported in 44 (17%) cases and for the majority (n=217, 82%) HCM was established at post-mortem. Death was attributed to ILVH in 253 (3%) cases (mean age 43±16 years, 80% males, LV maximal wall thickness 18±4 mm). MV abnormalities were found in 58 (22%) decedents with HCM (mean age 38±17 years; 72% males) and in 13 (5%) decedents with ILVH (mean age 55±15 years; 77% male), p&lt;0.001. Amongst the 58 (22%) cases with HCM and MV abnormalities, 15 (6%) cases had multiple MV abnormalities. These included impact lesions associated with thickening of the anterior leaflet of the MV (n=39) and degenerative changes (n=34) such as bulging and ballooning; and thickening and nodularity. Decedents with HCM exhibiting MV abnormalities were younger than decedents with a normal MV (38±17 versus 45±19 years; p=0.08). Among the 253 decedents with ILVH, 13 (5%) cases exhibited MV abnormalities, which largely included degenerative changes (n=12). Among decedents with HCM and ILVH exhibiting MV abnormalities, the former was significantly younger (38±17 versus 55±15; p=0.001). Myocardial fibrosis was observed in 162 (61%) cases of HCM and 99 (39%) cases of ILVH, p&lt;0.001.

Conclusions

MV abnormalities are over four-fold more common in individuals with HCM than those with ILVH and may be considered as additional macroscopic features to differentiate between these two entities. Furthermore, the inherent descriptive terminologies used when assessing the MV, support a greater emphasis on the standardisation and quantification of MV abnormalities as part of the autopsy in victims of SCD.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Acknowledgements: We thank the charitable organisation, Cardiac Risk in the Young (CRY) who fund and support the CRY Cardiovascular Pathology Unit and CRY database.

Sudden cardiac death during exercise in young individuals with hypertrophic cardiomyopathy

Background

Sudden cardiac death (SCD) in young individuals and athletes is generally caused by hereditary cardiac conditions, including cardiomyopathies such as hypertrophic cardiomyopathy (HCM). Although historically HCM has been reported as the predominant cause of SCD in young athletes, it is unclear as to what degree exercise is a trigger for possible fatal arrhythmias.

Aim

We aimed to report on the circumstances of SCD in a cohort of young individuals aged ≥10 and &lt;30 whose autopsy was consistent with HCM.

Methods

We reviewed 6860 consecutive cases of SCD referred to our specialist cardiac pathology centre 1994 and 2020. SCD was defined as death from a cardiovascular cause within 12 hours of apparent well-being. All cases underwent detailed autopsy evaluation of the heart, including histological analysis, by expert cardiac pathologists. A minimum of 10 blocks of tissue were taken for histological analysis. HCM was defined by the presence of increased heart weight or increased wall thickness and significant myocyte disarray at histological examination.

Results

Of the total cases of SCD, 264 (4%) were due to HCM. Our cohort of young decedents comprised of 66 individuals (average age 21±5 years, males 76%). For the majority (n=52, 79%) SCD was the first manifestation of HCM. The average heart weight was 507±152 grams and left ventricular (LV) fibrosis was found in 28 (42%) cases (Figure 1A). Death was more common between 16 and 20 years of age (n=24) (Figure 1B). Death occurred during exertion in 25 (38%) individuals and at rest or during daily activities in the remaining 41 (62%), including 5 individuals who died during sleep. Male sex was more represented among decedents who died during exertion (88% compared with 68% in the group that died at rest, p=0.07); LV fibrosis was more commonly observed in individuals who died during exertion (56% compared with 34% in the group who died at rest, p=0.08). Younger individuals between 10–15 years of age died mostly during exercise (80%), in other age groups death occurred mainly at rest (33% in age group 16–20 years, 30% in age group 21–25 years, 33% in age group 26–30 years) (Figure 1B).

Conclusions

We observed a high age-related variability in terms of circumstances of death. In the context of HCM, our findings suggest that individuals aged 10–15 years are the most vulnerable in terms of exercise-related-SCD. This exemplifies the importance of preventative cardiac screening in young individuals who might be harbouring quiescent cardiac conditions associated with young SCD.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Acknowledgements: We thank the charitable organisation, Cardiac Risk in the Young (CRY) who fund and support the CRY Cardiovascular Pathology Unit and CRY database.

Prevalence and outcomes of WPW pattern in the young: a report from a nationwide cardiac screening programme

Funding Acknowledgements

Type of funding sources: None.

Background

Individuals with accessory pathways, also referred as the Wolff-Parkinson-White pattern (WPWp), are usually asymptomatic and fatal arrhythmias may be the first presentation. Risk stratification is recommended, with electrophysiological study (EPS) being the gold standard. Catheter ablation offers a widely available, curative option, and provides incentive for screening, particularly in high-risk populations such as athletes.

Purpose

We sought to assess the prevalence, real-world clinical practice and outcomes of WPWp in young individuals identified through a nationwide cardiac screening programme.

Method

Between 2008 and 2018, 113,209 consecutive individuals (14 to 35 years old, 38% female) underwent cardiac screening with a health questionnaire, 12-lead electrocardiogram (ECG) and cardiology consultation. Individuals with suspected cardiac disease were referred for further investigations as necessary. Clinical outcomes were obtained via an online questionnaire and matched de-identified records from the Office of National Statistics database. Individuals were classified as elite athletes, non-elite athletes and non-athletes.

Results

A total of 214 (0.2%) individuals were referred for secondary evaluation with a suspected WPWp (Figure 1). Clinical outcomes were unavailable for 30 (14%) individuals. Follow-up confirmed an additional 13 individuals with a WPWp who were deemed to have normal investigations at screening, of which 8 (61%) had reported cardiovascular symptoms on their HQ and, in retrospect, 4 (30%) demonstrated subtle WPWp on their ECG. A WPWp was confirmed in 187 individuals (0.2%), of which 149 (80%) individuals were considered non-athletes, 114 (61%) reported cardiovascular symptoms, 116 (62%) underwent risk stratification with an EPS and 95 (43%) underwent catheter ablation. Report of palpitation was significantly greater in non-athletes than athletes (p=0.034). In asymptomatic individuals, those engaging in sports at elite level were more likely to be referred for an EPS (p=0.04). Four adverse cardiac events were reported over a follow up period of 7.4 years (IQR 4.9 to 9.2), including 3 individuals (16 years, 20 years, 40 years) with life-threatening arrhythmic events (LAE) requiring cardioversion, and 1 individual (20 years) with sudden cardiac death. Of these 4 individuals, only 1 with a LAE had undergone risk stratification with EPS.

Conclusions

The incidence of SCD in this young screened population was 0.72 per 1000 person-years. Clinical practice was variable and EPS was not offered to a significant proportion of patients, despite inadequate non-invasive risk stratification. The indication to EPS was driven by the athletic status in the asymptomatic individuals. The WPW syndrome may manifest with subtle ECG changes, posing a diagnostic challenge to interpreting physicians.

Results of a nationally implemented cardiac screening programme in elite cricket players in England and Wales

OBJECTIVES

We assessed the diagnostic yield and costs of an electrocardiogram-based national screening programme in elite cricket players and the incremental value of transthoracic echocardiography and periodic evaluation.

DESIGN

Cross-sectional study.

METHODS

Between 2008 and 2019, 1208 cricketers underwent screening with a health questionnaire, 12-lead electrocardiogram and cardiology consultation. Athletes with concerning findings underwent on-site transthoracic echocardiography and further investigations as necessary. In addition, despite a normal health questionnaire and electrocardiogram, 342 (28.3%) athletes had a transthoracic echocardiogram and 493 (40.8%) underwent repeat evaluations.

RESULTS

After initial evaluation, 47 (3.9%) athletes underwent on-site transthoracic echocardiography of whom 35 (2.8%) were referred for further evaluation. Four athletes (0.3%) were diagnosed with major cardiac conditions; hypertrophic cardiomyopathy (n = 1), arrhythmogenic cardiomyopathy (n = 1) and Wolff-Parkinson-White pattern (n = 2). Two athletes were identified with minor valvular abnormalities. Repeat evaluation of 493 athletes identified hypertrophic cardiomyopathy in a 22-year-old athlete, two years after his initial normal screening. During a follow-up of 5.8 ± 2.9 years no additional diagnoses or adverse cardiac events were reported. The cost of the electrocardiogram-based programme was £127,844, translating to £106 per athlete and £25,569 per major cardiac condition identified.Routine transthoracic echocardiography in 342 athletes identified two athletes with major cardiac conditions (bicuspid aortic valve with severe aortopathy and aortic regurgitation and an atrial septal defect associated with right ventricular volume overload) and 10 athletes with minor abnormalities.

CONCLUSIONS

An electrocardiogram-based national screening programme identified a major cardiac condition in 0.3% of athletes. Routine transthoracic echocardiography and periodic evaluation increased the diagnostic yield to 0.6%, at an incremental cost.

Can echocardiographic parameters predict mortality in COVID-19?

Introduction

The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), otherwise known as the coronavirus (COVID-19) pandemic presents one of the greatest medical challenges of our generation. Whilst commonly causing a viral pneumonitis, myocardial damage has also been suggested by elevated serum troponin values greater than the 99th centile in up to 30% of individuals who require hospitalisation and correlates with increased mortality.

Purpose

We aim to identify whether transthoracic echocardiography (TTE) parameters can elucidate the phenomenon of abnormal troponin levels. Furthermore, we seek to characterise the most frequent demographic, biochemical, echocardiographic features and co-morbidities associated with adverse outcomes in this cohort.

Methods

A retrospective analysis was conducted utilising electronic patient records of consecutive hospitalised patients with a positive COVID-19 swab between 1st March and 31st October 2020 who underwent a TTE at our institution. Pertinent variables were collected including: the clinical indication, demographics including cardiovascular (CV) risk factors, peak troponin values and fundamental echocardiographic parameters.

Results

During this 8-month period, a total of 90 patients underwent a TTE. The mean age of the cohort was 63 years of age and 56% were male. More than half (56.6%) were admitted to the intensive care unit (ICU). A salient 41.1% (n=37) of our cohort succumbed to this devastating virus. Notably, 38.9% (n=35) were of black and minority ethnic origin (BAME). A striking 64.9% (n=24) of patients who died had hypertension. The mean troponin levels were 168.7 ng/L and 176.6 ng/L (0–34 ng/L) in the survivors and non-survivors group respectively. With regards to TTE, the left ventricular parameters were similar between both groups with a mean left ventricular ejection fraction (LVEF) of 60.6% in the non-survivors. Conversely, both right ventricular (RV) dysfunction (37.8%) and raised pulmonary artery systolic pressures (PASP) (51.4%) were markedly more frequent in the patients who perished due to COVID-19 infection.

Conclusion

Remarkably, in this extremely ill group of patients who died, 91.9% of patients had a preserved LVEF. There were no overt differences between troponin levels in the survivors and non-survivors. However, hypertension, RV dysfunction and raised PASP were distinctly more prominent in the non-survivors. Thus, providing insight that a normally functioning left ventricle does not preclude to poor outcomes. Overall, this single-centre retrospective study demonstrates that the echocardiographic phenotype associated with mortality is consistent with a severe respiratory illness rather than direct myocardial injury from COVID-19. A multi-modality imaging approach may facilitate the identification of adverse tissue characterisation changes associated with this novel virus as well as guiding further risk stratification and patient management on a case-by-case basis.

Funding Acknowledgement

Type of funding sources: None.

Utility of Microhemorrhage as a Diagnostic Tool in Distinguishing Vestibular Schwannomas from other Cerebellopontine Angle (CPA) Tumors

Although a majority of tumors in the Cerebellopontine Angle (CPA) are vestibular schwannomas (VS), other masses can also be seen in the region and differentiation of various CPA tumors, particularly meningiomas can be difficult on imaging alone. Treatment options may vary based on specific pathology of the CPA tumor. In this study, the presence of microhemorrhage (MH) and other imaging features such as size of lesion, cystic features and pattern of IAC extension, were evaluated as a tool in distinguishing VS from other CPA masses. A review of CPA masses in the last 11 years at our institution was performed. All the pathology proven tumors with at least 1 pre-operative MRI were considered for analysis. A T2* GRE or SWI sequence was used to assess presence of MH within the lesion. Pattern of IAC extension ('centric' versus 'eccentric') of tumor was also evaluated. A total of 147 patients were reviewed out of which 102 patients (with T2* GRE or SWI) were included for analysis of MH. 57 patients (56%) had VS as the final histopathological diagnosis and 45 patients (44%) had other types of tumor. A sensitivity of 82% and a specificity of 98% was noted for the presence of MH favoring the diagnosis of VS from other tumors (p < 0.001). All meningiomas with IAC extension (25/31) showed an 'eccentric' pattern of extension into the canal. Visualization of MH and pattern of IAC extension is useful in the differentiation of schwannomas from other CPA masses, particularly meningiomas.

Race, gender and clinical presentation in apical hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Background

The apical variant of hypertrophic cardiomyopathy (ApHCM) has male predominance and is a relatively rare phenotype in Western population. Characteristics of female and black patients diagnosed with ApHCM are very limited in the existing literature.

Purpose

We aimed to investigate whether gender and race are associated with a different clinical presentation and CMR findings in apical HCM.

Methods

We retrospectively analysed 150 patients (113 males and 37 females) with a diagnosis of apical HCM who have been followed in our inherited cardiac conditions (ICC) clinic between 2010 and 2020. Only patients with a CMR study and apical hypertrophy defined as ≥ 13mm at the time of diagnosis were included.

Demographics and clinical characteristics were obtained from electronic records. Volumetric CMR data were taken from confirmed reports while other parameters were measured by standard protocol. "Pure" ApHCM was defined as isolated apical hypertrophy and "mixed" with both apical and septal hypertrophy but with the apex thickest (1). Apical displacement of papillary muscles (PM) was defined when the base of PM originated from the apical one-third of the left ventricle (LV) in the apical 4- or 2-chamber views. Giant T-wave inversion was defined as T-wave inversion that is equal or greater than 10 mm (1 mV) in any electrocardiogram lead.

Results

Our study population included patients of White (55, 37%), Black (37, 25%), Asian (36, 24%) and Mixed/Others (22, 15%) ethnicity.  Black patients were more likely to have a diagnosis of hypertension at presentation when compared to White (70% vs 40%, p = 0.01) and to Asian and Mixed/Other patients (70% vs 48%, p = 0.03). Similarly, they were more likely to have "mixed" ApHCM than White (49% vs 20%, p = 0.003) and Asian and Mixed/Other (49% vs 26%, p = 0.02) patients.

Females were diagnosed at an older age (63 ± 12 vs 52 ± 14, p &lt; 0.001) and were less likely to have deep T-wave inversion on their ECG at presentation (14% vs 32%, p = 0.03) compared to their male counterparts. Females in this cohort also had higher representation of black ethnicity and were more likely to have hypertension (68% vs 47%, p = 0.03). Apart from the expected gender related differences in volumes and LV mass, there were no differences in cardiomyopathy-specific parameters we investigated.

Conclusions

In our cohort, females with ApHCM presented at an older age and were less likely to have giant T-wave inversion on ECG. Black patients with ApHCM were more likely to have hypertension and the "mixed" type of the disease.

Just not cosmesis! Role of low-density lipoprotein apheresis in familial hypercholesterolemia: Experience at a newly developed tertiary care institution in Northern India

Familial hypercholesterolemia (FH) is characterized by an increase in plasma low-density lipoprotein-cholesterol (LDL-C) levels. It presents with tendon/skin xanthomas and premature atherosclerotic cardiovascular disease. The most available treatment options for FH are lipid-lowering medications such as statins, lifestyle modification, and LDL apheresis. As per American Society for Apheresis guidelines 2019, the treatment of FH using LDL apheresis falls under Category I. Here, we are reporting an interesting case of a young patient who presented with chief complaints of progressively increasing yellowish lesions around eyes, neck, hands, and legs. She was thoroughly investigated and was diagnosed provisionally as a case of Type 2 FH. Her total serum cholesterol and LDL-C were 717.2 mg/dl and 690.6 mg/dl, respectively, at presentation. One cycle of LDL apheresis was planned for her. We found immediate post-procedural reduction of 55.8% and 55.3% for total serum and LDL cholesterol levels respectively while 70.58% and 77.41% reduction in the levels from the day of presentation to the hospital.

Dancing doctors: exploring the potential of cultural dance education to improve cultural competency and clinical communication

OBJECTIVE

One of the largest barriers towards the utilization and overall success of health interventions for minority communities is the difference between the cultures of healthcare services and service users. Medical students, physicians, and healthcare systems are taught to be culturally competent, yet multiple studies demonstrate the persistence of differences in perception of care and disparities in outcomes for communities of colour. This article aims to offer a patient-centred, culturally nuanced medium for teaching cultural competency.

STUDY DESIGN

This is a brief report based on experiential learning, observations, and a short literature review on understanding culture through traditional dances.

METHODS

To address cultural disconnect between clinical medicine and diverse patients, we recommend encouraging patients from diverse backgrounds to teach physicians how to perform cultural dances.

RESULTS

Traditional dance appears to be a culturally rich source for holistically educating physicians on cultural competency.

CONCLUSION

This process of learning a cultural dance can improve cultural humility and cultural competency, and clinical communication between the provider and public.

Giant bilateral angiomyolipoma of the kidney

Angiomyolipoma is a benign solid renal neoplasm. A giant angiomyolipoma is more than 10cm by size, but it can grow to huge proportions. Our case appears to be the third largest angiomyolipoma and the largest among bilateral giant renal angiomyolipoma in the indexed literature. A 26-year-old man presented with large right abdominal swelling for the past three years, which was occupying his right flank and iliac region, extending beyond the midline. Computed tomography of the abdomen revealed a large well-defined mass in the right side of the abdomen, crossing the midline and measuring 35 × 20 × 12cm. The left kidney showed a similar fatty lesion of 14 × 6cm. The findings were consistent with angiomyolipoma. Further evaluation for tuberous sclerosis by magnetic resonance imaging the brain demonstrated multiple subependymal nodules. Giant renal angiomyolipoma is an uncommon tumour with bilateral giant angiomyolipoma being a rare entity. Preoperative embolisation helps in reducing size of the tumour. In case of giant and bilateral angiomyolipoma, evaluation for tuberous sclerosis should always be done.

Does human serotonin-1A receptor polymorphism (rs6295) code for pain and associated symptoms in fibromyalgia syndrome?

Genetic predisposition may play an important role in the development of fibromyalgia syndrome (FMS). Serotonin is known to be involved in pain modulation and serotonin-1A receptor plays a considerable role in determining the central 5-HT tone. Consequently, variation in 5-HT1A receptor gene (HTR1A) may be responsible for inter-individual variability in pain sensitivity and other clinical symptoms of FMS. Therefore, the objectives of this research work were to study the gene polymorphism of 5-HTR1A gene and to explore the correlation between rs6295 genotype (-1019C/G HTR1A) and duration of pain, pain intensity and pain related depression and anxiety, if any, in FMS. 5-HTR1A genotype for the C(-1019)G polymorphism was typed in 62 patients with FMS and 42 healthy subjects. Present pain intensity, components of pain and pain related depression and anxiety were assessed using the numerical pain rating scale, McGill pain questionnaire and Hamilton depression and anxiety rating scale respectively. 5-HTR1A gene was represented by three different genotypes, homozygous C/C, heterozygous C/G and homozygous G/G. Analysis of the 5-HTR1A gene showed a frequency of 58%, 31% and 11% for the C/C, C/G and G/G genotypes, respectively in FMS group. This proportion was 69%, 23% and 8% in healthy subjects. No significant correlation was observed between 5-HTR1A gene polymorphism and pain and related symptoms in FMS patients. To the best of our knowledge this is the first study which investigated the correlation between the 5-HTR1A gene polymorphism and pain intensity, the affective component of pain, pain related depression and anxiety in FMS.

Efficacy of Low-Frequency Repetitive Transcranial Magnetic Stimulation in Ischemic Stroke: A Double-Blind Randomized Controlled Trial

Objective

To investigate the role of low-frequency repetitive transcranial magnetic stimulation (rTMS) along with conventional physiotherapy in the functional recovery of patients with subacute ischemic stroke.

Design

Double-blind, parallel group, randomized controlled trial.

Setting

The outpatient department of a tertiary hospital participants: first ever ischemic stroke patients (N=96) in the previous 15 days were recruited and were randomized after a run-in period of 75±7 days into real rTMS (n=47) and sham rTMS (n=49) groups.

Intervention

Conventional physical therapy was given to both the groups for 90±7 days postrecruitment. Total 10 sessions of low-frequency rTMS on contralesional premotor cortex was administered to real rTMS group (n=47) over a period of 2 weeks followed by physiotherapy regime for 45-50 minutes.

Main Outcome Measures

The primary efficacy outcomes were change in modified Barthel Index (mBI) score (pre- to postscore) and proportion of participants with mBI score more than 90, measured at 90±7 days postrecruitment. The secondary outcomes were change in Fugl-Meyer Assessment–upper extremity, Fugl-Meyer Assessment–lower extremity, Hamilton Depression Scale, modified Rankin Scale, and National Institute of Health and Stroke Scale (pre- to post-rTMS) scores at 90±7 days post recruitment.

Results

Modified intention to treat analysis showed a significant increase in the mBI score from pre- to post-rTMS in real rTMS group (4.96±4.06) versus sham rTMS group (2.65±3.25). There was no significant difference in proportion of patients with mBI>90 (55% vs 59%; P=.86) at 3 months between the groups.

Conclusion

In patients with subacute ischemic stroke, 1-Hz low-frequency rTMS on contralesional premotor cortex along with conventional physical therapy resulted in significant change in mBI score.

CSF Oculorrhea Presenting as "Tearing" following the Repair of Fronto-Ethmoidal Encephalocele

INTRODUCTION

Cerebrospinal fluid (CSF) oculorrhea is extremely rare, and very few cases have been reported mostly following trauma. There is only 1 case in the published literature where oculorrhea occurred following the repair of fronto-nasal encephalocele.

CASE DESCRIPTION

A six-year-old girl presented with gradually increasing fronto-ethmoidal encephalocele with secondary papulo-nodular changes. She underwent bi-frontal craniotomy with excision of encephalocele sac and herniated gliotic brain followed by dural closure using peri-cranial graft. One month later, she presented again with swelling over the operative site and "tearing" from both her eyes. She was diagnosed with CSF oculorrhea. After failing conservative management, lumbar drain was inserted and kept on continuous drainage. Oculorrhea stopped with lumbar drain but restarted with its removal. Therefore, theco-peritoneal shunt was placed, following which oculorrhea stopped. She is doing well at 5 months' follow-up.

CONCLUSION

CSF oculorrhea must be considered by the pediatric neurosurgeons in any patient who presents with "tearing" following the repair of an anterior encephalocele.

Penile cancer and the HPV attributable fraction in Scotland; A retrospective cohort study

BACKGROUND

Penile cancer (PeC) is a highly morbid disease which is rising in certain settings including Scotland. A component of PeC is associated with Human Papillomavirus (HPV) although its influence on clinical outcomes is debatable as is whether the fraction attributable to HPV is increasing.

METHODS

A total of 122 archived tissue samples derived from patients diagnosed with PeC between 2006-2015 were collated and tested for HPV DNA using molecular PCR. HPV positivity was determined for the overall population and by calendar year of diagnosis to determine any temporal trends. The influence of age, deprivation, smoking, tumour stage and tumour grade on likelihood of HPV positivity was determined by logistic regression. In addition, the influence of HPV status and the other clinical and demographics variables on all-cause death and death from PeC was assessed.

RESULTS

HPV was detected in 43 % (95 % CI: 34-52) of penile cancers and the majority of infections were HPV 16. The HPV component of PeC did not increase over the time period (p for linear trend - 0.226). No demographic or clinical variables were associated with HPV positivity neither was HPV status associated with improved all-cause or cancer-specific survival during the follow up period.

CONCLUSION

The rise in PeC in Scotland may not be attributable to a rise in HPV-associated cancer; this is consistent with oropharyngeal cancer (OPC) in the UK where there is an increase in both HPV positive and negative cancer. This work calls for a larger multi centre study to enable further detailed investigation into the implications of HPV infection in PeC.

Effectiveness of autoinoculation in viral warts: A single arm, open-label, and clinical trial

Viral warts are well-defined, hyperkeratotic mucocutaneous lesions caused by human papilloma virus infection, that can occur anywhere on the body. Various medical and surgical modalities are required for treatment of warts as spontaneous regression is rarely seen. Despite the availability of multiple treatment options, warts are often recurrent and resistant to treatment. The effectiveness of autoinoculation in the treatment of multiple or recurrent verruca was evaluated. Consecutive cases with at least five warts or recurrent warts were included. A treatment-free washout period of 1 month was ensured. Patients with verruca vulgaris (n = 13), palmoplantar (n = 4), periungual (n = 5) were included in the study. The warty tissue was excised, minced and homogenous tissue implanted in a small dermal pocket in the left forearm. Patients were evaluated every 4 weeks. The procedure was repeated at 4th and 8th week. Response was assessed at each visit and at 12th week. Fifteen cases were recruited. Majority of the patients were diagnosed with verruca vulgaris (87%, n = 13) followed by periungual warts (33%, n = 5) and palmoplantar warts (27%, n = 4). Recurrent warts were present in 73% (n = 11) patients. Average improvement at the end of 12 weeks was seen in 65% cases. Ten (67%) patients showed complete resolution of warts. In two patients, warts increased in number while on treatment. Local site infection was seen in two patients. The study is limited by its small sample size. Autoinoculation is an effective modality of treatment for multiple and recurrent warts. Furthermore, it is an effective treatment modality for periungual and plantar warts, which are usually resistant to other modalities.