Extensive Post-EMR Procedure Related Artifact due to Novel Submucosal Lifting Agent, Mimicking Amyloid – A Diagnostic Pitfall

Introduction/Objective

Endoscopic mucosal resection (EMR) techniques are vital for the management of premalignant lesions and early-stage (T1N0) malignant lesions of the digestive tract. Recently FDA approved submucosal lifting agent “ORISE™” (Boston Scientific, Marlborough, MA) for EMR procedure to enable resection of the polyp or lesion. We herein present two hemicolectomy cases performed for a colon cancer showing an exuberant amyloid-like reaction due to ORISE™ Gel.

Methods/Case Report

At Veterans Affairs Medical Center, two cases of hemicolectomy were performed for colon cancer. Both cases had prior EMR procedure performed for a large cecal polyp. ORISE™ gel was injected with successful lift of the polyp during EMR. Pathology on both cases revealed tubulovillous adenoma with high grade dysplasia; hence right hemicolectomy was performed. Microscopic examination revealed submucosal area with extensive amorphous, eosinophilic/hyaline deposits and surrounding giant cell formation, underlying the cancerous polyp. The deposits were neither refractile nor polarizable. No tattoo pigmentation identified to explain this reaction. The fibrillary eosinophilic deposit raised the concern for concurrent amyloid deposits. This stained pale blue with Masson trichome special stain. Congo red special stain for amyloid was negative and no apple-green birefringence under polarized light was identified. Finally, after extensive ancillary work-up with literature review, the case was signed out as “changes consistent with post-EMR ORISE™ gel artifact”.

Results (if a Case Study enter NA)

N/A.

Conclusion

Knowledge of EMR procedure artifact due to use of ORISE™ gel is crucial in routine hemicolectomy specimens performed for unresectable polyps or colon cancer cases. ORISE™ gel creates amorphous hyaline deposits mimicking amyloid. The deposits encompass larger submucosal area with giant cells mimicking foreign body. Delay in turn around time of the case with additional cost for the ancillary work-up. Extensive amyloid-like reaction is a diagnostic pitfall in routine hemicolectomy specimens and, awareness of prior EMR procedure related artifact is important to avoid misinterpretation and delay in patient care.

Fistula-associated Mucinous anal Adenocarcinoma, a Surprise Diagnosis in a Benign Chronic Peri-Anal Fistula Resection

Introduction/Objective

Mucinous anal adenocarcinoma arising in a long standing, chronic peri-anal fistula is rare, accounting for 2-3% of the total anal adenocarcinomas with only few cases reported in a literature. These slow growing, locally aggressive neoplasms with a low-grade histologic appearance, clinically manifest late in a disease course. This entity’s pathogenesis and origin remains controversial. As it arises within a chronic fistula, these tumors present a late stage. Hence, this is generally a surprise finding upon fistula excision. Mucinous carcinomas from other sites should be ruled out with ancillary studies before making this diagnosis. Awareness of this rare cancer is crucial.

Methods/Case Report

67-year-old male with a known history of fistula, presented with reports of recent onset of pain and swelling near his anus. He had a history of seton placement, perirectal abscess drainage and past fistulotomy in 2006 and 2008. On physical exam, he had a firm, tender mass with an ostium just right and posterior to his anus. Pre- operative diagnosis was a chronic, recurrent fistula. Immunohistochemical stains showed mucinous adenocarcinoma with anal gland phenotype. Hence, by WHO criteria, this was diagnosed as Fistula-associated mucinous adenocarcinoma. After the diagnosis of cancer, imaging studies for staging did not reveal any metastatic disease, nor was there any residual lesion or fistulous tract as evaluated by the surgeon. Hence evaluation of the margins on the resection specimen was crucial for post-operative radiotherapy.

Results (if a Case Study enter NA)

NA.

Conclusion

1. Mucinous adenocarcinoma arising in a chronic, benign fistula is a rare entity with unsuspected diagnosis, and since the presentation is often delayed, a high degree of clinical suspicion is required for early diagnosis and management. Early detection is crucial as prognosis is worse if size is greater than 5 cm, and/or if there is lymphatic or vascular invasion. Acellular mucinous pool in excision of a benign fistula, should raise the suspicion of this entity. Excision specimen from the long standing chronic, fistulas should be submitted in its entirety for microscopic evaluation to avoid the possibility of missing this underlying malignancy. Most patients can be cured with aggressive surgical and adjuvant chemoradiotherapy, hence, when possible, this specimen should be inked to enable the evaluation of the margins.

Immunochemical Fecal Occult Blood Test Screening Results prior to Colorectal Cancer Diagnosis

Introduction/Objective

Immunochemical fecal occult blood testing (iFOBT) is one of the options outlined by the standard of care guidelines from the U.S. Preventive Services Task Force (USPSTF) for screening for colorectal cancer in adults. The iFOBT assay is a convenient and reasonably accurate screening assay. It has been shown in the literature, through a metanalysis of iFOBT tests, that the overall sensitivity of iFOBT in the general population for detecting colorectal cancer within 2 years of follow-up across different medical settings is 0.79 (95% confidence interval 0.69-0.86). However, similar investigation in the veteran population is sparse, but would be important given the significant differences between the Veteran population and the general population including increased medical comorbidities.

Methods/Case Report

A search of all iFOBT testing performed at a regional Veteran Affairs Medical Center (VAMC) from 10/1/2018 to 6/4/2022 was performed to identify patients with both diagnosed colorectal cancer by pathology examination and iFOBT testing within 2 years prior to this diagnosis. The iFOBT result (at least one positive prior to diagnosis or always negative) prior to diagnosis with colorectal cancer was recorded once per patient. iFOBT results collected after the day the positive colorectal pathology specimen was obtained were excluded. Demographic information was also recorded. iFOBT testing was performed using the Polymedco assay product (Cortlandt Manor, NY).

Results (if a Case Study enter NA)

There were a total of 26 patients (25 males and 1 female) with diagnosed colorectal cancer. The patient age range was 37 to 88 years (average 70) with an ethnic composition of 12 of 26 (46%) African Americans, 13 of 26 (50%) Caucasian American, and 1 of 26 (4%) Native Hawaiian or other Pacific Islander American. 20 of the 26 patients (77%) of the patients had at least one positive iFOBT test result prior to their colorectal cancer diagnosis, which is within the published observation for the accepted sensitivity in the general population.

Conclusion

While there are differences between the general population and the veteran population in terms of medical comorbidities, the iFOBT test assay performed similarly to the general population in terms of sensitivity for colorectal cancer diagnosed within 2 years of the iFOBT assay and remains an important part of the standard of care for colorectal screening for both populations.

Validation of High sensitivity cardiac troponin (HsTnI) – a breakthrough in diagnostic accuracy of acute coronary syndromes

Introduction/Objective

Cardiac troponin (cTn) testing is an essential component of the diagnostic workup and management of acute coronary syndromes (ACS). Rapid advances in immunoassay technologies has led to the development of high sensitivity troponin (HsTnl) assays with unprecedented analytic sensitivity and precision. These assays are FDA approved and the use of HsTnl assays is recommended by the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC), the Joint European Society of Cardiology (ESC), the American College of Cardiology (ACC), and the American Heart Association (AHA) in the Fourth Universal Definition of Myocardial Infarction (2018). The incidence of ACS and its mimics in emergency room visits are much more prevalent in veterans due to increased medical comorbidities. We report here our experience with its validation on two Unicel DXI 800 Access Immunoassays as it has not been well published, particularly in a Veterans Healthcare Clinical Laboratory setting.

Methods/Case Report

The quality assurance goal of the validation is to demonstrate that the Unicel DXI 800 Access Immunoassay HsTnl assay performs as expected on two analyzers and can be put into clinical use. Method to method correlation with a validated conventional Troponin I, within run precision, day to day precision, and a linearity study were performed as part of this validation.

Results (if a Case Study enter NA)

For the total of 60 specimens run for the method comparison, Data was plotted and evaluated against EP evaluator, both hsTnI and Troponin I were within the 95% confidence intervals of the method. The linearity study demonstrated results are linear with results as expected. Two levels of cardiac control were tested in a run of 60 replicates each in one day for within run precision, with all results as expected. The day to day precision with three levels of control run daily over 10 days also yielded results as expected.

Conclusion

The HsTnI is a highly accurate, faster test for the detection of ACS allowing earlier detection of smaller infarcts with much better precision, and there by reducing the morbidity and mortality. It allows rapid discharge of the patients with reducing the cost of hospital stay. This is an example of excellence in laboratory practice by extending the best quality laboratory care with proper validation of instrument methods conducive to laboratory workflow.

Excellence in Laboratory Practice with the Validation of Opiate Confirmation using Liquid Chromatography/Mass Spectrometry

Introduction/Objective

Veterans are more susceptible to opioid addiction as they are more likely to suffer from chronic pain which leads to increased need of confirmed identification of opiates in toxicology laboratories. Gas chromatography-mass spectrometry (GC-MS) had been a long-accepted method for the quantitative analysis of opiates in urine, but requires tedious, time-consuming, and complex sample preparation steps. On the other hand, liquid chromatography-mass spectrometry (LC/MS) has comparatively simpler sample preparation steps, can handle three times the number of specimens, much faster turnaround times and produces equally valid results. However, the validation experience of this simpler detection method has not been well published, particularly in a Veterans Healthcare Clinical Laboratory setting.

Methods/Case Report

The quality assurance goal of the validation is to demonstrate that the Agilent 6410 Triple Quadrupole LC/MS (Wilmington DE) is able to identify the same opiate drug analytes performed by the GC-MS. Method to method correlation, within run precision, day to day precision, carryover study, matrix (ion) suppression study, and a limit of detection study were performed as part of this validation.

Results (if a Case Study enter NA)

For the total of 156 specimens run for the method comparison, there was 94.9% agreement, or 148/156 samples were concordant. The 8 discrepancies had drugs that were present below the cutoff limit of the LC/MS. Within run precision with 20 replicates of negative, positive, and at the cutoff were run with all results as expected. The day to day precision of a positive and negative sample run over 10 days also yielded results as expected. The carryover study demonstrated minimal carryover. The matrix (ion) suppression study showed ion suppression at 16.8%, which is below the amount needed to affect analyte concentrations. The LC/MS was highly sensitive with a limit of detection of >97% at 25 ng/mL. Thus, the result of comparison showed good concordance.

Conclusion

LC/MS is a simpler, more efficient method of opiate testing that is comparable to GC-MS for the detection of opiate drugs of abuse in urine. This is an example of excellence in laboratory practice by extending the best quality laboratory care with proper validation of instrument methods conducive to laboratory workflow.

Benign Rete Testis Mimicking as a Small Cell Carcinoma in a Hydrocele Specimen – A Rare Finding in a Veteran Patient and a Diagnostic Pitfall

Introduction/Objective

Hydrocele specimens are one of the most common and routine urological specimens sent to pathology with mostly a benign outcome. Microscopic examination usually reveals loose connective tissue, mesothelial lining and possibly chronic inflammation, squamous metaplasia in long standing cases.

Methods

We present here a case of a veteran with rare finding of small, blue clusters of hyperchromatic cells in a hydrocele specimen mimicking small cell carcinoma.

Results

An elderly African American patient presented to the urology with a symptomatic hydrocele for elective removal. His review of systems preoperatively and intraoperative finding was otherwise unremarkable. Gross examination of the specimen showed a fibro-membranous tissue without any nodules or lesions. Microscopic examination showed fibromuscular tissue with scattered, detached clusters of small, blue, hyperchromatic cells with high nucleo-cytoplasmic ratio, nuclear molding without prominent nucleoli. Morphologically these features were suspicious for malignancy such as small cell carcinoma. However, no apparent mitotic figures or necrosis was noted. On immunohistochemical stains, these cells showed expression of CD 56, however proliferation rate on Ki67 was very low (0–1%).

Conclusion

Non-neoplastic proliferations are rare in testis and para-testicular structures. Rete testis is an anastomosing network of delicate channels located in the testicular hilum lined by flattened cuboidal to columnar epithelium with numerous microvilli. In a long-standing hydrocele specimen, the cells of rete testis may get sloughed off and form aggregates of small, blue hyperchromatic cells, morphologically mimicking as small cell carcinoma.

However, on close examination, these cells in cluster were “streaming”, no necrosis, atypical mitotic figures or apoptotic cells were noted. Also, it has been well known that normal rete testis cells are positive for CD 56. Thus, low ki67 proliferation rate, CD 56 positivity and absence of necrosis or mitotic figures were consistent with sloughed rete testis cells. This is a very rare finding in a routine hydrocelectomy specimens, not only highlighting the importance of thoroughly grossing the specimens; at the same time, knowledge of this benign mimicker is important to avoid erroneous diagnosis and management.

Incidence of Androgen Receptor and DNA Repair Gene Mutations in Advanced Solid Malignancies: Clinical Impact of Liquid Biopsy at Veteran Affairs Medical Center

Introduction/Objective

The advent of Liquid biopsy targeting genetic mutations in solid tumors is a major milestone in field of precision oncology. This minimally invasive, novel revolutionary technique analyses circulating tumor cells (CTC) in peripheral blood and detects signature genomic alterations. DNA repair gene (DDR) mutations have been reported in 25-40% of prostatic cancers and >50% of non-small cell lung cancers (NSCLC), being more common in late-stage and hormone refractory prostate cancers. One of the DDR, especially Tp53 has been found to be associated with poor prognosis and increased germline mutations. We herein present a quality assurance study to determine feasibility of liquid biopsy for personalized management in veterans for advanced solid malignancies and its clinical impact.

Methods

Quality assurance documentation from Foundation One (Cambridge MA, NGS) on liquid biopsies performed for the Corporal Michael J. Crescenz Veteran Affairs Medical Center (CMCVAMC) from May 2019 to April 15, 2020 were reviewed. Statistical data for adequacy, cases with notable mutations, frequency and type of mutations of AR, DNA damage repair (DDR) gene and Tp53 were noted.

Results

A total of 31 liquid biopsies were performed over this time period, of which 29/31 (93.50%) were adequate for evaluation. 23/29 (79.30%) showed notable mutations, in 4/23 (17.39%) guided treatment decisions based on androgen receptor (AR) amplification, and 7/29 (24.1%) of all cases showed DDR gene mutations indicating poor outcome and resistance to the current therapy. Greater than 50% (16/29 (55.7%)) of the veterans with advanced cancers harbored Tp53 mutation, which instills hope and future insight for patient tailored oncologic therapy.

Conclusion

The minimally invasive liquid biopsy shows a great promise as a diagnostic and prognostic tool in the personalized clinical management of advanced prostate and NSCLC in veteran patient population with unique demographic characteristics. Difference in frequency of the genetic mutations (DDR, TP53, AR) in this cohort provides valuable information for disease progression, lack of response, mechanism of resistance to the implemented therapy and clinical decision making. Precision oncology can be further tailored for this cohort by focusing on DNA repair genes and Tp53 in future for personalized targeted therapy.

Ethnic Differences in Infection with SARS-CoV-2; a Veteran Affairs Medical Center (VAMC) Experience

Introduction/Objective

An Institute of Medicine (IOM) report from 2002 has documented that racial and ethnic minorities have tended to receive worse health outcomes compared to non-minorities. This pattern has been demonstrated for many chronic and acute injuries and illnesses, but to the author’s knowledge, there is sparse literature on this study on outcomes related to the novel coronavirus (SARS-CoV-2). SARS-CoV-2 has become a pandemic of global importance with significant impact on all elements of society. As part of quality assurance, as becoming confirmed positive for SARS-CoV-2 would be adverse clinical news, a review was undertaken to see if there were ethnic differences in the veteran population being tested at the Veteran Affairs Medical Center (VAMC) on the risk of testing positive for SARS-CoV-2.

Methods

As part of a quality assurance/quality improvement project, a manual retrospective review of all SARS-CoV- 2 RT-PCR tests performed at the VAMC from March 11th, 2020 to April 13th, 2020. These tests were reviewed within

the computerized medical record system to determine the age, gender, ethnicity of the patients, and test result of the patient.

Results

There were 571 patients who had tested for SARS-CoV-2. Out of these patients, 99 of these patients had a positive test result. The ethnic breakdown of the unique patients with a positive test result was 67 were African- American (68% of positive results), 2 Asian-American (2%), 1 Native Hawaiian or other Pacific Islander/Hispanic mixed (1%), 17 Caucasian (17%), and 12 declined to answer or left ethnic field unanswered. Among the 471 who had negative results, only 197 or 42% were African American and 118 were Caucasian (25%).

Conclusion

African Americans had more infections with SARS-CoV-2 compared to the other ethnic groups. Caucasians had many of the negative results, and positive results were otherwise not common in the other ethnic groups in the VAMC cohort. Given this first report in the literature of the disproportionate impact SARS-CoV-2 is having on those of African American ethnicity, appropriate clinical access and low threshold to test is essential.

Adequacy And Rate Of Atypical Cytology On Fine Needle Aspiration Technique Using Suction (FNA-S) – A Quality Assurance Study At CMCVAMC

Introduction/Objective

Thyroid cancer is one of the most common prevailing conditions. Both genetic and environmental risk factors play a role in causation of thyroid cancers, with agent orange being the most documented risk factor in Veteran patient population. Based on the ultrasonographic appearance, thyroid nodules can be further investigated by minimally invasive fine needle cytology. This can be done by either of two available techniques, Fine needle aspiration with suction (FNA-S) and Fine needle capillary cytology without using suction (FNC), depending upon the preference of practicing endocrinologist. We aim to compare both cytology techniques for comparing the diagnostic yield and rate of atypia of undetermined significance (AUS) or Follicular lesion of undetermined significance (FLUS), requiring repeat FNA in approximately three months.

Methods

Retrospective study was conducted by searching the cases performed by an endocrinologist at Corporal Michael J Crescenz VA Medical Center between the period of January 1, 2015 and July 2, 2015. 30 nodules from 11 patients were tested by Fine needle capillary cytology technique (FNC). Yield for the diagnosis with rates of atypical (AUS) cytology were compared. On second set of the 29 patients with 38 nodules, both techniques - FNA-S versus FNC were carried out. Adequacy and rate of AUS/FLUS were calculated.

Results

Out of 30 total nodules performed by fine needle aspiration (FNA-S), all cases yielded diagnostic material. Of them, 14 (46.6%) were diagnosed as AUS and 16 (53.33%) were benign. On the follow-up/re-aspiration by FNC technique, all these 14 nodules were diagnosed benign. On second set of patients on whom both techniques (FNA-S and FNC) were used alternatively, 13 of 38 nodules (34.21%) were diagnosed as AUS/FLUS, 23 (60.52%) were benign/nodular goiter and 2 were non-diagnostic/inadequate (5.2%).

Conclusion

FNA-S (with suction) yields adequate diagnostic material, however, also has greater number of atypical cytology results requiring repeat patient visit which may increase morbidity with a burden on total health care cost.

FNC (without suction) has low rates of AUS/FLUS, is diagnostically superior with excellent smear quality, less blood clots, time savings, and less inconvenience of patients/physician. FNC (without suction) is a modality of choice for an effective screening of thyroid nodules in veterans.

The Wild West of Emergency Use Authorizations for SARS-CoV-2 Testing: What Could Be the True Sensitivity?

Introduction/Objective

SARS-CoV-2 is a pandemic that has required mobilization to meet urgent needs. In this mobilization, emergency use authorizations (EUA) have been issued by the FDA to expedite the deployment of these tests. This has led to a situation whereby sensitivity has not been rigorously studied for any of the assays with EUAs. Estimates can be extrapolated from the limited samples documented by the company in their instructions for use (IFU). Although the nationwide shortage of testing reagents prevent parallel testing of multiple platforms on all specimens, observations of repeat specimens at the Veteran Affairs Medical Center (VAMC) provides the first study in the literature of more complete data for SARS-CoV-2 nucleic acid (RT-PCR) assay on sensitivity on the Abbott (Abbott Park Ill) and Cepheid (Sunnyvale CA) assays.

Methods

A retrospective search was performed for all test results for SARS-CoV-2 by RT-PCR from 3/1/2020 to 4/14/2020 at Corporal Michael J. Crescenz Medical Center, in order to evaluate the sensitivity on Abbott m2000 and Cepheid platforms. Results across multiple reference laboratories and in-house testing platforms were collated in a table with all patients clinically requiring repeat testing recorded.

Results

114/863 patients had repeat testing. The tests were performed initially by outside reference laboratories (25 patients), on the Abbott m2000 (63 patients), and Cepheid Infinity (26 patients). 15/114 (13%) had discordant results on repeat testing. This included 1 test initially done by a reference laboratory. 8 days after the initial result from the reference lab, a positive for the same patient was identified on the Abbott platform. 11 initial Abbott results were discordant on further repeat testing on two platforms - Abbott (6 patients) and Cepheid (5 patients) 1-6 days later. In addition, 3 initial Cepheid were discordant on further repeat testing by the same Cepheid platform (1-16 days later).

Conclusion

While the instructions for use for both platforms suggest 100% sensitivity and specificity (due to the 100% positive and negative percent agreement in limited specimens), the true sensitivity is less than 100%, particularly early in the course of the infection. In our study, the positive percent agreement (surrogate for sensitivity) was 83% for initial Abbott tests, 88% for initial Cepheid tests, and 95% by Reference laboratory platform.

In-House Viral Transport Medium (VTM) Manufacture in the Time of Shortage, Supply and Crisis of COVID-19 at Veteran Affairs Medical Center (VAMC)

Introduction/Objective

With the outbreak of COVID-19 caused by SARS-CoV-2, there have been challenges in the maintenance of adequate supplies both in terms of PPE and for testing. The shortage of commercial VTM for the transport of specimens for PCR testing has created a situation in which laboratories would need to manufacture their own in-house VTM as commonly used commercial VTM is unavailable. However, there is sparse literature on the emergency manufacture of VTM. Here, we describe the VAMC experience in manufacturing/quality control on its own VTM.

Results

VTM was manufactured by pathology and laboratory medicine using strict aseptic technique with Hanks Balanced Salt Solution (HBSS) 500 ml bottle with phenol red, sterile heat-inactivated fetal bovine serum (FBS) gentamicin sulfate (50 mg/mL) and amphotericin B (250 ug/ml). First, 50 ml of amphotericin B and 50 ml of gentamicin sulfate were mixed. Then 10 ml of FBS was mixed with the HBSS bottle and then 2 ml of the gentamicin/amphotericin B mixture was also mixed into the HBSS bottle. 3 ml aliquots were made from this mixture to constitute individual tubes of VTM for clinical use. Sterility for each batch (after 24-hour incubation at 37o C in the CO2 incubator) was assessed visually and by culture on a blood agar, chocolate agar, and thioglycolate mediums. An efficacy check was performed for each batch by spiking positive and negative controls into the VTM aliquots; RT-PCR for SARS-CoV-2 was executed to verify the medium did not degrade viral RNA and produced expected results for room temperature, refrigerated, and frozen samples. Previously manufactured VTM without phenol red also underwent sterility and efficacy checks.

Results

VTM was successfully manufactured in-house, allowing testing to continue despite the shortage. Sterility and efficacy checks on all lots and bottles from which the VTM aliquots were made passed with no growth detected and efficacy passing with all expected positives and negatives resulting as expected.

Conclusion

To the author’s knowledge, this represents the first published abstract on VTM manufacture in this most unprecedented crisis involving COVID-19. In this national emergency with corresponding shortage of testing supplies including commercial VTM, the in-house manufacture of VTM is both feasible and prudent to ensure continuity of testing and quality patient/laboratory care.

Utility Of Ebus-Tbna In Diagnosis And Staging Of Lung Nodules In The Setting Of Known Second Malignancy In Veterans - A Quality Assurance Study

Introduction/Objective

Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) is minimally invasive procedure for diagnosis/staging/restaging of lung nodules, recommended by the National Comprehensive Cancer Network (NCCN) 2017 Clinical Practice Guidelines. Veteran patients are an elderly patient cohort with multiple comorbidities and many have existing known 2nd malignancy. It will be crucial to diagnose and appropriately stage lung nodules. Our primary aim was to assess the efficacy of EBUS-TBNA in diagnosis/nodal staging in elderly patients with known 2nd malignancy. Our secondary aim was to evaluate the safety of this procedure for veterans.

Methods

A retrospective search for cases of EBUS-TBNA in patients with known second malignancy was carried out in Vista/Fileman at the Corporal Michael J Crescenz VA Medical Center between the period of June 2019 to January 2020. Sites included lung, cervical lymph nodes, mediastinum and hilar region.

Results

Of total 93 EBUS-TBNA procedures performed; EBUS-TBNA targeted both the lung and lymph node (62 cases), lymph nodes alone (28 cases) and only lung (3 cases). Total 53 were diagnosed malignant; with primary being lung (39 cases) and pleura (2 cases); and diagnosis of new metastatic carcinomas to lung was made in (12 cases).

The metastatic neoplasms included 2 urothelial carcinoma, 7 squamous carcinoma, 2 metastatic adenocarcinoma, and 1 prostatic adenocarcinoma. 32/53 (60.3%) had the history of prior extrapulmonary second malignancy.

Immunohistochemical studies was able to be performed in 50/53 (94%) of malignant cases, predictive marker PD-L1 on 50/53 (94%) cases, molecular testing on 23/53(43.3%) cases and Foundation One testing (Cambridge, MA, NGS) on 11/53(20.7%) cases. In all 93 cases, there were no complications (0/93) (0%) of the procedure.

Conclusion

EBUS-TBNA is an efficient, cost effective and minimally invasive modality in elderly veteran patient population with multiple co-morbidities. EBUS-TBNA is successful in procuring adequate material for diagnosis, molecular and predictive marker studies; thus, it can play a crucial role in precision oncology. EBUS-TBNA plays a pivotal role diagnosing and ruling out metastatic nodal disease in veteran patient population which has a high incidence of known 2nd extrapulmonary malignancy. EBUS-TBNA is deemed safe in veterans.

Prognostic and Theragnostic Applications of Circulating Tumor DNA (CtDNA) in Metastatic Castrate- resistant Prostatic Carcinoma in Veterans: A Novel Promise in Precision Oncology

Introduction/Objective

Utility of CtDNA in peripheral blood through liquid biopsies serves as a robust biomarker for precision oncology. Prostate cancer is most common cancer diagnosed in veterans, more commonly presenting at advanced stage with increased incidence of metastatic castrate-resistant prostatic carcinoma (MCRPC). Minimally invasive liquid biopsy is not limited by tumor site, type, tumor heterogeneity, and most importantly enables real time disease monitoring for best therapy decisions in MCRPC. The literature is sparse depicting the role of CtDNA in MCRPC in veteran patient population with distinct demographics/frequency of Tp53 mutations. We herein aim to study role of CtDNA in liquid biopsies for prognosis, treatment decisions and outcome in veterans with MCRPC.

Methods

QA documents from Foundation One (Cambridge MA, NGS) on liquid biopsies performed for the Corporal Michael J. Crescenz Veteran Affairs Medical Center (CMCVAMC) from May 2019 to April 15, 2020 were reviewed. All liquid biopsies were performed on MCRPC with evidence of tumor progression. Statistical data for adequacy, type of mutations either altering therapy, disease course or outcome was noted.

Results

A total of 23 liquid biopsies were performed. 21/23 (91.3%) biopsies were adequate, 19/21 (90.4%) showed signature mutations for resistance to therapy, predicting prognosis, or suggesting poor outcome with decreased overall survival. 4/21 (19%) showed androgen receptor amplification (ARV7 mutation) that helped in making treatment decisions. Increased frequency of Tp53 mutations were noted (12/21 (57.1%) compared to general population (30- 40%)) indicating worse prognosis/aggressive disease course with decreased survival.

Conclusion

Combined exposure of herbicide agent orange and smoking may be a fertile soil for observed differences in type and frequency of genomic alterations in veteran patient population with MCRPC. Comprehensive genomic profiling on CtDNA through minimally invasive liquid biopsy is feasible and can be successfully implemented in veterans with multiple co-morbidities. Although ARV7 mutation is much more common in general population, veterans with advanced hormone resistant prostatic carcinoma may benefit from aggressive approach in developing targeted therapy focused on DNA repair genes, especially Tp53.

Validation/Verification of Abbott RealTime SARS-CoV-2 Assay on the Abbott m2000 System: The Veteran Affairs Medical Center (VAMC) Experience

Introduction/Objective

The extraordinary circumstances of the highly contagious SARS-CoV-2 pandemic have led the FDA to approve diagnostic assays with emergency use authorizations (EUA). One of these assays is the Abbott RealTime SARS-CoV-2 assay (Abbott Park, Ill.). However, the literature is sparse on the validation of EUA assays for SARS-CoV-2 assays for this crisis; therefore, we present the Veteran Affairs Medical Center (VAMC) experience in validating/verifying this test for clinical use.

Methods

Validation/verification was performed in three parts as part of quality assurance/quality improvement; 1) sample/patient correlation, 2) precision, and 3) validation/verification of accuracy at the lower limit of detection (LOD). The results from these studies was compiled, reviewed by the laboratory, and after performance was deemed satisfactory, the test would be put for clinical use.

Results

For the sample/patient correlation, a total of 68 known positive and 59 known negative samples were run; these included 56 positive contrived samples or controls, 12 known positive patient samples, 31 negative contrived or controls, and 28 known negative patient samples. All results from the assay were as expected with 100% positive and negative percent agreement except for one sample that was quantity not sufficient for testing. The precision study with 4 known positive and 4 known negative samples run once per day for 5 days yielded perfect 100% precision for both the positive and negative samples. Replicates to determine accuracy at the lower LOD (100 virus copies/ml per instructions for use of the assay) demonstrated accuracy even with dilutions down to 50 virus copies/ml. For this third step, 3 replicates each had been performed at 1000, 500, 250, 70, 60 and 50 virus copies/ml. As 100 virus copies/ml was the provided manufacturer LOD, 7 replicates were performed at 100 virus copies/ml.

Conclusion

The validation/verification indicated that the Abbott RealTime SARS-CoV-2 assay performed with expectations including with real patient samples and could be put into clinical use at the VAMC. After this validation/verification, the assay has been very successfully used for in-house testing for SARS-CoV-2. In fact, the validation demonstrated an LOD as low as 50 virus copies/ml, suggesting the assay may be even more sensitive to low levels of viremia than is stated in the EUA.

Liquid Biopsy In Stage Iv Non-Small Cell Lung And Prostate Cancers And Prevalence Of Ethnicity And Risk Factors: A Va Medcial Center Experience

Introduction/Objective

The advent of Liquid biopsy (LB) is a milestone in precision oncology. This minimally invasive revolutionary technique analyses circulating tumor DNA and detects signature genomic alterations. Advanced-stage prostate cancers are more common in African Americans both in general and veteran patient population, while general cohort Caucasians are more prone to advanced/metastatic NSCLC. Risk factor for these cancers is smoking; agent orange exposure and its relationship with aggressiveness/ethnicity for veterans is sparse in the literature. We performed a QA study for advanced lung/prostate cancers of veteran patients on LB.

Methods

QA documentation from Foundation One (Cambridge MA, NGS) on LB performed for the regional Veteran Affairs Medical Center (VAMC) from May 2019 to April 2020 were reviewed. The testing was performed on advanced NSCLC/prostate cancer cases with evidence of advanced tumor progression. Data for ethnicity, risk factors, post therapy PSA, Gleason score and genetic mutations noted.

Results

A total of 30 LBs were performed over this time period. Of 30 LBs, 23 were prostate and 7 were lung cancers. 2/30 had unknown ethnic background. 19/28 (67.8%) were of African American origin, 18 of which had advanced prostate cancers. 11/28 were white, of which 3/30 were advanced NSCLC. One patient declined to reveal risk factor exposure, hence 17/29 (58.6%) had smoking, 15/29 (51.7%) had a risk of herbicide, agent orange exposure; and, 10/29 (34.4%) had both risk factor exposures. 6/29 (20.6%) African American veterans had combined risk factors. 9/10 (90%) veterans which had dual exposure presented with either Gleason score of 9 or as metastasis. Post therapy PSA ranged from 0.5 to 1870 ng/ml and did not corelate with the aggressiveness of the cancer or therapy response.

Conclusion

Veteran patient population has slightly higher incidence of ethnic African Americans presenting with advanced NSCLC/prostate cancers compared to general patient cohort. Although incidence of smoking is similar, combined exposure with agent orange, increases the aggressiveness of the disease three-fold. Real-time monitoring of the therapy response and multimodal benefits by LB is of immense help in morbidly ill veterans, compared to post- therapy PSA monitoring or invasive tissue biopsy. Role of LB should also be explored for early screening/triaging the veterans.

Improved Across the Board Access to SARS-CoV-2 Laboratory Testing in an Integrated Medical System; the Veteran Affairs Medical Center (VAMC) Experience

Introduction/Objective

Due to the spread of SARS-CoV-2 – the causative pathogen behind COVID-19, a significant impact on society including significant death, morbidity, strain on the nation’s medical systems, and an economic shutdown of many sectors has come to pass. While society has been affected by this virus, it has also been documented in the mainstream news that this pandemic has disproportionately affected non-white minority groups, and that access to testing for vulnerable populations have been limited. Similarly, previously published epidemiological data by Zuvekas et al. show that populations with health insurance, higher socioeconomic class, and white in race have received significantly better access to private health care resources. As veterans represent a vulnerable population, as part of quality assurance, testing data was reviewed to verify that this trend was not also affecting the VAMC.

Methods

As part of a quality assurance/quality improvement project, a retrospective manual review of all SARS-CoV- 2 RT-PCR tests performed at the VAMC from March 11th, 2020 to April 13th, 2020. These tests were reviewed within the computerized medical record system to determine the age, gender, and ethnicity of the patients. The demographic data from this search was compared with the population statistics of the major metropolitan city that the VAMC is located in.

Results

Out of 571 patients who were tested for SARS-CoV-2, 264 (46%) had an ethnic African-Americans background, 135 (24%) had an ethnic Caucasian or white background, 8 had an ethnic Hispanic background, 3 had an ethnic native Hawaiian or other Pacific Islander background, 2 had an ethnic Asian background (0.4%), and 1 had an ethnic American Indian or Alaskan Native background. The rest had left ethnicity unanswered or was unknown/declined to state. The majority of those tested were males (392 or 69%). Ages of patients tested ranged from 24 to 98 years of age. The ethnic distribution of those tested was like the ethnic distribution within the city where the VAMC was located.

Conclusion

Quality healthcare to the entire population also means that healthcare should be accessible to all members who require it. The VAMC offers broad access for testing to all its patients of all ethnicities. This demonstrates, in the changing healthcare landscape, one of the many advantages of the Veteran Affairs system.

Multicenter Postmarket Analysis of the Neuroform Atlas Stent for Stent-Assisted Coil Embolization of Intracranial Aneurysms

BACKGROUND AND PURPOSE

The Neuroform Atlas is a new microstent to assist coil embolization of intracranial aneurysms that recently gained FDA approval. We present a postmarket multicenter analysis of the Neuroform Atlas stent.

MATERIALS AND METHODS

On the basis of retrospective chart review from 11 academic centers, we analyzed patients treated with the Neuroform Atlas after FDA exemption from January 2018 to June 2019. Clinical and radiologic parameters included patient demographics, aneurysm characteristics, stent parameters, complications, and outcomes at discharge and last follow-up.

RESULTS

Overall, 128 aneurysms in 128 patients (median age, 62 years) were treated with 138 stents. Risk factors included smoking (59.4%), multiple aneurysms (27.3%), and family history of aneurysms (16.4%). Most patients were treated electively (93.7%), and 8 (6.3%) underwent treatment within 2 weeks of subarachnoid hemorrhage. Previous aneurysm treatment failure was present in 21% of cases. Wide-neck aneurysms (80.5%), small aneurysm size (<7 mm, 76.6%), and bifurcation aneurysm location (basilar apex, 28.9%; anterior communicating artery, 27.3%; and middle cerebral artery bifurcation, 12.5%) were common. A single stent was used in 92.2% of cases, and a single catheter for both stent placement and coiling was used in 59.4% of cases. Technical complications during stent deployment occurred in 4.7% of cases; symptomatic thromboembolic stroke, in 2.3%; and symptomatic hemorrhage, in 0.8%. Favorable Raymond grades (Raymond-Roy occlusion classification) I and II were achieved in 82.9% at discharge and 89.5% at last follow-up. mRS ≤2 was determined in 96.9% of patients at last follow-up. The immediate Raymond-Roy occlusion classification grade correlated with aneurysm location (P < .0001) and rupture status during treatment (P = .03).

CONCLUSIONS

This multicenter analysis provides a real-world safety and efficacy profile for the treatment of intracranial aneurysms with the Neuroform Atlas stent.

Insulin resistance and body composition in cancer patients

Cancer cachexia, weight loss with altered body composition, is a multifactorial syndrome propagated by symptoms that impair caloric intake, tumor byproducts, chronic inflammation, altered metabolism, and hormonal abnormalities. Cachexia is associated with reduced performance status, decreased tolerance to chemotherapy, and increased mortality in cancer patients. Insulin resistance as a consequence of tumor byproducts, chronic inflammation, and endocrine dysfunction has been associated with weight loss in cancer patients. Insulin resistance in cancer patients is characterized by increased hepatic glucose production and gluconeogenesis, and unlike type 2 diabetes, normal fasting glucose with high, normal or low levels of insulin. Cancer cachexia results in altered body composition with the loss of lean muscle mass with or without the loss of adipose tissue. Alteration in visceral adiposity, accumulation of intramuscular adipose tissue, and secretion of adipocytokines from adipose cells may play a role in promoting the metabolic derangements associated with cachexia including a proinflammatory environment and insulin resistance. Increased production of ghrelin, testosterone deficiency, and low vitamin D levels may also contribute to altered metabolism of glucose. Cancer cachexia cannot be easily reversed by standard nutritional interventions and identifying and treating cachexia at the earliest stage of development is advocated. Experts advocate for multimodal therapy to address symptoms that impact caloric intake, reduce chronic inflammation, and treat metabolic and endocrine derangements, which propagate the loss of weight. Treatment of insulin resistance may be a critical component of multimodal therapy for cancer cachexia and more research is needed.

Behavioral persistence is associated with poorer olfactory discrimination learning in domestic dogs

Domestic dogs are trained for a wide variety of jobs; however, half of dogs that enter working dog training organizations never become certified. The aim of this study was to identify whether a basic measure of behavioral persistence was associated with sixteen dogs' performance on an odor discrimination learning task. Further, we evaluated whether dogs that adopted more of a win-stay or win-shift strategy during discrimination learning was associated with greater persistence. Lastly, we tested if measures of a standardized canine behavior questionnaire (the CBARQ) predicted discrimination learning. We found greater persistence during extinction was associated with poorer discrimination learning. Further, dogs that employed more of a win-stay strategy (compared to win-shift) during the discrimination learning phase showed greater persistence in the persistence task and poorer performance on the odor discrimination task. Lastly, the CBARQ measure of trainability showed a trend association with odor discrimination performance, but no other behavioral characteristics were related. Overall, high levels of behavioral persistence is detrimental to olfactory discrimination learning.

Risk Factors Associated With Musculoskeletal Injury: A Prospective Study of British Infantry Recruits

Background:

Musculoskeletal Injury (MSKI), a common problem in both military and physically active civilian populations, has been suggested to result from both extrinsic and intrinsic factors.

Objective:

To investigate prospectively whether gait biomechanics, aerobic fitness levels and smoking status as well as entry military selection test variables can be used to predict MSKI development during recruit training.

Methods:

British infantry male recruits (n = 562) were selected for the study. Plantar pressure variables, smoking habit, aerobic fitness as measured by a 1.5 mile run time and initial military selection test (combination of fitness, Trainability score) were collected prior to commencement of infantry recruit training. Injury data were collected during the 26 week training period.

Results:

Incidence rate of MSKI over a 26 week training period was 41.28% (95 % CI: 37.28 - 45.40%). The injured group had a higher medial plantar pressure (p < 0.03), shorter time to peak heel rotation (p < 0.02), current smoking status (p < 0.001) and a slower 1.5 mile run time (p < 0.03). In contrast, there were no significant differences (p > 0.23) in lateral heel pressure, age, weight, height, BMI and military selection test. A logistic regression model predicted MSKI significantly (p= 0.03) with an accuracy of 34.50% of all MSK injury and 76.70% of the non-injured group with an overall accuracy of 69.50%.

Conclusion:

The logistic regression model combining the three risk factors was capable of predicting 34.5% of all MSKI. A specific biomechanical profile, slow 1.5 mile run time and current smoking status were identified as predictors of subsequent MSKI development. The proposed model could include evaluation of other potential risk factors and if validated then further enhance the specificity, sensitivity and applicability.

Musculoskeletal injuries in British Army recruits: a prospective study of incidence in different Infantry Regiments

BACKGROUND

Musculoskeletal injuries and attrition incurred during basic military training are a significant socioeconomic burden across many Defence Forces. In order to plan an injury prevention strategy, the purpose of this study was to quantify the regiment-specific musculoskeletal injury patterns and training outcomes.

METHODS

This was a prospective observational study of the Parachute (n=734), Guards (n=1044), Line (n=3472) and Gurkha (n=458) Regiments of the British Army recruits during a 26-week basic military training programme over a 2-year period. The participant demographic characteristics were: age 18.9 years (SD±2.3), height 176.5 cm (SD±7.80), mass 69 kg (SD±9.7) and body mass index 22.14 kg/m² (SD±2.5).

RESULTS

The incidence of injuries (86%, 46%, 48% and 10%) was significantly different (p<0.001) as were the first time pass out rates (p=0.02) of 38%, 51%, 56% and 98% for Parachute, Guards, Line and Gurkha, respectively. Overuse injuries were more frequently reported than both acute and recurrent injuries in all regiments (X²=688.01, p<0.01).

CONCLUSIONS

The disparity in injury incidence and training outcome between Infantry Regiments suggests that the demands of training be taken into account when devising injury prevention strategies.

Pleomorphic Adenoma of the Parotid Gland: Report of a Case With Review of Literature

Background

Pleomorphic adenomas are benign salivary gland tumors, which predominantly affect the superficial lobe of the parotid gland. The “pleomorphic” nature of the tumor can be explained on the basis of its epithelial and connective tissue origin. The tumor has a female predilection between 30–50 years of age. Slowly progressing asymptomatic swelling is the usual presentation of the tumor. Surgical excision of the tumor mass forms the mainstay of treatment, with utmost care taken to preserve the facial nerve.

Case Details

This case report aims to throw light on an interesting case of pleomorphic adenoma of the parotid gland in a 50 years old female patient. The patient presented with a slowly progressing asymptomatic swelling on the left side of the face. There is also a special emphasis to a detailed review of literature.

Conclusion

Salivary gland neoplasms can occur at any site where salivary tissue is present. Pleomorphic adenoma is the commonest salivary gland tumor characterized by diverse histomorphological features. Early diagnosis and treatment plan entails thorough history taking, clinical examination, coupled with radiographic and histopathological findings.

Differentiating Gilbert Syndrome from Crigler Najjar Syndrome Type 2 by Phenobarbitone Test

Gilbert syndrome characterized by jaundice with intermittent elevations of indirect bilirubin, in the absence of haemolysis or underlying liver disease, has both autosomal dominant and recessive inheritance. Crigler-Najjar syndrome type II (CNS2) is a hereditary disorder of bilirubin metabolism characterized by unconjugated hyperbilirubinemia due to reduced and inducible activity of hepatic bilirubin glucuronosyltransferase (GT). We report 20 children between age 5 to 15 years with unconjugated hyperbilirubenemia who were given seven days of oral phenobarbitone (5mg/kg/day) and decrease in level of bilirubin was noted. There was only 30-40% reduction of bilirubin in Crigler Najjar Syndrome Type 2 compared to Gilberts Syndrome in which bilirubin level normalised. This case series highlights the importance of simple test to differentiate these two conditions. This test is also very helpful in a place where enzyme level and mutational study cannot be done.J Nepal Paediatr Soc 2015;35(1):82-84

Tuberculosis incidence and treatment completion among Ugandan prison inmates

BACKGROUND

The Uganda Prisons Service (UPS) is responsible for the health of approximately 32 500 inmates in 233 prisons. In 2008 a rapid UPS assessment estimated TB prevalence at 654/100 000, three times that of the general population (183/100 000). Although treatment programs exist, little is known about treatment completion in sub-Saharan African prisons.

METHODS

We conducted a retrospective study of Ugandan prisoners diagnosed with TB from June 2011 to November 2012. We analyzed TB diagnosis, TB-HIV comorbidity and treatment completion from national registers and tracked prison transfers and releases.

RESULTS

A total of 469 prisoners were diagnosed with TB over the 1.5-year period (incidence 955/100 000 person-years). Of 466 prisoners starting treatment, 48% completed treatment, 43% defaulted, 5% died and 4% were currently on treatment. During treatment, 12% of prisoners remaining in the same prison defaulted, 53% of transfers defaulted and 81% of those released were lost to follow-up. The odds of defaulting were 8.36 times greater among prisoners who were transferred during treatment.

CONCLUSIONS

TB incidence and treatment default are high among Ugandan prisoners. Strategies to improve treatment completion and prevent multidrug resistance could include avoiding transfer of TB patients, improving communications between prisons to ensure treatment follow-up after transfer and facilitating transfer to community clinics for released prisoners.

An account of multiple casualties in an austere environment

A satellite compound of an International Security Assistance Force Patrol Base came under assault during OP HERRICK 12 resulting in eight casualties. Multiple fragmentation type injuries were sustained over a short period of time which tested the locations medical capacity. This account describes the events that occurred in extracting and treating those injured.

An objective assessment of safety to drive in an upper limb cast

Patients managed with upper limb cast immobilization often seek advice about driving. There is very little published data to assist in decision making, and advice given varies between healthcare professionals. There are no specific guidelines available from the UK Drivers and Vehicles Licensing Agency, police, or insurance companies. Evidence-based guidelines would enable clinicians to standardize the advice given to patients. Six individuals (three male, three female; mean age 36 years, range 27-43 years) were assessed by a mobility occupational therapist and driving standards agency examiner while completing a formal driving test in six different types of upper limb casts (above-elbow, below-elbow neutral, and below-elbow cast incorporating the thumb [Bennett's cast]) on both left and right sides. Of the 36 tests, participants passed 31 tests, suggesting that most people were able to safely drive with upper limb cast immobilization. However, driving in a left above-elbow cast was considered unsafe.

Rotator cuff repair in patients over 70 years of age

This study reports the clinical and sonographic outcome of arthroscopic rotator cuff repair in patients aged ≥ 70 years and aimed to determine factors associated with re-tear. A total of 69 consecutive repairs were performed in 68 patients with a mean age of 77 years (70 to 86). Constant-Murley scores were collected pre-operatively and at one year post-operatively. The integrity of the repair was assessed using ultrasound. Re-tear was detected in 20 of 62 patients (32%) assessed with ultrasound. Age at operation was significantly associated with re-tear free survival (p = 0.016). The mean pre-operative Constant score was 23 (sd 14), which increased to 58 (sd 20) at one year post-operatively (paired t-test, p < 0.001). Male gender was significantly associated with a higher score at one year (p = 0.019).

We conclude that arthroscopic rotator cuff repair in patients aged ≥ 70 years is a successful procedure. The gender and age of the patient are important factors to consider when planning management.

Cite this article: Bone Joint J 2013;95-B:199–205.

Serum levels and mesenteric fat tissue expression of adiponectin and leptin in patients with Crohn's disease

Crohn's disease (CD) is characterized by inflammation and an aetiology that is still unknown. Hypertrophy of mesenteric fat is a reflection of disease activity, as this fat covers the entire length of the affected area. Adipocytes synthesize leptin and adiponectin, adipocytokines responsible for pro- and anti-inflammatory effects. Therefore, we evaluated serum levels of adiponectin and leptin, as well as mesenteral expression of adiponectin in active CD and those in remission. Sixteen patients with ileocaecal CD followed at the Outpatient Clinic, Coloproctology Unit of University of Campinas Clinical Hospital, participated in the study. Analysis of serum adiponectin and leptin by enzyme-linked immunosorbent assay was performed in patients with active CD (ACD group), remission CD (RCD group) and in six healthy controls. Ten patients with active ileocaecal CD (FCD group) and eight patients with non-inflammatory disease selected for surgery were also studied. The specimens were snap-frozen and the expression of adiponectin was determined by immunoblot of protein extracts. Serum C-reactive protein levels were higher in the ACD group when compared to the others and no difference of body mass index was observed between the groups. Serum adiponectin was lower in the ACD group when compared to control, but no differences were seen when comparing the ACD and RCD groups. Mesenteric adiponectin expression was lower in the FCD group when compared to the FC group. Serum leptin was similar in all groups. The lower levels of serum and mesenteric adiponectin in active CD suggest a defective regulation of anti-inflammatory pathways in CD pathogenesis.

BILATERAL SYMMETRICAL GIANT CELL TUMOURS OF THE THUMB

Giant cell tumours of tendon sheath are common in the hand but multiple lesions are relatively rare. A case report of bilateral symmetrical involvement is presented and discussed.

CARPAL TUNNEL SYNDROME PRESENTING AS A NON-HEALING ULCER

Skin ulceration in carpal tunnel syndrome is rare. A case report of a non-healing ulcer due to carpal tunnel with severe sensorimotor denervation is presented and discussed.

Peri-vesical fat interposition flap reinforcement in high vesico-vaginal fistulas

Background and Aim:

The urinary bladder becomes small, contracted and is associated with excess pelvic fat in long standing cases of vesico-vaginal fistulas (VVFs). The aim of this new technique was to use this excess pelvic fat for harvesting an interposition flap.

Materials and Methods:

An interposition flap of peri-vesical fat was raised from the anterior, superior and posterior surfaces of the urinary bladder and was interposed between the right angle closed vaginal vault and the urinary bladder to strengthen the repair. This technique was used in two patients of VVFs.

Results:

Both the patients had successful outcome and were able to retain sufficient quantity of urine at 3 months follow-up.

Conclusions:

Peri-vesical fat flap proved an effective interposition flap in the repairs of VVFs in selected cases.

Reliability of clinical coding of hip facture surgery: implications for payment by results?

In our hospital all operative procedures are coded using the OPCS 4.3 classification and in addition are entered into an independent theatre databases. Using these two databases we identified patients undergoing hip fracture surgery at this hospital between 1st November 2003 and 30th November 2006. We identified 408 cases. No single database identified all 408 cases. A quarter of cases (N=98) were not procedurally coded. Only 43.2% (N=176) of cases were recorded in both the theatre database and procedurally coded at the time of this study. Overall the coding accuracy of these 176 cases was 93.8%. Clinical coding at this hospital was unreliable and inaccurate, which has major implications for national statistics, performance analysis and most importantly Payment by Results. We discuss this further and offer possible solutions to improve the coding process.

Association between inflammatory markers, symptom burden, hypogonadism, and survival in cancer patients with cachexia

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Background: Cancer cachexia is characterized by muscle wasting, anorexia, and elevated inflammatory markers. Similarly, in patients without cancer, hypogonadism is associated with lower lean body mass, increased symptom burden and decreased survival. Hypogonadism in cancer cachexia could exacerbate symptom distress, facilitate a pro-inflammatory state and decrease survival. Currently, there are no guidelines for testosterone replacement therapy in cancer patients. We evaluated the relationship between hypogonadism, symptom severity, inflammation and survival in patients with cachexia. Methods: A retrospective chart review of 159 consecutive patients (61 females, 98 males) referred to a specialized cachexia clinic at a comprehensive cancer center. 98 patients (62%) had C-reactive protein (CRP) levels measured, and 68(69%) males had serum total testosterone evaluated. Testosterone levels were not evaluated in female patients. Symptoms were assessed by the Edmonton Symptom Assessment Scale (ESAS). Results: All patients reported weight loss of >5% within the preceding 6 months; Median age was 62, CRP 26mg/L and in males median total testosterone186ng/dL (normal level≥240 ng/dL). Spearman correlation revealed higher CRP levels (r=0.57, p<0.01) increased dyspnea (r=0.27, p<0.05) and poorer sleep scores (r=0.29, p<0.05) in males with low testosterone. In 46 males and females who underwent CRP testing within 30 days of their ESAS evaluation, pain (r=0.48, p<0.01), fatigue (r=0.39, p<0.01), poor appetite (r=0.49, p<0.01), insomnia (r=0.42, p<0.01), anxiety (r=0.29, p<0.05), and dyspnea (r=0.31, p<0.05) correlated with an elevated CRP. Survival of male patients with testosterone<186 ng/dL was decreased compared to those with levels ≥ 186ng/dL (13 vs.62 weeks, p=0.004). Patients with CRP>10 mg/L had decreased survival compared to those <10 mg/L (30 vs. 66 weeks, p=0.017). Conclusions: Elevated C-RP levels in cancer cachexia are associated with poorer survival and increased symptom burden. Low testosterone is strongly associated with decreased survival in cachectic male patients and correlates inversely with CRP levels, dyspnea and insomnia.

No significant financial relationships to disclose.

Clinical findings and interventions in cancer patients referred to a cachexia clinic (CC)

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Background: The cancer-related anorexia/cachexia syndrome is primarily caused by an aberrant inflammatory response and neurohormonal dysfunction. Secondary causes that contribute to diminished nutrient intake include early satiety, constipation, nausea, vomiting, mood alterations, dysgeusia, and dysphagia. We determined the frequency and management of both secondary cachexia causes and metabolic/endocrine alterations in a new CC at a Comprehensive Cancer Center. Methods: We conducted a retrospective chart review of 159 consecutive patients who underwent structured assessments at the CC. Demographics, weight loss, secondary causes and specific treatments were analyzed. Results: The patients had the following characteristics: median age 59, females 39%, median body mass index 20.3, median weight loss over the preceding 3 months 7%, and hypoalbuminemia 76%. At consultation, 102 (64%) were on chemotherapy/radiation and 13 (8%) were on enteral or parenteral nutrition. Appetite stimulants prior to consult included megestrol (n=36, 22%), corticosteroids (n=21, 13%) and dronabinol (n=10, 6%). The median number of secondary causes was 3 (Q1-Q3 2–4), with a median of 2 (Q1-Q3 1–3) interventions per patient. 22 (14%), 105 (66%) and 32 (20%) patients had 0–1, 2–4 and 5–8 secondary cachexia causes, respectively. The table lists the significant findings and corresponding interventions. 52 (33%) were enrolled onto clinical trials for primary cachexia. Conclusions: A total of 411 treatable secondary cachexia causes and 89 endocrine/metabolic alterations were identified in our cohort. Low cost effective interventions were available for most of the common findings.

[Table: see text]

No significant financial relationships to disclose.

The association between autonomic dysfunction and survival in advanced cancer: A preliminary report

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Background: Autonomic nervous system dysfunction (AD) is a common syndrome in patients with advanced cancer. It is associated with decreased survival in several patient populations including diabetes mellitus, heart failure and neurological diseases. Based on this available evidence, we hypothesized that autonomic dysfunction is associated with reduced survival in patients with advanced cancer. The objective of this preliminary study was to test the association between AD as measured by the standardized Ewing test and Heart Variability (HRV) measures and survival in patients with advanced cancer. Methods: We examined the relationship between survival and parameters of AD in male patients with advanced cancer who participated in a prospective study of autonomic dysfunction and hypogonadism. Eligibility criteria were defined based on the prospective study protocol. We collected demographic information, date of study entry and Ewing and HRV scores. Date of death was obtained from the online Social Security Death Index database. We defined survival as the interval between study entry and date of death. A survival analysis was used to test the association between survival (days) and Ewing test (0–5) and measures of heart rate variability (HRV), including time domain (SDNN) and frequency domain (Ultra low, Very low, Low, and High frequency) parameters.A spearman correlation test was also performed. Results: 47 male patients were included in this study. Median age was 59 (20–79) and 63% were caucasians. Autonomic dysfunction (AD), defined as Ewing score >2, was present in 80% (38/47) of the patients. Median Ewing score was 3 (1–5), indicating moderate to severe AD. Spearman correlation for Ewing and SDNN HRV was 0.44 (p=0.002). There was a significant association between abnormal Ewing score and survival (p<0.0001), and abnormal SDNN HRV and survival (p=0.056). Spearman correlation for Ewing score and survival and SDNN HRV and survival were r = -0.27620 (p=0.0602) and r =0.24198 (p= 0.1013) respectively. Conclusions: Autonomic dysfunction is associated with shorter survival in male patients with advanced cancer. Further longitudinal research in a larger cohort is justified based on these findings.

No significant financial relationships to disclose.

Tuberculosis risk among staff of a large public hospital in Kenya

SETTING

In sub-Saharan Africa, high rates of tuberculosis (TB) and human immunodeficiency virus (HIV) infection pose a serious threat for occupationally acquired TB among health care workers.

OBJECTIVE

To identify factors associated with TB disease among staff of an 1800-bed hospital in Kenya.

DESIGN

We calculated TB incidence among staff and conducted a case-control study where cases (n = 65) were staff diagnosed with TB and controls (n = 316) were randomly selected staff without recent TB.

RESULTS

The annual incidence of TB from 2001 to 2005 ranged from 645 to 1115 per 100000 population. Factors associated with TB disease were additional daily hours spent in rooms with patients (adjusted odds ratio [aOR] 1.3, 95%CI 1.2-1.5), working in areas where TB patients received care (aOR 2.1, 95%CI 1.1-4.2), HIV infection (aOR 29.1, 95%CI 5.1-167) and living in a slum (aOR 4.7, 95%CI 1.8-12.5) or hospital-provided low-income housing (aOR 2.6, 95%CI 1.2-5.6).

CONCLUSION

Hospital exposures were associated with TB disease among staff at this hospital regardless of their job designation, even after controlling for living conditions, suggesting transmission from patients. Health care facilities should improve infection control practices, provide quality occupational health services and encourage staff testing for HIV infection to address the TB burden in hospital staff.