Mortality and Complications of COVID-19 Among Adult Congenital Heart Disease Patients: A Retrospective Cohort Study Using the National Inpatient Sample Database

This study examines in-hospital mortality and complicated COVID-19 infection among adult congenital heart disease (ACHD) patients admitted with COVID-19, using the National Inpatient Sample (NIS). A total of 4219 COVID-19 patients with ACHD were included. We demonstrated that COVID-19 patients with ACHD were more likely to experience in-hospital mortality (OR 1.04, 95% CI 1.04-1.04, P < 0.01) and complicated COVID-19 infection (OR: 1.30, 95% CI: 1.11-1.53, P < 0.01). In our sub-group analysis, COVID-19 patients with tetralogy of Fallot (TOF) had higher mortality and COVID-19 patients with atrial septal defects (ASD) had a higher incidence of complicated infection when compared to COVID-19 patients with all other ACHDs. Risk factors for mortality among COVID-19 patients with ACHD include advanced age, lower income, unrepaired ACHD, malnutrition, and chronic liver disease. Accordingly, we recommend aggressive preventive care with vaccination and non-pharmacologic measures in order to improve survival for ACHD patients.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Disseminated Mycobacterium chelonae infection with Hughes-Stovin syndrome

Mycobacterium chelonae usually causes localized cutaneous infections and abscesses but has the potential to cause disseminated infections, especially in immunocompromised hosts. We report a 27-year-old man with Hughes-Stovin syndrome and catastrophic antiphospholipid syndrome who was on chronic immunosuppressant therapy and developed disseminated M. chelonae infection. To the best of our knowledge, this is the first case report of M. chelonae infection in a patient with Hughes-Stovin syndrome.

Gastrointestinal Hemorrhage From Esophageal Dissecans Superficialis After the Initiation of a Tyrosine Kinase Inhibitor

Esophagitis dissecans superficialis (EDS) is described as the peeling of squamous mucosa of the esophagus with regurgitation of esophageal casts. It is a rare endoscopic finding associated with chemical irritants, autoimmune disorders, or medications. Most patients are asymptomatic but clinical manifestations can include dysphagia, heartburn, bleeding, or vomiting. In this report, we present a case of a 70-year-old man with a previous history of small cell lung and hepatocellular carcinoma for which he had undergone chemoradiation and immunotherapy. He had presented with upper gastrointestinal hemorrhage manifested as coffee ground emesis. Endoscopic findings were consistent with EDS. No recurrence of his gastrointestinal hemorrhage was observed after acid-suppressive therapy. With our case report, we aim to increase awareness for EDS as a differential diagnosis for gastrointestinal hemorrhage.

Routine Use of Prescription Adderall Leading to Non-cardiogenic Pulmonary Edema and Respiratory Failure

A 47-year-old female with attention-deficit/hyperactivity disorder on prescription Adderall presented to the hospital with worsening dyspnea for the one-month duration. She was admitted to the medical intensive care unit with respiratory failure requiring non-invasive positive pressure ventilation. Cardiac catheterization confirmed the diagnosis of non-cardiogenic pulmonary edema. With the discontinuation of Adderall, use of BiPAP, and aggressive diuresis with loop diuretics, there was evidence of symptomatic, laboratory, and radiological improvement. Her symptoms were attributed to Adderall use as a diagnosis of exclusion. To our knowledge, this paper reports the first case of Adderall-induced non-cardiogenic pulmonary edema leading to respiratory failure. Although case reports of abuse or overdose of other stimulants such as amphetamine and cocaine leading to a plethora of cardiac and pulmonary complications such as acute respiratory distress syndrome (ARDS), cardiogenic pulmonary edema, and non-cardiogenic pulmonary edema exist, there are no reports that using Adderall at routine prescription doses can lead to these problems.

Primary Neuroendocrine Tumor of the Scrotum: An Uncommon Site for a Rare Tumor

Neuroendocrine tumors (NETs) are a heterogeneous group of tumors developing from neural crest cells, with numerous sites of origin, commonly the gastrointestinal and genitourinary tracts. NETs of the genitourinary tract are more common in women. Small cell carcinoma of the prostate or testicular carcinoid are the NETs in male. In this article, we present a rare case of NET of the scrotum. Our patient was a 47-year-old male with a history of complicated pilonidal cysts resulting in chronic scrotal wounds. Biopsy of a large nonhealing scrotal wound revealed a high-grade neuroendocrine carcinoma with features most suggestive of small cell carcinoma. Presenting with advanced disease at diagnosis, he was started on systemic therapy and unfortunately progressed through multiple lines of treatment, including CAPTEM (capecitabine and temozolomide). Unfortunately, due to multiple logistical reasons, the patient was unable to receive the then off-label immunotherapy based on DART (Dual Anti-CTLA-4 and Anti-PD-1 Blockade in Rare Tumors) trial. He, unfortunately, succumbed to his disease within months of diagnosis.

A Significant Pericardial Effusion Leading to Bronchial Compression: A Case Report

Commonly, pericardial effusions can cause suboptimal heart contractility. Larger pericardial effusions can lead to compression of structures that surround in the heart in the mediastinum. Our patient presented with dyspnea that required mechanical ventilation. Bronchoscopy revealed compression of the bronchus from an external source. Echocardiogram showed a large circumferential pericardial effusion, which compressed the left main stem bronchus causing left lung atelectasis and persistent respiratory failure. A subxiphoid pericardial window was performed, which led to an improvement in her oxygen requirements. This case portrays the importance of including pericardial effusions in patients who present with respiratory failure refractory to antibiotic treatment and intervention with bronchoscopy. Although our patient passed away, recognition and earlier appropriate management with a pericardial window or pericardiocentesis could have prevented this adverse event.

Meckel's diverticulum in an adult with iron deficiency

Meckel's diverticulum is a true diverticulum caused by the incomplete obliteration of the vitelline duct during gestation. It is the most common congenital malformation of the gastrointestinal tract. Meckel's diverticulum is a rare presentation in adults, especially because symptomatic patients present in early childhood. We present a 57-year-old woman with symptomatic iron deficiency after recent nonsteroidal anti-inflammatory use. After normal upper and lower endoscopy, a capsule endoscopy showed an oozing polyp in the distal ileum. The small bowel was surgically resected, and histopathology confirmed Meckel's diverticulum as the cause of her small bowel bleeding. Rare causes such as Meckel's diverticulum should be kept in mind in the differential diagnosis for patients with suspected small bowel bleeding.

Gastric Splenosis Mimicking Gastrointestinal Stromal Tumor

Translocation of splenic tissue in patients after traumatic spleen injury or splenectomy is called splenosis. Gastric splenosis is a rare presentation that can be mistaken for gastrointestinal stromal tumor (GIST). Patients are usually asymptomatic and do not require surgical intervention. In this report, we present a case of a 68-year-old male patient with a previous history of surgical splenectomy after traumatic splenic rupture, who underwent routine upper endoscopy for the evaluation of dysphagia. An endoscopic exam of the stomach revealed an incidental finding of a submucosal gastric nodule. On endoscopic ultrasound exam, the lesion was found to be suggestive of GIST originating from layer 4. A core biopsy was obtained from the nodule, which was consistent with gastric splenosis. The differentiation of gastric splenosis from other gastric lesions such as GIST is important since asymptomatic patients with gastric splenosis do not need to undergo surveillance or surgical resection. It should be suspected especially in patients with a history of splenectomy or splenic rupture. Endoscopic ultrasound (EUS)-guided core biopsy can help confirm the diagnosis and differentiate the condition from GIST.

Epicardial adipose tissue CD4+ T cells as novel drivers in the development of atrial fibrillation

Background

Epicardial adipose tissue (EAT) is now a well-established independent risk factor for all forms of atrial fibrillation (AF). However, the cellular profile and immune mediators within EAT remain poorly defined.

Purpose

This study sought to define the immunological signature of EAT critical to its role in the development of both persistent AF and de novo post-operative AF (POAF).

Methods

Adult patients undergoing elective cardiac surgery with no prior AF history and those with pre-existing AF were recruited to undergo EAT sampling alongside subcutaneous adipose tissue (SAT) and pre-operative blood (adipose tissue and systemic controls respectively) sampling. The blood and tissue samples were immediately taken to the laboratory for immune cell isolation, flow cytometry and quantitative polymerase chain reaction (qPCR) analysis.

Results

A total of 71 patients were recruited including 9 patients with a prior history of AF. Of the 62 a priori sinus rhythm (SR) patients, 42 remained in SR post-operatively and 20 developed de novo POAF. No differences in absolute numbers of immune cells in the blood, EAT or SAT were detected on flow cytometry analysis between the three groups of patients. However, there was a significant increase (p&lt;0.01) in EAT-resident CD4+ memory T cell populations in pre-existing AF patients and a trend towards significance (p=0.09) in POAF patients. qPCR analysis of immune mediator expression in EAT demonstrated pre-existing AF patients uniquely showed a significant reduction (p&lt;0.005) in the pro-fibrotic mediator transforming growth factor-β (TGF-β) compared to the pre-existing AF patients (graph 1).

Conclusions and implications

Resident CD4+ memory T cell populations are locally and exclusively elevated in the EAT of pre-existing AF and POAF patients. This would suggest primed antigen-specific CD4+ T cells are present prior to the development of AF in patients who go on to develop de novo POAF. The reduced TGF-β levels observed in the EAT of AF patients indicates the EAT immune mediator profile differs to the underlying myocardial tissue, where increased TGF-β levels have previously been described in the persistent AF cohort. Therapies targeting this EAT-resident CD4+ T cell population would provide a novel approach to the management of the inflammatory components of AF genesis.

Graph 1

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Barts Charity, Abbott

Catastrophic complications following cryoablation of lung cancer

Image-guided cryoablation has low procedure-related morbidity and mortality rates, with the complications usually being self-limiting. The most common complications include pneumothorax, hemoptysis, pleural effusion, cough, phrenic nerve injury, and tumor implantation. Bronchopleural or bronchocutaneous fistula formation is a rare but severe complication of lung cancer ablation. We report a patient with non-small cell lung cancer who developed a bronchocutaneous fistula, persistent empyema, and chest wall abscess a month after cryoablation. With this case report, we aim to sensitize physicians to such complications.

Lactobacillus masticator abscess after probiotics consumption

Popular probiotics contain Lactobacillus, Bifidobacterium, and Streptococcus. Lactobacillus is a gram-positive rod-shaped bacterium that colonizes human oropharyngeal, gastrointestinal, and female urogenital tracts. Although lactobacilli are generally nonpathogenic, they have been implicated in uncommon cases of infection and have the potential to cause bacteremia, endocarditis, endometritis, pulmonary abscesses, and orogastrointestinal abscesses, especially in the immunocompromised. We report a case of Lactobacillus infection in a diabetic patient that occurred 2 weeks after wisdom tooth extraction. The only bacterium found was Lactobacillus, possibly related to her diet of yogurt and smoothies after the tooth extraction.

Pneumococcal Meningitis Complicated by Subarachnoid Hemorrhage and Tonsillar Herniation

Bacterial meningitis is a fatal infectious disease with an annual incidence of four to six cases per 100,000 adults. The most common pathogens associated with this condition are Streptococcus pneumoniae, Neisseria meningitides, and Hemophilus influenzae. Mortality rates range between 10 and 40% despite the availability of highly effective antibiotic therapy, and severe neurological damage affects 30-52% of survivors. The causes of death in patients with pneumococcal meningitis are multifactorial and involve both neurological complications such as cerebral edema, hydrocephalus, infarction, and septic sinus or venous thrombosis and systemic complications such as septic shock, disseminated intravascular coagulation, and acute respiratory distress syndrome. We present an unfortunate case of a 42-year-old woman with asplenia and sickle cell disease, admitted for pneumococcal meningitis, who developed diffuse cerebral edema leading to tonsillar herniation and aneurysmal subarachnoid hemorrhage (SAH) with a fatal outcome. To the best of our knowledge, this is the only case ever reported of meningitis complicated by both SAH and brain herniation.

Bilateral pulmonary artery thrombectomy with saddle embolism and COVID-19 infection

Thrombotic complications such as venous thromboembolism, ischemic stroke, and myocardial infarction have emerged as causes of significant morbidity and mortality in patients infected with COVID-19. We present a 32-year-old man who developed a large saddle pulmonary embolus secondary to COVID-19 infection and underwent successful bilateral percutaneous pulmonary artery mechanical thrombectomy.

A Unique Interplay of Multiple Predisposing Factors Culminating in a Catastrophic QT Prolongation

Implantable cardioverter-defibrillators (ICDs) are used in patients without a reversible cause for long QT syndrome (LQTS) and secondary prevention in patients with LQTS-associated sudden cardiac arrest. We present a female patient with multiple reversible factors for QT prolongation, including the use of antidepressants, antidiarrheals, antiemetics, and antihistamines; chronic malabsorption from bariatric surgery; probable Gitelman syndrome and urinary losses of electrolytes, causing QT prolongation which leads to polymorphic ventricular tachycardia and a successfully resuscitated cardiac arrest. Our patient also had history suggestive of probable congenital LQTS with multiple childhood syncopal episodes and a history of seizures in first-degree relatives, further justifying the placement of an ICD. Also, this case gives us an opportunity to delve into the risks of catastrophic QT prolongation in the morbidly obese population undergoing bariatric surgery.

Intractable Left Internal Mammary Artery Spasm After Coronary Artery Bypass Grafting

Graft spasm is a rare but well-recognized complication of coronary artery bypass grafting (CABG). The occurrence of graft spam is multifactorial and can be fatal if not diagnosed and treated promptly. There are no well-defined guidelines for the management of a severe spasm. We report the case of a 29-year-old man with left internal mammary artery (LIMA) spasm in the immediate post-operative period following CABG. The intracoronary infusion of nitroglycerin relieved the spasm temporarily, confirming the diagnosis. The patient eventually underwent redo bypass grafting.

A Rare Case of Prostatic and Bilateral Renal Abscesses Caused by Community-acquired Methicillin-resistant Staphylococcus aureus Infection

Gram-negative bacilli are usually implicated in the formation of prostatic abscesses (PA) which is a rare complication of prostatitis. However, PA methicillin-resistant Staphylococcus aureus (MRSA) has emerged as a substantial cause of PA in recent years. Predisposing factors for MRSA prostatitis include immunocompromised states such as human immunodeficiency virus (HIV), uncontrolled diabetes, intravenous drug use (IVDU), urethral instrumentation, bladder outlet obstruction, preexisting prostatic disease, recent prostatic procedure, and chronic dialysis among others. MRSA PA should be promptly diagnosed and appropriately treated as delay in diagnosis can be detrimental. We present a case of a patient with a remote history of IVDU who developed simultaneous bilateral renal and PA caused by MRSA in the absence of MRSA bacteremia. Since our patient did not have the traditional risk factors for MRSA infection, we can argue that he was infected by the community-acquired strains of MRSA.

Traumatic Right Coronary Artery Dissection as a Cause of Inferior Wall ST-Elevation Myocardial Infarction

Blunt cardiac injury, causing coronary artery dissection in the absence of other forms of injury to the heart or lungs is a rare occurrence. Here we present a case of a 41-year-old male who presented with right coronary artery (RCA) dissection after blunt chest trauma. The patient initially presented with chest pain and was diagnosed with an inferior wall myocardial infarction (MI). He then developed a complete heart block and bedside echocardiogram showed right ventricular akinesis. Immediate coronary angiography showed RCA dissection, and TIMI 3 flow was established after the placement of four drug-eluting stents. Blunt trauma-induced RCA dissection is associated with high mortality which needs immediate treatment. Hence through this case report, we would like to stress the importance of having a high index of suspicion for this condition in patients with a blunt chest injury.

Three's a Crowd - An Extremely Rare Case of Cor Triatriatum Dexter

INTRODUCTION

Cor triatriatum is a congenital cardiac anomaly in which the left (sinister) or right (dexter) atrium is divided into two compartments by residual embryonic tissue, resulting in a tri-atrial heart. As cor triatriatum dextrum can present clinically in various ways and have multiple associated cardiac anomalies, this report attempts to contribute to what is known about this exceedingly rare disorder.

CASE

A 40 year old Hispanic man with a medical history of gastritis presented with complaints of palpitations, dizziness and bilateral lower extremity edema. He was found to have atrial fibrillation and new onset heart failure. The patient was admitted for rate control and further evaluation, which revealed several cardiac anomalies. Initial 2D echocardiography demonstrated severe right atrial enlargement, right ventricular hypertrophy and an engorged coronary sinus, which prompted further assessment of the patient's cardiovascular anatomy. Transesophageal echocardiography (TEE) revealed a severely enlarged, septated right atrium with a possible unroofed coronary sinus and a small patent foramen ovale (PFO). Left- and right-heart catheterization established a coronary-cameral fistula between the right coronary artery (RCA) and right atrium, as well as left-to-right shunt. The patient improved clinically with conservative management including diet modification, furosemide and digoxin for fluid and rate control, and was referred to cardiothoracic surgery for further evaluation.

DISCUSSION

Cor triatriatum dextrum is an extremely rare cardiac condition: In high-volume echocardiographic laboratories, prevalence is less than 0.01 percent. This case highlights the association between cor triatriatum and other congenital cardiac anomalies, including persistent left superior vena cava with an unroofed coronary sinus, PFO and left-to-right shunt; all of which were found in this patient. While cases of cor-triatriatum sinistrum often require correction in infancy (due to left sided heart failure, pulmonary edema and cyanosis), cor-triatriatum dextrum is sometimes diagnosed in adulthood due to the lack of left heart and pulmonary involvement.

FOOD FOR THOUGHT: MITRAL STENOSIS WITH A SIDE OF MAC AND CHEESE

Caseous mitral annular calcification (CMAC) is a rare variant of mitral annular calcification (MAC), most commonly seen in elderly women on the posterior mitral annulus. CMAC is usually diagnosed incidentally and has a benign course. However, it may cause abnormal blood flow across the mitral valve resulting in mitral regurgitation, and rarely, functional mitral stenosis. MAC occurs in 10 percent of the population, while CMAC occurs in 0.06 percent. Most cases of CMAC are misdiagnosed as other intracardiac masses, such as tumors, abscesses, thrombi, and vegetation.

Surgical ward rounds: a missed opportunity for multidisciplinary working?

While guidelines have been established for doctors’ and nurses’ ward rounds, there is no protocol in place for surgeons.

Primary mediastinal pleomorphic rhabdomyosarcoma: a case report

OBJECTIVE

To report a rare case of pleomorphic rhabdomyosarcoma which occurred in the mediastinum of a 34-year-old man.

CLINICAL PRESENTATION AND INTERVENTION

A young male labourer presented with dyspnoea on exertion. A large mediastinal mass was detected on chest CT scan. The chest surgeons advised against open biopsy. His alpha-fetoprotein was 22,000 IU/l; based on this the diagnosis of a germ cell tumour was made and the patient was treated with a bleomycin/etoposide/cisplatin regimen. He left for his native country where an open biopsy from the mediastinum was taken and reported as pleomorphic rhabdomyosarcoma. He was given five courses of chemotherapy with doxorubicin, etoposide, and ifosfamide with mesna protection without much relief. The inoperable disease occupied the whole of the right chest and mediastinum. The enormous size of the radiation field made radiotherapy prohibitive. Finally, the patient opted for symptomatic treatment and left for his native place.

CONCLUSION

This case is presented because of its difficulty in management and rarity.

Tolerance of avastin in metastatic colorectal cancer—a single institute Kuwait Cancer Control Centre experience

14156

Background: Bevacizumab is being used in combination with five fluorouracil(5-FU) based chemotherapy like FOLFIRI, FOLFOX, and capecitabine, since its inception in the treatment of metastatic colorectal cancer one year ago. Methods: a retrospective analysis was carried out to assess the toxicity profile of bevacizumab. Results: total 36 patients received bevacizumab in combination with various 5-FU based regimens .Twenty one were males 15 were females. A total of 288 cycles have been administered. Toxicities included change in medication for uncontrolled hypertension and mild epistaxis in 3 cases. One patient with intact primary in sigmoid colon developed perforation, peritonitis and she died subsequently. Conclusions: Conclusion- this preliminary results indicate that bevacizumab in combination with 5-FU based chemotherapy was tolerated. Extra precaution is required in cases of intact primary tumours.

No significant financial relationships to disclose.

A case report of primary osteosarcoma of the ovary

Primary osteosarcoma is one of the rare tumors affecting ovaries. This case is being reported for its rarity, along with a review of the literature. In this study, the patient, a 43-year-old woman, presented with an abdominopelvic mass. Exploratory laparotomy was performed, which revealed an extensive left ovarian mass infiltrating the uterus, small bowel, and urinary bladder. Subtotal hysterectomy and small bowel resection followed by end-to-end anastomosis and bilateral salpingo-ophorectomy were performed. Histopathology showed primary osteosarcoma of the ovary. Eighteen days after surgery, she started presenting with progressive abdominal distention and ultimately developed subacute intestinal obstruction. She was started on carboplatin and epirubicin combination but failed to respond and died of fast progressive disease. It is concluded that primary osteosarcoma of the ovary is a rare disease with poor prognosis.

Prevention of febrile neutropenia by prophylactic use of G-CSF with adjuvant TAC based on risk assessment—Single institute study

10711

Background: TAC confers significant disease free and overall survival benefits vs FAC for patients with node positive breast cancer. However TAC is associated with higher incidence of febrile neutropenia. In our study prophylactic G-CSF was used in patients, who developed grade 4 neutropenia with ANC < 100 or febrile neutropenia to prior cycle of TAC. Methods: Following surgery, patients with operable, 1–9 nodes positive breast cancer, ECOG 0–1, and adequate hematologic and organ function were enrolled on to the study, and were to receive TAC day 1 every 3 weeks for 6 cycles . All patients received prophylactic Ciprofloxacin 500-mg bid from days 5–14 after each cycle of chemotherapy unless prophylactic G-CSF was given. Eighty three patients were enrolled during the period 13–1-04 to 30–12–05. Patients who had received at least 2 cycles of TAC were eligible for evaluation. Patients were given prophylactic G-CSF if they had profound neutropenia (ANC < 100) or febrile neutropenia in prior cycle. Results: At the cut-off date for this analysis 79 patients were evaluable. 68 patients had completed the planned 6 cycles of TAC. Three, 2, 3 and 3 patients completed 2, 3, 4 and 5 cycles respectively. Sixty one patients required prophylactic G-CSF - 21 after febrile neutropenia in prior cycle, 39 after profound neutropenia in prior cycle and 1 received from first cycle itself because of post operative seroma with diabetes mellitus. 23 patients developed febrile neutropenia (29.1%) - 3, 8, and 12 after 3, 2 and 1 cycles respectively. Only two patients (3.2%) who received prophylactic G-CSF developed febrile neutropenia. Full dose of TAC could be maintained in 98.6% cycles. Conclusions: The use of G-CSF prophylaxis based on risk assessment could prevent febrile neutropenia in patients, who had profound neutropenia in prior cycle. Also G-CSF could prevent further febrile neutropenia in patients who had developed the same in prior cycle. The above strategy helped in maintaining the dose intensity of TAC.

No significant financial relationships to disclose.

Development of a fluorescence assay for the detection of L-ficolin-MASP in serum or purified samples

A fluorescence assay for the detection of L-ficolin-MASP in human serum or purified sample was developed by measuring the cleavage of fluorescent amide substrate by L-ficolin associated MASPs bound to the lipoteichoic acid (LTA). LTA (Staphylococcus aureus DSM 20233) was coated on NuncMaxisorp microtiter plates and serum or purified sample incubated overnight at 4 degrees C to allow the L-ficolin-MASP to bind LTA. Assay conditions for binding and complete cleavage of fluorescent amide substrate were standardized. The optimum temperature, incubation time and molarity of NaCl for LTA-ficolin binding were found to be 4 degrees C for 6 h at 1 M NaCl concentration. The optimum incubation time and pH for complete cleavage of fluorescent amide substrate by LTA bound L-ficolin associated MASP were found to be 2 h at pH 8.5. LTA-ficolin binding was found to be highly specific and was inhibited completely by LTA but not with mannose. A calibration curve was prepared by using the purified ficolin-MASP complex (1 to 12 mug/ml) and could be used to find concentration of ficolin-MASP complex in normal human serum.

A case report of primary osteosarcoma of the ovary

Primary osteosarcoma is one of the rare tumors affecting ovaries. This case is being reported for its rarity, along with a review of the literature. In this study, the patient, a 43-year-old woman, presented with an abdominopelvic mass. Exploratory laparotomy was performed, which revealed an extensive left ovarian mass infiltrating the uterus, small bowel, and urinary bladder. Subtotal hysterectomy and small bowel resection followed by end-to-end anastomosis and bilateral salpingo-ophorectomy were performed. Histopathology showed primary osteosarcoma of the ovary. Eighteen days after surgery, she started presenting with progressive abdominal distention and ultimately developed subacute intestinal obstruction. She was started on carboplatin and epirubicin combination but failed to respond and died of fast progressive disease. It is concluded that primary osteosarcoma of the ovary is a rare disease with poor prognosis.

Specific substitutions in the echinocandin target Fks1p account for reduced susceptibility of rare laboratory and clinical Candida sp. isolates

An association between reduced susceptibility to echinocandins and changes in the 1,3-beta-d-glucan synthase (GS) subunit Fks1p was investigated. Specific mutations in fks1 genes from Saccharomyces cerevisiae and Candida albicans mutants are described that are necessary and sufficient for reduced susceptibility to the echinocandin drug caspofungin. One group of amino acid changes in ScFks1p, ScFks2p, and CaFks1p defines a conserved region (Phe 641 to Asp 648 of CaFks1p) in the Fks1 family of proteins. The relationship between several of these fks1 mutations and the phenotype of reduced caspofungin susceptibility was confirmed using site-directed mutagenesis or integrative transformation. Glucan synthase activity from these mutants was less susceptible to caspofungin inhibition, and heterozygous and homozygous Cafks1 C. albicans mutants could be distinguished based on the shape of inhibition curves. The C. albicans mutants were less susceptible to caspofungin than wild-type strains in a murine model of disseminated candidiasis. Five Candida isolates with reduced susceptibility to caspofungin were recovered from three patients enrolled in a clinical trial. Four C. albicans strains showed amino acid changes at Ser 645 of CaFks1p, while a single Candida krusei isolate had a deduced R1361G substitution. The clinical C. albicans mutants were less susceptible to caspofungin in the disseminated candidiasis model, and GS inhibition profiles and DNA sequence analyses were consistent with a homozygous fks1 mutation. Our results indicate that substitutions in the Fks1p subunit of GS are sufficient to confer reduced susceptibility to echinocandins in S. cerevisiae and the pathogens C. albicans and C. krusei.

Pharmacokinetics of orally administered camptothecins

Phase I trials of oral camptothecins, including camptothecin (CPT) and irinotecan (CPT-11), have reported substantial interpatient variability in systemic exposure, which could result in suboptimal antitumor activity in some patients or enhanced risk for toxicity in others. This investigation evaluates the contribution of intestinal absorption and first-pass metabolism in the disposition of oral CPT and CPT-11, respectively. The transport of CPT in Caco-2 cell lines (validated model of intestinal drug transport) was concentration dependent and saturable (Vmax: 34 x 10(-5) cm/sec and Km: 20 microM), and was temperature dependent with an activation energy (Ea) of 11.7 kcal/mole. Cumulatively, this data was indicative of carrier-mediated intestinal transport. In addition, a reduction of transport in the presence of sodium azide plus deoxyglucose suggested ATP dependence. Thus, variable expression and availability of intestinal transporters could contribute to the observed wide variability in the exposure to oral CPT. CPT-11 is hydrolyzed by the ubiquitous enzyme carboxyl esterase to active SN-38, and first-pass metabolism of oral CPT-11 would include both intestinal and hepatic hydrolysis. Incubation of CPT-11 with S9 fractions of human liver and intestinal tissues resulted in variable rates of formation of SN-38. The mean (+/- SD) specific activities (pmoles/min/mg) were: liver (8.57 +/- 10.4, n = 8), duodenum (5.06 +/- 3.7, n = 4), jejunum (6.44 +/- 2.8, n = 5), ileum (4.81 +/- 2.4, n = 5), colon (1.93 +/- 1.5, n = 6), and rectum (0.82, n = 1). Interestingly, there was a decrease in SN-38 formation by tumor tissue compared to matched normal liver and colon tissues. Therefore variable first-pass metabolism could contribute to the substantial differences in the systemic exposures to CPT-11 and SN-38 in patients receiving oral CPT-11.

The intestinal absorption of camptothecin, a highly lipophilic drug, across Caco-2 cells is mediated by active transporter(s)

The intestinal transport properties and kinetics of camptothecin (CPT) through Caco-2 cell monolayers were characterized by determining concentration-, temperature-, and ATP-dependence as well as the effect of selected inhibitors. The absorptive permeability (Peff) of CPT was found to be concentration dependent and saturable (K(m) = 31.2 +/- 6.9 microM) indicating the involvement of a high affinity, low capacity transport system. CPT transport was also temperature dependent and inhibited by sodium azide plus 2-deoxyglucose, which deplete cellular ATP, further suggesting that an active, carrier-mediated transport system contributes to CPT absorption. Based on inhibition studies, the involvement of organic anion and cation transporters was implicated but not conclusively demonstrated. Total CPT transport decreased four fold with increasing pH from 5.5 to 8.5 indicating that CPT lactone contributed more significantly to overall CPT transport than CPT carboxylate. The results of these studies suggest that CPT absorption is mediated by multiple mechanisms including significant passive diffusion and active transport components. Since typical substrates for intestinal carriers are hydrophilic and charged, the involvement of putative absorptive carriers in the transport of CPT is a novel finding that may give insight into the erratic oral bioavailability of CPTs observed in the clinic.

Phase I clinical and pharmacologic study of 13-cis-retinoic acid, interferon alfa, and paclitaxel in patients with prostate cancer and other advanced malignancies

PURPOSE

Recent studies demonstrate that retinoids decrease expression of the anti-apoptotic protein bcl-2, enhance the effect of chemotherapy, and act synergistically with interferon alfa (IFNalpha) to inhibit tumor cell growth in vitro. A phase I trial of 13-cis-retinoic acid (CRA), IFNalpha, and paclitaxel (TAX) was conducted to determine the toxicity and recommended phase II dose of this combination. Pharmacodynamic studies were performed to determine whether CRA and IFNalpha could modulate bcl-2 expression in vitro and in patients.

PATIENTS AND METHODS

Twenty-two patients with prostate cancer or other advanced malignancies were treated with CRA/IFNalpha and escalating doses of TAX. The effect of CRA/IFNalpha on TAX pharmacokinetics was analyzed in both patients and human liver microsomes. The effect of CRA/IFNalpha on bcl-2 expression was assessed in vitro and in peripheral-blood mononuclear cells (PBMCs) by immunoblotting.

RESULTS

CRA 1 mg/kg on days 1 to 4, IFNalpha 6 MU/m(2) subcutaneously on days 1 to 4, and TAX 175 mg/m(2) on day 3 was well tolerated. Pharmacokinetic studies demonstrated that CRA/IFNalpha caused a 33% decrease in TAX clearance and a 23% decrease in the area under the concentration-time curve values of the TAX metabolite 6-alfa-hydroxytaxol (6-HT). CRA alone reduced conversion of TAX to 6-HT by 41% in human liver microsomes. CRA/IFNalpha decreased bcl-2 expression in vitro and in PBMCs.

CONCLUSION

CRA/IFNalpha and TAX is a well-tolerated regimen. CRA/IFNalpha increases TAX area under the concentration-time curve through an inhibitory effect of CRA on the metabolism of TAX to 6-HT. CRA/IFNalpha can modulate bcl-2 expression in vitro and demonstrates similar biologic activity in patients. Further studies will determine the activity of CRA/IFNalpha/TAX and validate the assessment of bcl-2 in PBMCs as a marker of tumor response.

In vitro activation of irinotecan to SN-38 by human liver and intestine

BACKGROUND

Irinotecan (CPT-11) is hydrolyzed by carboxyl esterase to the active metabolite SN-38 and oral irinotecan could undergo intestinal and hepatic activation. MATERNALS AND METHODS: Irinotecan was incubated with S9 fractions of human liver and intestinal tissues and the specific activity was determined based on the formation rate of SN-38.

RESULTS

Irinotecan was hydrolyzed to SN-38 by hepatic and intestinal S9 fractions with mean (+/- SD) specific activities (pmoles/min/mg) of: liver (8.57 +/- 10.4, n = 8), duodenum (5.06 +/- 3.7, n = 4), jejunum (6.44 +/- 2.8, n = 5), ileum (4.81 +/- 2.4, n = 5), colon (1.93 +/- 1.5, n = 6) and rectum (0.82, n = 1). When incubated with S9 fractions obtained from tumor tissues, there appeared to be a decrease in SN-38 formation compared to matched normal liver and colon tissues.

CONCLUSION

Irinotecan undergoes conversion to its active metabolite in human intestinal S9 fractions and there is variability in the extent of SN-38 formation. The localized intestinal activation of irinotecan to SN-38 may provide a rationale for the development of oral irinotecan for gastrointestinal malignancies but could also cause mucosal damage leading to toxicity.

High-performance liquid chromatographic quantitation of total and lactone 20(S)camptothecin in patients receiving oral 20(S)camptothecin

We have developed a sensitive high-performance liquid chromatography (HPLC) assay to quantitate total and lactone forms of 20(S)camptothecin (CPT) in human plasma. Lactone and total CPT were extracted using solid-phase extraction and liquid-liquid extraction, respectively. The extracted lactone samples could be stored without immediate HPLC analysis. The two forms of CPT were quantitated by reversed-phase HPLC with fluorescence detection. The extraction efficiencies were about 100% and 92% for the total and lactone forms, respectively. The lower limit of quantitation was 5.74 nM for the two forms. The method was reproducible with a mean interday and intraday variability of 6% for total CPT and 4% and 6%. respectively, for lactone CPT. The assay could effectively quantitate lactone and total CPT in patients receiving single dose and multiple doses of oral CPT.

Recipient age determines the success of intraperitoneal transplantation of peritoneal cavity B cells

In vivo studies of lymphocyte biology have used intravenous (i.v.) injection as the primary mode of cell transfer, a protocol consistent with the anatomic distribution of most lymphocytes. However, for study of peritoneal cavity B cells, i.v. injection does not correlate with anatomical localization. This report describes the restoration of B-cell function in B lymphocyte-defective X-chromosome-linked immune-defective (XID) mice after intraperitoneal transfer of immunoglobulin heavy chain (Igh)-disparate peritoneal cavity (PerC) cells. In contrast to i.v. transfer, intraperitoneal (i.p.) transfer restored B-cell function in young, but not adult (> 8 weeks), XID mice. When host and donor Igh allotype matched, PerC B-cell engraftment was noted in older recipients; this reconstitution however, was also age-dependent. Migration from the peritoneum to systemic circulation was necessary for serum IgM production as shown by the presence of donor antibody-secreting cells in the host spleen. Host lymphocytes also influenced the success of i.p. transplantation as severe combined immune-deficient mice, regardless of age, exhibited donor serum IgM production. Recipient age, Igh allotype, and immune-deficiency were found to have an impact on the ability of i.p.-transferred PerC B cells to restore B-cell function in XID mice.

Speed of sound, viscosity, and refractive index of multicomponent systems: analysis of experimental data from the Bertrand–Acree–Burchfield equation

The speed of sound in and the viscosity and refractive index of two ternary mixtures (I) toluene + n-heptane + n-hexane and (II) cyclohexane + n-heptane + n-hexane, and six binary combinations of these constituents have been measured experimentally. The excess values of these properties are calculated and the results are analysed using the Bertrand–Acree–Burchfield (BAB) model. All the experimental and theoretical values are in fairly reasonable agreement.