Management of tubal ectopic pregnancy with methotrexate in the setting of symptomatic Coronavirus disease 2019 (COVID-19): A case report

Background

Coronavirus Disease 2019 (COVID-19) represents a complex therapeutic challenge. As the pandemic progresses, patients are presenting with ectopic pregnancies (EPs) and symptomatic COVID-19.

Objective

We present the management of a patient with multiple medical comorbidities and tubal EP in the setting of severe symptomatic COVID-19 infection where all management options were precluded.

Methods

Case report with literature review of management of tubal EP in the setting of severe symptomatic COVID-19 infection.

Result

After careful consideration of options, the patient underwent successful medical management with methotrexate while receiving supportive care for COVID-19.

Conclusions

Methotrexate proved to be the safest therapeutic option in this patient. Management of patients with severe COVID-19 and gynaecologic emergencies should be individualised and carefully reviewed with evolving knowledge of COVID-19.

Effect of the administration program of 2 β-adrenergic agonists on growth performance and carcass and meat characteristics of feedlot ram lambs

The aim of the study was to determine the effects of 3 feeding dose programs of the β-adrenergic agonists (β-AA) ractopamine hydrochloride (RH) or zilpaterol hydrochloride (ZH) for the final 30 d before slaughter on growth performance and carcass and meat characteristics of feedlot ram lambs. Eighty-four Dorper × Katahdin ram lambs (30.0 ± 1.6 kg) were blocked by BW and randomly assigned to pens (4 lambs per pen and 3 pens per treatment). Pens within a block were assigned randomly to 1 of 7 dietary treatments: 1) control (CTL) = diet without β-AA; 2) RH constant (RHC) = 20.0 mg/kg of RH, d 1 to 30; 3) RH increasing (RHI) = 10.0 mg/kg, d 1 to 10; 20.0 mg/kg, d 11 to 20; and 30.0 mg/kg, d 21 to 30; 4) RH decreasing (RHD) = 30.0 mg/kg, d 1 to 10; 20.0 mg/kg, d 11 to 20; and 10.0 mg/kg, d 21 to 30; 5) ZH constant (ZHC) = 6.0 mg/kg of ZH, d 1 to 30; 6) ZH increasing (ZHI) = 3.0 mg/kg, d 1 to 10; 6.0 mg/kg, d 11 to 20; and 9.0 mg/kg d 21 to 30; and 7) ZH decreasing (ZHD) = 9.0 mg/kg, d 1 to 10; 6.0 mg/kg, d 11 to 20; and 3.0 mg/kg, d 21 to 30. Overall, β-AA supplementation reduced DMI (P < 0.001) compared with CTL lambs, but lambs fed RHI and ZHI programs had greater (P < 0.05) total BW gain, ADG, and G:F. Carcass weight was improved (P < 0.05) by RHI and ZHI programs, but dressing percentage was enhanced (P < 0.05) by only ZHC or ZHI treatments. Fat thickness and yield grade were reduced (P < 0.05) by ZH or RH regardless of feeding program. Most LM characteristics (pH, moisture loss, and chemical composition) were not different among treatments (P > 0.05), with the exception of fat content that was reduced (P < 0.001) in lambs fed β-AA, and diameter of muscle fibers that was increased (P < 0.05) by ZHI treatment. Constant and increasing doses of ZH reduced (P < 0.05) the a* value of LM and semitendinosus muscles, with no effects on L* or b* values. The mass of liver was reduced (P < 0.05) in ZHI-treated lambs compared with CTL lambs, and plasma urea concentration was reduced (P < 0.05) by RH or ZH administration regardless of feeding program, although there were no other differences in organ mass weight (P ≥ 0.35) or blood metabolites (P ≥ 0.16). Increasing doses of RH or ZH augmented the growth performance response without negative effects on organ mass weight or blood metabolites. Although a ZHI program improved carcass characteristics, the increased LM fiber diameter of lambs fed ZHI program could be unfavorable because of the potential negative effect on tenderness.

Updated results of a randomized phase II study comparing two schedules of temozolomide in combination with sorafenib in patients with advanced melanoma

8527

Background: The preliminary results for 90 patients (pt) on this 4-arm phase II trial testing sorafenib (SO), an oral Raf kinase/VEGFR2 inhibitor, and temozolomide (TEM) in pt with metastatic melanoma (MM) were presented in 2006. Since then 88% of target accrual is completed and the study is open at a second institution. The primary objective of this study is to estimate the duration of progression- free survival (PFS). Secondary objectives are to determine the optimal dosing of TEM, response, and toxicity rates. Correlative studies include BRAF genotyping and assessment of intratumoral Raf inhibition, and apoptosis. Methods: Pt with MM and ECOG PS<2 are eligible. Prior therapy is allowed. Target accrual is 167 pt in 1 stage. All pt receive SO 400 mg po bid continuously. After 1 week of SO alone, pt without brain metastasis or prior TEM (A+B) are randomized to receive either extended dosing (ED): TEM 75 mg/m2 po qd for 6/8 weeks (Arm A), or standard dosing (STD): TEM 150 mg/m2 po qd for days1–5/28 (Arm B). Pt with prior TEM are treated with ED (Arm C) and pt with brain metastasis without prior TEM are treated with STD (Arm D). Responses are assessed using RECIST. Results: Accrual is complete for arms A and B. Results for 147 pt were evaluated ( Table ). SO + TEM resulted in a 19% overall response rate (ORR) [95% CI 11–30%] for pt on arms A+B. In this group, 3/78 pt (4%) developed CNS metastases while on study. Pt on arm D had a 17 % ORR [95% CI 7–34%]. Common grade 3 toxicities were hand-foot syndrome (14%), rash (9%), nausea (9%), and diarrhea (5%). Grade 3 lymphopenia was more common in arm A v. B (43% v. 16%, p=0.01). No significant difference in PFS was found between pt with WT v. mutant BRAF (n=33). Therapy-induced apoptosis was found in 8/9 serial biopsies. Analysis of MAPK phosphorylation in serial biopsies is planned. Conclusions: Updated results confirm the encouraging antitumor activity and tolerability of SO + TEM in pt with MM without a prior history of TEM.

No significant financial relationships to disclose.

[Table: see text]

Ki67 expression levels are a better marker of reduced melanoma growth following MEK inhibitor treatment than phospho-ERK levels

The loss of tumour phospho-extracellular responsive kinase (pERK) positivity is the major treatment biomarker for mitogen-activated protein kinase/extracellular responsive kinase (MEK) inhibitors. Here, we demonstrate that there is a poor correlation between pERK inhibition and the anti-proliferative effects of MEK inhibitors in melanoma cells. We suggest that Ki67 is a better biomarker for future clinical studies.

Absence of BRAF mutations in UV-protected mucosal melanomas

BACKGROUND

Mutations in BRAF have recently been identified in a significant percentage of primary and metastatic cutaneous malignant melanomas. As ultraviolet (UV) exposure may play a role in the development of cutaneous melanoma lesions with BRAF mutations, BRAF mutation frequency in melanomas arising in sites protected from sun exposure may be lower than those from sun-exposed areas. Thus, we determined the BRAF mutation frequency in a panel of 13 mucosal melanomas and compared those data with data from all currently published series of cutaneous melanomas.

METHODS

BRAF exon 15 DNA from 13 archival primary mucosal melanomas (eight vulvar, four anorectal, and one laryngeal) was sequenced using intron-based primers. As archival DNA occasionally produces poor-quality template, results were confirmed with a TspRI restriction fragment length polymorphism (RFLP) that distinguishes wild-type BRAF from the common mutant form V599E. A binomial test was used to compare the mutation frequency in the mucosal melanomas with the published mutation frequency in cutaneous melanomas.

RESULTS

None of the 13 mucosal melanomas in this series had an exon 15 BRAF mutation, as compared to 54/165 (33%) primary cutaneous melanomas with BRAF mutations in a compilation of all current published studies (p = 0.006).

DISCUSSION

These data suggest that UV exposure, plays a role in the genesis of BRAF mutations in cutaneous melanoma, despite the absence of the characteristic C>T or CC>TT mutation signature associated with UV exposure, and suggests mechanisms other than pyrimidine dimer formation are important in UV-induced mutagenesis.

Effect of Fas and Fas ligand deficiency in resistance of C57BL/6 mice to HSV-1 keratitis and chorioretinitis

PURPOSE

To investigate the effect of Fas and Fas ligand (FasL) deficiency on the development of herpes stromal keratitis and on the von Szily model of herpes retinitis in C57BL/6 mice, which are ordinarily resistant to development of both of these herpetic diseases.

METHODS

Anterior chamber inoculation of the right eye of each mouse with various titers of HSV-1 (KOS strain) was performed. Both eyes of each mouse were enucleated on postinoculation day 15 and processed for histopathologic examination. HSV-1 was inoculated into one cornea of other mice, and the severity of stromal keratitis was scored.

RESULTS

Contralateral destructive chorioretinitis developed in susceptible Balb/cByj mice (19/23); ipsilateral chorioretinitis did not occur (0/23). Stromal keratitis developed in susceptible C.AL-20 mice (15/16). None of the C57BL/6 (0/10 for keratitis or 0/20 for retinitis) developed inflammation. Neither did B6.SMN.C3H.gld (FasL deficient; 0/12 or 0/28) or B6.MRL.lpr (Fas deficient; 0/11 or 0/34) mice (keratitis or contralateral chorioretinitis). Minimal scattering of inflammatory cells in the contralateral retina but not destructive chorioretinitis was observed in two C57BL/6, three B6.SMN.C3H.gld, and five B6.MRL.lpr mice. Few inflammatory cells were also found in the ipsilateral vitreous and vitreoretinal interface (but not destructive chorioretinitis) of all C57BL/6, two gld, and three lpr mice.

CONCLUSIONS

Immune dysregulation secondary to deficiency in Fas or FasL system does not influence the resistance of the C57BL/6 mice to develop herpes simplex keratitis or destructive herpes simplex chorioretinitis.

Pharmacomanipulation of HSV-1 induced chorioretinitis in mice

In the von Szily mouse model, intracameral inoculation of herpes simplex virus type-1 (HSV-1) results in inflammation of the ipsilateral anterior segment with relative chorioretinal sparing and destructive contralateral chorioretinitis. We studied the effect of the systemic antiviral agent acyclovir (ACV) and anti-HSV-1 antibody therapy in this model. Contralateral chorioretinitis developed in none of the 18 mice receiving ACV from post-inoculation day (pid) 1 (p < 0.0001), in 6 of 10 (60%) mice when treatment was delayed until pid 7 (p = 0.40) and in 14 of 18 (77%) controls. Contralateral disease developed in 8 of 16 (50%) mice that received anti-HSV-1 antibody from pid 1 (p = 0.02), in 13 of 16 (81%) treated from pid 5 (p = 0.64), in 7 of 8 (87.5%) treated from pid 7 (p = 1.0) and in 17 of 20 (85%) controls. We conclude that early treatment with ACV or anti-HSV-1 antibody reduces the incidence of contralateral chorioretinitis in mice.

The bladder tumor antigen (BTA) test compared to voided urine cytology in the detection of bladder neoplasms

PURPOSE

Tests to detect recurrent bladder neoplasms are limited and none is consistently accurate. Recent studies suggest that the bladder tumor antigen (BTA) test, an agglutination reaction for basement membrane complexes, is superior to voided urine cytology in clinical practice. We compared BTA and voided urine cytology to bladder washings and cystoscopy, emphasizing diagnostic yield among patients with causes of basement membrane complexes other than bladder cancer.

MATERIALS AND METHODS

Random voided urine specimens from 67 patients with a history of bladder neoplasms were collected before cystoscopy and bladder washing. Urine also was obtained from 34 patients with inflammatory bladder conditions including 5 with a history of prostate cancer. Each urine was tested for BTA according to a commercial kit. Positive results were indicated by yellow on a test pad. Blinded to all other results, each urine and each bladder washing were examined microscopically, and a positive test had malignant/suspicious cells. Bladder biopsies were performed when endoscopic lesions were seen. Specimens were grouped into 4 categories: group 1--biopsy proved bladder neoplasm, group 2--history of bladder cancer but not biopsy proved, group 3--history of prostate cancer and group 4--no history of urological cancer.

RESULTS

Voided urine cytology was positive in 54% of specimens from patients with biopsy proved bladder neoplasms compared to 29% for BTA. Relative yield for voided urine cytology versus BTA was not changed if all group 2 cases having a positive bladder washing and positive cystoscopy were assumed to have bladder cancer, nor was relative yield altered by subsequent short-term followup. Of voided urine specimens 14% from group 1 patients and 41% from group 2 patients had scant cells. Overall diagnostic yield was superior for bladder washing. False-positive BTA occurred in 7 of 34 patients with no history of urological or prostate cancer. There were no false-positive voided urine cytology interpretations in these groups.

CONCLUSIONS

BTA is not superior to voided urine cytology in detecting bladder neoplasms and may be limited by false-positive reactions in patients with other causes of basement membrane complexes in urine. Voided urine samples may be limited by high frequency of hypocellularity. Of 34 patients with a hypocellular urine specimen 4 had biopsy proved bladder cancer. Bladder washing yields best results but requires instrumentation. No test, including cystoscopy, is accurate always.

Restricted kappa chain expression in early ontogeny: biased utilization of V kappa exons and preferential V kappa-J kappa recombinations

To determine the extent of kappa chain diversity in the preimmune repertoire early in development, kappa cDNA libraries were analyzed from 15-d old fetal omentum, 18-d-old fetal liver, and 3-wk old bone marrow. An anchored polymerase chain reaction approach was used to avoid bias for particular V kappa families. From the sequence analysis of 27 bone marrow clones, 10 different families and 20 unique V kappa genes were identified. In contrast, the V kappa expression in the fetus is highly restricted and clearly differs from the broader distribution see in 3-wk-old bone marrow. Although several V kappa families were represented in the fetal library including V kappa 9, V kappa 10, V kappa 4,5, V kappa 8, and V kappa 1, one or two members of individual families were observed repeatedly. The fetal liver and omentum libraries were found to be largely overlapping. Given the V kappa families/exons identified in the fetal sequences, the mechanism of kappa rearrangements in the early repertoire appears to occur predominantly by inversion. Importantly, the fetal repertoire was further restricted by dominant V kappa-J kappa combinations such as V kappa 4,5-J kappa 5, V kappa 9-J kappa 4, and V kappa 10-J kappa 1. Since in some cases independent rearrangements could be established, the results indicate a bias for particular V kappa-J kappa joins. The results also suggest that clonal expansion/selection in the fetal repertoire takes place after light chain rearrangement as opposed to at the pre-B cell level in the bone marrow. The restriction observed in kappa light chain expression together with known restrictions in gene usage and junctional diversity at the heavy chain level indicate a remarkably conserved fetal repertoire.

Comparative expression of adult and fetal V gene repertoires

A hallmark of the immune system is the extraordinary diversity associated with antibodies. This is made possible by a series of genetic rearrangements involving variable region gene segments. Considerable detail is known about these genetic mechanisms except for the enzymatic machinery involved. An important question in studies of the generation of diversity is whether V genes are selected for rearrangement mainly in a random manner or selected by particular developmental rules. Past studies have indicated that the acquisition of fetal and neonatal specificity repertoires is a nonrandom process. In this report, we review our studies that directly compare the adult and fetal/neonatal V gene repertoires. The evidence suggests that the adult repertoire is more diverse with indications of a random use of VH gene families. However, whether V genes are indeed randomly used in the adult remains to be clarified at the VH gene member level. The fetal repertoire, on the other hand, appears nonrandom in V gene usage. In addition, the fetal repertoire is mostly germline encoded with little evidence of junctional diversity. Taken together, the results indicate different rules for generation of the adult and fetal repertoires, findings most likely explain by distinct B cell subsets and B cell progenitors at early stages in ontogeny.

Improved plaque production for short-term bone marrow and fetal liver cultures

The addition of 0.5% globulin-free (GF-BSA) or 0.5% delipidated BSA (D-BSA) to short-term murine bone marrow (BM) (cultures) increased the number of plaque-forming cells (PFC) responding to trinitrophenylated lipopolysaccharide (TNP-LPS) 2-5-fold (1.1 X 10(4)-2.7 X 10(4) PFC per 10 X 10(6) nucleated BM cells). Although it was necessary to continue to supplement these cultures with 5% fetal calf serum (FCS), the inclusion of the aforementioned BSA preparations provided enhanced PFC production for all lots of FCS tested. Similarly, these preparations of BSA made it feasible to also culture BM in autologous mouse sera (MS) or in medium without 2-mercaptoethanol (2-ME) if in the latter case the D-BSA was pretreated with 2-ME. Thus, the inclusion of GF-BSA or D-BSA in short term cultures of BM not only substantially increased the number of Ig-secreting B cells produced in response to TNP-LPS but seemed to eliminate the need to screen for supportive batches of FCS or MS. These preparations of BSA also facilitated hapten specific PFC responses of fetal liver cultures.