Concurrent Lymphoma and COVID-19: Diagnostic and Therapeutic Challenges of High-Grade Lymphoma and COVID-19

The coronavirus disease 2019 (COVID-19) global pandemic has put an unprecedented strain on cancer care. The initial months were marred by fears of immunocompromised patients becoming opportunistic hosts to this deadly virus. We present a case of newly diagnosed high-grade B-cell lymphoma in a patient with COVID-19 and discuss the diagnostic and therapeutic challenges posed.

A 76-year-old female presented with one month of progressive malaise, poor appetite, weight loss, and night sweats. A surveillance COVID-19 polymerase chain reaction (PCR) resulted positive. With strict isolation precautions, the daily focused physical examination masked several key findings including multifocal adenopathy. She developed hypoxic respiratory failure and progressive transaminitis and cytopenias. Image-guided, rather than excisional, biopsy revealed high-grade B-cell lymphoma. Superimposed COVID-19 infection presented multiple challenges, but she completed treatment and achieved remission. Suspicion for underlying malignancy was high. Institutional concerns included obtaining imaging studies and the gold standard excisional tissue biopsy while maintaining acceptable staff exposure. Fortunately, a lymph node core biopsy confirmed the histopathological diagnosis of high-grade B-cell lymphoma. The administration of chemoimmunotherapy (rituximab, cyclophosphamide, doxorubicin, dose-reduced vincristine, and prednisone (R-CHOP)) posed inherent risks, notably, worsening cytopenias and hepatotoxicity. The approach to treatment was further complicated as the interaction of high-grade lymphoma and COVID-19 remained unclear.

Medical teams have faced delays executing formerly routine diagnostic studies and formulating timely and appropriate treatment strategies. Careful consideration of risks and benefits must be weighed. A multidisciplinary approach is crucial to successfully treat patients. The relationship between COVID-19 and cancer treatment is yet to be established, and large sample-size studies are required.

pH-EVD: A pH-Paper-Based Extraction and Visual Detection System for Instrument-Free SARS-CoV-2 Diagnostics

The ongoing pandemic of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused millions of deaths worldwide. However, most SARS-CoV-2 detection methods depend on time-consuming sample preparation and large detection instruments. Herein, a method employing nonbleeding pH paper to achieve both RNA extraction and visual isothermal amplification is proposed, enabling rapid, instrument-free SARS-CoV-2 detection. By taking advantage of capillary forces, pH-paper-based RNA extraction can be accomplished within 1 min without need for any equipment. Further, the pH paper can mediate dye-free visual isothermal amplification detection. In less than a 46-min sample-to-answer time, pH-paper-based extraction and visual detection (termed pH-EVD) can consistently detect 1200 genome equivalents per microliter of SARS-CoV-2 in saliva, which is comparable to TaqMan probe-based quantitative reverse transcription PCR (RT-qPCR). Through coupling with a chemically heated incubator called a smart cup, the instrument-free, pH-EVD-based SARS-CoV-2 detection method on 30 nasopharyngeal swab samples and 33 contrived saliva samples is clinically validated. Thus, the pH-EVD method provides simple, rapid, reliable, low-cost, and instrument-free SARS-CoV-2 detection and has the potential to streamline onsite COVID-19 diagnostics.

Instrument-free, CRISPR-based diagnostics of SARS-CoV-2 using self-contained microfluidic system

Rapid and sensitive detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is critical for early diagnostics and timely medical treatment of coronavirus disease 2019 (COVID-19). However, current detection methods typically rely on expensive and bulky instrumentation. Here, we developed a simple, sensitive, instrument-free, CRISPR-based diagnostics of SARS-CoV-2 using a self-contained microfluidic system. The microfluidic chip integrates isothermal amplification, CRISPR cleavage, and lateral flow detection in a single, closed microfluidic platform, enabling contamination-free, visual detection. To simplify the operation and transportation of the device, we lyophilized the CRISPR reagents in the reaction chamber and pre-stored the liquid solutions in blisters. We employed a low-cost, portable hand warmer to incubate the microfluidic chip without the need for electricity. The self-contained microfluidic system can detect down to 100 copies of SARS-CoV-2 RNA. Further, we clinically validated our method by detecting 24 COVID-19 clinical nasopharyngeal swab samples, achieving excellent sensitivity (94.1%), specificity (100%), and accuracy (95.8%). This simple, sensitive, and affordable microfluidic system represents a promising tool for point-of-care diagnostics of COVID-19 and other infectious diseases.

Autonomous lab-on-paper for multiplexed, CRISPR-based diagnostics of SARS-CoV-2

The COVID-19 pandemic, caused by severe acute respiratory coronavirus 2 (SARS-CoV-2), has become a public health emergency and widely spread around the world. Rapid, accurate and early diagnosis of COVID-19 infection plays a crucial role in breaking this pandemic. However, the detection accuracy is limited for current single-gene diagnosis of SARS-CoV-2. Herein, we develop an autonomous lab-on-paper platform for multiplex gene diagnosis of SARS-CoV-2 by combining reverse transcription recombinase polymerase amplification (RT-RPA) and CRISPR-Cas12a detection. The autonomous lab-on-paper is capable of simultaneously detecting nucleoprotein (N) gene and spike (S) gene of SARS-CoV-2 virus as well as human housekeeping RNAse P gene (an internal control) in a single clinical sample. With the developed platform, 102 copies viral RNA per test can be detected within one hour. Also, the lab-on-paper platform has been used to detect 21 swab clinical samples and obtains a comparable performance to the conventional RT-PCR method. Thus, the developed lab-on-paper platform holds great potential for rapid, sensitive, reliable, multiple molecular diagnostics of COVID-19 and other infectious diseases in resource-limited settings.

Ultrasensitive and visual detection of SARS-CoV-2 using all-in-one dual CRISPR-Cas12a assay

The recent outbreak of novel coronavirus (SARS-CoV-2) causing COVID-19 disease spreads rapidly in the world. Rapid and early detection of SARS-CoV-2 facilitates early intervention and prevents the disease spread. Here, we present an All-In-One Dual CRISPR-Cas12a (AIOD-CRISPR) assay for one-pot, ultrasensitive, and visual SARS-CoV-2 detection. By targeting SARS-CoV-2’s nucleoprotein gene, two CRISPR RNAs without protospacer adjacent motif (PAM) site limitation are introduced to develop the AIOD-CRISPR assay and detect the nucleic acids with a sensitivity of few copies. We validate the assay by using COVID-19 clinical swab samples and obtain consistent results with RT-PCR assay. Furthermore, a low-cost hand warmer (~$0.3) is used as an incubator of the AIOD-CRISPR assay to detect clinical samples within 20 min, enabling an instrument-free, visual SARS-CoV-2 detection at the point of care. Thus, our method has the significant potential to provide a rapid, sensitive, one-pot point-of-care assay for SARS-CoV-2.

Rapid and early detection of SARS-CoV-2 will aid intervention to stop disease spread. Here the authors present a one-pot CRISPR-based rapid detection system with visual readout.

Mild COVID-19 infection despite chronic B cell depletion in a patient with aquaporin-4-positive neuromyelitis optica spectrum disorder

Coronavirus disease 2019 (COVID-19) is caused by the novel coronavirus SARS-CoV-2, which affects the lung and other organs. After an incubation period of 3-14 days, the infection presents with symptoms of variable severity, from mild flu-like disease to severe pneumonia and cytokine storm with increased mortality. Immunosuppressed patients may have higher risk of adverse outcomes; hence, there is an urgent need to evaluate the immune response and clinical outcomes of SARS-CoV-2 infection in these patients. Here, we report a 59-year-old woman with aquaporin-4-positive (AQPR4+) neuromyelitis Optica treated with rituximab who developed mild respiratory symptoms with COVID-19, despite B cell depletion at the time of infection.

P917 Additional value of atrial parameters evaluated by echocardiography on the scales of cardioembolic risk in atrial fibrillation

Background

Atrial morphological parameters may influence the presence of atrial thrombus, a factor strongly associated with cardiac thromboembolism, independently of those included in the CHA2DS2-VASc risk estimation scale in patients with a history of atrial fibrillation (AF). The aim of our study was to evaluate this possible association by transthoracic echocardiography (TTE).

Methods

Prospective multicenter study including 401 patients with a history of AF, in which a TTE and a transesophageal echocardiogram (TEE) were performed for evaluation of atrial thrombus between 2016-2019. The parameters included in the CHA2DS2-VASc scale, the heart rhythm at the time of the study and the anticoagulant treatment performed, as well as the atrial morphological parameters were collected.

Results

Twenty-three patients (6%) presented with atrial thrombus in TEE. The left atrial area (28 ± 6cm2 vs 33 ± 6cm2; p < 0.001), the presence of AF during the study (83% vs 17%; p = 0.002) and CHA2DS2-VASc (1.7 ± 1.5cm2 vs 3.0 ± 1.3cm2; p < 0.001) were associated with the presence of atrial thrombus. The left atrial area was a diagnostic predictor of atrial thrombus (area under the curve = 73%; p = 0.001): a value >30cm2 presented a sensitivity of 79% and a specificity of 70% to detect its presence. Logistic regression analysis, including heart rhythm during the study and anticoagulant treatment, showed that CHA2DS2-VASc (OR = 1.5; CI95%=1.1-1.9; p = 0.003) and left atrial area >30cm2 (OR = 5.2;CI 95% =1.7-16.0; p = 0.004) were independent predictors of atrial thrombus presence.

Conclusions

The left atrial area is associated with the presence of atrial thrombus in patients with a history of AF independently of the CHA2DS2-VASc scale, heart rhythm during the study, and anticoagulant treatment. This parameter should be evaluated to be included in the cardioembolic risk scales.

P1760 Cardiac prognosis of patients with subaortic membrane according to their morphology

INTRODUCTION

Subaortic membrane is an entity which evolves during adulthood and can associate cardiac complications. Different morphologies have been described, although it is unknown if their prognosis varies according to these patterns. The aim of this study was to evaluate the cardiac prognosis of patients with subaortic membrane according to their morphological characteristics in adulthood.

METHODS

Forty-five patients diagnosed with subaortic membrane by imaging techniques were consecutively included (March 1999-August 2018). Three morphologies were described: fibromuscular ridge (FR), crescent-shaped (CS) and filamentous-shaped (FS). Cardiac complications were defined as mortality due to heart failure and/or necessity of aortic valve surgery and/or membrane resection.

RESULTS

Twenty-six cases (58%) had FR, 16 (35%) had CS and 3 (7%) presented FS (7%) (Fig.1). No differences were found in basal clinical parameters between groups. FR type was associated with the presence of dynamic gradient in baseline study (27% vs 0%, p = 0.014), but there were no differences in left ventricular ejection fraction (68 ± 8% vs 64 ± 8%; p = 0.092), nor in maximum thickness of basal interventricular septum (12.1 ± 3.9mm vs 11.7 ± 4.1mm, p = 0.699), nor in the presence of moderate/severe aortic stenosis (15% vs 11%, p > 0.999) with the other morphologies. During follow-up (mean ± SD= 5.8 ± 4.4years) 15 (33%) patients presented cardiac complications (2 deaths due to heart failure and 12 valvular interventions and/or membrane resection). FR type patients presented a higher cardiac complication rate (50% vs 11%, p = 0.006) and greater necessity of open-heart surgery (46% vs 11%, p = 0.011) than the other groups during follow-up.

CONCLUSIONS

FR type is associated with a higher rate of cardiac complications during follow-up than other subaortic membrane morphologies. Dynamic gradient associated to this pattern could be the basis of a possible pathophysiological mechanism related to the worst prognosis of these patients.

Figure 1. Different morphologies of subaortic membranes. (A) Fibromuscular ridge type; (B) Crescent-shaped type; (C) Filamentous-shaped type. aL: anterior leaflet of mitral valve ; Ao: aorta; LA: left atrium; LV: left ventricle; RV: right ventricle.

Abstract P1760 Figure.

P367 Cardioprotective effect of angiotensin converting enzyme inhibitors and beta-blockers in the primary prevention of cardiotoxicity: systematic review and meta-analysis of randomised studies

Funding Acknowledgements

none

OnBehalf

none

Background

Chemotherapy cardiotoxicity is a serious complication in breast and haematological malignancies. However, its primary prevention with angiotensin converting enzyme inhibitors (ACEI)/angiotensin II receptor antagonists (ARB) and/or beta-blockers (BB) medication has discrepant results. The aim of our study was to establish whether primary prevention using these treatments prevents cardiotoxicity and whether any of them is superior to the others.

Methods

A systematic review and meta-analysis was performed following a search of EMBASE, MEDLINE and PsycINFO from January 2005 to April 2019 of all randomised studies evaluating primary prevention of cardiotoxicity by chemotherapy with any of these treatments. Cardiotoxicity was defined as the drop of the left ventricular ejection fraction below 50% or greater than 10% and/or clinical heart failure during the first year of follow-up.

Results

Nine randomised studies with 913 participants in which chemotherapy was performed were included: 337 (37%) received BB, 152 (17%) received ACEI/ARB, 45 (5%) received BB + ACEI and 379 (41%) were controls. One hundred and eight cases (12%) developed cardiotoxicity (follow-up range: 1-12 months). Patients receiving cardioprotective treatment had a lower risk of developing cardiotoxicity than controls (RR = 0.381, IC95%, 0.160-0.911, P = 0.030, I2 = 63.2%; Fig.1). The subgroup analysis showed a non-significant tendency for both treatments to have a cardioprotective effect (BB: RR = 0.477; IC95%, 0.178-1.275; P = 0.140; I2 = 57.3%) / ACEI/ARB: RR = 0.283; IC95%, 0.027-2.982; P = 0.293; I2 = 79.0%). There was no difference between both treatments in those studies comparing them (RR = 0.743, CI95%, 0.325-1.698, P = 0.481, I2 = 0.0%). The estimated number of patients to be treated to avoid one case of cardiotoxicity was 10 patients.

Conclusions

Primary prevention with BB and/or ACEI/ARB reduces cardiotoxicity by chemotherapy during the first year in breast and haematological malignancies. For every 10 patients treated, one case of cardiotoxicity could be avoided.

Figure 1. Cases treated with BB and/or ACEI/ARB versus control group without treatment of the different randomised studies comparing the number of patients who developed cardiotoxicity during the first year.

Abstract P367 Figure 1

P2763Clinical prognosis of pure right-sided infective endocarditis without association to cardiac devices or intravenous drug abuse

Background

Pure right-sided infective endocarditis (RSIE) without association with cardiac devices or intravenous drug users (IVDUs) is an entity with unclear predisposing factors and prognosis.

Purpose

To evaluate predisposing factors and prognosis of pure RSIE compared tothose associated to cardiac devices or IVDUs.

Methods

280 consecutive patients with endocarditis were included retrospectively in a protocol of clinical and imaging follow-up. Endocarditis-related event was defined as endocarditis mortality or open-surgery requirement. Besides, a review and meta-analysis of the literature between january 2000 and december 2018 were performed.

Results

Fifty-two (19%) patients presented RSIE: 20 of them (39%) were pure RSIE. Intravascular catheters carriers (25% vs 3%; p=0.026) and congenital heart diseases (20% vs 0%; p=0.018) were associated to pure RSIE. These patients demonstrated the worst clinical prognosis, with the highest in-hospital mortality (25% vs 3%; p=0.026) and endocarditis-related event rate (45% vs 6%; p=0.001), being pure RSIE independently associated with in-hospital endocarditis-related events (OR=8.40; 95% CI, 1.13–62.68; p=0.038). Four studies, including ours, with 315 participants diagnosed of RSIE were evaluated in meta-analysis: 94 individuals (30%) presented pure RSIE.This group demonstrated a higher in-hospital mortality than those with cardiac devices or IVDUs (RR=2.854; 95% CI, 1.640–4.965; P<0.001; I2=0.0%; Figure 1).

Figure 1. RSIE and in-hospital mortality based on groups: cases with pure RSIE versus those with cardiac devices or IVDUs.

Conclusions

Pure RSIE is the worst prognosis group among RSIE with the highest endocarditis-related event rate and in-hospital mortality. This growing group should stake out the benign impression and recommendations given to RSIE among IE patients.

Chylous Ascites: A Review of Pathogenesis, Diagnosis and Treatment

Chylous ascites (CA) is a rare form of ascites that results from the leakage of lipid-rich lymph into the peritoneal cavity. This usually occurs due to trauma and rupture of the lymphatics or increased peritoneal lymphatic pressure secondary to obstruction. The underlying etiologies for CA have been classified as traumatic, congenital, infectious, neoplastic, postoperative, cirrhotic or cardiogenic. Since malignancy and cirrhosis account for about two-thirds of all the cases of CA in Western countries, in this article we have attempted to reclassify CA based on portal and non-portal etiologies. The diagnosis of CA is based on the distinct characteristic of the ascitic fluid which includes a milky appearance and a triglyceride level of >200 mg/dL. The management consists of identifying and treating the underlying disease process, dietary modification, and diuretics. Some studies have also supported the use of agents such as orlistat, somatostatin, octreotide and etilefrine. Paracentesis and surgical interventions in the form of transjugular intrahepatic portosystemic shunt (commonly known as TIPS), peritoneal shunt, angiography with embolization of a leaking vessel, and laparotomy remain as treatment options for cases refractory to medical management.

MRI assessment and outcomes in patients receiving neoadjuvant chemotherapy only for primary rectal cancer: long-term results from the GEMCAD 0801 trial

Background

Primary chemotherapy has been tested as a possible approach for patients with high risk features but predicted clear mesorectal margins on preoperative MRI assessment. This study investigates the prognostic relevance of baseline and post-treatment MRI and pathology staging in rectal cancer patients undergoing primary chemotherapy.

Patients and methods

Forty-six patients with T3 tumour > =2 mm from the mesorectal fascia were prospectively treated with Neoadjuvant Capecitabine, Oxaliplatin and Bevacizumab prior to surgery between 2009 and 2011. The baseline and post-treatment MRI: T, Nodal and Extra-mural venous invasion (EMVI) status were recorded as well as post-treatment MRI Tumour regression grade (TRG) and modified-RECIST assessment of tumour length. The post-treatment pathology (yp) assessments of T3 substage, N, EMVI and TRG status were also recorded. Three-year disease-free survival (DFS) and cumulative incidence of recurrence were estimated by using the Kaplan-Meier product-limit method, and Cox proportional hazards models were used to determine associations between staging and response on MRI and pathology with survival outcomes.

Results

About 46 patients underwent neoadjuvant chemotherapy alone for high risk margin safe primary rectal cancer. The median follow-up was 41 months, 5 patients died and 11 patients experienced relapse (2 local, 8 distant and 1 both). In total 23/46 patients were identified with MRI features of EMVI at baseline. mrEMVI positive status carried independent prognostic significance for DFS (P = 0.0097) with a hazard ratio of 31.33 (95% CI: 2.3-425.4). The histopathologic factor that was of independent prognostic importance was a final ypT downstage of ypT3a or less, hazard ratio: 14.0 (95% CI: 1.5-132.5).

Conclusions

mrEMVI is an independent prognostic factor at baseline for poor outcomes in rectal cancer treated with neoadjuvant chemotherapy while ≤ypT3a is associated with an improvement in DFS. Future preoperative therapy evaluation in rectal cancer patients will need to stratify treatment according to baseline EMVI status as a crucial risk factor for recurrence in patients with predicted CRM clear rectal cancer.

Primary Follicular Lymphoma of the Gastrointestinal Tract: Case Report and Review

PURPOSE

Primary gastrointestinal follicular lymphoma (GI-FL) is considered a rare disease with fewer than 400 cases reported in the literature. It accounts for roughly 1-3 % of GI non-Hodgkins lymphomas (NHL). It originates in the GI tract and typically affects small bowel. The disease has an indolent course, and a prolonged survival can be expected in most cases. Due to its rarity, an optimal diagnostic work up and treatment plan has not been well established.

METHODS

Endoscopic evaluation of the entire gastrointestinal (GI) tract using esophagogastroduodenoscopy (EGD), wireless capsule endoscopy, double-balloon enteroscopy, colonoscopy, and whole body examination with fluorodeoxyglucose-positron emission tomography (FDG-PET) has been suggested to more accurately stage the disease and guide the treatment plan.

RESULTS

Treatment options for GI follicular lymphoma include watch and wait strategy, surgery, chemotherapy, radiation, immuno-radiotherapy, or a combination of these modalities.

CONCLUSION

In this article, we have summarized the existing information regarding clinical presentation, diagnostic evaluation, and treatment options for this rare entity after presenting a case of GI-FL who was diagnosed during an EGD for evaluation of belching, heartburn, and weight loss.

Appropriateness of testing for heparin-induced thrombocytopenia in hospitalized patients

252

Background: Heparin induced thrombocytopenia (HIT) is a devastating thrombotic complication of heparin therapy and occurs in 0.2 to 5% of patients receiving heparin products and is a clinicopathologic diagnosis. The American Society of Hematology Guidelines, recommend the use of the “4Ts” scoring system to determine the pre-test probability of suspected cases. Also, a presumptive clinical diagnosis of HIT must be followed by immediate cessation of all forms of heparin and initiation of alternate anticoagulation. Proper diagnosis and treatment can be difficult for medical and surgical clinicians, with implications for morbidity, mortality, patient safety, and cost. The Objective of this study was to assess the incidence and appropriateness of HIT testing at our institution before and after an educational session for clinicians. We hypothesized that our intervention would provide better quality care of patients with suspected HIT. Methods: First, a retrospective chart review was conducted for a 3-month period, in which we collected baseline patient and HIT-testing data. Next, an “in-service” type lecture was delivered on seven occasions to various hospitalist groups. Follow-up data for an additional 3-month period was collected after these sessions. Results: See Table. Conclusions: In this single-center study, our educational interventions were successful in reducing inappropriate HIT testing, and encouraging consultation with hematology colleagues. Future studies are needed to evaluate the utility of online teaching modules, electronic order sets,and applicability to other medical centers. [Table: see text]

Persistent natural acidification drives major distribution shifts in marine benthic ecosystems

Ocean acidification is receiving increasing attention because of its potential to affect marine ecosystems. Rare CO2 vents offer a unique opportunity to investigate the response of benthic ecosystems to acidification. However, the benthic habitats investigated so far are mainly found at very shallow water (less than or equal to 5 m depth) and therefore are not representative of the broad range of continental shelf habitats. Here, we show that a decrease from pH 8.1 to 7.9 observed in a CO2 vent system at 40 m depth leads to a dramatic shift in highly diverse and structurally complex habitats. Forests of the kelp Laminaria rodriguezii usually found at larger depths (greater than 65 m) replace the otherwise dominant habitats (i.e. coralligenous outcrops and rhodolith beds), which are mainly characterized by calcifying organisms. Only the aragonite-calcifying algae are able to survive in acidified waters, while high-magnesium-calcite organisms are almost completely absent. Although a long-term survey of the venting area would be necessary to fully understand the effects of the variability of pH and other carbonate parameters over the structure and functioning of the investigated mesophotic habitats, our results suggest that in addition of significant changes at species level, moderate ocean acidification may entail major shifts in the distribution and dominance of key benthic ecosystems at regional scale, which could have broad ecological and socio-economic implications.

Global regime shift dynamics of catastrophic sea urchin overgrazing

A pronounced, widespread and persistent regime shift among marine ecosystems is observable on temperate rocky reefs as a result of sea urchin overgrazing. Here, we empirically define regime-shift dynamics for this grazing system which transitions between productive macroalgal beds and impoverished urchin barrens. Catastrophic in nature, urchin overgrazing in a well-studied Australian system demonstrates a discontinuous regime shift, which is of particular management concern as recovery of desirable macroalgal beds requires reducing grazers to well below the initial threshold of overgrazing. Generality of this regime-shift dynamic is explored across 13 rocky reef systems (spanning 11 different regions from both hemispheres) by compiling available survey data (totalling 10 901 quadrats surveyed in situ) plus experimental regime-shift responses (observed during a total of 57 in situ manipulations). The emergent and globally coherent pattern shows urchin grazing to cause a discontinuous ‘catastrophic’ regime shift, with hysteresis effect of approximately one order of magnitude in urchin biomass between critical thresholds of overgrazing and recovery. Different life-history traits appear to create asymmetry in the pace of overgrazing versus recovery. Once shifted, strong feedback mechanisms provide resilience for each alternative state thus defining the catastrophic nature of this regime shift. Importantly, human-derived stressors can act to erode resilience of desirable macroalgal beds while strengthening resilience of urchin barrens, thus exacerbating the risk, spatial extent and irreversibility of an unwanted regime shift for marine ecosystems.

Application of a modified Neff classification to patients with uncomplicated diverticulitis

AIM

Severity of acute diverticulitis (AD) has traditionally been assessed using the Hinchey classification; however, this classification is predominantly a surgical one. The Neff classification provides an alternative classification based on CT findings. The aim of this study was to evaluate a modification of the Neff classification to select patients presenting with early-stage AD to receive outpatient management.

METHOD

All patients with AD, presenting to a single unit, were prospectively studied. All patients underwent emergency abdominal CT and were assigned a Neff stage, including a modification (mNeff) to Neff Stage I. The Neff stages used were: Stage 0, uncomplicated diverticulitis; Diverticula, thickening of the wall, increased density of the pericolic fat; Stage I, locally complicated (our modification included substages Ia (localized pneumoperitoneum in the form of air bubbles) and Ib (local abscess); Stage II, complicated with pelvic abscess; Stage III, complicated with distant abscess; and Stage IV, complicated with other distant complications. Patients who presented with Stage 0 or Stage Ia were selectively managed as outpatients. Patients with comorbidity or the presence of the systemic inflammatory response syndrome (SIRS) were excluded.

RESULTS

Between February 2010 and January 2013, 205 patients (mean age 59 years; age range 25-90 years) presented with AD. One-hundred and forty-nine met the radiological criteria for potential outpatient treatment. After applying the exclusion criteria, 68 were eventually assigned to an outpatient programme. Sixty-four (94%) successfully completed the outpatient treatment protocol; four patients were readmitted.

CONCLUSION

Our mNeff classification allowed selected patients with AD to be successfully managed in an outpatient programme.

Splenic morphological changes are accompanied by altered baseline immunity in a mouse model of sickle-cell disease

Although functional asplenia from infarctions may be a major contributor to increased infectious mortality in sickle-cell disease (SCD), this relationship has not been fully defined. We used the transgenic Berkeley SCD mouse to define blood and splenic immunophenotypic differences in this model compared with C57BL/6 and hemizygous controls. In the serum of SCD mice, we found increased IgG2a and suppressed IgM, IgG2b, and IgA levels. Serum IL-6 levels in SCD mice were elevated, whereas IL-1α, CXCL10, and CCL5 levels were decreased. The blood of SCD mice had higher white blood cell counts, with an increased percentage of lymphocytes and decreases in other leukocytes. Immunophenotyping of lymphocytes revealed higher percentages of CD8(+) and T-regulatory cells and lower percentages of B cells. SCD mouse spleens exhibited histological disorganization, with reduction of defined lymphoid follicles and expansion of red pulp, a greater than fourfold increase in splenic mononuclear cells, marked expansion of the nucleated red blood cell fraction, and B-cell and CD8(+) T-cell lymphopenia. Within the splenic B-cell population, there was a significant decrease in B-1a B cells, with a corresponding decrease in IgA secreting plasma cells in the gut. Confocal microscopy of spleens demonstrated complete disruption of the normal lymphofollicular structure in the white pulp of SCD mice without distinct B, T, and marginal zones. Our findings suggest that altered SCD splenic morphological characteristics result in an impaired systemic immune response.

Calcification in biliary hamartomatosis

We report a case of histologically confirmed biliary hamartomatosis with calcifications studied by CT.

An 18-year-old woman with Kabuki syndrome, immunoglobulin deficiency and granulomatous lymphocytic interstitial lung disease

Granulomatous lymphocytic interstitial lung disease, or GLILD, is an uncommon condition associated with common variable immunodeficiency (CVID). We present an interesting case of an 18-year-old woman with Kabuki syndrome and CVID who was seen in our clinic for an abnormal chest CT scan. She was subsequently diagnosed with GLILD. There are no established guidelines for the treatment of GLILD in CVID. Immune globulin replacement therapy is the main treatment for CVID and higher doses of intravenous immunoglobulin (IVIG) may prevent the progression of chronic lung disease. Patients with CVID and GLILD are at increased risk for malignancy and their prognosis is worse compared to patients with CVID without GLILD.

Continuous solid-phase extraction and gas chromatography-mass spectrometry determination of pharmaceuticals and hormones in water samples

A semi-automatic flow-based method for the simultaneous determination of 9 pharmaceuticals and 3 hormones in water samples in a single analytical run is proposed. The analytes were retained on a solid-phase extraction sorbent column and 1 microL of the eluate analysed by gas chromatography in combination with electron impact ionization mass spectrometry in the SIM mode. The sorbent used, Oasis-HLB, provided near-quantitative recovery of all analytes. The proposed method was validated with quite good analytical results including low limits of detection (0.01-0.06 ng L(-1) for 100 mL of water) and good linearity (r2>0.993) throughout the studied concentration ranges. The method provided good accuracy (recoveries of 85-103%) and precision (between- and within-day RSD values less than 7%) in the determination of the pharmaceuticals and hormones in tap, river, pond, well, swimming pool and wastewater.

PIQA: pipeline for Illumina G1 genome analyzer data quality assessment

Summary: PIQA is a quality analysis pipeline designed to examine genomic reads produced by Next Generation Sequencing technology (Illumina G1 Genome Analyzer). A short statistical summary, as well as tile-by-tile and cycle-by-cycle graphical representation of clusters density, quality scores and nucleotide frequencies allow easy identification of various technical problems including defective tiles, mistakes in sample/library preparations and abnormalities in the frequencies of appearance of sequenced genomic reads. PIQA is written in the R statistical programming language and is compatible with bustard, fastq and scarf Illumina G1 Genome Analyzer data formats.

Availability: The PIQA pipeline, installation instructions and examples are available at the supplementary web site (http://bioinfo.uh.edu/PIQA).

Contact:yfofanov@bioinfo.uh.edu

Simultaneous multidetermination of residues of pesticides and polycyclic aromatic hydrocarbons in olive and olive-pomace oils by gas chromatography/tandem mass spectrometry

A multiresidue method for determining major pesticides and polycyclic aromatic hydrocarbons (PAHs) in olive oils in a single injection by use of gas chromatography/tandem mass spectrometry (GC-MS/MS) is proposed. Samples are previously extracted with an acetonitrile/n-hexane mixture and cleaned up by gel permeation chromatography. Electron ionization and chemical ionization allow pesticides and PAHs to be determined in a single analysis. The precision obtained was quite satisfactory (relative standard deviations ranged from 3 to 7.8%), and so were recoveries (84-110%). The linear relation was observed from 1 to 500 microg/kg for pesticides and 0.3 to 200 microg/kg for PAHs; also, the determination coefficient, R(2), was better than 0.995 in all instances. The proposed method was applied to the routine analysis of PAH and pesticide residues in virgin and refined olive oil and olive-pomace oil samples.

Extreme lymphoplasmacytosis and hepatic failure associated with sulfasalazine hypersensitivity reaction and a concurrent EBV infection?case report and review of the literature

We present an unusual case of a patient with extreme lymphoplasmacytosis and hepatic failure in association with a reaction to sulfasalazine and a concurrent Epstein-Barr virus (EBV) infection. Sulfa drugs can cause a wide range of allergic and hypersensitivity reactions and occasionally can lead to a fulminant illness. In the case under discussion the patient had hepatotoxicity, skin rash, fever, and peripheral blood atypical lymphocytosis. Initial impressions suggested the possibility of a malignant lymphoproliferative disorder. Flow cytometry of peripheral blood and a bone marrow biopsy provided clear evidence for a reactive, polyclonal process as opposed to a malignant disorder. Cessation of the offending drug and administration of steroids led to dramatic improvement. This case illustrates that drug hypersensitivity reactions can be manifested by an extreme lymphocytoid leukemoid reaction.

Continuous solid-phase extraction and gas chromatographic determination of organophosphorus pesticides in natural and drinking waters

A simple, rapid continuous-flow solid-phase extraction method with gas chromatographic detection for the determination of organophosphorus pesticides is proposed. The continuous system consists of an adsorbent column where pesticides are preconcentrated and subsequently eluted with ethyl acetate. Various sorbent materials were assayed of which RP-C18 was found to provide the best results, with a sorption efficiency close to 100%. A comparative study of the determination of pesticides in aqueous samples was conducted using gas chromatography with nitrogen-phosphorus (NPD) and flame ionization (FID) detection. The detection limits of the method for 10 ml of sample were between 50-130 ng/l and 4.5-1 1.7 microg/l with NPD and FID detection, respectively. The method was used to determine organophosphorus pesticides in river, pond, well and tap waters, all with good precision (2.9-4.3%) and recoveries ranging from 93.8 to 104.5%.

Both duration and degree of hypercalcemia influence the reduced parathyroid hormone response to hypocalcemia after hypercalcemia

The stimulation of parathyroid hormone (PTH) secretion by hypocalcemia is reduced when hypocalcemia is preceded by hypercalcemia. The present study investigates whether the duration and degree of hypercalcemia influence the reduced PTH response to hypocalcemia after hypercalcemia. In addition, the implication of the arachidonic acid (AA) signaling pathway in this effect is evaluated. The PTH response to hypocalcemia has been studied in a control group and in four groups of rabbits subjected to hypercalcemia for different periods of time (between 30 and 120 min) and at two levels of hypercalcemia (1 x 9 and 2 x 1 mM). AA levels have been measured in parathyroid glands from rabbits subjected to hyper- and hypocalcemia. When compared with controls, rabbits that had been hypercalcemic (2 x 1 mM) for 2 h showed a markedly attenuated PTH response to hypocalcemia (50% of normal PTHmax), rabbits that had been in hypercalcemia (2 x 1 mM) for 75 min had an intermediate PTH response to hypocalcemia (70% of normal PTHmax) and rabbits that had been subjected to either 30 min hypercalcemia of 2 x 1 mM or 120 min hypercalcemia of 1 x 9 mM had a normal PTH response to hypocalcemia. AA levels increased in hypercalcemia and decreased in hypocalcemia; however, no differences were observed at either calcium level in short-time (30 min) versus long-time (120 min) hypercalcemia. In conclusion, the attenuated PTH response to hypocalcemia after hypercalcemia is dependent on both the period of time that the parathyroid glands have been exposed to hypercalcemia and the degree of hypercalcemia. In addition, this reduced PTH response does not seem to be related to changes in the AA signaling pathway.

The photosynthetic capacity of the seagrass Posidonia oceanica: influence of nitrogen and light

Photosynthetic capacity of the seagrass Posidonia oceanica was determined in two contrasting nutrient zones along a bathymetric gradient. Photosynthetic capacity was two times higher in the relatively eutrophic zone compared to the highly oligotrophic zone. The same trend was observed in the chlorophyll a+b and tissue nitrogen content. Photosynthetic capacity and chlorophyll a+b decreased with irradiance in the oligotrophic zone while increased in the eutrophic zone. Tissue nitrogen content followed the same trend in the oligotrophic zone and did not present any trend in the eutrophic zone. Overall, this study has shown the importance of large scale sampling when assessing metabolic parameters such as photosynthetic capacity where large differences have been observed associated to the nutrient regime. According to our results, in oligotrophic zones nitrogen seems to govern photosynthetic capacity and there is a coherent pattern between nitrogen content, pigments and photosynthetic capacities. In eutrophic zones, light is the dominant regulator and there is a coherent pattern between light and photosynthetic capacities.

Pharmacokinetic behaviour of phenylglyoxal bis(guanylhydrazone) (PGBG) after intravenous administration in rabbits

Phenylglyoxal bis(guanylhydrazone) (PGBG) is a synthesized analogue of methylglyoxal bis(guanylhydrazone) (MGBG), which has demonstrated anti-parasitic activity in rabbits. The pharmacokinetic behaviour of PGBG after intravenous administration (10 mg/kg bodyweight) was studied in five rabbits. Plasma concentrations of PGBG were measured by high-performance liquid chromatography. Plasma PGBG concentrations decreased rapidly and were not detectable beyond 90 min after treatment. The mean [+/- standard deviation (SD)] volume of distribution at steady state (Vdss) was 2.19 +/- 0.47 l/kg and the mean plasma clearance value (Cl) was 29.99 +/- 3.98 ml/min kg. This drug is rapidly eliminated from the body in rabbits, having a short elimination half-life (0.93 h) and mean residence time (1.21 h).

Analytical potential of fullerene as adsorbent for organic and organometallic compounds from aqueous solutions

In this work, the analytical potential of C60 fullerene as a sorbent for organic and organometallic compounds from aqueous solutions was studied for the first time. Fullerene adsorbs many types of organic substances (e.g., N-methylcarbamates, phenols, polycyclic aromatic hydrocarbons, amines) with efficiencies that depend on the nature of the compound concerned and never exceed 60%. Conventional sorbents such as XAD-2 or polyurethane foam are more efficient than C60 for this purpose. Organometallic compounds (viz. metalocenes and organoleads) are quantitatively adsorbed on C60 via the formation of neutral complexes or chelates; the adsorption constant is dramatically increased by the use of classical reagents such as pyrrolidinedithiocarbamate or diethyldithiocarbamate. A complementary comparative study on the adsorption of organometallic complexes on RP-C18 and silica gel 100, among others, showed C60 to be superior as sorbent. All experiments in this work were carried out by using continuous flow configurations and gas chromatography-atomic absorption spectrometry techniques.

Cleaning of liquid radioactive wastes using natural zeolites

Natural zeolite, clinoptilolite, was used to eliminate liquid radioactive wastes (LRW) 137Cs and 90Sr. The influence of several factors (pH of solution, grain size of the zeolite, etc.) on the process effectivity was studied. It was shown that clinoptilolite is an effective filter of the nuclides above.

Involvement of the L-arginine/nitric oxide neural pathway in non-adrenergic, non-cholinergic relaxation of the bovine oesophageal groove

1. The distribution and localization of nitric oxide synthase (NOS) immunoreactivity and nicotinamide adenine dinucleotide phosphate diaphorase (NADPH-d) activity in the bovine oesophageal groove were investigated by immnunohistochemical and histochemical staining techniques. Functional in vitro studies were performed to correlate the presence of NOS-immunoreactivity (IR) and NADPH-d staining with smooth muscle relaxations involving the L-arginine/nitric oxide neural pathway in the bovine oesophageal groove activity. 2. NOS-IR and NADPH-d were expressed in nerve cell bodies of the myenteric, submucosal and intramuscular ganglia, and in nerve fibres distributed around blood vessels and throughout the different muscular layers of the bovine oesophageal groove. 3. In oesophageal groove strips treated with guanethidine (10(-5) M) and atropine (10(-7) M) to block noradrenergic neurotransmission and muscarinic receptors, respectively, electrical field stimulation (EFS, 0.5-32 Hz, 1 ms duration, 20-s trains) induced relaxations which were practically abolished by tetrodotoxin (TTX, 10(-6) M). 4. Incubation with an inhibitor of nitric oxide synthesis, NG-nitro-L-arginine (L-NOARG, 3 x 10(-5) M), significantly inhibited relaxations induced by EFS. This inhibition was partially reversed by L-arginine (L-arg, 5 x 10(-3) M). D-NOARG (3 x 10(-5) M) had no effect on EFS-induced relaxations. 5. NO added as an acidified solution of NaNO2 (10(-6) - 10(-3) M) and S-nitroso-L-cysteine (10(-7) - 10(-4) M) caused concentration-dependent relaxations of the bovine oesophageal groove. These relaxations were unaffected by L-NOARG (3 x 10(-5) M). 6. The presence of NO-synthesizing enzyme in nerves and ganglia, and the pharmacological evidence for NO-mediated smooth muscle relaxation suggested that the L-arg/NO neuronal pathway is involved in the inhibitory neurotransmission of the bovine oesophageal groove.

CD5+ low-grade marginal zone B-cell lymphomas with localized presentation

Marginal zone B-cell lymphomas (MZBCLs) are low-grade lymphomas that characteristically lack CD5 expression. However, rare cases of MZBCL have been described in which the lymphomatous B cells coexpress CD5 (CD5+ MZBCL). In 7 of 9 reported CD5+ MZBCLs, there was evidence of widespread disease. We report four additional cases of CD5+ MZBCL. Three cases were low-grade B-cell lymphomas of mucosa-associated lymphoid tissue (MALT) involving the lungs, the conjunctiva (bilateral), and the uterus. The remaining case represented a monocytoid B-cell lymphoma involving a posterior cervical lymph node. Southern blot hybridization did not show rearrangements of bc11 or bc12 in the three cases analyzed. All four patients had localized disease and normal peripheral blood counts. Staging of bone marrow biopsies from three patients did not show evidence of bone marrow involvement. The remaining patient had bilateral conjunctival lesions that were present for 15 years without progression. These four additional cases of CD5+ MZBCL show that this group of low-grade B-cell lymphomas occasionally may exhibit an atypical phenotype. Furthermore, in this study, the CD5+ MZBCLs were clinically localized at presentation, in contrast to most other reported cases, which have had dissemination to bone marrow or peripheral blood.

Plasma cell granuloma of the oral cavity: a report of two cases and review of the literature

We report two rare cases of plasma cell granuloma arising in the extragingival oral cavity. These are tumorous proliferations composed predominantly of reactive plasma cells. Both patients presented with solitary mass lesions that were clinically suspicious for malignancy. One patient presented with a mass that grew slowly for 2 years and involved the lip; in the second patient, a mass developed in the buccal mucosa Histologically, both lesions were characterized by lobules of plasma cells separated by thick collagenous bands. A variable number of admixed lymphocytes and histiocytes was noted in both cases. In situ hybridization and immunostaining for kappa and lambda light chains revealed a polyclonal plasma cell population. In situ hybridization for Epstein-Barr virus failed to demonstrate evidence of viral expression in either case. Both patients are free of disease after 8-month and 12-month follow-ups. Although plasma cell granuloma in the oral cavity is rare, it is important to recognize this entity as a benign inflammatory lesion.

In vitro cytotoxicity of guanylhydrazones (MGBG and PGBG) on cultured Chinese hamster ovary cells

Guanylhydrazones, methylglyoxal bis(guanylhydrazone) (MGBG) and a new compound, phenylglyoxal bis(guanylhydrazone) (PGBG), interfering with polyamine biosynthesis have considerable potential for the use as antiparasitic and antitumor agents. The effect of these drugs on the cellular viability of Chinese hamster ovary cells was examined by in vitro neutral red assay. The time exposure and metabolic influence was studied. These compounds have a dose- and time-dependent cytotoxicity. The IC50 values were of 597.22 micrograms/ml and 1.77 micrograms/ml for MGBG after 3 and 24 h of incubation, respectively, and 380.50 micrograms/ml for PGBG after 24 h of incubation. The PGBG treatment during 3 h had no cytotoxic effect when the concentrations were lower than 3000 micrograms/ml. With the cytotoxicity assay used, we observed that the presence of S9 in cultured medium did not influence the cytotoxicity of these compounds.

Fine-needle aspiration diagnosis of enterogenous cyst of the orbit: a case report

Enterogenous cyst is a benign lesion derived from misplaced endodermal epithelium. We report the aspiration cytology findings of an orbital cyst from a 32-year-old woman. The smears contain benign-appearing cuboidal glandular cells with focal mucinous features. Carcinoembryonic antigen level in the cyst fluid was markedly elevated. These findings are consistent with recurrence of the enterogenous cyst initially diagnosed 7 years earlier.

Acetylcholinesterase histochemistry and functional characterization of the muscarinic receptor mediating the contraction of the bovine oesophageal groove

1. By using acetylcholinesterase (AChE) histochemistry and in vitro isometric techniques, we have studied the presence and distribution of AChE-positive nerves, as well as the effects of muscarinic cholinoceptor agonists and selective antagonists, in the bovine oesophageal groove. 2. AChE-positive nerves and cells were distributed widely on the oesophageal groove floor. These fibres originated from adventitial ganglia containing bodies with high AChE activity and were shown grouped as large adventitial nerve bundles. 3. Both in the presence and absence of physostigmine, acetylcholine (ACh) induced concentration dependent contractions of bovine oesophageal groove strips. The rank order of the pD2 values for muscarinic agonists was: oxotremorine-M (7.37) = carbachol (7.14) > acetylcholine plus physostigmine (6.46) > bethanechol (5.42) > McN-A-343 (4.45) > acetylcholine (4.06). 4. Hexamethonium (10(-6)-10(-4) M), a nicotine receptor blocker, did not affect the carbachol concentration-response curve, which was significantly inhibited by the muscarinic antagonist, atropine (10(-9)-10(-8) M). 5. The preferential muscarinic antagonists pirenzepine (M1), 11-(2(diethyl-amino)methyl)-1- piperidinylacetyl)-5,-11-dihydro-6H-pyrido(2,3-b)-(1,4)-benzodiaze pine-6-one (AF-DX 116) and methoctramine (M2), 4-diphenyl-acetoxy-N-methyl-piperidine methiodide (4-DAMP) and p-fluorohexahydrosiladiphenidol (p-F-HHSiD) (M3) evoked rightwards displacements in a parallel manner of the carbachol control curve, and there was no decrease of the maximum response with the highest concentration of antagonist utilized. The muscarinic antagonist affinities, expressed in terms of pA2, values, were: atropine (9.51) = 4-DAMP (9.32) > p-F-HHSiD (7.78) > tropicamide (7.40) > pirenzepine (6.91) = AF-DX 116 (6.88) = methoctramine (6.71). This muscarinic antagonist profile suggests that an M3 receptor is involved in the carbachol induced contraction. 6. The present results suggest that a rich network of AChE- positive fibres is present in the oesophageal groove floor, where they form a nerve trunk and thinner branches accompanying blood vessels and sometimes around ganglia. The muscarinic cholinergic contraction of the bovine oesophageal groove seems to be mediated via activation of an M3 postsynaptic muscarinic receptor.