Evaluation and management of hemoptysis in infants and children. A report of nine cases

Hemoptysis is an occasional complication of adult pulmonary disease and is rare in children. The most common causes in adults are infection, bronchiectasis, pulmonary neoplasm, cystic fibrosis, pulmonary infarct, and trauma; in children the most common causes are infection and congenital abnormalities of the cardiopulmonary vasculature. Nine cases of hemoptysis in seven infants and two children will be presented. Two cases were fatal, thus illustrating the importance of rapid and definitive therapy early in the course. One of the fatal cases is the first case report in the otolaryngological literature of fatal hemoptysis in the newborn as a result of vascular anomalies associated with an absent left pulmonary artery. Eight cases of various causes, including small vessel vascular abnormality, trauma, recurrent pulmonary infection, and laryngotracheal papilloma, are discussed. The literature is reviewed, embryology is discussed, and a mechanism of death is theorized for the patient with the congenital vessel anomaly. Management considerations for hemoptysis in infants and children are discussed.

Impact of mapping technology on procedural characteristics during radiofrequency or cryoballoon pulmonary vein isolation for atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction: Cryoballoon ablation (CBA) is often associated with shorter procedure times along with tradeoffs such as increased fluoroscopy use compared to radiofrequency (RF) ablation of atrial fibrillation (AF), however the impact of mapping technology on these characteristics is not fully understood.

Purpose

To assess the effect of mapping technology on trends in fluoroscopy use and procedure times in AF pulmonary vein isolation (PVI) procedures with an RF or CBA catheter.

Methods

Acute procedure data from 210 de novo AF cases using a 3D mapping system was prospectively collected from 48 centers in eight countries. Choice of technology was left to physician discretion; a PVI only ablation strategy was utilized in all cases. Procedure data such as total procedure and fluoroscopy times from cases using either an RF or CBA catheter with either a grid-style mapping catheter (HD Grid) or circular mapping catheter (CMC) were compared.

Results

Of the 210 cases, RF ablation was used in 103 (49%), and CBA used in 107 (51%). In RF cases, a relatively even split between CMC and HD Grid use was observed (n=46, 45% vs. n=57, 55%), while a CMC was used in 100% of CBA cases (Figure 1). Across all cases, fluoroscopy and procedure times were significantly shorter when HD Grid was used (7.4±26.7 minutes; 108.2±46.3 minutes) compared to a CMC (20.4±17.6 minutes; 133.7±62.7) (p<0.001; p=0.003). A similar trend was also observed in RF cases using HD Grid (7.4±26.7 minutes; 108.2±46.3 minutes) compared to a CMC (17.9±12.3 minutes; 175.1±50.5) (p=0.01; p<0.001). Fluoroscopy times in RF cases with HD Grid (7.4±26.7 minutes) were significantly shorter compared to CBA cases with a CMC (21.5±19.4 minutes) (p<0.001), while procedure times were similar (108.2±46.3 minutes; 116.0±59.2 minutes, p=0.20).

Conclusion(s)

Use of HD Grid resulted in significantly shorter procedure and fluoroscopy times compared to a CMC across all cases, including those using RF ablation. Fluoroscopy times were also significantly shorter in RF cases using HD Grid compared to CBA cases using a CMC, with similar procedure times. These observations suggest that use of HD Grid may better enable safer and more efficient PVI, specifically when employing RF ablation, in addition to safer and equally efficient RF PVI compared to CBA with a CMC. Further study in in a larger, randomized cohort may be necessary.

Anthelmintic Effect of Date Palm Fruit: A Systematic Review

Soil-transmitted helminth infections constitute a global affliction affecting people and livestock, resulting in a significant disease burden and economic losses in endemic regions. However, control has not been entirely successful and the problem is compounded by the development of resistance to available chemotherapy. Novel alternative compounds are urgently needed, encouraging the screening of largely plant-based sources for anthelmintic effects. Date palm fruit (Phoenix dactylifera) is a popular and nutritious food much coveted for its nutraceutical effect. There are convincing reports documenting the antibacterial, antiviral and antifungal effects of date palm fruit but evidence for any potential anthelmintic effect remains unclear. Here we conducted a systematic review of the published information through an electronic search using six scientific databases; SCOPUS, MEDLINE COMPLETE, OVID, EMBASE, WEB OF SCIENCE and CINAHL COMPLETE. Out of 58 studies that were initially identified only 2 manuscripts fitted our inclusion criteria. The first article reported on the anthelmintic effect of date palm fruit against the rodent nematodes Trichuris muris and Angiostrongylus cantonensis in vitro and in vivo while the second article was based only on in vivo assessment (with coconut) of the effect on the rodent cestode Hymenolepis microstoma. Our review revealed limited anecdotal reports of the anthelmintic effect of date palm fruit against parasitic helminths, however, the majority of reports were inconclusive due to mixed results, limited focus on date palm fruit and lack of any statistical analyses. Rigorous, systematic and fully controlled studies focusing on date palm fruit are needed to validate the anecdotal evidence.

An NFATc1/SMAD3/cJUN Complex Restricted to SMAD4-Deficient Pancreatic Cancer Guides Rational Therapies

BACKGROUND & AIMS

The highly heterogeneous cellular and molecular makeup of pancreatic ductal adenocarcinoma (PDAC) not only fosters exceptionally aggressive tumor biology, but contradicts the current concept of one-size-fits-all therapeutic strategies to combat PDAC. Therefore, we aimed to exploit the tumor biological implication and therapeutic vulnerabilities of a clinically relevant molecular PDAC subgroup characterized by SMAD4 deficiency and high expression of the nuclear factor of activated T cells (SMAD4-/-/NFATc1High).

METHODS

Transcriptomic and clinical data were analyzed to determine the prognostic relevance of SMAD4-/-/NFATc1High cancers. In vitro and in vivo oncogenic transcription factor complex formation was studied by immunoprecipitation, proximity ligation assays, and validated cross model and species. The impact of SMAD4 status on therapeutically targeting canonical KRAS signaling was mechanistically deciphered and corroborated by genome-wide gene expression analysis and genetic perturbation experiments, respectively. Validation of a novel tailored therapeutic option was conducted in patient-derived organoids and cells and transgenic as well as orthotopic PDAC models.

RESULTS

Our findings determined the tumor biology of an aggressive and chemotherapy-resistant SMAD4-/-/NFATc1High subgroup. Mechanistically, we identify SMAD4 deficiency as a molecular prerequisite for the formation of an oncogenic NFATc1/SMAD3/cJUN transcription factor complex, which drives the expression of RRM1/2. RRM1/2 replenishes nucleoside pools that directly compete with metabolized gemcitabine for DNA strand incorporation. Disassembly of the NFATc1/SMAD3/cJUN complex by mitogen-activated protein kinase signaling inhibition normalizes RRM1/2 expression and synergizes with gemcitabine treatment in vivo to reduce the proliferative index.

CONCLUSIONS

Our results suggest that PDAC characterized by SMAD4 deficiency and oncogenic NFATc1/SMAD3/cJUN complex formation exposes sensitivity to a mitogen-activated protein kinase signaling inhibition and gemcitabine combination therapy.

ATRT-07. DEFINING LOST AND GAINED TRANSCRIPTIONAL REGULATORY NETWORKS IN ATYPICAL TERATOID RHABDOID TUMOR

Atypical teratoid rhabdoid tumor (ATRT) is a central nervous system cancer of infancy and early childhood that may occur anywhere along the neuraxis and is associated with a high rate of mortality. While contemporary multimodal therapeutic approaches have significantly improved overall survival, targeted therapy remains elusive, and treatment is often associated with significant morbidity. ATRT is unique in its genomic stability, with the only recurrent genetic abnormality being bi-allelic loss of the SMARCB1 gene, which encodes a core subunit of the BAF chromatin remodeling complex. The epigenetic mechanisms by which SMARCB1 loss leads to tumorigenesis are not yet well-defined and addressing this gap in understanding is necessary for creating efficacious, targeted therapeutics. To better understand the epigenetic features gained and lost in ATRT, we re-expressed SMARCB1 in a library of patient-derived and established ATRT cell lines of multiple molecular subtypes. SMARCB1 restoration significantly reduced or eliminated the proliferative and clonogenic capacity of each cell line. We performed assay for transposase-accessible chromatin with high-throughput sequencing (ATAC-Seq) and RNA sequencing (RNA-Seq) to define putative transcriptional regulatory networks that are gained and lost in ATRT. SMARCB1 restoration was associated with global changes in chromatin openness consistent with the creation of new regulatory elements throughout the genome, and these were associated with induction of a diverse developmental transcriptional signature. Motif enrichment analysis of regions with increased accessibility defined a small but consistent number of centrally enriched transcription factor motifs across cell lines indicative of putative pioneer factors whose functions may be lost in ATRT. Pertinent chromatin immunoprecipitation with sequencing (ChIP-Seq) data will be discussed in the context of lost and gained transcriptional regulatory networks in ATRT and normal cellular development.

Global preferences in mapping technology and its impact on fluoroscopy and procedure times during catheter ablation of atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Choice in mapping technology may play a critical role in reducing fluoroscopy and procedure times during atrial fibrillation (AF) ablation, however this relationship is not well studied.

Purpose

To assess the impact of mapping technology on trends in fluoroscopy use and procedure times in AF ablation procedures.

Methods

Acute procedure data from 525 AF cases was prospectively collected from 68 centers in nine countries. Choice of technology and ablation strategy, including PVI and substrate modification, were left to physician discretion. Procedure data such as total procedure and fluoroscopy times from cases using a grid-style mapping catheter (HD Grid) were compared to those using a circular mapping catheter (CMC).

Results

Of the 525 cases, HD Grid was used in 230 (44%), and CMC was used in 295 (56%). HD Grid was routinely used for both de novo and redo procedures while CMC was used predominantly for de novo procedures (Table 1). Similar procedure times were noted in redo PAF and redo PersAF procedures, while significantly shorter procedure times were observed for the HD Grid group in both de novo PAF and PersAF (113.9±48.8 vs. 125.9±56.3 minutes, p=0.04; and 142.8±53.2 vs. 169.8±52.2 minutes, p=0.001).

Overall fluoroscopy times were significantly shorter using HD Grid compared to a CMC (9.0±19.6 minutes vs. 19.8±16.4 minutes, p<0.001), including significantly shorter fluoroscopy times in de novo PAF, de novo PersAF, and redo PAF (Table 1). There were 155 cases completed without fluoroscopy use; zero fluoroscopy cases accounted for 50% (114/230) and 14% (41/295) of total cases completed with HD Grid and a CMC, respectively (p<0.001).

Conclusion(s)

Use of HD Grid was observed in a significantly higher portion of zero fluoroscopy cases and resulted in significantly shorter procedure and fluoroscopy times in both de novo PAF and de novo PersAF and significantly shorter fluoroscopy times in redo PAF. These observations suggest that use of HD Grid may better enable faster and safer procedures in these specific AF types compared to CMCs, although further analysis in a larger, randomized cohort may be warranted.