Detection of clinically relevant carbapenemase encoding genes in carbapenem-resistant Enterobacter cloacae complex and Klebsiella pneumoniae isolated from farmed freshwater fish

AIMS

The present study was aimed to detect clinically relevant carbapenemase encoding genes in carbapenem-resistant Enterobacter cloacae complex (CR-ECC), Klebsiella pneumoniae (CR-KP), and Serratia plymuthica (CR-SP) isolated from farmed freshwater fish.

METHODS AND RESULTS

Out of 243 spatially diverse freshwater fish samples analysed, 5.3% were contaminated with CR-ECC, 1.6% with CR-KP, and 0.4% with CR-SP. The CR-ECC was further identified as E. asburiae (38.5%), E. mori (23.1%), E. cloacae (15.4%), E. hormaechei (15.4%), and E. kobei (7.7%) by 16S rRNA gene sequencing. The CR-ECC were resistant to carbapenems and cefoxitin, whereas CR-KP and CR-SP were multi-drug resistant (MDR). The CR-ECC harboured the carbapenemase gene blaIMI alone or in combination with blaTEM, blaEBC, blaCIT, blaACC, and tet(E). Whereas, CR-KP harboured carbapenemase gene, blaNDM-5 along with blaOXA-48, blaSHV, blaOXA-1, blaCTX-M-15, tet(A), sul1, and qnrB. No carbapenemase-encoding genes were detected in CR-SP. The MLST analysis showed that CR-KP belonged to ST231 and ST1561 lineages, while CR-ECC did not show exact match with any reported STs. The plasmid replicons predominantly detected were IncF and IncI1. Broth mating assays of CR-KP and CR-ECC with recipient Escherichia coli J53 indicated that blaNDM-5 was transferable but not blaIMI.

CONCLUSION

This study highlights the low-level contamination of carbapenem-resistant Enterobacterales (CRE) harbouring clinically relevant carbapenemase-encoding genes in farmed freshwater fish from India. The CR-ECC of fish origin did not show the potential to spread carbapenem resistance.

Molecular characterization of carbapenem resistant E. coli of fish origin reveals the dissemination of NDM-5 in freshwater aquaculture environment by the high risk clone ST167 and ST361

Aquatic environment can act as reservoir and disseminator of antimicrobial resistance and resistant pathogens. Novel high-risk carbapenem resistant E. coli (CREC) are continuously emerging worldwide; however, the occurrence of CREC in freshwater aquaculture environment is largely unexplored. To fill this gap, large scale sampling of freshwater pond sites and retail fish markets was done between Oct 2020 and Oct 2021 to investigate the CREC contamination in fish. The frequency of CREC contamination in the freshwater fish was 6.99% (95% CI: 3.78-10.20%). All the isolates were MDR and harbored carbapenemase encoding gene, bla_NDM-5 along with other antimicrobial resistance genes (ARGs), bla_TEM (64.7%), bla_CTX-M-15 (35.3%), bla_OXA-1 (5.9%), tet(A) (100%), sul1 (94.1%), qnrS (82.3%), cat1 (35.3%), and cat2 (23.5%). The isolates belonged to phylogroup C and showed low virulence gene profile. ERIC-PCR grouped the isolates into five clusters (I-V). The isolates of clusters I, II, and III were identified as ST167 (76.4%) and of cluster IV as ST361 (17.6%). This is the first report documenting the contamination of NDM-5 producing E. coli ST167 and ST361 of clinical/livestock lineage in freshwater fish from India. The bla_NDM-5 was significantly associated with ARGs, tet(A), and sul1; and plasmid replicons, IncF, IncI1, and IncP, signifying the presence of bla_NDM-5 and associated ARGs on these transferable plasmids. These findings were validated by the successful conjugal transfer of bla_NDM-5 and associated ARGs into non-CREC strain (J53). Our study highlights the ability of CREC to disseminate antimicrobial resistance which has health implications and environmental concerns.

Impact of adaptive natural killer cells, KLRC2 genotype and cytomegalovirus reactivation on late mortality in patients with severe COVID-19 lung disease

Objective

SARS-CoV-2 infection results in severe lung disease in up to 50% of hospitalised patients. The aetiopathogenesis in a subset of such patients, who continue to have progressive pulmonary disease following virus clearance, remains unexplored.

Methods

We investigated the role of NKG2C⁺/NKG2A^- adaptive natural killer (ANK) cells, KLRC2 genotype and cytomegalovirus (CMV) reactivation in 22 such patients.

Results

The median duration of virus positivity was 23 days, and the median duration of hospitalisation was 48 days. The overall survival at 60 days in this group was 50%. Older age and comorbidities impacted survival negatively. CMV viraemia was documented in 11 patients, with a survival of 25% vs 80% in those without viraemia with viral load correlating with mortality. Both NK and T cells were markedly depressed in all patients at day 15. However, only persistently low ANK cells at 30 days along with an inversely high NKG2C^-/NKG2A⁺ inhibitory NK cells significantly correlated with high CMV viraemia and mortality, irrespective of KLRC2 genotype. However, day 30 ANK cells were significantly lower in the KLRC2 deletion group. The release of IFN-γ and perforin was severely compromised in all patients at day +15, with significant improvement in the survivors at day +30, but not in those with adverse outcome.

Conclusion

Patients with progressive lung disease even after negative SARS-CoV-2 status, with persistently reduced and functionally compromised ANK cells, are more likely to have CMV reactivation and an adverse outcome, independent of KLRC2 genotype.

Early and Sustained Expansion of Adaptive Natural Killer Cells Following Haploidentical Transplantation and CTLA4Ig-Primed Donor Lymphocyte Infusions Dissociate Graft-versus-Leukemia and Graft-versus-Host Effects

BACKGROUND

Adaptive or memory natural killer (NK) cells with epigenetic imprints similar to memory T cells have been shown to develop in response to cytomegalovirus (CMV) infection with upregulation of activating receptor NKG2C. These cells have been shown to possess strong anti-tumour efficacy both in-vitro as well as in-vivo.

OBJECTIVES

To determine if reconstitution of adaptive NK cells (CD56^dimNKG2C⁺NKG2A^-) in patients with advanced leukemia undergoing haploidentical HCT had any impact on disease progression (DP).

STUDY DESIGN

The study cohort comprised of 60 patients with advanced acute leukemia, aged 2-65 years, receiving myeloablative PTCy based haploidentical transplantation from CMV seropositive donors, followed by CTLA4Ig-primed donor lymphocyte infusions (DLI). They were evaluated for the kinetics of reconstitution of adaptive NK cells, both phenotypic and functional, at days +30,+60, +90 and at regular intervals, to 3 years of follow-up, in relation to DP. Reconstitution of adaptive NK cells was compared with a retrospective cohort of patients in the same protocol receiving DLI without CTLA4Ig.

RESULTS

Non-relapse mortality, acute and chronic GVHD were 5.1%, 10.3% and 14.5%. DP was 17.5% at a median follow-up of 28 months. Adaptive NK cells were significantly higher in patients without DP at days+30, +60 and +90 (p = 0.0001), irrespective of CMV reactivation and remained elevated until 36 months post-HCT. These cells maintained their functional competence as measured by robust interferon-gamma production with higher expressions of KIR, NKG2D and CD57, without any increase in PD1 expression. Grafts from donors with higher adaptive NK cells were associated with a lower risk of DP (p = 0.0001). In multivariate analysis, adaptive NK cell recovery at day +90 had the most favorable impact on DP (HR-0.7). Tregs reconstituted briskly along with the adaptive NK cells and were sustained as well, without compromising the GVL effect. Comparison with a retrospective cohort receiving the same protocol with DLI without CTLA4Ig, showed a superior reconstitution of adaptive NK cells in those receiving CTLA4Ig-DLI (p < 0.0001).

CONCLUSION

Our study suggests that myeloablative transplantation from CMV seropositive haploidentical donors augmented with CTLA4Ig-primed DLI might favor early and sustained expansion of functionally competent adaptive NK cells irrespective of CMV reactivation, with a favorable outcome.

Prophylactic oseltamivir during major seasonal influenza H1N1 outbreak might reduce both H1N1 and associated pulmonary aspergillosis in children undergoing haploidentical transplantation

Following a major seasonal outbreak of H1N1 influenza in 2018 September, prophylactic oseltamivir for six months was initiated in children undergoing haploidentical HCT with regular monitoring for influenza and other respiratory virus infections. Influenza was not detected in 22 children undergoing prophylaxis, compared to 8 H1N1 infections in 21 adults without prophylaxis (P = .01). Four children on prophylaxis were detected to have other respiratory viruses, compared to 8 in those without prophylaxis. Invasive pulmonary aspergillosis (IPA) was observed only in association with H1N1 (4/8 with H1N1 vs 0/35 without H1N1, P = .001) and was thus lower in the prophylaxis group (P = .04). The overall incidence of episodes of respiratory illness and hospital stay were also lower in those on prophylaxis (P = .001). There were no untoward side effects associated with prophylactic oseltamivir. Prophylactic oseltamivir was safe and effective in prevention of H1N1 infection and subsequent IPA in children at-risk, early after haploidentical HCT.

CTLA4Ig in an Extended Schedule along with Sirolimus Improves Outcome with a Distinct Pattern of Immune Reconstitution Following Post-Transplantation Cyclophosphamide-Based Haploidentical Transplantation for Hemoglobinopathies

The major hindrances to the success of a haploidentical hematopoietic cell transplantation for hemoglobinopathies are graft failure, early post-transplant hemophagocytic syndrome (PTHPS), and graft-versus-host disease (GVHD). Following the successful incorporation of CTLA4Ig (abatacept) in post-transplantation cyclophosphamide-based haploidentical transplantation, we piloted this approach in 10 patients (aged 3 to 19 years), with thalassemia major (TM, n=5) and sickle cell disease (n = 5). Pretransplant immunosuppressive therapy (pTIST) was administered for 10 weeks. Conditioning was myeloablative. CTLA4Ig was administered every 2 weeks during pTIST and on days -1, +5, +20, and +35 and every 4 weeks thereafter for 6 months, along with sirolimus. A short course of low-dose dexamethasone was given from day +6 for 14 days. Nine patients engrafted at a median of 15 days, with 1 patient with TM dying of sepsis on day +19. None of the patients developed acute or chronic GVHD. All 9 patients are alive and disease free at a median follow-up of 28 months. Only 4 patients had cytomegalovirus reactivation. The pattern of immune reconstitution showed a prompt and sustained recovery of T cell subsets with memory phenotype, along with early and sustained increase of Tregs and NKG2C⁺ natural killer (NK) cells. This novel approach, targeting CD80 and CD86 on monocytes/macrophages, promoted engraftment and limited early-onset PTHPS and graft failure. The lack of GVHD and serious infections with this approach reflects an early recovery of Tregs, memory T cells, and persistence of NKG2C⁺ NK cells.

Abstract P6-05-06: Estrogen induced miR-489 acts as a negative feedback to confine uncontrolled estrogen signaling and cell proliferation in breast cancer

Estrogen induced miR-489 acts as a negative feedback to confine uncontrolled estrogen signaling and cell proliferation in breast cancer.

Mithil Soni1,2, Yogin Patel1,2,3, Ryann Shealy1, Hexin Chen1,2,4.

1Dept. of Biological Sciences, University of South Carolina, 2Center for colon cancer research, 3current location, National cancer institute, surgery branch, 4corrosponding author.

Approximately 75% of diagnosed breast cancer tumors are Estrogen receptor positive tumors and are associated with better prognosis due to response to hormonal therapies. However, around 40% of patients relapse after hormonal therapies. Identification of novel molecular targets is necessary to combat such resistant tumors. In the current study, using microarray, qRT-PCR, western blot, luciferase reporter assay and immunofluorescence, we found that miR-489 is an estrogen regulated miRNA that negatively regulates estrogen signaling. Depletion of miR-489 using Anti-miR-489 siRNA or CRISPR-Cas9 significantly increased estrogen induced proliferation, colony formation ability and stem like cell population. Loss of miR-489 also induced estrogen independent proliferation. Mechanistically we found that depletion of miR-489 enhanced nuclear localization of estrogen receptor while restoration of miR-489 increased cytosolic ER and inhibited estrogen induced transcription. Furthermore, we found that miR-489 depletion also increases estrogen independent growth through activation of MAPK and PI3K-AKT pathway. We also observed loss of miR-489 in tamoxifen resistance breast cancer cell line and found increased resistance to tamoxifen upon miR-489 inhibition while miR-489 restoration sensitized Tamoxifen resistant cell lines. Clinical analysis of estrogen receptor positive breast cancer patient showed that ER+ve breast cancers with low miR-489 expression represents aggressive cancers with significant reduction in survival time. In summary, these results indicate potential role of miR-489 as a biomarker to predict aggressiveness of ER+ve breast cancer and response to tamoxifen therapy and can potentially be used as a therapeutic agent to treat or sensitize tamoxifen resistant tumors.

Citation Format: Soni M, Patel Y, Shealy R, Chen H. Estrogen induced miR-489 acts as a negative feedback to confine uncontrolled estrogen signaling and cell proliferation in breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-05-06.

Safety assessment of a standardized cucumber extract (Q-Actin™): Oral repeat-dose toxicity and mutagenicity studies

Cucumus sativus (cucumber) is one of the most widely consumed fruit vegetables worldwide. Recent discovery of iminosugars in commonly consumed fruits and vegetables has promoted the interest in isolating these compounds and understanding the potential benefits to human health. The objective of the present study was to investigate the general toxicity and mutagenic effects of an aqueous extract of cucumber (Q-Actin), standardized to ≥1% (1-2%) ido-BR1 iminosugar. Single dose of Q-Actin was well tolerated without mortality at 2000 mg/kg body weight (bw) in Sprague Dawley rats. Oral (gavage) administration of Q-Actin up to 1000 mg/kg bw/day was well tolerated followed by repeated administration for a maximum period of 90 days in Sprague-Dawley rats. There were no treatment related changes in clinical observations, ophthalmic examinations, body weights and body weight gains or feed consumption, clinical chemistry and pathological changes compared to control. The mutagenicity as evaluated by Ames assay, in vitro chromosomal aberration test and in vivo micronucleus assay did not reveal any potential of Q-Actin to induce genotoxicity. The results showed that Q-Actin is well tolerated in general toxicity studies and did not induce mutagenicity. The no-observed-adverse-effect level (NOAEL) of the standardized aqueous cucumber extract (Q-Actin) is considered to be ≥1000 mg/kg bw/day, followed by repeated administration for90 days.

Overexpression of miR-489 derails mammary hierarchy structure and inhibits HER2/neu-induced tumorigenesis

Although it has been demonstrated that transformed progenitor cell population can contribute to tumor initiation, factors contributing to this malignant transformation are poorly known. Using in vitro and xenograft based models, previous studies demonstrated that miR-489 acts as a tumor suppressor miRNA by targeting various oncogenic pathways. It has been demonstrated that miR-489 directly targets HER2 and inhibits the HER2 signaling pathway; however, its role in mammary gland development and HER2 induced tumor initiation hasn’t been studied. To dissect the role of miR-489, we sorted different populations of mammary epithelial cells and determined that miR-489 was highly expressed in mammary stem cells. MMTV-miR-489 mice that overexpressed miR-489 in mammary epithelial cells were developed and these mice exhibited an inhibition of mammary gland development in early ages with a specific impact on highly proliferative cells. Double transgenic MMTV-Her2-miR489 mice were then generated to observe how miR-489 overexpression affects HER2 induced tumorigenesis. miR-489 overexpression delayed HER2 induced tumor initiation significantly. Moreover, miR-489 overexpression inhibited tumor growth and lung metastasis. miR-489 overexpression reduced mammary progenitor cell population significantly in preneoplastic mammary glands of MMTV-Her2 mice which showed a putative transformed population in HER2 induced tumorigenesis. The miR-489 overexpression reduced CD49f^hiCD61^hi populations in tumors that have stem- like properties, and miR-489 overexpression altered the HER2 signaling pathway in mammary tumors. Altogether, these data indicate that the inhibition of HER2 induced tumorigenesis by miR-489 overexpression was due to altering progenitor cell populations while decreasing tumor growth and metastasis via influencing tumor promoting genes DEK and SHP2.

Phytoestrogen consumption and risk for cognitive decline and dementia: With consideration of thyroid status and other possible mediators

It is predicted that around 20% of the worlds population will be age 60 or above by 2050. Prevalence of cognitive decline and dementia is high in older adults and modifiable dietary factors may be able to reduce risk for these conditions. Phytoestrogens are bioactive plant chemicals found in soy, which have a similarity in structure to natural estradiol (the most abundant circulating estrogen). This structural likeness enables phytoestrogens to interact with estrogen receptors in the brain, potentially affecting cognition. However, findings in this domain are largely inconsistent, with approximately 50% of studies showing positive effects of phytoestrogens on cognition and the other half resulting in null/negative findings. This paper provides an updated review of the relationship between consumption of phytoestrogens and risk for cognitive decline and/or dementia. In particular, possible mediators were identified to explain discrepant findings and for consideration in future research. A case can be made for a link between phytoestrogen consumption, thyroid status and cognition in older age, although current findings in this area are very limited. Evidence suggests that inter-individual variants that can affect phytoestrogen bioavailability (and thus cognitive outcome) include age and ability to breakdown ingested phytoestrogens into their bioactive metabolites. Factors of the study design that must be taken into account are type of soy product, dosage, frequency of dietary intake and type of cognitive test used. Guidelines regarding optimal phytoestrogen dosage and frequency of intake are yet to be determined.

Rituximab: A viable treatment option for epoetin-induced pure red cell aplasia

Pure red cell aplasia (PRCA) due to neutralizing antibodies can rarely develop following treatment with epoetin. The treatment of this condition is generally unsatisfactory and immunosuppression is often recommended, which improves chances of hematological recovery. We describe a case of PRCA due to neutralizing anti-epoetin antibodies following therapy with epoetin-α in a 68-year-old man on hemodialysis. He presented with severe transfusion-dependent anemia and was initially treated with prednisolone and oral cyclophosphamide. However, within 2 weeks the immunosuppressive drugs had to be stopped due to complications, following which he remained transfusion dependent. Subsequently, he was given two doses 700 mg each of rituximab following which there were hematological recovery and resolution of anti-epoetin antibodies.

Genetic polymorphisms associated with sulphadoxine-pyrimethamine drug resistance among Plasmodium falciparum field isolates in malaria endemic areas of Assam

Background:

The emergence of antimalarial drug resistance malaria parasite is widespread in North eastern region of India. During January 2012-December 2013, we conducted active surveillance for detection of antifolate resistance-associated genetic polymorphisms in Plasmodium falciparum malaria parasite from different malaria endemic areas of Assam.

Materials and Methods:

A total of 281 field samples were collected from suspected malaria patients of which 106 malaria P. falciparum positive cases were detected in microscopic slide examination. A nested PCR was done for amplification of a 648 bp portion of the dhfr gene and 710 bp portion of the dhps gene.

Results:

Mutation analysis revealed existence of three different haplotypes of the P. falciparum dhfr gene of which ANRNI was highly prevalent (90%). Triple mutant haplotypes AIRNI (N51I + C59R + S108N) of the dhfr gene associated with pyrimethamine resistance were prevalent in Chirang district of Assam. Whereas, dhps mutation study revealed that triple mutant haplotype AGEAA (S436A + A437G + K540E) associated with Sulphadoxine resistance was found among 26% of P. falciparum field isolates. However, P. falciparum dhfr-dhps two locus mutation analysis showed that there were a total of nine dhfr-dhps genotypes.

Conclusion:

It was noticed that 93.62% (88/94) isolates had mutations in the sequences of both enzymes, which is an indication of prevalence of high grade of Sulphadoxine — pyrimethamine resistance in P. falciparum malaria parasites in Assam.

Sheehan Syndrome: a Rare Complication of Post-partum Hemorrhage

Incidence of Sheehan syndrome, also known as post-partum hypopituitarism or post-partum pituitary insufficiency or hypopituitarism syndrome has reduced markedly but it does occur in under-developed countries with a reported incidence of 1:10000 deliveries.1-3 We are reporting the case of a 22 year old female with Sheehan syndrome occurring after massive post-partum hemorrhage. DOI: http://dx.doi.org/10.3126/njog.v9i2.11766 

Premature ovarian insufficiency and neurological function

Premature ovarian insufficiency (POI) involves loss of ovarian function before age 40. POI has been associated with neurological dysfunction and an increased risk of dementia, perhaps due to depletion in estrogen levels. The present review discusses the effects of POI caused by genetic disorder, natural premature menopause, surgical menopause, breast cancer treatment and gonadotropin-releasing hormone (GnRH) agonist treatment. Overall, data suggest an increased risk of neurological disorder where POI is due to premature menopause or induced from surgery. This increased risk appears to be most apparent on domains of global cognitive and verbal memory tests. Where POI is caused by genetic disorder, observed cognitive deficiencies may be more likely to have a genetic basis rather than being due to the effects of sex steroids on the brain. Findings related to loss of cognitive function after chemotherapy or GnRH treatments are mixed. There are also discrepant data related to use of hormone therapy after POI (particularly after surgical menopause). After surgery, hormone treatment appears to be most beneficial if initiated close to the average natural age of menopause.

Coexistence of giant cell fibroblastoma and encephalocele

Giant cell fibroblastoma (GCF) is a rare soft tissue tumour that occurs almost exclusively in children younger than 10 years of age and is mostly located in the superficial soft tissues of the back and thighs. We present a rare case of GCF with encephalocele in a 1.5-year-old boy who presented with a swelling in the occipital area of the scalp since birth. CT scan suggested encephalocele without any suspicion of a mass lesion. On histopathology, an ill-defined proliferation of fibroblasts in a heavily collagenised and focally myxoid stroma was seen containing numerous multinucleated cells having a floret-like appearance along with mature glial tissue bordering a cystic space. Immunohistochemically, the stromal cells were positive for both, vimentin (diffuse) and CD34 (focal) thereby confirming the histological diagnosis of GCF. This case highlights the unusual coexistence of GCF with congenital defects and its histogenetic resemblance to dermatofibrosarcoma protuberans.

White-blue pyelocalyceal cyst with hydrotic glomerulonephritis

A 5-month-old male infant presented with a 15 day history of distension of abdomen. On clinical examination, a soft lump was palpable in the left lumbar region. Radiological findings suggested an enlarged non-functional left kidney with ureteropelvic adhesive obstruction. The left renal mass was excised and submitted for histopathological examination. The excised renal mass was cystic with its wall partly white and partly blue. Gross and histopathological findings were diagnostic of a white-blue pyelocalyceal cyst with hydrotic glomerulonephritis. This entity needs to be differentiated from a large number of other cystic diseases of the kidney. Intrauterine screening and diagnosis may be significant for a possible early intrauterine uro-laparoscopic recanalisation of the pyeloureteral obstruction to save the affected kidney.

Familial hypercholesterolaemia IIA with bicuspid aortic valve

A young male presented with multiple xanthomas and xanthelesmas, progressive breathlessness and angina on exertion. Investigations confirmed diagnosis of familial hypercholesterolaemia, bicuspid aortic valve with severe aortic stenosis and significant obstructive coronary artery disease.

Anatrichosoma sp. in the footpads of a cat: diagnosis and pathology of Namibian case

Anatrichosoma species are an unusual group of zoonotic trichuroid nematodes. Due to limited knowledge of their life cycle and diagnostic challenges, anatrichosomiasis has been reported only 3 times in domestic animals. A short-haired cat from central Windhoek, Namibia, presented with ulceration, swelling, and sepsis on all four paws, a severe generalized lymphadenopathy and considerable invasive eosinophilia. Histological analysis revealed epidermal hyperplasia, with severe serocellular crusting on the skin surface. One specimen revealed a series of thick-walled eggs within nematode segments with a few sections containing eggs with bioperculate appearance which is compatible with the Aphasmid group of nematodes, more specifically, the genus Anatrichosoma. Ivermectin treatment completely cleared the condition. This is the first report of Anatrichosoma sp. in the Republic of Namibia, identified from a unique location in the capital, Windhoek.

Impact of Unsafe Abortion: A Case Report

Legalisation of abortion is a necessary but insufficient step towards improving women’s health, if it is not supported by a strong back-up of skilled providers, adequate facilities and easy access. We report a case of a 20-year old female, who presented with uterine, vaginal and rectal perforation with macerated fetus in the abdominal cavity with severe sepsis after an attempted unsafe abortion. NJOG 2011 Nov-Dec; 6 (2): 47-48 DOI: http://dx.doi.org/10.3126/njog.v6i2.6757

A second peritoneal cytology instead of the initial cytology as a prognostic factor in epithelial ovarian cancer

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Background: Ovarian cancer (OvCa) is the most common gynecological malignancy causing death. Positive (+ve) peritoneal cytology is an important prognostic factor. The role of a repeat peritoneal washing after resection of the tumor at the time of surgery has not been evaluated in the past. Methods: A retrospective analysis of our prospective cohort database was undertaken. Patients (pts) diagnosed with OvCa between 2001–2007 were included in the study. All pts underwent debulking surgery with two peritoneal washings during surgery: one before and one after resection of the tumor. The primary outcome was overall survival. Exclusion criteria included second malignancy, refusal of chemotherapy, or non-surgical candidates. Only stage III andIV pts were included in the follow-up analysis. Results: Forty three pts were included in our study. Of these, 8 (gp A) had both peritoneal washings +ve for malignancy, 16 (gp B) had the first washing +ve and the second one negative (-ve) for malignancy, and 19 (gp C) had both washings -ve for malignancy. There was no significant difference in the demographics and grade of disease (Table). There was more serous histology in gp B as compared to gp A and gp C. The median length of stay was 13.2, 10.9, 9 days and the median CA 125 level at the time of diagnosis was 651, 440 and 445 in gp A, B and C respectively. Bowel was involved and required radical resection in 75%, 41.7%, and 26.3% in gp A, B, and C, however the rates of optimal cytoreduction were 75%, 84.6% and 90.9% respectively. The minimum follow-up was 12 months. The percentage of pts with persistent or recurrent disease was 62.5%, 41.7%, and 36.4% in gpA, B and C respectively. There was improved survival in gp C as compared to gp B and gp A. (42 months vs 23.5 months vs 13 months respectively). Conclusions: While preliminary, our study shows that at the time of debulking surgery of OvCa, a -ve peritoneal washing after resection of the tumor following an initial +ve washing is a possible independent prognostic factor. [Table: see text]

No significant financial relationships to disclose.

The impact of the number of lymph node metastases on the overall recurrence of colon cancer in the era of sentinel lymph node mapping

4049

Background: Sentinel Lymph Node Mapping (SLNM) in colon Cancerc (Cca) has been shown to be successful, sensitive and accurate. We aimed to evaluate the recurrence rates in patients(pts) with Cca after SLNM and correlate it to the number of positive(+ve) LNs. Methods: Between 1996 and 2006, pts diagnosed with Cca were enrolled in a prospective trial and underwent SLNM and oncologic resection including regional LNs. The primary outcome was development of recurrence with minimum follow-up (f/u) of 24 months. For recurrence analysis, exclusion criteria included: stage IV disease, benign pathology, lost to follow-up, refusal of indicated chemotherapy, non cancer related death or second cancer. A retrospective matched control (diagnosed with Cca undergoing standard colon resection without SLNM, gp B) from our own institution were analyzed and compared to the SLNM group for the same period. Results: A total of 486 pts with Cca were included. Of these, 272 consecutive pts underwent SLNM between 1996–2006. SLNM was successful in 99.8% of pts, with a sensitivity, negative (-ve) predictive value, and overall accuracy of 85.3%, 91.7% and 94.4% respectively. The nodal positivity was 46.0%; of these, 15.1% had micrometastasis. The average number of LNs resected / pt was 15.0 and the average number of SLNs / pt was 2.4. For recurrence analysis, 153/272 pts with minimum f/u 2 years were included. Of these, 49 had stage I, 46 had stage II and 58 had stage III disease. The recurrence rates were 4.1%, 8.6% and 15.5% in stage I, II, and III disease respectively. The recurrence rates were significantly lower when our 153 pts were compared to 214 matched controls ( table 1 ). The recurrence rates increased from 6.3% in pts with no +ve LNs to 11.5% when one LN was +ve, 16.7% when 2 LNs were +ve and 20% when 3 or more LNs were +ve. Conclusions: SLNM in Cca is associated with decreased rates of recurrence as compared to conventional therapy. The number of positive LNs is an independent risk factor for recurrence.

[Table: see text]

No significant financial relationships to disclose.

Correlation of bone marrow micrometastasis to TNM stage of colorectal tumors

e15039

Background: Bone marrow (BM) micrometastasis(M) has been shown to be an important prognostic factor in Breast Cancer. However, there is paucity of data for BMM in Colorectal Cancer(CrCa). Hence a study was undertaken to find any correlation between TNM staging with BMM in CrCa patients(pts). Methods: A total of 155 consecutive patients(pts) from March 2004-October 2008 with CrCa were included in the study. Prior to resection of the primary tumor, pts underwent bilateral posterior-superior-iliac spine BM aspiration and samples were examined for presence of micrometastasis by Automated Cellular Imaging System using Chroma Vision Cytokeratin Detection Kit to detect cells expressing CK 8 as defined by CAM 5.2 monoclonal antibody. BMM and TNM staging were recorded and analyzed for correlations. Results: Of 155 CrCa pts, 11.6%(18/155) were found to have BMM. BMM was positive(+ve) in 50%(9/18) bilaterally and 50%(9/18) unilaterally. BMM was +ve in 11.5%(13/113) of colon pts and 12%(5/42) of rectal pts. When analyzed by T stage in colon pts, BMM was present in 10.5%(2/19) of T1 pts, 16.6%(2/12) of T2 pts, 14% (6/42) of T3 pts, 37.5%(3/8) of T4 pts, and 16%(5/31) of M1 pts. Upon analyzing rectal cancer pts data, BMM was found in 8.3%(1/12) of T1 pts, 16.6%(3/18) of T3 pts and 16.6% (3/18) of M1 pts. Of 113 total Colon pts, 27%(31/113) had nodal disease without distant metastasis(stage III); 13%(4/31) of these pts had BMM with 60% (3/5) unilaterally and 40%(2/5) bilaterally. In the Rectal group, 16%(7/42) had stage 3 disease; 14% (1/7) of stage 3 rectal pts had BMM. Conclusions: BMM did not correlate with tumor size, nodal status or distant metastasis. This discrepancy between tumor stage and BMM suggests BMM to operate independently of TNM staging. Further studies correlating prognosis and disease free survival in +ve BMM pts are needed to examine the significance of BMM in CrCa.

[Table: see text]

No significant financial relationships to disclose.

The number of lymph node metastases as a prognostic indicator of disease-specific survival in the era of sentinel lymph node mapping in colon cancer

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Introduction: Sentinel Lymph Node Mapping (SLNM) in colon cancer (CCa) is shown to be successful, sensitive and accurate. We aimed to evaluate the survival of patients (pts) undergoing SLNM in addition to the standard colon resection, compare it to pts without SLNM and correlate it to the number of LN metastasis. Methods: Staging and survival analysis from our prospective database (gpA, 195 pts) were compared to the Surveillance, Epidemiology, and End Results (SEER) database (gpB, 126,484 pts) between 1996–2003. All pts had invasive CCa. GpA pts underwent SLNM plus complete resection. The minimum follow up (F/U) was 5 years. The primary outcome was cancer-specific survival. Exclusion criteria were stage IV disease, 2nd malignancy, or lost to F/U. Cancer specific survival of gpA was then analyzed according to the number of positive LNs. Results: In gpA (195 pts), SLNM was successful in 99.7%, of pts with a sensitivity, negative (-ve) predictive value, and false -ve rates of 86.3%, 91.7% and 14.6% respectively. In 15.1% of node +ve pts, the disease was upstaged because of micrometastasis (0.2–2mm). In gpA, 128 pts were included, of which 17(13.3%) lost to F/U as compared to 89,483 pts included in gpB, of which 47,168 (52.7%) lost to F/U. The average number of LNs examined per pt was 15 in gpA as compared to 12.4 in gpB (p=<0.0001). The 5 year-cancer specific survival of pts in gpA vs gpB was 100% vs 94.9% in stage I, 91.2% vs 83.5% in stage II and 81.8% vs 63% in stage III disease. For gpA pts, the 5 year cancer-specific survival decreased from 95.0% in node -ve disease to 92.8% when 1 LN was +ve, 83.3% when 2 LNs were +ve and 71.4% when 3 or more LNs were +ve (Table). Conclusions: A significant number of pts with CCa are being upstaged and the true node -ve disease is being identified when SLNM is performed at the time of surgery leading to improved survival as compared to conventional surgery. Our study showed that the number of LN metastasis is a predictor of cancer specific survival even after SLNM in CCa. [Table: see text]

No significant financial relationships to disclose.

Nodal positivity between <12 and >12 lymph nodes harvested in colorectal cancer undergoing SLNM compared with conventional surgery

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Background: Sentinel Lymph Node Mapping (SLNM) upstages significantly more patients (pts) than conventional surgery (Conv Sx) in Colon Cancer (CCa). According to current guidelines, the examination of 12 or more LNs are required to ensure accurate staging. Our study compares the rates of nodal positivity between differing numbers of total Lymph Nodes (LNs) harvested to see if the nodal positivity of <12 LN harvested by SLNM is equivalent to >12 LN obtained by Conv Sx. Methods: Of 951 pts with CCa, 545 pts underwent SLNM and standard oncological resection; 406 pts received Conv Sx without SLNM. The total number of LNs harvested for each pt as well as number of pts with metastatic LNs were recorded. Pts were grouped according to 2–11 LNs, 12–25 LNs and >25 LNs. Results: Of 951 pts, 81 pts in SLNM group and 6 in Conv Sx group were excluded due to benign disease. Average (avg) total nodes harvested in 2–11 node group for SLNM and Conv Sx was 7.9 vs 6.8 nodes respectively. Overall nodal positivity for SLNM pts and Conv Sx pts in the 2–11 node groups was 48% vs. 33% (p=.02). In the 12–25 node group, avg total number of LNs harvested was 17.23 and 16.32 respectively. In the 12–25 node group, 53% of pts in the SLNM arm had +ve nodes vs 44% (p=0.17) in the Conv Sx group. In pts with >25 nodes harvested avg nodal positivity was 33.78% vs 32.38% for SLNM and Conv Sx. Overall nodal positivity was 55% for SLNM vs 37% for Conv Sx group. When SLNM pts with 2–11 LN harvested were compared to Conv Sx pts with 12–25 LN harvested, nodal positivity was 48% vs 44% (p=0.55). Conclusions: Increased survival has been shown when >12 nodes are harvested in CCa. On avg SLNM identified a higher number of total nodes than conventional surgery. In addition, SLNM pts had higher nodal positivity with <12 LNs harvested compared to the nodal positivity of >12 nodes harvested in the Conv Sx group. A higher number of LN harvested coupled with a greater nodal positivity with less LNs make SLNM a more accurate way to stage CCa.

[Table: see text]

No significant financial relationships to disclose.

C-reactive protein (CRP) as an indicator of sepsis in orthopaedic trauma

In the present study serial estimations of changes in plasma C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), total leucocyte count (TLC) and temperature were recorded in 100 patients. Nature and extent of tissue trauma varied from fresh soft tissue or bony injuries to elective orthopaedic procedures, besides acute orthopaedic infections. All the parameters showed a rise from day 1-3 from the normal levels, though the rise in temperature was minimal. However, from third day onwards, CRP level showed a sharp decline in all cases without any septic complication or infective patients who improved with treatment. Decline of ESR levels on the other hand was variable. Similarly, decline of TLC and temperature was also not consistent and sharp. Persistent rise of CRP level beyond third day or any subsequent rise in CRP level was consistent with a septic complication in the patient. CRP was therefore observed to be a sensitive and dependable indicator of orthopaedic sepsis even orthopaedic trauma.

Engelmann's disease with optic atrophy

Engelman-Camurati disease is a rare Diaphyseal dysplasia, characterized by endosteal and periostal thickness of cortex of shaft of tubular bone sparing metaphysis and epiphysis. The bone of the hand, feet, ribs, scapulae and pubis are not affected.