Frozen section analysis for organ-conserving surgery in penile cancer: Assessing oncological outcomes and trends of local recurrence

Introduction and objectives:

The local recurrence rate of penile cancer following surgical excision is reported in many series to be between 6 and 29%. Intra-operative frozen section (FS) is a useful tool to ensure safe microscopic margins in organ-sparing procedures in penile cancer. In this series, we assessed the rates of positive margins and patterns of local recurrence in a multicentre cohort of patients undergoing penile-preserving surgery assisted by intra-operative FS analysis.

Materials and methods:

We reviewed all those patients for whom intra-operative FS was employed during penile-preserving surgery in three tertiary referral centres between 2003 and 2016. We assessed whether the use of FS altered the surgical technique and what affect it had on positive margins and recurrence rates.

Results:

A total of 169 patients were identified. Of these, intra-operative FS examination of the surgical margin was positive in 21 (12%) cases. Final histological examination confirmed cancer-free margins in all but one patient (99.4%). Overall, 9 patients developed local recurrence (5.3%).

Conclusions:

In this series, intra-operative FS contributed to a very low rate (5.3%) of local recurrence. We noted an extremely low positive margin rate (0.6%) which highlights the benefit of incorporating FS analysis into organ-preserving surgery for penile cancer.

Level of evidence:

Not applicable for this multicentre audit.

A Glutathione-Responsive Short Sequence of Metal-Organic Complex Array

A short metal-organic complex array (MOCA) containing a sequence of RPtRRu (1Cl ) was found to exhibit unique responses to a major biothiol, glutathione (GSH). Upon binding of GSH to 1Cl , the resultant 1:1 complex (1GS ) formed nanofibrous assemblies that suggested supramolecular polymerization through the double-salt-bridge structure formation. The binding behavior of this MOCA sequence to calf thymus DNA was also dependent on GSH; a larger conformational change of DNA was observed upon binding with 1GS , relative to that with 1Cl .

Vortex-dislodged cells from bone marrow trephine biopsy yield satisfactory results for flow cytometric immunophenotyping

INTRODUCTION

A good bone marrow (BM) sample is essential in evaluating many hematologic disorders. An unsuccessful BM aspiration (BMA) procedure precludes a successful flow cytometric immunophenotyping (FCI) in most hematologic malignancies. Apart from FCI, most ancillary diagnostic techniques in hematology are less informative. We describe the feasibility of FCI in vortex-dislodged cell preparation obtained from unfixed trephine biopsy (TB) specimens.

METHODS

In pancytopenic patients and dry tap cases, routine diagnostic BMA and TB samples were complemented by additional trephine biopsies. These supplementary cores were immediately transferred into sterile tubes filled with phosphate-buffered saline, vortexed, and centrifuged. The cell pellet obtained was used for flow cytometric immunophenotyping.

RESULTS

Of 7955 BMAs performed in 42 months, 34 dry tap cases were eligible for the study. Vortexing rendered a cell pellet in 94% of the cases (32 of 34), and FCI rendered a rapid diagnosis in 100% of the cases (32 of 32) where cell pellets were available.

CONCLUSION

We describe an efficient procedure which could be effectively utilized in resource-limited centers and reduce the frequency of repeat BMA procedures.

Remarkable colorimetric sensing of heavy metal ions based on thiol-rich nanoframes

Tailored dimercaptosuccinic acid based nanoframes were developed for sensing heavy metal ions, where remarkable colorimetric changes were observed in response to different heavy metal ions. The present work demonstrates a simple and effective approach for the detection of heavy metal ions.

Pelvic exenteration for advanced malignancy in elderly patients

Background

Pelvic exenteration is an aggressive surgical procedure reserved for highly selected patients. Surgery in the elderly is often associated with increased morbidity and mortality. The aim of this study was to review outcomes following exenteration for advanced pelvic malignancy in this subgroup of patients.

Methods

All patients aged 70 years and over who underwent pelvic exenteration between 1999 and 2014 were included in the study. This comprised all primary rectal, gynaecological and bladder tumours. The primary outcome measure was 5-year overall survival. Secondary endpoints were postoperative morbidity and 30-day mortality.

Results

A total of 94 patients were included, with a median age of 76 (range 70–90) years. There were 65 rectal, 20 gynaecological and nine bladder tumours. The administration of neoadjuvant therapy was significantly different among tumour types (P = 0·002). A total of 32 patients (34 per cent) developed postoperative complications, and there were six deaths (6 per cent) within 30 days of surgery. Median survival was 64 months for patients with rectal cancer, 30 months for those with gynaecological tumours and 15 months for those with bladder cancer. Five-year survival rates in these groups were 47, 31 and 22 per cent respectively (P = 0·023).

Conclusion

Given the possibility of long-term survival, pelvic exenteration should not be withheld on the grounds of advanced age alone.

A water-soluble metal-organic complex array as a multinuclear heterometallic peptide amphiphile that shows unconventional anion dependency in its self-assembly

Water-soluble metal-organic complex array 1, bearing Ru(II), Pt(II) and Rh(III) complexes at the side residues of the short peptide, exhibits anion and pH-responsive self-assembly behaviours in aqueous media. NaCl-induced aggregation of 1 at neutral pH was suppressed in phosphate buffered saline containing a mixture of Cl(-), HPO4(2-) and H2PO4(-), which is unconventional for a peptide amphiphile.

The photoirradiation induced p-n junction in naphthylamine-based organic photovoltaic cells

The bulk heterojunction (BHJ) plays an indispensable role in organic photovoltaics, and thus has been investigated extensively in recent years. While a p-n heterojunction is usually fabricated using two different donor and acceptor materials such as poly(3-hexylthiophene-2,5-diyl) (P3HT) and phenyl-C61-butyric acid methyl ester (PCBM), it is really rare that such a BHJ is constructed by a single entity. Here, we presented a photoirradiation-induced p-n heterojunction in naphthylamine-based organic photovoltaic cells, where naphthylamine as a typical p-type semiconductor could be oxidized under photoirradiation and transformed into a new semiconductor with the n-type character. The p-n heterojunction was realized using both the remaining naphthylamine and its oxidative product, giving rise to the performance improvement in organic photovoltaic devices. The experimental results show that the power conversion efficiency (PCE) of the devices could be achieved up to 1.79% and 0.43% in solution and thin film processes, respectively. Importantly, this technology using naphthylamine does not require classic P3HT and PCBM to realize the p-n heterojunction, thereby simplifying the device fabrication process. The present approach opens up a promising route for the development of novel materials applicable to the p-n heterojunction.

Frontispiece: Rational Design and Synthesis of a Highly Porous Copper-Based Interpenetrated Metal-Organic Framework for High CO2 and H2 Adsorption

The frontispiece shows rational construction of a twofold interpenetrated metalorganic framework (MOF) with Pt₃ O₄ topology using an asymmetrical tricarboxylate organic linker. In spite of having structural interpenetration, the activated MOF shows high porosity along with high CO₂ and H₂ uptake. Details are given in the Full Paper by Ruqiang Zou and Yanli Zhao et al. page 1259.

A quinoxaline based N-heteroacene interfacial layer for efficient hole-injection in quantum dot light-emitting diodes

A series of N-heterocyclic quinoxaline derivatives was successfully synthesized and applied as hole transport layers in quantum dot light-emitting diodes (QLEDs). By inducing sp(2) N-atoms into the quinoxaline backbone, the electron affinity of the obtained material was enhanced, and its optical properties and bandgap became tunable. Quinoxaline based N-heteroacenes show a narrow bandgap, high thermal stability, and aligned film morphology. The resulting N-heteroacene polymer based QLED exhibits superior performance to poly(9-vinylcarbazole) based QLED. This study presents a strategy towards the design of novel N-rich molecules for the fabrication of QLEDs with improved performance.

Macroscopic architecture of charge transfer-induced molecular recognition from electron-rich polymer interpenetrated porous frameworks

Fluorescent and electron-rich polymer threaded into porous framework provides a scaffold for sensing acceptor molecules through noncovalent interactions. Herein, poly(9-vinylcarbazole) (PVK) threaded MIL-101 with confined nanospace was synthesized by vinyl-monomer impregnation, in situ polymerization, and interpenetration. The pore size of the resulted hybrid could be controlled by varying the time of polymerization and interpenetration. The interaction of PVK-threaded MIL-101 with guest molecules showed a charge-transfer progress with an obvious red shift in the optical spectra. Depending on the degree of the interaction, the solution color changed from blue to green or to yellow. In particular, electron-rich PVK-threaded MIL-101 could effectively probe electron-poor nitro compounds, especially 1,3,5-trinitrobenzene (TNP), a highly explosive material. This sensing approach is a colorimetric methodology, which is very simple and convenient for practical analysis and operation.

MRI texture analysis predicts p53 status in head and neck squamous cell carcinoma

BACKGROUND AND PURPOSE

Head and neck cancer is common, and understanding the prognosis is an important part of patient management. In addition to the Tumor, Node, Metastasis staging system, tumor biomarkers are becoming more useful in understanding prognosis and directing treatment. We assessed whether MR imaging texture analysis would correctly classify oropharyngeal squamous cell carcinoma according to p53 status.

MATERIALS AND METHODS

A cohort of 16 patients with oropharyngeal squamous cell carcinoma was prospectively evaluated by using standard clinical, histopathologic, and imaging techniques. Tumors were stained for p53 and scored by an anatomic pathologist. Regions of interest on MR imaging were selected by a neuroradiologist and then analyzed by using our 2D fast time-frequency transform tool. The quantified textures were assessed by using the subset-size forward-selection algorithm in the Waikato Environment for Knowledge Analysis. Features found to be significant were used to create a statistical model to predict p53 status. The model was tested by using a Bayesian network classifier with 10-fold stratified cross-validation.

RESULTS

Feature selection identified 7 significant texture variables that were used in a predictive model. The resulting model predicted p53 status with 81.3% accuracy (P < .05). Cross-validation showed a moderate level of agreement (κ = 0.625).

CONCLUSIONS

This study shows that MR imaging texture analysis correctly predicts p53 status in oropharyngeal squamous cell carcinoma with ∼80% accuracy. As our knowledge of and dependence on tumor biomarkers expand, MR imaging texture analysis warrants further study in oropharyngeal squamous cell carcinoma and other head and neck tumors.

Lymphoid associated antigen expression in new cases of Acute Myeloid Leukemia

Background: Occurrence of aberrant phenotype has been reported in acute leukemias with varying frequency though its prognostic importance remains controversial. In acute myeloid leukemias, aberrant phenotype, as high as 88 %, has been reported. To evaluate the occurrence of aberrant lymphoid phenotypes and to correlate their presence with various French American British classification, 100 cases of fresh acute myeloid leukemias were analyzed for lymphoid markers CD 4,7,8,10 and 19. Materials and Methods: Whole blood or bone marrow aspirate collected in EDTA were processed by standard method and subjected to immunophenotyping for B Cells marker CD 19 and 10 and T cell marker CD 4, 7 and 8. Results: Aberrant lymphoid markers were seen in 35(35%) cases. All FAB subtypes except M7 showed aberrancy for the markers studied. However it was the most common in M0 (100%), followed by M2 (51.9%). T cell aberrancy was the most common, comprising 62.8% (22/35) of total aberrancy. CD 7 was the most common aberrantly expressed marker, seen in 20% AML, followed by CD 4(14%) and CD 19 (8%). Conclusion: Occurrence of lymphoid phenotypes is frequent in pediatric as well adult AML. Though T cell markers are more common, only B cell as well as both B and T cell markers may be co expressed. DOI: http://dx.doi.org/10.3126/jpn.v3i6.8999   Journal of Pathology of Nepal (2013) Vol. 3, 487-490

Erratum: ING1 induces apoptosis through direct effects at the mitochondria

The ING family of tumor suppressors acts as readers and writers of the histone epigenetic code, affecting DNA repair, chromatin remodeling, cellular senescence, cell cycle regulation and apoptosis. The best characterized member of the ING family, ING1, interacts with the proliferating cell nuclear antigen (PCNA) in a UV-inducible manner. ING1 also interacts with members of the 14-3-3 family leading to its cytoplasmic relocalization. Overexpression of ING1 enhances expression of the Bax gene and was reported to alter mitochondrial membrane potential in a p53-dependent manner. Here we show that ING1 translocates to the mitochondria of primary fibroblasts and established epithelial cell lines in response to apoptosis inducing stimuli, independent of the cellular p53 status. The ability of ING1 to induce apoptosis in various breast cancer cell lines correlates well with its degree of translocation to the mitochondria after UV treatment. Endogenous ING1 protein specifically interacts with the pro-apoptotic BCL2 family member BAX, and colocalizes with BAX in a UV-inducible manner. Ectopic expression of a mitochondria-targeted ING1 construct is more proficient in inducing apoptosis than the wild type ING1 protein. Bioinformatic analysis of the yeast interactome indicates that yeast ING proteins interact with 64 mitochondrial proteins. Also, sequence analysis of ING1 reveals the presence of a BH3-like domain. These data suggest a model in which stress-induced cytoplasmic relocalization of ING1 by 14-3-3 induces ING1-BAX interaction to promote mitochondrial membrane permeability and represent a paradigm shift in our understanding of ING1 function in the cytoplasm and its contribution to apoptosis.

ING1 induces apoptosis through direct effects at the mitochondria

The ING family of tumor suppressors acts as readers and writers of the histone epigenetic code, affecting DNA repair, chromatin remodeling, cellular senescence, cell cycle regulation and apoptosis. The best characterized member of the ING family, ING1,interacts with the proliferating cell nuclear antigen (PCNA) in a UV-inducible manner. ING1 also interacts with members of the14-3-3 family leading to its cytoplasmic relocalization. Overexpression of ING1 enhances expression of the Bax gene and was reported to alter mitochondrial membrane potential in a p53-dependent manner. Here we show that ING1 translocates to the mitochondria of primary fibroblasts and established epithelial cell lines in response to apoptosis inducing stimuli, independent of the cellular p53 status. The ability of ING1 to induce apoptosis in various breast cancer cell lines correlates well with its degree of translocation to the mitochondria after UV treatment. Endogenous ING1 protein specifically interacts with the pro-apoptotic BCL2 family member BAX, and colocalizes with BAX in a UV-inducible manner. Ectopic expression of a mitochondria-targeted ING1 construct is more proficient in inducing apoptosis than the wild type ING1 protein. Bioinformatic analysis of the yeast interactome indicates that yeast ING proteins interact with 64 mitochondrial proteins. Also, sequence analysis of ING1 reveals the presence of a BH3-like domain. These data suggest a model in which stress-induced cytoplasmic relocalization of ING1 by14-3-3 induces ING1-BAX interaction to promote mitochondrial membrane permeability and represent a paradigm shift in our understanding of ING1 function in the cytoplasm and its contribution to apoptosis [corrected].

Abstract P4-09-07: ING1 Expression Measured by AQUA can be an Independent Prognostic Marker in Breast Cancer

Background: Breast cancer accounts for around 45,000 cancer related deaths in North America per year. The high incidence of breast cancer observed in this region is most likely due to the availability of various screening programs used to detect breast cancer, which otherwise may never get diagnosed. There is an inverse relation between the cost of treatment and patient survival as the breast cancer progresses to higher grades. Therefore, screening and diagnosing breast cancers at earlier stages is needed which can improve patient survival.

The INhibitor of Growth (ING) family of tumour suppressor proteins are implicated in diverse cellular processes including chromatin remodelling and apoptosis. ING proteins are stoichiometric members of histone acetyl transferase (HAT) and histone deacetylase (HDAC) complexes. Their expression is downregulated in several cancers, including breast carcinoma. Alternatively, ING function may be compromised by mislocalization to the cytoplasm. However, the association of expression of ING proteins and cancer specific survival has not been studied yet. In this study, we aimed to evaluate the prognostic significance of ING1 in breast cancer.

Patients and Methods: This study included 443 Breast Cancer patients diagnosed in Calgary, Canada from 1985–2000. Clinical data were obtained from the Alberta Cancer Registry and chart review. Tissue microarrays (TMAs) were assembled from triplicate cores of formalin-fixed paraffin-embedded tumour tissue. ING1 protein expression was quantified using fluorescent immunohistochemistry and automated quantitative analysis (AQUA) in normal breast epithelial cells and breast cancer samples. 5 year progression free survival (PFS) was analyzed using Kaplan-Meier plots and Cox proportional hazard modelling.

Results: In our study, we found that ING1 expression is significantly downregulated in the breast cancer patient samples relative to normal breast epithelia. High or low ING1 cytoplasmic/nuclear (C/N) ratio results in poor 5 year PFS. Also, the low tumor/stromal (t/s) ratio of ING1 results in poor prognosis. In univariate analysis, t/s ING1 expression showed a negative correlation with tumor stage [p = 0.008]; tumor grade [p = 0.000]; nodal status [p = 0.000] and 5 year PFS [p = 0.004]. However, no correlation was observed with ER, PR or HER2 status. In multivariate analysis, t/s ING1 proved to be an independent and better prognostic marker [HR 0.582, p = 0.037] than HER2 [HR 2.230, p = 0.057]; Age at diagnosis [HR 2.010, p = 0.205] and tumor size [HR 1.471, p = 0.189].

Discussion and Conclusions: This is the first study to evaluate ING1 expression in breast cancer using the AQUA technique. ING1 expression high or low in the C/N ratio might disrupt the stoichiometry of chromatin-modifying complexes and hamper ING1s extra nuclear functions, leading to poor survival. The significantly improved survival observed in patients with high t/s ING1 expression further strengthens the role of ING1 as a tumor suppressor.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-09-07.

Central pontine myelinolysis without hyponatraemia

A 55-year-old woman with a history of excess alcohol intake presented to the acute medical unit following concerns regarding her electrolyte disturbances. During correction of the electrolytes, the patient developed central pontine myelinolysis. The unusual features in the case were the absence of hyponatraemia which is usually associated with central pontine myelinolysis and also the good recovery that the patient made. Looking at the electrolyte changes, we suspect there may be a link to the rapid osmotic shifts occurring during refeeding and central pontine myelinolysis.

A review of tumour lysis syndrome with targeted therapies and the role of rasburicase

WHAT IS KNOWN AND OBJECTIVE

Tumour lysis syndrome (TLS) is an oncologic emergency with potentially devastating consequences classically associated with cytotoxic chemotherapy. In recent years, molecularly targeted drugs have assumed an increasingly important role in cancer therapeutics. The possibility of TLS is often overlooked in this setting. Rasburicase, a recombinant urate oxidase, is remarkably effective in treating hyperuricemia, thought to be central to the pathogenesis of renal injury in TLS. Our objective is to review the literature on TLS especially as it pertains to targeted therapies and summarize current knowledge and provide future directions regarding the role of rasburicase in the management of TLS.

METHODS

A MEDLINE search was conducted using PubMed and the keyphrase 'tumor lysis syndrome' to identify articles describing TLS with a broad range of novel anti-cancer agents. Meeting abstracts were also reviewed. Additionally, the biomedical literature was searched using the keyword 'rasburicase'.

RESULTS AND DISCUSSION

Tumour lysis syndrome has been described with nearly every class of 'targeted therapy'. This is not surprising as any drug causing death of cancer cells by any mechanism may lead to TLS in the appropriate setting. Although there is a wealth of evidence suggesting that rasburicase is extremely effective in correcting hyperuricemia, prospective trials showing that it improves hard outcomes such as acute renal failure, need for dialysis and mortality are lacking. Furthermore, much lower doses and durations of therapy than approved appear to be effective in controlling hyperuricemia, potentially leading to enormous cost savings.

WHAT IS NEW AND CONCLUSION

Any effective cancer therapy can lead to TLS. Physicians should consider the risk of TLS on a case-by-case basis and determine appropriate prophylaxis. The role of rasburicase continues to evolve. Randomized controlled trials evaluating clinically relevant outcomes are needed.

Response of AIDS-related plasmablastic lymphoma (PBL) to bortezomib

e19562

PBL are a group of highly aggressive neoplasms originally described in the oral cavity and jaws of HIV-infected patients. An AIDS-defining illness, PBL comprises 2.6% of AIDS-related lymphomas. PBL are best distinguished by their unique immunophenotype. They are terminally differentiated B-cell neoplasms, and typically lack common B-cell markers but uniformly express plasma cell markers. We report the first case of PBL that responded to bortezomib. A 42-year-old male with newly diagnosed AIDS presented with nausea, vomiting, bloody diarrhea and epigastric pain. EGD with biopsy revealed a high-grade PBL of the stomach. Flow cytometry was negative for CD45 and all common epithelial, T-cell and B-cell markers, but was positive for CD138 and p63(VS38c). Karyotyping revealed t(8;14), amongst other abnormalities. PET/CT showed significant hypermetabolism in multiple thoracic and abdominal lymph nodes, the left lung, liver and several bones. The diagnosis was stage IVBE PBL. Highly active anti-retroviral therapy was begun. Anthracycline-based chemotherapy was avoided due to persistent hyperbilirubinemia. Bortezomib was then administered at a dose of 1.3 mg/m2 IV on days 1, 4, 8 and 11. PET/CT on day 7 showed a marked decrease in hypermetabolism after only 2 doses, signifying a dramatic treatment response. After a total of 4 doses of bortezomib, he unfortunately succumbed to severe septic shock before a repeat PET/CT could be obtained. The prognosis of PBL is poor, with a median survival of about 6 months in most series. The WHO classifies PBL as a variant of diffuse large B-cell lymphoma. Accordingly, CHOP and CHOP-like regimens have mostly been used. However, studies of their immunophenotype and molecular histogenesis suggest that PBL are more closely related to plasma cell neoplasms. Bortezomib is a proteasome inhibitor widely used in multiple myeloma and mantle cell lymphoma. We chose bortezomib based on our patient's poor performance status and immune function, the desire to avoid combination chemotherapy, and translocations involving the immunoglobulin heavy chain gene locus (8;14) similar to those seen in multiple myeloma(4;14, 14;16) and mantle cell lymphoma(11;14). A shift in the paradigm of treatment of PBL towards agents effective in plasma cell malignancies may be necessary.

[Table: see text]

Three-day regimen improves faecal tagging for minimal preparation CT examination of the colon

This study set out to determine whether extending the length of oral contrast administration in minimal preparation CT of the colon improves faecal tagging. Two cohorts of 50 patients each were compared, one with a 2-day the other with a 3-day faecal tagging regimen. The degree of faecal tagging was graded by two blinded observers. The 3-day regimen showed significantly better tagging in the rectum and sigmoid colon (p = 0.006 and p = 0.009, respectively, using the Mann-Whitney test). The percentage of patients who had faecal tagging in the sigmoid colon graded as "complete" was 64% for the 3-day regimen as opposed to 34% for the 2-day regimen. The corresponding percentages for the rectum were 64% for the 3-day regimen and 36% for the 2-day regimen. Extending the length of oral contrast administration from 2 to 3 days significantly improves the quality of faecal tagging in the rectum and sigmoid colon.

Occurrence of synchronous invasive lobular breast carcinoma and poorly differentiated ovarian carcinoma in a single peritoneal deposit

The synchronous occurrence of breast and ovarian cancers within individual omental metastases has not been reported in the available medical literature. We report such a finding in a patient with previously diagnosed invasive lobular carcinoma of the right breast. After 5 years of surveillance and disease-free interval, there was development of ovarian cancer, ascites and peritoneal metastases. Ultrasound-guided biopsy of a peritoneal metastasis confirmed dual histology from breast and ovarian carcinoma. Despite the presence of a prolonged disease-free survival from the primary breast cancer, the subsequent finding of advanced ovarian cancer highlights the potential diagnostic and therapeutic dilemmas which persist in the management of these patients.

An epidemiologic study of mild cognitive impairment in Kolkata, India

OBJECTIVES

To estimate the prevalence of two types of mild cognitive impairment (MCI)-amnestic and multiple domain types-among nondemented and nondepressed elderly subjects aged 50 and older.

METHODS

The study was carried out in Kolkata, the eastern metropolis of India. A cross-sectional community screening was carried out, and 960 subjects were selected by systematic random sampling for the assessment of cognitive function with the help of a validated cognitive questionnaire battery administered through house-to-house survey. A case-control study was also undertaken to identify potential risk factors through univariate analysis.

RESULTS

Ultimately, full evaluation of cognitive function was possible in 745 of 960 subjects. An overall prevalence of MCI detected based on neuropsychological testing was 14.89% (95% CI: 12.19 to 17.95). Prevalence of the amnestic type was 6.04% (95% CI: 4.40 to 8.1) and that of the multiple domain type was 8.85% (95% CI: 6.81 to 11.32). Adjusted for age, education. and gender, the amnestic type was more common among men and the multiple domain type among women with advancement of age. Rates differed considerably with educational attainment. Hypertension and diabetes mellitus were the major risk factors for both types of MCI.

CONCLUSION

In this first community-based study of mild cognitive impairment (MCI) from India, prevalence of the amnestic type is comparable with and that of the multiple domain type is less than the prevalence in developed countries. Variations in age, education, and gender specific prevalence of MCI of both types were encountered. The putative risk factors identified merit further study.

Improving the accuracy of estimated blood loss at obstetric haemorrhage using clinical reconstructions

OBJECTIVES

Following the results of the Confidential Enquiries into Maternal Deaths report, which claims two maternal deaths annually in the UK from postpartum haemorrhage, our aim was to assess the accuracy of 'visual estimation of blood loss' and produce suitable pictorial and written algorithms to aid in the recognition and management of massive obstetric haemorrhage.

DESIGN

Observational study to determine discrepancy between actual blood loss (ABL) and estimated blood loss (EBL).

SETTING

Teaching hospital.

POPULATION

Hundred and three obstetricians, anaesthetists, midwives, nurses and healthcare assistants.

METHODS

Clinical scenarios were reproduced in the form of 12 Objective Structured Clinical Examination (OSCE) style stations augmented with known volumes of whole blood. Individual staff estimated the blood loss visually and recorded their results. Digital photographs were used to produce a pictorial 'algorithm' suitable for use as a teaching tool in labour ward.

MAIN OUTCOME MEASURES

Areas of greatest discrepancy between EBL and ABL.

RESULTS

Significant underestimation of the ABL occurred in 5 of the 12 OSCE stations: 500-ml (50-cm diameter) floor spill, 1000-ml (75-cm diameter) floor spill, 1500-ml (100-cm diameter) floor spill, 350-ml capacity of soaked 45- x 45-cm large swab and the 2-l vaginal postpartum haemorrhage on bed/floor.

CONCLUSIONS

Accurate visual estimation of blood loss is known to facilitate timely resuscitation, minimising the risk of disseminated intravascular coagulation and reducing the severity of haemorrhagic shock. Participation in clinical reconstructions may encourage early diagnosis and prompt treatment of postpartum haemorrhage. Written and pictorial guidelines may help all staff working in labour wards.

Enhancement of chemical-oxygen demand and color removal of distillery spent-wash by ozonation

Distillery spent-wash has very high organic content (75,000 to 125,000 mg/L chemical-oxygen demand [COD]), color, and contains difficult-to-biodegrade organic compounds. For example, anaerobic treatment of the distillery spent-wash used in this study resulted in 60% COD reduction and low color removal. Subsequent aerobic treatment of the anaerobic effluent resulted in enhancement of COD removal to 66%. In this paper, the effect of ozonation on various properties of the anaerobically treated distillery effluent, including the effect on its subsequent aerobic biodegradation, was investigated. Ozonation of the anaerobically treated distillery effluent at various ozone doses resulted in the reduction of total-organic carbon (TOC), COD, COD/TOC ratio, absorbance, color, and increase in the biochemical-oxygen demand (BOD)/COD ratio of the effluent. Further, ozonation of the anaerobically treated distillery effluent at an ozone dose of 2.08 mg/mg initial TOC and subsequent aerobic biodegradation resulted in 87.4% COD removal, as compared to 66% removal when ozonation was not used.

Aberrations of early trophoblast differentiation predispose to pregnancy failure: lessons from the anti-phospholipid syndrome

OBJECTIVES

The epithelium of the human placenta comprises an inner cytotrophoblast (CT) which proliferates and fuses with the outer differentiated syncytiotrophoblast (ST). Turnover has been studied focussing on second and third trimester placentas but with a paucity of data describing the normal first trimester trophoblast. The aim of this study was to compare the nuclear CT:ST ratio in normal and pathological pregnancy and thus establish the relationship between cytotrophoblast and syncytiotrophoblast nuclear number during early gestation.

METHODS

Archival first trimester material from placentas from healthy pregnancy and recurrent miscarriage (anti-phospholipid syndrome) was stained with H&E, cytokeratin-7 and Mib-1. The area of trophoblast as a fraction of total villous area was calculated and the number of sectioned cytotrophoblast and syncytiotrophoblast nuclei as well as the number of proliferating cytotrophoblast was evaluated.

RESULTS

Normal features of trophoblast development during the first trimester (rise in trophoblast area, increase in number of syncytiotrophoblast nuclei, increase in number of proliferating cytotrophoblast, decrease in the nuclear CT:ST ratio) are absent/reversed in tissues from recurrent miscarriage (decreasing trophoblast area, constant number of syncytiotrophoblast nuclei, decreasing number of proliferating trophoblast, constant nuclear CT:ST ratio).

CONCLUSIONS

Proliferation of cytotrophoblast in early gestation provides a pool of trophoblast stem cells critical for ongoing placental development. Premature cytotrophoblast differentiation in favour of syncytial fusion results in deficiencies of cytotrophoblast and rarification of villous trophoblast. Abnormal trophoblast differentiation in early gestation may be due to a premature onset of maternal perfusion of the placenta and may be a likely antecedent for conditions associated with failure of placentation such as recurrent miscarriage.