A Bivalent Human Norovirus Vaccine Induces Homotypic and Heterotypic Neutralizing Antibodies

A GII.2 outbreak in an efficacy study of a bivalent virus-like particle norovirus vaccine, TAK-214, in healthy US adults provided an opportunity to examine GII.4 homotypic vs GII.2 heterotypic responses to vaccination and infection. Three serologic assays-virus-like particle binding, histoblood group antigen blocking, and neutralizing-were performed for each genotype. Results were highly correlated within a genotype but not between genotypes. Although the vaccine provided protection from GII.2-associated disease, little GII.2-specific neutralization occurred after vaccination. Choice of antibody assay can affect assessments of human norovirus vaccine immunogenicity.

Evaluation of primary care physicians' competence in selective skin tumor triage after short versus long dermoscopy training A randomized non-inferiority trial

BACKGROUND

Although primary care physicians (PCPs) play a key role in skin cancer screening, their skills in detecting malignant tumors is suboptimal.

OBJECTIVES

To determine whether a short dermoscopy e-learning course (4 hours) in skin tumor diagnosis for PCPs is non-inferior to a long course (12 hours) in selective triage of skin lesions. Secondly, to evaluate whether regular refresher training sessions are necessary to maintain the PCPs' skills in the medium term.

METHODS

A randomized 2x2 factorial non-inferiority trial was conducted online over an 8-month period among 233 PCPs including 126 certified general practitioners, 94 PCPs in training, and 13 occupational physicians, all without prior advanced dermoscopy training. Participants were randomized 1:1:1:1 to receive short training and mandatory refreshers (n=58), short training and optional refreshers (n=59), long training and mandatory refreshers (n=58), or long training and optional refreshers (n=58). PCPs' skills were evaluated before training (T0), immediately after training (T1) to test the non-inferiority, and after five months (T2) to evaluate the impact of the refreshers. The primary endpoint was the difference in the change of score after short and long training. The non-inferiority margin was set at -28%.

RESULTS

Among the 233 randomized participants, 216 (93%) completed T1 and 197 (84.5%) completed T2. For short vs. long training, the primary endpoint was 1.392 (95% CI: 0.138; 2.645) in the per-protocol population (P<.001) and 1.016 (95% CI: -0.224; 2.256) in the modified intention-to-treat population (P<.001). After training, the type of refresher showed no impact on the score (P=.840). However, PCPs who completed all refreshers showed the best mean overall score at T2 (P<.001).

CONCLUSIONS

These findings confirm that short dermoscopy e-learning is non-inferior in training PCPs to triage skin lesions compared to long training. After training, regular refreshers are important to maintain the PCPs' acquired skills over time.

Antibodies Produced in Response to a Live-Attenuated Dengue Vaccine are Functional in Activating the Complement System

Background

Antibody-driven complement system (CS) activation has been associated with protection against symptomatic dengue virus (DENV) infection. Aggregation, opsonization, lysis, and phagocytosis are mechanisms triggered by antibody-antigen immunocomplexes following fixation of the component 1q (C1q) and activation of the classical pathway. As a result, DENV neutralization and clearance are facilitated, whereas antibody-dependent enhancement of infection is inhibited. We investigated the ability of antibodies produced in response to Takeda’s dengue vaccine candidate, TAK-003, to fix C1q and activate CS.

Methods

Serum samples were collected from seronegative and seropositive participants in a phase 2 clinical trial (DEN-203; ClinicalTrials.gov: NCT01511250), pre- and post-vaccination. Samples were evaluated for the presence of complement-fixing antibodies (CFAs) against DENV using a Luminex multiplex-based immunoassay.

Results

TAK-003 elicited production of CFAs against all 4 DENV serotypes, which persisted for 1 year post-vaccination, irrespective of baseline serostatus. CFA levels were correlated with neutralizing antibody titers and virus-binding total IgG and IgG1 concentrations. Furthermore, efficiency of CFA fixation was greater in samples with higher polyclonal IgG avidity.

Conclusion

These results indicate that antibodies produced after TAK-003 vaccination are functional in both activating CS and neutralizing virus infection by all DENV serotypes, which may contribute to efficacy of TAK-003.

Breadth and Dynamics of Human Norovirus-Specific Antibodies in the First Year of Life

We measured antibody binding to diverse norovirus virus-like particles over 12 months in 16 children. All had maternal antibodies at 2 months, with estimated lowest levels at 5 months of age. Antibody increases after 3 months suggested natural infections. This information could guide the timing of future norovirus vaccines.

Suspicious Skin Lesion Detection in Wide-Field Body Images using Deep Learning Outlier Detection

During consultation dermatologists have to address hundreds of lesions in a limited amount of time. They will not only evaluate the single lesion of interest but more importantly the context of it. Visually comparing the similarity of the majority of lesions within the same patient provides a strong indication for lesions with significantly differing aspects. Deep learning algorithms are capable to identify such outliers, i.e. images that differ considerably from the expected appearance on a larger cohort, and highlight the main differences in those cases. In the present study we evaluate the use of autoencoders as unsupervised tools to detect suspicious skin lesions based on evaluation of real world data acquired during consultation at the USZ Dermatology Clinic. Clinical Relevance- Deep learning algorithms are showing many promising results in dermatology lesion classification. However the context of the lesion is normally not considered in the analysis which prevents these tools to transition into routine practice. An outlier detector based on real world data would allow a dermatologist or general practitioner to detect the suspicious lesions for further examination. The algorithm would additionally provide useful insights by highlighting the feature differences between the original outlier (malignant lesion) and the lesion reconstructed by the autoencoder.

1051. Characterization of Immune Responses to a Live-Attenuated Tetravalent Dengue Vaccine

Background

A safe and effective vaccine against dengue is needed to address an unmet medical need that affects a large portion of the world’s population. Takeda’s live attenuated tetravalent dengue vaccine candidate (TAK-003) has shown protection in an ongoing Phase 3 efficacy trial. TAK-003 contains an attenuated dengue type 2 virus (DENV-2), and 3 genetically modified viruses in which the structural proteins from each of the serotypes 1, 3 and 4 have been placed into the DENV-2 backbone. Exploratory immunological assessments have been a part of the TAK-003 clinical development plan to better understand the mechanisms of action of TAK-003, and to identify immune response signatures that may correlate with protection.

Methods

Cellular and humoral immune responses elicited by vaccination in dengue-naïve and dengue-exposed individuals were measured across several clinical trials. For the humoral response, several methods were used to measure the magnitude and characteristics of the antibodies following vaccination with TAK-003 including studies of neutralizing antibodies, antibodies that bind to the viral components of the vaccine, the affinity and complement fixing capabilities of antibodies specific to structural proteins, and additionally the level of antibodies specific to nonstructural protein 1 (NS1).

Results

A multifunctional cellular immune response was found following vaccination that primarily targeted nonstructural proteins in the DENV-2 backbone and was cross reactive to epitopes found in the other serotypes. The vaccine elicited neutralizing antibodies with high tetravalent seropositivity rates among participants. Further assessment of this response revealed that it consists of serotype-specific and cross-reactive neutralizing antibodies against all four serotypes. In addition, sera from vaccinated individuals neutralized genotypically diverse dengue strains. In addition to antibodies specific to structural components, antibodies to DENV-2 NS1 that were cross reactive to the NS1 proteins of the other serotypes were found.

Conclusion

The breadth of the cellular and humoral immune responses elicited by TAK-003 in vaccine recipients across a wide age range living in different endemicities aligns with the response profile expected of a multivalent live vaccine.

Disclosures

Ralph Braun, PhD, Takeda Pharmaceuticals (Employee) Mayuri Sharma, PhD, Takeda Pharmaceuticals (Employee) Christina DeMaso, n/a, Takeda Pharmaceuticals (Employee) Allan Parker, n/a, Takeda Pharmaceuticals (Employee) David Dominguez, n/a, Takeda Pharmaceuticals (Employee) Heather Watkins, n/a, Takeda Pharmaceuticals (Employee) Hansi Dean, PhD, Takeda Pharmaceuticals (Consultant) Lovkesh Karwal, n/a, Takeda Pharmaceuticals (Employee) Eduardo Nascimento, n/a, Takeda Pharmaceuticals (Employee) Nicole Messere, n/a, Takeda Pharmaceuticals (Employee) Isamu Tsuji, n/a, Takeda Pharmaceuticals (Employee) Melissa Zahralban-Steele, n/a, Takeda Pharmaceuticals (Employee) Jeffrey R. Currier, PhD, Takeda Pharmaceuticals (Scientific Research Study Investigator) Heather Friberg-Robertson, PhD, Takeda Pharmaceuticals (Scientific Research Study Investigator)

Development and Characterization of a Multiplex Assay to Quantify Complement-Fixing Antibodies against Dengue Virus

Antibodies capable of activating the complement system (CS) when bound with antigen are referred to as "complement-fixing antibodies" and are involved in protection against Flaviviruses. A complement-fixing antibody test has been used in the past to measure the ability of dengue virus (DENV)-specific serum antibodies to activate the CS. As originally developed, the test is time-consuming, cumbersome, and has limited sensitivity for DENV diagnosis. Here, we developed and characterized a novel multiplex anti-DENV complement-fixing assay based on the Luminex platform to quantitate serum antibodies against all four serotypes (DENV1-4) that activate the CS based on their ability to fix the complement component 1q (C1q). The assay demonstrated good reproducibility and showed equivalent performance to a DENV microneutralization assay that has been used to determine DENV serostatus. In non-human primates, antibodies produced in response to primary DENV1-4 infection induced C1q fixation on homologous and heterologous serotypes. Inter-serotype cross-reactivity was associated with homology of the envelope protein. Interestingly, the antibodies produced following vaccination against Zika virus fixed C1q on DENV. The anti-DENV complement fixing antibody assay represents an alternative approach to determine the quality of functional antibodies produced following DENV natural infection or vaccination and a biomarker for dengue serostatus, while providing insights about immunological cross-reactivity among different Flaviviruses.

Clinical and Dermoscopic Features of Melanocytic Lesions on the Face Versus the External Ear

Introduction

Melanoma of the external ear is a rare condition accounting for 7-20% of all melanomas of the head and neck region. They present classical features of extra-facial melanomas clinically and dermoscopically. In contrast, facial melanomas show peculiar patterns in dermoscopy.

Objectives

To evaluate whether there are clinical and/or dermoscopic differences in melanocytic lesions located either at the external ear or on the face.

Methods

In this retrospective study we reviewed an image database for clinical and dermoscopic images of melanomas and nevi located either on the face or at the level of the external ear.

Results

65 patients (37 men; 63.8%) with 65 lesions were included. We found no significant differences in comparing face melanomas with melanomas at the level of the external ear, neither clinically nor dermoscopically. However, we provided evidence for differences in some clinical and dermoscopic features of melanomas and nevi of the external ear.

Conclusions

In this study, we reported no significant differences in comparing melanomas on the face with melanomas of the external ear, both clinically and dermoscopically. Furthermore, we provided data on clinical and dermoscopic differences comparing nevi and melanoma of the external ear.

International Dermoscopy Society criteria for non-neoplastic dermatoses (general dermatology): validation for skin of color through a Delphi expert consensus

BACKGROUND

The International Dermoscopy Society (IDS) recently released a set of five basic dermoscopic parameters (vessels, scales, follicular findings, "other structures," and specific clues) encompassing a total of 31 subitems to standardize the use of dermoscopy in non-neoplastic dermatoses, yet they have been developed taking into account Caucasian/Asian skin, with consequent possible limitations if used in dark skin.

OBJECTIVES

To validate the abovementioned criteria for the use in dark-skinned patients (phototypes IV-VI) through an expert consensus.

METHODS

The two-round Delphi method was adopted, with an iterative process consisting of two rounds of email questionnaires. Potential panelists were recruited via e-mail from all over the world based on their expertise on dermoscopy of non-neoplastic dermatoses in skin of color.

RESULTS

Twenty-two panelists took part in the validation process. All of the five originally proposed parameters and subitems reached agreement during the first round, aside from "follicular red dots." Additionally, during round 1, five new subitems were proposed (perifollicular scales distribution, follicular openings obliteration, broken hairs, eccrine pigmentation, and eccrine ostia obliteration), along with the possibility to change the denomination of parameter 3 (from "follicular findings" to "follicular/eccrine findings") and split it into two subparameters ("follicular findings" and "eccrine findings"). All such proposals reached agreement during the second round and therefore were included in the final list, for a total of 37 items.

CONCLUSIONS

Although nearly all the dermoscopic criteria originally proposed by the IDS are applicable even to darker phototypes, several additional variables need to be assessed.

POS0794 INCIDENCE AND PHENOTYPE OF ANTIPHOSPHOLIPID SYNDROME (APS) AFTER PREECLAMPSIA

Background:

Obstetric Antiphospholipid syndrom (oAPS) is induced by antiphospholipid antibodies (aPL) and associated with specific pregnancy complications. oAPS requires the combination of at least one obstetrical and one laboratory criteria (in 2 or more occasions at least 12 weeks apart). Multiple aPL positivity, lupus anticoagulant (LA) or persistently high aPL titers is defined as high risk aPL profile. “Non-criteria” oAPS are cases not fulfilling the clinical criteria.

Objectives:

To investigate the incidence of aPL after preeclampsia and the association of phenotypes of oAPS and pregnancy outcome.

Methods:

The present retrospective cohort analysis included women followed up after preeclampsia. Anti-PL (LA, aCL, anti-β2GBI of IgG and IgM isotype) are assessed 8 to 12 weeks after PE and if positive, again at least 12 weeks apart. According to the ISSHP PE is classified as severe if the blood pressure exceeds 160/110mmHg, or is associated with HELLP syndrome, or eclampsia. FGR is defined as estimated fetal weight <5th, and birth weight <10th percentile, and/or pathologic fetal Doppler.

Results:

Complete clinical and laboratory data were available for 99 women over a period of 6 years. 38.4% delivered <34 + 0 weeks. PE was severe in 63.6% of cases, and the incidence of FGR was 58.9%. HELLP syndrome was diagnosed in 34.3% and in 4 cases it was isolated. The prevalence of aPL was 35 (35.4%) at first evaluation, and 23 (23.2%) were still positive 12 weeks apart. 14/99 (14.1%) cases fulfilled the definition of classical oAPS, and 9/99 (9.1%) delivered >34 weeks (“non-criteria oAPS”). Of interest, the incidende og high risk aPL profiles was similar in both groups (64.3% vs. 77.8%; p=NS). The incidence of HELLP syndrome was higher in the presence of APS (APS: 9/23 [39.1%] vs. 21/76 [27.6%]; p=NS). 3 out of 4 cases with isolated HELLP syndrome were associated with high risk aPL profiles. Overall, aCL IgG was the dominant aPL. 32/35 (91.4%) and 22/23 (95.7%) had positive aCL at first and second investigation, respectively (p=NS). An aCL IgG titer >32.8CU at first assessment yield a LR of 10 for persistent aCL with a sensitivity and specificity of 91.3% and 90.9%, respectively.

Conclusion:

Classical and “non-criteria” obstetrical APS show a similar aPL pattern and distribution of aPL phenotypes regardless of gestational age at delivery. aCL IgG is the dominant aPL antibody and is highly predictive for aPL persistence at follow up. HELLP syndrome may be an additional feature of oAPS, in particular the isolated form. However, more studies are necessary to explore this possible association.

References:

[1]Tektonidou MG et al, EULAR recommendations for the management of antiphospholipid syndrome in adults Ann Rheum Dis. 2019 Oct;78(10):1296-1304. doi: 10.1136/annrheumdis-2019-215213. Epub 2019 May 15.

Disclosure of Interests:

None declared

A simple nomogram for early postoperative risk prediction of clinically relevant pancreatic fistula after pancreatoduodenectomy

PURPOSE

Postoperative pancreatic fistulae (POPF) present a serious and life-threatening complication after pancreatic head resections (PD). Therefore, reliable risk stratification to identify those at risk is urgently needed. The aim of this study was to identify postoperative laboratory parameters for the prediction of POPF in the early postoperative period.

METHODS

One hundred eighty-two patients who underwent PD from 2012 until 2017 were retrospectively analyzed. Multivariate logistic regression was performed using the GLM (general linear model) method for model building. Two nomograms were created based on the GLM models of postoperative day one and postoperative day one to five. A cohort of 48 patients operated between 2018 and 2019 served as internal validation.

RESULTS

Clinically relevant pancreatic fistulae (CR-POPF) were present in 16% (n = 29) of patients. Patients with CR-POPF experienced significantly more insufficiencies of gastroenterostomies, delayed gastric emptying, and more extraluminal bleeding than patients without CR-POPF. Multivariate analysis revealed multiple postoperative predictive models, the best one including ASA, main pancreatic duct diameter, operation time, and serum lipase as well as leucocytes on day one. This model was able to predict CR-POPF with an accuracy of 90% and an AUC of 0.903. Two nomograms were created for easier use.

CONCLUSION

Clinically relevant fistula can be predicted using simple laboratory and clinical parameters. Not serum amylase, but serum lipase is an independent predictor of CR-POPF. Our simple nomograms may help in the identification of patients for early postoperative interventions.

[Results of the Dry Eye Research Grant Award 2016]

The Sicca-Förderpreis (Dry Eye Award) supports the development of scientific research on the pathogenesis, diagnostics, and treatment of dry eye and ocular surface diseases. It is awarded after a limited call for proposals in German-speaking countries, written application and selection of the award winner after evaluation by a jury of ophthalmologists working in basic and clinical science. In this article examples of the results of funded projects of the Sicca-Förderpreis 2016 are cursorily described, which were presented at the Ophthalmological Academy of Germany 2019 (Augenärztliche Akademie Deutschland 2019) and therefore provide an insight into current scientific developments. The role of muscarinic receptors and those of urea in the pathogenesis of dry eye as well as the (missing) correlation of tear film stability, viscosity and surface tension are highlighted. A project on the early detection of ocular involvement in graft versus host disease and the idea of treating meibomian gland dysfunction with eyelid surgery techniques are also groundbreaking. The outlined projects represent the potential for further substantial developments in the understanding, diagnostics and treatment of dry eye; however, their long-term clinical relevance still needs to be established.

Utilising venom activity to infer dietary composition of the Kenyan horned viper (Bitis worthingtoni)

Bitis are well known for being some of the most commonly encountered and medically important snake species in all of Africa. While the majority of species possess potently anticoagulant venom, only B. worthingtoni is known to possess procoagulant venom. Although known to be the basal species within the genus, B. worthingtoni is an almost completely unstudied species with even basic dietary information lacking. This study investigated various aspects of the unique procoagulant effects of B. worthingtoni venom. Coagulation assays determined the primary procoagulant effect to be driven by Factor X activating snake venom metalloprotease toxins. In addition to acting upon the mammalian blood clotting cascade, B. worthingtoni venom was also shown to clot amphibian plasma. As previous studies have shown differences in clotting factors between amphibian and mammalian plasmas, individual enzymes in snake venoms acting on plasma clotting factors can be taxon-selective. As venoms evolve under purifying selection pressures, this suggests that the procoagulant snake venom metalloprotease toxins present in B. worthingtoni have likely been retained from a recent common ancestor shared with the related amphibian-feeding Proatheris superciliaris, and that both amphibians and mammals represent a substantial proportion of B. worthingtoni current diet. Thus, taxon-specific actions of venoms may have utility in inferring dietary composition for rare or difficult to study species. An important caveat is that to validate this hypothesis field studies investigating the dietary ecology of B. worthingtoni must be conducted, as well as further investigations of its venom composition to reconstruct the molecular evolutionary history of the toxins present.

Human surface anatomy terminology for dermatology: a Delphi consensus from the International Skin Imaging Collaboration

BACKGROUND

There is no internationally vetted set of anatomic terms to describe human surface anatomy.

OBJECTIVE

To establish expert consensus on a standardized set of terms that describe clinically relevant human surface anatomy.

METHODS

We conducted a Delphi consensus on surface anatomy terminology between July 2017 and July 2019. The initial survey included 385 anatomic terms, organized in seven levels of hierarchy. If agreement exceeded the 75% established threshold, the term was considered 'accepted' and included in the final list. Terms added by the participants were passed on to the next round of consensus. Terms with <75% agreement were included in subsequent surveys along with alternative terms proposed by participants until agreement was reached on all terms.

RESULTS

The Delphi included 21 participants. We found consensus (≥75% agreement) on 361/385 (93.8%) terms and eliminated one term in the first round. Of 49 new terms suggested by participants, 45 were added via consensus. To adjust for a recently published International Classification of Diseases-Surface Topography list of terms, a third survey including 111 discrepant terms was sent to participants. Finally, a total of 513 terms reached agreement via the Delphi method.

CONCLUSIONS

We have established a set of 513 clinically relevant terms for denoting human surface anatomy, towards the use of standardized terminology in dermatologic documentation.

Dermatoscopic features of thin (≤2 mm Breslow thickness) vs. thick (>2 mm Breslow thickness) nodular melanoma and predictors of nodular melanoma versus nodular non-melanoma tumours: a multicentric collaborative study by the International Dermoscopy Society

BACKGROUND

Thin nodular melanoma (NM) often lacks conspicuous melanoma-specific dermatoscopic criteria and escapes clinical detection until it progresses to a thicker and more advanced tumour.

OBJECTIVE

To investigate the dermatoscopic morphology of thin (≤2 mm Breslow thickness) vs. thick (>2 mm) NM and to identify dermatoscopic predictors of its differential diagnosis from other nodular tumours.

METHODS

Retrospective, morphological case-control study, conducted on behalf of the International Dermoscopy Society. Dermatoscopic images of NM and other nodular tumours from 19 skin cancer centres worldwide were collected and analysed.

RESULTS

Overall, 254 tumours were collected (69 NM of Breslow thickness ≤2 mm, 96 NM >2 mm and 89 non-melanoma nodular lesions). Light brown coloration (50.7%) and irregular brown dots/globules (42.0%) were most frequently observed in ≤2 mm NMs. Multivariate analysis revealed that dotted vessels (3.4-fold), white shiny streaks (2.9-fold) and irregular blue structureless area (2.4-fold) were predictors for thinner NM compared to non-melanoma nodular tumours. Overall, irregular blue structureless area (3.4-fold), dotted vessels (4.6-fold) and serpentine vessels (1.9-fold) were predictors of all NM compared to non-melanoma nodular lesions.

LIMITATIONS

Absence of a centralized, consensus pathology review and cases selected form tertiary centres maybe not reflecting the broader community.

CONCLUSIONS

Our study sheds light into the dermatoscopic morphology of thin NM in comparison to thicker NM and could provide useful clues for its differential diagnosis from other non-melanoma nodular tumours.

Man against machine: diagnostic performance of a deep learning convolutional neural network for dermoscopic melanoma recognition in comparison to 58 dermatologists

Background

Deep learning convolutional neural networks (CNN) may facilitate melanoma detection, but data comparing a CNN's diagnostic performance to larger groups of dermatologists are lacking.

Methods

Google's Inception v4 CNN architecture was trained and validated using dermoscopic images and corresponding diagnoses. In a comparative cross-sectional reader study a 100-image test-set was used (level-I: dermoscopy only; level-II: dermoscopy plus clinical information and images). Main outcome measures were sensitivity, specificity and area under the curve (AUC) of receiver operating characteristics (ROC) for diagnostic classification (dichotomous) of lesions by the CNN versus an international group of 58 dermatologists during level-I or -II of the reader study. Secondary end points included the dermatologists' diagnostic performance in their management decisions and differences in the diagnostic performance of dermatologists during level-I and -II of the reader study. Additionally, the CNN's performance was compared with the top-five algorithms of the 2016 International Symposium on Biomedical Imaging (ISBI) challenge.

Results

In level-I dermatologists achieved a mean (±standard deviation) sensitivity and specificity for lesion classification of 86.6% (±9.3%) and 71.3% (±11.2%), respectively. More clinical information (level-II) improved the sensitivity to 88.9% (±9.6%, P = 0.19) and specificity to 75.7% (±11.7%, P < 0.05). The CNN ROC curve revealed a higher specificity of 82.5% when compared with dermatologists in level-I (71.3%, P < 0.01) and level-II (75.7%, P < 0.01) at their sensitivities of 86.6% and 88.9%, respectively. The CNN ROC AUC was greater than the mean ROC area of dermatologists (0.86 versus 0.79, P < 0.01). The CNN scored results close to the top three algorithms of the ISBI 2016 challenge.

Conclusions

For the first time we compared a CNN's diagnostic performance with a large international group of 58 dermatologists, including 30 experts. Most dermatologists were outperformed by the CNN. Irrespective of any physicians' experience, they may benefit from assistance by a CNN's image classification.

Clinical trial number

This study was registered at the German Clinical Trial Register (DRKS-Study-ID: DRKS00013570; https://www.drks.de/drks_web/).

Sequential somatic mutations upon secondary anti-HER2 treatment resistance in metastatic ERBB2S310F mutated extramammary Paget's disease

Metastatic extramammary Paget’s disease is a rare adenocarcinoma with poor prognosis. Several reports of human epidermal growth factor receptor 2 alterations point to its pathogenic role in the disease. However, the occurrence of treatment resistance to anti-HER2 therapy demand the need for further knowledge. We report of a patient with metastatic penoscrotal extramammary Paget’s disease, with an ERBB2^S310F mutation, in which near complete response was achieved upon treatment with trastuzumab and carboplatin. However, after 10 cycles of trastuzumab and carboplatin, widespread metastasis re-occurred. Analysis of a newly developing metastasis revealed additional genomic alterations including ERBB3^A232V and PIK3CA^G106V point mutations as well as MET and CDK6 amplification, providing a potential mechanism of acquired treatment resistance. Therefore, ERBB family inhibitor afatinib was initiated. Unfortunately, the patient succumbed to disease-related complications shortly after treatment initiation. This is the first report of ERBB2^S310F mutated, metastatic extramammary Paget’s disease with secondary resistance to trastuzumab / carboplatin, potentially due to additional acquired genomic alterations. This case contributes to the growing evidence of HER2 in the pathogenesis of metastatic extramammary Paget’s disease and emphasizes the importance of repetitive, genomic analysis in rare diseases.

[Advanced medical post within hospitals as possible tactical instrument for handling mass casualty incidents]

BACKGROUND

An important instrument for handling mass casualty incidents in preclinical settings is the use of an advanced medical post. In certain circumstances, however, the establishment of such an advanced medical post on or close to the incident site is impossible. Terrorist attacks are a prime example for this. The highest priority for hospitals during mass casualty incidents is to adjust the treatment capacity to the acute rise in demand and to sustain its functionality throughout the duration of the incident. By establishing an advanced medical post within hospitals during certain types of mass casualty incidents these aims could potentially be accomplished.

AIMS

The aims of this pilot study were to test the practicability of the establishment of an advanced medical post within a university hospital and to identify potential problems. The results provide the foundation of a generalized concept, which will then be integrated into the hospital emergency plans.

METHODS

After the formation of a multiprofessional expert committee, different areas within the hospital were evaluated based on spatial and tactical considerations. Predefined questions were assessed and harmonized with respect to organization, vehicle management, communication, leadership and patient transport through the means of a practice run.

RESULTS

The establishment and operation of an advanced medical post within the hospital were easily possible. The consequent deployment of section leaders enabled the smooth coordination of transport and an unobstructed simulated patient flow. The management of the treatment area by a senior emergency physician and a senior emergency medical service officer in close cooperation with the operational hospital lead proved to be a useful concept. Technical problems with communication within the hospital were resolved by using wireless phones and the installation of a digital radio repeater.

DISCUSSION

During acute scenarios with only short prior notice, the authors prefer concepts that supplement the normal hospital operation through additional staff and material. In circumstances with prior notice of more than 60 min an advanced intrahospital advanced medical post, staffed by civil protection units, could be a concept that enables the absorption of the first patient arrivals within the first hour of a mass casualty incident without disturbing the functionality of hospitals to any great extent. Further practice runs are, however, necessary to further develop and adjust this concept to real-life circumstances.

In Depth Breadth Analyses of Human Blockade Responses to Norovirus and Response to Vaccination

To evaluate and understand the efficacy of vaccine candidates, supportive immunological measures are needed. Critical attributes for a norovirus vaccine are the strength and breadth of antibody responses against the many different genotypes. In the absence of suitable neutralization assays to test samples from vaccine clinical trials, blockade assays offer a method that can measure functional antibodies specific for many of the different norovirus strains. This paper describes development and optimization of blockade assays for an extended panel of 20 different norovirus strains that can provide robust and reliable data needed for vaccine assessment. The blockade assays were used to test a panel of human clinical samples taken before and after vaccination with the Takeda TAK-214 norovirus vaccine. Great variability was evident in the repertoire of blocking antibody responses prevaccination and postvaccination among individuals. Following vaccination with TAK-214, blocking antibody levels were enhanced across a wide spectrum of different genotypes. The results indicate that adults may have multiple exposures to norovirus and that the magnitude and breadth of the complex preexisting antibody response can be boosted and expanded by vaccination.

Assessment of the Safety Risk of Dermatoscope Magnets in Patients With Cardiovascular Implanted Electronic Devices

Importance

Cardiovascular implanted electronic devices (CIEDs) are susceptible to electromagnetic interference. Dermatologists regularly use devices containing magnets, including dermatoscopes and their attachments, which could pose a hazard to patients with CIEDs.

Objective

To investigate the safety risk of magnets in dermatoscopes to patients with CIEDs.

Design, Setting, and Participants

This cross-sectional observational study was conducted between January 1, 2018, and March 31, 2018, in a controlled laboratory setting. Two experiments were performed. In the first experiment (performed in the Dermatology Service at Memorial Sloan Kettering Cancer Center, New York), dermatoscopes that contain magnets were obtained from 3 manufacturers. Using a magnometer, the magnetic field strength of the dermatoscopes was measured over the magnet; at the faceplate; and at a distance of 0.5 cm, 1 cm and 15 cm away from the faceplate. In the second experiment (performed in the University Heart Center Zurich, Zurich, Switzerland), ex vivo measurements were conducted to determine how the dermatoscopes affected old-generation and new generation CIEDs (pacemakers and implantable defibrillators).

Main Outcomes and Measures

Magnetic field strength as measured directly over the dermatoscope magnet; at the faceplate; and at distances of 0.5 cm, 1 cm, and 15 cm from the faceplate. Pacemaker and defibrillator operation when exposed to dermatoscopes.

Results

After conducting 24 measurements, the magnetic field (measured in gauss [G]) strength varied between 24.26 G and 163.04 G over the dermatoscope magnet, between 2.22 G and 9.98 G at the dermatoscope faceplate, between 0.82 G and 2.4 G at a distance of 0.5 cm, and between 0.5 G and 1.04 G at a distance of 1 cm; it was 0 for all devices at a 15 cm distance. The field strength at the faceplate was found to be generally below the CIED industry standard safety threshold. None of the dermatoscopes in the ex vivo experiment exerted any demonstrable disruptions or changes to the CIEDs.

Conclusions and Relevance

In real life, dermatoscope magnets likely present no measurable safety risk to patients with CIEDs. Using the polarized noncontact mode permits dermoscopy to be performed at least 0.5 cm from the skin surface, where the magnetic field strength was well below the 5-G safety threshold.

25-Hydroxyvitamin-D3 serum modulation after use of sunbeds compliant with European Union standards: A randomized open observational controlled trial

BACKGROUND

Regular use of sunbed exposure has been reported to increase 25-hydroxyvitamin-D3 [25(OH)D] serum levels. However, the influence of sunbeds compliant with the recent European Union standard EN-60335-2-27 on 25(OH)D serum levels is unknown.

OBJECTIVE

We investigated the impact of standard sunbed use compliant with the European Union standard on 25(OH)D serum modulation and well-being.

METHODS

In a randomized controlled study, 25(OH)D serum levels were measured at enrollment, after 1 week, and after completion of the 12-week period of sunbed use with twice weekly exposure and compared with the control group without any sunbed exposure.

RESULTS

In the sunbed intervention group (N = 31), a 27% increase of mean 25(OH)D levels was noted 1 week after starting sunbed use (P < .01). However, after 12 weeks, mean 25(OH)D levels had declined and were no longer different from baseline (P = .06). After 12 weeks, 25(OH)D levels did not differ between the intervention and control group (P = .36). Also the 5-item World Health Organization Well-Being Index score did not differ between the sunbed and control groups (P = .19).

LIMITATIONS

For ethical reasons recruitment was limited to persons actively seeking sunbed exposure.

CONCLUSIONS

Standard use of sunbeds compliant with the European Union standard induced a transient increase of 25(OH)D levels, whereas no change in well-being was observed.

[Bilateral ciliary body oedema under treatment with ciclosporine]

We present the case of a 27-year-old female patient who developed bilateral ciliary body edema with secondary glaucoma and myopic shift during systemic treatment with cyclosporine for aplastic anemia. After application of topical atropine and prednisolone acetate and conversion from cyclosporine to tacrolimus, the ophthalmologic symptoms resolved completely. Since an infectious etiology was not evident, we hypothesize that ciliary body edema was caused by impairment of microvascular integrity by cyclosporine.

The updated Swiss guidelines 2016 for the treatment and follow-up of cutaneous melanoma

Cutaneous melanoma is the most deadly cutaneous neoplasm. In order to guide treatment decisions and follow-up of melanoma patients, guidelines for the management of melanoma in Switzerland were inaugurated in 2001 and revised in 2006 and 2016. Recent data on surgical and medical treatments from randomised trials necessitated modification of the treatment and follow-up recommendations.

Swiss clinical practice guidelines on field cancerization of the skin

Actinic keratosis (AK) affects millions of people worldwide, and its prevalence continues to increase. AK lesions are caused by chronic ultraviolet radiation exposure, and the presence of two or more AK lesions along with photodamage should raise the consideration of a diagnosis of field cancerization. Effective treatment of individual lesions as well as field cancerization is essential for good long-term outcomes. The Swiss Registry of Actinic Keratosis Treatment (REAKT) Working Group has developed clinical practice guidelines for the treatment of field cancerization in patients who present with AK. These guidelines are intended to serve as a resource for physicians as to the most appropriate treatment and management of AK and field cancerization based on current evidence and the combined practical experience of the authors. Treatment of AK and field cancerization should be driven by consideration of relevant patient, disease, and treatment factors, and appropriate treatment decisions will differ from patient to patient. Prevention measures and screening recommendations are discussed, and special considerations related to management of immunocompromised patients are provided.

The role of skin self-examination at the Swiss skin cancer day

BACKGROUND

The rising incidence of melanoma - Switzerland has the highest incidence in Europe - is a major public health challenge. Swiss dermatologist introduced the "Swiss Skin Cancer Day" (SSCD) in 2006, which provides skin cancer screening at no costs. The aim of the study was to describe the participating subjects and their motivation and investigate factors influencing the probability of a clinical diagnosis of skin malignancy.

METHODS

150 dermatologists were involved in the SSCD in May 2012. Dermatologists were not remunerated. Participants had the opportunity to show a single skin lesion to a dermatologist at no cost. A questionnaire for each participating subject collected data about subjects' age, sex, risk factors and reason for encounter; furthermore the dermatologist noted down clinical diagnosis and further management. We used descriptive statistics to report characteristics of participants and skin lesions. We built two multiple logistic regression models, one regarding the clinical diagnosis of skin malignancy and one regarding the further management.

RESULTS

5266 subjects (55.6% female) were assessed; in 308 (5.8%) participants a clinical diagnosis of skin malignancy was found. In 1732 participants (32.9%) a clinical follow up or an excision was recommended. In the multiple logistic regression model age, sex, skin phototype and the reason for participation at the SSCD were found as significant risk factors regarding the clinical diagnosis of skin malignancy. Participants with skin cancer risk factors were more likely to get a clinical follow up recommended even if the clinical diagnosis was benign.

CONCLUSION

A self-perceived suspicious lesion was the strongest predictor for a clinical diagnosis of skin malignancy at the SSCD. This suggests that skin self-examination might also work in general population. Future research should focus on better access to a specialist in case a suspicious skin lesion was discovered. Safety and quality of the SSCD should be further investigated, especially concerning the discrepancy between the low number of malignant lesions and the high quantity of participants where further clinical examinations or interventions were recommended.

Zur Wirkung von N-Methyl-N-β-chloräthylhydrazin und seinem Benzaldehydhydrazon auf die RNA -und Proteinsynthese sowie Stoffwechsel von synchronisierten Hefezellen / Effect of N-Methyl-N-β-chloroethylhydrazine and Its Benzaldehydhydrazone on RNA- and Protein Synthesis as Soon as Metabolism of Synchronously Growing Yeast Cells ( Saccharomyces cerevisiae)

N-methyl-N-β-chloroethylhydrazine and its benzaldehydhydrazone inhibit the influx of [6-3H]- uracil and ʟ- [U-14C] leucin in yeast cells as well as the incorporation in RNA and protein. Experi­ments with synchronously and asynchronously growing cells showed the N-methyl-N-β-chloroethyl- hydrazine essentially influences the dividing phase while the benzaldehydhydrazone is more ef­fective in the growthphase. The effect of these two substances on respiration, glycolysis and the concentration of fructose-1,6-diphosphate, triose phosphate, and adenosine triphosphate is small.

Über den biologischen Einfluß von N-Methyl-N-β-chloräthylhydrazin und seinem Benzaldehydhydrazon auf Hefezellen ( Saccharomyces cerevisiae) / Effect of N-Methyl-N-β-chloroethyl-hydrazine-HCl on the Growth and Multiplication of Yeast Cells (Saccharomyces cerevisiae)

N-Methyl-N-β-chloroethyl-hydrazine-HCl and its benzaldehydhydrazone inhibit growth and multi­plication of yeast cells. The DNA-synthesis is partially blocked. After removal of the substances the rate of this synthesis is much more increased than that of RNA and protein. The both sub­ stances we tested are more effective than simple alkylhydrazines.

Fast intraoperative testosterone assay confirms the location of an ovarian virilizing tumor in a young girl

The detection of testosterone-producing ovarian tumors in childhood and adolescence by imaging techniques only can be difficult because of the tumors' radiological structure and sometimes diminutive size. We describe an 11.5-year-old girl with a 9-month history of voice deepening, mild hirsutism, minor acne, increased growth velocity, weight gain, and clitoromegaly. Laboratory investigation revealed an extremely elevated serum testosterone level without any additional endocrine abnormalities. Abdominal ultrasound and MRI showed a sparsely noticeable solid mass in the center of the right ovary. At laparotomy, blood was selectively drawn from the right and the left ovarian veins. Rapid testosterone measurement revealed a 70-fold higher testosterone concentration in the right ovarian vein within 45 min. Based on this finding, a right salpingo-oophorectomy was performed. The patient's postoperative testosterone level declined within 24 h. The histopathological diagnosis was Leydig cell tumor. In conclusion, the implementation of a fast intraoperative testosterone assay enabled the localization and curative therapy of a Leydig cell tumor. This technique seems to be a good alternative to preoperative selective venous blood sampling when body imaging does not unveil the tumor's site.

Dermatofibrosarcoma protuberans in childhood treated with slow Mohs micrographic surgery

Dermatofibrosarcoma protuberans (DFSP) in childhood is a rare tumor with high recurrence rates. Wide local excision can result in disfiguring mutilation, whereas Mohs micrographic surgery (MMS) reduces surgical margins. MMS in children is not performed routinely, as the required infrastructures such as a histopathology lab in close proximity to the operating room is often lacking. We retrospectively reviewed children diagnosed with DFSP treated at our hospital over 2 years. We recorded surgical treatment details, including margins, duration of inpatient stay, outcome, follow-up, and molecular genetic tumor tissue analysis. Four children with a median age of 6.8 years (range 6.0-8.8 years) were identified who had a diagnostic delay of a median of 2.5 years (range 0.5-4.0 years); all underwent complete tumor excision using the slow MMS technique using vacuum-assisted closure systems between repeated excisions and before wound closure. The median maximal safety margins were 1.5 cm (range 1.0-3.0 cm). By using vacuum-assisted closure systems, no dressing changes were needed, pain was limited, and full mobility was maintained in all children. The median total time in the hospital was 11 days (range 10-14 days). No relapses occurred during a median follow-up of 25.8 months (range 11.3-32.6 months). Collagen 1A1/platelet-derived growth factor B (COL1A1/PDGFB) translocation on chromosomes 17 and 22 was detected in all three analyzable specimens. Lesions suspected of being DFSP warrant prompt histologic evaluation; interdisciplinary management is mandatory in particular for children. Micrographic surgery allows smaller surgical margins than wide excision and should be considered as the treatment of choice in children with DFSP. The interim usage of vacuum-assisted closure systems increases patient comfort. Translocations in the COL1A1/PDGFB gene imply susceptibility to targeted treatment modalities for therapy-resistant cases.

Investigation of different yeast strains for the detoxification of ochratoxin A

High concentrations of ochratoxin A (OTA) in feed lead to growth depression in animals. It has been reported that binders can be used for deactivating aflatoxins but not for other mycotoxins without negatively influencing the animals health. In this study a strain from the genus ofTrichosporon with the ability to cleave ochratoxin A very selectively into phenylalanine and the non-toxic ochratoxin α (OTα) could be isolated. This strain was selected from a pool of OTA detoxifying microorganism by carrying out several investigations.Trichosporon sp. nov. can be fermented and stabilized. In a feeding trial with broilers lyophilizedTrichosporon-cells could compensate performance losses caused by OTA.