Limitations of antifungal prophylaxis in preventing invasive Candida surgical site infections after liver transplant surgery

Invasive primary Candida surgical site infections (IP-SSIs) are a common complication of liver transplantation, and targeted antifungal prophylaxis is an efficient strategy to limit their occurrence. We performed a retrospective single-center cohort study among adult single liver transplant recipients at Duke University Hospital in the period between 1 January 2015 and 31 December 2020. The study aimed to determine the rate of Candida IP-SSI according to the peri-transplant antifungal prophylaxis received. Of 470 adult single liver transplant recipients, 53 (11.3%) received micafungin prophylaxis, 100 (21.3%) received fluconazole prophylaxis, and 317 (67.4%) did not receive systemic antifungal prophylaxis in the peri-transplant period. Ten Candida IP-SSIs occurred among 5 of 53 (9.4%) micafungin recipients, 1 of 100 (1.0%) fluconazole recipients, and 4 of 317 (1.3%) recipients who did not receive antifungal prophylaxis. Our study highlights the limitations of antifungal prophylaxis in preventing invasive Candida IP-SSI after liver transplant surgery. We hypothesize that pathogen, host, and pharmacokinetic-related factors contributed to the occurrence of Candida IP-SSI despite antifungal prophylaxis. Our study reinforces the need for a risk-based, multi-pronged approach to fungal prevention, including targeted antifungal administration in patients with risks for invasive candidiasis and close monitoring, especially among patients with surgically complex procedures, with timely control of surgical leaks.

THE ROLE OF DISTAL LOCKING IN INTRAMEDULLARY NAILS FOR HIP FRACTURE FIXATION: A REVIEW OF CURRENT LITERATURE

Traditionally, it was believed that both proximal and distal locking are essential for achieving stability during intra-medullary fixation for extra-capsular hip fractures. However, recent literature has presented varying perspectives on the necessity of distal locking. Distal locking plays a significant role in managing hip fractures with uncertainties regarding longitudinal and rotational stability. This includes cases of comminuted intertrochanteric fractures with subtrochanteric extension, reverse oblique and high oblique fractures, broad medullary canals, comminution of the lateral wall, diaphyseal fractures, and large posteromedial fragments extending below the level of the lesser trochanter. In stable pertrochanteric fractures, with the lag screw passing through the lateral cortex of the distal fragment, may not require a distal locking screw. Distal locking has been associated with potential complications, including irritation of the fascia lata, prolonged operation time, increased radiation exposure, greater blood loss, implant loosening, secondary femoral stress fractures, and damage to the femoral artery. Thus, although distal locking is of doubtful significance in stable pertrochanteric fractures it is essential in unstable fracture patterns.

CURRENT CONCEPTS IN THE MANAGEMENT OF BOXER'S FRACTURE

Fractures of the metacarpal particularly the 5th metacarpal is quite common among all hand fractures and has a high incidence in male adult population. Proper management of these fractures plays a key role in rehabilitation and early return to work thus reducing the economic burden. Treatment of these injuries depends on the type of injury: whether it is a closed/open fracture, degree of angulation at the fracture site and also mal-rotation and shortening of the finger. Non-operative management is suitable for fractures which are closed, non-displaced and without angulation or rotation. Open fractures, fractures with angulation and/or mal-rotation and fractures with neuro-vascular injury are more suitable for operative management. The acceptable angulation for conservative management for most studies is 70 degrees. Buddy strapping with a Futura splint provides good functional results. In fractures requiring operative intervention, K-wire fixation is a minimally invasive method of fixation, which in most cases has good functional results. Plate and screw fixation, however, is preferred for cases with significant comminution or multiple metacarpal fractures.

Adult outcomes of complex pulmonary atresia, ventricular septal defect and major aortopulmonary collaterals following repair during childhood, a single centre experience

Background

Complex pulmonary atresia with a ventricular septal defect and major aortopulmonary collateral arteries (PA VSD MAPCA) is a rare and complex form of congenital heart disease. Staged surgical palliation is carried out in childhood, and in expert centres, is associated with good medium term survival. Adult outcomes following transition to adult care are not known.

Purpose

To establish adult outcomes of PA VSD MAPCA following repair during childhood in our institution

Methods

Review of clinical records for outcome data including life status, NYHA class, employment status, re-intervention in adult life, arrhythmia, pregnancy, exercise capacity and mode of death, where known. We predefined our population into two groups based on their status at transition to adult care, A) complete repair with RV-PA conduit and VSD closed and B) repaired but VSD left open.

Results

188 patients from our series have transitioned to adult services. As many were tertiary referrals (nationally and internationally) the local follow up population was 53 adults (54.7% male), mean age of those alive under follow up is 27.2±6.5 years, with a mean follow up of 25.3±6.1 years. There were 43 in group A and 10 in group B. Mortality in the total population was 18.9% (10/53), group A (16.3%), group B (30.0%), mean age at death 37.5±10.3 years and 29.9±8.4 years, 6/10 deaths were sudden. 22.6% of the whole group had DiGeorge/22q11 microdeletion, with a learning deficit in 32.7% of the cohort, where this could be assessed. Reinterventions included RV-PA conduit change, coil occlusion, pacemaker implantation, ICD implantation and ablation procedures, overall 39.6% underwent reintervention in adult life. Pregnancy occurred in 33.3% of 24 female patients. 50% of individuals were found to have undertaken some form of paid work and of these 11.5% had DiGeorge.

Conclusions

Complex PA VSD MAPCA is associated with good late survival with late attrition including sudden death and heart failure. 22q11 is associated with learning deficit and consequent lack of employment. Non 22q11 have good educational outcomes and there is less observed deficit regarding employment. Successful pregnancy is possible within this population.

Funding Acknowledgement

Type of funding sources: None.

Endocardial pacing is not haemodynamically superior to trans-coronary sinus epicardial pacing in cardiac resynchronization therapy: the Endo-Epi CRT study

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Medtronic

Background

Cardiac resynchronization therapy (CRT) conventionally involves trans-coronary sinus, epicardial left ventricular (LV) pacing. Some studies have suggested that endocardial LV pacing may be superior to epicardial LV pacing.

Objectives

To compare the acute haemodynamic effects of CRT when delivered from endocardial (Endo-CRT) and epicardial LV stimulation sites (Epi-CRT).

Methods and results

Sixteen CRT recipients (aged 70.4 ± 10.1 years [mean ± SD], 62.5% male, QRS: 156.5 ± 16.1 ms, LBBB in 13 [81.3%]) in sinus rhythm underwent intra-procedural measurements of the rate of rise of LV pressure (dP/dtmax) during Endo- and Epi-CRT (RADI pressure wire). Epi-CRT was delivered in basal, mid and apical positions. The Endo-CRT pacing site was chosen using iterative, biplane fluoroscopic views, to target the same position as the Epi-CRT site on the endocardium (see Figure A). Compared to AAI pacing (10 beats per minute above intrinsic rate), both Endo-CRT and Epi-CRT led to an increase in LV dP/dtmax (6.52 ± 8.90% and 6.15 ± 7.97% respectively, both p < 0.001). There were no significant differences in the change in LV dP/dtmax (ΔLV dP/dtmax) between Endo-CRT and Epi-CRT at basal (p = 0.54), mid (p = 0.78) or apical LV stimulation sites (p = 0.12) [Figure B].

Conclusions

Endo-CRT is not haemodynamically superior to Epi-CRT. Abstract Figure.

A phase I study of binimetinib (MEK 162), a MEK inhibitor, plus carboplatin and pemetrexed chemotherapy in non-squamous non-small cell lung cancer

INTRODUCTION

MEK inhibition is a potential therapeutic strategy in non-small cell lung cancer (NSCLC). This phase I study evaluates the MEK inhibitor binimetinib plus carboplatin and pemetrexed in stage IV non-squamous NSCLC patients (NCT02185690).

METHODS

A standard 3 + 3 dose-escalation design was used. Binimetinib 30 mg BID (dose level 1 [DL1]) or 45 mg BID (dose level 2 [DL2]) was given with standard doses of carboplatin and pemetrexed using an intermittent dosing schedule. The primary outcome was determination of the recommended phase II dose (RP2D) and safety of binimetinib. Secondary outcomes included efficacy, pharmacokinetics, and an exploratory analysis of response based on mutation subtype.

RESULTS

Thirteen patients (6 DL1, 7 DL2) were enrolled: 7 KRAS, 5 EGFR, and 1 NRAS mutation. The RP2D was binimetinib 30 mg BID. Eight patients (61.5%) had grade 3/4 adverse events, with dose limiting toxicities in 2 patients at DL2. Twelve patients were evaluated for response, with an investigator-assessed objective response rate (ORR) of 50% (95% CI 21.1%-78.9%; ORR 33.3% by independent-review, IR), and disease control rate 83.3% (95% CI 51.6%-97.9%). Median progression free survival (PFS) was 4.5 months (95% CI 2.6 months-NA), with a 6-month and 12-month PFS rate of 38.5% (95% CI 19.3%-76.5%) and 25.6% (95% CI 8.9%-73.6%), respectively. In an exploratory analysis, KRAS/NRAS-mutated patients had an ORR of 62.5% (ORR 37.5% by IR) vs. 25% in KRAS/NRAS wild-type patients. In MAP2K1-mutated patients, the ORR was 42.8%.

CONCLUSION

The addition of binimetinib to carboplatin and pemetrexed appears to have manageable toxicity with evidence of activity in advanced non-squamous NSCLC.

Scheduling nab-paclitaxel combined with gemcitabine as first-line treatment for metastatic pancreatic adenocarcinoma

BACKGROUND

Nab-paclitaxel plus gemcitabine (nabP+gemcitabine) offers modest survival gains for patients with metastatic pancreatic ductal adenocarcinoma (PDAC). Sequential scheduling of nabP+gemcitabine in a PDAC mouse model improved efficacy; this hypothesis was tested in a clinical trial.

METHODS

Patients with previously untreated metastatic PDAC were randomised to receive nabP+gemcitabine administered either concomitantly on the same day, or sequentially, with gemcitabine administered 24 h after nabP. The primary outcome measure was progression-free survival (PFS). Secondary outcome measures were objective response rate (ORR), overall survival (OS), safety, quality of life (QoL) and predictive biomarkers.

RESULTS

In total, 71 patients received sequential (SEQ) and 75 concomitant (CON) treatment. Six-month PFS was 46% with SEQ and 32% with CON scheduling. Median PFS (5.6 versus 4.0 months, hazard ratio [HR] 0.67, 95% confidence interval [95% CI] 0.47-0.95, p = 0.022) and ORR (52% versus 31%, p = 0.023) favoured the SEQ arm; median OS was 10.2 versus 8.2 months (HR 0.93, 95% CI 0.65-1.33, p = 0.70). CTCAE Grade ≥3 neutropaenia incidence doubled with SEQ therapy but was not detrimental to QoL. Strongly positive tumour epithelial cytidine deaminase (CDA) expression favoured benefit from SEQ therapy (PFS HR 0.31, 95% CI 0.13-0.70).

CONCLUSIONS

SEQ delivery of nabP+gemcitabine improved PFS and ORR, with manageable toxicity, but did not significantly improve OS.

CLINICAL TRIAL REGISTRATION

ISRCTN71070888; ClinialTrials.gov (NCT03529175).

Photoluminescence spectroscopy of anthrathiophenes and benzonaphthothiophenes in Shpol'skii matrixes

The dispersion of harmful oil components into the ocean waters could pose long-term risks to flora and fauna. Due to the complexity of oil-contaminated sites, the unambiguous identification and quantitation of environmental pollutants often requires the sequence of high-performance liquid chromatography and gas chromatography-mass spectrometry. A classic example is the analysis of polycyclic aromatic hydrocarbons. This article tackles a different aspect of environmental analysis as it focuses on the Shpol'skii spectroscopy of polycyclic aromatic sulfur heterocycles, specifically those belonging to the subgroups often known as anthrathiophenes and benzonaphthothiophenes. Photoluminescence measurements were made with a commercial spectrofluorimeter equipped with a continuous wave excitation source for steady state measurements and a pulsed excitation source for time-resolved measurements in the phosphorescence time domain. To the extent of our literature search, this is the first report on the 4.2 K fluorescence and phosphorescence spectra of anthrathiophenes and benzonaphthothiophenes, and the 77 K and 4.2 K phosphorescence lifetimes of benzonaphthothiophenes. 77 K and 4.2 K analytical figures of merit revealed the possibility to detect the studied compounds at the parts-per-billion (ng mL^-1) concentration levels. The spectral and lifetime data gathered in this article provides the required information to choose an appropriate photoluminescence technique for the analysis of four-ring polycyclic aromatic sulfur heterocycles in complex environmental extracts.

P77 Type II PEG fractures: collar or no collar

Objectives

Type 2 peg fractures are known to have low fusion rates but most are elderly with comorbidities and not fit for surgery. Increasingly, clinicians want to stop using hard collars due to its complications, but with little supporting evidence. We aim to provide data to add to this debate.

Design

Single centre cohort study.

Subjects

145 consecutive patients referred to a Major Trauma Centre as type 2 peg fracture.

Methods

All patients referred with a suspected peg fracture between March 2015 and December 2017 were included. All imaging were assessed and case notes reviewed for patient demographics, fracture management, complications and outcomes.

Results

102 cases were peg fractures (mean age=80 years). 92 (90.2%) were managed conservatively with a hard collar (mean of 87 days). 37% developed symptoms from the collar, namely pain, stiffness and non-tolerance. Bony union was achieved in only 39.1% of patients with increasing age being an independent risk factor (p<0.001). Of the 56 patients who did not have bony union, there were no reported symptoms and 90% were discharged without a collar. 2 patients were offered but declined fixation and neither reported any on-going symptoms.

Conclusions

This study adds to the body of evidence that fusion rates are low, and collar complications are not insignificant when type 2 peg fractures are treated in a hard collar. However, outcomes are good regardless of union, potentially rendering the collar unnecessary. We aim to conduct a randomised prospective study to further investigate.

Impacts of improved extension services on awareness, knowledge, adoption rates and perceived benefits of smallholder dairy farmers in Pakistan

The provision of effective extension services to smallholder farmers across both developing and developed countries remains a challenge worldwide. The objective of the study is to demonstrate the impacts of improved extension services on awareness, knowledge, adoption rates and perceived benefits of smallholder dairy farmers in Pakistan. An extension program was developed and implemented in five districts of Punjab (Okara, Pakpattan, Jhelum, Kasur and Bhakkar) and two districts of Sindh (Thatta and Badin) provinces. The extension program involved the provision of research-based information on a monthly basis to smallholder farming families (FF = 523) over a 4-year period. The extension program was primarily a knowledge transfer-based system, but also relied on farmer engagement and feedback to help drive research and topics for discussion. No financial incentives were provided to the farmers for their participation. A ‘whole-family approach’ was used in the extension program, where comprehensive interdisciplinary training on the whole dairy-farming system was provided to the males, females and children of the farming household. To encourage greater participation and support different learning strategies, several information transfer media were used (including group discussions, one-on-one visits, practical demonstrations, problem-based learning techniques and videos). To assess the impact of this extension program on farms involved, data on farmer awareness, knowledge, adoption and their perceived benefits were collected using a mixed-method approach from three different groups of farmers; registered (IMPreg = 179) farmers directly involved in the extension program, non-registered (IMPnon-reg = 116) farmers indirectly benefiting from the program and traditional (IMPtrad = 104) farmers not associated with any project activities. Overall awareness, knowledge and adoption rates relating to seven different recommendations in the extension program were significantly (P &lt; 0.05) higher in the registered farmers than in the non-registered and traditional farmers. The perceived benefits of the adopted recommendations varied between the different extension messages, but farmers described that they observed increases in milk production, improvements in animal health (body condition and morbidity) and labour efficiency (time savings). These results suggest that adopting improved extension services using a whole-family approach we can significantly achieve higher adoption rates, leading to on-farm benefits to smallholder dairy farmers and their families.

β-cell specific T-lymphocyte response has a distinct inflammatory phenotype in children with Type 1 diabetes compared with adults

AIM

To examine the hypothesis that the quality, magnitude and breadth of helper T-lymphocyte responses to β cells differ in Type 1 diabetes according to diagnosis in childhood or adulthood.

METHODS

We studied helper T-lymphocyte reactivity against β-cell autoantigens by measuring production of the pro-inflammatory cytokine interferon-γ and the anti-inflammatory cytokine interleukin-10, using enzyme-linked immunospot assays in 61 people with Type 1 diabetes (within 3 months of diagnosis, positive for HLA DRB1*0301 and/or *0401), of whom 33 were children/adolescents, and a further 91 were unaffected siblings.

RESULTS

Interferon-γ responses were significantly more frequent in children with Type 1 diabetes compared with adults (85 vs 61%; P = 0.04). Insulin and proinsulin peptides were preferentially targeted in children (P = 0.0001 and P = 0.04, respectively) and the breadth of the interferon-γ response was also greater, with 70% of children having an interferon-γ response to three or more peptides compared with 14% of adults (P < 0.0001). Islet β-cell antigen-specific interleukin-10 responses were similar in children and adults in terms of frequency, breadth and magnitude, with the exception of responses to glutamic acid decarboxylase 65, which were significantly less frequent in adults.

CONCLUSIONS

At diagnosis of Type 1 diabetes, pro-inflammatory autoreactivity is significantly more prevalent, focuses on a wider range of targets, and is more focused on insulin/proinsulin in children than adults. We interpret this as indicating a more aggressive immunological response in the younger age group that is especially characterized by loss of tolerance to proinsulin. These findings highlight the existence of age-related heterogeneity in Type 1 diabetes pathogenesis that could have relevance to the development of immune-based therapies.

Long-term mortality and follow-up after carotid artery stenting

BACKGROUND

Carotid artery stenting (CAS) is an alternative to carotid endarterectomy for the prevention of stroke and transient ischemic attack (TIA). The high long-term mortality among patients who underwent CAS seems to be related to the high comorbidity burden, including coronary and peripheral artery disease. However, limited data on very long-term mortality (over four years) and predictors of death are available.

AIM

We sought to investigate the very long-term survival after CAS and the impact of comorbidities on mortality at follow-up.

METHODS

Data of 194 symptomatic and asymptomatic patients who underwent CAS with cerebral protection systems from December 2002 to March 2014 were analyzed. All cause mortality during long-term follow-up was assessed. Univariate and multivariate Cox regression analysis was used to find independent predictors of death.

RESULTS

The median age of patients was 66 [interquartile range (IQR): 60-73] years and 78.9 % of patients were male. The median follow-up was 7.6 (IQR: 4.4-10.2) years. The all-cause mortality rate after 30 days, one year, four years, and at maximum follow-up was 0 %, 5.1 %, 17.5 % and 31.4 %, respectively. Out of 61 deaths, 37 (60 %) were cardio-cerebral vascular related deaths, 15 (25 %) non-cardiovascular deaths, and 9 (15 %) due to unknown reasons. Among cardio-cerebral vascular deaths, there were 12 fatal strokes, 18 fatal myocardial infarctions and seven other cardiac related deaths. Non-cardiac deaths were due mainly to cancer (9/15). Age and diabetes mellitus were independent predictors of all-cause death during long-term follow-up.

CONCLUSIONS

The mortality rate during short and long-term follow-up after CAS was lower than reported in the literature. Age and diabetes mellitus were independent predictors of all-cause death. Further research is needed to confirm the potential association between those risk factors and decreased survival. Hippokratia 2016, 20(3): 204-208.

The development and evaluation of a community-based clinical diagnosis tool and treatment regimen for postpartum sepsis in Bangladesh and Pakistan

BACKGROUND

Postpartum sepsis accounts for most maternal deaths between three and seven days postpartum, when most mothers, even those who deliver in facilities, are at home. Case fatality rates for untreated women are very high. Newborns of ill women have substantially higher infection risk.

METHODS/DESIGN

The objectives of this study are to: (1) create, field-test and validate a tool for community health workers to improve diagnostic accuracy of suspected puerperal sepsis; (2) measure incidence and identify associated risk factors and; (3) describe etiologic agents responsible and antibacterial susceptibility patterns. This prospective cohort study builds on the Aetiology of Neonatal Infection in South Asia study in three sites: Sylhet, Bangladesh and Karachi and Matiari, Pakistan. Formative research determined local knowledge of symptoms and signs of postpartum sepsis, and a systematic literature review was conducted to design a diagnostic tool for community health workers to use during ten postpartum home visits. Suspected postpartum sepsis cases were referred to study physicians for independent assessment, which permitted validation of the tool. Clinical specimens, including urine, blood, and endometrial material, were collected for etiologic assessment and antibiotic sensitivity. All women with puerperal sepsis were given appropriate antibiotics.

DISCUSSION

This is the first large population-based study to expand community-based surveillance for diagnoses, referral and treatment of newborn sepsis to include maternal postpartum sepsis. Study activities will lead to development and validation of a diagnostic tool for use by community health workers in resource-poor countries. Understanding the epidemiology and microbiology of postpartum sepsis will inform prevention and treatment strategies and improve understanding of linkages between maternal and neonatal infections.

Characterization of the autoimmune response against the nerve tissue S100β in patients with type 1 diabetes

Type 1 diabetes results from destruction of insulin-producing beta cells in pancreatic islets and is characterized by islet cell autoimmunity. Autoreactivity against non-beta cell-specific antigens has also been reported, including targeting of the calcium-binding protein S100β. In preclinical models, reactivity of this type is a key component of the early development of insulitis. To examine the nature of this response in type 1 diabetes, we identified naturally processed and presented peptide epitopes derived from S100β, determined their affinity for the human leucocyte antigen (HLA)-DRB1*04:01 molecule and studied T cell responses in patients, together with healthy donors. We found that S100β reactivity, characterized by interferon (IFN)-γ secretion, is a characteristic of type 1 diabetes of varying duration. Our results confirm S100β as a target of the cellular autoimmune response in type 1 diabetes with the identification of new peptide epitopes targeted during the development of the disease, and support the preclinical findings that autoreactivity against non-beta cell-specific autoantigens may have a role in type 1 diabetes pathogenesis.

Multi-parametric flow cytometric and genetic investigation of the peripheral B cell compartment in human type 1 diabetes

The appearance of circulating islet-specific autoantibodies before disease diagnosis is a hallmark of human type 1 diabetes (T1D), and suggests a role for B cells in the pathogenesis of the disease. Alterations in the peripheral B cell compartment have been reported in T1D patients; however, to date, such studies have produced conflicting results and have been limited by sample size. In this study, we have performed a detailed characterization of the B cell compartment in T1D patients (n = 45) and healthy controls (n = 46), and assessed the secretion of the anti-inflammatory cytokine interleukin (IL)-10 in purified B cells from the same donors. Overall, we found no evidence for a profound alteration of the B cell compartment or in the production of IL-10 in peripheral blood of T1D patients. We also investigated age-related changes in peripheral B cell subsets and confirmed the sharp decrease with age of transitional CD19(+) CD27(-) CD24(hi) CD38(hi) B cells, a subset that has recently been ascribed a putative regulatory function. Genetic analysis of the B cell compartment revealed evidence for association of the IL2-IL21 T1D locus with IL-10 production by both memory B cells (P = 6·4 × 10(-4) ) and islet-specific CD4(+) T cells (P = 2·9 × 10(-3) ). In contrast to previous reports, we found no evidence for an alteration of the B cell compartment in healthy individuals homozygous for the non-synonymous PTPN22 Trp(620) T1D risk allele (rs2476601; Arg(620) Trp). The IL2-IL21 association we have identified, if confirmed, suggests a novel role for B cells in T1D pathogenesis through the production of IL-10, and reinforces the importance of IL-10 production by autoreactive CD4(+) T cells.

Eastern Canadian colorectal cancer consensus conference: application of new modalities of staging and treatment of gastrointestinal cancers

The annual Eastern Canadian Colorectal Cancer Consensus Conference was held in Ottawa, Ontario, October 22-23, 2010. Health care professionals involved in the care of patients with colorectal cancer participated in presentation and discussion sessions for the purpose of developing the recommendations presented here. This consensus statement addresses current issues in the management of colorectal cancer, such as the use of epidermal growth factor inhibitors in metastatic colon cancer, the benefit of calcium and magnesium with oxaliplatin chemotherapy, the role of microsatellites in treatment decisions for stage II colon cancer, the staging and treatment of rectal cancer, and the management of colorectal and metastatic pancreatic cancers.

Proinsulin peptide immunotherapy in type 1 diabetes: report of a first-in-man Phase I safety study

Immunotherapeutic strategies under consideration for type 1 diabetes include modification of the autoimmune response through antigen-specific routes. Administration of short peptides representing T cell epitopes targeted by patients with the disease represents one approach. This study evaluated safety and mechanistic outcomes during first-in-man intradermal administration of a human leucocyte antigen-DR4 (HLA-DR4)-restricted peptide epitope of proinsulin (C19-A3). This randomized, open-label study assessed two major theoretical risks of peptide immunotherapy, namely induction of allergic hypersensitivity and exacerbation of the proinflammatory autoimmune response, using clinical assessment and mechanistic assays in vitro. Patients with long-standing type 1 diabetes and HLA-DRB1*0401 genotype received 30 microg (n = 18) or 300 microg (n = 18) of peptide in three equal doses at 0, 1 and 2 months or no intervention (n = 12). Proinsulin peptide immunotherapy in the dosing regimen used is well tolerated and free from risk of systemic hypersensitivity and induction/reactivation of proinsulin-specific, proinflammatory T cells. Peptide-specific T cells secreting the immune suppressive cytokine interleukin (IL)-10 were observed at month 3 in four of 18 patients in the low-dose group (versus one of 12 in the control group; P = not significant). Mean IL-10 response to peptide in the low-dose group increased between 0 and 3 months (P = 0.05 after stimulation with 5 microM peptide in vitro) and then declined to baseline levels between 3 and 6 months (P = 0.01 at 10 microM peptide in vitro). These studies pave the way for future investigations in new-onset patients designed to examine whether proinsulin peptide immunotherapy has beneficial effects on markers of T cell autoimmunity and preservation of beta cell mass.

Cytoarchitectural and kinetic features in the histological evaluation of follicular thyroid neoplasms

AIMS

The diagnosis of follicular thyroid carcinomas is mainly based on capsular and vascular invasion. The aim of this study was to determine the diagnostic relevance of nuclear features, inflammation and stromal changes.

METHODS AND RESULTS

Anisokaryosis, chromatin pattern, nucleolus, nuclear pleomorphism, nuclear/cytoplasmic ratio, necrosis, stromal changes and tumour interstitial lymphocytes (TIL) were analysed in adenomatous hyperplastic nodules (39), adenomas (43) and carcinomas (28 minimally invasive, 48 widely invasive and 27 anaplastic). Ki67 immunostaining, in situ end labelling (ISEL) for apoptosis and the Ki67/ISEL index were analysed by topographical compartments. Variables were compared by histological diagnosis using Fisher's exact test, analysis of variance and Student's t-tests and considered significant if P < 0.05. TIL were absent in 96% of neoplasms and 54% of adenomatous hyperplastic nodules. Conspicuous nucleoli, increased nuclear-cytoplasmic ratio and coexistent apoptosis-myxoid changes distinguished minimally invasive carcinomas from adenomas. The most specific variables of high-grade carcinoma were vasculonecrotic patterns, nuclear hyperchromatism and pleomorphism. A kinetic advantage predominated in the internal compartments of benign lesions and in the peripheral compartments of malignant lesions.

CONCLUSIONS

Follicular carcinomas show up-regulation of proliferation markers and the distinctive topographical kinetic profiles provide a basis for the distinction between benign and malignant and an explanation for the circumscription and encapsulation of benign lesions.

Intravascular leiomyomatosis and benign metastasizing leiomyoma: an unusual case

Benign metastasizing leiomyoma (BML) and intravascular leiomyomatosis (IVL) are rare variants of uterine leiomyomas. In our search of available literature, there have been only two reports of these conditions occurring in the same patient. We report a case of a 42-year-old female presenting with a left L4 nerve root lesion, left paravesical lesion, left ovarian cyst, multiple pulmonary metastases, and an intracaval lesion. Histology confirmed these to be leiomyomata strongly positive for estrogen receptors. Treatment included surgery, in two stages, to remove the L4 nerve root, left paravesical lesion, intracaval lesion, and a single pulmonary nodule. The remaining tumor was treated with a gonadotrophin-releasing hormone agonist, resulting in significant reductions in tumor size. It was concluded that the lesions in the lungs were an example of BML arising from the initial diagnosis of uterine leiomyoma, and the caval lesion was an IVL. Long-term follow-up is recommended, and familiarity with rare forms of benign smooth muscle uterine tumors is essential in avoiding misdiagnosis and overtreatment.

Intravascular leiomyomatosis and benign metastasizing leiomyoma: an unusual case

Benign metastasizing leiomyoma (BML) and intravascular leiomyomatosis (IVL) are rare variants of uterine leiomyomas. In our search of available literature, there have been only two reports of these conditions occurring in the same patient. We report a case of a 42-year-old female presenting with a left L4 nerve root lesion, left paravesical lesion, left ovarian cyst, multiple pulmonary metastases, and an intracaval lesion. Histology confirmed these to be leiomyomata strongly positive for estrogen receptors. Treatment included surgery, in two stages, to remove the L4 nerve root, left paravesical lesion, intracaval lesion, and a single pulmonary nodule. The remaining tumor was treated with a gonadotrophin-releasing hormone agonist, resulting in significant reductions in tumor size. It was concluded that the lesions in the lungs were an example of BML arising from the initial diagnosis of uterine leiomyoma, and the caval lesion was an IVL. Long-term follow-up is recommended, and familiarity with rare forms of benign smooth muscle uterine tumors is essential in avoiding misdiagnosis and overtreatment.

Histopathologic parameters of prognosis in cervical cancer--a review

Apart from clinical stage and lymph node status, acknowledged to be among the most powerful predictors of outcome in cervical cancer, the determination of prognosis and thereby the need for adjuvant therapy in surgically treated patients currently relies on a variety of histopathologic factors. The role of many of these is controversial. This may be because histopathology is genuinely lacking in sensitivity for predicting tumor behavior in vivo. There is, however, wide variation in histopathologic definitions and criteria. This is probably the major reason for both the lack of reproducibility in the reporting of certain factors and in their diminished value in predicting behavior. Tumor type, grade, vascular invasion, pattern of invasion, and depth are all extremely important prognostic indicators when used individually or as a part of a scoring system.

Histopathologic parameters of prognosis in cervical cancer – a review

Apart from clinical stage and lymph node status, acknowledged to be among the most powerful predictors of outcome in cervical cancer, the determination of prognosis and thereby the need for adjuvant therapy in surgically treated patients currently relies on a variety of histopathologic factors. The role of many of these is controversial. This may be because histopathology is genuinely lacking in sensitivity for predicting tumor behavior in vivo. There is, however, wide variation in histopathologic definitions and criteria. This is probably the major reason for both the lack of reproducibility in the reporting of certain factors and in their diminished value in predicting behavior. Tumor type, grade, vascular invasion, pattern of invasion, and depth are all extremely important prognostic indicators when used individually or as a part of a scoring system.

Impact of microscopic extranodal tumor deposits on the outcome of patients with rectal cancer

PURPOSE

Microscopic mesorectal soft tissue extranodal deposits discontinuous with the primary tumor are identified in many rectal adenocarcinomas. Current guidelines consider them to be involved lymph nodes. We studied the impact of these deposits on the outcome of patients with rectal cancer.

METHODS

This was a retrospective study, in which histology slides were reviewed from 55 patients whose resection specimens for rectal cancer were staged as Dukes C or Dukes B with extranodal deposits. Twenty-nine patients had extranodal deposits (19 males), and 26 control patients had lymph node involvement only (14 males). Patient outcome was analyzed in terms of local and systemic control and survival.

RESULTS

Distant metastases were diagnosed earlier in patients with extranodal deposits (mean, 14 months) compared with controls (mean, 37 months; P = 0.001). On follow-up, 31.03 percent (9/29) from the extranodal deposit group developed liver metastases compared with 11.5 percent (3/26) of the control group (P = 0.08). Local recurrence was seen in 17.2 percent of patients from the extranodal deposit group and 3.8 percent of the control group (P = not significant). Cancer-related mortality was higher in the extranodal deposit group (16 vs. 7 patients; P = 0.09). The three-year actuarial survival was 48.27 percent in patients with extranodal deposits and 65.38 percent in those without. A significant association was noted between the number of extranodal deposits and intramural vascular invasion (P = 0.017), extramural vascular invasion (P = 0.039), perineural invasion (P = 0.039), and lymph node involvement (P = 0.008).

CONCLUSION

These data suggest that extranodal deposit is a distinct form of metastatic disease in patients with rectal cancer. The association with vascular invasion and earlier development of metastases probably infers that a significant proportion of extranodal deposits may represent blood-borne spread. These tumor foci should be considered as indicators of poor prognosis.

Promiscuous binding of proinsulin peptides to Type 1 diabetes-permissive and -protective HLA class II molecules

AIMS/HYPOTHESIS

Presentation of peptide epitopes derived from beta-cell autoantigens, such as insulin and its precursor molecules, by MHC class II molecules to autoreactive T-cells is believed to play a role in the development of Type 1 diabetes. However, little is known about the interaction between peptides of (prepro)insulin and MHC class II molecules permissive and protective for Type 1 diabetes. In this study therefore, peptides spanning the human preproinsulin sequence were assessed for their binding characteristics to Type 1 diabetes-protective and -permissive HLA molecules.

METHODS

HLA-DR2, -DQ6.2 (Type 1 diabetes-protective) and HLA-DR4, -DQ8 (Type 1 diabetes permissive) molecule binding affinity for overlapping synthetic 20mer peptides spanning human preproinsulin was measured in a direct competition binding assay against a biotinylated indicator peptide.

RESULTS

All HLA molecules tested showed similarity in their binding characteristics across the preproinsulin molecule, with regions of the insulin A-chain showing the highest affinity and C-peptide regions the lowest affinity for all HLA molecules tested. Furthermore, an insulin peptide implicated as a major CD4+ T-cell target in disease pathogenesis (B9-23) had high affinity binding to both protective and permissive HLA molecules but did not represent the highest affinity region of (prepro)insulin identified in either case.

CONCLUSION/INTERPRETATION

The results suggest that peptide binding affinity alone is unlikely to be the major determinant of disease susceptibility in relation to interactions between (prepro)insulin epitopes and HLA molecules. The identification of epitopes derived from beta-cell autoantigens that bind promiscuously to diabetes-permissive HLA molecules could be important in the design of peptide-based immunotherapeutic strategies for the prevention of Type 1 diabetes.

Hashimoto's thyroiditis shares features with early papillary thyroid carcinoma

Neoplastic transformation is a multistep process that results in a continuous spectrum from the normal (physiological) state to a fully established neoplasm. The gold standard for diagnosis of papillary thyroid carcinoma is conventional histology, the essential element being the characteristic nuclear features, regardless of whether papillary structures are present or not. However, other criteria are being used increasingly in the diagnosis of neoplasms, including immunohistochemical staining and molecular profile. The RET/PTC gene rearrangement is highly specific for papillary thyroid carcinoma and is associated with the characteristic nuclear features seen in papillary thyroid carcinoma. There is an overlap in the morphological features, immunohistochemical staining pattern, and most importantly, molecular profile between papillary thyroid carcinoma and Hashimoto's thyroiditis. Although considered a 'benign' condition, Hashimoto's thyroiditis almost always harbours a genetic rearrangement that is strongly associated with and is highly specific for papillary thyroid carcinoma. Submicroscopic foci of papillary thyroid carcinoma must be present in Hashimoto's thyroiditis, although the clinical behaviour is still benign. Further studies are required to predict which foci will progress to papillary thyroid carcinoma.

3 beta hydroxysteroid dehydrogenase autoantibodies in patients with idiopathic premature ovarian failure target N- and C-terminal epitopes

The steroid cell enzyme 3 beta hydroxysteroid dehydrogenase (3 beta HSD) has been identified as a target of steroid cell autoantibodies, and autoantibodies to this enzyme are present in patients with premature ovarian failure and patients with autoimmune polyendocrine syndrome 1. The aim of the present study was to develop a radioligand binding assay for 3 beta HSD autoantibodies and to exploit this to examine regions of the molecule targeted by autoantibodies. We generated a construct of 3 beta HSD coupled to a luciferase fusion partner in order to maximize the yield of (35)S-radiolabeled protein. Labeled 3 beta HSD was then immunoprecipitated and the autoantibodies quantified by phosphoimaging. Autoantibodies to 3 beta HSD were detected in 12 of 100 (12%) idiopathic premature ovarian failure patients and 0 of 103 (0%) healthy age-matched controls (P < 0.0001). Three overlapping fragments of 3 beta HSD cDNA were cloned downstream of luciferase to examine autoantibody binding sites. Two of nine sera with 3 beta HSD autoantibodies (22%) displayed reactivity to the N terminus of 3 beta HSD, and seven (77%) showed reactivity to the C terminal; no sera reacted with the middle region. Our study demonstrates a markedly enhanced disease specificity of autoantibodies to 3 beta HSD detected using this novel assay and shows that distinct regions of the molecule are targeted.

The skin we are in--knowledge and practices regarding skin cancer in pre-clinical medical students

OBJECTIVE

To assess the level of knowledge about skin cancer in youth and to explore the influence of gender and system of education on their knowledge and practices.

MATERIALS AND METHODS

A questionnaire-based study was conducted at The Aga Khan University Medical College (AKUMC), on Year 2 pre-clinical medical students. Descriptive analyses to examine the frequency distribution, chi-square test and factor analysis were applied using SPSS.

RESULTS

Seventyone students participated in the study; 90% scored > 55% in the questions regarding knowledge of Malignant melanoma (MM), whereas in the questions assessing practice only 11% of the respondents scored > 52%. They were largely unaware that appearance of a new mole is a risk factor for MM (56% respondents incorrect) and that skin cancer is one of the most common cancers (54% respondents incorrect). 73% reported being sunburned at least once during childhood and 40% suffered sunburns at least once this summer, which points to the inadequacy of sun protection. The risk of MM may double if severe sunburns are experienced during childhood. Education system and gender did not affect the knowledge and practices. The popular sources of learning about skin cancer were magazines (52%) followed by television (42%).

CONCLUSION

There is a need for epidemiological studies in Pakistani population regarding skin cancer. For preventing excessive solar exposure which leads to sunburns, we recommend interventions like a Pilot Program for photoprotection education and Sun Awareness Week to improve knowledge and sun protection behavior.

T-Cell reactivity to the P2C nonstructural protein of a diabetogenic strain of coxsackievirus B4

Enteroviruses are proposed as initiating factors in the etiology of Type 1 diabetes mellitus (Type 1 DM). Molecular mimicry between the autoantigen glutamic acid decarboxylase 65 (GAD65) and the coxsackievirus B4 (CVB4) nonstructural protein P2C is frequently cited as a mechanism by which this virus triggers the disease, but little is known about the immunogenicity of this viral protein in humans, mainly due to the problem of obtaining highly pure preparations of P2C. We generated large amounts of highly pure, soluble P2C protein, coupled to the fusion partner maltose binding protein (MBP-P2C) using the PMAL-c2 bacterial expression plasmid and a two-step purification system comprising amylose resin and ion exchange. Using purified viral protein we show that specific T-cell responses against P2C are detected in the blood of healthy donors and Type 1 DM patients. Proliferation responses to P2C were detected only in subjects also demonstrating T-cell proliferation to CVB4 Vero cell lysates. However, in additional cases T-cell responses to P2C were detectable through the release of interferon-gamma or interleukin-4 in individuals who did not make proliferative responses. Taken together, our data show that the P2C nonstructural protein of CVB4 is targeted by T cells during the antiviral immune response and may trigger the production of T helper 1 and T helper 2 cytokines. The availability of pure, immunogenic P2C should allow the putative role of antiviral responses in the development of autoimmune diabetes to be investigated.

Prevalence of autoantibodies to autonomic nervous tissue structures in Type 1 diabetes mellitus

AIMS

The pathogenesis of diabetic autonomic neuropathy is multifactorial, but recent studies have suggested a link between the presence of autoantibodies to nervous tissue structures and severe, symptomatic autonomic neuropathy. The present study was designed to examine the true prevalence of these autoantibodies in a large clinic-based population of Type 1 diabetic patients compared to nondiabetic controls.

METHODS

The presence of complement fixing autoantibodies to vagus nerve (CF-VN), sympathetic ganglion (CF-SG) and adrenal medulla (CF-ADM) was assessed by immunofluorescence in a large cohort of patients (n = 394) of varying duration of Type 1 DM (median 28 years, range 6 months to 73 years) and 160 age and sex-matched nondiabetic control subjects.

RESULTS

All three autoantibodies were frequently detected in Type 1 DM (CF-VN, 22.1%; CF-SG, 30.7%; CF-ADM, 13.2%) but only rarely in healthy control subjects (4.4%, 4.4% and 3.1%, respectively; P < 0.0005 for all). There was no association between any of the autoantibodies and retinopathy (fundoscopy), peripheral somatic neuropathy (biothesiometry) or nephropathy (urinary albumin-creatinine ratio).

CONCLUSIONS

Our results on this large cohort establish the extensive presence of autonomic nervous tissue autoantibodies in Type 1 DM. Their role in reflecting, causing or predicting autonomic neuropathy remains to be determined.

Human leukocyte antigen-DQB1* genotypes encoding aspartate at position 57 are associated with 3beta-hydroxysteroid dehydrogenase autoimmunity in premature ovarian failure

Premature ovarian failure (POF) has an autoimmune pathogenesis in a significant proportion of cases. Autoantibodies to the steroid cell enzyme, 3beta-hydroxysteroid dehydrogenase (3betaHSD) are present in one fifth of patients and may identify an autoimmune subgroup. As autoimmune diseases are associated with alleles of the human leukocyte antigen (HLA) genes, we examined the distribution of HLA-DRB1 and -DQB1 genotypes in 118 women with POF, of whom 21% had 3betaHSD autoantibodies, and 134 racially matched control subjects. Two HLA-DQB1 alleles, 0301 and 0603, were associated with 3betaHSD autoantibody positivity (P = 0.04 and P = 0.006, respectively). As the DQB1*0301 and -0603 genes share an identical codon at position 57 (aspartate, Asp), we analyzed the frequency of DQbeta-Asp57 encoding DQB1 genes in our series. Eighteen of 21 POF patients with 3betaHSD autoantibodies had DQbeta-Asp57-encoding genotypes (haplotype frequency, 27 of 42; 64%) compared with 92 of 134 control subjects (haplotype frequency, 109 of 268; 41%; P = 0.004), and 9 of 21 (43%) cases were homozygous for codon 57 genotypes compared with 17 of 134 (13%) control subjects (P = 0.0006). These probability values were not significant after correction for multiple testing, and these trends will therefore require confirmation in larger cohorts. HLA class II molecules present antigenic peptides to CD4+ T lymphocytes. DQbeta57 occupies a key site at the boundary of the peptide binding groove, with a major impact on peptide binding. Our preliminary demonstration of an association between POF, 3betaHSD autoimmunity, and a distinctive HLA-DQ molecule supports the hypothesis that autoantibodies to this steroid cell enzyme may be markers of autoimmune ovarian failure and suggests that presentation of autoantigenic or external peptides to T lymphocytes by HLA-DQ molecules with Asp57-beta-chains is important in the pathogenesis of this disease.