Clinicopathological Profile and Survival Outcomes in Patients with Localised Extremity Synovial Sarcomas

AIMS

Synovial sarcoma is a rare but aggressive variant of soft-tissue sarcoma. Literature is sparse and reported mostly from the West. We analysed the clinical profiles and prognostic factors of extremity synovial sarcoma patients in order to study their clinical journey.

MATERIALS AND METHODS

This was a retrospective analysis. All patients with extremity synovial sarcoma treated between 1992 and 2020 were included. Patients with metastases at presentation were excluded. A descriptive analysis of demographic and clinicopathological features of patients undergoing limb salvage surgery (LSS) or amputation was carried out. Overall survival and disease-free survival were calculated for the entire cohort as well as for the LSS and amputation groups. Factors prognostic for survival were identified.

RESULTS

In total, 157 patients had localised extremity synovial sarcoma. Predominantly, young adults (median 31 years) and males (61%) were affected. Over 70% of patients presented after recurrence or unplanned surgeries. Sixty-seven per cent of tumours were >5 cm, 69% were deep and 23% involved bone. The limb salvage rate was 64%. In the LSS group, adjuvant radiotherapy and chemotherapy were given to 72% and 68% of patients, respectively. In the amputation group, 72% of patients received adjuvant chemotherapy. In a median follow-up of 59 months, 39.4% of patients had recurrences, the majority (61.2%) were systemic. Five-year overall survival and disease-free survival were 53.4% and 49.8%, respectively. Overall survival was 63.9% and 29.7% in the LSS and amputation groups, respectively. On multivariate analysis, tumour size, depth, omission of radiotherapy and bone invasion were found to be the adverse prognostic factors.

CONCLUSION

This is one of the largest studies on extremity synovial sarcoma. Mostly males and young adults were affected. The limb salvage rate was 64%, despite most being referred after unplanned surgery. Almost 70% of patients received radiotherapy and chemotherapy. Overall survival was inferior in the amputation group. Tumour size >5 cm, depth and bone invasion were negative, whereas adjuvant radiotherapy was a positive prognostic factor for survival. Chemotherapy had no impact on survival.

Bench-to-bedside imaging in brain metastases: a road to precision oncology

Radiology has seen tremendous evolution in the last few decades. At the same time, oncology has made great strides in diagnosing and treating cancer. Distant metastases of neoplasms are being encountered more often in light of longer patient survival due to better therapeutic strategies and diagnostic methods. Brain metastasis (BM) is a dismal manifestation of systemic cancer. In the present scenario, magnetic resonance imaging (MRI), computed tomography (CT) and positron emission tomography (PET) are playing a big role in providing molecular information about cancer. Lately, molecular imaging has emerged as a stirring arena of dynamic imaging techniques that have enabled clinicians and scientists to noninvasively visualize and understand biological processes at the cellular and molecular levels. This knowledge has impacted etiopathogenesis, detection, personalized treatment, drug development, and our understanding of carcinogenesis. This article offers insight into the molecular biology underlying brain metastasis, its pathogenesis, imaging protocols, and algorithms. It also discusses disease-specific molecular imaging features, focusing on common tumors that spread to the brain, such as lung, breast, colorectal cancer, melanoma, and renal cell carcinoma. Additionally, it covers various targeted treatment options, criteria for assessing treatment response, and the role of artificial intelligence in diagnosing, managing, and predicting prognosis for patients with brain metastases.

Post-treatment imaging of gliomas: challenging the existing dogmas

Gliomas are the commonest malignant central nervous system tumours in adults and imaging is the cornerstone of diagnosis, treatment, and post-treatment follow-up of these patients. With the ever-evolving treatment strategies post-treatment imaging and interpretation in glioma remains challenging, more so with the advent of anti-angiogenic drugs and immunotherapy, which can significantly alter the appearance in this setting, thus making interpretation of routine imaging findings such as contrast enhancement, oedema, and mass effect difficult to interpret. This review details the various methods of management of glioma including the upcoming novel therapies and their impact on imaging findings, with a comprehensive description of the imaging findings in conventional and advanced imaging techniques. A systematic appraisal for the existing and emerging techniques of imaging in these settings and their clinical application including various response assessment guidelines and artificial intelligence based response assessment will also be discussed.

Improved Stability and Manufacturability of Nucleocapsid Antigens for SARS-CoV2 Diagnostics through Protein Engineering

The COVID-19 pandemic has had a significant impact on human health management. A rapid diagnosis of SARS-CoV2 at the point-of-care (POC) is critical to prevent disease spread. As a POC device for remote settings, a LFIA should not require cold-chain maintenance and should be kept at normal temperatures. Antigen stability can be enhanced by addressing instability issues when dealing with fragile components, such as proteinaceous capture antigens. This study used immunologically guided protein engineering to enhance the capture nucleocapsid (NP) antigen stability of SARS-CoV2. A search of the IEDB database revealed that antibodies detecting epitopes are almost uniformly distributed over NP1-419. In contrast, N-terminal stretches of NP1-419 are theoretically more unstable than C-terminal stretches. We identified NP250-365 as a NP stretch with a low instability index and B-cell epitopes. Apart from NP1-419, two other variants (NP121-419 and NP250-365) were cloned, expressed, and purified. The degradation pattern of the proteins was observed on SDS-PAGE after three days of stability studies at -20 °C, 4 °C, and 37 °C. NP1-419 was the most degraded while NP250-365 exhibited the least degradation. Also, NP1-419, NP250-365, and NP121-419 reacted with purified antibodies from COVID-19 patient serum. Our results suggest that NP250-365 may be used as a stable capture antigen in LFIA devices to detect COVID-19.

Impact of COVID-19 pandemic early response measures on myocardial infarctions and acute cardiac care in Singapore

BACKGROUND

The COVID-19 pandemic impacted acute myocardial infarction (AMI) attendances, ST-elevation myocardial infarction (STEMI) treatment and outcomes. We collated data from majority of primary percutaneous coronary intervention (PPCI)-capable public healthcare centres in Singapore to understand the initial impact COVID-19 had on essential time-critical emergency services. We present data comparisons from 'Before Disease Outbreak Response System Condition (DORSCON) Orange', 'DORSCON Orange to start of circuit breaker (CB)' and during the first month of 'CB'.

METHODS

We collected aggregate numbers of weekly elective PCI from 4 centres and AMI admissions, PPCI and in-hospital mortality from 5 centres. Exact door-to-balloon (DTB) times were recorded for 1 centre; another 2 reported proportions of DTB times exceeding targets.

RESULTS

Median weekly elective PCI cases significantly decreased from 'Before DORSCON Orange' to 'DORSCON Orange to start of CB' (34 vs. 22.5, p=0.013).Median weekly STEMI admissions and PPCI did not change significantly. In contrast, the median weekly NSTEMI admissions decreased significantly from 'Before DORSCON Orange' to 'DORSCON Orange to start of CB' (59 vs. 48, p=0.005) and was sustained during CB (39 cases).Exact DTB times reported by 1 centre showed no significant change in the median. Out of 3 centres, 2 reported significant increases in the proportion that exceeded DTB targets.In-hospital mortality rates remained static.

CONCLUSION

In Singapore, STEMI and PPCI rates remained stable, while NSTEMI rates decreased during DORSCON and CB. The SARS experience may have helped prepare us to maintain essential services such as PPCI during periods of acute healthcare resource strain. However, data must be monitored and increased pandemic preparedness measures must be explored to ensure that AMI care is not adversely affected by continued COVID fluctuations and future pandemics.

Outcomes among preterm infants with patent ductus arteriosus: Relationship with treatment, gestational age, hemodynamic status and timing of treatment

BACKGROUND

There remains controversy regarding the outcomes resulting from treatment versus conservative management of patent ductus arteriosus (PDA) among preterm infants. The effects of extreme prematurity, hemodynamic status of the PDA, and age at treatment remain poorly defined.

STUDY DESIGN

This retrospective case-control study including infants <  1250 gm who were categorized into 3 groups: Group 1: without PDA, Group 2: with untreated PDA, and Group 3: treated PDA. Diagnosis and treatment of PDA extracted from the medical records. Demographics, clinical characteristics, and outcomes compared using chi-square and analysis of variance. Logistic regression used to estimate adjusted odds ratios.

RESULTS

The study included 734 infants, with 141(19%) in Group 1, 329 (45%) in 2, and 264 (36%) in 3. Group 3 had higher incidence of bronchopulmonary dysplasia (BPD) (aOR, 2.9; 95%CI 1.7-4.8). Infant treated for hemodynamically significant PDA (HSPDA) had higher incidence of BPD (aOR, 1.9; 95%CI 1.0-3.8) and retinopathy of prematurity (ROP) (aOR, 3.4; 95%CI 1.6-6.9). There were no differences in outcome associated with treatment among≤26 weeks gestation and the age when treated.

CONCLUSION

Infants with PDA who were treated had higher incidence of BPD. Among those who were treated, those with HSPDA had a higher incidence of BPD and ROP.

Microbial community in human gut: a therapeutic prospect and implication in health and diseases

The interest in the working and functionality of the human gut microbiome has increased drastically over the years. Though the existence of gut microbes has long been speculated for long over the last few decades, a lot of research has sprung up in studying and understanding the role of gut microbes in the human digestive tract. The microbes present in the gut are highly instrumental in maintaining the metabolism in the body. Further research is going on in this field to understand how gut microbes can be employed as potential sources of novel therapeutics; moreover, probiotics have also elucidated their significant place in this direction. As regards the clinical perspective, microbes can be engineered to afford defence mechanisms while interacting with foreign pathogenic bodies. More investigations in this field may assist us to evaluate and understand how these cells communicate with human cells and promote immune interactions. Here we elaborate on the possible implication of human gut microbiota into the immune system as well as explore the probiotics in the various human ailments. Comprehensive information on the human gut microbiome at the same platform may contribute effectively to our understanding of the human microbiome and possible mechanisms of associated human diseases.

The long noncoding RNA MALAT1 suppresses miR-211 to confer protection from ultraviolet-mediated DNA damage in vitiligo epidermis by upregulating sirtuin 1

BACKGROUND

The absence of melanocytes poses a challenge for long-term tissue homeostasis in vitiligo. Surprisingly, while individuals with Fitzpatrick phototypes I-II (low melanin content) have a higher incidence of melanoma and nonmelanoma skin cancer, people with vitiligo are at a decreased risk for the same.

OBJECTIVES

To understand the molecular mechanisms that protect vitiligo skin from ultraviolet (UV)-induced DNA damage by (i) characterizing differentially expressed microRNAs in lesional vs. nonlesional epidermis and (ii) identifying their upstream regulators and downstream gene targets.

METHODS

Genome-wide microRNA profiling of nonlesional and lesional epidermis was performed on five individuals with stable nonsegmental vitiligo using next-generation RNA sequencing. The relevance of the upstream regulator and downstream target gene of the most differentially expressed microRNA was studied.

RESULTS

Our study found sirtuin1 (SIRT1), an NAD-dependent deacetylase, to be a direct target of miR-211 - the most significantly downregulated microRNA in lesional epidermis. Inhibition of SIRT1 with EX-527 downregulated keratin 10 and involucrin, suggesting that SIRT1 promotes keratinocyte differentiation. Overexpression of miR-211 mimic led to a significant increase in γ-H2AX positivity and cyclobutane pyrimidine dimer (CPD) formation, hallmarks of UVB-mediated DNA damage. These effects could be ameliorated by the addition of resveratrol, a SIRT1 activator. Furthermore, a long noncoding RNA, MALAT1, was identified as a negative upstream regulator of miR-211. Overexpression of MALAT1 resulted in increased expression of SIRT1 and a concomitant removal of UVB-induced CPDs in primary keratinocytes.

CONCLUSIONS

These findings establish a novel MALAT1-miR-211-SIRT1 signalling axis that potentially confers protection to the 'amelanotic' keratinocytes in vitiligo.

Impact of the COVID-19 Pandemic on Door-to-Balloon Time for Primary Percutaneous Coronary Intervention - Results From the Singapore Western STEMI Network

BACKGROUND

Little is known about the effect of the coronavirus disease 2019 (COVID-19) pandemic and the outbreak response measures on door-to-balloon time (D2B). This study examined both D2B and clinical outcomes of patients with STEMI undergoing primary percutaneous coronary intervention (PPCI).Methods and Results:This was a retrospective study of 303 STEMI patients who presented directly or were transferred to a tertiary hospital in Singapore for PPCI from October 2019 to March 2020. We compared the clinical outcomes of patients admitted before (BOR) and during (DOR) the COVID-19 outbreak response. The study outcomes were in-hospital death, D2B, cardiogenic shock and 30-day readmission. For direct presentations, fewer patients in the DOR group achieved D2B time <90 min compared with the BOR group (71.4% vs. 80.9%, P=0.042). This was more apparent after exclusion of non-system delay cases (DOR 81.6% vs. BOR 95.9%, P=0.006). Prevalence of both out-of-hospital cardiac arrest (9.5% vs. 1.9%, P=0.003) and acute mitral regurgitation (31.6% vs. 17.5%, P=0.006) was higher in the DOR group. Mortality was similar between groups. Multivariable regression showed that longer D2B time was an independent predictor of death (odds ratio 1.005, 95% confidence interval 1.000-1.011, P=0.029).

CONCLUSIONS

The COVID-19 pandemic and the outbreak response have had an adverse effect on PPCI service efficiency. The study reinforces the need to focus efforts on shortening D2B time, while maintaining infection control measures.

Roflumilast counteracts DMH-induced preneoplastic colon damage in albino Wistar rats

OBJECTIVE

The study explored the chemoprophylactic potential of roflumilast against 1,2-dimethylhydrazine (DMH) actuated preneoplastic colon damage in albino Wistar rats.

METHODS

Animals were arbitrarily divided into five groups of six animals each. DMH was used to induce preneoplastic colon damage (20 mg/kg/7 days, subcutaneously, for 42 days). Roflumilast was administered subcutaneously at two doses (1 and 5 mg/kg/day, from day 28 to 42). At the end of the study, the animals were recorded for the electrocardiographic changes and heart rate variability (HRV) paradigms on 42nd day, using PowerLab system. Blood samples were collected from all the animals to measure hydrogen sulfide (H₂S) and nitric acid. The colon tissue was dissected out and analyzed for inflammatory markers, biochemical parameters including, superoxide dismutase, thiobarbituric acid reactive substances, catalase, and glutathione reductase and histopathology.

RESULTS

DMH caused derangement of HRV factors, abnormal antioxidant markers, and elevated levels of inflammatory markers. H₂S and nitric oxide levels upsurge in DMH-treated rats and promoted preneoplastic damage. Histopathologically, loss of crypts, goblet cells, and distorted lamina propria were observed in toxic group. Treatment with roflumilast was able to curtail down oxidative stress and inflammatory markers and stabilitate the hemodynamic derangements as well as was able to restore the normal architecture of colonic mucosa.

CONCLUSION

The findings from the present study conclude that treatment with roflumilast positively modulates the preneoplastic colon damage.

Isolated right ventricle infarction

We described two patients who were successfully resuscitated from out-of-hospital cardiac arrest. Their ECGs showed ST elevations in V1 and aVR, as well as diffuse ST depression. Their ST elevation in V1 was noted to be greater than in aVR. While one patient was found to have an occlusion of the right ventricular (RV) branch of the right coronary artery, the other was found to have an occlusion of a proximal non-dominant right coronary artery supplying the RV branch. Successful primary percutaneous coronary intervention was performed for each patient with angioplasty and implantation of a drug-eluting stent. Both patients made good physical and neurological recovery.

The mental health burden in acne vulgaris and rosacea: an analysis of the US National Inpatient Sample

BACKGROUND

Little is known about the mental health (MH) hospitalization among patients with acne and rosacea.

AIMS

To determine the MH disorders and cost burden associated with acne and rosacea.

METHODS

Data were examined from the 2002-2012 US National Inpatient Sample, comprising a sample of ~20% of all US paediatric and adult hospitalizations (n = 87 053 155 admissions).

RESULTS

A diagnosis of ≥ 1 MH disorder was much more common among all inpatients with vs. those without a diagnosis of acne (43.7% vs. 20.0%, respectively) and rosacea (35.1% vs. 20.0%, respectively). In multivariable logistic regression models controlling for sex, age, race/ethnicity and insurance status, acne (adjusted OR = 13.02; 95% CI 11.75-14.42) and rosacea (adjusted OR = 1.70; 95% CI 1.56-1.95) were associated with significantly higher odds of a primary admission for an MH disorder (13 and 8, respectively, of 15 MH disorders examined). Both acne and rosacea were associated with higher risk of mood, anxiety, impulse control and personality disorders, and with > $2 million of excess mean annual costs of hospitalization for MH disorders in the USA.

CONCLUSION

In this study, inpatients with acne or rosacea had increased odds of comorbid MH disorders. In particular, there was an increased number of hospital admissions secondary to a primary MH disorder with coexistent acne/rosacea. MH comorbidities were associated with considerable excess costs among inpatients with acne or rosacea.

The aza-Michael reaction: towards semi-crystalline polymers from renewable itaconic acid and diamines

This paper reports, for the first time, semi-crystalline polymers based on bis-pyrrolidone dicarboxylic acids (BPDA) obtained from the aza-Michael reaction between renewable itaconic acid and various diamines.

Efficacy and safety of brodalumab in patients with psoriasis who had inadequate responses to ustekinumab: subgroup analysis of two randomized phase III trials

BACKGROUND

Brodalumab, a fully human anti-interleukin-17 receptor A monoclonal antibody, has demonstrated superior efficacy and safety over ustekinumab as induction therapy for moderate-to-severe psoriasis.

OBJECTIVES

To evaluate the efficacy and safety of brodalumab through week 52 in patients who had inadequate responses to ustekinumab.

METHODS

A subgroup analysis of the phase III AMAGINE-2/-3 double-blind randomized controlled trials was performed. Participants were aged 18-75 years and had a Psoriasis Area and Severity Index (PASI) ≥ 12, static Physician's Global Assessment score ≥ 3 and involvement of ≥ 10% body surface area. The studies were registered at ClinicalTrials.gov: AMAGINE-2, NCT01708603; AMAGINE-3, NCT01708629.

RESULTS

At baseline, patients with or without prior biologic experience who had an adequate response at week 16 on ustekinumab or brodalumab had lower rates of involved body surface area, PASI, prior biologic use, psoriatic arthritis and body mass index than patients who experienced inadequate response at or after week 16. Among patients who experienced inadequate response to ustekinumab, those rescued with brodalumab had PASI ≥ 75%, ≥ 90% and 100% improvement response rates of 72·6%, 58·1% and 36·3%, respectively, at week 52 compared with 61·7%, 25·5% and 5·4%, respectively, in patients who continued ustekinumab. Exposure-adjusted rates of treatment-emergent adverse events were similar among patients rescued with brodalumab (377·3 adverse events per 100 patient-years) and those who remained on ustekinumab (389·9 adverse events per 100 patient-years).

CONCLUSIONS

Among patients who experienced inadequate responses to ustekinumab, rescue with brodalumab improved skin clearance outcomes compared with continuing ustekinumab.

Role of extra oral monofocal distractor device in the correction of the facial asymmetry, sleep apnoea, and quality of life associated with TMJ ankylosis

OBJECTIVES

The purpose of this study is to evaluate the role of primary osteo-distraction prior to ankylosis release in patients, diagnosed with sleep apnoea, facial asymmetry, and reduced quality of life secondary to temporomandibular joint (TMJ) ankylosis.

METHODS

Ten patients in the age group of 13-40 years with TMJ ankylosis underwent primary osteo-distraction for mandibular advancement. They were evaluated pre- and post-operatively using radiographs, various questionnaires, and subjective evaluation of facial asymmetry, sleep apnoea, and quality of life (QOL).

RESULTS

All the ten patients showed significant improvement in their sleep apnoea symptoms with a mean of 6.20 ± 1.39 (P < 0.05). The mean advancement of the mandible in all the ten patients (both bilateral and unilateral ankylosis) was 15.8 mm (P < 0.05). The quality of life showed marked improvement from very poor to very satisfactory (P < 0.001).

CONCLUSION

Primary mandibular distraction is an effective method of correction of facial asymmetry, sleep apnoea, and quality of life in patients with TMJ ankylosis.

Disparity Between Metro-Centric Cancer Care and Rural Outreach in India: Situational Analysis and Future Trends in Context of Developing Countries

Background: Radiation therapy is used in two-third of all patients diagnosed with cancer in any form and it has become an integral part of modern treatment strategies for many types of cancers in recent decade. Semi-urban and rural places in India lack healthcare facilities and so as the cancer care facilities. Aim: To identify the propensity of a metro-centric oncologic care in developing countries undermining the need of availability of facilities in smaller towns and cities. Methods: Data for state-wise population for 2016 and 2026 was projected using cohort component method. For the projection of cancer incidence and prevalence in 2016 and 2026, we assumed that the state-level prevalence and incidence of cancer in the year 2015 will not change over time in 2016. Data collected through telephonic interviews from the radiotherapy centers listed by Atomic Energy Regulatory Board (AERB), India. Further, we assumed few scenarios of cancer incidence and prevalence increase and projected state wise cancer burden in 2026. Results: With almost 70% population of India residing in districts and cities lacking quality health care, the situation of cancer care is much grave. India is currently equipped with only 394 RTU (Radiation Therapy Unit) against requirement of almost 1300 RTU, amounting to 0.38 RTU per million populations as per World Health Organization. The public sponsored healthcare infrastructure for cancer treatment, and research is centralized with all the resources centered in metro/major cities. Eight metro cities of India with a combined population of 140.6 million hold control of 188 RTU under their boundaries. Thus, while habitants of these eight metro cities, constituting only 10.9% of the national population, avail treatment benefit from 38% of total RTU capacity of India, rest of Indian population at 1143.8 million strengths is left prey to the wrath of cancer with just 306 machines at disposal. In comparison, the developed nations as the United States of America, Australia, and the United Kingdom fare far better in RTU availability for treatment of diagnosed cancer patients, with RTU per million population density of 12.45, 10.12 and 5.04 respectively. Similar scenario has been seen in other LMICs in world like Congo, Mongolia, Sudan, Nigeria, Nepal etc. Conclusion: We observed that wide disparity exists in India concerning RTU and cancer facility availability and density per million populations in between metro cities and rest of India and a dire need of improvement to fight against cancer which is very similar to the situation in developing countries.