Bronchial artery to pulmonary artery fistula initially misdiagnosed as pulmonary embolism: A case report

INTRODUCTION

Bronchopulmonary arterial fistulas have been reported following lung transplant, and in association with COPD, trauma, radiation therapy, and infection. They may also arise congenitally. Embolization is the most frequent treatment.

CASE PRESENTATION

We present a case of a 58-year-old male with a prior history of pulmonary tuberculosis who initially presented with minimal hemoptysis for several months. Right upper lobe bronchial artery to pulmonary artery fistulas were discovered by angiography. These were excluded by particle and microcoil embolizations.

CLINICAL DISCUSSION

Relatively unopacified blood from bronchial artery enters right pulmonary artery and causes ill-defined hypodensities mixing with opacified blood, especially compared to uniformly, brightly enhancing left pulmonary artery. As a result, interpreters will frequently incorrectly conclude that right pulmonary artery embolism exists rather than a bronchopulmonary arterial fistula.

CONCLUSION

In most cases, bronchopulmonary arterial fistulas are treated by bronchial artery embolization; however, direct puncture or stent grafting are alternate considerations depending on the patient's anatomy. In all instances, a multidisciplinary approach is a must.

Endovascular management of colic artery pseudoaneurysm: A case report of successful intervention in a 59-year-old male with abdominal hematoma

Visceral artery pseudoaneurysms, including inferior mesenteric artery pseudoaneurysms, are rare, occurring at an estimated incidence of 0.01%-0.2%. The literature reports only around 60 cases of inferior mesenteric pseudoaneurysm to date. The management of this condition lacks a consensus; nevertheless, coil embolization remains the preferred approach for stable patients. Here, we present a unique clinical scenario involving a 59-year-old male who underwent exploratory laparotomy for a retroperitoneal hematoma. Subsequently, he was diagnosed with an inferior mesenteric pseudoaneurysm, specifically affecting the left colic artery, and successfully managed using coil embolization.

Insights from neuroradiology in acute disseminated encephalomyelitis

Acute disseminated encephalomyelitis (ADEM) is a rare immune-mediated demyelinating disorder primarily observed in children, typically triggered by recent vaccination or viral infection. Although uncommon, there have been reports of ADEM occurring in adults, with varying radiological findings compared to pediatric cases. Distinguishing ADEM from other demyelinating disorders, such as multiple sclerosis (MS) and neuromyelitis optica (NMO), can pose a diagnostic challenge. We present a case report of an 18-year-old male with a history of polysubstance use who was successfully treated with corticosteroids and highlight the neuroradiological presentation of ADEM, emphasizing the importance of accurate diagnosis and management in both pediatric and adult populations.

Management of inadvertent puncture of the hepatic capsule accompanied by post-TIPS hemoperitoneum secondary to bleeding diathesis

Since its advent, the transjugular intrahepatic portosystemic shunt (TIPS) procedure has been accepted as an effective option to treat patients with complications of portal hypertension. While generally considered a safe procedure, TIPs can be associated with certain complications, including inadvertent puncture of the liver capsule with the needle/catheter combination during needle passes. In addition, the accompanying post-TIPS intraperitoneal hemorrhage has not been well reported and guidelines behind its management are not well described. We present a case of a 33-year-old male with refractory ascites who underwent TIPS, during which the hepatic capsule was inadvertently punctured, leading to the development of hemoperitoneum in the patient due to a bleeding diathesis.

Peripheral stent-graft for the management of an ulnar artery pseudoaneurysm

Penetrating injury can cause pseudoaneurysm which can then affect nerve compression. Although rare, penetrating injuries leading to ulnar artery pseudoaneurysm (UAP) are implicated slightly more frequently than other upper extremity arterial segments. Manual compression, thrombin injections, and surgical reconstruction are typically chosen to effect repair. Conversely, peripheral stent-graft implantation has rarely been reported as an option to exclude upper extremity pseudoaneurysm. We describe a case of a 25-year-old male who was stabbed, presented with signs of ulnar nerve compression, and in whom UAP was instead discovered and treated by stent-graft deployment.

Unveiling a rare radiological discovery: Interlobar pneumothorax in a young female patient

Pneumothorax is a medical condition characterized by air in the space between the visceral and parietal pleural surfaces, with spontaneous and traumatic classifications. Spontaneous pneumothorax is further divided into primary and secondary groups based on the presence or absence of clinically apparent underlying lung disease. Here we present a case of a 23-year-old female with no past medical history who presented with chest pain and shortness of breath, ultimately diagnosed with primary spontaneous interlobar pneumothorax. Despite advancements in medical diagnosis techniques, spontaneous interlobar pneumothorax remains a rare presentation of pneumothoraces. Treatment strategies for clinically stable patients with a first episode of primary spontaneous pneumothorax include observation with or without supplemental oxygen, with further intervention only if the pneumothorax fails to improve or worsens.

Hemiazygos vein dilation as a radiological finding and multifactorial cause of dysphagia

Dysphagia is a common issue observed among the elderly, which can arise from various etiologies such as motility disorders and chronic neurologic conditions. Radiologists play a crucial role in diagnosing the cause of dysphagia, as they can identify anatomical abnormalities that may lead to the condition. One such anomaly is the hemiazygos vein, which is the left side equivalent of the azygos vein and can cause dysphagia if it crosses over the esophagus. To our knowledge, there are only 2 other recorded cases of azygos aneurysm/dilation causing esophageal dysphagia. In this context, we present a case report of a 73-year-old female with a 1-month history of weight loss and dysphagia due to a prominent hemiazygos vein. The case highlights the importance of thorough radiological evaluation in identifying the underlying cause of dysphagia and ensuring timely and appropriate treatment.

Iatrogenic subclavian artery rupture: A unique case report on balloon occlusion

INTRODUCTION

Inadvertent subclavian artery puncture during attempted central venous catheterization can be devastating. Percutaneous stent grafting, closure devices and conventional surgery have been described to effect repair. Balloon occlusion has also been described and often recommended. Numerous publications advise use of balloon expanded to no less than the diameter of the punctured artery.

CASE PRESENTATION

We describe the case of a 21 year-old male whose right subclavian artery was inadvertently punctured after central-line removal. Our balloon when expanded was purposely slightly smaller than the inner arterial diameter. Balloon occlusion nevertheless alone sufficed to effect closure and repair.

CLINICAL DISCUSSION

When the expanded balloon surpasses the diameter of the subclavian artery, it is expected that blood flow to the upper extremity will be cut off. Presently, there is a lack of definitive data concerning the maximum duration for balloon inflation that could lead to upper extremity ischemia. However, in this particular case, there was a temporary reduction in vertebral artery flow, while the flow in the carotid and axillosubclavian arteries remained rapid and uninterrupted. To our understanding, only one other case documents the use of a balloon shorter than the vessel diameter.

CONCLUSION

In specific scenarios, it is advisable to consider the use of smaller balloon diameters to effectively stop extravasation while ensuring adequate perfusion to the brain and hand. While alternative approaches such as open repair, and stent graft procedure have been reported for repairing subclavian artery rupture, balloon tamponade provides interventional radiologists with a distinct technical advantage.

Vancomycin-Resistant Enterococcus Endocarditis Complicated by Splenic Infarction and Embolic Stroke

Infective endocarditis (IE) is a serious condition associated with high morbidity and mortality rates. The risk factors for IE include underlying heart disease, intravenous drug use, cardiac surgery, and interventional procedures. Enterococci are a common cause of IE, and vancomycin-resistant enterococci (VRE) infections are becoming increasingly prevalent. In this report, we present the case of an 88-year-old female patient with multiple cardiac comorbidities who developed VRE endocarditis with splenic infarction and embolic stroke. The patient was successfully treated with a combination of antibiotics and anticoagulation therapy. This report highlights the importance of recognizing the potential complications of VRE endocarditis and the need for appropriate management to prevent adverse outcomes. To the best of our knowledge, only one other case of VRE endocarditis with multiple systemic complications has been documented so far.

Primary Mucosal Melanoma of the Lip With GNA11 Mutation in a 23-Year-Old Pregnant Woman

Mucosal melanoma represents a small proportion of all melanoma cases and is associated with a worse prognosis. Primary malignant melanoma of the lip (PMML) is far less common, and only a few cases have been reported since 1997, most commonly in China, Japan, Uganda, and India. Most of these cases have been associated with the gene C-KIT. As a result, treatment guidelines surrounding mucosal melanoma are unclear, especially in complicated populations such as pregnant women. Mutations in theGNAQ and GNA11 genes have been found to be associated with uveal melanoma, while they are rarely associated with mucosal melanoma. We present the case of a 23-year-old pregnant woman who was found to have likely primary malignant melanoma of the lip that metastasized to the left jaw, neck, breast, lungs, and ovaries and was found to be positive for both the BRAF-MLL3 and GNA11 mutation.

Simultaneous Presentation of Secondary Adrenal Insufficiency and Primary Hypothyroidism due to Pembrolizumab: A Case Report

Checkpoint inhibitors have gained increased traction in recent years as they have improved prognosis in various malignancies. Pembrolizumab, an anti-programmed cell death protein (PD-1) monoclonal antibody, has become a first-line chemotherapeutic agent for stage II non-small cell lung cancer since 2019. Although much more common with nivolumab, several immune-related adverse effects, particularly endocrinopathies, have been linked with pembrolizumab. We describe a case of a 59-year-old man with a history of unspecified lung cancer who presented with severe hyponatremia later attributed to secondary adrenal insufficiency and accompanying primary hypothyroidism secondary to pembrolizumab. Diagnosing adrenal insufficiency in patients on immune checkpoint inhibitors like pembrolizumab can be challenging due to nonspecific symptoms, making it crucial to rule out other causes of hyponatremia. Immunotherapy is known to cause thyroid immune-related adverse events, and anti-thyroid antibodies may not always be present in the diagnosis of hypothyroidism. Although there are some reported cases of pembrolizumab-induced adrenal insufficiency, the link between immunotherapy and endocrine disorders remains unclear. To our knowledge, no case reports exist that describe both primary hypothyroidism and secondary adrenal insufficiency after taking pembrolizumab, although such cases have been documented with axitinib. Timely diagnosis and treatment of adrenal insufficiency is crucial to prevent adverse effects, especially in patients with cancer receiving immunotherapy, as highlighted in this case.

Delayed-Onset Losartan-Induced Pancreatitis Secondary to an Overdose: A Case Report

Acute pancreatitis is defined as inflammation of the pancreas and is most commonly caused by gallstones and alcohol use. Less commonly, acute pancreatitis can be drug induced from medications that are divided into 5 subgroups (classes Ia-V). The subgroups are determined based on the cases reported, reaction with rechallenge and a consistent period of latency. We describe a case of a 34-year-old female who overdosed on losartan pills in a suicide attempt but developed symptoms of drug-induced acute pancreatitis nearly a week later without gallstones, alcohol involvement, or other drug toxicity.

POS0423 CYCLIC CITRULLINATED PEPTIDE APTAMER TREATMENT ATTENUATES COLLAGEN INDUCED ARTHRITIS

Background

Anti-citrullinated peptide antibodies (ACPA) appear 10–15 years before the diagnosis of rheumatoid arthritis (RA) and are associated with a more severe disease course. In previous work, we rationally designed and screened ACPA-binding peptide aptamer sequences in silico and constructed a nanoparticle with chitosan and hyaluronic acid(1). A developmental stage version of this nanoparticle was able to reduce disease activity in the collagen-induced arthritis (CIA) and the serum transfer arthritis mouse models (2).

Objectives

Here, we investigated the effect and potential toxicity of three different versions of the aptamer nanoparticle (loading of 20%, 10% and 5% aptamer, respectively) in the CIA rat model.

Methods

Wistar rats (males and females) were given a single intravenous dose (100 mg/kilo) of type II collagen in PBS in the tail vein. The dosing was repeated three times with one day interval, followed by blood sample collection at day 7 after the initial collagen injection. To evaluate route of administration and dosing, we injected a single intravenous and subcutaneous dose (2.5 mg/kg) of aptamer-nanoparticles (A/N ratio 20%) in PBS in the tail vein/abdomen, and plasma concentration−time profiles were followed for 2 days after dosing with weekly blood sampling. To evaluate organ uptake, rats were given a single intravenous and subcutaneous dose (2.5 mg/kg) of aptamer-nanoparticles (A/N ratio 20%) in PBS in the tail vein/abdomen. The procedure was repeated after 24 hours. Blood and urine samples were taken once a week. A group of 10 animals was sacrificed every week over a three-week period, and the organs were processed. To examine efficacy, rats were given a single subcutaneous dose (2.5 mg/kilo) of aptamer-nanoparticles and nanoparticle controls without aptamer or PBS alone in the abdomen. The procedure was repeated once a week over a course of three weeks. Weight, joint measurement, blood, and urine samples were taken once a week. Paw swelling was measured on a weekly basis. In the plasma samples we measured CPEP2 and anti-collagen II by enzyme linked immunosorbent assay (ELISA).

Results

Using a rather high dose of collagen (100 mg/kilo) via an intravenous administration route, ACPA was measurable in all CIA rats with rapid development of RA in 82% of the included animals. Intravenous administration resulted in an immediate high plasma concentration post injection, which decreased rapidly to low levels. The s.c. administration route gave a steady, long-term aptamer release with a maximum availability 8 hours post-injection. After three aptamer-nanoparticle doses (2.5 mg/kg; either 20%, 10% or 5% aptamer), we observed a dose-dependent reduction in swollen joint count for the aptamer-nanoparticle treated groups (10 rats in each group) compared with the healthy control group (10 rats) (P-value = 2,1E-6). We observed decreased ACPA IgG levels in the rats treated with aptamer-nanoparticle. The decrease in ACPA levels correlated with the aptamer-nanoparticle having higher loading. Anti-collagen II IgG levels slightly increased towards the end of the study.

Conclusion

We developed and tested a novel peptide aptamer-based drug candidate for seropositive rheumatoid arthritis in CIA rats. Over a 3-week course of treatment with subcutaneous administration of aptamer-nanoparticles, joint swelling was decreased during treatment, and completely reversed at the end of the observation period. The reduction of joint swelling was associated with decreased levels of ACPA in the blood.

References

[1]Khatri S, Hansen J, Mendes AC, et al. Citrullinated Peptide Epitope Targets Therapeutic Nanoparticles to Human Neutrophils. Bioconjug Chem. 2019;30(10):2584-2593. doi:10.1021/acs.bioconjchem.9b00518

[2]Khatri S, Hansen J, Clausen MH, et al. LB0002 A FIRST IN CLASS THERAPEUTIC NANOPARTICLE FOR SPECIFIC TARGETING OF ANTI-CITRULLINATED PROTEIN ANTIBODY AMELIORATES SERUM TRANSFER AND COLLAGEN INDUCED ARTHRITIS. Annals of the Rheumatic Diseases 2020;79:212.

Disclosure of Interests

Sangita Khatri: None declared, Jonas Hansen: None declared, Nadia Pedersen: None declared, Sanne Gram-Nielsen: None declared, Ana Mendes: None declared, Ioannis Chronakis: None declared, Ulrik Keiding: None declared, Bence Réthi: None declared, Mads Hartvig Clausen Shareholder of: affiliated with IBIO TECH ApS, Tue Wenzel Kragstrup Shareholder of: affiliated with IBIO TECH ApS, Speakers bureau: TWK received speaking fees from Pfizer, Bristol-Myers Squibb, Eli Lilly, Novartis, UCB, and Abbvie., Consultant of: Consultancy fees from Bristol-Myers Squibb and Gilead, Grant/research support from: Received research grant from Gilead, Kira Astakhova Shareholder of: KA is affiliated with iBio tech.

Practical consensus recommendaton for adjuvant bone-modifying agents in breast cancer

Bone-modifying therapy is a primary research interest in breast cancer. Several features contribute to the importance of the bone environment in the management of breast cancer. Firstly, bone metastases represent the most common site of breast cancer metastases and secondly, the emergence of cancer treatment-induced bone loss (CTIBL) among breast cancer survivors and patients is of increasing concern. In the adjuvant setting, bisphosphonates can be given to prevent and treat tumor therapy-induced bone loss in premenopausal and postmenopausal women and, owing to their beneficial effect on bone turnover, have also been evaluated for prevention of bone metastases occurrence. Expert oncologists discusses on the update on the approaches of Bone-modifying Agents and its treatment options. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

LB0002 A FIRST IN CLASS THERAPEUTIC NANOPARTICLE FOR SPECIFIC TARGETING OF ANTI-CITRULLINATED PROTEIN ANTIBODY AMELIORATES SERUM TRANSFER AND COLLAGEN INDUCED ARTHRITIS

Background:

Rheumatoid arthritis (RA) is an immune mediated inflammatory disease with autoimmune features, including antibodies to citrullinated proteins and peptides (ACPAs). Several in vitro studies have suggested a pathogenic role of ACPAs in RA. However, in vivo proof of this concept has been hampered by the lack of therapeutic strategies to reduce or deplete ACPA in serum and synovial fluid. Previously, we constructed a chitosan-hyaluronic acid nanoparticle formulation with the ability to use neutrophil recruitment as a delivery mechanism to inflamed joints. Specifically, nanoparticles got phagocytosed and then released to synovial fluid upon death of the short-lived neutrophils

Objectives:

We hypothesized that reducing ACPA levels would have a therapeutic effect by blocking cytokine production. In this study, we prepared and tested a series of therapeutic nanoparticles for specific targeting of ACPA in synovial fluid.

Methods:

Nanoparticles were prepared by the microdroplet method and then decorated with synthetic cyclic citrullinated peptide aptamer PEP2, PEG/hexanoic acid and fluorophore (Cy5.5). Nanoparticles were characterized by dynamic light scattering (DLS), scanning electron microscopy (SEM) and high-performance liquid chromatography (HPLC). Nanoparticles were then used in a series of in vitro assays, including cell uptake with flow cytometry (FACS) detection, and in vivo studies including disease activity scores, cytokine measurements and near-infrared imaging.

Results:

We screened a series of citrullinated peptide epitopes and identified a fibrinogen-derived 21-amino-acid-long citrullinated peptide showing high selectivity toward autoantibodies in RA samples. We incorporated this aptamer in the chitosan-hyaluronic acid nanoparticle formulation previously described. Average nanoparticle size was 230 nm ± 10 nm by DLS and SEM; z potential was -0.0012. Purity by HPLC was over 95%. Attachment efficiency of the aptamer was 92% by HPLC. FACS study showed selective uptake of Cy5.5 labelled aptamer-nanoparticle conjugates by neutrophils in the concentration range 0.5-4 nM. Similar to previous studies,1there was no apparent immunogenicity for this nanoparticle formulation measured by cytokine secretion from human peripheral blood leukocytes. In vivo, over 50% reduction of disease activity was achieved in three weeks treatment using as little as 1 nM drug candidate (dosed every 48 hours) in the collagen-induced (CIA) mouse model of RA (N=30; p<0.001 for treated vs placebo). Same was observed in the serum transfer model (N=10). The aptamer-nanoparticle conjugate significantly reduced IL-6 and TNFα levels in the mouse sera (p<0.01). The effects were not inferior to tocilizumab treated controls (N=30). To confirm mode of action, we applied Cy5.5-labelled aptamer-nanoparticles in the collagen-induced mouse model (N=10) and analyzed the resulting uptake by near-infrared imaging. We confirmed over 6-fold higher signal accumulation in inflamed vs healthy joints (p<0.01), which strongly supports the fact that the aptamer is highly specific to the inflammatory process.

Conclusion:

Overall, we have designed a first-in-class therapeutic nanoparticle drug for specific targeting of anti-citrullinated protein antibodies. The marked effect of this nanoparticle observed in vivo holds promise for targeting ACPAs as a therapeutic option in RA.

References:

[1]Khatri S, Hansen J, Mendes AC, Chronakis IS, Hung S-C, Mellins ED, Astakhova K. Bioconjug Chem. 2019 Oct 16;30(10):2584–259

Disclosure of Interests:

Sangita Khatri: None declared, Jonas Hansen: None declared, Mads Hartvig Clausen Shareholder of: iBio Tech ApS, Tue Wenzel Kragstrup Shareholder of: iBio Tech ApS, Consultant of: Bristol-Myers Squibb, Speakers bureau: TWK has engaged in educational activities talking about immunology in rheumatic diseases receiving speaking fees from Pfizer, Bristol-Myers Squibb, Eli Lilly, Novartis, and UCB., Shu-Chen Hung: None declared, Elisabeth Mellins: None declared, Kira Astakhova: None declared

HDAC Regulates Transcription at the Outset of Axolotl Tail Regeneration

Tissue regeneration is associated with complex changes in gene expression and post-translational modifications of proteins, including transcription factors and histones that comprise chromatin. We tested 172 compounds designed to target epigenetic mechanisms in an axolotl (Ambystoma mexicanum) embryo tail regeneration assay. A relatively large number of compounds (N = 55) inhibited tail regeneration, including 18 histone deacetylase inhibitors (HDACi). In particular, romidepsin, an FDA-approved anticancer drug, potently inhibited tail regeneration when embryos were treated continuously for 7 days. Additional experiments revealed that romidepsin acted within a very narrow, post-injury window. Romidepsin treatment for only 1-minute post amputation inhibited regeneration through the first 7 days, however after this time, regeneration commenced with variable outgrowth of tailfin tissue and abnormal patterning. Microarray analysis showed that romidepsin altered early, transcriptional responses at 3 and 6-hour post-amputation, especially targeting genes that are implicated in tumor cell death, as well as genes that function in the regulation of transcription, cell differentiation, cell proliferation, pattern specification, and tissue morphogenesis. Our results show that HDAC activity is required at the time of tail amputation to regulate the initial transcriptional response to injury and regeneration.

Health concerns of cancer survivors after primary anti-cancer treatment

PURPOSE

Cancer survivors experience significant health concerns compared to the general population. Sydney Survivorship Clinic (SSC) is a multi-disciplinary clinic aiming to help survivors treated with curative intent manage side effects, and establish a healthy lifestyle. Here, we determine the health concerns of survivors post-primary treatment.

METHODS

Survivors completed questionnaires assessing symptoms, quality of life (QOL), distress, diet, and exercise before attending SSC, and a satisfaction survey after. Body mass index (BMI), clinical findings and recommendations were reviewed. Descriptive statistical methods were used.

RESULTS

Overall, 410 new patients attended SSC between September 2013 and April 2018, with 385 survivors included in analysis: median age 57 years (range 18-86); 69% female; 43% breast, 31% colorectal and 19% haematological cancers. Median time from diagnosis, 12 months. Common symptoms of at least moderate severity: fatigue (45%), insomnia (37%), pain (34%), anxiety (31%) and with 56% having > 5 moderate-severe symptoms. Overall, 45% scored distress ≥ 4/10 and 62% were rated by clinical psychologist as having 'fear of cancer recurrence'. Compared to population mean of 50, mean global QOL T-score was 47.2, with physical and emotional well-being domains most affected. Average BMI was 28.2 kg/m² (range 17.0-59.1); 61% overweight/obese. Only 31% met aerobic exercise guidelines. Overall, 98% 'agreed'/'completely agreed' attending the SSC was worthwhile, and 99% would recommend it to others.

CONCLUSION

Distress, fear of cancer recurrence, fatigue, obesity and sedentary lifestyle are common in cancer survivors attending SSC and may best be addressed in a multi-disciplinary Survivorship Clinic to minimise longer-term effects. This model is well-rated by survivors.

Rediscovering the Axolotl as a Model for Thyroid Hormone Dependent Development

The Mexican axolotl (Ambystoma mexicanum) is an important model organism in biomedical research. Much current attention is focused on the axolotl's amazing ability to regenerate tissues and whole organs after injury. However, not forgotten is the axolotl's equally amazing ability to thwart aspects of tissue maturation and retain juvenile morphology into the adult phase of life. Unlike close tiger salamander relatives that undergo a thyroid hormone regulated metamorphosis, the axolotl does not typically undergo a metamorphosis. Instead, the axolotl exhibits a paedomorphic mode of development that enables a completely aquatic life cycle. The evolution of paedomorphosis allowed axolotls to exploit relatively permanent habitats in Mexico, and preadapted axolotls for domestication and laboratory study. In this perspective, we first introduce the axolotl and the various meanings of paedomorphosis, and then stress the need to move beyond endocrinology-guided approaches to understand the axolotl's hypothyroid state. With the recent completion of the axolotl genome assembly and established methods to manipulate gene functions, the axolotl is poised to provide new insights about paedomorphosis and the role of thyroid hormone in development and evolution.

Nasal Carriage Rate of Methicillin Resistant Staphylococcus aureus among Health Care Workers at a Tertiary Care Hospital in Kathmandu, Nepal

BACKGROUND

Methicillin-resistant Staphylococcus aureus is one of the most common causes of nosocomial infections. Due to its multidrug resistant nature; infections due to Methicillin-resistant Staphylococcus aureus are often very difficult to treat. Colonized health care workers are the important sources of Methicillin-resistant Staphylococcus aureus. The objectives of this study were to determine the nasal carriage rate of Methicillin-resistant Staphylococcus aureus among health care workers at Kathmandu Medical College and Teaching Hospital, Nepal and to assess their antimicrobial susceptibility patterns.

METHODS

A cross sectional study was conducted among 252 health care workers from July to November 2013. Mannitol salt agar was used to culture the nasal swabs. Antimicrobial susceptibility testing was performed by Kirby-Bauer disc diffusion technique following Clinical and Laboratory Standards Institute guidelines. Methicillin-resistant Staphylococcus aureus strains were confirmed by using cefoxitin disc and by determining the minimum inhibitory concentration of oxacillin by agar dilution method.

RESULTS

Of 252 healthcare workers, 46(18.3%) were positive for Staphylococcus aureus among which 19(41.3%) were Methicillin-resistant Staphylococcus aureus carriers. Overall rate of nasal carriage of Methicillin-resistant Staphylococcus aureus was 7.5% (19/252).The higher percentages of lab personnel were nasal carriers of S. aureus (31.6%) and Methicillin-resistant Staphylococcus aureus (10.5%).The percentages of nasal carriage of S. aureus (35.7%) and Methicillin-resistant Staphylococcus aureus (14.3%) were highest in the health care workers from post operative department. Higher percentage of Methicillin-resistant Staphylococcus aureus were susceptible toward amikacin (100%) and vancomycin (100%) followed by cotrimoxazole (84.2%).

CONCLUSIONS

High rates of nasal carriage of S. aureus and Methicillin-resistant Staphylococcus aureus were observed among the healthcare workers, which indicate the need of strict infection control measures to be followed to control the nosocomial infections.

Longitudinal stability of asthma characteristics and biomarkers from the Airways Disease Endotyping for Personalized Therapeutics (ADEPT) study

Background

Asthma is a biologically heterogeneous disease and development of novel therapeutics requires understanding of pathophysiologic phenotypes. There is uncertainty regarding the stability of clinical characteristics and biomarkers in asthma over time. This report presents the longitudinal stability over 12 months of clinical characteristics and clinically accessible biomarkers from ADEPT.

Methods

Mild, moderate, and severe asthma subjects were assessed at 5 visits over 12 months. Assessments included patient questionnaires, spirometry, bronchodilator reversibility, fractional exhaled nitric oxide (FENO), and biomarkers measured in induced sputum.

Results

Mild (n = 52), moderate (n = 55), and severe (n = 51) asthma cohorts were enrolled from North America and Western Europe. For all clinical characteristics and biomarkers, group mean data showed no significant change from visit to visit. However, individual data showed considerable variability. FEV1/FVC ratio showed excellent reproducibility while pre-bronchodilator FEV1 and FVC were only moderately reproducible. Of note bronchodilator FEV1 reversibility showed low reproducibility, with the nonreversible phenotype much more reproducible than the reversible phenotype. The 7-item asthma control questionnaire (ACQ7) demonstrated moderate reproducibility for the combined asthma cohorts, but the uncontrolled asthma phenotype (ACQ7 > 1.5) was inconstant in mild and moderate asthma but stable in severe asthma. FENO demonstrated good reproducibility, with the FENO-low phenotype (FENO < 35 ppb) more stable than the FENO-high phenotype (FENO ≥ 35 ppb). Induced sputum inflammatory phenotypes showed marked variability across the 3 sputum samples taken over 6 months.

Conclusions

The ADEPT cohort showed group stability, individual stability in some parameters e.g. low FEV1/FVC ratio, and low FENO, but marked individual variability in other clinical characteristics and biomarkers e.g. type-2 biomarkers over 12 months. This variability is possibly related to seasonal variations in climate and allergen exposure, medication changes and acute exacerbations. The implications for patient selection strategies based on clinical biomarkers may be considerable.

Asthma characteristics and biomarkers from the Airways Disease Endotyping for Personalized Therapeutics (ADEPT) longitudinal profiling study

BACKGROUND

Asthma is a heterogeneous disease and development of novel therapeutics requires an understanding of pathophysiologic phenotypes. The purpose of the ADEPT study was to correlate clinical features and biomarkers with molecular characteristics, by profiling asthma (NCT01274507). This report presents for the first time the study design, and characteristics of the recruited subjects.

METHODS

Patients with a range of asthma severity and healthy non-atopic controls were enrolled. The asthmatic subjects were followed for 12 months. Assessments included history, patient questionnaires, spirometry, airway hyper-responsiveness to methacholine, fractional exhaled nitric oxide (FENO), and biomarkers measured in induced sputum, blood, and bronchoscopy samples. All subjects underwent sputum induction and 30 subjects/cohort had bronchoscopy.

RESULTS

Mild (n = 52), moderate (n = 55), severe (n = 51) asthma cohorts and 30 healthy controls were enrolled from North America and Western Europe. Airflow obstruction, bronchodilator response and airways hyperresponsiveness increased with asthma severity, and severe asthma subjects had reduced forced vital capacity. Asthma control questionnaire-7 (ACQ7) scores worsened with asthma severity. In the asthmatics, mean values for all clinical and biomarker characteristics were stable over 12 months although individual variability was evident. FENO and blood eosinophils did not differ by asthma severity. Induced sputum eosinophils but not neutrophils were lower in mild compared to the moderate and severe asthma cohorts.

CONCLUSIONS

The ADEPT study successfully enrolled asthmatics across a spectrum of severity and non-atopic controls. Clinical characteristics were related to asthma severity and in general asthma characteristics e.g. lung function, were stable over 12 months. Use of the ADEPT data should prove useful in defining biological phenotypes to facilitate personalized therapeutic approaches.

Unprotected left main coronary artery stenting for cardiac allograft vasculopathy

Cardiac allograft vasculopathy is the leading cause of death after the first year of transplantation. Treatment outcomes with medication, balloon angioplasty, bypass surgery, and retransplantation have been disappointing. We present our initial experience with stenting of the left main coronary artery in the setting of allograft vasculopathy.

Tumour necrosis factor-alpha and interleukin-2 in pus aspirate and blood in patients with amoebic liver abscess

OBJECTIVES

Cell mediated immunity (CMI), cytokines and humoral immunity have been implicated in the pathogenesis of invasive amoebiasis.

METHODS

The role of cytokines--tumour necrosis factor-alpha (TNF-alpha) and interleukin 2 (IL-2) in blood and pus aspirate was studied in 20 patients of amoebic liver abscess (ALA), before and after treatment and 10 controls.

RESULTS

The mean TNF-alpha levels (pg/ml) in the controls and before treatment in the patients in serum and pus were 24.3 +/- 11.6, 28 +/- 14.5 and 161.2 +/- 81.3 (p < 0.002) respectively. The mean IL-2 levels (pg/ml) in the controls, serum and pus aspirate in the patients prior to treatment were 10.3 +/- 8.5, 39.2 +/- 26.1 and 117.0 +/- 65.9 respectively. The levels in the patients after therapy, increased to 47 +/- 25.7 (p < 0.001) and 134 +/- 59.4 (p < 0.01).

CONCLUSIONS

The higher levels of TNF-alpha and IL-2 in the pus aspirate compared to blood pre treatment, supports the role of locally released cytokines in the target organ i.e. liver in amoebiasis. The rise in values observed after therapy are indicative of increased macrophage activity due to CMI occurring late in the course of the disease which may contribute to disease limitation and localisation in amoebiasis. The study suggests that locally released cytokines play an important role in the pathogenesis of ALA.

Spontaneous rupture of hepatic hydatid cyst causing inferior vena cava thrombosis

We report a patient with an infected hepatic hydatid cyst, which spontaneously ruptured into the inferior vena cava, with resultant thrombosis of the inferior vena cava, and left renal, right common iliac and right external iliac veins.

Tuberculous mediastinitis: a rare presentation

Granulomatous mediastinitis is a rare condition, and tuberculosis and fungal infections are the most important causes of this potentially lethal condition. Tuberculous mediastinitis usually presents with fever, cough, dyspnoea and rarely, florid features of obstruction to intra-thoracic structures are seen. A case of tuberculous mediastinitis presenting as a suprasternal lump, a rare presentation, is described here.