Incidental multifocal granular cell tumor in the setting of chronic gastritis discovered following gastric sleeve operation: a case report and brief review of the literature

Granular cell tumors are uncommon neoplasms of Schwannian origin that can present nearly anywhere in the body, but are most commonly seen in the head and neck region. While the majority of these tumors are benign, a subset can behave aggressively and even have metastatic potential. We are reporting a case of a 35-year-old female with a history morbid obesity presenting for bariatric surgery (sleeve gastrectomy). Upon receiving the specimen in pathology, nodular vaguely defined lesions were identified in the gastric wall. Representative sections were submitted for microscopic examination, which revealed the incidental finding of a multifocal granular cell tumor with a background of chronic gastritis. The patient has not had any regional recurrences or metastasis in the past 2 years following the procedure.

Induction of the alternative lengthening of telomeres pathway by trapping of proteins on DNA

Telomere maintenance is a hallmark of malignant cells and allows cancers to divide indefinitely. In some cancers, this is achieved through the alternative lengthening of telomeres (ALT) pathway. Whilst loss of ATRX is a near universal feature of ALT-cancers, it is insufficient in isolation. As such, other cellular events must be necessary - but the exact nature of the secondary events has remained elusive. Here, we report that trapping of proteins (such as TOP1, TOP2A and PARP1) on DNA leads to ALT induction in cells lacking ATRX. We demonstrate that protein-trapping chemotherapeutic agents, such as etoposide, camptothecin and talazoparib, induce ALT markers specifically in ATRX-null cells. Further, we show that treatment with G4-stabilising drugs cause an increase in trapped TOP2A levels which leads to ALT induction in ATRX-null cells. This process is MUS81-endonuclease and break-induced replication dependent, suggesting that protein trapping leads to replication fork stalling, with these forks being aberrantly processed in the absence of ATRX. Finally, we show ALT-positive cells harbour a higher load of genome-wide trapped proteins, such as TOP1, and knockdown of TOP1 reduced ALT activity. Taken together, these findings suggest that protein trapping is a fundamental driving force behind ALT-biology in ATRX-deficient malignancies.

Deep cerebral venous abnormalities in premature babies with GMH-IVH: a single-centre retrospective study

PURPOSE

Germinal matrix haemorrhage/intraventricular haemorrhage (GMH-IVH) is a multifactorial injury with both anatomic and haemodynamic involvement. Normal variants in preterm deep cerebral venous anatomy associated with GMH-IVH have been previously described using MRI susceptibility weighted imaging (SWI). The aims of this study were to use SWI to compare the deep venous systems of a cohort of preterm neonates with various grades of GMH-IVH to a group of age-matched controls without GMH-IVH and to present novel retrospective SWI imaging findings.

METHODS

A neuroradiologist retrospectively evaluated 3T MRI SWI and phase imaging of 56 preterm neonates with GMH-IVH (14 of each grade) and 27 controls without GMH-IVH, scoring the venous irregularities according to three variables: decreased venous patency, increased lumen susceptibility and the presence of collaterals. Eight different venous locations, including indicated bilateral components, were evaluated: straight sinus, vein of galen, internal cerebral, direct lateral, thalamostriate, atrial and the anterior septal veins. Variables were analysed for statistical significance. Inter-rater reliability was determined via subset evaluation by a second paediatric radiologist.

RESULTS

Deep venous abnormalities were significantly more common in patients with GMH-IVH, with Wilcoxon Rank Sum Test demonstrating significant increase with GMH-IVH for total decreased venous patency (W=0, p<0.0001), increased lumen susceptibility and collateral formation. Venous abnormalities were also positively correlated with an increase in GMH-IVH grade from I to IV (patency, ρ=0.782, p<0.01) (increased lumen susceptibility, ρ=0.739, p<0.01) (collaterals, ρ=0.649, p<0.01), not just GMH-IVH alone.

CONCLUSION

Deep venous abnormalities are significantly correlated with GMH-IVH alone and an increase in GMH-IVH grade. Further study is needed to determine cause and effect.

A Case of Unilateral Sixth Cranial Nerve (CN VI) Avulsion in the Prepontine Cistern After Severe Head Trauma

The patient was a 46-year-old woman who presented with right sixth cranial nerve (CN VI) palsy following severe head trauma secondary to a motor vehicle collision one month prior. In this case report, we aim to add to the literature an additional example of unilateral CN VI avulsion as visualized by MRI secondary to head trauma. 3D T2 MRI was used to visualize the CN VI avulsion. CT was also used in the evaluation of head trauma. In our view, the force trajectory of the patient's impact with the vehicle dashboard, as evidenced by the right occipital lobe fracture, explains the etiology of the unilateral right CN VI avulsion. The combination of clinical and imaging findings was central to the analysis of this case.

A case of clinically aggressive EBV-negative ENKTL in a non-Asian female patient

BACKGROUND

The patient was a 65-year-old White woman who presented to dermatology with a painless, rapidly growing exophytic nodule on her left upper cheek.

AIMS/PURPOSE

In this case report, we aim to demonstrate the difficulty of diagnosing Epstein-Barr virus-negative extranodal NK cell lymphomas given the broad differential of NK cell lymphomas and the rarity of EBV-negative extranodal NK cell lymphoma.

METHODS

Immunohistochemical studies confirmed the diagnosis of cutaneous, extranodal NK cell lymphoma. Interestingly, Epstein-Barr virus in situ hybridization was negative, which is unusual for most NK cell lymphomas.

RESULTS/CONCLUSIONS

In our view, a combination of immunohistochemistry, clonality assessment, sequencing, and flow cytometric studies is required.

Abstract WP253: Increased Hydrogen Sulfide As A New Mechanism For Hyperglycemic Worsening Of Stroke Outcome

Introduction: Hyperglycemia at stroke onset worsens outcome and reduces the effectiveness of reperfusion therapies. Increased oxidative and mitochondrial injury likely contribute. To treat this mechanism, we synthesized (PEG)-ylated carbon nanoparticles (CNPs) from acid oxidation of activated charcoal (OAC) generating 3 nm discs, catalytic superoxide dismutase mimetics that protect mitochondrial complexes. Cellular uptake is rapid and delayed I.V. PEG-CNPs are highly protective in reversible MCAO in hyperglycemic rats. Hydrogen sulfide (H 2 S) is an essential gaseous transmitter with a narrow therapeutic index associated with many disorders e.g., diabetes. Its synthesis is influenced by radicals. Excess H 2 S is toxic to mitochondrial complex IV. H 2 S is endogenously oxidized to polysulfides (PS), potent antioxidants also needed for protein persulfidation. We hypothesized that OAC’s favorable redox potential will catalyze H 2 S oxidization to PS, acute hyperglycemia will increase H 2 S and PEG-OACs will blunt the increase.

Methods: b.End3 brain endothelial and HEK293 cultured cells were employed. SSP4 fluorescence measured PS levels with increasing concentrations of PEG-OACs. AzMC fluorescence detected H 2 S levels in cells incubated in 100 mg/dL glucose media followed by glucose 500 mg/dL with or without PEG-OACs, first in normoxia followed by anoxia/normoxia.

Results: PEG-OACs dose dependently increased cellular PS levels (Fig 1a). High glucose increased H 2 S levels especially during anoxia/normoxia (Fig 1b). PEG-OACs completely eliminated the glucose-induced increase in H 2 S (Fig 1c).

Conclusions: Acute hyperglycemia increased H 2 S production especially under conditions mimicking ischemia/reperfusion, an effect eliminated by PEG-OACs. Because of mitochondrial toxicity, an H 2 S increase may contribute to worsened outcome in hyperglycemic stroke. These results suggest a new therapeutic target for this important cause of poor stroke outcome.

Alternative Lengthening of Telomeres: Lessons to Be Learned from Telomeric DNA Double-Strand Break Repair

The study of the molecular pathways underlying cancer has given us important insights into how breaks in our DNA are repaired and the dire consequences that can occur when these processes are perturbed. Extensive research over the past 20 years has shown that the key molecular event underpinning a subset of cancers involves the deregulated repair of DNA double-strand breaks (DSBs) at telomeres, which in turn leads to telomere lengthening and the potential for replicative immortality. Here we discuss, in-depth, recent major breakthroughs in our understanding of the mechanisms underpinning this pathway known as the alternative lengthening of telomeres (ALT). We explore how this gives us important insights into how DSB repair at telomeres is regulated, with relevance to the cell-cycle-dependent regulation of repair, repair of stalled replication forks and the spatial regulation of DSB repair.

Automatable Distributed Regression Analysis of Vertically Partitioned Data Facilitated by PopMedNet: Feasibility and Enhancement Study

BACKGROUND

In clinical research, important variables may be collected from multiple data sources. Physical pooling of patient-level data from multiple sources often raises several challenges, including proper protection of patient privacy and proprietary interests. We previously developed an SAS-based package to perform distributed regression-a suite of privacy-protecting methods that perform multivariable-adjusted regression analysis using only summary-level information-with horizontally partitioned data, a setting where distinct cohorts of patients are available from different data sources. We integrated the package with PopMedNet, an open-source file transfer software, to facilitate secure file transfer between the analysis center and the data-contributing sites. The feasibility of using PopMedNet to facilitate distributed regression analysis (DRA) with vertically partitioned data, a setting where the data attributes from a cohort of patients are available from different data sources, was unknown.

OBJECTIVE

The objective of the study was to describe the feasibility of using PopMedNet and enhancements to PopMedNet to facilitate automatable vertical DRA (vDRA) in real-world settings.

METHODS

We gathered the statistical and informatic requirements of using PopMedNet to facilitate automatable vDRA. We enhanced PopMedNet based on these requirements to improve its technical capability to support vDRA.

RESULTS

PopMedNet can enable automatable vDRA. We identified and implemented two enhancements to PopMedNet that improved its technical capability to perform automatable vDRA in real-world settings. The first was the ability to simultaneously upload and download multiple files, and the second was the ability to directly transfer summary-level information between the data-contributing sites without a third-party analysis center.

CONCLUSIONS

PopMedNet can be used to facilitate automatable vDRA to protect patient privacy and support clinical research in real-world settings.

Abstract 106: Safety and Efficacy of Sonothrombolysis in Acute Ischemic Stroke Patients With Large Vessel Occlusion: International Collaborative Individual Patient Data Meta-Analysis

Introduction: Conflicting evidence has been published regarding the safety and efficacy of ultrasound-enhanced thrombolysis (sonothrombolysis) in acute ischemic stroke (AIS) patients with large vessel occlusion (LVO).

Methods: We conducted an individual participant data meta-analysis of available randomized controlled trials (RCTs) comparing sonothrombolysis with or without addition of microspheres (treatment group) to intravenous thrombolysis alone (control group) in AIS patients with LVO.

Results: We included 6 in total RCTs that enrolled 1077 AIS patients. A total of 138 and 134 confirmed LVO patients were randomized to treatment and control groups respectively (median age 68 years, 58% men, median baseline NIHSS score 16). Patients randomized to sonothrombolysis had increased odds of complete recanalization compared to patients receiving intravenous thrombolysis alone (40.3% vs. 22.4%; OR=2.30, 95%CI: 1.05-5.02; adjusted OR=2.33, 95%CI: 1.02-5.34). They also tended to have increased odds of any (complete or partial recanalization (66.4% vs. 53.0%; OR=1.78, 95%CI: 0.95-3.33; adjusted OR=1.85, 95%CI: 0.97-3.53). The likelihood of symptomatic intracranial hemorrhage did not differ between the two groups (7.3% vs. 3.7%, OR=2.52, 95%CI: 0.77-8.29; adjusted OR=2.55, 95%CI: 0.76-8.52). No differences in the likelihood of asymptomatic intracranial hemorrhage (adjusted OR: 1.30, 95%CI: 0.38-4.39), three-month mortality (adjusted OR: 1.23, 95%CI: 0.25-6.05), three-month favorable functional outcome (mRS-scores of 0-1; adjusted OR: 1.43, 95%CI: 0.64-3.19) and three-month functional independence (mRS-scores of 0-2; adjusted OR: 1.43, 95%CI: 0.77-2.64) were documented.

Conclusion: Sonothrombolysis was associated with a two-fold increase in the odds of complete recanalization compared to intravenous thrombolysis alone in AIS patients with LVOs. Further study of the safety and efficacy of sonothrombolysis is warranted.

Alternative Lengthening of Telomeres in Pediatric Cancer: Mechanisms to Therapies

Achieving replicative immortality is a crucial step in tumorigenesis and requires both bypassing cell cycle checkpoints and the extension of telomeres, sequences that protect the distal ends of chromosomes during replication. In the majority of cancers this is achieved through the enzyme telomerase, however a subset of cancers instead utilize a telomerase-independent mechanism of telomere elongation-the Alternative Lengthening of Telomeres (ALT) pathway. Recent work has aimed to decipher the exact mechanism that underlies this pathway. To this end, this pathway has now been shown to extend telomeres through exploitation of DNA repair machinery in a unique process that may present a number of druggable targets. The identification of such targets, and the subsequent development or repurposing of therapies to these targets may be crucial to improving the prognosis for many ALT-positive cancers, wherein mean survival is lower than non-ALT counterparts and the cancers themselves are particularly unresponsive to standard of care therapies. In this review we summarize the recent identification of many aspects of the ALT pathway, and the therapies that may be employed to exploit these new targets.

The effect of a locally adapted, secondary stroke risk factor self-management program on medication adherence among veterans with stroke/TIA

We targeted stroke/transient ischemic attack (TIA) survivors to engage in self-management practices to manage secondary stroke risk factors. We conducted a randomized, regional pilot trial of a locally adapted, secondary stroke prevention program. We implemented the program at two Veterans Administration Medical Centers. Program sessions targeted stroke risk factor self-management. Specifically, we evaluated the effect of the program on the reach, implementation, and effectiveness on patient self-efficacy; stroke-specific, health-related quality of life; and medication adherence for the prevalent stroke risk factors: (1) diabetes, (2) hypertension, and (3) hyperlipidemia. Medication possession ratios were calculated to evaluate medication adherence using VA pharmacy benefits data pre (6 months prior) and post (6 months after) the stroke/TIA event. Based upon the literature standard of 80 % compliance rate, we dichotomized compliance and modeled the data using logistical regression. Final sample included 174 veterans with an acute stroke or TIA who were randomized to receive either the intervention (n = 87) or attention control program (n = 87). Patient self-efficacy and stroke-specific, health-related quality of life at 6 months did not significantly differ between groups. We found improvements in medication adherence within the intervention group. In the intervention group, the odds of compliance with diabetes medications post-stroke were significantly larger than the odds of compliance prior to the stroke (odds ratio = 3.45 (95 % CI = 1.08-10.96). For compliance to hypertension medications, the intervention group showed significantly greater odds of compliance post intervention than pre intervention (odds ratio = 3. 68 (95 % CI = 1.81-7.48). The control group showed no difference in compliance rates from baseline to follow-up. For adherence to hypercholesterolemia medications, both the intervention (odds ratio = 5.98 (95 % CI = 2.81-12.76) and control groups (odds ratio = 3.83 (95 % CI = 1.83-8.01), had significant increases in the odds of compliance to statin medications; however, the comparison of changes in log odds of compliance between these two groups showed that the increases were not significantly different. We observed within group improvements in medication adherence among those receiving a post-stroke risk factor self-management program suggesting that a self-management format may be feasible to enable adherence to prescribed medications to reduce secondary stroke risk after stroke in concordance with guideline care. Additional research is needed to enhance intervention components to improve effectiveness outcomes.

Burden of illness in systemic lupus erythematosus: results from a UK patient and carer online survey

Objective The objective of this study was to assess the impact of systemic lupus erythematosus (SLE) on patients and carers. Methods Adults with SLE and carers of SLE patients completed a UK-specific online survey covering many aspects of the disease. Surveys were developed in collaboration with an NHS lupus unit and a lupus patient organization. Results A total of 121 patients and 31 carers completed the surveys. Of the 70% of patients initially misdiagnosed with another condition, 59% received treatment for the misdiagnosis. Fatigue was the most debilitating symptom, experienced daily by 79% of patients. The proportion of patients not reporting flares to healthcare providers varied with flare severity: mild flares (43%), moderate flares (15%) and severe flares (5%). Most patients (89%) reported reduced ability to socialize, and 76% had changed employment; of these, 52% stopped working completely. Over one-half (52%) of carers in paid employment missed time from work, and 55% of carers reported a worsened financial status. Most carers (87%) experienced interference with social activities. Conclusion SLE is commonly misdiagnosed and has a considerable impact on the physical, social and financial status of patients and carers. Increased awareness of the disease among healthcare providers and employers of patients and their carers is needed.

Using intervention mapping to develop and adapt a secondary stroke prevention program in Veterans Health Administration medical centers

Secondary stroke prevention is championed by the stroke guidelines; however, it is rarely systematically delivered. We sought to develop a locally tailored, evidence-based secondary stroke prevention program. The purpose of this paper was to apply intervention mapping (IM) to develop our locally tailored stroke prevention program and implementation plan. We completed a needs assessment and the five Steps of IM. The needs assessment included semi-structured interviews of 45 providers; 26 in Indianapolis and 19 in Houston. We queried frontline clinical providers of stroke care using structured interviews on the following topics: current provider practices in secondary stroke risk factor management; barriers and needs to support risk factor management; and suggestions on how to enhance secondary stroke risk factor management throughout the continuum of care. We then describe how we incorporated each of the five Steps of IM to develop locally tailored programs at two sites that will be evaluated through surveys for patient outcomes, and medical records chart abstraction for processes of care.

Edema of pregnancy: a comparison of water aerobics and static immersion

OBJECTIVE

To compare the edema-relieving effects of static immersion with water aerobics.

METHODS

Eighteen healthy women between 20 and 33 weeks' gestation were studied standing on land, immersed to the axilla, and participating in a water aerobics class, each for 30 minutes.

RESULTS

Water aerobics and the static immersion led to a similar diuresis, 187 and 180 mL, respectively. Both were significantly greater than standing 30 minutes on land, 65 mL (P < .01). The dilutional effect as measured by a decline in urine specific gravity was also similar between static immersion and water aerobics and greater than standing on land (P < .01). Standing on land led to a small increase in leg volume compared with water aerobics or static immersion (P < .01).

CONCLUSION

Water aerobics had diuretic and edema-relieving effects similar to static immersion. When women develop edema of pregnancy, water aerobics classes may be used as a potential treatment.

Leadership in the formation of new health care environments

The capacity for managers to be effective leaders is clearly being challenged by rapid changes in the health care environment. In this climate, transformational leadership is considered superior to hierarchy-dependent, transactional leadership. This approach may also be very effective in motivating staff and fostering organizational transformation. The article describes six processes that are critical for those who seek to be dynamic leaders: visioning, communicating for meaning, creating possibilities, developing stakeholders, building spirit and will, and sustaining focus.

Laparoscopic staging of Hodgkin's lymphoma

A 57-year-old female with Hodgkin's lymphoma, diagnosed by a cervical lymph node biopsy and surgically staged laparoscopically, is presented. Staging included a pelvic and para-aortic lymphadenectomy as well as splenectomy. Laparoscopic staging of Hodgkin's lymphoma has not been previously reported. The procedure, its limitations, and potential modifications are discussed.

Experimental syphilitic orchitis. Relationship between Treponema pallidum infection and testis synthesis of proteoglycans

The relationship between Treponema pallidum infection and the synthesis of proteoglycans by organ cultures of rabbit testes was investigated. Two proteoglycan fractions, large (CL-6B Kav 0.05) and small (Kav 0.25), that were not synthesized at detectable levels by cultures from rabbits infected with T. pallidum for 0 or 5 days, were produced by cultures from 10-, 15- and 20-day infected rabbits. The small proteoglycan appeared to be synthesized first because greater amounts of this fraction were detected in extracts of cultures from 10-day infected animals. The large proteoglycan fraction may have been induced directly by T. pallidum because increased synthesis correlated with maximal treponemal numbers, 15 days after infection. In contrast, the induction of the smaller proteoglycan did not appear to be directly related to numbers of elutable organisms. The proteoglycans synthesized between 10 and 20 days after infection were analyzed for glycosaminoglycan (GAG) size and composition. The size of GAGs beta-eliminated from the proteoglycans generally increased over the 10-20-day infection period. Whereas the composition of the small proteoglycan fraction was largely unchanged during the 10-20-day period (45% chondroitin sulphate (CS), 55% dermatan sulphate (DS)), the amount of DS in the high molecular weight proteoglycan fraction decreased from 50-20% during this period (CS 50-80%). Autoradiography studies revealed that increased proteoglycan synthesis in T. pallidum-infected testes was localized to cells lining the seminiferous tubules and to fibroblasts infiltrating peritubular spaces.

Mössbauer investigation of deoxymyoglobin in a high magnetic field. Orientation of the electric field gradient and magnetic tensors

We have examined the Mössbauer spectra of deosymyoglobin in a 6 T magnetic field in the temperature range 4.2-195 K. Spectra were fitted by the least-squares method using a phenomenological model in which the internal magnetic hyperfine field was assumed to be related to the applied field by a temperature dependent tensor õmega. The results indicate that õmega has axial symmetry and a principal axis system aligned with that of the electric field gradient (efg). The principal component of the latter is negative and lies on the symmetry axis of õmega. Our fits indicate that of efg asymmetry parameter is eta = 0.7, with no appreciable temperature dependence. Both axial and transverse components of õmega have the expected 1/T temperature dependence for T greater than 20 K. Our experimentally determined value of eta, combined with published single crystal zero-field measurements, constrains the efg-heme relative orientation to two possibilities. In neither of these is an efg principal axis near to the heme normal.

Parotid neoplasms: a report of 250 cases and review of the literature

A 25-year experience with parotid tumors was reviewed. From a total of 250 neoplasms, 173 were histologically benign and 77 were malignant. Benign mixed tumors accounted for 59% of all lesions. Clinical parameters used to diagnose parotid neoplasms were found to be unreliable in determining whether a given tumor was benign or malignant. The mean age for malignant lesions was 10 years greater than for benign lesions. The phenomenon of malignant transformation of a benign tumor was considered in four patients. Complete surgical excision is the safest and preferred method for diagnosis. Preoperative needle or incisional biopsy are associated with a high degree of local recurrence. The appropriate management of any parotid tumor is predicated on special histological type. Local excision or enucleation no longer have a place in the surgical management of benign parotid tumors. Postoperative tumor recurrence and morbidity are directly related to awareness of surgical anatomy and pursuit of correct surgical techniques for adequate resection. The five-year recurrence rate for 102 benign mixed tumors was 6%. Recurrence in malignant tumors varied with specific histological types but was generally high. Five-year survival for all malignant parotid tumors was 48%.