Role of circulating tumour cells (CTCs) in recurrent/metastatic head and neck squamous cell carcinoma (HNSCC)

Background

Liquid biopsy is emerging as a non-invasive tool, providing a personalized snapshot of a primary and metastatic tumour. It aids in detecting early metastasis, recurrence or resistance to the disease. We aimed to assess the role of circulating tumour cells (CTCs) as a predictive biomarker in recurrent/metastatic head and neck cancer (head and neck squamous cell carcinoma (HNSCC)).

Methodology

Thirty-five patients receiving palliative chemotherapy underwent blood sampling [2 mL in Ethylenediaminetetraacetic acid (EDTA) vial] at baseline and at 3 months intervals. The CTCs were isolated and evaluated using anti-epithelial cell adhesion molecule antibody-based enrichment using the OncoDiscover platform.

Results

CTCs isolated from 80% of patients (n = 28) showed the sensitivity of cell detection at the baseline and 3 months intervals. The median CTC count was 1/1.5 mL of blood and the concordance with clinic-radiological outcomes was 51.4%. The median CTC count (1 (range:0-4) to 0 (range:0-1)) declined at 3 months in responders, while the non-responders had an increase in levels (0 (range :0-2) to 1 (range :0-3)). Although CTCs positively correlated with progression-free survival (PFS) and overall survival (OS), the association of CTCs did not show a significant difference with these parameters (PFS: 6 months versus 4 months; hazard ratio: 0.68; 95% confidence interval (CI): 0.29-1.58, p = 0.323; OS: 10 months versus 8 months; hazard ratio: 0.54; 95% (CI):0.18-1.57 p = 0.216) between CTC positive and CTC negative patients at 3 months.

Conclusion

This study highlights the utility of CTC as a disease progression-monitoring tool in recurrent HNSCC patients. Our findings suggest the potential clinical utility of CTC and the need for exploration in upfront settings of the disease as well (NCT: CTRL/2020/02/023378).

Abstract 6684: Detection of PD-L1, HER2 and EGFR on circulating tumor cells in carcinoma patients

Background: Small molecular inhibitors and immunotherapy has emerged as a novel alternative treatment regime for a variety of epithelial cancers. Large number of clinical trials are in progress to gauge efficacy of tyrosine kinase inhibitors or immune checkpoint inhibitors against actionable targets such as receptor tyrosine kinases and program death ligand 1 (PD-L1). Although highly effective, the outcome of PD-L1 based ICI or TKI against RTKs is vitally contingent on the presence of PD-L1 or RTK expression on circulating tumor cells. We report validation of CTCs with PD-L1, HER2 and EGFR expression in different epithelial cancers.

Methods: We retrospectively evaluated 134 carcinoma patients blood for presence of CTCs expressing PD-L1, HER2 or EGFR markers respect. 45 % patients had lung cancer, while 25 % and 20 % were presented with breast and GI and CRC malignancies. Remaining were gallbladder, ovarian, prostate, and head and neck cancers. CTCs were isolated from DCGI approved OncoDiscover platform with immunomagnetic targeting of EpCAM. CTCs were confirmed with expression of CK18, absence of CD45 and presence of DAPI nucleus. Presence/absence of biomarkers was determined using fluorescence imaging. Expression of PD-L1, HER2 or EGFR was detected by fluorescence microscopy using fluorescently labelled anti PD-L1, HER2 or EGFR antibodies respect. Based on fluorescence intensity CTCs were binned as PD-L1, HER2 or EGFR negative for no detectable fluorescence signal or weakly or strongly positive based on low or high fluorescence signal.

Results: Among the evaluated cohort, 51% of CTCs showed presence of PD-L1 expression. While 63% showed HER2 positive CTCs (breast cancer). 20% from the PD-L1 positive population showed stronger PD-L1 expression. 78% of CTCs from lung cancer patients showed presence of detectable PD-L1 signal, while 66% breast, GI and CRC patients showed CTCs with PD-L1 expression. CTCs from HNC and gall bladder cancer patients showed low PD-L1 expression (25% and 50% respect.). Among CTCs originating from different cancer types, breast cancer CTCs showed higher mean expression of PD-L1 compared to CTCs from CRC patients. A clear subset of CTCs for PD-L1 and Her2 expression was observed in lung and breast cancer patients respect, suggesting the heterogeneity in expression or presence of different subclones within the same tumor type. CTCs evaluated for EGFR expression, 50% showed presence of detectable EGFR compared to the cut-off signal.

Conclusions: CTC can be used as a real-time surrogate for molecular profiling of PD-L1, HER2 and EGFR expression. These CTC cell surface markers offer alternative for immunotherapy or targeted therapies decisions in a adenocarcinomas.

Citation Format: Jayant Khandare, Atul Bharde, Sreeja Jayant, Gourishankar Aland, Meghana Garbhe, Sayali Gosavi, Apoorva Janorkar, Purva Tikekar, Mrunmayi Patil, Vikas Jadhav, Ganesh Khutale, Amrut Ashturkar, Aravindan Vasudevan, Kumar Prabhash, Nirmal Raut, Pankaj Chaturvedi. Detection of PD-L1, HER2 and EGFR on circulating tumor cells in carcinoma patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 6684.

Abstract PR007: Comprehensive ctDNA profiling reveals potential metastatic genomic signatures in treatment-naive early-stage breast cancer patients

Background: Genomic profiling has revolutionized precision oncology impacting the diagnosis, prognosis, and therapy decisions. Considering high spatiotemporal diversity and heterogenicity of breast tumor-cell genomes, small-gene panels often fail to capture rare but important genomic alterations. Conversely, comprehensive ctDNA sequencing approaches enable the identification of under characterized ‘long tailed driver’ genomic alterations and capture Intra and inter metastatic heterogeneity. Here, we demonstrate the clinical utility of comprehensive genome profiling with higher sensitivity to predict the possibility of metastasis in early-stage breast cancer patients. Methods: We retrospectively analyzed ctDNA and genomic DNA (gDNA) from FFPE samples as well as circulating tumor cells (CTC) in 10 treatment-naive hormone positive and HER2 negative, primary-stage breast cancer patients [GS1] using the OncoIndx comprehensive 600 gene panel. The panel captures all important cancer-relevant genomic alterations including Tumor Mutation Burden (TMB), Micro Satellite Instability (MSI), homologous recombination deficiency (HRD) prediction, and cfDNA tumor fraction (TF). CTCs were enumerated from 1.5 ml of blood using the OncoDiscover platform approved by the Drug Controller General of India having anti-EpCAM antibody-mediated immunomagnetic nanoparticles. CTCs were confirmed for cytokeratin 18+ and DAPI + markers and the absence of CD45. Results: Comprehensive genomic profile obtained from ctDNA and gDNA from FFPE of early-stage breast cancer patients predominantly exhibited the presence of alterations in PIK3CA and ESR1 signaling pathways. PIK3CA mutations were present in 77% and 44% of baseline ctDNA and gDNA samples, while ESR1 mutations were present in 44% and 22% of baseline ctDNA and gDNA, respectively. In addition, we observed about 70% additional driver mutations in ctDNA samples suggesting shedding of ctDNA together with CTC (80% positive), a likely positive biomarker of metastasis. About 50% of the patients showed higher TMB and HRD. Notably, TF representing ctDNA varied between 13% to 27% in blood samples with a corresponding ploidy range of 2.9 to 4.7. Surprisingly, ~50% of the patient population matched the mutation profile of clinically confirmed metastatic patients. All the patients harboring potential metastatic driver alterations showed the presence of CTCs in peripheral blood. Conclusions: Comprehensive ctDNA genomic profiling showed potential metastasis driving alterations suggesting the role of ctDNA-based liquid biopsy to predict metastasis in early breast cancer patients. We observed enhanced TF at the time of diagnosis, possibly due to the presence of distant metastasis, high disease burden, and aggressive tumor biology. Our results suggest that ctDNA dynamics at the time of disease presentation can predict early metastasis, and may demonstrate the divergent response of tumor heterogeneity to treatment in early-stage breast cancer.

Citation Format: Gowhar Shafi, Manoj Dongare, Atul Bharde, Moubeen Fauzul, Kanchan Hariramani, Alain D’Souza, Bhagwat Jadhav, Trupti Kad, Sangeeta Prajapati, Vikas Jadhav, ManojKumar Kumaran, Sumit Haldar, Vatsal Mehra, Sujit Joshi, Gourishankar Aland, Richa Dave, Sreeja Jayant, Aravindan Vasudevan, Mohan Uttarwar, Jayant Khandare. Comprehensive ctDNA profiling reveals potential metastatic genomic signatures in treatment-naive early-stage breast cancer patients [abstract]. In: Proceedings of the AACR Special Conference: Cancer Metastasis; 2022 Nov 14-17; Portland, OR. Philadelphia (PA): AACR; Cancer Res 2022;83(2 Suppl_2):Abstract nr PR007.

A Rare Case of Unilateral Xanthogranulomatous Ureteritis Mimicking an Inferior Vena Cava Tumor

Xanthogranulomatous pyelonephritis (XPG) is a known clinical entity; however, the further progression of this inflammatory pathology to adjacent organs, including the ureter, bladder and urethra, is extremely rare. Xanthogranulomatous inflammation of the ureter is a chronic inflammatory state where foamy macrophages are seen in the lamina propria along with multinucleated giant cells and lymphocytes forming a granulomatous inflammation, which is benign. Based on its appearance on computed tomography (CT) scan images, it can easily be misidentified as a malignant mass, and the patient can be subjected to surgery that can lead to complications. Here we present a case of an elderly male with a known case of chronic kidney disease with uncontrolled type 2 diabetes mellitus who presented with fever and dysuria. Upon further radiological investigations, the patient had underlying sepsis and was seen to have a mass involving the right ureter and inferior vena cava. Upon biopsy and histopathology, he was diagnosed with xanthogranulomatous ureteritis (XGU). The patient underwent further treatment and was followed up.

Extracorporeal microchannel device to capture and eliminate circulating tumor cells from cancer patient’s blood

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Background: Metastatic progression accounts for nearly 90% of cancer-related deaths and has been directly correlated with the presence of circulating tumor cells (CTCs) in numerous carcinomas including breast, lung, ovarian, colorectal, and head and neck cancers. The removal of CTCs from cancer patient’s blood is directly implicated with reduction of extravasation and disease invasiveness to secondary organs. Methods: We designed and printed 3 Dimensional (3D) microchannel devices using biocompatible polymer and packed it with anti-EpCAM (EpCAM) mediated glass-based (G) compositions (G-EpCAM). The computational fluid dynamic (CFD) analysis simulation was explored to optimize the hemodynamic effect of the G-EpCAM device for measuring the pressure and velocity difference for blood along the spiral flow microchannels. Red blood cell (RBC) hemolysis was estimated using G-EpCAM compositions packed in a device to determine optimal biocompatibility. We assessed cancer cell lines (breast cancer MCF7, lung cancer A549) interactions and capture with varying incubation time points, effect of anti-EpCAM concentrations, number of G-EpCAMs, and series of devices. We evaluated G-EpCAM-on-device’s CTC capture capability and biocompatibility using head and neck, colorectal, lung, and ductal breast cancer patient’s blood samples. All G-EpCAM captured CTCs were immuno-stained for cytokeratin 18 (CK18) expression and the optimal fluorescence acquisition intensity was quantified. Results: Extracorporeal G-EpCAM microchannel device was 3D printed and consisted of interlocking top lid and bottom base with inlet and outlet channels. The path length of the spiral device consisted of 20 microchannels with 6.0-feet length. Device accommodated 28 gm of non-hemolytic G-EpCAM compositions. CFD analysis showed 3.8 mm as the ideal channel diameter and 2mm as the superlative G-EpCAM diameter for maximal cells and CTC capture with minimal blood hemolysis (less than 1%) as compared to control. Series 1 and 2 device indicated 90% and 85% cell capture efficiency, respectively using G-EpCAM devices indicating highest interactions and efficiency with cells. Conversely, the first device in series captured the highest cells. In addition, the efficiency improved as the number of G-EpCAM compositions was increased. We accounted device to capture CTCs with specificity having G-EpCAM composition and observed no hemolysis and non-specific interactions with other blood cells like RBCs or leukocytes. Conclusions: Continuous CTC removal from cancer patient’s blood circulation using such device offers promising therapeutic utility in stemming aggressive metastatic invasion and progression for improving the overall survival of epithelial origin cancer patients. Clinical trial information: CTRI U1111/1192-3951.

AI-enabled identification prediction of homologous recombination deficiency (HRD) from histopathology images

3019

Background: Homologous recombination deficient (HRD) tumors are highly responsive to platinum-based chemotherapy and poly (ADP-ribose) polymerase inhibitor (PARPi) therapy. Pathogenic BRCA-1 and BRCA-2 (BRCA1/2) alterations are key members of the HR DNA repair pathway but genomic instability status, including loss of heterozygosity, telomeric allelic imbalance and large scale state transitions across the genome are also predictive of HRD. HRD testing is currently performed by next generation sequencing which can take 2-4 weeks for results, has a high failure rate, requires significant tissue and is costly. We developed and tested the ability of an AI enabled platform to predict HRD status from the analysis of whole slide imaging of the diagnostic H&E slide. This platform, iPREDICT-HRD is rapid, precise, and cost effective. Methods: The AI engine was trained on 120 H&E slides that were used to identify tumor prior to manual microdisseection for HRD assessment by NGS. Histopathological features were extracted, followed by feature mapping to predict HRD status based on the results of NGS testing. ResNet AI algorithm was trained to segment, annotate and predict HRD status. 10 lac tiles of 256x256 size at 40x magnification were generated per pathological class. 70% of the data set was used for training and 30% for validation of the AI model. Results: Using single blinded clinical samples, iPREDICT-HRD tool detected HRD + ve samples with 99.3% accuracy with 100% sensitivity and 99% specificity in the test set. Patch-level predictions of HRD status demonstrated intra-tumor heterogeneity within the H&E slides. Visual inspection of the heatmap suggested the presence of patches with high predictive ability of HRD status and this outperformed an average HRD score for slides with heterogeneity. Conclusions: AI-enabled prediction of HRD status can be accurately performed on diagnostic H&E slides potentially yielding results quickly and afforadably, even when limited tissue is available for testing.

A feasibility study of EMF(erlotinib+methotrexate+5-fluorouracil) regimen in recurrent head and neck squamous cell carcinoma (HNSCC) and role of circulating tumour cells(CTCs) in assessment of outcomes

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Background: Head and neck cancer is a huge burden in South East Asia with frequent relapse after curative therapy while the rest presenting in advanced unresectable stages. Financial constraints for targeted and immunotherapy make it inaccessible for the bulk of population. Thus, low-cost but efficacious regimen is highly implicated. We assessed if readily available triplet therapy of EMF, is superior in terms of extending life and maintaining quality of life along with evaluation of CTCs as a predictive biomarker in such patients. Methods: This was a single arm, phase II, investigator initiated interventional study, wherein 35 patients were enrolled. Platinum resistant/refractory patients of HNSCC were treated with combination of erlotinib 150mg daily, methotrexate 40 mg/m2 and 5-fluourouracil 500 mg/m2 (d1, d8) q28 days till progression or unacceptable toxicities. The primary endpoint was overall response rate(ORR) at 3 months; additional endpoints were disease control rate(DCR) at 3 months, overall survival (OS), progression free survival (PFS) safety and patient reported quality of life(QOL). The role of CTCs in gauging the responders and non-responders was monitored using anti Epithelial Cell Adhesion Molecule antibody based enrichment - OncoDiscover Drug Controller General of India (DCGI) approved platform. Results: The ORR and DCR at 3 months was 45.7% and 68.5%, respectively. The median PFS was 5 months (95%CI: 3.9-6 months) and median OS was 9 months (95%CI:7.4 -10.5 months). The 3 and 6 months PFS rates was 86 + 6% and 45 + 9%, respectively, while OS rates at 3 and 6 months were 91+ 5% and 68+ 8%, respectively. Rash, mucositis and fatigue were common adverse events occurring in 23 (65%), 14 (40%) and 9 (25.7%) respectively. The grade 3 events seen were rash in 5 (14.2%) and diarrhea in 2 (5.7%). Clinically significant improvement was seen in domains of role functioning, social functioning, fatigue, pain and global health status, swallowing, dryness of mouth and feeling ill. The mean CTC count at baseline was 0.90 + 1.1 /1.5ml of blood. Responders showed decline in levels from 1.19 + 0.25 to 0.33 + 0.48, while non-responders had increasing trend: 0.29 + 0.48 to 1+ 0.10 at 3 months (p = 0.010); with concordance rates with response being 52.9%. Additionally, CTC clearance at 3 months had numerically better PFS ̃ 6 months (95% CI: 4.72-7.72) and OS of 10 months (95% CI: 2.3-5.65) vs 4 months (95% CI: 2.3-5.65), p = 0.258 and 8 months (95% CI: 4.3-11.6), p = 0.203 in those with persistence of CTCs. Conclusions: The triplet regimen of EMF is a feasible, safe therapeutic option with favourable response rates and improved QOL in patients with platinum resistant/refractory HNSCC. CTCs have a promising futuristic role as a predictive biomarker and can be extrapolated in clinical upfront setting too. Clinical trial information: CTRI/2020/02/023378.

Inflammatory Subcutaneous Pseudotumour due to Migrating Foreign Body through Concealed Colonic Perforation: A Case Report

Foreign body ingestion though a common occurrence, rarely leads to bowel perforation. Thus, foreign body migration presents a diagnostic challenge. The author presents a case report of a 75-year-old female with a inflammatory subcutaneous pseudotumour due to migrating foreign body through a concealed colonic perforation. The patient presented with insidious abdominal pain and fever since two months, with local tenderness and palpable lumbar in right lumbar region on examination. The diagnosis was initially made on ultrasound and confirmed on Computed Tomography (CT). Surgical removal of the foreign body was done.

Painful Abdominal Lump in the Pediatric Age Group: A Diagnostic Dilemma

Any cystic lesion occurring in the mesentery which may or may not extend into the retroperitoneum is referred to as a mesenteric cyst; they have an infrequent incidence rate in the pediatric age group. Definitive etiology of the cystic lymphatic malformations is still not known but there are multiple hypotheses. A young male child presented with acute onset abdominal pain and palpable intra-abdominal mass and ultrasonography revealed presence of two lesions, one of them as an encysted turbid fluid collection in the right lumbar region and the other as a dilated, tortuous, intercalated structure. On CT, the first one was identified definitively as a mesenteric cyst while the other as a possible neoplastic mass in close proximity to the first one. Histopathology confirmed the diagnosis as a cystic lymphatic malformation of the mesenteric cyst. The limited awareness of its existence along with its usually asymptomatic nature, are the likely reasons that it still remains an elusive diagnosis. Based on our case we discuss, the use of a multi-modality approach towards diagnosing cystic malformation disorders and how the use of MRI is under-utilised when it could prove decisive.

Application of hot melt extrusion for improving bioavailability of artemisinin a thermolabile drug

Hot melt extrusion has been used to produce a solid dispersion of the thermolabile drug artemisinin. Formulation and process conditions were optimized prior to evaluation of dissolution and biopharmaceutical performance. Soluplus^®, a low T_g amphiphilic polymer especially designed for solid dispersions enabled melt extrusion at 110 °C although some drug-polymer incompatibility was observed. Addition of 5% citric acid as a pH modifier was found to suppress the degradation. The area under plasma concentration time curve (AUC_0-24h) and peak plasma concentration (C_max) were four times higher for the modified solid dispersion compared to that of pure artemisinin.

Cryptanalytic Attacks on IDEA Block Cipher

International data encryption algorithm (IDEA) is a secret key or symmetric key block cipher. The purpose of IDEA was to replace data encryption standard (DES) cipher, which became practically insecure due to its small key size of 56 bits and increase in computational power of systems. IDEA cipher mainly to provide data confidentiality in variety of applications such as commercial and financial application e.g. pretty good privacy (PGP) protocol. Till 2015, no successful linear or algebraic weaknesses IDEA of have been reported. In this paper, author explained IDEA cipher, its application in PGP and did a systematic survey of various attacks attempted on IDEA cipher. The best cryptanalysis result which applied to all keys could break IDEA up to 6 rounds out of 8.5 rounds of the full IDEA cipher1. But the attack requires 264 known plaintexts and 2126.8 operations for reduced round version. This attack is practically not feasible due to above mention mammoth data and time requirements. So IDEA cipher is still completely secure for practical usage. PGP v2.0 uses IDEA cipher in place of BassOmatic which was found to be insecure for providing data confidentiality.

Are we overconcerned about secondary hyperparathyroidism and underestimating the more common secondary hypoparathyroidism in our dialysis patients?

OBJECTIVES

The aim of the study was to determine the prevalence of hyper and hypo-parathyroid state in prevalent dialysis patients. The second part of the study was to look for the prevalence of vascular calcification (abdominal aortic) and factors predicting calcification in these patients.

METHODS

All adult patients, who were more than 1 month on dialysis, were included in the study. A total of 68 patients, of which 75% were on hemodialysis and 25% on peritoneal dialysis, were finally studied. Patients' parathyroid status was defined as per target recommendation of KDOQI--hypoparathyroid with iPTH < or = 150 pg/ml and hyperparathyroid with iPTH > 300 pg/ml. Vascular calcification was determined by X ray of lateral lumbar spine to look for abdominal aortic calcification (AAC). The AAC was scored as validated. The prevalence of hyper- and hypoparathyroidism in dialysis patients was determined as percentage of total dialysis patients. The prevalence of AAC and factors predicting it was analyzed by 'univariate' and 'multiple logistic regression analyses.

RESULTS

The mean age of patients was 50.04 +/- 14.15 years, 58.82% were males and 42.64% were diabetics. Mean duration of dialysis was 22.36 +/- 19.17 months. Hyperparathyroidism was seen in only 27.94% of all dialysis patients, while hypoparathyroidism was in 45.58%. Abdominal aortic calcification was seen in 79.41% of overall patients and 13.23% had significant calcification (score 7-24). On univariate analysis, age (0.000) and iPTH (0.03) were the only variables predicting AAC and on logistic regression analysis, age was the only independent predictor of abdominal aortic calcification (p = 0.002, OR 1.11, CI 1.038-1.186).

CONCLUSION

Hypoparathyroidism is more common (46%) in our dialysis patients as compared to hyperparathyroidism (28%). There is high prevalence of vascular (abdominal aortic) calcification (80%) in our dialysis patients.

Lake contamination by accumulation of heavy metal ions in Eichhornia crassipes: a case study of Rankala Lake, Kolhapur (India)

The absorption of heavy metals into biomaterial derived from the plant Eichhornia crassipes was investigated. The root, stem and leaf samples of the plant collected from the Rankala Lake of Kolhapur city (India) were analyzed for the metal ion concentrations using Atomic Absorption Spectrometer. It has been observed that in root, stem and leaf, Pb ions get absorbed, while the extent of absorption for each element found different in the parts analyzed. In root, the order for metal ion absorption found to be Fe>Mn>Cu>Zn>Cr>Pb>Ni>Co>Cd ions. Thus, it is clear that Eichhornia crassipes absorbs heavy metal ions and can be used for minimizing the pollution taking place due to toxic metal ions in the effluents from various industries.

Endoscopic management of spontaneous perforation of a cystic duct in a 10-year-old child

A 10-year-old boy presented to us with acute abdominal pain and vomiting. The patient was stable on clinical examination. On ultrasound and computed tomography scan of the abdomen he had persistent peritoneal collection with edematous pancreas. Abdominal paracentesis revealed bile and 99m Tc HIDA (hepatobiliary iminodiacetic acid) scan showed a biliary leak. A percutaneous drain was inserted for collection, and endoscopic retrograde cholangiopancreatography (ERCP) was performed. A spontaneous cystic duct perforation was confirmed on ERCP and a biliary stent was inserted. The patient's general condition improved, his percutaneous drain was removed on day 6 post ERCP and the biliary stent removed after 3 months. The patient is asymptomatic and doing well at 6 months' follow up. Spontaneous perforation of a cystic duct is an extremely rare condition with very few reported cases in the literature. Radionuclide scanning and ERCP are reliable modes for diagnosis and localization of the site of the leak. ERCP and biliary stenting are successful in the management of these patients.

Long-term effects of melatonin after intracerebral hemorrhage in rats

Free radical scavengers have been shown to improve short-term outcome after intracerebral hemorrhage (ICH). The purpose of this study was to evaluate whether melatonin (a potent free radical scavenger and an indirect antioxidant) can improve short- and/or long-term neurological function after ICH, which was induced by collagenase injection into the striatum of adult rats. Melatonin (15 mg/kg) was administered by intraperitoneal injection at 1, 24, 48, and 72 h. Neurological and behavioral testing was performed at several time points from 1 day to 8 weeks post-ICH. Neurological and behavioral deficits were observed in ICH rats at all time points, but the melatonin treatment regimen did not improve performance or level of brain injury.

Parastomal hernia: Is prevention better than cure? Use of preperitoneal polypropylene mesh at the time of stoma formation

BACKGROUND

This is a prospective study of prophylactic mesh placement in the preperitoneal space at the time of stoma formation to prevent parastomal hernia.

METHODS

Patients undergoing elective permanent stoma formation and resiting of a stoma were included. Patients with peritoneal contamination were excluded. A 6x6-cm polypropylene mesh was placed in the preperitoneal space (no stitches), and a circular hole was made to let the bowel come through with ease and the stoma was constructed. At follow-up, the patients were examined standing and lying down for parastomal hernia. In the event of clinical uncertainty, a CT scan was done.

RESULTS

A total of 42 patients (20 women, 22 men, mean age 61 years) were eligible for the study. The patients were followed up for a mean of 31 months (range 9-68 months). There were 29 end-colostomies and 8 end-ileostomies and 5 stomas resited. Four parastomal hernias were detected during the follow-up period (9.52%). One required repair due to an ill-fitting stoma bag and leakage. The other three were asymptomatic. One patient developed stomal necrosis which required a new segment of bowel to be brought out through the same opening and the underlying mesh was left undisturbed.

CONCLUSIONS

The results of the 2-year follow-up in this study (incidence of parastomal herniation 9.5%) along with available evidence in the literature (incidence 0-8.3%), compared to the results of repair make a strong case for the use of a mesh at the time of initial surgery for the formation of any permanent stoma to prevent parastomal herniation.

Acute appendicitis: are we over diagnosing it?

INTRODUCTION

Appendicectomy is by far the commonest major emergency general surgical operation and laparoscopic appendicectomy is now becoming common. The question of whether a normal-looking appendix should be removed laparoscopically is more pertinent than ever before.

PATIENTS AND METHODS

A retrospective study was undertaken to review the histopathology results and compare macroscopic with microscopic descriptions of all patients who underwent an appendicectomy, either by open surgery or laparoscopically, over a 1-year period from 1 September 2004 to 31 August 2005.

RESULTS

A total of 199 appendicectomies were carried out in the year of which histopathology results for 190 could be retrieved. Of the 190 who had an appendicectomy, 110 (57.9%) were female and 80 (42.1%) were male. While appendicitis was confirmed histologically in 65 of 80 (81.2%) male patients, it could only be confirmed histologically in 57 of 110 (51.8%) female patients. However, in a large number of female patients in whom macroscopically normal appendices had been removed, other findings were noted including fibro-obliterative changes in 10, luminal inflammation in 6, serositis in 5, lymphoid hyperplasia in 3, feacoliths in 2, and pinworm in 1, making another abdominal pathology a possibility.

CONCLUSIONS

The number of macroscopically normal appendices removed was much larger in female patients. However in 27 of 49 normal looking appendices in females, findings such as serositis, luminal inflammation, lymphoid hyperplasia, etc. were noted on histology, suggesting that another abdominal pathology may have been missed or the appendix may still have been the cause for pain. On the basis of these findings, we suggest that diagnostic laparoscopy should be performed at least in all female patients before an appendicectomy; if no other findings are noted on laparoscopy, it is likely to be worthwhile to remove the appendix.

Cervical intraepithelial changes & HIV infection in women attending sexually transmitted disease clinics in Pune, India

BACKGROUND & OBJECTIVES

Cervical cancer is the most important cause of malignancy associated deaths among women in India. Western studies have reported higher risk of abnormal Pap smears in HIV infected women. A large burden of HIV infection and increasing HIV epidemic in India threatens to exacerbate incidence of cervical cancer. The objective of this study was to assess the frequency of Pap smear abnormalities and its association with HIV infection in women attending sexually transmitted disease (STD) clinics and to identify associated risk factors.

METHODS

Between June 1996 and September 1999, women attending two STD clinics in Pune were screened for HIV infection, offered STD laboratory diagnosis and treatment and their Pap smears were evaluated.

RESULTS

Squamous cell abnormality was detected in 10 per cent of HIV sero negative women attending STD clinics. This proportion was nearly double (19.2%) (Odds ratio = 2.14, 95% C.I. 1.03-4.48, P = 0.04) in HIV seropositive women. Having more than one life time partners and presence of STDs were also significantly associated with Pap smear abnormality in univariate analysis. In multivariate analysis, women presenting with STD and HIV infection both, were 2.8 times more likely to have inflammatory Pap smear and 3.5 times more likely to have abnormal Pap smear compared to HIV seronegative women presenting without STDs.

INTERPRETATION & CONCLUSION

Pap smear abnormalities were common in women attending STD clinics in Pune. Presence of HIV infection further increased the risk two-folds. Therefore, women suffering from STDs should undergo periodic Pap smear screening for early detection of cervical abnormalities and should receive appropriate management to reduce morbidity and mortality.

Activation of Pig Liver Esterase in Organic Media with Organic Polymers. Application to the Enantioselective Acylation of Racemic Functionalized Secondary Alcohols

Pig liver esterase (PLE) shows practically no activity in acylation of alcohols with vinylic esters in organic solvents. However, addition of methoxypoly(ethylene glycol) (MPEG), bovine serum albumin (BSA), TentaGelAmino resin (TGA), or aminomethyl polystyrene (AMPS) confers activity to PLE in acylation of alcohols with vinyl propionate in organic solvents of low water content. Polymer-activated PLE showed high enantioselectivities (E > 100) in the acylation of racemic 1-alkoxy-, 1-ethylsulfanyl-, and 1-fluoro-3-aryl-2-propanols as well as racemic 1-phenoxy-2-propanol and racemic 1-methoxy-2-phenoxy-2-propanol. The synthetic utility of polymer-activated PLE has been demonstrated by the gram-scale resolution of 1-methoxy-3-phenyl-2-propanol, 1-ethylsulfanyl-3-phenyl-2-propanol, 1-methoxy-3-p-methoxyphenyl-2-propanol, 1-fluoro-3-phenyl-2-propanol, and 1-methoxy-3-phenoxy-2-propanol. In PLE-catalyzed acylation of alcohols with vinyl propionate, acetaldehyde and propionic acids, both being detrimental to the enzyme, are formed as byproducts. In addition, the water content of the system, which is critical for the activity of pig liver esterase, is lowered because of a competing enzymatic hydrolysis of the acyl donor. The polymers TGA, BSA, and AMPS not only scavenge the aldehyde and the acid through imine formation and neutralization, respectively, but replenish at least in part also the water consumed in the competing hydrolysis of the acyl donor. A recovery of PLE together with the polymer was achieved without major loss of activity through their immobilization on a water-saturated polyaramide membrane, which occurs spontaneously in organic solvents.

The effect of a dedicated emergency theatre facility on emergency operating patterns

Following the introduction of a dedicated 24-hour emergency theatre facility in a 500-bed district general hospital, the total amount of emergency general surgery performed after 22.00 hours has been reduced from 37.2 to 13.1%, with a concomitant increase in emergency day-time operating from 22.1 to 51.2%. The majority of the workload was previously performed by the junior grades, and this has remained unchanged. Operative experience has not been diminished with the reduction in night-time surgery, and senior supervision has been enhanced. There has been no significant difference in mortality or morbidity with the changes in operating patterns. Utilization of the theatre staff and time during the night has been improved.