Blood clots in COVID-19 patients: Simplifying the curious mystery

The universal phenomenon of blood clotting is well known to be protective in external cellular/ tissue injury. However, the emergence of unusual thrombotic presentations in COVID-19 patients is the real concern. Interaction of the spike glycoprotein with ACE2 receptor present in the host cell surface mediates the entry of SARS-CoV-2 causing COVID-19 infection. New clinical findings of SARS-CoV-2 pathogenesis are coming out every day, and one such mystery is the formation of mysterious blood clots in the various tissues and organs of COVID-19 patients, which needs critical attention. To address this issue, we hypothesis that, high ACE2 expression in the endothelium of blood vessels facilitates the high-affinity binding of SARS-CoV-2 using spike protein, causing infection and internal injury inside the vascular wall of blood vessels. This viral associated injury may directly/indirectly initiate activation of coagulation and clotting cascades forming internal blood clots. However, the presence of these clots is undesirable as they are responsible for thrombosis and need to be treated with anti-thrombotic intervention.

Atypical theileriosis with cutaneous involvement in a cow in India: a case report

Bovine tropical theileriosis caused by Theileria annulata is an overwhelming haemoprotozoan tick-borne disease in taurine and cross-bred cattle in Punjab, India. However, there seems to be no report from India of cutaneous nodules associated with the disease. This report describes a five-year-old cross-bred cow presented to a university clinic with a history of fever, inappetence and malaise for the past six to seven days. Clinical examination revealed normal vital parameters, pale mucous membranes, mild enlargement of the prescapular lymph nodes and multiple subcutaneous nodular masses (2-4 cm) on the neck and abdomen. Haematology revealed mild anaemia and leucopenia with 48% neutrophils, 48% lymphocytes and 4% eosinophils. Romanowsky-stained smears of fineneedle aspiration biopsy samples from swollen lymph nodes and subcutaneous masses showed an increased number of lymphoid cells, suggesting cutaneous lymphomatosis. However, a critical examination of the smears from subcutaneous nodules showed a large number of Koch's blue bodies in macrophages and lymphoblasts, and several piroplasms were also noticed within the red blood cells in lymph node smears. A peripheral blood smear revealed mild to moderate parasitaemia. Extracted DNA from the parasitologically positive blood sample was subjected to nested polymerase chain reaction (nPCR) using T. annulata speciesspecific primers encoding the 30-kiloDalton major sporozoite surface antigen. The desired 572-base pair amplified product of the nPCR was comparable to the positive control. This seems to be a rare case of T. annulata in an adult cross-bred cow, showing cutaneous nodular involvement.

Structural and biochemical studies of phosphopantetheine adenylyltransferase from Acinetobacter baumannii with dephospho-coenzyme A and coenzyme A

Phosphopantetheine adenylyl transferase catalyzes a rate limiting penultimate step of the multistep reaction which produces coenzyme A (CoA) as a final product. CoA is required as an essential cofactor in a number of metabolic reactions. Therefore inhibiting the function of this enzyme will lead to cell death in bacteria. Acinetobacter baumannii is multi drug resistant pathogen and causes infections in immunocompromised patients. AbPPAT has been cloned, expressed, purified and crystallized and structures of two complexes of AbPPAT with dephospho coenzyme A (dPCoA) and coenzyme A (CoA) have been determined. Both dPCoA and CoA molecules are observed in the substrate binding site of AbPPAT. A comparison with the structures of the complexes of PPAT from other species shows that the orientations of dPCoA are identical in all the structures. On the other hand, as observed from the structures of the complexes of CoA with PPAT, the orientations of CoA are found to differ considerably. This shows that the substrates occupy identical positions in the substrate binding sites of enzymes whereas the positions of inhibitors may differ. The binding studies carried out using fluorescence method and surface plasmon resonance techniques showed that binding affinity of CoA towards AbPPAT is nearly three times higher than that of dPCoA.

Meta-analysis of the influence of a positive circumferential resection margin in oesophageal cancer

Background

The evidence regarding the prognostic impact of a positive circumferential resection margin (CRM) in oesophageal cancer is conflicting, and there is global variability in the definition of a positive CRM. The aim of this study was to determine the impact of a positive CRM on survival in patients undergoing oesophagectomy for oesophageal cancer.

Methods

A systematic review and meta‐analysis was performed. PubMed and Embase databases were searched for articles to May 2018 examining the effect of a positive CRM on survival. Cohort studies written in English were included. Meta‐analyses of univariable and multivariable hazard ratios (HRs) were performed using both Royal College of Pathologists (RCP) and College of American Pathologists (CAP) criteria. Risk of bias was assessed using the Newcastle–Ottawa Scale. Egger regression, and Duval and Tweedie trim‐and‐fill statistics were used to assess publication bias.

Results

Of 133 studies screened, 29 incorporating 6142 patients were finally included for analysis. Pooled univariable HRs for overall survival in patients with a positive CRM were 1·68 (95 per cent c.i. 1·48 to 1·91; P < 0·001) and 2·18 (1·84 to 2·60; P < 0·001) using RCP and CAP criteria respectively. Subgroup analyses demonstrated similar results for patients by T category, neoadjuvant therapy and tumour type. Pooled HRs from multivariable analyses suggested that a positive CRM was independently predictive of a worse overall survival (RCP: 1·41, 1·21 to 1·64, P < 0·001; CAP: 2·37, 1·60 to 3·51, P < 0·001).

Conclusion

A positive CRM is associated with a worse prognosis regardless of classification system, T category, tumour type or neoadjuvant therapy.

Confirmation of a Rare Genetic Leukoencephalopathy due to a Novel Bi-allelic Variant in RPIA

Ribose 5-phosphate isomerase deficiency is a rare genetic leukoencephalopathy caused by pathogenic sequence variants in RPIA, that encodes ribose 5-phosphate isomerase, an enzyme in the pentose phosphate pathway. Till date, only three individuals with ribose 5-phosphate isomerase deficiency have been described in literature. We report on a subject with RPIA associated progressive leukoencephalopathy with elevated urine arabitol and ribitol levels and a novel missense variant c.770T > C p.(Ile257Thr) in exon 8 of RPIA. We also compare the phenotypes of all the four subjects. Our report confirms the phenotype and the genetic cause of this condition.

Identification of a novel homozygous variant confirms ITPA as a developmental and epileptic encephalopathy gene

ITPA related epileptic encephalopathy (epileptic encephalopathy, early infantile, 35) is a rare inborn error of metabolism. All reported individuals with this condition, including the present case manifest global developmental delay, seizures, progressive postnatal microcephaly, hypotonia, thin corpus callosum, cerebral atrophy, delayed myelination and white matter changes in posterior limb of internal capsule. Cataract and dilated cardiomyopathy are other characteristic findings. Currently, a single publication describes this condition in four families. Three truncating and two missense variants in ITPA have been identified in these families. We hereby report another family with ITPA related disorder and review the genotype and phenotype of the reported subjects.

Abstract P1-15-10: A prospective multicenter real-world study on neoadjuvant treatment and clinical outcome in TNBC patients

Introduction

Controversy exists with regards to the optimal regimen for neoadjuvant chemotherapy (NAC) of TNBC. Platinum-based regimens seem to be more active in TNBC improving pCR rates significantly. But adding platinum to an anthracycline/taxane chemotherapy regime comes at the expense of greater toxicity. Its impact on survival and long-term-outcomes remains undetermined. Practical guidelines vary across leading international professional societies. In this real-world multicenter study neoadjuvant regimens, pCR rates and survival were evaluated.

Material and methods

This study was conducted from 2012-2017 in six certified breast cancer centers in the region of Hanover, Germany, including rural and urban populations by using a personal questionnaire and data from the medical records. All patients with primary TNBC (ER&lt;1%, PR&lt;1%, Her2/neu 0, 1+ or 2+ FISH/CISH negative) and no evidence of distant disease were eligible.

Results

143/217 patients (66%) received NAC and 74/217patients (34%) adjuvant chemotherapy. 63/143 (44%) patients achieved pCR. 23/63 (35%) received platinum-based NAC and 40/63 (65%) received chemotherapy without platinum. In 80 patients pCR was not achieved. 12/80 patients received platinum and 68/80 non platinum-based NAC. pCR was significantly higher among patients with platinum-based chemotherapy (chi-square, p &lt; 0.003). 20/23 patients who achieved pCR received NAC containing anthracycline/taxane/carboplatin, 3/23 patients received a taxane/carboplatin-based regime. Treatment discontinuation was seen in 12/35 (34%) patients receiving platinum-based NAC vs 15/108 (14%) in non-platinum-based NAC. Mean follow up was 17 months (1-70months). A significant difference in OS (p=0.007) and DFS (p=0.001) was seen for patients with a pCR.

Conclusion

Our trial confirms that platinum based NAC achieves significantly higher rates of pCR in patients with TNBC. pCR was associated with significantly longer DFS and OS. The CALBG protocol (CALBG 40603) was the preferred choice of treatment regimen followed by the GeparSixto protocol. In our study the pCR rate was comparable to that of both trials in which pCR rates of 60% (CALBG 40603) and 53% (GeparSixto) were achieved. However, in our trial 34% of the patients discontinued treatment due to toxicity. Therefore these protocols should be used in carefully selected patients. In a real world setting less toxic chemotherapy regimens achieved a pCR rate of 37%. In terms of toxicity and adherence to chemotherapy, these regimens are reasonable alternative options. In daily care close monitoring of treatment response is essential during NAC. In patients who have a rapid clinical response to platinum-free NAC the benefit of adding platinum is questionable. In contrast, the addition of platinum seems to be appropriate in those patients who show only limited response under NAC.

Citation Format: Kuehnle E, Kaur P, Siggelkow W, Luebbe K, Schrader I, Uleer C, Noeding S, Noeding K-H, Noesselt T, Arfsten M, Busch C, Krentel N, Hillemanns P, Dörk T, Park-Simon T-W. A prospective multicenter real-world study on neoadjuvant treatment and clinical outcome in TNBC patients [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-15-10.

Nanoengineering ABO3 active sites from low-energy routes (TX100-stabilised water-in-oil microemulsions, surface segregation and surface complexation on colloidal AlOOH/sol-gel Al2O3 surfaces) for pollution control catalysis

It is shown that water-in-oil microemulsions (m/e or μE) can produce BaCeO3 (BCO) and LaCoO3 (LCO) precursors. The nanoparticles (NPs) adsorb on AlOOH sols, in much the same way as Turkevich previously immobilised platinum group metal sols. BCO is active in CO and propane oxidation and NO removal under stoichiometric exhaust conditions, but LCO is a better oxidation catalyst. Activity was also seen when Ba,Ce and La,Co are inserted into/segregate at the surface of AlOOH/Al2O3. However, there is only formation of low levels of BCO, CAIO3 (CAO), LCO and LaAIO3 (LAO) perovskites, along with aluminates and separate oxides. The complexing of cations by AlOOH surface-held oxalate ions, albeit with different efficiencies, has also been explored. All three routes yield active catalysts with micro-domains of crystallinity; microemulsions produce the best defined perovskite NPs, but even those from surface segregation have higher turnover numbers than traditional Pt catalysts. Perovskite NPs may open up green chemistry for air pollution control that is consistent with a circular economy.

Report of the Third Family with Multiple Mitochondrial Dysfunctions Syndrome 5 Caused by the Founder Variant p.(Glu87Lys) in ISCA1

Iron-sulfur cluster assembly 1 (ISCA1) is one of the essential proteins operating in the mitochondrial iron-sulfur (Fe-S) cluster biogenesis pathway. We reported the variant c.259G > A [p.(Glu87Lys)] in homozygous state in exon 4 of the ISCA1 gene as the likely cause of multiple mitochondrial dysfunction syndrome 5 in a previous publication. We now report the third patient with the same phenotype and variant, further supporting the possibility of a founder event. Our observation confirms the clinical presentation associated with a probable founder variant in this condition.

Biosimilars: what the dermatologist should know

Biosimilars are highly similar versions of approved branded biologics. In contrast to generics, which are identical copies of the originator medicines, biosimilars are considered unique but related molecules that differ from the originator reference product as well as from each other. Owing to the complexity of biologic medicines, such as therapeutic monoclonal antibodies, minor differences between biosimilars and the reference products are acceptable provided these differences do not result in any clinically meaningful differences in safety or efficacy. In addition, minor changes in structure and function may occur over time in originator biologic products as a result of alterations in production materials (e.g. cell lines), processes or conditions. The developmental process for biosimilars focuses on a 'totality of evidence' approach that emphasizes a stepwise investigational process, including comprehensive structural, functional, pharmacologic and clinical assessment for similarity. The goal of the phase 3 clinical development programme for a biosimilar is not to establish efficacy, per se, but to demonstrate that there are no clinically meaningful differences between the proposed biosimilar and the reference product. The requirement to show clinical similarity informs biosimilar study design, including the selection of the patient population, disease state (indication), study endpoints and statistical methods. Based on the clinical trial results in a representative patient population, results may be extrapolated to other indications provided scientific justification is demonstrated based on, among other things, similar mechanism of action in the extrapolated indications. This review presents the current state of knowledge with respect to biosimilars. We aim to provide the practising clinician with a working knowledge of biosimilars as well as provide some practical guidance on their use and potential benefits in treating dermatologic diseases.

Abstract P2-01-04: The whole transcriptional landscape of circulating tumor cells compared to metastases in stage IV breast cancer

Background: Metastatic breast cancer (MBC) and the circulating cells (CTCs) leading to macrometastasis are inherently different than primary breast cancer, evolving under the selection pressure of systemic therapy. A better understanding of the tumor biology of CTCs compared to metastasis may shed light on treatment opportunities.

Methods: We performed whole transcriptome sequencing (RNA Seq) on fresh metastatic tumor biopsies (mets), CTCs, and peripheral blood (PB) from 21 newly diagnosed MBC patients. CTCs were harvested using the ANGLE Parsortix to isolate cells based on size and deformability. Data were analyzed for differential expression, pathways, single nucleotide variants (SNV), fusions, intrinsic subtype, and a CTC-mets shared gene signature was validated using data from The Cancer Genome Atlas (TCGA). Detailed clinical-pathological and treatment data was evaluated.

Results: CTCs as a group showed much stronger gene expression of oncogenes, stem cell genes, keratins and mesenchymal markers than did mets from the same patients. Matched patient comparisons for 66 potentially clinically actionable genes for 8/9 pathways showed no significant difference in gene expression targets between CTCs and mets on ANOVA, although fold-change did vary. Eight SNVs in the ESR1 gene (n=5 patients) and 5 SNVs in the HER2 gene (n=2 patients) were shared between CTCs and distant metastases.

Differential gene expression analysis identified a signature of 8870 genes that were statistically significantly correlated between CTCs and mets (FDR adjusted p&lt;0.05). Ingenuity pathway analysis was applied to the list of genes shared between CTCs and mets, with analysis of canonical pathways and upstream regulators revealing numerous oncogenes and breast cancer related genes. The top upstream regulators of CTCs-mets were beta-estradiol, progesterone, FOXA1, HNRPA2B1 and HNF1A. The top 50 genes of this CTC-mets shared signature were prognostic of worse overall survival in the TCGA breast cancer dataset (p&lt;0.001), which included 817 patients with a median follow-up of 59.5 months. Second time-point data for n=5 patients with subsequent PB draws 6 months after baseline is currently pending. Intrinsic subtyping of mets by either NanoString assays or RNA Seq were not concordant with intrinsic subtyping of CTCs by RNA Seq.

Four of 21 CTC samples showed strong whole transcriptome RPKM correlation with PB (R2)&gt;0.9, however, 3/21 CTC samples showed strong whole transcriptome RPKM correlation with mets (R2)&gt;0.8. The remainder showed low correlation with both. Coverage was 91.4X for CTCs, 140.2X for mets and 138.5X for PB.

Conclusions: We present the transcriptomic landscape of CTCs with comparison to metastases and peripheral blood all acquired prior to treatment of newly diagnosed Stage IV breast cancer. Multiple genes, including oncogenes and stem cell genes, were found with higher expression in CTCs versus metastases. When focusing on 66 known potentially clinically actionable genes in breast cancer, CTCs did not show significantly different patterns of expression than mets in terms of up-regulation versus down-regulation compared to PB. RNA Seq of CTCs may be utilized to identify molecular alterations that are potentially clinically actionable.

Citation Format: Ring A, Porras T, Campo D, Kaur P, Forte VA, Tripathy D, Lu J, Zada G, Wagle N, Wecsler JS, Lang JE. The whole transcriptional landscape of circulating tumor cells compared to metastases in stage IV breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-01-04.

Effect of NBS1 Gene Polymorphism on the Risk of Cervix Carcinoma in a Northern Indian Population

Cervical cancer is one of the most common neoplastic diseases affecting women, with a worldwide incidence of almost half a million cases. A history of smoking and use of oral contraceptives have been confirmed to be risk factors for cervical cancer. Genetic susceptibility and immune response, especially impaired cellular immune response, may well be related to the development of cervical cancer. NBS1 is one of the key proteins participating in the recognition and repair of double-strand breaks that may lead to genomic instability and cancer if unrepaired. The objective of the present study was therefore to investigate NBS1 Glu185Gln gene polymorphisms and the risk of cervix cancer in a northern Indian population. We found that passive smokers having particular NBS1 genotypes (Glu/Gln, Gln/Gln or Glu/Gln + Gln/Gln) have an increased risk of developing cervix cancer (OR 5.21, p=0.000001; OR 4.60, p=0.001; OR 5.10, p=0.0000009, respectively). The risk was increased 2.4-fold in oral contraceptive users with a Glu/Gln genotype. We conclude that the risk of cervical cancer is increased in passive smokers and in users of oral contraceptives with certain NBS1 genotypes.