A Case of Spontaneous Intestinal Perforation in Osteogenesis Imperfecta

A 51-year-old male with known osteogenesis imperfecta (OI) (type 1) presented with symptoms and signs of infective endocarditis. Transthoracic echocardiography showed chordal rupture and free mitral regurgitation, resulting in an emergency mitral valve repair. The surgical procedure was largely uneventful but subsequent clinical course on the intensive care unit was complicated by bowel perforation requiring two laparatomies for a colonic resection and loop ileostomy formation. Histology of the excised tissue demonstrated absent musculature with no evidence of ischemia. Spontaneous non-ischemic bowel perforation as a complication of osteogenesis imperfecta is to date unreported. Our case highlights the need for a high index of suspicion of non-ischemic bowel perforation in patients with connective tissue disorders.

Implementation of a Composite Score System for Evaluation of Circulating Tumor Cells in Blood of Breast Cancer Patients

Background: We present a highly specific immunomagnetic separation technique in combination with an improved multimarker gene panel for molecular identification and characterization of circulating breast tumor cells in blood. Here we describe the creation of a new composite score in order to manage results and avoid false positives. Methods: Blood from breast cancer patients with primary or metastatic disease was drawn into two 10mL EDTA-tubes. The high affinity antibodies BM7 (MUC1) and VU1D9 (EpCAM) were used for immunomagnetic tumor cell enrichment. Separated cells were lysed and used for mRNA isolation and c-DNA synthesis (Qiagen®). A real-time quantitative RT-PCR approach using MESA FAST SYBR Assay (Eurogentec®) and primers selected from the UniversalProbeLibrary system (Roche AG®) for the epithelial markers cytokeratin 19 (CK19), mammaglobin 1 (MG1), epithelial cell adhesion molecule (EpCAM), baculoviral IAP repeat-containing 5 (Sur), immunosuppressive CD276 (CD276), carcinoembryonic antigen-related cell adhesion molecule 5 (CEA), HER-2, aldehyde dehydrogenase 1 family, member A1 (ALDH1), hypoxia inducible factor (HIF-1alpha) and CD44 molecule (CD44) was used for tumor cell identification and characterization. The ß-actin transcript was used for internal control and matched calibrator probes containing 2 or 10 tumor cells were used for quantitative expression analysis of tumor associated genes present in blood.Results: Positivity rate was based on a score that consists of 2 different characteristics: Marker detection (ranking according to the number of positive markers, varies from 0 – negative - to 1 – positive - for each marker) in combination with the marker expression level (ranking according to the C(t) values and varies from 0 – less then 2 tumor cells – to 1 – more then 2 tumor cells). This composite score is based on the expression of CK19, MG1, EpCAM, Sur and CD276 and has a ranking from 0 to 10. Negative cases are classified with score 0 and 1, cases ranked with score 2 need retesting and finally scores above 2 indicate clearly positive patients. The additional surrogate markers CEA, HER-2, ALDH, HIF and CD44 are analysed in positive patients in order to obtain further information. In our group of metastatic breast cancer patients, 53% were classified as positive, 42% of the patients were negative and in 5% a retesting is needed. Conclusion: The results of the composite score clearly show an increase of sensitivity and specificity for this assay. The implementation of this test in the routine monitoring of patients should help us to evaluate treatment response and create individualized treatment schedules.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3015.

Implant for Augmentation of Cerebral Blood Flow Trial 1: A Pilot Study Evaluating the Safety and Effectiveness of the Ischaemic Stroke System for Treatment of Acute Ischaemic Stroke

Introduction

In rat stroke models, sphenopalatine ganglion stimulation up to 24 h after stroke onset augments cerebral blood flow, reduces infarct volume and improves neurological deficits. The ischaemic stroke system 500 has been designed to stimulate the sphenopalatine ganglion in humans.

Objectives

( 1 ) To determine the safety and tolerability of the ischaemic stroke system 500 in acute ischaemic stroke within 24 h of stroke onset. ( 2 ) To determine the effectiveness of ischaemic stroke system 500 in acute ischaemic stroke treatment.

Design/Methods

Implant for augmentation of cerebral blood flow trial-1 is a multi-national open-label study in patients of acute ischaemic stroke in the anterior circulation with National Institutes of Health Stroke Scales 7–20. The treatment initiation will be within 24 h of stroke onset. The ischaemic stroke system is implanted adjacent to the sphenopalatine ganglion via the greater palatine canal using local anaesthesia and a minimally invasive approach. The treatment protocol is constituted as 3–4 h of daily stimulation over 5–7 days. Conclusions The implant for augmentation of cerebral blood flow trial-1 will determine the safety and tolerability of the ischaemic stroke system 500 in acute ischaemic stroke as reflected by the incidence of adverse events.

Natriuretic peptides and heart failure in the patient with chronic kidney disease: a review of current evidence

Natriuretic peptides such as brain natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) are commonly used in the diagnosis and evaluation of heart failure. However, their utility in patients with chronic kidney disease (CKD) is less clear as renal dysfunction itself can be associated with elevated concentrations of these biomarkers. Given the high prevalence of left ventricular hypertrophy and left ventricular systolic dysfunction in patients with CKD, diagnosis or exclusion of heart failure becomes important in this population. Most studies to date indicate that upward adjustment of diagnostic cut points preserves the usefulness of both BNP and NT-proBNP in the CKD patient, with similar clinical performance of each biomarker. We review the role of natriuretic peptide in heart failure in the setting of chronic renal disease.

Sarcoglycanopathies: a clinico-pathological study

BACKGROUND

Limb girdle muscular dystrophy (LGMD) is a heterogeneous group of disorders characterized by limb girdle weakness. There are no clear clinical features that distinguish various types of LGMD.

MATERIALS AND METHODS

We studied 26 patients with chronic progressive weakness in limb girdle distribution without early facial involvement with muscle biopsies suggestive of dystrophy/myopathy and positive for dystrophin antibodies. Immunohistochemistry studies of muscle biopsies were done on all patients to classify different types of sarcoglycanopathies.

RESULTS

The mean age of presentation was in the third decade. There were 14 male and 12 female patients. The common pattern of inheritance was autosomal recessive, seen in 53.8%. The more frequent type of LGMD was sarcoglycanopathy (SGP) (53.8%). Amongst the SGPs, alpha-SGP (26.9%) was the most common followed by beta-SGP (15.3%), gamma-SGP (3.8%) and delta-SGP (7.6%). Calf hypertrophy was noted in 53.5% of LGMD and 57.1% of SGPs, extensor digitorum brevis hypertrophy in 42% of LGMD and 35.7% of SGPs, winging of scapula in 39.2% of the LGMD group and 35.7% of the SGPs, valley sign in 28.5% of the LGMD group and 21.4% of the SGPs. Hip abductor sign was positive in 71.4% of LGMD and 64.2% of SGPs. Differential weakness of knee flexors was more common in SGP (57.1%). The mean creatine phosphokinase (CK) value was 2519IU/L and was elevated in 92.8% patients. Muscle biopsy showed a dystrophic pattern in 75% of LGMD and a myopathic pattern in the remaining. Symptomatic cardiac involvement was seen in one patient. ECG changes were seen in 44% of LGMD patients and 50% of the SGP. The common changes noted were T wave inversion in V1, V2 (16%), left ventricular hypertrophy LVH (12%) and right bundle branch block (RBBB) in 12% of the LGMD group.

CONCLUSION

Sarcoglycanopathy is a more frequent form of LGMD whereas alpha type is the most common among the SGP. The four types of SGP do not differ in the pattern of muscle involvement. A relatively earlier onset, selective weakness of knee flexors and a very high CK may help differentiate SGP from other forms of LGMD. Immunohistochemistry is very useful in classifying the different types of LGMD prior to genetic analysis.

Tumor cell quantification and normalized multi-gene expression analysis of micrometastatic cells in blood and bone marrow of cancer patients: introduction of the embedded tumor cell calibrator technique

Abstract #5029

Background: The purpose of this study was the validation of a new preanalytical enrichment and molecular detection method using embedded tumor cell calibrators (ETC) for process control, relative tumor cell enumeration and quantitative gene expression analysis of circulating tumor cells (CTC) in breast cancer patients.
 Methods: Samples from every patient were devided in native probes and matched calibrator probes containing either 2, 4 or 8 breast carcinoma tumor cells (ETC). The high affinity antibodies BM7 (MUC-1) and VU1D9 (EpCAM) were used for immunomagnetic tumor cell enrichment in 10 mL of peripheral EDTA-blood of patients with primary and metastatic breast cancer. Mononuclear cells from bone marrow of patients with primary breast cancer were analysed in parallel by standardized cytospin immunocytology techniques (2x106 cells) and by the immunobead enrichment technique (1x107 cells). Separated cells were lysed and used for mRNA isolation and c-DNA synthesis. A real-time quantitative RT-PCR approach for the tumor identifier cytokeratin 19 (CK19) and mammaglobin 1 (MG1) and the surrogate markers HER-2, survivin (Sur), prostate-specific ets factor (PSE), CXCR4, Nanog, CD276 and FGFR2 was established using primers and FAM-labeled TaqMan probes selected with the UniversalProbeLibrary system (Roche AG, Basel, CH).
 Results: Positivity rate of ETC controlled realtime RT-PCR on the basis of CK19 and MG1 was 6.9% in 205 patients with primary breast cancer and 61.1% in patients with metastatic disease. Clonal selection or conversion from a HER2 negative (histology) to a HER2 positive phenotype was determined by qRT-PCR in 21 from 73 (28.8%) patients. During a 18 months follow-up of 92 patients with primary breast cancer, multimarker positivity was determined in 10 patients, and in three of these patients early metastasis was clinically confirmed. Tumor cell detection rate in bone marrow on the basis of
 1x107 cells was 10.5% (11/104) while cytology at the level of 2x106 cells resulted in a positivity rate of only 1% (1/104).
 Conclusion: For the first time we describe embedded tumor cells (ETC) as internal calibrators for accurate process control and normalization of the complex techniques of the immunobead separation and the quantitative RT-PCR technique. Tumor cell quantification was performed with the tumor identifiers CK19 and MG1, while corresponding expression levels of surrogate markers were determined on the basis of spiked calibrator cells. The ETC technique improved monitoring and gene expression analysis of disseminated tumor cells in peripheral blood and bone marrow significantly.
 Characterization of clinically relevant markers from the networks of apoptosis (Sur, PSE), tumor related/induced angiogenesis (CD276), growth factor receptors (HER-2, FGFR2) and cytostatica resistence (ABCG2) may improve early detection of metastasis, monitoring of treatment regimes and prediction of (new) therapeutic targets.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5029.

Corticobasal syndrome due to a thalamic tuberculoma and focal cortical atrophy

Corticobasal syndrome (CBS) is characterised by asymmetric apraxia, cortical sensory loss, extrapyramidal features and cognitive decline. Although CBS is classically described as a taupathy, heterogeneity of its aetiology is increasingly recognised. Clinical presentation of CBS appears to reflect areas of the brain involved and not necessarily the nature of the underlying pathology. We report a patient in whom resolution of a thalamic tuberculoma was associated with progressive atrophy of the parietotemporal cortex, resulting in an unusual presentation of CBS.

Prosthetic rehabilitation of an adolescent with hypohidrotic ectodermal dysplasia with partial anodontia: case report

Ectodermal dysplasia is a hereditary syndrome characterized by dysplasia of tissues of ectodermal origin (hair, skin, nails, and teeth) and occasionally, dysplasia of mesodermally derived tissues. The triad of nail dystrophy (onychodysplasia), alopecia, or hypotrichosis (scanty, fine, light hair on the scalp and eyebrows) and palmoplantar hypohidrosis is usually accompanied by lack of sweat glands and partial or complete absence of primary and permanent dentition. Hypohidrotic ectodermal dysplasia usually has an X-linked inheritance and affects only males severely, while female heterozygotes show only minor defects. The clinical management of children with ectodermal dysplasia provides a unique opportunity for cooperative effort between the pedodontist and the prosthodontist. The following case report discusses the management of a young boy with hypohidrotic ectodermal dysplasia. Removable prostheses were employed in the treatment. The aim was to rehabilitate the adolescent prosthodontically and boost him psychologically.

Non-invasive ventilation in chronic obstructive pulmonary disease: management of acute type 2 respiratory failure

Non-invasive ventilation (NIV) in the management of acute type 2 respiratory failure in patients with chronic obstructive pulmonary disease (COPD) represents one of the major technical advances in respiratory care over the last decade. This document updates the 2002 British Thoracic Society guidance and provides a specific focus on the use of NIV in COPD patients with acute type 2 respiratory failure. While there are a variety of ventilator units available most centres now use bi-level positive airways pressure units and this guideline refers specifically to this form of ventilatory support although many of the principles encompassed are applicable to other forms of NIV. The guideline has been produced for the clinician caring for COPD patients in the emergency and ward areas of acute hospitals.