Evaluating the impact of the metastatic spinal cord compression coordinator in a regional cancer network: a prospective, non-randomized pilot study

BACKGROUND

Extradural metastatic spinal cord compression (MSCC) is a debilitating and potentially irreversible complication of cancer. Delay in treatment could lead to irreversible neurological damage, adverse quality of life and a burden on health care resources. Lack of effective communication between teams has been identified as one of the reasons for delay in treatment. The MSCC coordinator (often a nurse, radiotherapy radiographer or a doctor) is responsible for coordinating the diagnosis and management of patients with MSCC. The role has been shown to streamline service, ensure timely decision-making and improved survival outcomes. However, available data are anecdotal or from limited series presented as abstracts in conferences. In this study, we assessed the impact (time to treatment) of the newly introduced role on the treatment pathway compared to similar period in the preceding year.

METHODS

This was a multi-centre, prospective, pilot study carried out in Kent, UK between 1st April to 30th June 2021. Patients were considered eligible if they had magnetic resonance imaging (MRI)-confirmed cauda equina or cord compression. The data prospectively collected include: (I) time from diagnostic imaging to radiotherapy treatment; (II) number of referrals to hospital palliative care (HPC), occupational/physiotherapy (OPH) and community hospice referrals (CHP). A comparative retrospective data for (I) was collected for the same time period in the preceding year. The study outcome assessed was reduction in time from radiological diagnosis of MSCC to receiving radiotherapy.

RESULTS

Fifty-eight patients in 2020 and 24 patients in 2021 were included in the dataset. The MSCC coordinator role (introduced in 2021) led to reduction in the time from imaging to treatment (P=0.045). Compared to 2020, there was a shorter mean/median time to treatment, seeing more patients being treated within 24 hours. All hospitals except East Kent Hospitals saw more patients being treated within 24 hours. 7 referrals each made to HPC, OPH and CHP respectively.

CONCLUSIONS

Introduction of MSCC coordinator role led to improved time from imaging to radiotherapy treatment. The new service led to engagement with rehabilitative and palliative services. Future work should be done to assess the long-term impact of this role on utilization of support services and patient recovery.

Monitoring pond water quality to improve the production of Labeo rohita (Hamilton, 1822) in Bannu Fish Hatchery of Bannu district, Khyber Pakhtunkhwa province; An Implications for artificial fish culture

Abstract The water quality parameters of a fish pond are essential to be managing properly under control for successful operations of fish culture. Improper management of pond water quality during the juvenile stages can create stressful conditions to produce various harmful diseases, which may decrease the fish quality and results in low profits. The present study was aimed to monitored important water quality parameters of nursery ponds of Labeo rohita culturing in Bannu fish hatchery. The study duration was 75 days extends from 10th June to 24th August 2019 for the successful culture of this specie which can play a significant role in breeding season. Furthermore, the concentration of some heavy metals like copper (Cu), nickel (Ni), manganese (Mn), iron (Fe), cadmium (Cd), and zinc (Zn) in pond water and fry stages of this species was also determined. The data obtained from all water quality parameters were analyzed expressed as range, mean and standard deviation using MS Excel 2013. The obtained results of 75 days study revealed that the water pH & temperature, electric conductivity, total dissolved solids (TDS), and total dissolved oxygen (DO) of pond water samples were found within a tolerable limit except salinity and dissolved ammonia concentration were not permissible for fish growth. The average concentration of heavy metals in pond water exhibited descending order Fe>Ni>Mn>Zn>Cd>Ni, which was found in acceptable ranges. Whereas, the average values of heavy metals in fry stages were in the order of Zn>Fe>Ni>Cu>Cd>Mn, and found within the recommended values of WHO/FAO. Thus, it was concluded from this study that good water quality is a precondition, maintaining balanced levels of water quality parameters is fundamental for both the health and growth of fish culture which is quite necessary for assuring increased fish productivity. It is recommended to monitor and assess water quality parameters on a routine basis for promoting healthy fish culture.

Assessments of some trace metals in water samples of nursery pond of Grass Carp (Ctenopharyngodon idella, Valenciennes, 1844) in Bannu Fish Hatchery of Khyber Pakhtunkhwa, Pakistan

Abstract The present investigation was aimed to examine the concentrations of trace metals including e.g copper (Cu), manganese (Mn), nickel (Ni), and zinc (Zn) in water samples collected from nursery pond of grass carp (Ctenopharyngodon idella) in Bannu Hatchery of Khyber Pakhtunkhwa during the period from April 2018 to January 2019. The temperature and pH of each water sample were measured for the whole study duration. The concentration of Copper (Cu), Manganese (Mn), Nickel (Ni), and Zinc (Zn) in collected water samples were measured in mg/liter by using Atomic Absorption Spectrophotometer. The blank and standard solutions for device calibration Standard solutions i.e., 2.0 mg, 4.0 mg, and 6.0 were used to measure the concentration of these metals in water samples to verify the measurements. The data was statistically analyzed on descriptive statistics (estimation of proportions and standard deviation) used to summarize mean concentration. The results obtained of both temperature and pH of water samples were found in ranged 10 to 36 0C and 7.0 to 8.44; whereas the size of fry stages was ranged from 4.0 to 56.0 mm in total length. The results of investigated metals found in pond water samples are in order of Zn>Mn>Ni>Cu, respectively. As optimum temperature and pH for grass carp were mostly between 15 0C and 30 0C and pH 6.5 to 8.0. It was concluded from obtained results that temperature, pH, and trace metals were found appropriate for the growth of Ctenopharyngodon idella from fry to fingerling stages, but the highest amount of zinc can cause its mortality. It is a preliminary study on grass carp culturing in Bannu fish hatchery so, it would provide useful information for model fish seed production unit in a hatchery.

Reversing the Friday peak in metastatic cord compression referrals: Not as simple as previously thought?

e14050

Background: Historically, metastatic spinal cord compression (MSCC) referrals trend towards a Friday peak in incidence (Koiter E, Radioth Onc 2013). However, data from a single, tertiary centre in the UK showed a reversal in the Friday peak (Adeleke S, Annals of Oncology 2020). This was attributed to early case referrals and quicker treatment decisions. In this new study, we explored whether a similar pattern was apparent in multiple district general hospital (DGH) settings and attempt to identify underlying causes. DGHs manage a larger proportion of cancer patients in the UK. Methods: 1,069 patients between 1 Jan 2015 and 31 Dec 2020 were identified across 4 hospitals in Kent, UK with a population of 1.6 million people. 220, 181, 182, 159, 134 and 193 MSCC patients were identified annually (2015-2020). Commonest cancers were prostate (24.1%), lung (19.3%) and breast (12.3%). Thoracic and lumbar regions constituted 80% of MSCC sites. Kruskal Wallis was used to compare differences in referrals across weekdays. Data was then dichotomised to Fridays only vs. other days of the week combined, as previously reported (De Bono B, Acta Neurochir 2019). Chi squared was used to compare frequency of referrals between the two groups. Chi squared goodness of fit test was conducted to detect if Friday reflected the day with highest referrals across the week. Results: Across the region, 2015 saw the highest number of Friday referrals relative to other days, p= 0.002. Friday referrals continued to drop, year on year, until 2018 with a corresponding increase in mid-week referrals. After 2018, there was a return in trend to a further Friday peak across the region, though p= 0.836. On an individual hospital basis, the persistent Friday peak in the region was driven by two hospitals. Having a 7-day acute oncology service (AOS), 7-day radiology reporting and single referral point of contact in the department, were factors identified that kept the referrals across the week uniform. On another note, a substantial shift towards a single 8Gy fraction vs. 20Gy in 5 fractions was observed across the region. This change coincided with SCORAD III data (Hoskin P, ASCO 2017) and demonstrates adherence to evidence-based practice in the region. Conclusions: This large multi-centre retrospective study shows a differential referral pattern in the region, with hospitals with 7-day AOS/Radiology reporting and single point of referral (e.g, similar to MSCC coordinator role) having a quicker treatment turnaround and uniform referrals across the week. The MSCC coordinator has been shown to streamline service, ensure timely decision-making and improved survival outcomes (Richards L, Spine J 2017). The role is recommended by NICE UK. DGHs should consider appointing an MSCC coordinator when designing/auditing their service. The shift towards single 8Gy fraction can provide a ‘one-stop’ service where patients are scanned, planned and treated on the same day.

COMPARATIVE STUDY OF EFFECTIVENESS OF VENLAFAXINE, DULOXETINE AND SERTRALINE IN MANAGEMENT OF DIABETIC SENSORY NEUROPATHY

Objective: To compare efficacy of 3 commonly prescribed anti-depressants from classes’ selective serotoninreuptake inhibitor and serotonin-nor epinephrine reuptake inhibitors i.e. Venlafaxine, Duloxetine and Sertralinein the management of diabetic sensory neuropathy in subjects with type 2 diabetes mellitus. Study Design: Comparative, prospective study. Place and Duration of Study: Combined Military Hospital Jhelum, Mar 2018 to Jul 2018. Methodology: This study included 94 patients with metabolically stable type 2 Diabetes Mellitus with diabeticsensory neuropathy. Patients were randomly assigned into 3 treatment group, treatment group 1 (n1=29) receiving Venlafaxine 37.5mg × BD, treatment group 2 (n2=33) receiving duloxetine 30mg × BD and treatment group 3 (n3=25) receiving Sertraline 50mg × OD, each group being treated for 6 weeks, with optional dose titration fortnightly. The efficacy measure was done by revised Neuropathy Disability Score (NDS), measured at baseline and at the end of treatment period i.e. 6 weeks. The primary outcome of this study was “functional outcome” assessed by Disability Neuropathy scale (DNS) and overall improvement and adverse events were measured as secondary outcome measures. Results: There was significant improvement in Neuropathy Disability scale (DNS) at the end of treatment periodin all treatment groups from their baseline score, with comparable efficacy among all drug groups i.e. p-valuebetween venlafaxine and duloxetine, venlafaxine and sertraline were non-significant i.e. p>0.05 except betweenDuloxetine and Sertraline group where there was significant difference in efficacy (p<0.05). Good, moderate andmild improvement in symptoms was noticed in all study groups. Conclusion: Non-tricyclic Anti-depressants i.e. Venlafaxine..........

Co-existing Bilateral Pulmonary Embolism and Intra-cardiac Mass: A Case of Catastrophic Antiphospholipid Syndrome-like Disease

Young patients presenting with thrombotic events like pulmonary embolism and cardiological phenomenon such as presence of an intracardiac mass, without any underlying risk factors, should be promptly investigated for thrombophilias including antiphospholipid syndrome (APLS). This case is reported to highlight rare occurrence of co-existing bilateral extensive pulmonary embolism and an intra-cardiac mass at presentation of antiphospholipid syndrome as well as progression to near catastrophic APLS.

Abstract PD5-05: Metabolic obesity, adipose inflammation and aromatase: Potential drivers of breast cancer risk in women with normal body mass index

Background: Elevated body mass index (BMI) is associated with increased risk of postmenopausal breast cancer, which may be partly attributable to an inflammation-aromatase axis. Most individuals with elevated BMI harbor white adipose tissue inflammation (WATi), defined by the presence of crown-like structures in the breast (CLS-B). CLS-B are composed of a dead/dying adipocyte surrounded by CD68+ macrophages. This inflammation is associated with activation of NF-κB and elevated expression of aromatase, which could contribute to tumor development. Additionally, WATi correlates with several circulating changes, including hyperinsulinemia, which increase breast cancer risk. Although breast WATi correlates with rising BMI, it is also present in some normal BMI individuals. Beyond inherited germline syndromes, the etiology of breast cancer in individuals with normal BMI is not well understood. Here we examined the impact of breast WATi on breast aromatase expression and circulating factors in women with normal BMI.

Methods: Non-tumorous breast tissue and fasting blood were collected from 72 women with BMI &lt; 25 kg/m2 undergoing mastectomy at MSKCC. Breast inflammation was detected by the presence of CLS-B using CD68 immunohistochemistry. The primary objective was to determine if breast WATi in normal BMI individuals correlates with elevated aromatase levels in the breast, measured by qPCR, western blotting, immunofluorescence and enzyme activity. Secondary objectives included assessment of breast adipocyte size and circulating metabolic and inflammatory factors.

Results: Breast inflammation was present in 39% of women. Median BMI was 23.0 (range 18.4 to 24.9) in women with breast WATi versus 21.8 (range 17.3 to 24.6) in those without inflammation (P=0.04). Aromatase mRNA expression was positively correlated with WATi (CLS-B/cm2; P=0.002). Those with severe WATi had highest aromatase mRNA levels, compared to those with no or mild WATi (P=0.005). Aromatase protein, assessed by measuring adipose stromal cell-specific immunofluorescence or western blotting, and activity were also higher in CLS-B+ cases compared to CLS-B- (P&lt;0.001). Breast WATi correlated with larger adipocytes (P=0.01) and higher circulating levels of C-reactive protein, leptin, insulin, and triglycerides (P&lt;0.05). Insulin resistance, characterized by the homeostasis model (HOMA2-IR), correlated with breast WATi (P=0.004). Finally, leptin, a known inducer of aromatase and driver of cancer growth, correlated with higher breast aromatase levels (P=0.02) and larger adipocytes (P&lt;0.01).

Conclusions: A metabolically unhealthy state occurs in women with inflamed breast adipose despite having a normal BMI. This subclinical inflammatory state is characterized by elevated aromatase in the breast, insulin resistance, and dysplipidemia. The presence of enlarged adipocytes in the breasts of normal BMI women with inflammation suggests a state of hyperadiposity which could not be predicted based on BMI alone. These findings indicate that normal BMI metabolic obesity may be associated with increased cancer risk. Our results suggest that objective measurements of adiposity rather than BMI may help to identify individuals at increased risk for disease.

Citation Format: Iyengar NM, Brown KA, Zhou XK, Subbaramaiah K, Giri DD, Gucalp A, Howe LR, Zahid H, Bhardwaj P, Wendel NK, Falcone DJ, Morrow M, Wang H, Williams S, Pollak M, Hudis CA, Dannenberg AJ. Metabolic obesity, adipose inflammation and aromatase: Potential drivers of breast cancer risk in women with normal body mass index [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr PD5-05.

[Infectious pleurisy as first sign of multiple myeloma in a young 28 years old]

Multiple myeloma is a malignant proliferation of plasma cells, mainly affecting the bone marrow. It rarely occurs in young patients. The medical observation study reveals multiple myeloma discovered through a purulent pleurisy in a 28-year-old subject. This patient was admitted to the pneumology service of the Mohamed V military hospital in Rabat for a fever and dyspnea evolving into a context of poor general condition. Clinical examination found a right pleural fluid effusion syndrome. The pleural puncture reveals a germ-free exudative purulent fluid without plasma cells. The myeloma diagnosis was suspected due to the combination of an aplastic normochromic normocytic anemia at 4.5g/dL of hemoglobin, an accelerated erythrocyte sedimentation rate, hypercalcemia, renal failure and osteolytic lesions located mainly in the skull and pelvis area, oriented by electrophoresis and serum protein immunosubstraction revealing a narrow peak in monoclonal beta-2 globulin at 70.56g/L with a lambda monoclonal gammopathy with immunoglobulin G, and confirmed by the myelogram showing a 74% rate of bone marrow plasma cells. The occurrence of myeloma at a young age is rare and the purulent pleurisy without plasma cells is a rare form of presentation and represents a poor prognosis.

Recovery of Schistosoma haematobium ovum from Labeo rohita: first report from Pakistan

Schistosomiasis, also known as bilharzia, is a parasitic disease caused by trematodes from the genus Schistosoma that can infect humans and animals. S. mansoni, S. japonicum, and S. mekongi all causes intestinal schistosomiasis except S. haematobium that causes urinary schistosomiasis. It is only specie which effects urinary system, it can affect liver, heart, lungs also but very rarely. Schistosoma haematobium is endemic to over 50 countries in Africa and the Middle East and Western Asia and may be fatal in HIV positive people. A number of reports from the African countries like Nigeria have been reported. A few cases are reported but in Pakistan it has never been reported before in native people. It is first time reported in Pakistan in the intestine of Rahu (Labeo rohita). The purpose of this study is to elaborate the approach of zoonotic agent by various other routes including the commonly available fish.

[Carbimazole can be the cause of iron deficiency anemia?]

Iron deficiency anemia as a hematologic complication of the antithyroid medication (ATS) that has not been already described in the literature. We report on two exceptional cases: the first case concerns a 24 years old man admitted for an anemic syndrome. He was treated with carbimazole for Graves' disease. The blood count showed a non-regenerative microcytic anemia. Serum ferritin was severely decreased. The etiologic searching for bleeding, hemolysis, malabsorption or iron deficiency was negative. Treatment with iron salts was introduced without any real improvement. Given this situation, and given the negativity of the etiologic investigations, the decision to stop carbimazole was taken. Since that, the clinical and biological evolutions have been favorable. The second observation is much more original and concerns a 35 years old woman. The clinical, laboratory, etiological and treatment data are similar to those of the first observation. The evolution after withdrawal of carbimazole was favorable. The originality of this observation is that a reintroduction test of carbimazole was performed and allowed to reproduce the same haematological effects. These findings led us to hold the diagnosis of anaemia due to carbimazole. In this occasion, and in the light of the data in the literature, we underline the exceptional character of these two cases and we raise the possibility of an etiopathogenic link between administration of ATS and the occurrence of anaemia by iron deficiency.

[Seroprevalence of HBV and HCV in blood donors at the Blood Transfusion Center of Mohammed V Military Teaching Hospital in Rabat Morocco]

The purpose of this report is to present the findings of a retrospective study (2008-2009) to determine the seroprevalence of hepatitis B and C virus in blood donors at the Blood Transfusion Center of Military Teaching Hospital Mohammed V in Rabat, Morocco. Samples from 19,801 consecutive blood donors were analyzed by the immuno-enzymatic method (Enzyme Linked Immunosorbent Assay, third generation). The overall seroprevalence of HBV and HCV was 0.8% and 0.2% respectively. A total of 98 units were rejected because of elevated alanine transaminase. No case of co-infection was found. From 1991 to 2010, HBV and HCV seropositivity showed a significant declining trend. In spite of the low prevalence observed, this study confirms that the risk of transfusion transmitted infection exists and thus underlines the need to implement preventive strategies to improve blood transfusion safety.