The utility of inflammatory biomarkers in predicting overall survival and recurrence in skull base chordoma

OBJECTIVE

Numerous studies have investigated the impact of inflammatory factors in cancer, yet few attempts have been made to investigate these markers in skull base chordoma (SBC). Inflammatory values including neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), lymphocyte-monocyte ratio (LMR), systemic immune inflammation index (SII), and systemic inflammation response index (SIRI) can serve as prognostic markers in various cancers. This study aimed to determine whether these inflammatory factors influence overall survival (OS) or progression-free survival (PFS) in patients with primary SBC.

METHODS

The electronic medical records of patients with primary SBC who underwent resection from 2001 to 2020 were retrospectively reviewed for the associations of sex, age at diagnosis, preoperative steroid use, tumor volume, extent of resection, adjuvant radiation after surgery, tumor metastasis, Ki-67 index, percent homozygous deletion of 9p23 and percent 1p36 loss, and potential prognostic inflammatory markers of NLR, PLR, LMR, SII, and SIRI with the primary outcome measures of OS and PFS. Maximum log-rank statistical tests were used to determine inflammatory marker thresholds for grouping prior to Kaplan-Meier and Cox proportional hazards analysis for OS and PFS of the elucidated groups.

RESULTS

The cohort included 115 primary SBC patients. The mean ± SD tumor volume was 23.0 ± 28.0 cm3, 73% of patients received gross-total resection, 40% received postoperative radiation, 25% had local recurrence, and 6% had subsequent metastatic disease (mean follow-up 47.2 months). Univariable Cox analysis revealed that NLR (p < 0.01), PLR (p = 0.04), LMR (p = 0.04), SII (p < 0.01), and SIRI (p < 0.01) were independently associated with PFS. Additionally, NLR (p = 0.05) and SII (p = 0.03) were significant in multivariable Cox analysis of PFS. However, both univariable and multivariable Cox analysis revealed no correlations with OS.

CONCLUSIONS

The routine assessment of inflammatory biomarkers such as NLR and SIRI could have prognostic value in postresection SBC patients.

Toward Optimized and Cost-Efficient Protocols for Inferior Petrosal Sinus Sampling in the Diagnosis of Cushing Disease

BACKGROUND AND OBJECTIVE

Conventional protocols for inferior petrosal sinus sampling (IPSS) during the workup of hypercortisolemia require adrenocorticotrophic hormone (ACTH) measurement at multiple time points with corticotropic-releasing hormone (CRH) used as a stimulator. Modernized evidence-based protocols must also reflect the increased utilization of desmopressin (DDAVP) for ACTH stimulation as the manufacturing shortage of traditionally used CRH continues. We model the diagnostic accuracy and potential economic savings of DDAVP utilization and reduced time point sampling.

METHODS

A single-institution, retrospective review of patients undergoing IPSS between 2007 and 2021 was performed. A computational search for the minimal set of time points which preserves conventional diagnostic accuracy was performed by testing all 1 through 5-point combinations generated using a binomial expansion. Economic savings were modeled using a publicly available hospital chargemaster.

RESULTS

A total of 50 patients qualified for inclusion, 47 of whom were diagnosed with Cushing disease and 3 with ectopic Cushing syndrome. Single-point diagnostic accuracy for DDAVP-stimulated tests was 71.4%-92.9%, and seven 2-point combinations (5-25 procedural minutes) were found, which preserved conventional diagnostic accuracy. Single-point accuracy for CRH-stimulated tests was 67.9%-89.3%, and two 2-point combinations ( t = -15, t = +2 and t = -15, t = +10) preserved accuracy. For every time point removed, the cost of ACTH laboratory tests was reduced by $507 from $3042 for 6-point IPSS). The shortest and most economical stimulator and time point combination that preserved conventional accuracy was DDAVP sampling at t = 0 and t = +5 or t = +2 and t = +5 minutes, which cost $2028 total compared with the most expensive 6-point IPSS option with CRH ($6392).

CONCLUSION

DDAVP is a cost-efficient and effective alternative to CRH during IPSS. Our results encourage prospective evaluation of potentially fewer sampling time points in the interest of time and cost efficiency balanced with preserved accuracy.

The role of surgical management for prolactin-secreting tumors in the era of dopaminergic agonists: An international multicenter report

OBJECTIVE

First-line prolactin-secreting tumor (PST) management typically involves treatment with dopamine agonists and the role of surgery remains to be further explored. We examined the international experience of 12 neurosurgical centers to assess the patient characteristics, safety profile, and effectiveness of surgery for PST management.

METHODS

Patients surgically treated for PST from January 2017 through December 2020 were evaluated for surgical characteristics, outcomes, and safety.

RESULTS

Among 272 patients identified (65.1% female), the mean age was 38.0 ± 14.3 years. Overall, 54.4% of PST were macroadenomas. Minor complications were seen in 39.3% of patients and major complications were in 4.4%. The most common major complications were epistaxis and worsened vision. Most minor complications involved electrolyte/sodium dysregulation. At 3-6 months, local control on imaging was achieved in 94.8% of cases and residual/recurrent tumor was seen in 19.3%. Reoperations were required for 2.9% of cases. On multivariate analysis, previous surgery was significantly predictive of intraoperative complications (6.14 OR, p < 0.01) and major complications (14.12 OR, p < 0.01). Previous pharmacotherapy (0.27 OR, p = 0.02) and cavernous sinus invasion (0.19 OR, p = 0.03) were significantly protective against early endocrinological cure. Knosp classification was highly predictive of residual tumor or PST recurrence on 6-month follow-up imaging (4.60 OR, p < 0.01). There was noted institutional variation in clinical factors and outcomes.

CONCLUSION

Our results evaluate a modern, multicenter, global series of PST. These data can serve as a benchmark to compare with DA therapy and other surgical series. Further study and longer term outcomes could provide insight into how patients benefit from surgical treatment.

Crooke Cell Adenoma Confers Poorer Endocrinological Outcomes Compared with Corticotroph Adenoma: Results of a Multicenter, International Analysis

BACKGROUND

Crooke cell adenomas (CCAs) are a rare, aggressive subset of secretory pituitary corticotroph adenomas (sCTAs) found in 5%-10% of patients with Cushing disease. Multiple studies support worse outcomes in CCAs but are limited by small sample size and single-institution databases. We compared outcomes in CCA and sCTA using a multicenter, international retrospective database of high-volume skull base centers.

METHODS

Patients surgically treated for pituitary adenoma from January 2017 through December 2020 were included.

RESULTS

Among 2826 patients from 12 international centers, 20 patients with CCA and 480 patients with sCTA were identified. No difference in baseline demographics, tumor characteristics, or postoperative complications was seen. Microsurgical approaches (60% CCA vs. 62.3% sCTA) were most common. Gross total resection was higher in CCA patients (100% vs. 83%, P = 0.05). Among patients with gross total resection according to intraoperative findings, fewer CCA patients had postoperative hormone normalization of pituitary function (50% vs. 77.8%, P < 0.01) and remission of hypersecretion by 3-6 months (75% vs. 84.3%, P < 0.01). This was the case despite CCA having better local control rates (100% vs. 96%, P < 0.01) and fewer patients with remnant on magnetic resonance imaging (0% vs. 7.2%, P < 0.01). A systematic literature review of 35 studies reporting on various treatment strategies reiterated the high rate of residual tumor, persistent hypercortisolism, and tumor-related mortality in CCA patients.

CONCLUSIONS

This modern, multicenter series of patients with CCA reflects their poor prognosis and reduced postsurgical hormonal normalization. Further work is necessary to better understand the pathophysiology of CCA to devise more targeted treatment approaches.

Clinical characteristics of familial and sporadic pediatric cerebral cavernous malformations and outcomes

OBJECTIVE

Cerebral cavernous malformation (CCM) is a subtype of the vascular malformations found within the cerebral cortex. Although rare and usually discovered incidentally, these vascular abnormalities can predispose patients to spontaneous cerebral hemorrhage and subsequently lead to a myriad of neurological symptoms at presentation such as seizures and other focal neurological deficits. Although the symptoms and presentations of CCM have been adequately described in the adult population, disease characteristics and outcomes have not been extensively described in the pediatric population. Furthermore, the etiology of CCM-e.g., familial versus sporadic disease, as well as the risk factors for hemorrhage and neurological deficits and predictors of clinical and surgical outcomes-has not been adequately explored in the pediatric population. The current study attempts to classify and characterize differences in the clinical presentation, characteristics, and outcomes of CCMs between familial and sporadic cases within the pediatric population.

METHODS

A retrospective review identified 131 pediatric patients with radiographically confirmed diagnosis of CCM. All pertinent demographic and clinical variables were collected. CCM lesions were characterized using T2-weighted and susceptibility-weighted angiography (SWAN) MRI. Statistical analysis was conducted using the t-test for continuous variables, whereas categorical variables were analyzed with the Fisher exact test or chi-square test. Multivariate analysis was performed using a Cox proportional hazards model with R version 4.2.0.

RESULTS

This retrospective study identified 131 pediatric CCM patients with a mean age of 8.4 years, and 54% (n = 71) were male. Twenty-seven percent (n = 35) were identified as cases with familial CCM, with the remainder classified as sporadic. The most common symptoms at presentation included generalized symptoms (headaches, nausea, and vomiting) or seizures, with a large proportion of patients also presenting as asymptomatic. No significant differences were observed in severity of symptoms between patients harboring different forms of the disease. Patients with familial CCM were noted to have a larger lesion size on average (5.26 cm3 vs 1.6 cm3, p = 0.047). These patients also had a shorter progression-free follow-up interval, with 50% of patients showing progression by 888 days, compared with only 15% of sporadic CCM patients during the same period (p = 0.0019). Familial etiology of the disease and larger average lesion volume were independent, significant predictors of disease progression (p = 0.001, HR 3.29, 95% CI 1.65-6.54) and future hemorrhage (p = 0.023, HR 1.1, 95% CI 1.01-1.10), respectively.

CONCLUSIONS

Familial and sporadic CCMs tend to present with similar characteristics within the pediatric population. Patients with the familial form of the disease have an increased risk of progressive disease in terms of further hemorrhagic events.

A Multicenter, Propensity Score-Matched Assessment of Endoscopic Versus Microscopic Approaches in the Management of Pituitary Adenomas

BACKGROUND AND OBJECTIVES

There is considerable controversy as to which of the 2 operating modalities (microsurgical or endoscopic transnasal surgery) currently used to resect pituitary adenomas (PAs) is the safest and most effective intervention. We compared rates of clinical outcomes of patients with PAs who underwent resection by either microsurgical or endoscopic transnasal surgery.

METHODS

To independently assess the outcomes of each modality type, we sought to isolate endoscopic and microscopic PA surgeries with a 1:1 tight-caliper (0.01) propensity score-matched analysis using a multicenter, neurosurgery-specific database. Surgeries were performed between 2017 and 2020, with data collected retrospectively from 12 international institutions on 4 continents. Matching was based on age, previous neurological deficit, American Society of Anesthesiologists (ASA) score, tumor functionality, tumor size, and Knosp score. Univariate and multivariate analyses were performed.

RESULTS

Among a pool of 2826 patients, propensity score matching resulted in 600 patients from 9 surgery centers being analyzed. Multivariate analysis showed that microscopic surgery had a 1.91 odds ratio (OR) ( P = .03) of gross total resection (GTR) and shorter operative duration ( P < .01). However, microscopic surgery also had a 7.82 OR ( P < .01) for intensive care unit stay, 2.08 OR ( P < .01) for intraoperative cerebrospinal fluid (CSF) leak, 2.47 OR ( P = .02) for postoperative syndrome of inappropriate antidiuretic hormone secretion (SIADH), and was an independent predictor for longer postoperative stay (β = 2.01, P < .01). Overall, no differences in postoperative complications or 3- to 6-month outcomes were seen by surgical approach.

CONCLUSION

Our international, multicenter matched analysis suggests microscopic approaches for pituitary tumor resection may offer better GTR rates, albeit with increased intensive care unit stay, CSF leak, SIADH, and hospital utilization. Better prospective studies can further validate these findings as matching patients for outcome analysis remains challenging. These results may provide insight into surgical benchmarks at different centers, offer room for further registry studies, and identify best practices.

Defining benchmark outcomes for transsphenoidal surgery of pituitary adenomas: a multicenter analysis

IMPORTANCE

Benchmarks aid in improve outcomes for surgical procedures. However, best achievable results that have been validated internationally for transsphenoidal surgery (TS) are not available.

OBJECTIVE

We aimed to establish standardized outcome benchmarks for TS of pituitary adenomas.

DESIGN

A total of 2685 transsphenoidal tumor resections from 9 expert centers in 3 continents were analyzed.

SETTING

Patients were risk stratified, and the median values of each center's outcomes were established. The benchmark was defined as the 75th percentile of all median values for a particular outcome. The postoperative benchmark outcomes included surgical factors, endocrinology-specific values, and neurology-specific values.

RESULTS

Of 2685 patients, 1149 (42.8%) defined the low-risk benchmark cohort. Within these benchmark cases, 831 (72.3%) patients underwent microscopic TS, and 308 (26.8%) patients underwent endoscopic endonasal resection. Of all tumors, 799 (29.8%) cases invaded the cavernous sinus. The postoperative complication rate was 19.6% with mortality between 0.0% and 0.8%. Benchmark cutoffs were ≤2.9% for reoperation rate, ≤1.9% for cerebrospinal fluid leak requiring intervention, and ≤15.5% for transient diabetes insipidus. At 6 months, benchmark cutoffs were calculated as follows: readmission rate: ≤6.9%, new hypopituitarism ≤6.0%, and tumor remnant ≤19.2%.

CONCLUSIONS

This analysis defines benchmark values for TS targeting morbidity and mortality and represents the best outcomes in the best patients in expert centers. These cutoffs can be used to assess different centers, patient populations, and novel surgical techniques. It should be noted that the benchmark values may influence each other and must be evaluated in their own context.

Bibliometric Analysis of the Top 100 Cited Articles on Stereotactic Radiosurgery for Trigeminal Neuralgia

Background Stereotactic radiosurgical rhizolysis of the trigeminal nerve is an established modality increasingly employed to alleviate the symptoms of refractory trigeminal neuralgia. This study analyzes the academic impact of the top 100 cited articles on the radiosurgical management of trigeminal neuralgia.

Methods The Scopus database was searched for articles containing “radiosurgery” and one or more of “trigeminal neuralgia,” “trigeminus neuralgia,” and “tic douloureux.” The top 100 articles written in English were arranged in descending order by citation count. Documents were evaluated for authors, publication year, journal and impact factor, total citations, nationality, study type, radiosurgical modality, and the affiliated institution. Quantitative and qualitative analyses were performed on the data.

Results The most cited articles were published between 1971 and 2019. The average citation per year was 4.3. The most targeted anatomic area was the “root entry zone” or proximal portion of the cisternal segment of the trigeminal nerve. The most utilized modality was Gamma Knife radiosurgery. The country with the highest number of publications was the United States. Thirty-six percent of the articles were published in the Journal of Neurosurgery. Lunsford, Kondziolka, Flickinger, and Régis, respectively, were the most frequently listed co-authors. The most prolific institute was the University of Pittsburgh Medical Center.

Conclusion Stereotactic radiosurgery is an important modality in the management of medically or surgically refractory trigeminal neuralgia. This analysis assesses its contributions over the past five decades to identify trends in treatment practices for neurosurgeons and to highlight areas where further study is needed.

Polycystic ovary syndrome preceding the diagnosis of acromegaly: a retrospective study in 97 reproductive-aged women

BACKGROUND

Acromegaly is a disease of growth hormone excess that results in enlargement of extremities, abnormal glucose and lipid metabolism, and gonadal disruption. Manifestations of the disease are insidious and typically lead to a diagnostic delay of 7-10 years. Classically the polycystic ovary syndrome (PCOS) phenotype is described in women with irregular menses, clinical or biochemical evidence of androgen excess, and/or multiple ovarian follicles on pelvic ultrasonography. Women with acromegaly may present with some or all of these symptoms. Our objective was to evaluate the prevalence of PCOS in patients with acromegaly and to determine if diagnosis of PCOS results in a delay in diagnosing acromegaly.

METHODS

Using patient databases at two academic health centers, we identified 97 premenopausal women aged 18-49 years old presenting with acromegaly. Data were collected regarding pelvic sonography and reproductive history, including the diagnosis of PCOS. Patients carrying the diagnosis of PCOS before their diagnosis of acromegaly were identified and the remaining patients were screened using the Rotterdam criteria to identify additional patients meeting the criteria for PCOS prior to their diagnosis of acromegaly.

RESULTS

Mean age of the population (n = 97) at the time of diagnosis of acromegaly was 33.4 ± 7.5 years (SD). Thirty-three percent of patients (n = 32) either carried a diagnosis of PCOS or met diagnostic criteria for PCOS before their diagnosis of acromegaly. In the subset of patients in whom data on symptom onset were available, those who met criteria for PCOS were diagnosed with acromegaly a median of 5 years [4, 9] after the onset of symptoms compared to 2 years [0.92, 3] (p =  0.006) in the patients who did not meet criteria for PCOS.

CONCLUSIONS

Our data demonstrate a high prevalence of signs and symptoms of PCOS in reproductive-aged women with acromegaly and a longer time to diagnosis in women who meet the clinical criteria for PCOS. As screening for acromegaly is relatively simple and done with measurement of a random, non-fasting IGF-1 level that can be drawn at any time during the menstrual cycle, screening patients with PCOS for acromegaly may lessen the delay in diagnosis for reproductive-aged women with this disease.

The synbiotic mixture of Bacillus licheniformis and Saccharomyces cerevisiae extract aggravates dextran sulfate sodium induced colitis in rats

BACKGROUND

Uncertain effects of probiotics and/or prebiotics have been reported in experimental and clinical colitis. This study aims to examine the effects of a synbiotic combination comprising Bacillus licheniformis DSM 17236 and Saccharomyces cerevisiae cell wall extract on dextran sulfate sodium (DSS)-induced colitis in Sprague Dawley rats.

METHODS

Acute colitis was induced in rats by oral administration of DSS 3.5% for 7 days. Fifty rats were divided equally into five groups; one control group and the other groups were induced with colitis and treated with or without the tested synbiotic, mixed with diet, for 28 days and sulfasalazine (100 mg/kg) via intragastric tube once daily for 14 days.

RESULTS

Symptomatically, the synbiotic administration raised the disease activity index (DAI) to comparable scores of the DSS group, specially from the 2nd to 7th days post DSS intoxication. It also induced a significant (p < 0.05) amplification of WBCs, myeloperoxidase (MPO), malondialdehyde (MDA), nuclear factor kappa B (NF-kB) expression and proinflammatory cytokines tumor necrosis factor alpha (TNFα), interferon gamma (INFγ), and interleukin-1 beta (IL-1β) while depressed the antioxidant enzymes glutathione peroxidase (GPx), catalase (CAT), and superoxide dismutase (SOD) when compared with the DSS and control groups. The DSS intoxicated and Synbiotic+DSS groups showed desquamations of the covering epithelium, noticeable diffuse leukocytic infiltrations, sever catarrhal enteritis, ischemic colitis with diffuse coagulative necrosis of the entire colonic mucosa. Contrarily, sulfasalazine proved to be effective in the reduction of the tested inflammatory markers and the pathological degenerative changes of the DSS ulcerative colitis.

CONCLUSION

The examined synbiotic did not ameliorate but aggravated the DSS-induced colitis, so it should be subjected to intensive experimental and clinical testing before their use in animals and human.

Prevalence of extended-spectrum β-lactamase-producing Enterobacterales in retail sheep meat from Zagazig city, Egypt

Background

The goal of this study was to investigate the prevalence of extended-spectrum β-lactamase production in Enterobacterales isolated from retail sheep meat in Zagazig, Egypt.

Methods

One hundred random samples of sheep meat were collected from different retail butcher shops (n = 5) in the city of Zagazig, Egypt. Bacterial isolates were identified by MALDI-TOF MS and screened for antibiotic susceptibility by disk diffusion; further genotypic characterization of β-lactamase-encoding genes was performed with Real-Time PCR. E. coli strains were phylotyped with the Clermont triplex PCR method.

Results

Of the total of 101 bacterial isolates recovered from retail sheep meat samples, 93 were E. coli, six were Enterobacter cloacae and two were Proteus mirabilis. As many as 17% of these 100 samples showed ESBL phenotypes, all were E. coli. The bla_CTX-M genes were detected in seven isolates (six were bla_CTX-M-15 and one was bla_CTX-M-14), three isolates harboured bla_TEM (all were bla_TEM-one), and two carried genes of the bla_SHV family (both were bla_SHV-12). Eight E. coli isolates expressed ESBL phenotype but no bla_TEM, bla_SHV or bla_CTX-M genes were detected by PCR. ESBL- positive E. coli isolates were nearly equally distributed over the commensal groups A/B1 and the virulent group D.

Conclusion

Nearly one in five sheep meat samples was contaminated with ESBL-E. coli. This further corroborates the potential role played by contaminated meat in the increasing resistance rates that have been reported worldwide.

Reduction of giant parietooccipital fibrous dysplasia using dynamic mirror image guidance: a case report and review of the literature

BACKGROUND

Craniofacial fibrous dysplasia (CFD) typically occurs in the facial bones and anterior cranial vault and can produce both disfigurement and functional limitations for patients disfigurement. Treatment consists of reducing the abnormal bone. Bone contouring can become challenging when the exposure does not extend to the corresponding normal contralateral structures for comparison or when normal landmarks are not available, which may compromise the overall aesthetic outcome. We describe a technique using dynamic mirroring to accurately contour the involved part of the cranium in a case of giant CFD.

OBSERVATIONS

A 49-year-old male presented with a giant deforming fibrous dysplasia of the right mastoid and parieto-temporo-occiput that was causing functional limitations due to the size of the bony mass. This was managed with multidisciplinary bony reduction. Several neurovascular structures were in proximity to the areas of planned drilling of the expansile lesion, and dynamic mirroring of the uninvolved left skull was utilized to maximize safety and symmetry of reduction. High-speed drilling of the right occipital bone was performed until the navigation system alerted the surgeon that symmetric depth had been achieved. There were no complications from the procedure and this technique maximized the limits of symmetric reduction without significantly increasing surgical complexity or duration.

LESSONS

Dynamic mirroring of bony structures in the posterior cranium is not commonly employed in neurosurgical practice. This technique may help improve the aesthetic outcomes of bony reduction in craniofacial dysplasia and a variety of similarly managed bony lesions, contour cranioplasties, and in unilateral craniosynostosis surgery.

An Integrated Management Paradigm for Skull Base Chordoma Based on Clinical and Molecular Characteristics

Objective  Previous work categorized skull base chordoma (SBC) into three genetic risk groups based on 1p36 and homozygous 9p21(p16) deletions, accounting for a wide variability in prognosis (A = low-risk, B = intermediate-risk, C = high-risk). However, it remains unclear how these groups could guide management. Study Design  By integrating surgical outcome and adjuvant radiation (AdjXRT) information with genetic data on 152 tumors, we sought to develop an evidence-based management algorithm for SBC. Results  Gross total resections (GTRs) were associated with improved progression free survival (PFS) in all genetic groups. For Group C tumors, GTR and AdjXRT independently contributed to PFS (multivariate Cox proportional hazard ratio [HR] = 0.14, p  = 0.002, and HR = 0.40, p  = 0.047, respectively). For Group B tumors, AdjXRT improved outcomes only when GTR was not feasible (log-rank p  = 0.008), but not following GTR (log-rank p  = 0.54). However, 24 of 25 Group A tumors underwent GTR, and AdjXRT for these did not confer any benefit (log-Rank p  = 0.285). The high GTR rates in Group A could be explained by smaller tumor sizes (mean = 0.98cc/4.08cc/4.92cc for Group A/B/C, respectively, p  = 0.031) and lack of invasiveness. Group A tumors were also more frequently diagnosed in young people ( p  = 0.002) as asymptomatic lesions ( p  = 0.001), suggesting that they could be precursors to tumors in higher risk groups. Conclusion  Genotypic grouping by 1p36 and homozygous 9p21(p16) deletions can predict prognosis in SBC and guide management. GTR remains the cornerstone of SBC treatment and can be sufficient without AdjXRT in low and intermediate risk tumors. Low-risk tumors are associated with a less invasive phenotype, which makes them more amenable to GTR.

Adjuvant chemotherapy for pulmonary sarcomatoid carcinoma: A retrospective analysis of the National Cancer Database

OBJECTIVES

Pulmonary sarcomatoid carcinoma (PSC) is a rarely occurring variant of non-small cell lung cancer with sarcoma-like features. Compared with traditional non-small cell lung cancer, PSC patients typically present later and have poorer prognoses, irrespective of stage. The standard of care is resection, but guidelines for the use of adjuvant chemotherapy have not been established. To advance the development of evidence-based management algorithms for PSC after resection, a statistical analysis on a nationwide representative sample of patients was performed.

METHODS

A retrospective cohort study was performed by querying the National Cancer Database for patients with a diagnosis of PSC between 2004 and 2015. Patients who received complete anatomical resection with or without adjuvant chemotherapy were included. Multivariable regression was used to detect factors associated with the receipt of adjuvant chemotherapy. Multivariable Cox regression of overall survival and Kaplan-Meier survival analysis on propensity-matched groups was conducted to study the association between adjuvant chemotherapy and prognosis.

RESULTS

We included 1497 patients with PSC in the final analysis. Factors associated with receiving adjuvant chemotherapy were age, histology, and receipt of adjuvant radiation. The results of multivariable Cox analysis and Kaplan-Meier analysis on propensity matched groups yielded similar trends: adjuvant chemotherapy was associated with improved 5-year overall survival for stage II and III disease, but not for stage I disease.

CONCLUSIONS

Multiple factors are associated with receipt of adjuvant chemotherapy for PSC, and this treatment appears to be associated with improved survival in stage II and stage III, but not stage I patients.

Effect of cereal type and plant extract addition on the growth performance, intestinal morphology, caecal microflora, and gut barriers gene expression of broiler chickens

Feeding broiler chickens on diets based on cereal grains of high non-starch polysaccharides content such as wheat and barley can negatively impact their performance and gut health. Plant extracts can be used as a potential tool to alleviate these negative effects. The present study assessed the effects of dietary cereal type and the inclusion of a plant extract blend (PEB) on the growth performance, intestinal histomorphology, caecal microflora, and gene expression of selected biomarkers for gut integrity in broiler chickens in a 42-d experiment. Ross-308 male broilers were assigned into different dietary treatments and fed on two cereal types (corn- vs. wheat/barley-based) with/without added graded concentrations of a PEB (0, 250, 500, 1000, and 2000 mg/kg diet). There were no significant differences in the growth performance parameters, intestinal histomorphology, and caecal microflora due to the impact of dietary cereal type. However, lactobacilli count in the caecal microflora was increased in the group fed on a corn-based diet. The PEB supplementation especially at a level of 500 to 1000 mg/kg diet significantly increased the average BW and decreased the feed conversion ratio. It also increased the villi length of duodenum, jejunum, and ileum, decreased the duodenal crypt depth, and increased the villi length to crypt depth ratio in the duodenum, jejunum and ileum. Supplementation of the PEB decreased the total bacterial and coliform count and increased the lactobacilli count in a linear pattern. Gene expression of Occludin and Junction Adhesion Molecule was significantly increased in the PEB supplemented diets, whereby no influence was observed on mucin expression. In conclusion, supplementation of a PEB at levels of 500-1000 mg/kg can be used as a tool to improve broiler performance and gut health.

A Minimal Physiologically-Based Pharmacokinetic Model Demonstrates Role of the Neonatal Fc Receptor (FcRn) Competition in Drug-Disease Interactions With Antibody Therapy

Disease trajectories following antibody therapy can have a significant impact on the pharmacokinetics of the antibody. Although this phenomenon can often be explained by reduced target-expressing cells, other mechanisms may play a role. We use a novel minimal physiologically-based pharmacokinetic model to evaluate an alternative drug-disease interaction mechanism involving competitive inhibition of neonatal Fc receptor (FcRn)-mediated Immunoglobulin G recycling by paraproteins. The model is validated with clinical data from the anti-FcRn antibody M281 and is used to conduct a scenario test to quantify the interaction among M-protein, the characteristic paraprotein of multiple myeloma (MM), and the anti-CD38 antibody daratumumab indicated for MM treatment. Simulations predict up to a 3.6-fold increase in daratumumab half-life following M-protein reduction, which lends credence to the hypothesis that FcRn competition in MM can manifest as time-dependent reduction of clearance for daratumumab. This model can inform optimal dosing strategies for antibodies in MM and other pathologies of paraprotein excess.

Prevalence of plasmid-mediated AmpC in Enterobacteriaceae isolated from humans and from retail meat in Zagazig, Egypt

Background

The objective of this study was to determine the prevalence of plasmid-mediated AmpC (pAmpC) among Enterobacteriaceae isolated from humans and from retail meat in Egypt.

Methods

Enterobacteriaceae were isolated from patients with suspected bloodstream infection, human fecal samples, retail chicken meat samples and retail sheep meat samples. All group I Enterobacteriaceae were analyzed for presence of pAmpC genes by PCR. Antibiotic susceptibility testing was performed in all pAmpC positive isolates, followed by phenotypic and genotypic ESBL and carbapenemase testing on indication.

Results

The prevalence of pAmpC among group I Enterobacteriaceae isolated from 225 patients with bloodstream infection was 5.6% [95%CI 2.2–13.4]. Among 100 patients with community-onset gastroenteritis the prevalence in fecal samples was 4.8% [95%CI 2.1–10.7]. The prevalence among 112 chicken carcasses and 100 sheep meat samples was 2.4% [95%CI 0.7–8.4] and 1.1% [95%CI 0.2–5.7], respectively. In half of the AmpC positive isolates we detected an ESBL gene and 2 isolates harbored a carbapenemase gene. In five isolates there was resistance to at least three important alternative antibiotic drugs.

Conclusions

We consider the prevalence of pAmpC in Egypt, as found in our study, moderately low. To follow future trends in prevalence of pAmpC worldwide, a standardized screening algorithm for the detection of pAmpC is needed.

Computational Analysis of Altering Cell Fate

The notion of reprogramming cell fate is a direct challenge to the traditional view in developmental biology that a cell's phenotypic identity is sealed after undergoing differentiation. Direct experimental evidence, beginning with the somatic cell nuclear transfer experiments of the twentieth century and culminating in the more recent breakthroughs in transdifferentiation and induced pluripotent stem cell (iPSC) reprogramming, have rewritten the rules for what is possible with cell fate transformation. Research is ongoing in the manipulation of cell fate for basic research in disease modeling, drug discovery, and clinical therapeutics. In many of these cell fate reprogramming experiments, there is often little known about the genetic and molecular changes accompanying the reprogramming process. However, gene regulatory networks (GRNs) can in some cases be implicated in the switching of phenotypes, providing a starting point for understanding the dynamic changes that accompany a given cell fate reprogramming process. In this chapter, we present a framework for computationally analyzing cell fate changes by mathematically modeling these GRNs. We provide a user guide with several tutorials of a set of techniques from dynamical systems theory that can be used to probe the intrinsic properties of GRNs as well as study their responses to external perturbations.

Marjoram extract down-regulates the expression of Pasteurella multocida adhesion, colonization and toxin genes: A potential mechanism for its antimicrobial activity

Due to the emergence of virulent and antibiotic-resistant microbes, natural antimicrobials from herbal origins have been given more attention as an alternative therapy. This study provides an in vitro research framework to investigate the antibacterial activities of 5 herbal (marjoram, garlic, onion, cinnamon and black seed) oil extracts against 16 multidrug-resistant (MDR) and virulent P. multocida serogroup A isolates recovered from dead and clinically diseased rabbits. Pathogenicity of the screened isolates was further proven experimentally and was verified by PCR analyses of 5 randomly selected virulence genes encoding attachment and colonization proteins (ptfA, pfhA, and omp87), sialidases (nanB) and dermonecrotoxin (toxA). A total of 12 P. multocida isolates were highly pathogenic with the possession of all examined virulence genes, while the other 4 isolates were of lower pathogenicity with expression of the target genes except toxA. In vitro anti-P. multocida activities of the 5 extracts and their synergism rates with 4 antibiotic drugs revealed that marjoram and cinnamon extracts had the highest antibacterial activities and the highest synergism rates against the screened isolates. Pasteurella multocida virulence gene expression profiles were assessed via real-time quantitative reverse transcription PCR (qRT-PCR) in response to marjoram extract. The quantitative analyses showed less than five-fold reduction in the targeted virulence genes expression in presence of marjoram extract compared with the control. The findings from this study document a novel molecular inhibitory activity of marjoram against P. multocida multiple virulence genes and provide a proof of concept for its implementation as an alternative candidate for the treatment of pasteurellosis in farm animals in future.

The effects of the dietary supplementation of Echinacea purpurea extract and/or vitamin C on the intestinal histomorphology, phagocytic activity, and gene expression of the Nile tilapia

In this study, the influence of the dietary incorporation of Echinacea purpurea (EP) extract and/or vitamin C on the intestinal histomorphology and some immunological indices were tested in the Nile tilapia (Oreochromis niloticus Linn.). O. niloticus were randomly divided into four groups. The control group G₁ was fed on a basal diet, while the G₂ and G₃ were fed on basal diets, supplemented with EP extract and vitamin C at the doses of 500 mg kg^-1 and 400 mg kg^-1, respectively. Meanwhile, G₄ was fed on a basal diet, supplemented with a mixture of EP extract and vitamin C. After 28 days of feeding, the intestinal tissues were collected for histological observation and immune status, was based on an assay for measuring the phagocytic activity. Furthermore, the expression of the transforming growth factor-beta 1 (TGF-β1), interleukin-1beta (IL-1β), and tumor necrosis factor alpha (TNF-α) genes was evaluated in intestine and head kidney. The results revealed that the G₄ successfully surpassed the other groups in terms of the heights of intestinal villi, the number of goblet cells and intraepithelial lymphocytes (IELs), and the phagocytic activity, followed by the G₃ and G₂. The expression of the IL-1β and TNF-α genes were up regulated only in G₄ but in the G₃ only the expression of the IL-1β gene was up regulated. Hence, EP extract along with vitamin C could be used as a feed additive in order to improve the structure of the intestinal mucosal epithelium and immune response in tilapia.

Fecal carriage of extended-spectrum β-lactamase- and carbapenemase-producing Enterobacteriaceae in Egyptian patients with community-onset gastrointestinal complaints: a hospital -based cross-sectional study

Objectives

The aim of this study was to determine the prevalence of extended-spectrum β-lactamase (ESBL) and carbapenemase production among Enterobacteriaceae isolated from ambulatory patients with gastrointestinal complaints admitted to El-Ahrar General Hospital, Zagazig, Egypt in the period between January 2013 and May 2013.

Methods

One hundred and thirteen Enterobacteriaceae isolates were recovered from 100 consecutive Egyptian patients with community–onset gastrointestinal complaints. The fecal samples were plated directly on selective EbSA-ESBL Screening Agar and on MacConkey agar. Isolate identification was performed with matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF-MS). Screening for ESBLs and carbapenemases production was done by both the automated VITEK®2 system with AST N198 and by disk diffusion method. Real-time PCR and sequencing were used to characterize the resistance genes. Phylogroups of the E. coli isolates were determined by a triplex PCR-based method.

Results

Of 100 patients screened for fecal colonization with extended-spectrum β-lactamase -producing Enterobacteriaceae (ESBL-E) and carbapenemase- producing Enterobacteriaceae (CPE), 68 were colonized with ESBL-E whereas five patients were positive for CPE. One hundred and thirteen Enterobacterceae isolates were recovered from 100 fecal samples, they belonged to E. coli (n = 72), Klebsiella pneumoniae (n = 23), Enterobacter cloacae(n = 3), Salmonella spp. (n = 1) and other Enterobacterceae isolates (n = 14). The bla_CTX-M gene was detected in 89.04% (65/73) of the ESBL-producing Enterobacteriaceae, whereas bla_SHV and bla_TEM were detected in 30.14% (22/73) and 19.18% (14/73) respectively. Three out of 5 carbapenem-resistant isolates harbored New Delhi metallo-beta-lactamase (NDM) and 2 produced Verona integron-encoded metallo- beta -lactamase (VIM). Twenty-two (47.83%) of the ESBL positive isolates were multidrug resistant (MDR). Phylogenetic analysis showed that, of the 51 ESBL-EC isolates, 17 belonged to group B2, 13 to group D, 11 to group A and 10 to group B1.

Conclusions

Nearly two-thirds of the Enterobacteriaceae isolates recovered from feces of ambulatory patients with community–onset gastrointestinal complaints admitted to El-Ahrar General Hospital, Zagazig, Egypt were ESBL producers and one in every 20 patients included in our study was colonized by carbapenemase-producing Enterobacteriaceae. These high colonization rates are worrying, therefore prudent antimicrobial use should be adopted in Egyptian community settings.

Genomic organization of the human hairless gene (HR) and identification of a mutation underlying congenital atrichia in an Arab Palestinian family

Congenital atrichia is a rare form of hereditary human hair loss, characterized by the complete shedding of hair shortly after birth, together with the formation of papular lesions on the skin. Recently, we cloned the human homolog of the mouse hairless gene and identified pathogenic mutations in several families with inherited congenital atrichia. Here, we present the genomic organization of the human hairless gene (HGMW-approved symbol HR), which spans over 14 kb on chromosome 8p12 and is organized into 19 exons. In addition, we report the identification of a 22-bp deletion mutation in exon 3 of the hairless gene in a large consanguineous Arab Palestinian family from a village near Jerusalem, Israel. These findings extend the body of evidence implicating mutations in the hairless gene as an underlying cause of congenital atrichia in humans.

Comparison of Alprostadil (Caverject) and a combination of vasoactive drugs as local injections for the treatment of erectile dysfunction

The efficiency and side effects of a single dose of 20 mcg of intracorporeally applied Alprostadil (Caverject, Upjohn), a prostaglandin E1, in inducing penile erection were examined in 30 patients. In addition, the effect of this dose of prostaglandin E1 was compared to that of 30 mg of papaverine plus 0.5 mg of regitine (phentolamine). All patients received a first injection of the combination of the vasoactive drugs and a second injection of the prescribed dose of Caverject. The degree of erection, time interval between injections and achievement of full erection as well as side effects during and after injection were compared. All patients had a burning sensation during the injection of Caverject. Two patients given the vasoactive combination got priapism and were evacuated; this complication was not reported for Caverject. In the doses used Caverject was superior to papaverine plus phentolamine in inducing penile erection and in achieving a higher grade of erection.

Variations of direct fluorescent antibody test and serum bile acids levels following praziquantel treatment in Schistosoma mansoni experimentally infected mice

This study was performed to evaluate the efficiency and use of an immunopathological test viz "Direct Fluorescent Antibody Test (DFAT) for detection of IgG and IgM deposits in liver and kidney biopsies" and a biochemical test viz "estimation of serum bile acids by enzymatic colorimetric technique" for follow up Schistosoma mansoni infection using Swiss albino mice. Test were done during infection and after Praziquantel (PZQ) treatment. Mice were classified according to the duration of infection and post-therapy periods. It was found that both tests should be used together to provide good parameters to demonstrate S. mansoni infection and to test the regression of the disease after treatment.

Transmission-line electric field induction in humans using charge simulation method

This paper is aimed at determining the distribution of the fields, induced charges, and currents on a human body standing in the high electric fields produced by high voltage overhead transmission lines. This method of analysis is based on the charge simulation technique. This will serve to explain the biological studies of possible long-term exposure effects to electric fields.

Immune complexes as monitors of cure in Schistosoma mansoni infected mice

This study was done to assess the use of immune complexes estimated by micro-ELISA as monitors of cure of schistosomiasis mansoni experimentally infected Swiss albino mice which received praziquantel (PZQ) treatment. They were grouped according to duration of infection (4, 8, 12, 16w) and then subgrouped owing to post-treatment life span (4, 6, 8w). It was found that the changes observed in serum level of immune complexes (IC) would provide a good parameter to demonstrate the severity of infection and being an indication of improvement after treatment. The recorded changes confirmed the relationship between schistosomal hepatic affection and serum levels of IC. The study showed the potent anti-schistosomal effect of PZQ. It cured completely when it was given early after infection or improved moderately when given late.

Effect of praziquantel treatment on hepatic pathology of Schistosoma mansoni experimentally infected mice

In this study we used Schistosoma mansoni (S. mansoni) infected mice were used to assess the pathological changes in the liver at various stages of the disease as well as the effectiveness of Praziquantel (PZQ) treatment on hepatic pathology also at different stages. The S. mansoni infected mice were divided into 7 groups and subgroups according to post infection and/or post treatment periods. The various hepatic pathological changes were recorded and it was concluded that PZQ is an effective yet, safe non hepatotoxic drug and that the earlier the application of treatment in the course of the disease the better cure we can get with minimal or no insult to the liver tissue.

Diagnosis of active urinary schistosomiasis using homologous adult Schistosoma haematobium antigen

The role of antigen prepared from Schistosoma haematobium adult worm (ShAWA, W.H.O. Geneva) in diagnosis of active urinary schistosomiasis, by counterimmunoelectrophoresis (CIEP), was evaluated by comparison with simpler methods as sedmentation of urinary ova and detection of haematuria by chemical reagent strips. Sixty patients (30 school boys and 30 adults) passing living S. haematobium eggs, as detected, by nucleopore filtration technique (NF), and 30 controls were studied. Results showed statistically significantly higher (P < 0.001) egg counts in school boys than adults. Sensitivities of haematuria detection, ova sedimentation and CIEP were 93.3%, 80%, 50%, 70%, 73.3%, 33.3% in school boys and adults respectively. It was concluded that direct parasitological examination of urine samples is more superior than CIEP using homologous ShAWA to detect active urinary schistosomiasis both qualitatively and quantitatively. Haematuria detected by chemical reagent strips can identify a high proportion of active urinary schistosomiasis in epidemiological surveys in endemic areas. Nucleopore filtration is more superior than ova sedimentation method for detection of active urinary schistosomiasis.

Relation between bilharzial arthropathy and histocompatibility leucocytic antigen B27

Fifty cases of active schistosomiasis divided into group I test group consists of twenty-five patients with arthropathy and group II control group consists of twenty-five patients without arthropathy, were subjected to clinical examination, indirected haemagglutination test (IHAT) for bilharziasis and plain X-ray on lumbosacral, sacroiliac and knee joints. HLA-B27 antigen typing was also done as a trial to find association between this antigen and the Egyptian cases of bilharzial arthropathy. Clinical examination of patients with arthropathy showed that the frequency of joint affection was knee joint 76%, shoulder joint 12% and hip, elbow and sacroiliac joints were equally 4% affected. Although the affected joints were tender and with limited movement, there were no hotness, deformities and morning stiffness. There was no effusion nor swelling except in one case of knee joint arthropathy. The results of the IHAT showed hundred percent positivity in all the patients without significant statistical difference between the test and the control groups (P greater than 0.05). X-ray on the sacroiliac, lumbosacral and knee joints showed no abnormalities in all the cases. The results of the HLA-B27 antigen typing showed that the frequency of this antigen in the test group was 16% and in the control group was 4%. The relation risk was 4.57 and the aetiological fraction was very small 0.12. However there was insignificant statistical difference between the test and the control groups (P greater than 0.05).

Immunological changes in opportunistic parasitic infections

This study was done on 110 patients with different types of malignant diseases and 20 healthy controls. Cases were divided into four groups according to parasitological and serological examination. The first group included 37 patients without any parasitic infection, the second 28 patients with no opportunistic parasitic infection, the third group 33 patients with opportunistic parasitic infection while the fourth included 12 patients with mixed opportunistic and non opportunistic parasites. Immunological status was estimated by carrying out leucocyte migration inhibition test and intradermal skin test for cell mediated immunity and quantitative determination of immunoglobulins IgG, IgM and IgA for humoral immunity testing. It was found that cell mediated immunity was decreased in cancer patients compared with the normal control group. Super added parasitic infections lead to greater decrease. Opportunistic parasitic infection aggravated the condition more. Marked suppression of the cell mediated immunity was found in the group of cancer patients with mixed opportunistic and non opportunistic parasitic infections. IgG and IgA were increased in the first three groups and decreased in the mixed one, IgM was increased in the first and second groups while decreased in groups with opportunistic infections.

Specificity of crude and purified Fasciola antigens in immunodiagnosis of human fascioliasis

A study has been done to find the effect of purification of crude antigens extracted from adult F. gigantica and F. hepatica on the cross reactions encountered in C.I.E.P., I.H.A. and E.L.I.S.A. serological techniques with sera o other parasitic and non-parasitic diseases. It was performed on 75 patients and 20 healthy controls. It was found that sera of many diseases may cross-react with crude Fasciola antigen in serological diagnosis. These diseases include schistosomiasis, hydatidosis, amoebic liver abscess, heterophyiasis, trichinosis, non parasitic liver diseases (liver neoplasms, pyogenic liver abscess, viral hepatitis and acute leukaemic) and rheumatoid arthritis. Partial purification of crude Fasciola antigens is a suitable method to avoid cross reactivity when using C.I.E.P. or to diminish them when using E.L.I.S.A. No need for this purification when using I.H.A. So using partially purified adult Fasciola antigens C.I.E.P. was the most specific test (100%) of followed by C.L.I.S.A. then I.H.A.