Analysis of the care management protocol for COVID pregnant women and detection of improvement proposals applying clinical simulation methodology

Introduction

The current SARS-CoV-2 pandemic has been the world's largest socio-health crisis experienced in the last century. Each healthcare center has been compelled to adapt the treatment guidelines established by the different scientific societies.

Objective

Analyze the impact of the methodology based on simulation as a tool to improve our clinical practice: work dynamics, effectiveness and safety of all the physicians involved in the management of labor in COVID pregnant women and its usefulness to facilitate the adaptation of protocols to a specific clinical context.

Method

Descriptive observational study that includes the C-sections and deliveries of COVID pregnant women performed in our hospital. The actions carried out in each procedure were analyzed using the simulation multidisciplinary briefing and debriefing tools, before and after each case.

Results

A total of 5 clinical cases were analyzed. Difficulties were found in the execution of the protocols established for the care of the COVID pregnant. Organizational, structural, material resources and human factors obstacles were the most common.

Conclusions

Our results showed that the analysis example using simulation methodology was a tool of great value in three aspects: teamwork improvement, actions consent and improvement proposals for the adaptation and implementation of protocols.

Abstract PD3-11: HER2/ERBB2 status in “HER2 equivocal” breast cancers by FISH and ASCO-CAP guidelines: False-positives due to heterozygous deletions of alternative control loci

Background. The ASCO-CAP guidelines for HER2 testing by fluorescence in situ hybridization (FISH) have a category, referred to as “equivocal” (average HER2 copies per tumor cell >4-6 with HER2/CEP17 ratio <2·0), which is neither “HER2-positive” nor “HER2-negative”. Approximately 4% - 12% of invasive breast cancers are “HER2-equivocal” based on FISH. Cancers in this category may be resolved as “negative” or “positive” by FISH alternative control probes (2013/2014 guidelines) or HER2 immunohistochemistry (IHC) (2018 update). Our objectives were to evaluate the following hypotheses: 1.) Genetic loci used as alternative controls show heterozygous deletion in a substantial proportion of breast cancers; 2.) Use of these loci for assessment of HER2 by FISH leads to false-positives; 3.) HER2 FISH false-positive breast cancer patients have outcomes that do not differ from clinical outcomes for HER2-negative breast cancer patients; and 4.) HER2-equivocal breast cancers seldom show HER2 protein overexpression (IHC 3+).

Methods. We retrospectively assessed the use of chromosome 17 p-arm and q-arm alternative control genomic sites (TP53, D17S122, SMS, RARA, TOP2A), as recommended by the 2013/2014 ASCO-CAP guidelines, in patients whose data were available through the Molecular Taxonomy of Breast Cancer International Consortium (METABRIC)(N=1980) or whose tissues were available from the BCIRG-005 clinical trial (N=3298). We used either FDA-approved HER2 IHC (HercepTest) or laboratory-developed HER2 (10H8) IHC assays to assess HER2 protein expression.

Results. Using METABRIC we found heterozygous deletions, particularly in specific p-arm sites, were common in both HER2-amplified and HER2-not-amplified breast cancers. Use of alternative control probes from these regions to assess HER2 by FISH in “HER2 equivocal” as well as HER2-not-amplified breast cancers resulted in high rates of false-positive ratios (HER2-to-alternative control ratio >2·0) due to heterozygous deletions of control p-arm genomic sites used as ratio denominators. Misclassifications of HER2 status was observed not only in breast cancers with ASCO-CAP “equivocal” status but also in breast cancers with an average of <4·0 HER2 copies per tumor cell. These deletions were also identified by FISH. IHC demonstrated <1% of FISH “HER2-equivocal” breast cancers in BCIRG-005 had IHC3+ immunostaining, consistent with HER2-not-amplified status. Clinical outcomes of “HER2-equivocal” breast cancer patients with HER2-to-alternative control ratio >2·0 did not differ significantly from clinical outcomes of those with HER2-to-alternative control ratio<2·0.

Conclusion. Using chromosome 17 p-arm alternative controls, as recommended by 2013/2014 ASCO-CAP guidelines, instead of CEP17 for resolution of “HER2 equivocal” cases, is problematic due to frequent heterozygous deletions of these loci in breast cancers. The indiscriminate use of alternative control probes to calculate a HER2 FISH ratio in “HER2-equivocal” breast cancers leads to false-positive interpretations of HER2 status resulting from unrecognized heterozygous deletions in one or more of these alternative control genomic sites and incorrect HER2 ratio determinations.

Citation Format: Press MF, Seoane JA, Curtis C, Quinaux E, Guzman R, Sauter G, Eiermann W, Mackey JR, Robert N, Pienkowski T, Crown J, Martin M, Valero V, Bee V, Ma Y, Villalobos I, Slamon DJ. HER2/ERBB2 status in “HER2 equivocal” breast cancers by FISH and ASCO-CAP guidelines: False-positives due to heterozygous deletions of alternative control loci [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 PD3-11.

Carpectomía proximal. Estudio por elementos finitos

Se realiza un análisis comparativo por elementos finitos del comportamiento de un modelo de muñeca sana con otro al que se le ha practicado una carpectomía proximal. Los parámetros valorados fueron las tensiones y áreas de contacto entre las superficies articulares del radio y semilunar en el modelo de la muñeca sana y entre el radio y la cabeza del hueso grande en el modelo de la muñeca con carpectomía proximal. Asimismo, se analizó el desplazamiento que experimenta el centroide de contacto en ambos modelos. De los resultados obtenidos se pudo comprobar que, a pesar de que se producen unas mayores tensiones, tanto en el radio como en la cabeza del hueso grande, éstas se distribuyen por un área mayor, es decir, cada zona articular del radio se encuentra menos tensionada por la cabeza del hueso grande y, por tanto, justificarían cómo una mayoría de pacientes a los que se les ha practicado una carpectomia proximal, no muestren un incremento en la tendencia a desarrollar una artrosis secundaria entre el radio y la cabeza del hueso grande. Por otra parte, el hecho de que durante el movimiento de flexoextensión se produce, no solo un movimiento de rotación sino también de traslación hacia el centro del radio, haría que se consiguiera una disipación adicional de tensiones.

Purified protein derivative reaction in systemic lupus erythematosus patients. Indirect study of cellular immunity

Cutaneous anergy in SLE patients results from disease activity and/or immunosuppressive treatment (IT). The aim of this study was to evaluate purified protein derivative (PPD) reaction in SLE patients. A total of 145 patients and 20 controls were studied. Five units of PPD were applied on day 0, and skin reaction was measured after 3 (PPD1) and 6 (PPD2) days. A booster was applied (day 14), and the reaction was measured after 3 (PPD3) and 6 (PPD4) days. Non-parametric ANOVA test and unpaired Student's t-test were performed. Forty patients (group I) were inactive (MexSLEDAI < 3), receiving no IT (at least 3 months previous to the PPD test); 39 (group II) were inactive receiving IT; 24 (group III) were active without IT, and 42 (group IV) were active with IT. Active patients had lower PPD1 (group III, 1.4 +/- 0.9; group IV, 0.6 +/- 0.5) than inactive patients (group I, 8.4 +/- 2.3; group II, 5.1 +/- 1.9) and than controls (9.4 +/- 3; P < or = 0.001). Group IV had lower delayed response (PPD2 = 0.3 +/- 0.3) than inactive groups (group I, 2.6 +/- 0.9; group II, 3.1 +/- 0.8) and than controls (7.9 +/- 2.5; P < or = 0.001). Group III had lower delayed reaction (PPD2 = 1.2 +/- 0.8) than controls (P < or = 0.001). Active SLE patients, receiving or not receiving IT, had lower skin response to PPD than inactive patients and controls.

[Stratification of a hyperendemic city in hemorrhagic dengue]

Any effort to control dengue hemorrhagic fever (DHF) faces a number of challenges. Among these are the great environmental heterogeneity of homes and neighborhoods in urban centers where the primary dengue vector, Aedes aegypti, breeds, as well as shortages of resources and of personnel trained in mosquito control. Adequate epidemiological surveillance could serve as a basis to begin to stratify urban communities and identify the areas in them where control efforts should be focused. In this study we stratified Maracay, Venezuela, a city with hyperendemic dengue hemorrhagic fever, using a geographic information system and analyzing the persistence, incidence, and prevalence of dengue, by means of clinical diagnoses reported from 1993 through 1998. Maracay has around one million inhabitants living in some 349 neighborhoods in the six communities that make up the greater Maracay metropolitan area. During that 1993-1998 period the Maracay area reported 10,576 cases of dengue, 2,593 cases of DHF, and 8 deaths. The incidence of DHF was related to the incidence of dengue, the number of inhabitants in an area, and population density. The spatial pattern of dengue incidence was stable over the years that were studied, and significant, positive relationships were found between pairs of years and the incidence of dengue by neighborhood. The persistence of dengue was related directly to monthly incidence by neighborhood. These spatial patterns helped to divide the city into three strata: 68 neighborhoods without apparent dengue, 226 neighborhoods with low persistence and prevalence, and 55 neighborhoods with high persistence and prevalence. We recommend giving the highest priority for control efforts to these 55 neighborhoods, which make up just 35% of the Maracay urban area but had 70% of all the reported dengue cases.

Leukocyturia in women with diabetes and its clinical implications

BACKGROUND

Urinalysis is one of the most common studies performed on the diabetic patient at every visit. The presence of leukocyturia is relatively common but it is not clear what the attitude of the physician toward this particular finding should be. The main objective of the present study was to investigate the clinical significance of leukocyturia in diabetic women.

METHODS

Ninety-eight diabetic women (84.7% type 2) aged 57 +/- 13 years who were being seen at the diabetic out-patient clinic were randomly selected. All patients underwent a clinical and gynecologic examination and a urinalysis. A Papanicolaou smear and a urine culture were also obtained.

RESULTS

The overall prevalence of leukocyturia (>5 cells/high power field (hpf)) was 46.5%. Patients with urinary tract infections (UTI) were 7.5 times more likely to have leukocyturia, while a leukocyte count <5cells/hpf predicted the absence of UTI in 96% of the women. In the comparison of patients with and without leukocyturia, we found that proteinuria (p = 0.06) and bacteriuria (p <0.002) were more common in the women with leukocyturia. A significant association with leukorrhea was not demonstrated. The empirical use of antibiotics was 12 times more frequent in the patients with leukocyturia.

CONCLUSIONS

A urinary culture should be requested in all diabetic patients with leukocyturia. The possibility of a UTI is remote when leukocyturia is absent.

Dengue virus structural differences that correlate with pathogenesis

The understanding of dengue virus pathogenesis has been hampered by the lack of in vitro and in vivo models of disease. The study of viral factors involved in the production of severe dengue, dengue hemorrhagic fever (DHF), versus the more common dengue fever (DF), have been limited to indirect clinical and epidemiologic associations. In an effort to identify viral determinants of DHF, we have developed a method for comparing dengue type 2 genomes (reverse transcriptase PCR in six fragments) directly from patient plasma. Samples for comparison were selected from two previously described dengue type 2 genotypes which had been shown to be the cause of DF or DHF. When full genome sequences of 11 dengue viruses were analyzed, several structural differences were seen consistently between those associated with DF only and those with the potential to cause DHF: a total of six encoded amino acid charge differences were seen in the prM, E, NS4b, and NS5 genes, while sequence differences observed within the 5' nontranslated region (NTR) and 3' NTR were predicted to change RNA secondary structures. We hypothesize that the primary determinants of DHF reside in (i) amino acid 390 of the E protein, which purportedly alters virion binding to host cells; (ii) in the downstream loop (nucleotides 68 to 80) of the 5' NTR, which may be involved in translation initiation; and (iii) in the upstream 300 nucleotides of the 3' NTR, which may regulate viral replication via the formation of replicative intermediates. The significance of four amino acid differences in the nonstructural proteins NS4b and NS5, a presumed transport protein and the viral RNA polymerase, respectively, remains unknown. This new approach to the study of dengue virus genome differences should better reflect the true composition of viral RNA populations in the natural host and permit their association with pathogenesis.