Testing for t(3;8) in MYC/BCL6 re-arranged large B cell lymphoma identifies a high risk subgroup with inferior survival

A reciprocal t(3;8) BCL6::MYC fusion is common in large B cell lymphoma (LBCL) with MYC and BCL6 disruption. These pseudo-double hit cases are not adverse, whereas t(3;8) negative MYC/BCL6 lymphoma has an inferior prognosis relative to other MYC-rearranged LBCL.

Ibrutinib as first-line therapy for mantle cell lymphoma: a multicenter, real-world UK study

ABSTRACT

During the COVID-19 pandemic, ibrutinib with or without rituximab was approved in England for initial treatment of mantle cell lymphoma (MCL) instead of immunochemotherapy. Because limited data are available in this setting, we conducted an observational cohort study evaluating safety and efficacy. Adults receiving ibrutinib with or without rituximab for untreated MCL were evaluated for treatment toxicity, response, and survival, including outcomes in high-risk MCL (TP53 mutation/deletion/p53 overexpression, blastoid/pleomorphic, or Ki67 ≥ 30%). A total of 149 patients from 43 participating centers were enrolled: 74.1% male, median age 75 years, 75.2% Eastern Cooperative Oncology Group status of 0 to 1, 36.2% high-risk, and 8.9% autologous transplant candidates. All patients received ≥1 cycle ibrutinib (median, 8 cycles), 39.0% with rituximab. Grade ≥3 toxicity occurred in 20.3%, and 33.8% required dose reductions/delays. At 15.6-month median follow-up, 41.6% discontinued ibrutinib, 8.1% due to toxicity. Of 104 response-assessed patients, overall (ORR) and complete response (CR) rates were 71.2% and 20.2%, respectively. ORR was 77.3% (low risk) vs 59.0% (high risk) (P = .05) and 78.7% (ibrutinib-rituximab) vs 64.9% (ibrutinib; P = .13). Median progression-free survival (PFS) was 26.0 months (all patients); 13.7 months (high risk) vs not reached (NR) (low risk; hazard ratio [HR], 2.19; P = .004). Median overall survival was NR (all); 14.8 months (high risk) vs NR (low risk; HR, 2.36; P = .005). Median post-ibrutinib survival was 1.4 months, longer in 41.9% patients receiving subsequent treatment (median, 8.6 vs 0.6 months; HR, 0.36; P = .002). Ibrutinib with or without rituximab was effective and well tolerated as first-line treatment of MCL, including older and transplant-ineligible patients. PFS and OS were significantly inferior in one-third of patients with high-risk disease and those unsuitable for post-ibrutinib treatment, highlighting the need for novel approaches in these groups.

SARS-CoV-2 vaccine responses following CD20-depletion treatment in patients with haematological and rheumatological disease: a West Midlands Research Consortium study

B-cell-depleting agents are among the most commonly used drugs to treat haemato-oncological and autoimmune diseases. They rapidly induce a state of peripheral B-cell aplasia with the potential to interfere with nascent vaccine responses, particularly to novel antigens. We have examined the relationship between B-cell reconstitution and SARS-CoV-2 vaccine responses in two cohorts of patients previously exposed to B-cell-depleting agents: a cohort of patients treated for haematological B-cell malignancy and another treated for rheumatological disease. B-cell depletion severely impairs vaccine responsiveness in the first 6 months after administration: SARS-CoV-2 antibody seroprevalence was 42.2% and 33.3% in the haemato-oncological patients and rheumatology patients, respectively and 22.7% in patients vaccinated while actively receiving anti-lymphoma chemotherapy. After the first 6 months, vaccine responsiveness significantly improved during early B-cell reconstitution; however, the kinetics of reconstitution was significantly faster in haemato-oncology patients. The AstraZeneca ChAdOx1 nCoV-19 vaccine and the Pfizer BioNTech 162b vaccine induced equivalent vaccine responses; however, shorter intervals between vaccine doses (<1 m) improved the magnitude of the antibody response in haeamto-oncology patients. In a subgroup of haemato-oncology patients, with historic exposure to B-cell-depleting agents (>36 m previously), vaccine non-responsiveness was independent of peripheral B-cell reconstitution. The findings have important implications for primary vaccination and booster vaccination strategies in individuals clinically vulnerable to SARS-CoV-2.

Characterizing Agreement in the Level of Interarm Blood Pressure Readings of Adults in the Emergency Department (CALIBRATE Study)

Background: Increased interarm systolic blood pressure difference (IASBPD) is one of the major predictors of cardiovascular disease. An IASBPD of >10 mmHg is of clinical significance. However, studies have reported a high number of patients visiting the emergency department (ED) with high IASBPD and varying correlation of IASBPD to age, ethnic background, and comorbidities such as hypertension and diabetes. Objective: The CALIBRATE study aimed to measure the IABPDs in the multiethnic patient population presenting to the ED in Qatar and to assess the distribution of IASBPD in this population. Methods: In a sitting position, two consecutive blood pressure (BP) measurements were recorded from the right and left arms for each participant using a calibrated automated machine and appropriate cuff sizes. The data were recorded using predefined data fields, including patient demographics, past medical, and social and family history. The continuous variables were reported as mean or median based on the distribution of data. The data were analyzed using Stata MP 14.0. Results: A total of 1800 patients, with a mean age of 34 (10) years, were prospectively recruited from the ED. The median absolute systolic BP difference (ΔSBP) between the right and left arms was 6 (3-10) mmHg, and it was the same for the first (ΔSBP1) and the second readings (ΔSBP2). The absolute average of ΔSBP1 and ΔSBP2 was 7 (4-10) mmHg. The difference in systolic BP difference (SBP) of < 20 mmHg for interarm blood pressure was seen in the 95th percentile of the population. No meaningful association could be detected between the IABPD and the study variables such as age, demographics, regions of interest, and risk factors. Conclusion: In population presenting to the ED, the IASBPD of at least 20 mmHg reached at the 95th percentile, validating the known significant difference. The utility of SBP difference can be improved further by taking the average of two individual readings.

Cost benefit with early operative fixation of unstable ankle fractures

INTRODUCTION

Ankle fractures are common and many require surgical intervention. It has been well documented that a delay in fracture fixation results in increased length of hospital stay and increased complication rate. Initial delay can also allow swelling or blistering to develop which may necessitate a further delay in operative fixation for up to 1 week. The aim of the current study was to review the length of hospital in-patient stay for operative ankle fractures over the previous 12-month period at our hospital and compare this to the length of hospital stay following the introduction of a fast-track system for the fixation of these fractures (all fractures fixed within 48 h).

PATIENTS AND METHODS

A retrospective review of all ankle fractures managed by open reduction and internal fixation over a 12-month period was undertaken. A protocol was then agreed to openly reduce and fix these fractures at the earliest possible opportunity over the next 6-month period. We then collected the data on all ankle fractures that needed open reduction and internal fixation over this 6-month period. The pre-protocol and post-protocol groups were then compared for total hospital length of stay and complication rate.

RESULTS

In the 12-month retrospective review, there were 83 ankle fractures that required surgical intervention. Sixty-two of these had surgery within 48 h (mean length of stay, 5.4 days), and 21 had surgery after 48 h (mean length of stay, 9.5 days). There were 39 ankle fractures in the post-protocol group who all had surgery within 48 h (mean length of stay, 5 days). There was no increase in complication rate after implementation of the fast-track system.

CONCLUSIONS

This study shows that early operative intervention for ankle fractures reduces the length of hospital stay. Intensive physiotherapy and co-ordinated discharge planning are also essential ingredients for early discharge. Early operative fixation for unstable ankle fractures has substantial cost-saving implications with no increase in complication rate.

Acute idiopathic scrotal oedema in an adult: a case report

In the evaluation of a patient of any age presenting with an acute scrotal swelling, a surgical emergency should be carefully excluded. However, acute idiopathic scrotal oedema must be considered to avoid unnecessary surgical exploration.

The stomach divalent ion-sensing receptor scar is a modulator of gastric acid secretion

Divalent cation receptors have recently been identified in a wide variety of tissues and organs, yet their exact function remains controversial. We have previously identified a member of this receptor family in the stomach and have demonstrated that it is localized to the parietal cell, the acid secretory cell of the gastric gland. The activation of acid secretion has been classically defined as being regulated by two pathways: a neuronal pathway (mediated by acetylcholine) and an endocrine pathway (mediated by gastrin and histamine). Here, we identified a novel pathway modulating gastric acid secretion through the stomach calcium-sensing receptor (SCAR) located on the basolateral membrane of gastric parietal cells. Activation of SCAR in the intact rat gastric gland by divalent cations (Ca(2+) or Mg(2+)) or by the potent stimulator gadolinium (Gd(3+)) led to an increase in the rate of acid secretion through the apical H+,K+ -ATPase. Gd(3+) was able to activate acid secretion through the omeprazole-sensitive H+,K+ -ATPase even in the absence of the classical stimulator histamine. In contrast, inhibition of SCAR by reduction of extracellular cations abolished the stimulatory effect of histamine on gastric acid secretion, providing evidence for the regulation of the proton secretory transport protein by the receptor. These studies present the first example of a member of the divalent cation receptors modulating a plasma membrane transport protein and may lead to new insights into the regulation of gastric acid secretion.

Complications of thyroidectomy for benign disease

BACKGROUND

Goitre is a common ailment seen in mountainous regions, like the periphery of Abbottabad. Thyroidectomies are very common in our center.

METHODS

This study was done to find out the complication rate of thyroidectomies.

RESULTS

189 cases were operated in Ayub Hospital Complex, Abbottabad during July 96 and Dec. 99. All patients were with benign disease and any case found to have malignancy were excluded from the study. The overall complication rate for all the categories was 15%. In total 5 patients died within one month of surgery.

Human cost of political violence

OBJECTIVE

To evaluate the cost of political violence in terms of human life and its influence on social, psychological and financial aspects of community.

DESIGN

Retrospective study conducted from 1987 to 1989.

SETTING

Department of Accident and Emergency, Jinnah Postgraduate Medical Centre, Karachi.

SAMPLE SIZE

Nine hundred and fifty four victims including two hundred and fifty seven dead.

RESULTS

The mean age of the victims was 27.29 +/- 9.46 years with a male to female ratio of 33:1. All ethnic groups suffered to some extent. No case of violence on religious differences was reported during this period. Firearms were frequently used. Most of the deaths (92.2%) occurred due to firearm injuries. Landhi, Korangi, Malir and Shah Faisal Colony were the worst affected areas. There was however no significant difference between them. The projected loss of life for the dead was approximately 3.15 million days. The same was difficult to assess for the injured because of multifactorial reasons. Six thousand four hundred and ninety two close family members suffered from Psychological and Physical Trauma. The number of distant members affected psychologically was estimated to be 0.566 million. Schooling of approximately five thousand four hundred thirty seven children of the victims suffered.

CONCLUSION

Political violence has significant short and long term effects on the society in terms of physical and psychological trauma, financial losses, poor schooling and health, biased pattern of child development, migration of families and further division of society into identifiable communities which may prolong the conflict.

Butyrate mediates Caco-2 cell apoptosis via up-regulation of pro-apoptotic BAK and inducing caspase-3 mediated cleavage of poly-(ADP-ribose) polymerase (PARP)

Butyrate exerts potent anti-tumor effects by inhibiting cancer cell growth and inducing apoptosis. However, the molecular mechanisms mediating these effects remain largely unknown. Using the Caco-2 cell line, a well established model of colon cancer cells, our data show that butyrate induced apoptosis (maximum 79%) is mediated via activation of the caspase-cascade. A key event was the proteolytic activation of caspase-3, triggering degradation of poly-(ADP-ribose) polymerase (PARP). Inactivation of caspase-3 with the tetrapeptide zDEVD-FMK completely inhibited the apoptotic response to butyrate. In parallel, butyrate potently up-regulated the expression of the pro-apoptotic protein bak, without changing Caco-2 cell bcl-2 expression. Butyrate-induced Caco-2 cell apoptosis was completely blocked by the addition of cycloheximide, indicating the necessity of protein synthesis. However, when this inhibitor was added at a time point where bak expression was already enhanced (12 - 16 h after butyrate stimulation), it failed to protect Caco-2 cells against apoptosis. Taken together, these data provide evidence that the molecular events involved in butyrate induced colon cancer cell apoptosis include the caspase-cascade and the mitochondrial bcl-pathway.

Expression of an extracellular calcium-sensing receptor in rat stomach

BACKGROUND & AIMS

Circulating levels of Ca2+ can influence secretory functions and myoelectrical properties of the stomach. A Ca2+-sensing receptor (CaR) has recently been identified in tissues that regulate systemic Ca2+ homeostasis. The aim of this study was to evaluate expression of CaR in the stomach of the rat.

METHODS

In forestomach and glandular stomach, reverse-transcription polymerase chain reaction was used to amplify a 380-base pair product, which is 99% homologous with transcripts obtained in parathyroid and kidney.

RESULTS

Northern analysis of gastric mucosal polyA+ RNA revealed 7. 5- and 4.1-kilobase transcripts, similar to those obtained in rat parathyroid and kidney. Immunohistochemistry revealed CaR expression in regions of the submucosal plexus and myenteric neurons. In sections of intact tissue, preparations of primary culture surface cells and surgically dissected gastric glands, staining was observed consistently in epithelial cells of the gastric glands and in gastric surface cells. In parietal cells in isolated gastric glands, intracellular levels of Ca2+ responded to conditions that are known to activate CaR.

CONCLUSIONS

These are the first reported observations that CaR is expressed in different epithelial cells of mammalian gastric mucosa and its enteric nerve regions. The effects of extracellular Ca2+ on gastric function may be attributable to activation of CaR.

Screening for iron deficiency anemia in a well baby clinic

With a view to combating the long-term effects of iron deficiency anemia in infants, we carried out a screening program of infants at nine months of age in the Well Baby Clinic. We screened 4751 infants using complete venous blood count analysis, 2668 were anemic (Hb <11 gm/dL). Those with hemoglobin less than 10 gm/dL were recalled to be given iron therapy and further follow-up. Although we faced problems with both compliance and follow-up, we felt that it was feasible to screen for iron deficiency anemia in the Well Baby Clinic setting. A very high prevalence of anemia was found in the population screened. This justified continuation of the program, intensifying parent education to comply with iron therapy and, more importantly, to teach the proper weaning of their infants to prevent iron deficiency anemia.

Cloning and expression of the large-conductance Ca(2+)-activated K+ channel from colonic smooth muscle

We have cloned cDNAs encoding the alpha- and beta-subunits of a large-conductance Ca(2+)-activated K+ channel (BK channel) from canine colonic smooth muscle (cslo-alpha and cslo-beta). Nucleotide sequence homology of cslo-alpha with mslo and dslo suggests that it is the canine homologue of these genes. The carboxy-terminal end of the protein is the most diverse between species, and we have also found alternative exons in cslo-alpha in this region. We have identified a unique splice site in the carboxy-terminal region of cslo-alpha, which we term site 5. Northern analysis demonstrates expression of both alpha- and beta-subunits in all canine vascular and visceral smooth muscles tested. Expression of alpha-1 alone and alpha + beta-subunit cRNA in Xenopus oocytes results in a Ca(2+)- and voltage-dependent conductance. The activity of alpha/beta-channels, measured as either changes in the voltage of half-maximal activation (V0.5) in open probability (NP0) or in the normalized conductance (G/Cmax), was more sensitive to [Ca2+]free than channels composed of the alpha-subunit alone. Neither alpha- nor alpha/beta-channels expressed in membrane patches of Xenopus oocytes were found to be regulated by protein kinase G.

Epidemiology of adults hospitalized with burns in Karachi, Pakistan

Burns are a leading cause of adult death in Karachi slums, therefore we reviewed 1 year's logged experience (November 1992 to October 1993) at Karachi's two adult burn units for patient age, sex, burn severity and outcome. Also 47 inpatients were interviewed regarding their circumstances of injury. We grouped these using Haddon's Matrix. The log identified 832 patients. Females (57 per cent) outnumbered males and were younger on average (25.1 vs 27.6 years, P = 0.002). Females had more severe burns than males (57 per cent vs 50 per cent total body surface area (TBSA) burn, P = 0.002). At the unit with outcome data (n = 556), the case fatality was 56 per cent. The estimated adult mortality due to burns in Karachi was 10.2/100 000, 6.8/100 000 and 14.1/100 000 for men and women, respectively. Burns of interviewed patients were most often associated with flames (33/47), but stove bursts caused the most severe injury (52 per cent TBSA). These patients were predominantly young uneducated female houseworkers, clothed in loose attire who were injured during daylight at home around a floor-level stove, unaware of fire safety, and who received no first aid. It was concluded that the high burn severity and case fatality rates demand: (1) preventive measures, such as kitchen sand buckets, safer stove design and placement and education on fire safety and first aid, and (2) risk factor analysis to refine interventions.

Atherosclerosis in aortocoronary bypass grafts. Morphologic study and risk factor analysis 6 to 12 years after surgery

Segments of aortocoronary vein grafts from a selective group of 42 patients who underwent a second revascularization procedure or came to autopsy 6 to 12 years after coronary bypass surgery were studied. Complex atheromata often associated with an acute thrombus were present in 71% of the grafts. In 14% of the cases, aneurysms of the atherosclerotic type were noted. The medical records of 40 of these patients were reviewed. Special attention was paid to risk factors associated with coronary artery disease. A control population of 535 patients who had undergone coronary artery bypass surgery and had not had recurrence of symptoms requiring reoperation 5 or more years later was drawn from the Milwaukee Cardiovascular Data Registry. Significantly higher triglyceride and cholesterol levels and lower high density lipoprotein levels were noted in the patients undergoing two bypass procedures. In addition more diabetics, cigarette smokers, and patients with abnormal lipoprotein phenotypes were noted in the study group. Hypertension did not appear to be a significant risk factor. Atherosclerosis appears to be an important factor in late graft failure. Vein grafts that develop atherosclerosis appear to be susceptible to aneurysm formation. Risk factors associated with atherosclerosis in coronary arteries also appear to play a role in the development of atherosclerosis in aortocoronary bypass grafts.

Significance of transported glycine in the conjugation of sodium benzoate in spf mutant mice with ornithine transcarbamylase deficiency

3H-glycine and 14C-serine were injected intraperitoneally, during treatment of spf mutant mice with 2% sodium benzoate in drinking water. Urinary hippurate was separated by thin layer chromatography and counted for 3H and 14C labels representing transported and newly synthesized glycine, respectively. The specific activity of 3H-hippurate increased significantly in mutant and normal groups, while the increase of 14C was seen only in mutants. The ratio of specific activity 3H:14C showed significant increases in normal (0.99 to 1.93; p less than 0.01) and mutant (1.53 to 3.05; p less than 0.05) groups, which shows that glycine transported from body pools played a significantly greater role in the conjugation of benzoate, compared to glycine synthesized de novo from serine. In spf mice, benzoate treatment also resulted in a decrease in orotate excretion, indicating amelioration of the hyperammonemic state. It is postulated that the elimination of glycine transported from body pools may be the primary mechanism for the reduction of ammoniagenicity in benzoate therapy, and that the de novo synthesis of glycine may have a secondary effect.

Total parenteral nutrition in very low birth weight infants with Travasol 10% blend C

Ten very low birth weight (VLBW) infants (birth weight: 994 +/- 66 g, gestational age: 27 +/- 0.5 wk) requiring total parenteral nutrition (TPN) were studied in order to evaluate their metabolic response to the amino acid solution Travasol 10% blend C. These patients received the solution at a constant rate, providing 2.61 +/- 0.02 g/kg/day of amino acids and 76 +/- 1 kcal/kg/day. Plasma amino acids analysis was performed after 4.6 +/- 0.3 day of infusion and compared to values reported previously with Travasol blend B. The new solution (blend C) showed a significantly lower (p less than 0.001) glycinemia (485 +/- 24 vs 993 +/- 69 mumol/liter), methioninemia (39 +/- 2 vs 114 +/- 12 mumol/liter) and phenylalaninemia (67 +/- 3 vs 92 +/- 5 mumol/liter) related to the lower intake of these amino acids. Despite the provision of 47.5 mmol/liter of serine with blend C no changes in plasma level (182 +/- 15 vs 196 +/- 41 mumol/liter) were noted. The increased molar arginine/glycine ratio (blend C: 0.48 vs blend B 0.22) could have contributed to keep ammoniemia within normal levels (55.1 +/- 4.2 mumol/liter). Wide variations in insulin response (9.9 to 26.4 microU/ml) allowed for a correlation between its plasma concentration and those of sensitive amino acids, underlining its role in protein metabolism. Despite the immaturity of the study population no short-term metabolic imbalance has been encountered with the Travasol blend C solution.