Clinical features of patients hospitalised with COVID-19 from February to October 2020, during the early waves of the pandemic in New Zealand

AIM

As New Zealand transitions towards endemic SARS-CoV-2, understanding patient factors predicting severity, as well as hospital resourcing requirements will be essential for future planning.

METHODS

We retrospectively enrolled patients hospitalised with COVID-19 from 26 February to 5 October 2020 as part of the COVID-19 HospitalisEd Patient SeverIty Observational Study NZ (COHESION). Data on demographics, clinical course and outcomes were collected and analysed as a descriptive case series.

RESULTS

Eighty-four patients were identified across eight district health boards. Forty-one (49%) were male. The median age was 58 years [IQR: 41.7-70.3 years]. By ethnicity, hospitalisations included 38 NZ European (45%), 19 Pasifika (23%), 13 Māori (15%), 12 Asian (14%) and 2 Other (2%). Pre-existing co-morbidities included hypertension (26/82, 32%), obesity (16/66, 24%) and diabetes (18/81, 22%). The median length of stay was four days [IQR: 2-15 days]. Twelve patients (12/83, 14%) were admitted to an intensive care unit or high dependency unit (ICU/HDU). Ten (10/83, 12%) patients died in hospital of whom seven (70%) were not admitted to ICU/HDU; the median age at death was 83 years.

CONCLUSION

Despite initially low case numbers in New Zealand during 2020, hospitalisation with COVID-19 was associated with a high mortality and hospital resource requirements.

Adverse effects and duration of treatment of TB in Canterbury, New Zealand

BACKGROUND Treatment of TB is often extended beyond the recommended duration. The aim of this study was to assess prevalence of extended treatment and to identify associated risk factors. We also aimed to determine the frequency and type of adverse drug reactions (ADR) experienced by this study population.METHODS We performed a retrospective cohort study of all patients treated for active TB at Christchurch Hospital, Christchurch, New Zealand, between 1 March 2012 and 31 December 2018. Data for 192 patients were collected on patient demographics, disease characteristics and treatment characteristics, including planned and actual duration of treatment and ADRs.RESULTS Of 192 patients, 35 (18.2%) had treatment extended, and 85 (46.5%) of 183 with fully drug-susceptible TB received ≥9 months treatment. The most common reasons for extension were persistent or extensive disease and ADR. Extended treatment duration was not associated with any patient or disease characteristics. We found 35 (18.2%) patients experienced at least one ADR. The most common ADRs were hepatitis, rash and peripheral neuropathy.CONCLUSION TB treatment extension beyond WHO guidelines is common. Further research is needed to guide management of those with slow response to treatment. Methods for early detection of ADR, systems to improve adherence and therapeutic drug monitoring are potentially useful strategies.

Proliferative activity in placentas with hydropic change and hydatidiform mole as detected by Ki-67 and proliferating cell nuclear antigen immunostaining

Complete hydatidiform moles (CHM) and partial hydatidiform moles (PHM) represent different clinicopathologic entities. To obtain prognostic and therapeutic information about both entities, it is important that pathologic classification be as accurate as possible. The distinction of molar pregnancy and an abortus with hydropic changes (AHC) can sometimes be very difficult. The acquisition of 2 antibodies against nuclear antigens expressed in cycling cells, Ki-67 and proliferating cell nuclear antigen (PCNA), allow the study of trophoblastic proliferation in CHM, PHM, and AHC. The purpose of this study is to determine whether immunocytochemical stains can help in the distinction between those entities. All materials were obtained by curettage from 95 patients with hydropic villi evident on microscopic examination. The 95 cases included 33 cases of CHM, 42 cases of PHM, and 20 cases of AHC. In the case of the Ki-67 staining, the mean was much lower in the ACH group (8.7%) than in the PHM group (65.3%) or in the CHM group (84.6%). In the case of PCNA staining, the mean differences among the 3 groups (AHC, 23.1%; PHM, 80%; and CHM, 89.2%) were all statistically significant. On the basis of the means and the Gaussian results, it appears that the Ki-67 distribution gives a better separation among the 3 groups. In conclusion, proliferative activity is an additional useful parameter for evaluation of molar pregnancies and hydropic changes, with Ki-67 staining allowing better separation than PCNA staining does.

Undetectable serum prostate-specific antigen associated with metastatic prostate cancer: a case report and review of the literature

A 63-year-old man, who had undergone prostatectomy for prostate cancer that was positive for prostate-specific antigen (PSA) was examined and found to have metastatic disease, proven radiologically and pathologically, but with an undetectable PSA and highly elevated prostatic acid phosphatase (PAP). Prostatic acid phosphatase levels fell in response to chemotherapy but his clinical status continued to deteriorate. A review of the literature is presented and several possible explanations for PSA remaining undetectable in these situations are discussed. The authors conclude that although PSA can be used to monitor the majority of patients postprostatectomy, physicians may still need to rely on clinical suspicion, serum PAP, and bone scan for the detection of recurrent disease.

Low p27 expression predicts poor disease-free survival in patients with prostate cancer

PURPOSE

p27 is an inhibitor of the cell cycle with potential tumor suppressor function. Decreased levels of p27 protein expression have been correlated with poor prognosis in patients with breast and colorectal carcinomas. Although as many as a third of patients with clinically localized prostate cancer will have relapse after radical prostatectomy, predicting who will have recurrence remains enigmatic. We examined the ability of p27 protein levels to predict outcome in patients with clinically localized disease who underwent radical prostatectomy.

MATERIALS AND METHODS

p27 protein expression was evaluated in 86 patients with clinical stage T1-2 prostate cancer who were treated with radical prostatectomy. Archived paraffin embedded specimens were sectioned and immunostained with p27 antibody, and scored by 2 independent observers in a blinded fashion. The absence or presence of p27 protein was then correlated with biochemical relapse in univariate and multivariate analyses.

RESULTS

In a multivariate analysis that included age, preoperative prostate specific antigen, Gleason score and pathological stage p27 was a strong independent predictor of disease-free survival (p = 0.0184, risk ratio 3.04), second only to pathological stage (p = 0.0001, risk ratio 6.73). Even more strikingly, multivariate analysis demonstrated that p27 was the strongest predictor of biochemical recurrence (p = 0.0081, risk ratio 4.99) among factors studied in patients with pathological T2a-T3b disease.

CONCLUSIONS

Absent or low levels of p27 protein expression appear to be an adverse prognostic factor in patients with clinically organ confined disease treated by radical prostatectomy. This marker appears to be especially useful in those patients in whom surgery is believed to be potentially curative, that is patients with pathological T2-T3b disease. Patients with low or absent p27 protein expression may be candidates for novel adjuvant therapies.

Modified technique for fine needle aspiration biopsy that eliminates needle manipulation

OBJECTIVE

To evaluate a modified technique of fine needle aspiration biopsy that eliminates needle manipulation after aspiration.

STUDY DESIGN

Fine needle aspiration biopsy of 112 palpable lesions was performed using both the conventional and modified techniques. Cellularity, cell preservation and diagnostic yield of the new procedure were compared to those of the conventional technique.

RESULTS

Cytologic smears prepared from each method were comparable in quality, quantity and diagnostic yield.

CONCLUSION

The modified approach eliminates the hazard of needle manipulation without diminishing the diagnostic efficacy of fine needle aspiration biopsy.

Fine needle aspiration of invasive cribriform carcinoma with benign osteoclast-like giant cells of histiocytic origin. A case report

We report the fine needle aspiration findings, with histologic confirmation, of a case of invasive cribriform carcinoma of the breast with benign osteoclast-like giant cells. We suggest that this diagnosis be considered when low to moderate grade malignant epithelial cells and numerous benign giant cells are seen in fine needle aspirates of the breast. We also confirmed immunohistochemically the histiocytic origin of the benign giant cells.

Intratubular germ cell neoplasia in infantile yolk sac tumor. Verification by tandem repeat sequence in situ hybridization

The strong association of intratubular germ cell neoplasia (ITGCN) with adult germ cell testicular tumors is well known, but studies noting the absence of ITGCN in certain germ cell neoplasms such as spermatocytic seminoma, childhood teratoma, and infantile yolk sac tumor (YST) have raised the issue of whether these latter neoplasms follow a different path of tumorigenesis, accounting for their more benign behavior. A case study illustrating the association of ITGCN with infantile YST is presented to challenge this hypothesis. In addition to the usual characteristic features that included strong cytoplasmic glycogen deposits, and focal placental alkaline phosphatase immunoreactivity, the atypical intratubular germ cells manifested triploidy by in situ hybridization using as probe a telomeric tandem repeat sequence, p1-79, specific to chromosome 1. The invasive YST cells, in contrast, showed evidence of tetraploidy by both in situ hybridization and flow and image cytometric studies, excluding the possibility that the atypical intratubular germ cells represented intratubular invasion by adjacent YST. These findings challenge the belief that the infantile YST follows a different path of tumorigenesis than its adult germ cell counterpart and suggest other hypotheses that might better explain its more benign behavior.

Differentiation of seminomatous from nonseminomatous testicular tumors with MR imaging

Distinguishing seminomatous from nonseminomatous testicular neoplasms preoperatively is useful because treatment of these two tumors types is different. We evaluated whether the distinction could be made with MR imaging in six patients with seminomatous and nine patients with nonseminomatous testicular tumors (including teratoma, teratocarcinoma, embryonal cell, and choriocarcinoma). The MR diagnoses, which were obtained from the formal reports of the MR studies done and interpreted before orchiectomy, were compared with the pathologic diagnosis. The distinction between the two tumor types on MR images was based on the signal intensity and heterogeneity of the lesion. We also retrospectively compared the MR findings with tissue histology. MR scans in nonseminomatous tumors showed a marked heterogeneous mix of signals, with some regions less intense and others more intense than normal testicular tissue on both proton-density and T2-weighted images. The typical background signal was nearly equal to normal testicular tissue. The tumors also had a dark band at their periphery that correlated with a fibrous tumor capsule on histologic examination. In contradistinction, seminomatous tumors were isointense with testis on proton-density images and consistently hypointense and relatively homogeneous on T2-weighted images. These tumors typically lacked a capsule on MR images. One lesion, only 3 mm in diameter, could not be characterized on MR images because of limitations in spatial and contrast resolution. In 13 of the 14 lesions that could be characterized, the histologic type was predicted correctly on the basis of the MR appearance. The one error occurred in a patient with pure seminoma. Although the MR appearance of the lesion was otherwise similar to the other seminomas, the lesion had a single focus of bright signal that was due to hemorrhage. This focus was interpreted incorrectly as a nonseminomatous element. Our findings in this small series of patients suggest that MR imaging can be used to distinguish seminomatous from nonseminomatous testicular tumors.

Two live-born infants with trisomy 22

The autopsy findings and karyotypes of two live-born fetuses with full trisomy 22 are discussed. Confined placental mosaicism was documented in one of the two cases. Confined placental mosaicism may play a role in the intrauterine survival of some trisomy 22 conceptions.

Oligohydramnios sequence and renal tubular malformation associated with maternal enalapril use

We present the case of a child who died of pulmonary hypoplasia as a result of the oligohydramnios sequence. The mother was taking enalapril, as well as propranolol and hydrochlorothiazide, for treatment of hypertension associated with systemic lupus erythematosus. Autopsy examination revealed severe renal tubular malformation. Correlation of animal data with previous case reports of neonatal anuria in association with maternal angiotensin converting enzyme inhibitors suggests that these agents may have a deleterious effect on fetal renal development and general well-being.

Automated enzymatic method for determining ammonia in plasma, with 14-day reagent stability

This is an automated, cost-efficient enzymatic method for determining ammonia in plasma. In most assays for ammonia the reagents are stable for only one or two days at 4 degrees C, but the reagents in our method are stable for at least 14 days. Our method was developed for use with a Cobas-Fara analyzer but can be easily adapted to other automated analyzers. It is essential to use closed sample vials. Our results, obtained at much less cost, correlate well with those by the Du Pont aca method. Precision studies gave the following results: within-run (n = 20 each), for x = 46 mumol/L, SD = 0.7 mumol/L, CV = 1.6%, and for x = 593 mumol/L, SD = 4.0 mumol/L, and CV = 0.7%; day-to-day precision during a year: for x = 47.7 mumol/L, SD = 2.4 mumol/L, CV = 5.0% (n = 360); and for x = 643 mumol/L, SD = 20.5 mumol/L, and CV = 3.2% (n = 365). The standard curve was linear to 1000 mumol of NH3 per liter.

Automated enzymatic method for determining ammonia in plasma, with 14-day reagent stability

This is an automated, cost-efficient enzymatic method for determining ammonia in plasma. In most assays for ammonia the reagents are stable for only one or two days at 4 degrees C, but the reagents in our method are stable for at least 14 days. Our method was developed for use with a Cobas-Fara analyzer but can be easily adapted to other automated analyzers. It is essential to use closed sample vials. Our results, obtained at much less cost, correlate well with those by the Du Pont aca method. Precision studies gave the following results: within-run (n = 20 each), for x = 46 mumol/L, SD = 0.7 mumol/L, CV = 1.6%, and for x = 593 mumol/L, SD = 4.0 mumol/L, and CV = 0.7%; day-to-day precision during a year: for x = 47.7 mumol/L, SD = 2.4 mumol/L, CV = 5.0% (n = 360); and for x = 643 mumol/L, SD = 20.5 mumol/L, and CV = 3.2% (n = 365). The standard curve was linear to 1000 mumol of NH3 per liter.

Burrowing, feeding, egestion and energy budgets of Allolobophora rosea (Savigny) (Lumbricidae)

Allolobophora rosea (Savigny) was found to be common in mull type soils beneath bramble (Rubus fruticosus L.). Burrow construction in this soil type in the laboratory at 4.4, 10.0 and 14.8°C ranged between 133 and 516 mm g^-1 fresh wt of worm day^-1. Burrowing was affected by both body size and temperature. Rates of soil displacement during burrowing were estimated from burrowing rates, burrow dimensions and soil density; depending on body size and temperature they were in the range 809-1,928 mg dry wt of soil g^-1 fresh wt of worm day^-1. These values were in reasonable agreement with measured egestion rates (range: 1,000-2,000 mg dry wt of egesta g^-1 fresh wt of worm day^-1). It was concluded that A. rosea eats its way through the soil and is adapted to its rapid turnover. Gut turnover times were calculated to be between 1 and 2.5 h.Direct observation indicated that feeding was by a "grazing" procedure and it was shown that A. rosea preferentially selects the more organic fractions of the soil for ingestion.The evaluation of energy budgets for individual small immature, large immature and adult worms at 10°C revealed respiration to production ratios (R/P) of 1.0, 1.8 and 4.1, respectively. Assimilation efficiencies (A/C) were always less than 2.5%.

Biomass and production of large African herbivores in relation to rainfall and primary production

Standing crop biomass, energy expenditure and production by large mammalian herbivores in the African savannas show a high degree of correlation with mean annual precipitation and predicted above ground primary production. These relationships possess the potential for predicting carrying capacity and protein production from simple meteorological data.

Litter input, litter decomposition and the evolution of carbon dioxide in a beech woodland-Wytham woods, Oxford

Tree litter fall was measured from May 1969 to April 1973 and varied between 205 and 388 g m^-2a^-1. Peak standing crops of the ground flora were determined between September 1969 and October 1972 and fell in the range 17.3 to 20.9 g m^-2 a^-1. Litter losses due to wind action had a net value of 8 g m^-2 a^-1 and the mean above ground litter input to the soil was 235 g m^-2 a^-1.Between February 1971 and January 1973 above ground litter loss due to decomposition was calculated from litter standing crop depletions and litter turnover times. It was estimated to be 235.8 g m^-2 a^-1. Steady state conditions were thus assumed for this woodland.The contribution to litter from dying roots was estimated at 92 g m^-2 a^-1 and hence the total input of dead organic matter to the site was 327 g m^-2 a^-1.Soil metabolism, measured as carbon dioxide evolution, showed a significant correlation with temperature and during 1973-1974 had a dry matter equivalent of 342 g m^-2 a^-1. The difference between the above ground litter input (235 g m^-2 a^-1) and the dry matter equivalent of soil metabolism (342 g m^-2 a ^-1) was attributed to the decomposition of root litter, root respiration and the respiratory activity of fungal mycorrhizae. Total organic matter decomposition accounted for 95% of total soil metabolism whilst the contributions by root and mycorrhizal respiration approximated 4 and 1%, respectively.