Electrochemotherapy as a treatment option for feline nasal melanoma

Case summary

A 4-year-old domestic shorthair cat presented to North Downs Specialist Referrals for treatment of a 7 mm melanoma of the nasal planum. Two treatments of electrochemotherapy using intravenous bleomycin as a chemotherapeutic agent were administered. The tumour was no longer visible after treatment. At the 292-day follow-up there was no recurrence at the site and the patient was clinically well.

Relevance and novel information

There are few data concerning the outcomes of cats with non-ocular feline melanomas and there are currently minimal descriptions in the literature of electrochemotherapy as a treatment option. The available data suggest that nasal melanoma may have a worse prognosis, and that melanomas are locally invasive and have a high propensity for metastasis. The current most effective means for local control is surgery with wide margins. Given the location in this case, this would have required nasal planectomy, while electrochemotherapy provided an effective and possibly more attractive alternative.

Toxicity of zoledronic acid after intravenous administration: A retrospective study of 95 dogs

BACKGROUND

There is a paucity of veterinary literature on the safety or outcome of zoledronic acid (ZA) use in dogs for either bone pain or hypercalcemia.

HYPOTHESIS/OBJECTIVES

The primary aim was to report the adverse events in dogs receiving intravenous administration of ZA.

ANIMALS

Ninety-five dogs with ZA use.

METHODS

A retrospective cohort study was performed; all dogs that received at least 1 dose of ZA and had a serum biochemistry profile performed before and after treatment were reviewed. Diagnosis, indication for treatment, adverse events and survival times were recorded.

RESULTS

Ninety-five dogs met the inclusion criteria. Thirty-one (33%) received multiple intravenous infusions of ZA (range, 2-7), making a total of 166 administrations in all dogs. The dose range was 0.13 to 0.32 mg/kg, given at intervals of 4 to 6 weeks. Thirteen adverse events were recorded in 10 dogs: azotemia (n = 8), vomiting (n = 2), pancreatitis (n = 1), cutaneous ulceration (n = 1), and diarrhea (n = 1). Zoledronic acid could not be confirmed as the cause of azotemia in any case. The change in serum creatinine concentration from dose to dose was not related to the total dose received (P = .46). Five dogs (5%) changed Veterinary Comparative Oncology Group Common Terminology Criteria (VCOG-CTAE) renal/genitourinary grade after administration of ZA; their total dose 0.4 mg/kg (range, 0.26-0.66) was not significantly different to the group which did not change VCOG-CTAE renal/genitourinary grade 0.35 mg/kg (range, 0.2-1.50; P = .93).

CONCLUSIONS AND CLINICAL IMPORTANCE

Multiple doses of ZA were well tolerated in dogs within this study. A small number of dogs developed progressive azotemia which was not associated with cumulative dose.

Gene Expression Profiling of B Cell Lymphoma in Dogs Reveals Dichotomous Metabolic Signatures Distinguished by Oxidative Phosphorylation

Gene expression profiling has revealed molecular heterogeneity of diffuse large B cell lymphoma (DLBCL) in both humans and dogs. Two DLBCL subtypes based on cell of origin are generally recognized, germinal center B (GCB)-like and activated B cell (ABC)-like. A pilot study to characterize the transcriptomic phenotype of 11 dogs with multicentric BCL yielded two molecular subtypes distinguished on the basis of genes important in oxidative phosphorylation. We propose a metabolic classification of canine BCL that transcends cell of origin and shows parallels to a similar molecular phenotype in human DLBCL. We thus confirm the validity of this classification scheme across widely divergent mammalian taxa and add to the growing body of literature suggesting cellular and molecular similarities between human and canine non-Hodgkin lymphoma. Our data support a One Health approach to the study of DLBCL, including the advancement of novel therapies of relevance to both canine and human health.

Clozapine toxicity: a cautionary palliative care tale

OBJECTIVE

This case report presents an unusual case of clozapine toxicity secondary to reduced smoking habit mimicking a patient approaching end of life.

METHODS

It is a cautionary tale for palliative care specialists, perhaps unaware of the effect of cigarette smoke on metabolism of this antipsychotic, to be aware of.

RESULTS

Following specialist advice and change of antipsychotic medication, this patient's condition improved to the point that he was discharged from the hospice.

CONCLUSION

Palliative care specialists should be aware that reducing cigarette consumption can alter metabolism of clozapine, potentially causing drug accumulation and toxicity with features which mimic deterioration towards end of life. Specialist advice should be sought in such a situation.

Tracey judgement and hospice DNACPR orders: steady as she goes or seismic change?

OBJECTIVES

The 2014 Court of Appeals decision with respect to Tracey vs Cambridge University Hospital ('the Tracey judgement') changed the requirements for discussing Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions with patients. This study is a retrospective case note review aiming to identify any changes in practice around discussing DNACPR decisions in hospices following the judgement.

METHODS

150 case notes from 2013 (before the Tracey judgement) were compared with 150 case notes from 2015 (following the Tracey judgement). These notes came from five hospices in the West Midlands. The notes were analysed to determine if the judgement resulted in changes to how frequently DNACPR decisions were discussed with patients and their families, as well as whether there were any changes in the documentation of reasons for not discussing such decisions.

RESULTS

Discussions with patients around DNACPR decisions increased from 31% to 60% and with relatives from 29% to 59% following the Tracey judgement. Prior to the judgement the most frequently documented reason for not discussing was to avoid distress (23%), whereas after judgement it was patients lacking capacity to engage in such a discussion (40%). There was a lack of consistency and clarity in defining the concept of 'physical or psychological harm'.

CONCLUSIONS

Although DNACPR decisions are being discussed more frequently with patients and families following the Tracey judgement, clarity on what constitutes 'physical or psychological harm' caused by these discussions is still required. Future research must examine whether the judgement is delaying or preventing DNACPR decisions being made.

Does place of death vary by deprivation for patients known to specialist palliative care services?

OBJECTIVES

Referral to, and usage of, specialist palliative care (SPC) services are not equitable and social deprivation may be a contributory factor in this. Deprivation may also affect the place of death of patients with cancer. No study, however, has investigated whether inequalities persist following referral to SPC services. This study investigates whether place of death varies by deprivation for patients known to SPC services.

METHODS

Place of death and postcode were obtained for 485 consecutive patients known to SPC services within NHS Lothian who died in 2014-2015. From this information, deprivation quintile (DQ) was derived using the Scottish Index of Multiple Deprivation (SIMD) database and place of death compared between DQs and analysed statistically.

RESULTS

Across all DQs, patients known to SPC services were more likely to die in the hospice than at home or in hospital. There was, however, a small but statistically significant difference in the ratio of hospital deaths compared to hospice deaths between the DQs, with higher death rates in hospital for the most deprived compared to the least deprived and higher death rates in the hospice for the least deprived compared to the most deprived.

CONCLUSIONS

This study suggests that even after referral to specialist palliative care services variation in place of death by deprivation persists. Greater deprivation is associated with increased likelihood of dying in hospital and decreased likelihood of dying in a hospice, although no difference was noted for home deaths.

Efficacy and long-term outcomes of palivizumab prophylaxis to prevent respiratory syncytial virus infection in infants with cystic fibrosis in Northern Ireland

BACKGROUND

RSV causes considerable morbidity and mortality in children. In cystic fibrosis (CF) viral infections are associated with worsening respiratory symptoms and bacterial colonization. Palivizumab is effective in reducing RSV hospitalization in high risk patient groups. Evidence regarding its effectiveness and safety in CF is inconclusive. CF screening in N. Ireland enabled timely palivizumab prophylaxis, becoming routine in 2002.

OBJECTIVES

To determine the effect of palivizumab on RSV-related hospitalization and compare lung function and bacterial colonization at age 6 years for those born pre- and post-introduction of palivizumab prophylaxis.

METHODS

A retrospective audit was conducted for all patients diagnosed with CF during the period from 1997 to 2007 inclusive. RSV-related hospitalization, time to Pseudomonas aeruginosa (PA) 1st isolate, lung function and growth parameters were recorded. Comparisons were made for outcomes pre- and post-introduction of routine palivizumab administration in 2002. A cost evaluation was also performed.

RESULTS

Ninety-two children were included; 47 pre- and 45 post-palivizumab introduction. The overall RSV-positive hospitalization rate was 13%. The relative risk of RSV infection in palivizumab non-recipients versus recipients was 4.78 (95%CI: 1.1-20.7), P = 0.027. Notably, PA 1st isolate was significantly earlier in the palivizumab recipient cohort versus non-recipient cohort (median 57 vs. 96 months, P < 0.025) with a relative risk of 2.5. Chronic PA infection at 6 years remained low in both groups, with similar lung function and growth parameters. Total costs were calculated at £96,127 ($151,880) for the non-recipient cohort versus £137,954 ($217,967) for the recipient cohort.

CONCLUSION

Palivizumab was effective in reducing RSV-related hospitalization infection in CF patients. Surprisingly, we found a significantly earlier time to 1st isolate of PA in palivizumab recipients which we could not explain by altered or improved diagnostic tests.

Diagnostic value of neutrophil-lymphocyte and albumin-globulin ratios in canine soft tissue sarcoma

OBJECTIVE

To investigate the ability of neutrophil-to-lymphocyte ratio and albumin-to-globulin ratio to differentiate soft tissue sarcoma from benign soft tissue tumours.

METHODS

A retrospective study of pretreatment haematology and biochemistry in dogs diagnosed with soft tissue sarcoma or benign soft tissue tumours. The neutrophil-to-lymphocyte ratio and albumin-to-globulin ratio were compared between the two groups. In dogs diagnosed with soft tissue sarcoma, the relationship of neutrophil-to-lymphocyte ratio and albumin-to-globulin ratio to histological tumour grade (I to III) was assessed.

RESULTS

In the dogs with soft tissue sarcoma (n=22), the neutrophil-to-lymphocyte ratio was significantly increased and the albumin-to-globulin ratio decreased compared to those with benign soft tissue tumours (n=14). The neutrophil-to-lymphocyte ratio and albumin-to globulin ratio were not useful as predictors of tumour grade in dogs diagnosed with soft tissue sarcoma.

CLINICAL SIGNIFICANCE

Pretreatment neutrophil-to-lymphocyte ratio and albumin-to globulin ratio may aid with diagnosis and optimal treatment planning. Further investigation into their prognostic implications is warranted.

IFN-gamma is the primary cause of aplastic anemia not autoreactive T cells (111.2)

Aplastic anemia (AA) is characterized by hypocellular marrow and peripheral pancytopenia. Although cases of AA caused by environmental factors have been reported, the etiology of AA is largely unknown. Since IFN-γ and T-bet can be detected in AA patients' T cells, it was believed that autoreactive T lymphocytes played a major role in destroying the hematopoietic stem cells (HSCs) in bone marrow (BM). Thus, AA has been treated as an autoimmune disease. We have observed AA-like symptoms in our IFN-γ AU-rich element (ARE) knock-out (KO) mice. These mice have a targeted deletion in the 3'untranslated region of the IFN-γ mRNA. The deletion increases the half-life of IFN-γ mRNA. Thus, these mice constitutively express low level of IFN-γ under normal condition. In this study, we used IFN-γ ARE KO mice as an animal model to understand the etiology of AA. These mice exhibited signs of immunodeficiency when their immune organs were examined. Also, T cells from these mice failed to produce cytokines when stimulated with anti-CD3 and anti-CD28 antibodies. Upon examining the cell population in BM, we did not detect any infiltration of T cells. In addition, we observed an increase in long term HSCs (LT-HSCs) and a decrease in short term HSCs (ST-HSC). We also observed the same phenomena in WT recipients of IFN-γ ARE KO BM. The results of this study suggest AA occurs when IFN-γ inhibits the generation of ST-HSCs from LT-HSCs, as opposed to infiltration of autoreactive T cells.

Switching from aerobic glycolysis to oxidative phosphorylation modulates the sensitivity of mantle cell lymphoma cells to TRAIL

TRAIL (TNF (tumour necrosis factor)-related apoptosis-inducing ligand) a putative anti-cancer cytokine induces apoptosis through DISC (death-inducing signalling complex)-mediated activation of caspase-8 and/or cleavage of Bid. TRAIL is relatively specific for tumour cells but primary chronic lymphocytic leukaemia and mantle cell lymphoma (MCL) cells are resistant. Herein, we show that cellular metabolism influences cell death and that MCL cells (Z138 cell line) can survive/proliferate in glucose-free media by switching from aerobic glycolysis to 'coupled' oxidative phosphorylation. Extracellular flux analysis and mitochondrial inhibitors reveal that in the absence of glycolysis, Z138 cells have enhanced respiratory capacity coupled to ATP synthesis, similar to 'classical' state 3 mitochondria. Conversely, 2-deoxyglucose (2DG) blocked glycolysis and partially inhibited glycolytic-dependent oxidative phosphorylation, resulting in a 50% reduction in cellular ATP levels. Also, 2DG sensitised Z138 cells to TRAIL and induced a marked decrease in caspase-8, -3, cFLIP(S), Bid and Mcl-1 expression but Bak remained unchanged, altering the Mcl-1/Bak ratio, facilitating cytochrome c release and cell death. Conversely, under glucose-free conditions, Z138 cells were less sensitive to TRAIL with reduced TRAIL-R1/R2 surface receptor expression and impaired DISC formation. Anti-apoptotic proteins Bcl-2 and XIAP were up-regulated while pro-apoptotic BAX was down-regulated. Additionally, mitochondria had higher levels of cytochrome c and ultrastucturally exhibited a condensed configuration with enhanced intracristal spaces. Thus, metabolic switching was accompanied by mitochondrial proteome and ultrastructural remodelling enabling enhanced respiration activity. Cytochrome c release was decreased in glucose-free cells, suggesting that either pore formation was inhibited or that cytochrome c was more tightly bound. Glucose-free Z138 cells were also resistant to intrinsic cell death stimuli (ABT-737 and ionising radiation). In summary, in MCL cells, the anti-glycolytic effects of 2DG and glucose restriction produced opposite effects on TRAIL-induced cell death, demonstrating that mitochondrial metabolism directly modulates sensitivity of tumour cells to apoptosis.

The second wave of 2009 pandemic influenza A(H1N1) in New Zealand, January-October 2010

This paper uses data from multiple surveillance systems to describe the experience in New Zealand with the second complete wave of pandemic influenza A(H1N1)2009 in 2010. Measures such as hospitalisation rates suggest the overall impact of influenza A(H1N1)2009 in 2010 was between half and two thirds that of the first wave in 2009. There was considerable regional and sub-regional variation with a tendency for higher activity in areas that experienced low rates in 2009. Demographic characteristics of the second wave were similar to those in 2009 with highest rates seen in children under the age of five years, and in indigenous Māori and Pacific peoples. Hospital services including intensive care units were not under as much pressure as in 2009. Immunisation appears to have contributed to the reduced impact of the pandemic in 2010, particularly for those aged 60 years and older.

The second wave of 2009 pandemic influenza A(H1N1) in New Zealand, January–October 2010

This paper uses data from multiple surveillance systems to describe the experience in New Zealand with the second complete wave of pandemic influenza A(H1N1)2009 in 2010. Measures such as hospitalisation rates suggest the overall impact of influenza A(H1N1)2009 in 2010 was between half and two thirds that of the first wave in 2009. There was considerable regional and sub-regional variation with a tendency for higher activity in areas that experienced low rates in 2009. Demographic characteristics of the second wave were similar to those in 2009 with highest rates seen in children under the age of five years, and in indigenous M?ori and Pacific peoples. Hospital services including intensive care units were not under as much pressure as in 2009. Immunisation appears to have contributed to the reduced impact of the pandemic in 2010, particularly for those aged 60 years and older.

Successful decolonization of meticillin-resistant Staphylococcus aureus in paediatric patients with cystic fibrosis (CF) using a three-step protocol

Methicillin-resistant Staphylococcus aureus (MRSA) is recognized as a bacterial pathogen in patients with cystic fibrosis (CF) although its clinical effects can be variable. The aim of this study was to evaluate the efficacy of a three-step decolonization protocol for MRSA (Belfast CF MRSA decolonization protocol). Of the 17 paediatric patients treated during the five years of the study, eight (47%) were successfully decolonized following one five-day course of oral rifampicin and fusidic acid. The success rate increased to 12 (71%) patients after a second five-day oral treatment course in the 11 patients who remained culture positive at the end of the first treatment cycle. In a further four patients, clearance was achieved with a course of intravenous teicoplanin, increasing the decolonization rate to 16 of 17 patients (94%). These results compare favourably with other published studies and show that MRSA decolonization can be successful in a high proportion of paediatric CF patients.

Insulin-like growth factor binding protein 3 (IGFBP-3) potentiates TRAIL-induced apoptosis of human colorectal carcinoma cells through inhibition of NF-kappaB

There is growing evidence that the insulin-like growth factor-binding protein 3 (IGFBP-3) can have IGF-independent effects on cell growth. However, despite the fact that IGFBP-3 has been reported to be both antiproliferative and proapoptotic, the molecular mechanisms underlying the action of IGFBP-3 have not been elucidated. We report that although addition of IGFBP-3 (either synthetic or secreted protein) had no effect on cell survival, IGFBP-3 (100 ng/ml) significantly enhanced TNF-related apoptosis-inducing ligand (TRAIL)-induced cell death in colonic carcinoma-derived cell lines (20-30% depending on cell line), whereas it had no effect on the survival of the TRAIL-resistant adenoma-derived cells. Both addition of IGFBP-3 protein to cell cultures or enforced expression of IGFBP-3 in the HT29 carcinoma cell line inhibited nuclear factor kappa B (NF-kappaB) activation in response to the induction of apoptosis by TRAIL. We propose that IGFBP-3 is a non-toxic NF-kappaB inhibitor, which could be used as an adjuvant in the treatment of colon cancer.

Manifestations of adrenal cortical carcinoma with high oestrogen excretion

A 27-yr.-old woman with adrenal cortical carcinoma excreted large amounts of dehydroepiandrosterone (21–25 mg./day) and oestriol (94 μg./day). The latter may have prevented the development of virilizing features and so added to the difficulty in diagnosis. The clinical features and studies of adrenal steroid metabolism are presented, and the significance of the high levels of urinary dehydroepiandrosterone is discussed.