Clinicopathological Profile and Survival Outcomes in Patients with Localised Extremity Synovial Sarcomas

AIMS

Synovial sarcoma is a rare but aggressive variant of soft-tissue sarcoma. Literature is sparse and reported mostly from the West. We analysed the clinical profiles and prognostic factors of extremity synovial sarcoma patients in order to study their clinical journey.

MATERIALS AND METHODS

This was a retrospective analysis. All patients with extremity synovial sarcoma treated between 1992 and 2020 were included. Patients with metastases at presentation were excluded. A descriptive analysis of demographic and clinicopathological features of patients undergoing limb salvage surgery (LSS) or amputation was carried out. Overall survival and disease-free survival were calculated for the entire cohort as well as for the LSS and amputation groups. Factors prognostic for survival were identified.

RESULTS

In total, 157 patients had localised extremity synovial sarcoma. Predominantly, young adults (median 31 years) and males (61%) were affected. Over 70% of patients presented after recurrence or unplanned surgeries. Sixty-seven per cent of tumours were >5 cm, 69% were deep and 23% involved bone. The limb salvage rate was 64%. In the LSS group, adjuvant radiotherapy and chemotherapy were given to 72% and 68% of patients, respectively. In the amputation group, 72% of patients received adjuvant chemotherapy. In a median follow-up of 59 months, 39.4% of patients had recurrences, the majority (61.2%) were systemic. Five-year overall survival and disease-free survival were 53.4% and 49.8%, respectively. Overall survival was 63.9% and 29.7% in the LSS and amputation groups, respectively. On multivariate analysis, tumour size, depth, omission of radiotherapy and bone invasion were found to be the adverse prognostic factors.

CONCLUSION

This is one of the largest studies on extremity synovial sarcoma. Mostly males and young adults were affected. The limb salvage rate was 64%, despite most being referred after unplanned surgery. Almost 70% of patients received radiotherapy and chemotherapy. Overall survival was inferior in the amputation group. Tumour size >5 cm, depth and bone invasion were negative, whereas adjuvant radiotherapy was a positive prognostic factor for survival. Chemotherapy had no impact on survival.

Variation in performing kidney biopsy amongst nephrologists in the Asia-Pacific region: A multinational survey

AIM

Kidney biopsy (KB) is the gold standard procedure for diagnosing kidney diseases. Globally, nephrologists are trained to perform KB. However, the past few decades have witnessed a transition where interventional radiologists (IRs) are now preferentially performing the procedure. Our survey-based cross-sectional study aimed to investigate the current trends of KB operators in the Asia-Pacific region (APR) in practicing interventional nephrologists.

MATERIAL AND METHODS

The Association of Vascular Access and intervenTionAl Renal Physicians (AVATAR) Foundation from India conducted a multinational online survey among interventional nephrologists from the APR to investigate who does KB, if the nephrology training curriculum includes KB, and whether nephrologists have access to ultrasound.

RESULTS

Out of 21 countries from the APR that participated in our survey, 10 countries (47.4%) reported that more than 70% of their nephrologists performed KB, whereas in 11 countries (57.6%), KB was most likely done by an IR. The frequency of nephrologists performing KB ranged from 0% in Afghanistan to 100% in countries such as Pakistan, Singapore, and Thailand. Formal training for KB and access to ultrasound was available to nephrologists in 80% of the responding countries.

CONCLUSION

Our study shows that despite the availability of training and access to USG, a significant number of nephrologists are not performing KB in the APR. Similar to the trends observed in Western countries, the observed pattern in the APR could be due to lack of time, less incentive, hospital policy, or interest of nephrologists in other aspects of intervention nephrology.

Practice of dialysis access interventional nephrology procedures in the Asia-Pacific region: Getting lay of the land

AIM

This cross-sectional survey aimed to determine the prevalence of Interventional Nephrology (IN) practice amongst nephrologists in the Asia-Pacific Region (APR), specifically related to dialysis access (DA).

METHODS

The Association of VA and intervenTionAl Renal physicians (AVATAR) Foundation from India conducted a multinational online survey amongst nephrologists from the Asia-Pacific to determine the practice of IN in the planning, creation, and management of dialysis access. The treatment modalities, manpower and equipment availability, monthly cost of treatment, specifics of dialysis access interventions, and challenges in the training and practice of IN by nephrologists were included in the survey.

RESULTS

Twenty-one countries from the APR participated in the survey. Nephrologists from 18 (85.7%) countries reported performing at least one of the basic dialysis access-related IN procedures, primarily the placement of non-tunnelled central catheters (n-TCC; 71.5%). Only 10 countries (47.6%) reported having an average of <4% of nephrologists performing any of the advanced IN access procedures, the most common being the placement of a peritoneal dialysis (PD) catheter (20%). Lack of formal training (57.14%), time (42.8%), incentive (38%), institutional support (38%), medico-legal protection (28.6%), and prohibitive cost (23.8%) were the main challenges to practice IN. The primary obstacles to implementing the IN training were a lack of funding and skilled personnel.

CONCLUSION

The practice of dialysis access-related IN in APR is inadequate, mostly due to a lack of training, backup support, and economic constraints, whereas training in access-related IN is constrained by a lack of a skilled workforce and finances.

Tunneled femoral vein catheterization for long-term hemodialysis – Experience from a tertiary care center

Introduction:

Tunneled femoral vein hemodialysis catheters are used when all other options for permanent vascular access or jugular central vein catheter are exhausted. There is little published literature on the outcome and survival of tunneled femoral vein catheters.

Methods:

Using a retrospective database, we identified all tunneled femoral dialysis catheters placed in the Nephrology department of our institute over a one-and-half year period. The outcomes, complications, and patency of these procedures was retrospectively evaluated.

Results:

Out of total 21 patients, 14 were female and 7 males with a mean age of 45 (range 17–73 years) and about one-fourth had diabetes mellitus (26%). Right-sided femoral catheter insertion was performed in 18 patients (85.7%) and 3 patients underwent left-sided insertion. Technical success of placement was 100% with no immediate complications. Median follow up period was 24 days. Primary catheter patency at 30, 60, 90, and 180 days were 81, 29, 18, and 12.5%, respectively. Three patients (15.7%) developed catheter-related deep venous thrombosis. Three catheters (14.2%) were removed for catheter-related infection and seven (33.3%) were removed because of absent blood flow.

Conclusion:

Our experience with tunneled femoral catheters revealed low catheter survival and significant complications (deep venous thrombosis and malfunction/occlusion).

86 Ultrasonographic evaluation of preovulatory follicle and endometrial echo texture for ovulation prediction in Marwari mares

The objective of the present study was to evaluate the application of ultrasonographic changes in the preovulatory follicle and uterus for ovulation prediction in Marwari mares. Mares (n=20) were teased daily by a teaser pony and, from the day of first detected oestrus, the ovaries and uterus were examined by transrectal ultrasonography using Exago ECM ultrasound equipped with linear rectal probe (10MHz) until ovulation. Recorded data were analysed by one-way ANOVA and correlation coefficients. The duration of the oestrus period ranged from 5 to 7 days in all mares, with an average of 6.35±0.13 days, consistent with rectal findings. The last day of oestrus was marked by disappearance of the preovulatory follicle and presence of a corpus haemorrhagicum. The mean diameter of the follicles increased significantly (P&lt;0.01) from Day 1 to Day 7, and the diameter of follicles before ovulation was 44.88±0.46 mm; follicles changed from round to oval or irregular before ovulation. In 65% (13/20) of the mares, ovulation occurred on the left ovary. The daily mean growth rate of size of ovulating follicles from the first day of oestrus until ovulation was 3.51±0.42 mm/d. The mean average growth rate of follicles was significantly different (P ≤ 0.01) on different days of oestrus. The mean endometrial echo texture score was 1.30±0.10 on Day 1, 2.10±0.16 on Day 2, 3.20±0.15 on Day 3, and highest 3.85±0.08 on Day 4, declining thereafter to reach a score of 1.36±0.11 on Day 7 of the oestrous cycle. The mean slope values of pixel intensity for the granulosa and anechoic layers of the preovulatory follicles determined by Image-Pro software (Media Cybernetics) from Days −3 to −1 was 13.8±0.7 on Day −3, 15.7±0.9 on Day −2, and 20.1±1.3 on Day −1. None of the follicles ovulated before granulosa layer echogenicity reached a score of ≥2.5 and prominence of anechoic layer reached a score of ≥2. Significant positive correlations were found between the cross-sectional diameter of the uterine horn and estrual endometrial echotexture score (P&lt;0.01; r=0.95), estrual endometrial echo texture score and preovulatory follicle diameter (P&lt;0.01; r=0.25), and preovulatory follicle diameter and cross-sectional diameter of uterine horn (P&lt;0.01; r=0.36) during the oestrous cycle. We conclude that various ultrasonographic characteristics of preovulatory follicle and uterus can be used to predict ovulation in Marwari mares.

48 Transrectal color Doppler evaluation of umbilicus, placentomes, and uterine vascularity changes throughout pregnancy in Surti buffalo

With an objective to record the appearance, vascularity changes in umbilicus, placentomes, and blood flow to the uterus, adult (age 5-10 yr) Surti buffalo (parity=2-6; n=24) were inseminated during natural oestrus during the breeding season and scanned by transrectal B mode and colour flow mode ultrasonography every 3-4 days till Day 90 of gestation and then at an interval of 15 days for the complete gestation. The umbilical cord was first visible on Day 38; however, colour Doppler wave fronts could first be obtained on Day 46, which became increasingly distinct thereafter. The placentomes could first be identified at Day 76 of gestation. The placentome diameters increased from Day 76 until the month 7 with significant increases (P&lt;0.05) during Day 80, and months 4, 5, and 6 of gestation; thereafter, the increase was not significant. The vascularity of placentomes could also be recognised at Day 76 and this increased with increasing months of gestation. The blood flow to the middle uterine arteries could be identified after month 2 of gestation. The resistive index values of the middle uterine artery ipsilateral to the gravid horn showed an almost linear decline with a significant (P&lt;0.05) drop at months 4 and 9 of gestation. Similarly, resistive index values of the middle uterine artery contra-lateral to the gravid horn revealed a significant (P&lt;0.05) decrease on month 3, 5, and 6. A significant decrease for pulsatility index values of the middle uterine artery ipsilateral to the gravid horn was observed in months 3, 6, and 8 of gestation. However, the pulsatility index values for the middle uterine artery contralateral to the gravid horn showed a nonsignificant decrease. It was concluded that the umbilicus and placentomes are first visible at 38 and 76 days of gestation and the vascularity of the umbilicus, placentomes, and middle uterine artery increases with advancement of gestation in Surti buffalo.

The biochemical womb of schizophrenia: A review

The conclusive identification of specific etiological factors or pathogenic processes in the illness of schizophrenia has remained elusive despite great technological progress. The convergence of state-of-art scientific studies in molecular genetics, molecular neuropathophysiology, in vivo brain imaging and psychopharmacology, however, indicates that we may be coming much closer to understanding the genesis of schizophrenia. In near future, the diagnosis and assessment of schizophrenia using biochemical markers may become a "dream come true" for the medical community as well as for the general population. An understanding of the biochemistry/ visa vis pathophysiology of schizophrenia is essential to the discovery of preventive measures and therapeutic intervention.

Efflux pumps in drug resistance of Candida

The incidences of human pathogenic yeast Candida albicans and its related species acquiring resistance to antifungals have increased considerably, which poses serious problems towards its successful chemotherapy. The resistance of these pathogenic fungi is not restricted to the commonly used triazole compounds but is even encountered, though not often, with polyene derivatives as well. The efflux pump proteins belonging to ABC (ATP Binding Cassette) and MFS (Major Facilitators) super family are the most prominent contributors of multidrug resistance (MDR) in yeasts. The abundance of the drug transporters and their wider specificity suggest that these transporters may not be exclusively drug exporters in yeasts and may have other cellular functions. In this article we focus on some of the recent advances on the structure and function, evolution and transcriptional control of drug efflux proteins of Candida. A short discussion on the physiological relevance of drug transporters is also included.

Megakaryocytes derived from human embryonic stem cells: a genetically tractable system to study megakaryocytopoiesis and integrin function

BACKGROUND

The platelet fibrinogen receptor, a heterodimer consisting of integrin subunits alpha(IIb) and beta(3), is required for platelet aggregation, spreading, and hemostasis. Platelet agonists such as thrombin and adenosine diphosphate (ADP) lead to the activation of alpha(IIb)beta(3), thereby enhancing its affinity and avidity for binding fibrinogen (inside-out signaling). Furthermore, fibrinogen binding to alpha(IIb)beta(3) triggers cytoskeletal changes and granule release (outside-in signaling).

AIM

Genetic approaches to characterize the molecular pathways involved in alpha(IIb)beta(3) signaling are not possible with anucleate blood platelets. Therefore, we have established an OP9 stromal cell co-culture system to generate megakaryocytes from human embryonic stem cells (hESCs).

RESULTS

alpha(IIb)beta(3) activation, measured by soluble fibrinogen binding to hESC-derived megakaryocytes, /GPIbalpha(+) cells, is readily detectable following stimulation with known platelet agonists. Dose-response curves for peptide agonists specific for the two platelet thrombin receptors, protease-activated receptor 1 (PAR1) and PAR4, show a relative responsiveness that mirrors that of human platelets, and sub-maximal ADP responses are augmented by epinephrine. Moreover, hESC-derived megakaryocytes undergo lamellipodia formation, actin filament assembly, and vinculin localization at focal adhesions when plated on a fibrinogen-coated surface, characteristic of alpha(IIb)beta(3) outside-in signaling. Undifferentiated hESCs genetically modified by lentiviral infection can be cloned and maintained in an undifferentiated state and then differentiated into megakaryocytes capable of alpha(IIb)beta(3) activation.

CONCLUSION

Using hESCs, we have developed a renewable source of human megakaryocytes, and a genetically tractable system for studying megakaryocytopoiesis and alpha(IIb)beta(3) signaling in the native cellular environment.

Characterization of Mpl mutants using primary megakaryocyte-lineage cells from mpl(-/-) mice: a new system for Mpl structure-function studies

Mpl is the thrombopoietin (TPO) receptor. The current molecular understanding of how Mpl activation stimulates proliferation of megakaryocyte-lineage cells is based largely on the engineered expression of Mpl in nonmegakaryocyte-lineage cell lines. However, the relevance of these findings to Mpl signaling in primary megakaryocyte-lineage cells remains largely unknown. Therefore, a system was developed to study Mpl function in primary mpl(-/-) megakaryocyte-lineage cells. Expressing avian retroviral receptors on the surfaces of mammalian cells overcomes their natural block to avian retroviral infection; 815 bp of human GPIIb regulatory sequence was used to generate transgenic mice with megakaryocyte-lineage expression of the subgroup A avian leukosis virus receptor, TVA. Avian retroviral infection of unfractionated bone marrow from these mice is restricted to megakaryocyte-lineage cells. The transgenic mice were crossed to an mpl(-/-) background generating GPIIb-tva+mpl(-/-) mice. By using avian retroviruses to express wild-type or mutant Mpl on the surfaces of primary megakaryocyte-lineage cells, it was demonstrated that (1) the 10 membrane-proximal, cytoplasmic amino acids of Mpl are required for TPO-induced proliferation; (2) Y582F mutation confers a proliferative advantage over wild-type Mpl and imparts a constitutive anti-apoptotic signal; (3) truncating the 50 C-terminal Mpl amino acids reduces but does not eliminate TPO-induced mitogen-activated protein kinase activation, yet it does not alter the synergistic effect of stem cell factor on TPO-induced proliferation; and (4) TPO-induced proliferation of early, primary megakaryocyte-lineage cells does not require Stat-5 phosphorylation. The system reported provides an improved approach for Mpl structure-function studies, and the method can be applied to any hematopoietic lineage.

Inductively coupled plasma emission spectroscopic and flame photometric analysis of goat epididymal fluid

AIM

The elemental composition of the epididymal luminal fluid (ELF) in adult goat (Capra indica) was investigated.

METHODS

ELF was collected by micropuncture from twelve sites along the epididymal duct. The elemental contents was analyzed with inductively coupled plasma (ICP) emission spectroscopy, a microanalytical technique that can simultaneously measure many elements in minute volumes of sample. The Na and K concentrations were determined by flame photometry.

RESULTS

ICP spectroscopy showed the presence of copper, calcium, nickel, iron, magnesium, chromium, titanium and zinc in ELF, with fluctuating levels at different sites along the length of the epididymis. Cadmium, cobalt, lead and manganese were not found. The Na+/K+ ratio was seen to be higher at the initial segments of the epididymis and lower at the distal.

CONCLUSION

It is proposed that the observed characteristic distribution of elements in ELF may have far reaching implications in sperm maturation and storage known to occur in the epididymis.

Mutations in the human immunodeficiency virus type 1 integrase D,D(35)E motif do not eliminate provirus formation

The core domain of human immunodeficiency virus type 1 (HIV-1) integrase (IN) contains a D,D(35)E motif, named for the phylogenetically conserved glutamic acid and aspartic acid residues and the invariant 35 amino acid spacing between the second and third acidic residues. Each acidic residue of the D,D(35)E motif is independently essential for the 3'-processing and strand transfer activities of purified HIV-1 IN protein. Using a replication-defective viral genome with a hygromycin selectable marker, we recently reported that a mutation at any of the three residues of the D,D(35)E motif produces a 10(3)- to 10(4)-fold reduction in infectious titer compared with virus encoding wild-type IN (A. D. Leavitt et al., J. Virol. 70:721-728. 1996). The infectious titer, as measured by the number of hygromycin-resistant colonies formed following infection of cells in culture, was less than a few hundred colonies per microg of p24. To understand the mechanism by which the mutant virions conferred hygromycin resistance, we characterized the integrated viral DNA in cells infected with virus encoding mutations at each of the three residues of the D,D(35)E motif. We found the integrated viral DNA to be colinear with the incoming viral genome. DNA sequencing of the junctions between integrated viral DNA and host DNA showed that (i) the characteristic 5-bp direct repeat of host DNA flanking the HIV-1 provirus was not maintained, (ii) integration often produced a deletion of host DNA, (iii) integration sometimes occurred without the viral DNA first undergoing 3'-processing, (iv) integration sites showed a strong bias for a G residue immediately adjacent to the conserved viral CA dinucleotide, and (v) mutations at each of the residues of the D,D(35)E motif produced essentially identical phenotypes. We conclude that mutations at any of the three acidic residues of the conserved D,D(35)E motif so severely impair IN activity that most, if not all, integration events by virus encoding such mutations are not IN mediated. IN-independent provirus formation may have implications for anti-IN therapeutic agents that target the IN active site.

Rejuvenation of epididymal principal cells by prolactin under androgen deficiency

Influence of prolactin on the ultrastructure of principal cells lining the epididymal epithelium was investigated in Wistar rats. Orchidectomy produced degenerative changes suggesting that structural integrity of principal cell is maintained by factors originating in the testis. The atrophic changes in the principal cell of ordhidectomised rats were significantly reversed when prolactin was administered to these animals. The number of cells that responded were found to increase with the dose of prolactin injected. On the otherhand, bromocryptine treatment did not appreciably change the ultrastructure of principal cells in orchidectomised rats. Results suggest that prolactin may have a rejuvenating epididymal principal cells in androgen deficient states.

Impact of prolactin on epididymal lipid profile in castrated rats

Prolactin treatment to castrated rats led to accumulation of triacylglycerol and esterified cholesterol. There was no appreciable drift in epididymal cholesterol: phospholipid ratio between the prolactin treated and control animals. However, further analysis of phospholipids showed a build up of phosphatidyl inositol, phosphatidyl choline and phosphatidyl ethanolamine but a drop in the levels of phosphatidyl serine and sphingomyelin in prolactin treated castrated rats as compared to those castrated animals injected with vehicle alone. Changes in phospholipids reported above were prominently seen in the group of castrated rats that received 100 micrograms oPRL/100 g body weight but not in those animals which received either lower or higher doses of the hormone. Interestingly, bromocryptine treatment in castrated rats produced a general depletion in the levels of all lipid classes studied in the epididymis. It is suggested that this may be due to impaired synthesis and/or increased breakdown of lipids in this organ.

[Small disturbance in arterial blood flow]

The behaviour of a small disturbance in an arterial blood flow has been studied analytically. The growth equation governing growth or decay of a disturbance has been obtained and solved. The behaviour of wave amplitude has been investigated as the wave propagates in time. The application of results to the human arterial system shows that the shock waves are not expected under normal physiological conditions. In the case of a pathologically increased pressure rise at the root of aorta, shock-like transitions may develop in the periphery. It is observed that the friction effects are to resist the tendency of shock formation in arteries.