A156 OUTCOMES FOLLOWING ENDOSCOPIC RESECTION OF GASTRIC NEUROENDOCRINE TUMOURS FROM A TERTIARY-CARE ACADEMIC CENTRE

Background

Gastric neuroendocrine tumours (G-NET) are rare cancers derived from neuroendocrine cells of the stomach. A steady increase in the incidence of these tumours has been observed. Current treatment and surveillance strategies are guided by various tumour characteristics including size, grade, and depth of invasion. There exists conflicting evidence, however, on the rates of recurrence from positive resection margins following primary endoscopic resection. Thus, it remains uncertain whether complete endoscopic resection (R0) of these indolent tumours is clinically significant and whether follow-up endoscopic or surgical intervention is justified.

Purpose

Our aim is to characterize current management patterns and clinical outcomes in patients undergoing endoscopic resection of G-NETs.

Method

We conducted a retrospective, single-centre cohort study at The Centre for Advanced Therapeutic Endoscopy and Endoscopic Oncology at St. Michael’s Hospital, Toronto, Ontario. Consecutive patients over the age of 18 who underwent endoscopic resection of histologically proven G-NETs between 2011 and 2020 were included. Data on patient, endoscopic, and tumour characteristics were collected through electronic chart review. Descriptive statistics were conducted for data analysis.

Result(s)

A total of 155 foregut neuroendocrine tumours were endoscopically resected during the study period, of which 108 were identified as G-NETs. 95.3% were classified as Type I. Mean tumour size was 8.93 ± 5.27 mm. Cap-assisted EMR was performed most frequently (n=51), followed by conventional EMR (n=35). ESD was performed in eight cases. Seven intra-procedural perforations occurred, of which all were closed endoscopically. One patient experienced post-procedural perforation requiring ICU and surgery. Positive resection margins (R1) were found in 25% of cases (n=27), of which 78% were assessed at surveillance endoscopy 1 (SE1). Six patients with R1 margins were referred for surgical evaluation and four were lost to follow-up. 78% of all resected G-NETs were followed at SE1 with a median interval of 196 days (range, 23 to 3373). SE1 recurrence rate at the primary resection site was 14% (n=12), of which two were from routine scar biopsies in the absence of endoscopically identifiable recurrence. All visible recurrences at these sites (n=10) were managed with repeat endoscopic resection. Patient and tumour characteristics in the evaluation of G-NET recurrence are presented in Table I.

Image

Conclusion(s)

G-NET recurrence occurs in less than 15% of patients at surveillance endoscopy following endoscopic resection in spite of a predictably higher R1 resection rate. Patient, endoscopic, and tumour factors including method of resection and margin status do not appear to impact the development of early recurrence. Given the indolent nature of these tumours, patients with positive resection margins can be followed conservatively. Further investigation is warranted to determine the optimal duration and surveillance strategy for these patients.

Please acknowledge all funding agencies by checking the applicable boxes below

None

Disclosure of Interest

None Declared

A155 OUTCOMES FOLLOWING ENDOSCOPIC RESECTION OF DUODENAL NEUROENDOCRINE TUMOURS FROM A TERTIARY-CARE ACADEMIC CENTRE

Background

Duodenal neuroendocrine tumours (D-NET) are rare cancers derived from neuroendocrine cells of the duodenum. A steady increase in the incidence of these tumours has been observed. Current treatment and surveillance strategies are guided by various tumour characteristics including size, grade, and depth of invasion. There exists conflicting evidence, however, on the rates of recurrence after positive resection margins following endoscopic resection. Thus, it remains uncertain whether complete endoscopic resection (R0) of these indolent tumours is clinically significant and whether follow-up endoscopic or surgical intervention is justified.

Purpose

Our aim is to characterize endoscopic management and clinical outcomes in patients undergoing endoscopic resection of D-NETs.

Method

We conducted a retrospective, single-centre cohort study at The Centre for Advanced Therapeutic Endoscopy and Endoscopic Oncology at St. Michael’s Hospital, Toronto, Ontario. Consecutive patients over the age of 18 who underwent endoscopic resection of histologically proven D-NETs between 2011 and 2020 were included. Data on patient, endoscopic, and tumour characteristics were collected through electronic chart review. Descriptive statistics were conducted for data analysis.

Result(s)

A total of 155 foregut neuroendocrine tumours (NET) were endoscopically resected amongst 96 patients during the study period. 47 of these were histologically identified as D-NETs. Mean tumour size was 9.88 ± 6.86 mm. Conventional endoscopic mucosal resection (EMR) was performed most frequently (55%, n=26/47), followed by cap-assisted EMR (30%, n=14/47). Hybrid endoscopic submucosal dissection (ESD)/EMR was performed in one case. A total of two intra-procedural perforations occurred, both of which were successfully closed endoscopically. One patient with a peri-ampullary D-NET experienced significant intra-procedural bleeding requiring Hemospray® and subsequent endotracheal intubation resulting in a brief hospitalization. 57% of all resected D-NETs were followed at surveillance endoscopy 1 (SE1) at a median interval of 199 days (range, 84 to 830). Positive resection margins (R1) were found in 26 cases (55%), of which 16 were assessed at SE1 while nine were lost to follow-up. One patient with R1 margins was electively treated with APC at SE1. Tumour recurrence at SE1 occurred in only two patients.

Image

Conclusion(s)

D-NET recurrence is found in less than 5% of patients at surveillance endoscopy following endoscopic resection in spite of a high R1 resection rate. Given this indolent nature of these tumours, our study suggests that patients with positive resection margins can be followed conservatively with surveillance endoscopy. Further investigation is warranted to determine the optimal duration and surveillance strategy for these patients.

Please acknowledge all funding agencies by checking the applicable boxes below

CAG

Disclosure of Interest

None Declared

Automatic computation of bone defective volume from tomographic images

One of the most difficult aims of modern biomaterial science is predicting the shape and volume of a bone defect and adjusting the implementation of a bone substitute. Prior to implantation, practitioners must carefully identify the architecture and volume of the defective bone to be filled. This information is often accessed via imaging techniques. The defective bone is frequently confused with its surroundings and the image background. The use of conventional segmentation for the selection and isolation of the cavity to be filled proves to be difficult. In this work, a defect in a dead bone is created and then imaged with the microtomography technique (343 cuts generated). The goal is to separate the defect's shape and volume from both the bone and the background image. An adaptive morphological operation technique was employed to complete these tasks. The proposed method allows for exact segmentation and calculation of the volume of the cavity to be filled. Using several calculated phantoms, the approach is subjectively and quantitatively evaluated: Compared to the high error value of the conventional method, the error value of the proposed one has no bearing on the overall data. The method's accuracy was also confirmed by comparing the calculated volume of the bone defect (0.91 cm3) and the volume of prepared calcium phosphate cement paste necessary for its filling (0.87 cm3). To challenge the method even further, another direct application on a mandibular bone is realized with an advanced number of cuts (1236 cuts). The result of this application proved that the proposed algorithm overcomes the performance of the classical approaches of segmentation with a gain of 2 min on average. A comparison study between the proposed method and other classical segmentation approaches is also presented. The effectiveness of the method is proved by the various reports and metrics generated. The automated procedure can be beneficial in implantology for realizing and guiding surgical acts, as well as in computer-aided scaffolding techniques.

Bone markers and bone mineral density associates with periodontitis in females with poly-cystic ovarian syndrome

INTRODUCTION

Studies suggest an association between poly-cystic ovarian syndrome (PCOS) and chronic periodontitis (CP), both being inflammatory conditions. However, insufficient evidence assesses the impact of this inflammation on bone metabolism and bone turnover markers (BTMs). The present study aimed to determine the association between BTMs, bone mineral density (BMD), and clinical periodontal parameters in PCOS women with CP.

MATERIALS AND METHODS

Three groups, each with 40 newly diagnosed (1) PCOS+CP, (2) PCOS alone, (3) CP alone, and fourth group (n = 20) systemically and periodontally healthy females aged 18-30 years were included in the study. Full mouth clinical periodontal parameters, C-terminal telopeptides of type I collagen (CTX), bone alkaline phosphatase (ALP), BMD and 25-hydroxyvitamin D (VD) were recorded for all.

RESULTS

Low BMD (0.89 ± 0.11 g/cm²), increased CTX levels (2.76 ± 4.64 ng/ml), decreased bone ALP levels (11.09 ± 6.86 ng/ml), higher VD levels (289.02 ± 168.28 nmol/l) and poor clinical periodontal status were observed in PCOS + CP females. BMD-spine showed weak positive correlation with CTX, bone ALP, VD (r = 0.02, r = 0.07, r = 0.15, respectively) in PCOS + CP group. ANCOVA depicted covariates had no confounding effect. Multiple regression model explained 21.0% for BMD-spine and 12.7% for BMD-femur of total variability signifying association with all measured parameters among all groups.

CONCLUSION

Enhanced inflammatory thrust by periodontitis increases CTX levels and decreases bone ALP and BMD levels in women with PCOS. Screening PCOS women for periodontal disease and vice versa may have a direct bearing on overall bone health.

Potential plasma biomarkers: miRNA-29c, miRNA-21, and miRNA-155 in clinical progression of Hepatocellular Carcinoma patients

This study evaluated differences in the clinical appearance of patients with hepatocellular carcinoma (HCC) based on plasma level and regulation of microRNAs (miRNA-29c, miRNA-21, and miRNA-155). The observational-analytical study with a cross-sectional design was conducted on 36 HCC patients and 36 healthy controls. The blood samples were collected from 2 Province Hospitals (Dr. Sardjito Hospital and Prof. Dr. Margono Soekarjo Hospital) for HCC and the Blood Bank Donor of the Indonesian Red Cross for 36 healthy controls. These blood samples were treated as follows: plasma isolation, RNA isolation, cDNA synthesis, quantification by qRT-PCR using a sequence-specific forward primer, and normalization of miRNA using housekeeping-stably miRNA-16. There were only 27 HCC patients with complete clinical variables (neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), platelet count, albumin, C-reactive protein (CRP), and cholinesterase (ChE)) that were able to analyses for regulation miRNAs based on its fold change expression miRNA target. All 27 HCC subjects were follow-up until 3-years of monitoring for their overall survival. The miRNA plasma expression was analyzed by Bio-Rad CFX 96 Manager software to determine the cycle of quantification, followed by the calculation of expression levels using Livak’s methods. Data were analyzed using STATA 11.0, with a significant value of p<0.05. The miRNAs expression of HCC subjects were lower than that healthy control subjects in miRNA-29c (down-regulation 1.83-fold), higher than that healthy control subjects in miRNA 21 and miRNA-155 (up-regulation, 1.74-fold; 1.55-fold) respectively. NLR, CRP, ChE, and platelet count showed a significant difference in miRNA-29c regulation, though neutrophil count showed a significant difference in miRNA-21 and miRNA-155 regulation (p<0.05). Conclusion: Plasma biomarkers: miRNA-21 and miRNA-155 might be potential biomarkers as onco-miR in HCC subjects, while miRNA-29c might act as a tumor suppressor. Significant evidence was identified with clinical progression based on the regulation of miRNAs, which was consistent with miRNA -29c.

Natural History of Perianal Fistulising Lesions in Patients With Elderly-onset Crohn's Disease: A Population-based Study

INTRODUCTION

Most studies of elderly-onset Crohn's disease [CD; diagnosed in patients aged 60 or over] have described a mild course. However, data on the natural history of perianal fistulising CD [pfCD] in this population are scarce. In a population-based cohort study, we described the prevalence, natural history, and treatment of pfCD in patients with elderly-onset CD vs patients with paediatric-onset CD.

METHOD

All patients diagnosed with CD at or after the age of 60 between 1988 and 2006, were included [n = 372]. Logistic regression, Cox models, and a nested case-control method were used to identify factors associated with pfCD.

RESULTS

A total of 34 elderly patients [9% of the 372] had pfCD at diagnosis. After a median follow-up of 6 years (interquartile range [IQR]: 3; 10), 59 patients [16%] had pfCD; the same prevalence [16%] was observed in paediatric-onset patients. At last follow-up, anal incontinence was more frequent in elderly patients with pfCD than in elderly patients without pfCD [22% vs 4%, respectively; p < 10-4]. Rectal CD at diagnosis was associated with pfCD: hazard ratio (95% confidence interval [CI] = 2.8 [1.6-5.0]). Although 37% of the patients received immunosuppressants and 17% received anti-tumour necrosis factor agents, 24% [14 out of 59] had a definitive stoma at last follow-up.

CONCLUSION

During the first 6 years of disease, the prevalence of pfCD was similar in elderly and paediatric patients. Rectal involvement was associated with the appearance of pfCD in elderly-onset patients. Around a quarter of patients with elderly-onset CD will have a stoma. Our results suggest that treatment with biologics should be evaluated in these patients.

Cost-effectiveness analysis of stent type in endoscopic treatment of gastric leak after laparoscopic sleeve gastrectomy

Background

Gastric leak is the most feared surgical postoperative complication after sleeve gastrectomy. An endoscopic procedure is usually required to treat the leak. No data are available on the cost-effectiveness of different stent types in this procedure.

Methods

Between April 2005 and July 2016, patients with a confirmed gastric leak undergoing endoscopic treatment using a covered stent (CS) or double-pigtail stent (DPS) were included. The primary objective of the study was to assess overall costs of the stent types after primary sleeve gastrectomy. Secondary objectives were the cost-effectiveness of each stent type expressed as an incremental cost-effectiveness ratio (ICER); the incremental net benefit; the probability of efficiency, defined as the probability of being cost-effective at a threshold of €30 000, and identification of the key drivers of ICER derived from a multivariable analysis.

Results

One hundred and twelve patients were enrolled. The overall mean costs of gastric leak were €22 470; the mean(s.d.) cost was €24 916(12 212) in the CS arm and €20 024(3352) in the DPS arm (P = 0·018). DPS was more cost-effective than CS (ICER €4743 per endoscopic procedure avoided), with an incremental net benefit of €25 257 and a 27 per cent probability of efficiency. Key drivers of the ICER were the inpatient ward after diagnosis of gastric leak (surgery versus internal medicine), type of institution (private versus public) and duration of hospital stay per endoscopic procedure.

Conclusion

DPS for the treatment of gastric leak is more cost-effective than CS and should be proposed as the standard regimen whenever possible.

Dramatic Increase in Incidence of Ulcerative Colitis and Crohn's Disease (1988-2011): A Population-Based Study of French Adolescents

OBJECTIVES

Few data are available to describe the changes in incidence of pediatric-onset inflammatory bowel disease (IBD). The aim of this study was to describe changes in incidence and phenotypic presentation of pediatric-onset IBD in northern France during a 24-year period.

METHODS

Pediatric-onset IBD (<17 years) was issued from a population-based IBD study in France between 1988 and 2011. Age groups and digestive location were defined according to the Paris classification.

RESULTS

1,350 incident cases were recorded (8.3% of all IBD) including 990 Crohn's disease (CD), 326 ulcerative colitis (UC) and 34 IBD unclassified (IBDU). Median age at diagnosis was similar in CD (14.4 years (Q1=11.8-Q3=16.0)) and UC (14.0 years (11.0-16.0)) and did not change over time. There were significantly more males with CD (females/males=0.82) than UC (females/males=1.25) (P=0.0042). Median time between onset of symptoms and IBD diagnosis was consistently 3 months (1-6). Mean incidence was 4.4/10⁵ for IBD overall (3.2 for CD, 1.1 for UC and 0.1 for IBDU). From 1988-1990 to 2009-2011, a dramatic increase in incidences of both CD and UC were observed in adolescents (10-16 years): for CD from 4.2 to 9.5/10⁵ (+126%; P<0.001) and for UC, from 1.6 to 4.1/10⁵ (+156%; P<0.001). No modification in age or location at diagnosis was observed in either CD or UC.

CONCLUSIONS

In this population-based study, CD and UC incidences increased dramatically in adolescents across a 24-year span, suggesting that one or more strong environmental factors may predispose this population to IBD.

Extra-intestinal Manifestations at Diagnosis in Paediatric- and Elderly-onset Ulcerative Colitis are Associated With a More Severe Disease Outcome: A Population-based Study

BACKGROUND AND AIMS

Data on extra-intestinal manifestations [EIM] and their impact on the disease course of ulcerative colitis [UC] in population-based cohorts are scarce, particularly in paediatric- and elderly-onset UC patients. The aims of this population-based study were to assess: 1] the occurrence of EIM in paediatric- and elderly-onset UC; 2] the factors associated with EIM; and 3] their impact on long-term disease outcome.

METHODS

Paediatric-onset [< 17 years at diagnosis] and elderly-onset UC patients [> 60 years at diagnosis] from a French prospective population-based registry [EPIMAD] were included. Data on EIM and other clinical factors at diagnosis and at maximal follow-up were collected.

RESULTS

In all, 158 paediatric- and 470 elderly-onset patients were included [median age at diagnosis 14.5 and 68.8 years, median follow-up 11.2 and 6.2 years, respectively]. EIM occurred in 8.9% of childhood- and 3% of elderly-onset patients at diagnosis and in 16.7% and 2.2% of individuals during follow-up [p < 0.01], respectively. The most frequent EIM was joint involvement [15.8% of paediatric onset and 2.6% of elderly-onset]. Presence of EIM at diagnosis was associated with more severe disease course [need for immunosuppressants or biologic therapy or colectomy] in both paediatric- and elderly-onset UC (hazard ratio [HR] = 2.0, 95% confidence interval [CI]: 1.0-4.2; and HR = 2.8, 0.9-7.9, respectively). Extensive colitis was another independent risk factor in both age groups.

CONCLUSIONS

Elderly-onset UC patients had lower risk of EIM either at diagnosis or during follow-up than paediatric-onset individuals. EIM at diagnosis predicted more severe disease outcome, including need for immunosuppressive or biologic therapy or surgery, in both paediatric- and elderly-onset UC.

Role of 17 α Hydroxy Progesterone Caproate (17OHPC) in the Prevention of Preterm Labor

OBJECTIVE

To evaluate the role of 17 α hydroxyprogesterone caproate (17OHPC) in the prevention of preterm labor in high risk asymptomatic patients with a history of preterm delivery.

METHODS

The study included 96 patients with a singleton pregnancy and having a prior preterm birth. They were divided in 2 groups, group I (treatment group) included 46 asymptomatic patients who were given 17OHPC injections starting from 16-20 weeks till 36 weeks and group II (control group) included 50 patients who did not receive any treatment.

RESULTS

The incidence of preterm delivery was found to be 6.9 %. The median gestational age at delivery was 36 weeks in group I and 33 W5D in controls. 50 % cases in group I and 80 % of controls delivered prematurely in the group with a prior preterm birth between 20-28 weeks.

CONCLUSION

In patients who had a prior history of a preterm delivery the recurrence of a preterm birth was less in the treated group as compared to controls. The median gestational age at delivery was significantly higher in 17OHPC treated patients with history of earliest prior preterm delivery at 20-28 weeks.

[Hypersalivation - inauguration of the S2k Guideline (AWMF) in short form]

Hypersalivation describes a relatively excessive salivary flow, which wets the patient himself and his surroundings. It may result because of insufficient oro-motor function, dysphagia, decreased central control and coordination. This reduces social interaction chances and burdens daily care. Multidisciplinary diagnostic and treatment evaluation is recommended already at early stage and focus on dysphagia, and saliva aspiration. Therefore, a multidisciplinary S2k guideline was developed. Diagnostic tools such as fiberoptic endoscopic evaluation of swallowing and videofluoroscopic swallowing studies generate important data on therapy selection and control. Especially traumatic and oncologic cases profit from swallowing therapy programmes in order to activate compensation mechanisms. In children with hypotonic oral muscles, oralstimulation plates can induce a relevant symptom release because of the improved lip closure. In acute hypersalivation, the pharmacologic treatment with glycopyrrolate and scopolamine in various applications is useful but its value in long-term usage critical. The injection of botulinum toxin into the salivary glands has shown safe and effective results with long lasting saliva reduction. Surgical treatment should be reserved for isolated cases. External radiation is judged as ultima ratio. Therapy effects and symptom severity has to be followed, especially in neurodegenerative cases. The resulting xerostomia should be critically evaluated by the responsible physician regarding oral and dental hygiene.

Activation of the EGFR/ERK pathway in high-grade mucoepidermoid carcinomas of the salivary glands

Background:

Mucoepidermoid carcinoma (MEC) shows differences in biological behaviour depending mainly on its histological grade. High-grade tumours usually have an aggressive biological course and they require additional oncological treatment after surgery.

Methods:

In a series of 43 MECs of the salivary glands, we studied the epidermal growth factor receptor (EGFR) gene by using dual-colour chromogenic in situ hybridisation (CISH). Moreover, we assessed the protein expressions of the EGFR and the activated extracellular signal-regulated kinases (pERK1/2) by using immunohistochemistry. These results were correlated with the histological grade of the tumours and the outcome of the patients.

Results:

The CISH study demonstrated a high-EGFR gene copy number, with balanced chromosome 7 polysomy, in 8 out of 11 high-grade MECs (72.7%), whereas 27 low-grade and 15 intermediate-grade tumours had a normal EGFR gene copy number (P<0.001). The EGFR gene gains correlated with disease-free interval (P=0.003) and overall survival of the patients (P=0.019). The EGFR protein expression had a significant correlation with the histological grade of the tumours but not with the outcome of the patients. The pERK1/2 expression correlated with histological grade of tumours (P<0.001), disease-free interval (P=0.004) and overall survival (P=0.001).

Conclusions:

The EGFR/ERK pathway is activated in high-grade MECs with aggressive behaviour. Patients with these tumours who require oncological treatment in addition to surgery could benefit from EGFR and mitogen-activated protein kinase pathway inhibitors.

Management of biliary ascariasis in children living in an endemic area

BACKGROUND

One quarter of the world's population is known to be infected with ascariasis. It is endemic in various parts of the Indian subcontinent with a high incidence in the Kashmir valley. Although intestinal obstruction is the commonest complication of ascariasis in children, biliary ascariasis remains the second most common complication. We aimed to study the various types of clinical presentations, complications and different diagnostic tools and to assess various options for the management of biliary ascariasis.

MATERIALS AND METHODS

Sixty-one cases of ultrasound documented hepatobiliary ascariasis were studied prospectively over a period of 3 years from Jan 2003 to Dec 2005 at the Sheri-Kashmir Institute of Medical Sciences in Srinagar, Kashmir. All patients were children aged between 3 and 14 years. All patients were admitted to hospital and put on intravenous fluids, nothing per os until patients were symptom-free, broadspectrum antibiotics and antispasmodics. All patients received antihelminthics in the form of albendazole 400 mg as soon as patients could accept oral medication. Conservative management was continued until the patients were symptom-free. Endoscopic extraction was deferred until 3 weeks later except in patients with pyogenic cholangitis where urgent endoscopic intervention was carried out. Surgical intervention was carried out if both conservative management and endoscopic extraction failed or ERCP could not be performed for technical reasons or complications developed.

RESULTS

The most common presentation was upper abdominal pain in 36 (59%) patients followed by vomiting of worms in 20 (33.3%) cases. Complications included cholangitis in 8 (13.1%), obstructive jaundice in 7 (11.4%), acute pancreatitis in 1 (1.6%) and hepatic abscess in 1 (1.6%) patient. Spontaneous passage of worms from the biliary ducts was observed in 44 (72.1%) patients. ERCP was successful in 8 (13.1%) patients, and 9 (14.7%) patients needed surgical intervention.

CONCLUSION

In endemic countries, ascariasis should be suspected in patients with biliary disease. Most patients respond to conservative management although a few may need surgical intervention. Although this disease is prevalent in developing countries, because of increased travel and migration, clinicians elsewhere should be aware of the problems associated with ascariasis.

Feasibility of combining humanized anti-epidermal growth factor receptor monoclonal antibody h-R3 (nimotuzumab) with chemotherapy-A study of toxicity profile and tolerance

14151

Background. Anti-EGFR antibodies have been approved in combination with radiotherapy for the treatment of head and neck squamous cell carcinoma(SCCHN) and being tried in glioblastoma multiforme(GBM). The overall toxicity profile is tolerable. There is no data available on Humanized Anti EGFR antibody in combination with chemotherapeutic agents. Nimotuzumab, the humanized MAb derived from ior EGFR/R3, is a genetically engineered IgG1, with high affinity and specificity to EGFR. This study was undertaken to record the immediate and early toxicity of combining Nimotuzumab with various chemotherapeutic agents. Methods. Patients with SCCHN and GBM, scheduled to receive chemotherapy alone were additionally given 400mg of Nimotuzumab, every three weeks. Two patients with GBM received weekly Nimotuzumab 200 mg along with radiation and chemotherapy. Overall 19 events have been analyzed. The chemoschedules used in combination with Nimotuzumab included-Docetaxel, Carboplatin and Capecitabine in patients with SCCHN and Temozolamide/ Procarbazine in GBM. Antibody infusion was always preceded by antihistaminics and dexamethasone. Results.The combination of Nimotuzumab with chemotherapy was well tolerated. There were no acute infusion related events. No febrile, allergic or anaphylactic episodes were seen. Cutaneous rash classical of other EGFR blockers was not recorded. Two episodes of grade 3 diarrhea, and four events of asthenia were seen. Dryness of the mouth was a complaint in SCCHN patients. None of the patients showed neurological or cardiovascular adverse events. Hematological and biochemical derangements were not observed. Conclusion. Nimotuzumab can safely be combined with various chemotherapeutic agents .There is no unacceptable toxicity associated with combination of chemotherapy and humanized anti-EGFR monoclonal antibody. New schedules combining Nimotuzumab and chemotherapy can be safely explored.

No significant financial relationships to disclose.

Tryptophan hydroxylase-2 gene polymorphisms in rhesus monkeys: association with hypothalamic-pituitary-adrenal axis function and in vitro gene expression

Tryptophan hydroxylase-2 (TPH2) is a newly identified second form of TPH responsible for serotonin synthesis in the brain and has been increasingly implicated as a contributor to the etiology of various psychiatric disorders. In this study, we have identified the constellation of polymorphisms in rhesus monkey TPH2 and investigated genotype/phenotype association as well as gene expression effects of specific polymorphisms. Genomic DNA was obtained from 247 rhesus monkeys, among which 24 had been previously examined for plasma cortisol level, dexamethasone suppression, and combined dexmethasone/ACTH challenge. Polymorphisms in all exons, splicing junctions and approximately 2 kb of the 5'-flanking region (5'-FR) of TPH2 were identified by sequencing. We identified 17 single nucleotide polymorphisms (SNPs) including two that are predictive of amino-acid change (25Pro>His and 75Gly>Ser, respectively), two mononucleotide repeats, one dinucleotide repeat, and one 159-bp insertion polymorphism. The 3'-UTR polymorphisms were significantly associated with hypothalamic-pituitary-adrenal (HPA) axis activity, especially 2051A>C, which was strikingly correlated with plasma cortisol level in the morning only (F=10.203, P=0.001). Luciferase reporter gene assays showed that the 3'-UTR polymorphisms and haplotypes had a profound effect on in vitro gene expression. Accordingly, these investigations revealed that polymorphisms in 3'-UTR of rhesus monkey TPH2 modulate HPA axis function, presumably by affecting levels of TPH2 expression.

Chlamydia trachomatis infection & female infertility

BACKGROUND & OBJECTIVES

Chlamydia trachomatis is a well recognized sexually transmitted pathogen. Besides its potential to produce genital tract infection, C. trachomatis is increasingly being associated with long-term complications like infertility. The present study was undertaken to assess the role of C. trachomatis in female infertility as such data are lacking.

METHODS

Women of primary and secondary infertility (n=110) and 30 healthy term pregnant women as control group were enrolled in the study. Detailed clinical history of each patient was recorded. Hysterosalpingography was performed in all patients. Endocervical swabs were collected for culture on cycloheximide treated McCoy cell line and for antigen detection by ELISA.

RESULTS

C. trachomatis was detected in 31 (28.1%) of the 110 infertile women while one (3.3%) in control group was positive for C. trachomatis (P<0.01). Cell culture alone identified 25 (22.72%) patients suffering from chlamydial infection while C. trachomatis antigen was detected by ELISA in 18 (16.37%) patients. The one control case was positive for Chlamydia antigen by ELISA and not by cell culture. Chlamydial positivity was seen in 20 of the 74 (27%) women with primary infertility and in 11 of the 36 (30.6%) with secondary infertility. Of the 58 asymptomatic women, 21(36.2%) had chlamydia infection while among the 52 symptomatic cases 10 (19.2%) were infected; 38 per cent women with chlamydial infection also had tubal occlusion.

INTERPRETATION & CONCLUSION

A significantly high rate of C. trachomatis infection was found in infertile women and more so in asymptomatic females and in secondary infertility cases. Lack of symptoms make clinical diagnosis of chlamydial infection difficult. Screening of infertile women for C. trachomatis is therefore recommended so far early therapeutic interventions.

Normal-pressure hydrocephalus

This article presents a brief history of normal-pressure hydrocephalus, its clinical presentation, and different theories on its pathophysiology. The different diagnostic tests, differential diagnosis, and its treatment are presented.

Analysis of a 1-megabase deletion in 15q22-q23 in an autistic patient: identification of candidate genes for autism and of homologous DNA segments in 15q22-q23 and 15q11-q13

We have identified a one megabase deletion in the 15q22-15q23 region in a patient with autism, developmental delay, and mild dysmorphism. Genes that map within the deletion region and genes that are interrupted or rearranged at the deletion breakpoints are candidate genes for autism. Fluroescence in situ hybridization studies in this patient revealed that part or all of the PML gene is absent from one chromosome 15 and a BAC clone containing the D15S124 gene locus hybridizes to only one chromosome 15. BAC clones containing the PTPN9, and SLP-1[hUNC24] genes showed markedly reduced hybridization in the 15q22-q23 region on one chromosome 15 in the patient. These BACs also hybridize to the 15q11-q13 region in close proximity to SNRPN and HERC2, and in this region there is equal intensity of signal on the normal and on the deleted chromosome. There are previous reports of deletions and duplications of the 15q11-q13 region in patients with autism. Our patient represents the first report of a 15q22-q23 deletion. Hybridization of the PTPN9 and Slp-1 Bac clones to the 15q11-q13 and the 15q22-q23 regions of chromosome 15 may be due to the presence of PTPN9 or SLP-1 gene sequences or to the presence of other gene sequences or to non-coding homologous DNA sequences. The PTPN9 gene encodes a non-receptor protein tyrosine phosphatase. The Slp-1 [hUNC24] gene is expressed mainly in the brain. Am. J. Med. Genet. (Neuropsychiatr. Genet.) 96:765-770, 2000.

A radiation hybrid map of human chromosome 5 with integration of cytogenetic, genetic, and transcript maps

One of the major goals of the human genome project is to establish a physical map of each human chromosome with a density of sequence-tagged site (STS) markers exceeding one every 100 kb. We report here the generation of a human chromosome 5-specific radiation hybrid (RH) map that includes 556 markers. Of these markers, 132 loci are ordered with a maximum likelihood ratio of >1000:1 compared with the next most likely order. An additional 113 loci were ordered relative to these backbone markers with a maximum likelihood ratio of >10:1 but <1000:1. Together, these 245 loci form an ordered framework map for the chromosome. Using this framework, >300 more markers were localized based on two-point analysis with the ordered set. On average, there are 50 markers in common with the RH map presented here and other chromosome 5 maps included in the current whole genome cytogenetic, genetic, and physical maps. The accuracy of all the maps is evident in that there are no more than two discrepancies between any one of them and these data. All of the maps encompassing chromosome 5 complement each other providing excellent STS coverage with >2200 loci combined. The chromosome 5-specific RH map contains 20% of these independent loci. In addition, our RH map contains STSs derived from clones suitable for fluorescent in situ hybridization, allowing alignment to the cytogenetic map. Together, these maps will assist in the assembly of sequence-ready contigs and will aid in the identification of disease loci on chromosome 5 by positional cloning and positional candidate approaches.

Ultrasound in the assessment of cranial bone thickness

Preoperative knowledge of skull thickness before harvesting cranial bone grafts would be ideal to help minimize intracranial complications. Previous research has demonstrated regional variations in calvaria; however, accurate preoperative and intraoperative methods of skull thickness measurement are not available. The aim of this research represents the first attempt to examine the reliability of ultrasound to determine cranial bone thickness. Four previously studied calvarial sites were marked in 10 adult male cadaveric skulls. The individual points were insonified using an A-mode ultrasonic transducer operating in pulse-echo mode. The times of flight of the waves propagating in the bone samples were compared with caliper measurements. The mean difference in cranial bone thickness was 0.16 mm, with a standard deviation of 0.09 mm. Student's t-test failed to reveal any statistically significant differences between caliper and ultrasonic measurements (p = 0.569) and Pearson's correlation coefficient supported an extremely strong and positive relationship between the two modalities (r > 0.992). Multiple linear regression models predicted that calvarial thickness could be accurately predicted by ultrasound without consideration of cadaveric specimen or sampling point location (R2 = 0.988). The convergent values between ultrasonic and caliper measurements suggest that this modality can accurately and reliably determine skull thickness. A-mode ultrasound can have significant implications in guiding the harvest of in situ split cranial bone grafts, the placement of osseointegrated implants, skull anthropometrics, and related craniomaxillofacial applications.

Outcome analysis of the modified Mathieu hypospadias repair: comparison of stented and unstented repairs

PURPOSE

We compared surgical outcomes of stented and unstented Mathieu repairs in boys with primary distal hypospadias, and evaluated the efficacy and safety of caudal analgesia relative to other forms of analgesia (penile block and epidural analgesia).

MATERIALS AND METHODS

We retrospectively reviewed the records of 336 consecutive boys who underwent the modified Mathieu repair for primary distal hypospadias. A urethral stent was placed in 114 patients and nonstented repair was performed in 222. Adjunct caudal analgesia was given in 136 cases, a penile block in 158 and continuous epidural analgesia in 42.

RESULTS

None of the unstented cases had urinary retention. Analysis of surgical outcomes revealed no difference in fistula formation between patients with and without stents (2.63 versus 2.70%, respectively, p > 0.999). Overall complication rates in the stented and unstented groups were not significantly different (2.63 versus 3.60%, respectively, p = 0.756). The fistula rate in patients who received adjunct caudal analgesia was no different than in those who received other forms of adjunct analgesia (2.21 versus 3.0%, respectively, p > 0.999).

CONCLUSIONS

These data suggest that successful Mathieu hypospadias repair is independent of the use of a stent. Caudal analgesia, a penile block and epidural analgesia provided effective postoperative pain control with no difference in complication rates. To our knowledge our report represents the largest observational study reported to date comparing stented and unstented repairs. However, because of the small number of complications in each group, a much larger study is required to determine statistically significant differences among these groups.

The attractiveness of a liquid bait to white-tailed deer in the Central Appalachian Mountains, Virginia, USA

We determined the attractiveness of a bait composed of apple juice, apple odor, water, glycerin, and salt to captive white-tailed deer (Odocoileus virginianus) at the National Zoological Park Conservation and Research Center, Front Royal, Virginia, USA. Thirty-nine deer (three adult males, 20 adult females, eight male fawns, eight female fawns) were presented with the bait formulation in a 22-ha enclosure during January, February, and May 1994. Daily consumption, and the frequency of visits to bait dispensers and the frequency of drinking bouts were recorded. Overall consumption was greatest in May (P < 0.001). While adults and fawns visited bait dispensers equally often, fawns drank more frequently (P < 0.001).

The human and mouse receptors for hyaluronan-mediated motility, RHAMM, genes (HMMR) map to human chromosome 5q33.2-qter and mouse chromosome 11

The gene for the receptor for hyaluronan-mediated motility, RHAMM (designated hyaluronan-mediated motility receptor, HMMR (human) and Hmmr (mouse), for mapping purposes), was localized to human chromosome 5q33.2-qter by somatic cell and radiation hybrid analyses. Investigation of two interspecific backcrosses localized the mouse RHAMM (Hmmr) locus 18 cM from the centromere of mouse chromosome 11 within a region of synteny homology with human chromosome 5q23-q35 genes. The map position of the human RHAMM gene places it in a region comparatively rich in disease-associated genes, including those for low-frequency hearing loss, dominant limb-girdle muscular dystrophy, diastrophic dysplasia, Treacher Collins syndrome, and myeloid disorders associated with the 5q- syndrome. The RHAMM gene location and its ability to transform cells when overexpressed implicate RHAMM as a possible candidate gene in the pathogenesis of the recently described t(5;14)(q33-q34;q11) acute lymphoblastic leukemias.

Grafting of cultured uroepithelium and bladder mucosa into de-epithelialized segments of colon in rabbits

Urinary tract reconstruction using bowel can result in acid-base and electrolyte abnormalities. We tested the feasibility of grafting bladder mucosa and urothelial cells grown on a biodegradable polyglactin 910 scaffold onto de-epithelialized segments of bowel in the rabbit. A segment of de-epithelialized colon was either grafted with cultured urothelium on a collagen mesh scaffold (12 rabbits) or with free bladder mucosa (11 rabbits). In 10 rabbits that served as a control group another segment of bowel was isolated and de-epithelialized. No urothelial or bowel epithelial growth was present 4 weeks later in 10 of the isolated de-epithelialized colonic segments grafted with the cultured urothelium. In 2 segments a minute focus of epithelium staining positively for anticytokeratin antibodies AE1 and AE3 was seen but this could not be histologically differentiated as either urothelium or native colonic epithelium. All 7 surviving animals that underwent a bladder mucosal graft had viable urothelium at sacrifice 30 days postoperatively. In 2 of the 7 rabbits microscopic nests of colonic epithelium were also found underneath the urothelial layer. Of the 7 internal controls 6 had no evidence of bowel epithelial regrowth 4 weeks after de-epithelialization. This study demonstrated that a confluent layer of urothelial cells could be grown in culture using a scaffold of biodegradable mesh and rat tail collagen. We also showed that bladder mucosal grafts can be grown on de-epithelialized bowel segments. We were unable to graft successfully cultured urothelial cells onto a de-epithelialized bowel segment. Further improvement in understanding the role of the submucosal matrix in cell growth may lead to future success in covering large segments of de-epithelialized bowel with autologous urothelium.

Use of biodegradable mesh as a transport for a cultured uroepithelial graft: an improved method using collagen gel

OBJECTIVES

To create an improved delivery vehicle for cultured uroepithelial cells using biodegradable mesh and collagen gel.

METHODS

Twenty uroepithelial grafts were prepared by seeding cultured urothelial cells onto previously prepared collagen gel-polyglactin mesh. As a control, cells were seeded onto 20 plain polyglactin mesh (without gel) squares in the same fashion.

RESULTS

The presence of urothelial cells was confirmed in all cultures by immunohistochemistry testing with anticytokeratin antibody. After 5 to 7 days, a confluent monolayer of cells covered 90% to 100% of the surface of all 20 collagen gel-mesh grafts. A confluent monolayer of cells did not form on any control graft (plain mesh). After 3 weeks, the cells had formed a sporadic, multiple cell layer confluence over 10% to 50% of the control graft surface; however, the mesh became friable and fell apart.

CONCLUSIONS

By combining collagen gel with a biodegradable mesh scaffold, we created a surgically implantable cultured uroepithelial graft. The production of the collagen gel-mesh vehicle is simple and inexpensive. With this technique, the use of cultured urothelium for reconstructive urologic surgery can be investigated in greater detail.

Psoas abscess following intravesical bacillus Calmette-Guerin for bladder cancer: a case report

An 87-year-old man with an abdominal aortic aneurysm received intravesical bacillus Calmette-Guerin therapy for transitional cell carcinoma of the bladder. He presented 9 months later with a psoas abscess that mimicked a contained retroperitoneal abdominal aortic aneurysm rupture. The abscess cultures yielded Mycobacterium bovis. Recent transurethral resection and high voiding pressures after instillations of bacillus Calmette-Guerin may have led to distant dissemination of the drug.

Verapamil as a hypotensive agent under general anaesthesia

Thirty-six adult female patients undergoing abdominal hysterectomy under general anaesthesia were evaluated for the haemodynamic effects of IV verapamil in bolus dose of either 50 micrograms/kg (group A), 60 micrograms/kg (group B) or 75 micrograms/kg (group C). The result showed a dose dependent fall in the mean arterial pressure and increase in the P-R interval. The fall in heart rate was marginally more in group A and B as compared to group C.

Impaired neutrophil function in patients with AIDS or AIDS-related complex: a comprehensive evaluation

We measured the neutrophil function of 6 patients with AIDS and Kaposi's sarcoma (KS); 22 patients with AIDS-related complex (ARC); and 28 healthy, heterosexual controls. Neutrophils from patients with ARC showed significantly less chemotaxis (P less than or equal to .025) than did those from patients with AIDS and KS or from controls. Serum from patients with AIDS and KS or with ARC significantly (P less than or equal to .05) inhibited chemotaxis of neutrophils from controls; heat treatment of the serum abolished this inhibitory effect. Bacterial killing by neutrophils from patients with AIDS and KS or with ARC was also significantly (P less than or equal to .05) less than for neutrophils from controls, as was neutrophil phagocytosis binding of Candida albicans (P less than or equal to .05). Expression of OKM1 antigen was increased in the patients studied. Enzyme degranulation, adherence, and aggregation were also examined. The defects found in neutrophil function are selective and may be important in the increased susceptibility of patients with human immunodeficiency virus infection to bacterial and fungal infections.

Visualization of acute hepatic necrosis with a bone imaging agent

A case of massive hepatic necrosis has been found to have intense, diffuse accumulation of Tc-99m HMDP in the liver. A review of three similar cases revealed that diffuse intense uptake of bone-scanning agents is a grave prognostic sign.

Congestive heart failure in valvular heart disease in pregnancies with and without valvular prostheses and anticoagulant therapy

The course and complications of pregnancies in 46 patients with valvular disease and congestive heart failure with or without valve prostheses are described. In group I consisting of 33 women without valve replacement and without anticoagulant therapy one thromboembolic event was seen, emergency closed or open heart surgery was necessary five times. One still-birth happened after open heart surgery. In group II, of 13 patients with prosthetic valve replacement and anticoagulation therapy there was no thromboembolism, but 2 spontaneous abortions and 2 premature stillbirths; 2 fetuses died after delivery, 3 had congenital abnormalities. Pregnancies in patients with valvular disease and congestive heart failure can be sustained relatively safely for the mother, even if emergency heart surgery becomes necessary. Heart surgery and anticoagulation treatment carry a higher risk for the fetus. Uterine blood loss is not increased, if coumadine treatment is switched to heparin administration shortly before delivery.