Rhino-orbito-cerebral mucormycosis: patient characteristics in pre-COVID-19 and COVID-19 period

Background: Rhino-orbito-cerebral-mucormycosis (ROCM), a rare and potentially fatal disease was seen in increasing numbers during the COVID-19 pandemic. This study describes and compares the patient characteristics and outcomes in COVID-19 associated mucormycosis (CAM) and non-COVID-19 mucormycosis (non-CAM). Methodology: CAM patients (24 cases) were recruited from the COVID-19 period and non-CAM (24 controls) from the pre-COVID-19 period. Clinical data of the CAM group was collected retrospectively with 3 month outcomes prospectively. The non-CAM group data was collected retrospectively. Patient characteristics were compared and risk factors for mortality in ROCM were assessed. Results: Orbital symptoms [altered vision, restricted eye movements, ptosis] and intracranial involvement were higher in CAM patients on presentation. Similarly, the radiological involvement of orbit (orbital apex, superior orbital fissure) and intracranial cavity (intracranial thrombosis, cavernous sinus) was also higher in CAM patients. Newly detected diabetes was found only in CAM patients (29.2%). Although univariate analysis suggested an increased mortality risk in ROCM patients with orbital involvement, the multivariate analysis showed no increased risk with any of the parameters assessed, including COVID-19 positivity. Conclusions: Compared to the non-CAM, the disease presentation was severe in CAM with higher frequency of orbital and intracranial involvement. However, with early detection and treatment, the short term survival was comparable in both groups.

Good survival rate, moderate overall and good respirator quality of life, near normal pulmonary functions, and good return to work despite catastrophic economic costs 6 months following recovery from Acute Respiratory Distress Syndrome

Introduction:

Long-term quality of life, return to work, economic consequences following Acute Respiratory Distress Syndrome (ARDS) are not well described in India. This study was aimed to address the question.

Methods:

A prospective cohort study of 109 ARDS survivors were followed up for a minimum of 6 months following discharge. Quality of life was assessed using the SF-36 questionnaire. Respiratory quality was assessed using the St Georges Respiratory Questionnaire. Time to return to work was documented. Costs-direct medical, as well as indirect were documented up to 6 months.

Results:

At 6 months, 6/109 (5.5%) had expired. Low energy/vitality and general heath were noted in the SF-36 scores at 6 months; overall a moderate quality of life. Pulmonary function tests had mostly normalized. Six-min walk distance was 77% of predicted. Respiratory quality of life was good. It took at the median of 111 days to go back Interquartile range (55–193.5) to work with 88% of previously employed going back to work. There were no significant differences in the severity of ARDS and any of these outcomes at 6 months. The average total cost from the societal perspective was 231,450 (standard deviation 146,430 -, 387,300). There was a significant difference between the 3-ARDS severity groups and costs (P < 0.01). There were no independent predictors of return to work.

Conclusion:

ARDS survivors have low 6-month mortality. Pulmonary physiology and exercise capacity was mostly normal. Overall, quality of life is average was moderate, while respiratory quality of life was good. Return to work was excellent, while cost of care falls under a catastrophic heath expense.

Trainee doctors in medicine prefer case-based learning compared to didactic teaching

BACKGROUND

Sustaining interest and promoting deep learning is a challenge in any teaching method. The purpose of the study is to find the perception of trainee doctors in Internal Medicine and teaching faculty on the usefulness of case-based learning (CBL) and to compare assessment knowledge outcome with didactic seminars.

METHODS AND MATERIALS

We developed and conducted a CBL teaching program on eight topics in infectious diseases. First group had CBL and second group had didactic seminars. In step 1, a clinical case was introduced in stages. Learning objectives were formulated and topics were divided among the trainees. At step 2, trainees shared what they had learnt from self-directed learning. Faculty summarized the case and learning points. In the seminar group, trainees made presentations on the given topics. Trainees who had CBL underwent a questionnaire survey. Multiple choice questions-based test was administered for both the groups.

RESULTS

The trainee doctors and staff overwhelmingly found CBL to be more interesting, stimulating, and useful compared to didactic seminars. There was no statistical difference in the test scores.

CONCLUSIONS

CBL is a useful and interesting method of learning and should be employed more often in teaching for trainee doctors.

Lupus cystitis: unusual cause of renal failure in systemic lupus erythematosus

A 42-year-old woman presented with chronic fever, abdominal pain, intermittent loose stools and dysuria for 3 months. She had recently developed acute dyspnoea with acute kidney injury. She was found to have a contracted, thick-walled bladder with bilateral hydroureteronephrosis. She underwent bilateral percutaneous nephrostomies, following which her renal function recovered. She satisfied the clinical and immunological features of the Systemic Lupus International Collaborating Clinics criteria for systemic lupus erythematosus (SLE). She was initiated on immunosuppression. Lupus cystitis with a contracted bladder is an uncommon presentation of SLE.

Abstract P3-01-11: A novel six-parameter assay for comprehensive phenotyping of circulating tumor cells

Background. The presence and number of circulating tumor cells (CTCs) are prognostic for breast cancer treatment outcome. Direct imaging assays traditionally employ four markers to identify canonical epithelial CTCs: nucleus, exclusion (CD45), and inclusion (EpCAM and cytokeratin). There is intense interest in the ability to phenotype CTCs in order to provide a noninvasive means by which to predict treatment benefit from endocrine therapy and/or HER2-directed therapy in breast cancer. To address this, a 6-parameter assay for detection of ER and HER2 expression on CTCs was developed. We applied this assay to four well characterized breast cancer cell lines representative of various ER and HER2 phenotypes. Methods. BT474, MCF-7, SKBR3, or MDA-MB-231 cells were spiked into peripheral blood from healthy donors and processed using the AccuCyte® sample preparation system; nucleated cells, including CTCs, are captured onto glass slides (8 slides per 7.5 mL blood sample) for subsequent immunofluorescent staining. Slides were stained using the combined epithelial marker and ER/HER2 CTC assay and then analyzed with the CyteFinder® imaging system. CTCs were identified as nucleated cells with positive EpCAM and/or cytokeratin staining, and negative CD45 staining. ER and HER2 expression were assessed as present or absent. Results. All cell lines expressed both cytokeratin and EpCAM, except for MDA-MB-231 which was EpCAM-negative. The ER / HER2 expression patterns observed were consistent with reported phenotype: BT474 (+/+), MCF-7 (+/–), SKBR3 (–/+), and MDA-MB-231 (–/–). Conclusions. Identification of epithelial CTCs and phenotypic characterization of ER and HER2 status are feasible in a combined assay applied to a single blood sample. This approach has implications for efficiency and cost effectiveness, which are of particular importance given the interest in longitudinal testing. Assay evaluation is currently underway using blood samples from breast cancer patients with known receptor status, treatment history, and clinical outcomes. Results will be available for presentation at the meeting.

Citation Format: Liu MC, Sun Y, Ramirez A, Campton D, George T, Haselkorn KE, Clein A, Gadi V, Sabath D, Kaldjian E. A novel six-parameter assay for comprehensive phenotyping of circulating tumor cells [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-01-11.

Single-fabrication-step Ge nanosphere/SiO2/SiGe heterostructures: a key enabler for realizing Ge MOS devices

We report channel and strain engineering of self-organized, gate-stacking heterostructures comprising Ge-nanosphere gate/SiO₂/SiGe-channels. An exquisitely-controlled dynamic balance between the concentrations of oxygen, Si, and Ge interstitials was effectively exploited to simultaneously create these heterostructures in a single oxidation step. Process-controlled tunability of the channel length (5-95 nm diameters for the Ge-nanospheres), gate oxide thickness (2.5-4.8 nm), as well as crystal orientation, chemical composition and strain engineering of the SiGe-channel was achieved. Single-crystalline (100) Si_1-x Ge _x shells with Ge content as high as x = 0.85 and with a compressive strain of 3%, as well as (110) Si_1-x Ge _x shells with Ge content of x = 0.35 and corresponding compressive strain of 1.5% were achieved. For each crystal orientation, our high Ge-content, highly-stressed SiGe shells feature a high degree of crystallinity and thus, provide a core 'building block' required for the fabrication of Ge-based MOS devices.

The pivotal role of oxygen interstitials in the dynamics of growth and movement of germanium nanocrystallites

An unusual “symbiotic” chain reaction is activated by oxygen interstitials acting in concert with Ge and Si interstitials, inducing the coalescence of sparsely-distributed Ge nanocrystallites and their autonomous migration within SiO₂/Si₃N₄layers.

Electron Beam Pumped MQW InGaN/GaN Laser

E-beam pumped lasers are attractive for Laser Cathode Ray Tubes (LCRT) in projection displays and a variety of applications typically associated with optically pumped lasers. For the first time an InGaN/GaN multiple quantum well (MQW) in-plane laser pumped by surface normal pulse and scanning electron beams was demonstrated. Pumping at room temperature (RT) and 80 K showed peak stimulated emission wavelengths of 402 and 409 nm with a full width half maximum (FWHM) of 0.6 nm and 1.2 nm, respectively. The threshold electron beam current densities have been estimated as 60 A/cm2 for 35 keV electron energy at 80 K using scanning e-beam pumping and 200-300 A/cm2 at RT using pulsed e-beam pumping with a maximum electron energy of 150 keV. At 80 K, light output of 150 mW was measured out of one facet at an e-beam current of 1.7 mA.

Severe methemoglobinemia due to insecticide poisoning

Methemoglobinemia is an altered state of hemoglobin resulting in impaired oxygen delivery to the tissues. Deliberate ingestion of certain insecticides and pesticides may result in this condition. We report a case of severe methemoglobinemia after deliberate ingestion of an insecticide marketed to be safe and containing only biological extracts and fillers. Methemoglobinemia should be suspected with low oxygen saturation on pulse oxymetry and the presence of chocolate colored blood. The methemoglobin level of 91% in our patient is the highest level reported among methemoglobinemia survivors.

Scrub typhus meningitis in South India--a retrospective study

Background

Scrub typhus is prevalent in India although definite statistics are not available. There has been only one study on scrub typhus meningitis 20 years ago. Most reports of meningitis/meningoencephalitis in scrub typhus are case reports

Methods

A retrospective study done in Pondicherry to extract cases of scrub typhus admitted to hospital between February 2011 and January 2012. Diagnosis was by a combination of any one of the following in a patient with an acute febrile illness- a positive scrub IgM ELISA, Weil-Felix test, and an eschar. Lumbar puncture was performed in patients with headache, nuchal rigidity, altered sensorium or cranial nerve deficits.

Results

Sixty five cases of scrub typhus were found, and 17 (17/65) had meningitis. There were 33 males and 32 females. Thirteen had an eschar. Median cerebrospinal fluid (CSF) cell count, lymphocyte percentage, CSF protein, CSF glucose/blood glucose, CSF ADA were 54 cells/µL, 98%, 88 mg/dL, 0.622 and 3.5 U/mL respectively. Computed tomography was normal in patients with altered sensorium and cranial nerve deficits. Patients with meningitis had lesser respiratory symptoms and signs and higher urea levels. All patients had received doxycycline except one who additionally received chloramphenicol.

Conclusion

Meningitis in scrub typhus is mild with quick and complete recovery. Clinical features and CSF findings can mimic tuberculous meningitis, except for ADA levels. In the Indian context where both scrub typhus and tuberculosis are endemic, ADA and scrub IgM may be helpful in identifying patients with scrub meningitis and in avoiding prolonged empirical antituberculous therapy in cases of lymphocytic meningitis.

Pancreatitis and MODS Due to Scrub Typhus and Dengue Co-Infection

We report a 40 year old woman admitted with an acute abdomen. Investigations revealed pancreatitis, bilateral pleural effusion, renal failure, disseminated intravascular coagulation, and scrub IgM ELISA and dengue NS1 positivity. She improved with azithromycin and appropriate pain and fluid management. She also developed central venous catheter-related MRSA sepsis that was managed in the hospital.

Medullary carcinoma of the breast: ten year clinical experience of the Kuwait cancer control centre

BACKGROUND

Medullary carcinomas of the breast account for fewer than 7% of all invasive breast cancers. Some investigators include medullary carcinomas in the favourable histologic subtype, despite its aggressive histologic appearance. However, others fail to confirm its favourable prognosis.

METHODS

This was a retrospective analysis of sixty-one (61) cases of breast cancer cases diagnosed with Medullary Carcinoma, presenting to the Kuwait Cancer Control Center between 1995 and 2005.

RESULTS

Median survival time was 122 months and the seven-year disease free survival was 82%. Overall survival rate was not assessed as no cases died during the study period. No cases were metastatic from the start and only eight cases developed metastases, local recurrence or contralateral breast primary. 68.8% of the cases were Stage I or IIA (i.e. no lymph node affection).

CONCLUSION

There is no overt favourable prognosis of medullary carcinoma when compared to invasive ductal carcinoma. Prognosis is more related to stage than histologic subtyping. The majority of cases were negative estrogen and progesterone receptor status and node negative.

Prediction of lymph node metastases by preoperative nuclear morphometry in oral squamous cell carcinoma: a comparative image analysis study

CONTEXT

Prediction of metastases of oral squamous cell carcinoma (OSCC) using incisional biopsy.

AIMS

To assess the efficacy of nuclear morphometry in predicting the nodal metastases of OSCC and to compare manual and computer-based image analyses.

MATERIALS AND METHODS

Sixteen cases of moderately differentiated squamous cell carcinoma (8 with metastasized lymph nodes and 8 node-negative cases) were examined using manual and computer-based image analyses. Nuclear area, perimeter, circular rate, larger to shorter axis ratio, and coefficient of variance of nuclear area (NACV) were calculated from 100 nuclei of the processed incisional biopsy specimen.

STATISTICAL ANALYSIS

The parameters were compared between the node positive and negative cases using Student's t test and with the level of lymph node involved using ANOVA test and Bonferroni's post hoc assessment. Manual and computer-based image analyses were compared by Spearman's correlation.

RESULTS

A significant variation between the node positive and negative groups was observed with respect to circular rate (P = 0.031) and NACV (P = 0.036). The nuclear area (P = 0.009), perimeter (P = 0.0001), circularity (P = 0.045), and larger to shorter diameter ratio (LS ratio) (P =0.02) were significantly different in the levels of the nodes involved. There was good a correlation between manual and computer-based analyses (Spearman's rho, 0.616-0.824) in nuclear size parameters and the circular rate had a negative correlation (-0.118, P = 0.664). Nuclear circularity was better assessed by computer-based analysis.

CONCLUSION

Preoperative morphometric assessment of the nuclear features may detect early cellular changes and thus, are useful in predicting nodal metastases in OSCC.

The prevalence of undiagnosed metabolic abnormalities in people with serious mental illness

The prevalence of metabolic syndrome is increased 2-3-fold in people with serious mental illness (SMI). Monitoring of physical health in these individuals is poor, despite clear guidance from the National Institute of Health and Clinical Excellence. The aim of this study was to assess the proportion of people with SMI who had been screened for metabolic abnormalities within the previous year and in a further study to assess the prevalence of undiagnosed metabolic abnormalities in people who had not been screened. The notes and computer records of 100 patients with SMI from community and in-patient settings were evaluated. In a subsequent study, the prevalence of metabolic syndrome was assessed in 71 previously unscreened patients. The study was carried out at the psychiatric in-patient and out-patient units in Southampton and Winchester. The frequency of screening and prevalence of the metabolic syndrome as defined by the International Diabetes Federation (IDF) were assessed. There was documented evidence that the following cardiovascular risk factors had been measured in the previous year: blood pressure (32%), glucose (16%), lipids (9%) and weight (2%). In the metabolic abnormalities study, 41 of 71 (58%) patients were found to fulfil the IDF criteria for the metabolic syndrome. Two had previously undiagnosed diabetes. Twelve percent of patients had a greater than 20% risk of a cardiovascular event within the next 10 years. Despite clear guidance and a high prevalence of undiagnosed metabolic syndrome, screening rates for metabolic abnormalities in people with SMI remain low. Improved screening of metabolic complications should lead to better identification and treatment of this clinical problem.

Impact of a simple intervention that improves colon cancer lymph node yield and assessement

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Background: The National Quality Forum has endorsed the 12 lymph node (LN) benchmark as a quality metric. Currently, less than 40% of institutions meet this requirement. The purpose of this study was to determine whether implementation of a simple pathology template with dedicated fields for LN reporting led to an increase in the number of colon cancer resections where >12 LNs were reported. Methods: A simple pathology template, derived from the College of American Pathology, using standardized terminology and dedicated fields for LN reporting was implemented in August 2007. Using a pre and post- test design, all consecutive pathology cases were retrospectively reviewed. Inclusion criteria consisted of all stage 0-IV colon cancer patients who underwent surgical resection at a single Veterans Affairs Medical Center. The primary outcome was the percentage of cases in which >12 LNs were assessed between the pre and post-template group. Age, gender, anatomic location, and stage were also collected. Statistical comparisons were made using chi-square and Fisher's exact t-test. Results: 111 pre-template and 71 post-template cases were analyzed. The majority of patients were Caucasian (74%) males (97%). There were no significant differences between the two groups (see Table 1 ), however there was a trend towards more right-sided colon cancers in the pre-template group. 51% of all pre-template pathology reports evaluated >12 LNs compared to 68% of post-template reports (33% improvement in LN yield; p=0.03). Conclusions: Examination of >12 LNs has important therapeutic and prognostic implications in colon cancer patients. Use of a standardized pathology template with dedicated fields for LN reporting is a simple intervention that can increase yield of LN reporting. This can have a significant impact for institutions striving to reach the 12 LN quality metric.

[Table: see text]

No significant financial relationships to disclose.

A rare presentation of oral pemphigus vulgaris as multiple pustules

Pemphigus vulgaris is an autoimmune blistering disease affecting the mucous membrane and skin. Ulcers, vesicles, bulla, erosions are the common manifestations of the disease. It is uncommon to find multiple pustular lesions in the oral cavity. Here, we report the first case of multiple pustules involving the lateral borders of tongue, buccal mucosa, hard palate, soft palate, vestibule and the gingiva of a 53 year old male. Histopathologic and Immunofluoroscence study was suggestive of pemphigus vulgaris. The condition improved with systemic corticosteroid along with adjuvant therapy. Key words: pemphigus vulgaris, multiple pustules, immunofluorescence, corticosteroids.

Alloantigen recognition is critical for CD8 T cell-mediated graft anti-tumor activity against murine BCL1 lymphoma after myeloablative bone marrow transplantation

The goal of the current study was to determine whether whole bone marrow cells or splenic CD8(+) T cells from C57BL/6 (H-2(b)) donor mice, which are tolerant to BALB/c (H-2(d)) alloantigens, are capable of mediating graft anti-tumor activity against a BALB/c B-cell lymphoma after injection into irradiated BALB/c hosts. The experimental results show that high doses of splenic CD8(+) T cells mixed with T cell-depleted bone marrow cells from C57BL/6 non-tolerant (normal) donors eliminate the BCL(1) B-cell lymphoma cells and induce lethal graft-versus-host disease (GVHD). CD8(+) T cells from tolerant donors simultaneously lose both their ability to induce GVHD and their anti-tumor activity. Whole bone marrow cell transplants from normal donors eliminated BCL(1) tumor cells without inducing GVHD, and bone marrow cells from tolerant donors failed to eliminate the tumor cells. The infused BCL(1) tumor cells expressed an immunogenic tumor-specific idiotype antigen disparate from host alloantigens, indicating that recognition of the tumor-specific antigen alone was insufficient to elicit graft anti-tumor activity from unimmunized allotolerant donor splenic CD8(+) T cells or whole bone marrow cells. We conclude that CD8(+) T cells from unimmunized normal donor mice require alloantigen recognition to mediate their anti-tumor activity following allogeneic BMT.

Tumours associated with gastrointestinal stromal tumors (GIST): A case report

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Background: Much progress has been made in the diagnosis and treatment of GIST but the rarity of second neoplasms in association with gastro intestinal tumours (GIST) have rarely been reported. Methods: We present three case reports of breast cancer, Hodgkin's disease and thyroid cancer associated with GIST Results: The first pt, aged 50 underwent left lumpectomy and axillary clearance for infiltrating ductal carcinoma. Estrogen and Progesterone receptors were positive. Adjuvant chemotherapy , radiotherapy and tamoxifen was administered .Three years later patent was operated for a sub mucous nodule in the stomach which was reported as GIST, CD117+ve,CD34 positive and the patient was followed up. The second pt, male aged 50 was operated for a large intrabdominal GIST tumour (16x16cm) arising from the stomach and later on referral found to have a Rt Supraclavicular node with a nodule in the thyroid. He under went total thyroidectomy with functional node dissection for papillary carcinoma. This was followed Radioactive iodine ablation and eltroxin. Three months later he presented with thoraco abdominal metastasis and treatment with Imatnib was begun, but he soon progressed and succumbed to his disease. The third pt, female, with a history of Hodgkin's disease treated with chemotherapy on follow up. Twelve years later the pt was subjected to extensive debulking for pelvic GIST (16cmx15cm).CD117 positve.She was kept on follow up. A ct chest abdomen and pelvis eight months following surgery was unremarkable. Conclusions: Very few cases have been reported in literature regarding association of second tumours with GIST .And no correlation can be made to generate a hypothesis regarding these associations.

No significant financial relationships to disclose.

Neutrophil and eosinophil participation in atopic and vernal keratoconjunctivitis

PURPOSE

A retrospective study was conducted at three centers to examine the participation of neutrophils and eosinophils in the inflammatory processes associated with atopic keratoconjunctivitis (AKC) and vernal keratoconjunctivitis (VKC).

METHODS

Conjunctival specimens were obtained from four patients with AKC, six with VKC, and five normal subjects. Indirect immunofluorescent staining was used to localize neutrophil elastase (NE) and eosinophil granule major basic protein (MBP) in serial sections of all specimens.

RESULTS

Specimens from both AKC and VKC patients revealed extracellular deposition of NE and MBP. Control specimens showed no or minimal extracellular NE, and no MBP. Statistical analysis demonstrated significantly greater extracellular MBP deposition in AKC specimens compared to controls (p = 0.009), and VKC specimens showed significantly greater staining for both extracellular MBP (p = 0.005) and NE (p = 0.006).

CONCLUSIONS

These results suggest that neutrophils, in addition to eosinophils, play an active role in the pathogenesis of AKC and VKC as evidenced by the extracellular deposition of their specific granule proteins.

Comparable efficacy and safety profiles of once-per-cycle pegfilgrastim and daily injection filgrastim in chemotherapy-induced neutropenia: a multicenter dose-finding study in women with breast cancer

BACKGROUND

Neutropenia is common in patients receiving myelotoxic chemotherapy. Pegfilgrastim, a sustained-duration filgrastim is a once-per-cycle therapy for prophylactic neutrophil support.

PATIENTS AND METHODS

Women, treated with four cycles of doxorubicin/docetaxel chemotherapy every 21 days, received pegfilgrastim or filgrastim 24 h after chemotherapy as a single subcutaneous injection per chemotherapy cycle (pegfilgrastim 30, 60 or 100 microg/kg) or daily subcutaneous injections (filgrastim 5 microg/kg/day). Safety, efficacy and pharmacokinetics were analyzed.

RESULTS

The incidence of grade 4 neutropenia in cycle 1 was 95, 90 and 74%, in patients who received pegfilgrastim 30, 60 and 100 microg/kg, respectively, and 76% in patients who received filgrastim. Mean duration of grade 4 neutropenia in cycle 1 was 2.7,2 and 1.3 days for doses of pegfilgrastim, and 1.6 days for filgrastim. The pharmacokinetics of pegfilgrastim were non-linear and dependent on both dose and neutrophil count. Pegfilgrastim serum concentration was sustained until the neutrophil nadir occurred then declined rapidly as neutrophils started to recover, consistent with a self-regulating neutrophil-mediated clearance mechanism. The safety profiles of pegfilgrastim and filgrastim were similar.

CONCLUSIONS

A single subcutaneous injection of pegfilgrastim 100 microg/kg provided neutrophil support and a safety profile comparable to daily subcutaneous injections of filgrastim during multiple chemotherapy cycles.