Vulvar Perivascular Epithelioid Cell Tumor: A Case Report of a Rare Neoplasm in an Uncommon Site

Introduction/Objective

Perivascular epithelioid cell tumors (PEComas) are rare mesenchymal neoplasms that arise in a variety of soft tissue and visceral sites. In the female genital tract, PEComas arise in the uterine corpus and are rarely identified outside the uterus, with only a few cases reported in the vulva in the English literature.

Methods/Case Report

We report a case of a 75-year-old African American female, with a history of smoking and type II diabetes, who presented with a painless and mobile introital mass (2.5 cm). Incision and drainage were done, and a curettage sample was submitted for surgical pathology. Histologic features of the lesion revealed nests of epithelioid tumor cells with eosinophilic cytoplasm, round to oval nuclei and prominent nucleoli, in addition to thin-walled capillary vessels between nests of tumor cells. Immunohistochemical stains showed the tumor cells were positive for smooth muscle actin, MiTF, cathepsin-K, and focal MSA. Melan-A showed focal patchy staining. SMARCA4 and INI1 showed normal/retained nuclear staining. The tumor cells were negative for TFE3, vimentin, PAX8, p63, keratin, CK7, CK20, EMA, CK5, desmin, myoglobin, CD45, CD68, CD138, CD163, GATA3, chromogranin, synaptophysin, INSM1, S100 protein, HMB45, SOX10, inhibin, calretinin, CD31, and CD34. The tumor was morphologically and immunophenotypically consistent with PEComa. Complete excision of the lesion showed a 1.2 x 1.0 x 0.6 cm well circumscribed lesion, with no infiltrative borders and clear margins. The morphologic features of the tumor, including the relatively small size with absence of tumor necrosis, vascular invasion, and high mitotic activity favor a benign nature of this PEComa and suggest a low risk of recurrence. Therefore, no additional treatment was indicated.

Results (if a Case Study enter NA)

NA

Conclusion

PEComas are uncommon mesenchymal neoplasms that arise from distinctive perivascular epithelioid cells, typically arranged around blood vessels and usually express combined myomelanocytic immunophenotype. There are only a few reported cases of PEComas in the vulva. Malignant neoplasms tend to be ≥ 5cm and illustrate nuclear atypia, marked pleomorphism, conspicuous mitoses, vascular invasion and infiltrative margins. Based on the gross and microscopic features, the tumor in our case is likely to behave in a benign fashion; however, more studies are needed to further understand the behavior and the pathophysiology of vulvar PEComas.

945 Are Extended Criteria Donor Kidneys from 70 years-old and above Good Enough to Accept? A Single Centre Experience

Aim

As a result of increasing demand in recent years in organ donation and transplantation, the transplant community has been utilizing organs previously considered unsuitable for transplantation, including organs from extended criteria donors (ECD) and donors after circulatory arrest (DCD). This has led to higher rates of non-functioning and poorer outcomes, increasing the uncertainty when to accept or decline a donor organ. Our objective is to measure patient and graft outcomes of kidney transplants from ECDs aged 70 years and older.

Method

A retrospective study of 104 renal transplanted patients from ECDs between April 2010 and March 2014. Recipients referred to other centres were excluded from the study. Follow-up period was 7 years.

Results

At 7 years follow up, graft survival among recipients from ECDs older were 42.5%(n=17/40) while from ECDs younger were 58% (n=37/64) (P = 0.1594). Death censored graft survival (patient died with functioning graft). ECDs older death censored graft survival was 80% (n=32/40) and 82.8% (n=53/64) for ECDs younger (P = 0.7963).

Patient survival

70.3% of recipients from ECDs younger and 60% of recipients from ECDs older were alive at seven years post-transplant. (P = 0.2945).

Conclusions

There was no significant difference between the two cohorts in graft and patient survival. The use of kidneys from donors aged ≥70 years has yielded generally satisfactory results when compared to younger ECDs 50–69 years old donors.

Knowledge, attitudes, and practice with respect to antibiotic use among pharmacy students: a cross-sectional study

OBJECTIVE

Antibiotic resistance is a major health threat and efforts should be intensified to reduce its burden. Healthcare providers, especially pharmacists, can be actively involved in the reduction of antibiotic resistance. However, negative practices among pharmacists have been observed. This study evaluated knowledge, attitudes, and practices (KAP) among Jordanian pharmacy students.

PATIENTS AND METHODS

A cross-sectional study used an online questionnaire that was developed and distributed to Jordanian pharmacy students from five different universities. KAP scores were calculated, with students categorized into low and high levels based on each score mean.

RESULTS

A total of 890 pharmacy students completed the questionnaire. High positive response rate (PR%) for the majority of the knowledge items was observed, exceeding 60% in all knowledge items, and similar PR% was observed in attitude items. The variables significantly associated with attitude were age [OR=0.92 (95% CI 0.87: 0.98), p=0.01] and knowledge [OR=1.35 (95% CI 1.01:1.82), p=0.04], while knowledge was significantly associated with practice [OR=0.23 (95% CI 0.16:0.31), p<0.001].

CONCLUSIONS

Jordanian pharmacy students showed adequate KAP toward the use of antibiotics although several aspects of malpractice were identified. Hence, adequate knowledge about antibiotics among pharmacy students should be ensured as knowledge is associated with attitudes and practices.

Factors associated with glycemic control among patients with type 2 diabetes: a cross-sectional study

OBJECTIVE

Achieving glycemic control significantly improves the progression of the disease among diabetes mellitus patients although this is not achieved by many diabetics. The aim of the study is to explore the factors associated with glycemic control among patients with type 2 diabetes.

PATIENTS AND METHODS

In addition to sociodemographic variables, beliefs about medications and medication adherence were evaluated using the validated Beliefs about Medications Questionnaire and the 4-item medication adherence scale. A cut-off point of HbA1c% <7 was used as an indicator of glycemic control. Stepwise binary logistic regression was conducted to explore the variables associated with poor glycemic control.

RESULTS

A total of 287 patients participated in the study. More than half (58%) were found to have poor glycemic control‎. Females had significantly higher odds of having controlled diabetes (OR=2.28, p-value <0.01). Increasing necessity for diabetes medications was significantly associated with improved glycemic control (OR=2.75, p-value <0.01). Participants in low or moderate adherence groups had significantly higher odds of having uncontrolled diabetes.

CONCLUSIONS

Future diabetes management programs should focus on emphasizing medication necessity and improving medication adherence, particularly for male patients, with the aim of improving glycemic control and health outcomes among patients with type 2 diabetes.

Primary small cell neuroendocrine carcinoma of oropharynx: A potential diagnostic pitfall with Human papillomavirus (HPV)-related squamous cell carcinoma

Introduction/Objective

Small cell neuroendocrine carcinoma (SCNEC) primary to the head and neck region, especially from oropharynx, is very rare. Published data have shown that Human papillomavirus (HPV) positivity may be associated with a better overall survival in these tumors. Here we report a case of p16 positive SCNEC arising from the tonsil.

Methods/Case Report

A 51-year-old man with former smoking history was evaluated for sore throat and difficulty swallowing. Nasopharyngolaryngoscopy showed a left tonsillar mass and imaging revealed left jugular chain lymphadenopathy with no other evidence of a primary tumor elsewhere, including the lung. Biopsy of the mass was performed which revealed nested proliferation of uniform, hyperchromatic tumor cells with scant cytoplasm, indistinct nucleoli, areas of nuclear molding, and brisk mitotic activity. No keratinization was present, but a vague peripheral palisade was seen in some of the nests. The major differential diagnostic considerations included HPV-related nonkeratinizing squamous cell carcinoma, basaloid squamous cell carcinoma, and SCNEC. Immunohistochemistry revealed tumor cells were positive for AE1/AE3 with partial dot-like perinuclear pattern, cytokeratin 8/18, synaptophysin, and strong p16; negative for P40, P63, cytokeratin 5/6, cytokeratin 7, chromogranin, and CD56. Because SCNEC at any site may be positive for p16, testing for HPV RNA by in-situ hybridization was performed and showed negative for HPV subtypes 6, 11, 16, and 18.

Results (if a Case Study enter NA)

NA

Conclusion

This case highlights the differential diagnosis of a “basaloid” appearing carcinoma in the oropharynx. It also reinforces the fact that although p16 is considered a reliable surrogate marker for HPV infection in oropharyngeal squamous cell carcinoma, the same does not hold true for SCNEC.

190 Evaluating the Management of Cephalic Arch Stenosis in A North London Hospital

Aim

Brachiocephalic fistulas (BCFs) are the most commonly used arteriovenous fistulas (AVFs). They are commonly associated with cephalic arch stenosis (CAS), a leading cause of dysfunction and failure. The 2018 European Society of Vascular Surgery guidelines recommend the consideration of stent grafts for managing CAS. In this study, we sought to evaluate the management of CAS in a North London hospital.

Method

We carried out a retrospective study of patients who had undergone a fistulogram/fistuloplasty for CAS between May 2014 and May 2020. We extracted demographic data, information about their access, and information regarding surgical management of CAS, from the patients’ records on VitalData. We extracted data about recurrence of CAS from their Cerner records.

Results

Seventy patients were included. 54.3% were still alive at the time of data collection. The average age of those still alive was 65.8±14.1 years. 78.6% had a left BCF. 66% had previous access. 4.29% underwent stenting for CAS. The rest had fistulopasties alone. 90% required multiple fistulopaslties (mean=3.44±1.51). Median interval between access creation and first fistuloplasty was 1.90 years. 34.3% of patients underwent surgical repair of their AVF. AVF failure rate was 34.3%. Median interval between access creation and failure was 3.05 years. Median interval between first fistuloplasty and access failure was 1.34 years.

Conclusions

Our data demonstrate a high rate of access failure in patients with CAS treated at our centre. Few of our patients had stent grafts inserted. The majority had fistuloplasties without stenting, which was associated with a high recurrence rate.

Assessment irradiation effects on different development stages of Callosobruchus maculatus and on chemical, physical and microbiological quality of cowpea seeds

Irradiation is a physical, environmentally friendly treatment which does not leave any residues in the product. It is increasingly used as an alternative to methyl bromide and other chemical fumigants for disinfestation of insect pest in stored grains. In this research, we try to evaluate the effect of low gamma irradiation doses in the range of 50-1200 Gy on the different stages of Callosobruchus maculatus. It was found that no adults emerged after irradiation of eggs at 450 Gy. No emerging adults (F1 generation) have been shown when larvae or pupae were exposed to 650 Gy. Also, no emerging adult has been shown from the parental C. maculatus adults irradiated with 650 Gy. When suppression of F1 generation was used for the measuring effective irradiation dose and phytosanitary efficacy, 650 Gy was required for disinfestation of cowpea seed weevils. The irradiation dose level of 650 Gy was used for the large-scale confirmatory tests applied to 27,754 adults of C. maculatus in cowpea seeds resulting in non F1 adults' production with a confidence level of 93.77%. All the physical and chemical characteristics of cowpea seeds were non-significantly (P ≤ 0.05) affected by the irradiation dose of 650 Gy. Meanwhile, this irradiation dose very slightly reduced the microbial load of cowpea seeds. We recommend the generic dose 650 Gy as the phytosanitary irradiation dose for the cowpea seed weevil.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

The efficacy of endoscopic third ventriculostomy in children 1 year of age or younger: A systematic review and meta-analysis

PURPOSE

Hydrocephalus is a major cause of morbidity in the pediatric population, with potentially severe consequences if left untreated. Two viable strategies for management of non-communicating hydrocephalus are endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunting. However, there is uncertainty over the safety and efficacy of ETV in younger infants aged 1 year or below. In this systematic review, we aim to elucidate the success rate and procedural risks of ETV in this age group.

METHODS

A multi-database (PubMed, Embase, Web of Science) literature search between January 1990 and April 2018 was performed in accordance with PRISMA guidelines. Eligible studies were included if they (i) examined non-communicating hydrocephalus; (ii) quantified the success/failure rates of ETV; and (iii) assessed outcomes in children 1 year of age or younger.

RESULTS

A total of 19 articles with 399 patients were eligible for inclusion. Mean age at procedure was 4.2 months (range 34 weeks gestation to 12 months), with 116 females and 143 males. Commonest underlying aetiology was congenital aqueductal stenosis (AS) (60.4%). Remaining causes included post-haemorrhagic, post-infection, Chiari malformations, malignancies and others. Overall and AS mean success rates were 51.6% and 56.5% respectively. Overall complication rate was 10.0%, consisting mainly of CSF leak, infection, and haemorrhage. Younger age was significantly associated with poorer ETV success rate when divided into <6 months and 6-12 months of age (44.4 vs 66.7%; p = 0.0007). Underlying pathology had no significant association with ETV outcome when divided into AS and other pathologies (p = 0.53).

CONCLUSIONS

Age is significantly associated with ETV success rates. Pathology-dependent effects were not found in this age group. Despite a lower ETV success rate at younger ages (44.4 vs 66.7%), it offers a comparable safety profile that is independent of age. ETV remains a viable treatment option for non-communicating hydrocephalus for infants aged 1 year or younger.

Next generation HLA typing and haplotypes by descent in Gaza individuals

Forty-two individuals from the Gaza Strip were typed by Next Generation Sequencing (NGS) for HLA-A, -B, -C and -DRB1. Haplotypes were established by descent and only one haplotype was found to occur more than once; HLA-A*23:01 ~ B*41:01 ~ DRB1*07:01. The allele and haplotype frequencies and the individual genotypes are deposited at www.allelefrequencies.net (AFND) under population name Gaza and population ID number 3664 Dos Santos et al. (2016) [1].

A68 Characterization and comparative genomic analysis of two Bacillus megaterium lytic bacteriophages

Next-generation sequencing technologies provide unique possibilities for the comprehensive assessment of the environmental diversity of bacteriophages. Many Bacillus bacteriophages have been isolated, but very few Bacillus megaterium bacteriophages have been characterized. Here, we describe biological characteristics and whole-genome sequences and their annotations for two new isolates of the B. megaterium bacteriophages (BM5 and BM10), isolated from Egyptian soil samples and representing two different groups according to their host range and amplified fragment length polymorphism profiles. Both phages have been displaying different thermal inactivation points (82 and 78 °C) and pH tolerance range (5–9.2 and 5–8.4 pH) while having the same longevity in vitro (192 h). Electron microscopy observation has proved that both phages belonged to the Myoviridiae family. Furthermore, growth analyses indicated that phages BM5 and BM10 have a shorter latent period (20 and 25 min) and smaller burst size (103 and 117 PFU) than is typical for Bacillus phages. The genome sizes of phages BM5 and BM10 were 165,031 bp and 165,213 bp, respectively, with a modular organization. Bioinformatic analyses of BM5 and BM10 genomes enabled assignments of putative functions to 97 and 65 putative ORFs, respectively. Comparative analysis of BM5 and BM10 genome structures with other B. megaterium bacteriophages revealed relatively high levels of sequence and organizational identity. Both genomic comparisons and phylogenetic analyses support the conclusion that the sequenced phages (BM5 and BM10) belong to different sub-clusters (L5 and L7) within L cluster and display different lifestyles (lysogenic and lytic). Sequenced phages encode proteins associated with Bacillus pathogenesis. BM5 does not contain any tRNA sequences, while BM10 genome codes for 17 tRNAs.

Epidemiological and molecular investigation of resurgent cutaneous leishmaniasis in Sudan

OBJECTIVES

Local health personnel have drawn attention to an apparent increase in incidence and severity of cutaneous leishmaniasis (CL) in Sudan. The objective of this study was to investigate CL burden and surveillance.

METHODS

Surveillance data were compiled from the KalaCORE programme, Leishmania coordinators in Northern Kordofan and Southern Darfur, and Khartoum Dermatology Hospital. CL lesions were sampled from 14 suspected cases from Northern Kordofan and the Hospital for Tropical Diseases in Omdurman. PCR-restriction fragment length polymorphism analysis and multilocus sequencing were used to characterize the disease agent.

RESULTS

All sites reported substantial increases from 2014 to 2016/7, far exceeding World Health Organization case reports for 2014, consistent with a widespread outbreak. Single seasonal peak incidence was observed, except for two peaks in Southern Darfur. In Northern Kordofan, the odds ratio for CL in the 35-44 years age group was 2.6 times higher than in the >45 years age group (p<0.0001); in Southern Darfur, the OR was 2.38 greater in males than females (p<0.0001). Lesions included severe presentations, despite chemotherapy. Leishmania major was identified as the agent.

CONCLUSIONS

Active surveillance is required to understand the extent of CL in Sudan, as well as training to standardize surveillance, diagnosis, reporting, and quality control. Point-of-care rapid diagnosis would be valuable. Genotyping and phenotyping are required to monitor the emergence of pathogenic strains, drug resistance, outbreaks, and changes in severity.

Serum RANKL, osteoprotegerin (OPG) and RANKL/OPG ratio in children with systemic lupus erythematosus

Background

Systemic lupus erythematosus (SLE) patients have lower bone mineral density (BMD) compared with healthy individuals because of general, genetic, disease and medication-related factors. The disturbance of the receptor activator of nuclear factor-κB ligand (RANKL)/osteoprotegerin (OPG) ratio has been reported to be associated with low BMD in many disorders in adults and children alike.

Objectives

The objectives of this study were (i) to assess serum OPG, RANKL and RANKL/OPG ratio levels in SLE children and controls, (ii) to determine whether the cumulative glucocorticoid (CGCS) dose had any effect on the concentration of serum RANKL, OPG and RANKL/OPG ratio, and (iii) to determine the relation of these parameters to BMD.

Methods

We evaluated 50 SLE children and 50 age- and sex-matched healthy controls. RANKL and OPG were assessed in serum and compared between patients and controls. For SLE patients, a univariate followed by multivariable analysis were carried out to detect the possible predictors of the changes in RANKL, OPG and RANKL/OPG ratio levels. Lumbar BMD for all patients was assessed by dual-energy X-ray absorptiometry (DXA) scan and then correlated to different probable correlated factors.

Results

RANKL, OPG and RANKL/OPG ratio were significantly higher in SLE patients ( p ≤ 0.001). Univariate analysis showed significant correlations of RANKL with CGCS ( p ≤ 0.001) and with DXA scan z-score ( p = 0.007): OPG was significantly correlated to Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) score ( p = 0.001) and anti-double-stranded DNA ( p = 0.001), whereas RANKL/OPG was significantly correlated to duration of illness and DXA z-score ( p = 0.002). The multivariable analysis showed that DXA z-score was an independent predictor of RANKL and RANKL/OPG ratio ( p = 0.019 and 0.008, respectively), whereas SLEDAI score was an independent predictor of OPG levels. BMD was negatively correlated to disease duration ( p = 0.008) and CGCS dose ( p = 0.015), but no significant correlation has been found between BMD and cumulative SLEDAI score ( p = 0.29).

Conclusions

Serum RANKL/OPG ratio is elevated in Egyptian children with SLE and is considered a risk factor for reduced bone mass in these children. Other risk factors for low BMD include high CGCS dose and disease duration, supporting that osteoporosis in SLE is multifactorial.

Angiotensin II type 2 receptor gene polymorphisms and serum angiotensin-converting enzyme level in Egyptian children with systemic lupus erythematosus

Background

There are no reports about the association of angiotensin II type 2 receptor ( AT2R) gene polymorphisms and susceptibility to systemic lupus erythematosus (SLE) in children.

Objective

The objective of this research is to study AT2R gene polymorphisms in exon 3 (C1593A) and intron 1 (A1675G) in Egyptian children with SLE and its correlation with disease manifestations and serum angiotensin-converting enzyme (ACE) level.

Methods

Typing of AT2R gene polymorphisms was conducted in 123 children with SLE in comparison with 100 healthy controls using the restriction fragment length polymorphism method.

Results

Significant differences were found between SLE patients and controls for A-containing genotypes (CA + AA) and A-allele frequencies of AT2R in exon 3 (C1593A) ( p = 0.01, odds ratio (OR) = 2.5, 95% confidence interval (CI) = 1.3–5.05; p = 0.01, OR = 2.2, 95% CI = 1.2–4.1, respectively). G-containing genotypes (AG + GG) and G allele of AT2R in intron 1 (A1675G) were more frequent in SLE patients compared to controls ( p = 0.01, OR = 2.3, 95% CI = 1.2–4.5; p = 0.02, OR = 2.1, 95% CI = 1.2–3.7, respectively). Serum ACE level was significantly higher in SLE patients than in controls ( p < 0.001). There was no association between AT2R gene polymorphisms and ACE level in serum. Moreover, there was no association between AT2R gene polymorphisms and SLE clinical manifestations.

Conclusion

AT2R gene polymorphisms can be considered risk factors for SLE development in Egyptian children.

Henoch-Schönlein Purpura After Living Donor Liver Transplantation: Report of the First Case

Henoch-Schönlein purpura (HSP) is a systemic vasculitis affecting the small vessels that mainly presents in children and young adults. It is characterized by tissue deposition of immunoglobulin A (IgA) immune complexes with the classic manifestations of purpura, arthritis, arthralgia, and gastrointestinal and renal involvements. We report a case of HSP nephritis that occurred 2 years after living-donor liver transplantation (LDLT). After pulse steroid administration, the patient's symptoms disappeared and blood markers normalized. To the best of our knowledge, this is the first HSP case to be reported in a liver transplant recipient.

Population-based study of the impact of surgical and adjuvant therapy at the same or a different institution on survival of patients with pancreatic adenocarcinoma

Background

Pancreatic cancer surgery is increasingly regionalized in high‐volume centres. Provision of adjuvant chemotherapy in the same institution can place a burden on patients, whereas receiving adjuvant chemotherapy at a different institution closer to home may create disparities in care. This study compared long‐term outcomes of patients with pancreatic adenocarcinoma receiving adjuvant chemotherapy at the institution where they had undergone surgery with outcomes for those receiving chemotherapy at a different institution.

Methods

This was a population‐based study of patients receiving adjuvant chemotherapy after resection of pancreatic adenocarcinoma performed at ten designated hepatopancreatobiliary centres in Ontario, Canada, between 2004 and 2014. Patients were divided into those receiving chemotherapy at the same institution as surgery or a different institution from where surgery was performed. The primary outcome was overall survival (OS). Multivariable Cox regression assessed the association between OS and each chemotherapy group, adjusted for potential confounders.

Results

Of 589 patients, 374 (63·5 per cent) received adjuvant chemotherapy at the same institution as surgery. After adjusting for age, sex, co‐morbidity, socioeconomic status, rural living, tumour stage, margin positivity and year of surgery, the location of adjuvant chemotherapy was not independently associated with OS (hazard ratio 1·03, 95 per cent c.i. 0·85 to 1·24). For patients who underwent chemotherapy at a different institution, mean travel distance to receive chemotherapy was less (22·9 km) than that needed for surgery (106·7 km).

Conclusion

After pancreatectomy for pancreatic adenocarcinoma at specialized hepatopancreatobiliary surgery centres, OS was not affected by the location of the centre delivering adjuvant chemotherapy. Receiving this treatment in a local centre reduced patients' travel burden.

GATA3 rs3824662 gene polymorphism as possible risk factor for systemic lupus erythematosus

Background

There is no report about the association between GATA3 rs3824662 polymorphism and systemic lupus erythematosus (SLE).

Objective

To investigate the possible role of GATA3 rs3824662 polymorphism as a susceptibility risk factor for either adult SLE (aSLE) or pediatric SLE (pSLE) and to evaluate its role in the development of lupus nephritis (LN) in pSLE.

Methods

Typing of GATA3 rs3824662 polymorphism was done using real-time polymerase chain reaction for three groups; 104 pSLE patients, 140 aSLE patients and 436 age- and sex-matched healthy controls.

Results

Non-significant differences were found between SLE patients and healthy controls for the allele and genotype frequencies of GATA3 rs3824662 ( p > 0.05). In pSLE; the AC genotype was associated with LN ( p = 0.04); the A allele and AC genotype were associated with persistent proteinuria ( p = 0.036 and 0.01, respectively) and both the A allele and AA genotype were associated with higher chronicity index ( p = 0.031 and 0.04, respectively). In aSLE; the C allele was associated with cellular cast ( p = 0.03) and thrombocytopenia ( p = 0.01). Logistic regression analysis revealed significant association between the AC+AA genotypes and the prediction of LN and renal active disease in pSLE ( p = 0.04 and 0.01, respectively).

Conclusion

GATA3 rs3824662 is not associated with susceptibility to SLE either in adult or in pediatric patients; however, in pSLE patients, the heterozygous AC genotype could be considered a risk factor for LN. At the same time, the AC and AA genotypes could be considered as predictors for LN and active renal disease. However, the small sample size is a limiting factor of the present study when interpreting the positive association.

Exome Sequencing Identifies Two Variants of the Alkylglycerol Monooxygenase Gene as a Cause of Relapses in Visceral Leishmaniasis in Children, in Sudan

Background

Visceral leishmaniasis (kala-azar, KA) is the most severe form of leishmaniasis, characterized by fever, weight loss, hepatosplenomegaly, and lymphadenopathy. During an outbreak of KA in Babar El Fugara (Sudan), 5.7% of cured patients displayed relapses, with familial clustering in half the cases.

Methods

We performed whole-exome sequencing on 10 relapsing individuals and 11 controls from 5 nuclear families.

Results

Rare homozygous and compound-heterozygous nonsense (c.1213C > T, rs139309795, p.Arg405*) and missense (c.701A > G, rs143439626, p.Lys234Arg) mutations of the alkylglycerol monooxygenase (AGMO) gene were associated with KA relapse in 3 families. Sequencing in additional family members confirmed the segregation of these mutations with relapse and revealed an autosomal dominant mode of transmission. These mutations were detected heterozygous in 2 subjects among 100 unrelated individuals with KA who never relapsed after cure, suggesting incomplete penetrance of AGMO deficiency. AGMO is expressed in hematopoietic cells, and is strongly expressed in the liver. AGMO modulates PAF production by mouse macrophages, suggesting that it may act through the PAF/PAF receptor pathway previously shown to have anti-Leishmania activity.

Conclusions

This is the first demonstration that relapses after a first episode of KA are due to differences in human genetic susceptibility and not to modifications of parasite pathogenicity.

Coexistent End-stage Nonalcoholic Steatohepatitis and Colon Cancer: Should We Do Liver Transplantation?

BACKGROUND

Colon cancer accompanying decompensated liver cirrhosis is a rare clinical condition. Usually, treatment of colon cancer is prioritized, with cirrhosis dealt with later.

CASE REPORT

We present a case of end-stage liver disease due to nonalcoholic steatohepatitis evaluated for living donor liver transplant. During the pretransplant examination, an ascending colon cancer was detected. Liver function was too poor to perform colon resection first. Simultaneous living donor liver transplant and colonic resection were carried out. The patient developed left lung metastasis at 2 different times during the first postoperative year, and both of them were resected. The patient received the standard chemoradiotherapy. Now, the patient is alive at 42 months postprocedure and recurrence-free at 31 months postoperatively.

CONCLUSION

Simultaneous liver transplantation and colon resection are possible with acceptable long-term outcomes. Immunosuppressive therapy after transplantation increases the risk for cancer recurrence. So the patient should undergo close surveillance.

Interferon regulatory factor 5 gene polymorphism in Egyptian children with systemic lupus erythematosus

Background

Increased expression of interferon-inducible genes is implicated in the pathogenesis of systemic lupus erythematosus (SLE). Interferon regulatory factor 5 (IRF5) is one of the transcription factors regulating interferon and was proved to be implicated in the pathogenesis of SLE in different populations.

Objectives

The objective of this study was to investigate the correlation between polymorphisms of the IRF5 gene and SLE susceptibility in a cohort of Egyptian children and to investigate their association with clinico-pathological features, especially lupus nephritis.

Subjects and methods

Typing of interferon regulatory factor 5 rs10954213, rs2004640 and rs2280714 polymorphisms were done using polymerase chain reaction-restriction fragment length polymorphism for 100 children with SLE and 100 matched healthy controls.

Results

Children with SLE had more frequent T allele and TT genotype of rs2004640 ( Pc = 0.003 and 0.024, respectively) compared to controls. Patients with nephritis had more frequent T allele of rs2004640 compared to controls ( Pc = 0.003). However the allele and genotype frequencies of the three studied polymorphisms did not show any difference in patients with nephritis in comparison to those without nephritis. Haplotype GTA of rs10954213, rs2004640 and rs2280714, respectively, was more frequent in lupus patients in comparison to controls ( p = 0.01) while the haplotype GGG was more frequent in controls than lupus patients ( p = 0.011).

Conclusion

The rs2004640 T allele and TT genotype and GTA haplotype of rs rs10954213, rs2004640, and rs2280714, respectively, can be considered as risk factors for the development of SLE. The presence of the rs2004640 T allele increases the risk of nephritis development in Egyptian children with SLE.

Angiotensin-converting enzyme insertion/deletion gene polymorphism in Egyptian children with systemic lupus erythematosus: a possible relation to proliferative nephritis

Introduction Angiotensin-converting enzyme (ACE) is crucial in the pathogenesis of systemic lupus erythematosus through angiotensin II which regulates vascular tone and endothelial functions. Objectives To study the frequency of ACE insertion/deletion (I/D) gene polymorphism in Egyptian children with systemic lupus erythematosus and its possible relation to the renal pathology in cases with lupus nephritis. Subjects and methods The frequency of ACE gene insertion/deletion polymorphism genotypes was determined in 78 Egyptian children with systemic lupus erythematosus and compared to a matched group of 140 healthy controls using polymerase chain reaction. Results The DD genotype of the ACE gene was higher in systemic lupus erythematosus patients when compared to controls ( P<0.0001; odds ratio (OR) 2.4; 95% confidence interval (CI) 1.7-3.3) and the D allele was more frequent than the I allele in systemic lupus erythematosus patients in comparison to controls ( P < 0.0001; OR = 2.2; 95% CI = (1.6-3.1). In the lupus nephritis group, the DD genotype was significantly higher in those with proliferative lupus nephritis when compared to those with non-proliferative lupus nephritis ( P = 0.02; OR = 1.45; 95% CI = 1.4-1.6). Also, patients with proliferative lupus nephritis showed a higher frequency of the D allele ( P < 0.001; OR = 1.98; 95% CI = 1.3-2.9). Conclusion The D allele and DD genotype of the ACE gene appear to be a risk factor for the susceptibility of systemic lupus erythematosus and occurrence of proliferative nephritis in Egyptian children.

Serum interleukin-17 in Egyptian children with systemic lupus erythematosus: is it related to pulmonary affection?

Objective Pulmonary involvement in paediatric systemic lupus erythematosus (pSLE) is not an uncommon finding; however, subclinical affection occurs more frequently. Many studies have reported that cytokine dysregulation as interleukin-17 (IL-17) over-expression plays a key role in the pathogenesis of systemic lupus erythematosus (SLE). We aim to assess serum levels of IL-17 A and their association with pulmonary involvement in children with SLE. Methods Serum IL-17A levels - determined by solid phase sandwich ELISA - were assessed in forty-two pSLE patients and compared to 45 age-matched healthy controls. All patients were subjected to pulmonary function tests to detect subclinical pulmonary affection. High-resolution CT (HRCT) chest scan was carried out in patients with abnormal pulmonary function tests (PFTs) and those with chronic respiratory symptoms. Results Abnormal PFTs were found in 73% of patients; of them, only 25% had abnormal findings in HRCT chest. Serum levels of IL-17 A were significantly elevated in pSLE patients as compared to healthy controls ( p < 0.001). The serum levels of IL-17 A had a highly significant positive correlation with SLEDAI ( r = 0.811 and p < 0.001) Strong negative correlation was found between serum levels of IL-17A with both FEV1 and FVC ( p < 0.05). Conclusions Serum IL-17A is elevated in pSLE patients, which correlates with disease activity. IL-17 seems to have a possible role in the pathogenesis of subclinical lung affection. Abnormal PFTS may be found in pSLE patients even with normal radiology.

Theory of the deformation of aligned polyethylene

Solitons are proposed as the agents of plastic and viscoelastic deformation in aligned polyethylene. Interactions between straight, parallel molecules are mapped rigorously onto the Frenkel-Kontorova model. It is shown that these molecular interactions distribute an applied load between molecules, with a characteristic transfer length equal to the soliton width. Load transfer leads to the introduction of tensile and compressive solitons at the chain ends to mark the onset of plasticity at a well-defined yield stress, which is much less than the theoretical pull-out stress. Interaction energies between solitons and an equation of motion for solitons are derived. The equation of motion is based on Langevin dynamics and the fluctuation-dissipation theorem and it leads to the rigorous definition of an effective mass for solitons. It forms the basis of a soliton dynamics in direct analogy to dislocation dynamics. Close parallels are drawn between solitons in aligned polymers and dislocations in crystals, including the configurational force on a soliton. The origins of the strain rate and temperature dependencies of the viscoelastic behaviour are discussed in terms of the formation energy of solitons. A failure mechanism is proposed involving soliton condensation under a tensile load.

C1q rs292001 polymorphism and C1q antibodies in juvenile lupus and their relation to lupus nephritis

C1q deficiency is related strongly to systemic lupus erythematosus (SLE), but very few and inconsistent studies explored the single nucleotide polymorphisms of the C1q gene in relation to juvenile SLE (jSLE) and lupus nephritis (LN). The objective of this study was to analyse whether C1q rs 292001 polymorphism is associated with SLE and disease phenotype, especially nephritis, and to investigate the relation between this polymorphism and clinical data, treatment outcome, serum level of C1q protein and antibodies. Typing of C1q rs292001 polymorphism using restriction fragment length polymorphism and measuring serum levels of C1q protein and antibodies by enzyme-linked immunosorbent assay (ELISA) were performed for 130 children with SLE and 208 healthy controls. The A allele of C1q rs292001 was associated with jSLE and LN (P = 0·005 and 0·013, respectively) and the AA genotype was associated with jSLE (P = 0·036). Low serum levels of C1q protein were found in jSLE and LN (P < 0·001 and 0·009, respectively), and these levels were increased after treatment in patients with LN (P = 0·009) and active renal disease (P = 0·027). Higher titres of C1q antibodies were found in patients with LN (P = 0·015) and correlated negatively with C1q protein level (P < 0·001) and patient age (P = 0·04). The A allele and AA genotype of C1q rs292001 can be considered a susceptibility risk factor and the GG genotype could be considered protective for jSLE and LN in the studied cohort of Egyptian children. Decreased serum levels of C1q protein and increased titres of C1q antibodies may be involved in the pathogenesis of jSLE, especially LN.

CD56+ T cells are increased in kidney transplant patients following cytomegalovirus infection

BACKGROUND

CD56+ T cells previously have been identified as potentially cytotoxic lymphocytes, and relative numbers are increased in some infectious diseases.

PATIENTS AND METHODS

Relative proportions of CD56+ T cells were measured by flow cytometry in groups of renal transplant patients differing in cytomegalovirus (CMV) status of donor (D) and recipient (R). These measurements were related to episodes of CMV viremia.

RESULTS

Patient groups in which recipients (R+) or donors (D+/R-) were CMV+ had significantly higher proportions of CD56+ T cells (5.11 ± 0.69% and 5.42 ± 1.01%, respectively) than the D-/R- group (1.9 ± 0.35%; P = 0.0018 and 0.017, respectively). In the high-risk D+/R- group, it was found that patients who had post-transplant CMV viremia had higher levels than those who remained CMV negative (9.09 ± 2.34% vs. 3.16 ± 1.22%; P = 0.01). CD56+ T cells from R+ and D+/R- groups had higher proportions of both CD4+ and CD8+ cells than the D-/R- group. When activation markers were examined, some CD56+ T cells from both CMV+ groups had a TEM phenotype, with significantly more expressing CD45RO and NKG2C, and less expressing CD28, CD62L, CD127, and CD161 compared to the D-/R- group. Some CD56+ T cells showed specificity for CMV antigens and similar proportions of CD8+ cells were positive for class I HLA-CMV tetramers containing immunodominant CMV peptides compared to the majority CD56- T cells.

CONCLUSION

The results show significant increases in proportions of CD56+ T cells in relation to CMV infection in renal transplant patients and suggest that these cells have a cytotoxic function against CMV-infected cells.

Comparative assessment of next-generation sequencing, denaturing gradient gel electrophoresis, clonal restriction fragment length polymorphism and cloning-sequencing as methods for characterizing commercial microbial consortia

Characterization of commercial microbial consortia products for human and environmental health risk assessment is a major challenge for regulatory agencies. As a means to develop an approach to assess the potential environmental risk of these products, research was conducted to compare four genomics methods for characterizing bacterial communities; (i) Denaturing Gradient Gel Electrophoresis (DGGE), (ii) Clonal-Restriction Fragment Length Polymorphism (C/RFLP), (iii) partial 16S rDNA amplification, cloning followed by Sanger sequencing (PRACS) and (iv) Next-Generation Sequencing (NGS) based on Ion Torrent technology. A commercially available microbial consortium, marketed as a remediation agent for degrading petroleum hydrocarbon contamination in soil and water, was assessed. The bacterial composition of the commercial microbial product was characterized using the above four methods. PCR amplification of 16S rDNA was performed targeting the variable region V6 for DGGE, C/RFLP and PRACS and V5 for Ion Torrent sequencing. Ion Torrent technology was shown to be a promising tool for initial screening by detecting the majority of bacteria in the consortium that were also detected by DGGE, C/RFLP and PRACS. Additionally, Ion Torrent sequencing detected some of the bacteria that were claimed to be in the product, while three other methods failed to detect these specific bacteria. However, the relative proportions of the microbial composition detected by Ion Torrent were found to be different from DGGE, C/RFLP and PRACS, which gave comparable results across these three methods. The discrepancy of the Ion Torrent results may be due to the short read length generated by this technique and the targeting of different variable regions on the 16S rRNA gene used in this study. Arcobacter spp. a potential pathogenic bacteria was detected in the product by all methods, which was further confirmed using genus and species-specific PCR, RFLP and DNA-based sequence analyses. However, the viability of Arcobacter spp. was not confirmed. This study suggests that a combination of two or more methods may be required to ascertain the microbial constituents of a commercial microbial consortium reliably and for the presence of potentially human pathogenic contaminants.

Measuring depression and stigma towards depression and mental health treatment among adolescents in an Arab-American community

There has been limited research that has examined the prevalence of depression and attitudes towards depression and mental health treatment in Arab-American adolescents; we sought to assess these in a predominantly Arab-American community in metro Detroit. A health survey of adolescents aged 12-17 years was conducted (n=98). Participants were recruited from two local community organizations in Dearborn, MI. Depression was assessed by the Patient Health Questionnaire-9 (PHQ-9) Depression Scale, and attitude towards depression and willingness to seek help for mental health conditions were assessed by the Self-Stigma of Depression Scale (SSDS). To assess whether attitudes might be affected by information about mental health treatment, adolescents were randomized to view either an educational video about mental health, or a control video before responding to questions about their willingness to seek help for mental health conditions. Overall, 14% of Arab-American adolescents in this study endorsed moderate or moderately severe depression (PHQ-9 ≥ 11), suggesting a need to increase awareness of and access to mental health services and screening for Arab-American youth.

The emergence of systemic lupus erythematosus in hypothyroid patients: two case reports and mini review

Systemic lupus erythematosus (SLE) is a multi-systemic autoimmune disease that involves almost all the organs in the human body and is characterized by auto antibodies formation. Autoimmune thyroid diseases (AITD) are organ-specific diseases that are associated with a production of a variety of antibodies such as antinuclear antibodies, anti-double-stranded DNA, anti-Ro antibodies, anti-cardiolipin antibodies, and others. The diagnosis of AITD in patients with SLE is well known, but the reverse is rarely reported. We present two cases of adolescent girls in whom SLE evolved one year after being diagnosed with hypothyroidism.

Urinary neutrophil gelatinase-associated lipocalin as a marker of severe lupus nephritis in children

INTRODUCTION

More than 60% of children with systemic lupus erythematosus (SLE) develop lupus nephritis (LN). Neutrophil gelatinase-associated lipocalin (NGAL) is a protein secreted by leukocytes during inflammation and is overexpressed in the kidneys following ischemic and nephrotoxic damage.

AIM

To study urinary and serum NGAL in children with SLE and investigate their possible role as markers of renal involvement. Methods Urinary and serum levels of NGAL were assessed in 33 children with active SLE (22 with and 11 without LN) and compared to 15 matched controls.

RESULTS

Children with SLE had elevated urinary NGAL as compared to controls (P<0.001). Levels of urinary NGAL were higher in patients with LN than those without LN (P<0.001). In patients with LN, serum levels of NGAL were not significantly different from controls (P=0.4) and urinary NGAL correlated with the renal score of the Systemic Lupus Erythematosus Disease Activity Index (r=0.5, P=0.02) but not with serum NGAL (P=0.5). Urinary NGAL was significantly predictive of class III and IV LN (P=0.005) with 91% sensitivity and 70% specificity to levels ≥ 10.07 ng/mg creatinine. Conclusions Urinary NGAL is a sensitive marker of proliferative nephritis in juvenile SLE.

Colonic stent and percutaneous ethanol injection as a treatment for colocutaneous fistula secondary to benign stricture

We report successful treatment of colocutanteous stulae at the site of a benign colonic anastomotic stricture using Self-Expandable Metal Stents (SEMS) and Percutaneous Ethanol Injection (PEI). The stricture and the secondary stulae developed after Hartmann's procedure for sigmoid diverticular abscess followed by reversal of the Hartmann's procedure with a de-functioning loop ileostomy. Although there have been previously reported cases of SEMS for closure of malignant colonic stula, there are limited reports of SEMS for closure of benign colonic stulae and none of SEMS combined with PEI for benign colonic fistula. We conclude that this patient's case exemplies the potential applications of SEMS combined with PEI as a feasible option of therapy for benign colorectal disease.

Clostridium perfringens sepsis and liver abscess following laparoscopic cholecystectomy

Clostridium perfringens sepsis with intravascular haemolysis is a catastrophic process with a reported mortality of between 90 to 100%. We successfully treated a case of severe clostridial infection with a liver abscess following laparoscopic cholecystectomy, the first to our knowledge. A 59-year-old man presented one week after an uneventful laparoscopic cholecystectomy with jaundice, peritonism, sepsis and acute renal failure. He was found to have a haemolytic anaemia, unconjugated hyperbilirubinemia and blood cultures grew Clostridium perfringens. A CT revealed a large gas forming abscess in the gallbladder fossa and right lobe of liver. He was treated with directed antibiotic therapy and underwent emergency laparotomy, drainage of the abscess and peritoneal washout. He required intensive care support, parenteral nutrition and inotropic support for a limited period. CT liver angiogram post op was normal. Continued renal dysfunction necessitated protracted haemofiltration. This resolved and the patient was discharged home at 2 months.