Ketamine intolerance in patients on enhanced recovery after surgery protocols undergoing colorectal operations

BACKGROUND

Ketamine is used in enhanced recovery after surgery (ERAS) protocols because of its beneficial antihyperalgesic and antitolerance effects. However, adverse effects such as hallucinations, sedation, and diplopia could limit ketamine's utility. The main objective of this study was to identify rates of ketamine side effects in postoperative patients after colorectal surgery and, secondarily, to compare short-term outcomes between patients receiving ketamine analgesia and controls.

METHODS

This was a retrospective observational cohort study. Subjects were adults who underwent ERAS protocol-guided colorectal surgery at a large, integrated health system. Patients were grouped into ketamine-receiving and preketamine cohorts. Patients receiving ketamine were divided into tolerant and intolerant groups. Propensity score-adjusted models tested multivariate associations of ketamine tolerance/intolerance vs control group.

RESULTS

A total of 732 patients underwent colorectal surgery within the ERAS program before ketamine's introduction (control). After ketamine's introduction, 467 patients received the medication. Intolerance was seen in 29% of ketamine recipients, and the most common side effect was diplopia. Demographics and surgical variables did not differ between cohorts. Multivariate models revealed no significant differences in hospital stays. Pain scores in the first 24 hours after surgery were slightly higher in patients receiving ketamine. Opiate consumption after surgery was lower for both ketamine tolerant and ketamine intolerant cohorts than for controls.

CONCLUSION

Rates of ketamine intolerance are high, which can limit its use and potential effectiveness. Ketamine analgesia significantly reduced opiate consumption without increasing hospital stays after colorectal surgery, regardless of whether it was tolerated.

Central and peripheral tau retention modulated by an anti-tau antibody

Tau protein blood levels dependent on its distribution to peripheral organs and possible elimination from the body. Thus, the peripheral distribution of CSF-derived tau protein was explored, especially since there is a transition to blood-based biomarkers and the emerging idea that tau pathology may spread beyond brain. Near infrared fluorescence (NIRF) was mainly used to analyze tau (tau-NIRF) distribution after its intracisternal or intravenous injection. There was a striking uptake of blood- or CSF-derived tau-NIRF protein by the skeletal structures, liver, small intestine (duodenum), gall bladder, kidneys, urinary bladder, lymph nodes, heart, and spleen. In aging and in older APP/PS1 mice, tau uptake in regions, such as the brain, liver, and skeleton, was increased. In bone (femur) injected tau protein was associated with integrin-binding sialoprotein (IBSP), a major non-collagenous glycoprotein that is associated with mineralization. Tau-NIRF was cleared slowly from CSF via mainly across the cribriform plate, and cervical lymph nodes. In brain, some of the CSF injected tau protein was associated with NeuN-positive and PDGFRý-positive cells, which may explain its retention. The presence of tau in the bladders suggested excretion routes of tau. CSF anti-tau antibody increased CSF tau clearance, while blood anti-tau antibody decreased tau accumulation in the femur but not in liver, kidney, and spleen. Thus, the data show a body-wide distribution and retention of CSF-derived tau protein, which increased with aging and in older APP/PS1 mice. Further work is needed to elucidate the relevance of tau accumulation in each organ to tauopathy.

Cutaneous and Subcutaneous Perineuriomas in 2 Pediatric Patients

Perineuriomas are rare benign peripheral nerve sheath tumors that can present in a variety of locations with varying histologic patterns, most commonly in young to middle-aged adults; they are particularly rare in the pediatric population. Perineuriomas have a distinctive constellation of morphologic, immunohistochemical, and ultrastructural characteristics that allows for distinction from other benign peripheral nerve sheath tumors. We present 2 cases of perineuriomas that arose as cutaneous lesions in children.

Impaired fibrinolysis in severe Covid-19 infection is detectable in early stages of the disease

BACKGROUND

A significant degree of mortality and morbidity in Covid-19 is due to thromboembolic disease. Coagulopathy has been well described in critically unwell patients on ICU. There is less clear evidence regarding these changes at the time of presentation to the Emergency Department and the progression of disease over time.

OBJECTIVE

We sought to investigate whether coagulation markers can predict severity and how they change over the disease course.

METHODS

Patients presenting to a single University Teaching Hospital were recruited and followed up if PCR was positive. Alongside routine blood testing, Rotational Thromboelastometry (ROTEM) was performed. Outcome data was recorded for all patients, and ROTEM values were compared across outcome groups.

RESULTS

Extem and Intem Maximum Lysis were significantly reduced in those who died or required an ICU admission, indicating a reduced ability to break down clot mass in the most critically unwell patients.

CONCLUSION

Comparisons between groups demonstrated that one distinguishing feature between those who require ICU admission or die of Covid-19 compared with those who survive a hospital stay to discharge was the extent to which fibrinolysis could occur. Mortality and morbidity in Covid-19 infection appears in part driven by an inability to break down clot mass.

Phase I Study of Entinostat in Combination with Enzalutamide for Treatment of Patients with Metastatic Castration-Resistant Prostate Cancer

LESSONS LEARNED

Entinostat at the selected dose levels in combination with a standard dose of enzalutamide showed a promising safety profile in this small phase I study BACKGROUND: Entinostat inhibits prostate cancer (PCa) growth and suppresses Treg cell function in vitro and in vivo.

METHODS

This was a phase I study to explore the safety and preliminary efficacy of entinostat (3 and 5 mg orally per week) in combination with enzalutamide in castration resistant PCa (CRPC). The study was carried out in an open-label two-cohort design. Patients who had developed disease progression on or were eligible for enzalutamide were enrolled in the study. The safety profile of the combination therapy, Prostate specific antigen (PSA) levels, the pharmacokinetics of enzalutamide after entinostat administration, peripheral T-cell subtype (including Treg quantitation), and mononuclear cell (PBMC) histone H3 acetylation were analyzed.

RESULTS

Six patients with metastatic CRPC were enrolled. There was no noticeable increment of fatigue related to entinostat. Toxicities possibly or probably related to entinostat or the combination therapy included grade 3 anemia 1/6 (17%), grade 2 white blood cell (WBC) decrease 1/6 (17%), and other self-limiting grade 1 adverse events (AEs). Median duration of treatment with entinostat was 18 weeks. Entinostat did not affect the steady plasma concentration of enzalutamide. Increased PBMC histone H3 acetylation was observed in blood samples. No evident T-cell subtype changes were detected, including in Treg quantitation.

CONCLUSION

Entinostat 5 mg weekly in combination with enzalutamide showed an acceptable safety profile in this small phase I study. A planned phase II part of the trial was terminated because of sponsor withdrawal.

COVID-19 effect on cancer diagnosis: A retrospective comparative analysis

e18506

Background: In response to the COVID-19 pandemic, many health systems postponed routine screening and care to conserve resources and reduce patient exposure. As a result, several studies have shown a decline in the diagnosis of new cancer cases, a process that relies heavily on the use of screening tools and modalities. The Washington D.C. area is home to a heterogeneous patient population and one of the highest income gaps in the United States. Patterns in healthcare inequality in the area mirror these disparities. This study aims to identify the impact of the COVID-19 pandemic on cancer diagnosis rates compared to prior years and analyze whether vulnerable populations in the D.C. area were disproportionately affected. Methods: Data was collected from the George Washington University (GWU) Cancer Registry. The study population included patients age 18 and up residing in D.C., Maryland or Virginia who were diagnosed with any cancer at the GWU Health System within the following date ranges: April 1 to September 30 of 2018, 2019, 2020 and September 1, 2019 to February 29, 2020. Data collected included age at diagnosis, race, ethnicity, cancer site, stage at diagnosis, and patient zip code as a proxy for socioeconomic status (SES). Median income by zip code was labeled as low, middle or high. Chi square analysis was used to compare changes in each of these demographic and SES categories between each time frame. Results: There were 372 new cancer diagnoses during the COVID-19 period, April 1 2020 to September 30 2020. During this time period in 2018 and 2019, there were 525 and 539 new cancer diagnoses, respectively. Immediately prior to the COVID-19 period, September 1 2019 to February 29 2020, there were 588 new cancer diagnoses. Patterns of cancer type, age at diagnosis, sex, clinical stage, pathological stage and SES did not significantly differ between the COVID-19 period and any other time period (p > 0.05 for all categories). However, ethnicity did change significantly with a slight increase in the number of Hispanic patients diagnosed during the COVID-19 period as compared to the 2018 and 2019 time periods (p = 0.041) and the September 2019 to February 2020 time period (p = 0.0005). Conclusions: Through this retrospective analysis, we observed a decrease in new cancer diagnoses during the COVID-19 period with no significant differences in patient age, sex, cancer type, cancer stage or SES. There was a slight increase in cancer diagnoses among Hispanic patients during the COVID-19 period. These results suggest that most groups were equally impacted by the COVID-19 pandemic with respect to cancer diagnosis. However, this may be specific to the region we studied and limited by the population size and our means of collecting data about patient SES. Further studies comparing early and late impacts of COVID-19 on cancer care will be important to identify specific communities for targeted outreach and intervention.

Phase I study of entinostat in combination with enzalutamide for treatment of patients with castration-resistant prostate cancer

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Background: Entinostat (SNDX-275, MS-275) is an oral histone deacetylase (HDAC) inhibitor with selectivity towards class I and IV HDACs. Entinostat inhibits prostate cancer (PCa) growth and suppresses Treg cell function in vitro and in vivo. The primary objective of this study was to determine the safe dose of Entinostat in combination with Enzalutamide in prostate cancer patients (PCa). Methods: Phase I, 2 cohorts "3+3", dose-escalation study to explore the safety and preliminary efficacy of Entinostat in combination with Enzalutamide in castration-resistant PCa (CRPC). The planned dose level of Entinostat was 3 and 5 mg orally per week. CRPC Patients progressed on Enzalutamide or eligible for Enzalutamide, able to tolerate 160 mg daily dose (in the initial run-in phase if Enzalutamide naïve), ECOG 0-1, and acceptable organ functions were enrolled in the study. The safety profile of the combination therapy, PSA, pharmacokinetics of Enzalutamide post-Entinostat administration, and peripheral T cell subtype (including Treg), mononuclear cell (PBMC) histone 3 acetylation were analyzed. Results: Total 6 mCRPC patients were enrolled. There was no dose limiting toxicity related to Entinostat in these patients. No obvious increased fatigue related to Entinostat. Toxicities possibly or probably related to Entinostat or the combination therapy included G3 anemia 1/6 (17%), G2 WBC decrease 1/6 (17%), All other toxicities were grade 1 only (Nausea 2/6, anorexia 1/6, emesis 1/6, constipation 1/6, headache 1/6, platelet count decrease 1/6, hypokalemia 1/6, hypoalbuminemia 1/6, hypermagnesemia 1/6). The median duration of treatment with Entinostat was 18 weeks. For patients already progressed on Enzalutamide there was no PSA response after Entinostat was added. Entinostat did not affect the steady plasma concentration of Enzalutamide. Increased PBMC H3 acetylation was observed (up to 3.6 fold from baseline) in the tested samples. No evident T cell subtype, including Treg, changes from these sample analysis. Phase II part of the trial was terminated because of sponsor withdrawal. Conclusions: Entinostat at the selected dose levels in combination with standard dose of enzalutamide showed promising safety profile in this small phase I study. Clinical trial information: NCT03829930.

Abstract SS2-09: Telemedicine usability for cancer care during the COVID-19 pandemic

Background Healthcare delivery via telemedicine has increased substantially amid COVID-19. The George Washington Cancer Center (GWCC) now provides cancer care services via tele-visits for patients at high risk of morbidity and mortality secondary to COVID-19. This study was performed to assess usability of virtual cancer care delivery for patients and providers across specialties.

Methods Participants included patients and providers surveyed to assess baseline usability after initiating tele-visits. Surveys included demographics, Telehealth Usability Questionnaire (TUQ), and questions on perceived safety and preferences around telemedicine. Subjects also provided open-ended feedback for quality improvement.

Results For patients (n=133), 93% of surveys sent were completed and analyzed. Most patients were between ages 60-69 (26%), 70-79 (24%), 50-59 (22%). Breast cancer (41%) was the most commonly reported cancer type. Mean patient TUQ scores based on a 5-point scale (1-strongly disagree, 5 - strongly agree) were: 4.4 for Interface Quality (IfQ), 4.3 for Ease of Use (EU), 4.2 for Usefulness (U) and Satisfaction (S), 4.1 for Interaction Quality (ItQ), 3.4 for Reliability (R). No association was found between mean TUQ scores and age groups (p=0.33), sex (p=0.79), timing of diagnosis in relation to telemedicine visit (p=0.67), stage of diagnosis (p=0.98), or treatment type (p=0.65). However, patients with more telemedicine visits did score significantly higher in Reliability (P=0.018) and Satisfaction (P=0.039), compared to those with fewer telemedicine visits.

Compared to in-person visits, 77% of patients agreed/strongly agreed that telemedicine made them feel safer, 75% agreed/strongly agreed that it reduced stress, and 72% expressed interest in using it with other medical specialties.

For providers (n=109), 84% of surveys sent were completed and analyzed. Most providers were between ages 30-39 (33%) or 40-49 (21%), and 41% had 50 or more experiences with telemedicine. The predominant specialty participating was Internal Medicine (27%). Mean provider TUQ scores were 4.3 for U, 4.1 for S, 3.8 for EU, 3.7 for ItQ, 3.6 for IfQ, and 2.7 for R. No association was found between mean TUQ scores and experience with telemedicine (p=0.31), age groups (p=0.06), or specialty (p=0.53). However, providers with more experiences with telemedicine scored significantly higher in Satisfaction (p=0.01) and Usefulness (p=0.02).

The majority of providers (97%) agreed/strongly agreed that telemedicine improves access to care, yet 59% expressed concern about missing something they may have caught in person. Furthermore, older providers generally had lower reliability scores compared to younger providers (p=0.03), and also showed generally greater concern about losing personal interface with patients with the use of telemedicine than younger providers (p= 0.006).

Conclusion

The utility of telemedicine in cancer care during the COVID-19 pandemic was perceived favorably by both patients and providers. All patient groups scored highly on perceived safety, reduced stress and improved access, independently of subject characteristics. Older providers were more wary of the reliability of telemedicine and its effects on patient-provider relationships. These findings provide a useful benchmark for advancement of virtual care delivery in cancer care, beyond the COVID-19 pandemic.

Citation Format: Andrea Leon, Rebecca Kaltman, Hannah Arem, Richard Amdur, Andrea Gesteira, Samuel Duffy, Christian Miller, Brooke Burgess, Christiane Morecock. Telemedicine usability for cancer care during the COVID-19 pandemic [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr SS2-09.

Early phase process scale-up challenges for fungal and filamentous bacterial cultures

Culture pelleting and morphology has a strong influence on process productivity and success for fungal and filamentous bacterial cultures. This impact is particularly evident with early phase secondary metabolite processes with limited process definition. A compilation of factors affecting filamentous or pelleting morphology described in the literature indicates potential leads for developing process-specific control methodologies. An evaluation of the factors mediating citric acid production is one example of an industrially important application of these techniques. For five model fungal and filamentous bacterial processes in an industrial fermentation pilot plant, process development strategies were developed and effectively implemented with the goal of achieving reasonable fermentation titers early in the process development cycle. Examples of approaches included the use of additives to minimize pelleting in inoculum shake flasks, the use of large-volume frozen bagged inoculum obtained from agitated seed fermentors, and variations in production medium composition and fermentor operating conditions. Results were evaluated with respect to productivity of desired secondary metabolites as well as process scalability. On-line measurements were utilized to indirectly evaluate the cultivation impact of changes in medium and process development. Key laboratory to pilot plant scale-up issues also were identified and often addressed in subsequent cultivations.

Carbon and complex nitrogen source selection for secondary metabolite cultivation at the pilot scale

The fermentation of desmethyl-asterriquinone B-1, a diabetes target, by a Pseudomonasarias species was conducted at the 600-l scale using a revised complex medium containing yeast extract and soy hydrolysate. Oat flour and tomato paste were removed from this medium due to difficulties in sterilization. An initial cerelose charge of 40 g/l improved titer and reduced product degradation in the broth at cultivation conditions. An initial mannitol concentration of 65 g/l effectively avoided mid-cycle mannitol additions necessary for the 40 g/l mannitol concentration without the reduction in productivity seen at 90 g/l mannitol. These additions diluted the broth because of the low aqueous solubility of mannitol. Titers reached 3.0 g/l after 158 h with an optimized process, increasing two-fold from the original medium and operating conditions. Reproducible foaming occurred at the point of glucose exhaustion when the culture switched to mannitol consumption. Use of alternative carbon sources (glycerol, soybean oil, sorbitol in conjunction with cerelose) was not effective in attaining similar productivity and did not reduce the extent of foaming. In the case of fructose, the extent of foaming was markedly reduced but product formation was negligible.

Reproductive decisions after neonatal screening identifies cystic fibrosis

AIMS

To document the reproductive choices made by women in New South Wales, Australia, after neonatal screening has identified cystic fibrosis (CF).

METHODS

A sample of women attending cystic fibrosis clinics in New South Wales who had a child (or children) diagnosed by neonatal screening between 1981 and 1996 were interviewed.

RESULTS

Two thirds of the women chose to avoid having another child with CF. The uptake of prenatal diagnosis was 66% in women who had a subsequent pregnancy; of these 69% terminated or would have terminated an affected fetus. Fifty nine per cent of the women who decided against a further pregnancy made this decision in order to avoid having another child with CF.

CONCLUSIONS

These data show that having a child with CF influenced subsequent reproductive choices. In addition to the medical advantages of an early diagnosis offered by neonatal screening, this also allows informed future reproductive decisions.

Production of a family of kinase-inhibiting lactones from fungal fermentations

During the course of our screening for natural products from fungi, extracts of several cultures were found to make a family of related resorcylic acid lactone compounds, which are potent inhibitors of MEK kinase. Comparative and empirical studies of fermentation conditions improved the titers of the compounds of interest. Striking changes in the ratios and amounts of the major and minor compounds in some cases were achieved by manipulations of media composition.

Clinics go electronic: two stories from the field

We hear a lot about computerized record system implementations in hospitals, but other settings are making the transition as well. How does the move to an electronic record system affect day-to-day operations in clinics? Our writers tell how a student health center and a family clinic did it--and how they're working now.

Perforated duodenal ulcer presenting with shock in a child

Presentation of peptic ulcer disease in children covers a broad spectrum ranging from subtle, and thus overlooked and underdiagnosed, to catastrophic, as in this case. It is important for the emergency physician to realize the potential morbidity and mortality of this disease and be aware of the spectrum of presentation for primary and secondary pediatric ulcer disease.

A case of pneumatosis coli managed by restorative proctectomy and ileal pouch-anal anastomosis

Pneumatosis coli is a rare condition in which gas filled cysts occur in the wall of the intestines. Most symptomatic patients can be managed conservatively but those who fail medical management or who develop bowel obstruction will require surgery. Surgery usually involves a limited colectomy with a potential for recurrence. We describe a case of pneumatosis coli managed successfully by restorative proctocolectomy and ileal pouch-anal anastomosis.

Overexpression of ferredoxin I in Azotobacter vinelandii

Azotobacter vinelandii has recently been used for a variety of genetic experiments which take advantage of its facile transformation system and its high-frequency homologous recombination. One gene that has been cloned and sequenced is the fdxA gene that encodes a small Fe-S protein called A. vinelandii ferredoxin I (AvFdI). Because this protein has been extensively characterized by X-ray crystallography and spectroscopic methods, we are using it as a model to address some general questions in Fe-S biochemistry. AvFdI is not a very abundant protein in wild-type cells, so to facilitate our biochemical studies we have developed the overexpression system described herein. The results show that AvFdI can be easily overproduced ca. 50-fold in its native background, by introducing multiple copies of the fdxA gene into A. vinelandii, on the broad-host-range multicopy plasmid, pKT230. The protein can be expressed from its own constitutive promoter or from the controlled nifH promoter. The overproduced protein has no deleterious effects on the organism and is identical to the protein produced by wild-type cells. This A. vinelandii-based system should be generally useful for the overproduction of other A vinelandii proteins or for the expression of genes from thermophilic or other organisms with similarly high G-C contents, or for the expression of O2-sensitive metalloproteins that are unstable in other systems.

Characterization of cultured alveolar epithelial cell xanthine dehydrogenase/oxidase

Conversion of xanthine dehydrogenase (XDH) to xanthine oxidase (XO) and the toxic reactions of subsequent XO-derived superoxide, hydrogen peroxide and hydroxyl radical, have been suggested to be critical factors in several mechanisms of tissue pathophysiology. In the lung, intracellular XO-derived products may modulate type II pneumocyte surfactant turnover and barrier function, jeopardizing the pulmonary air-blood barrier. We characterized total cellular XDH/XO enzymatic activity in freshly isolated and cultured rat pulmonary type II epithelial cells. Type II cells were isolated and cultured on fibronectin-pretreated dishes, with a plating efficiency after 36 h in culture of 40% or 14% when quantified via cellular protein or DNA, respectively. Over the subsequent 96 h in culture, monolayer DNA was unchanged, whereas protein per cell increased continuously. Alterations in different cellular enzymatic activities were also detected in these cultured cells. In culture, total cellular XDH/XO and catalase activities decreased in a logarithmical fashion with respect to time, whether normalized for cellular protein or DNA. The rate of loss of these enzymes was greatest when normalized for cell protein, but was also significant when the activities were normalized for DNA. When compared to freshly isolated type II cells, catalase and total XDH/XO activities normalized for protein decreased 78% and 72%, respectively, during the first 36 h of culture. After 132 h in culture, XDH/XO and catalase activities normalized for protein decreased 93% and 84%, respectively, when compared to freshly isolated cell values. Total cellular XDH/XO activity in the oxidase form (% XO) was initially 31% in freshly isolated type II cells and increased to 67% during the 132 h culture period. In contrast to the loss of total cellular XDH/XO and catalase, no significant change in lactate dehydrogenase (LDH) activity occurred during culture of the type II cells. In type II cells the conversion of XDH to XO, the cytotoxic potential of XO, and the activity of the hydrogen peroxide scavenger, catalase, is expected to be strongly influenced by in vitro culture. Thus, strong consideration should be made before transposing information obtained from cultured type II cells to in vivo situations.

A study of postmortem autolysis in the human organ of Corti

Forty-six human temporal bones from 24 individuals were removed at autopsy and prepared for electron microscopy. The adequacy of histologic preservation was evaluated by light and electron microscopy. Characteristic autolytic changes included vacuolization of afferent neurons and neural poles of inner and outer hair cells, lysis of limiting membranes of hair and supporting cells, swelling of endoplasmic reticulum, and dissolution of mitochondrial cristae. The rate of autolysis varied significantly within cellular components of the inner ear. The neural poles of hair cells demonstrated more rapid autolysis than apical poles and nerve terminals showed more autolysis than myelinated nerve fibers. Postmortem time and the cause of death affected the adequacy of histologic preservation. Fixation in patients dying of pneumonia, hypoxia, head injury, or malignancy tended to be poor, whereas the fixation achieved in patients dying of cardiac disease with postmortem time of under 140 minutes was generally good.

Cochleosaccular degeneration of the inner ear and progressive cataracts inherited as an autosomal dominant trait

A new syndrome of cataracts and progressive sensorineural hearing loss, inherited as an autosomal dominant trait, is described. The histopathology of the inner ears in the proband demonstrated severe degeneration limited to the cochlea and saccule. This case represents the second reported example of genetically determined cochleosaccular degeneration in man. The cochleosaccular pattern of histopathology is found in both man and animals and may be the end result of prenatal dysplasia or postnatal degeneration. It also appears that cochleosaccular dysplasia and degeneration may be the result of genetically determined or acquired defects. Previously reported examples of cochleosaccular dysplasia and degeneration are reviewed including human cases in which the histopathology is similar to, but not characteristic of, the cochleosaccular pattern.

Depressed cell-mediated immunity in megaloblastic anemia due to folic acid deficiency

Cell-mediated immunity has been studied in patients with 1) megaloblastic anemia of folic acid deficiency, 2)megaloblastic anemia of pregnancy, or 3) iron-deficiency anemia. Using dinitrochlorobenzene skin tests, phytohemagglutinin-stimulated lymphocyte transformation, and rosette inhibition by antilymphocyte globulin, we have shown that cell-mediated immunity is depressed in megaloblastic anemia due to folate deficiency; this depression was reversed by folate treatment. Cell-mediated immunity was not impaired by iron-deficiency anemia. Suggested interactions between iron deficiency and folate metabolism were not clarified by these studies.