Tumor resistance to anti-mesothelin CAR-T cells caused by binding to shed mesothelin is overcome by targeting a juxtamembrane epitope

Despite many clinical trials, CAR-T cells are not yet approved for human solid tumor therapy. One popular target is mesothelin (MSLN) which is highly expressed on the surface of about 30% of cancers including mesothelioma and cancers of the ovary, pancreas, and lung. MSLN is shed by proteases that cleave near the C terminus, leaving a short peptide attached to the cell. Most anti-MSLN antibodies bind to shed MSLN, which can prevent their binding to target cells. To overcome this limitation, we developed an antibody (15B6) that binds next to the membrane at the protease-sensitive region, does not bind to shed MSLN, and makes CAR-T cells that have much higher anti-tumor activity than a CAR-T that binds to shed MSLN. We have now humanized the Fv (h15B6), so the CAR-T can be used to treat patients and show that h15B6 CAR-T produces complete regressions in a hard-to-treat pancreatic cancer patient derived xenograft model, whereas CAR-T targeting a shed epitope (SS1) have no anti-tumor activity. In these pancreatic cancers, the h15B6 CAR-T replicates and replaces the cancer cells, whereas there are no CAR-T cells in the tumors receiving SS1 CAR-T. To determine the mechanism accounting for high activity, we used an OVCAR-8 intraperitoneal model to show that poorly active SS1-CAR-T cells are bound to shed MSLN, whereas highly active h15B6 CAR-T do not contain bound MSLN enabling them to bind to and kill cancer cells.

Role of socioeconomic factors in developing mycetoma: Results from a household survey in Sennar State, Sudan

BACKGROUND

Mycetoma is a chronic, progressively destructive disease of subcutaneous tissues and bones caused by certain species of bacteria or fungi. We conducted a cross-sectional community-based study alongside mapping of mycetoma in five administrative units with high mycetoma endemicity in the Eastern Sennar Locality, Sennar State, Sudan.

METHODS

A household survey was administered which included questions about the household members, household characteristics, economic activity and history of mycetoma. A clinical examination was conducted on all members of the household. If mycetoma was suspected, an individual questionnaire was completed collecting demographic, clinical and epidemiological data as well as information on the use of health care and associated costs. Geographical coordinates and photos of the lesions were taken, and the affected persons were referred to the medical centre for confirmation of the diagnosis and treatment. We compared the characteristics of households with confirmed cases of mycetoma with those without confirmed cases, and individuals with confirmed mycetoma with those in whom mycetoma was not confirmed.

RESULTS

In total 7,798 households in 60 villages were surveyed; 515 suspected cases were identified and 359 cases of mycetoma were confirmed. Approximately 15% of households with mycetoma had more than one household member affected by this disease. Households with mycetoma were worse off with respect to water supply, toilet facilities, electricity and electrical appliances compared to the survey households. Only 23% of study participants with mycetoma had sought professional help. Of these, 77% of patients travelled an average of six hours to visit a medical facility. More than half of patients had to pay towards their treatment. The estimated average cost of treatment was 26,957 Sudanese pounds per year (566 US dollars, exchange rate 2018).

CONCLUSIONS

Results of this survey suggest that agricultural practices and reduced access to sanitation and clean water can be risk factors in developing mycetoma. Poor access to health care and substantial financial costs were barriers to seeking treatment for mycetoma.

Estimating the burden of mycetoma in Sudan for the period 1991-2018 using a model-based geostatistical approach

Mycetoma is widespread in tropical and subtropical regions favouring arid areas with low humidity and a short rainy season. Sudan is one of the highly endemic countries for mycetoma. Estimating the population at risk and the number of cases is critical for delivering targeted and equitable prevention and treatment services. In this study, we have combined a large dataset of mycetoma cases recorded by the Mycetoma Research Centre (MRC) in Sudan over 28 years (1991-2018) with a collection of environmental and water and hygiene-related datasets in a geostatistical framework to produce estimates of the disease burden across the country. We developed geostatistical models to predict the number of cases of actinomycetoma and eumycetoma in areas considered environmentally suitable for the two mycetoma forms. Then used the raster dataset (gridded map) with the population estimates for 2020 to compute the potentially affected population since 1991. The geostatistical models confirmed this heterogeneous and distinct distribution of the estimated cases of eumycetoma and actinomycetoma across Sudan. For eumycetoma, these higher-risk areas were smaller and scattered across Al Jazirah, Khartoum, White Nile and Sennar states, while for actinomycetoma a higher risk for infection is shown across the rural districts of North and West Kurdufan. Nationally, we estimated 63,825 people (95%CI: 13,693 to 197,369) to have been suffering from mycetoma since 1991 in Sudan,51,541 people (95%CI: 9,893-166,073) with eumycetoma and 12,284 people (95%CI: 3,800-31,296) with actinomycetoma. In conclusion, the risk of mycetoma in Sudan is particularly high in certain restricted areas, but cases are ubiquitous across all states. Both prevention and treatment services are required to address the burden. Such work provides a guide for future control and prevention programs for mycetoma, highly endemic areas are clearly targeted, and resources are directed to areas with high demand.

Individual Risk Factors of Mycetoma Occurrence in Eastern Sennar Locality, Sennar State, Sudan: A Case-Control Study

Mycetoma is a serious chronic subcutaneous granulomatous inflammatory disease that is endemic in tropical and subtropical regions, where it impacts profoundly on patients, families, and communities. Individual-level risk factors for the disease are poorly understood. To address this, a case-control study was conducted based on data collected from 60 villages in Eastern Sennar Locality, Sennar State, Sudan. Based on the presence of swelling in any part of the body, or sinus formation with or without grain discharge evident from the lesion by ultrasound examination, we diagnosed 359 cases of mycetoma. For each case, we included three healthy sex-matched persons, with no evidence of mycetoma, from the same village as the control group (n = 1077). The odds for mycetoma were almost three times higher in individuals in the age group 16–30 years (Adjusted Odds Ratio (AOR) = 2.804, 95% CI = 1.424–5.523) compared to those in age group ≤ 15 years. Other factors contributing to the odds of mycetoma were history of local trauma (AOR = 1.892, 95% CI = 1.425–2.513), being unmarried (AOR = 3.179, 95% CI = 2.339–4.20) and owning livestock (AOR = 3.941, 95% CI = 2.874–5.405). In conclusion, certain factors found to be associated with mycetoma in this study could inform a high index of suspicion for mycetoma diagnosis, which would improve early case detection. Other factors found to be associated could inform the development of an interventional program for mycetoma control in Sudan, including education on healthy farming practices and the risks of puncture wounds for individuals residing in endemic areas. However, this work was conducted in one endemic state, while mycetoma cases occur in all states of Sudan. Replicating this study over a wider area would give a fuller picture of the situation, providing the control program with more comprehensive information on the risk factors for the disease.

Clinical epidemiological characteristics of mycetoma in Eastern Sennar locality, Sennar State, Sudan

Mycetoma epidemiological features remain uncharacterised. Few studies have been conducted in a community-based setting to explore the epidemiological features and risk factors for mycetoma in Sudan. To bridge this gap, this study was conducted in Eastern Sennar Locality, Sennar State, Sudan, to report the clinical, epidemiological characteristics of mycetoma patients and the disease burden in the state. We used cluster sampling; sixty villages were randomly selected across the locality's five administrative units, and a household-to-household survey was conducted. We collected data using pre-designed questionnaires at the community, household, and individual levels. We performed descriptive analyses of the data and produced prevalence maps using ArcGIS 10.5 ([ESRI] Inc., Redlands CA, USA). A total of 41,176 individuals were surveyed, and 359 mycetoma patients were identified. The overall prevalence of mycetoma was 0.87% (95%CI = 0.78-0.97%), the prevalence among males was 0.83% (95%CI = 0.71-0.96%), and females 0.92% (95% CI = 0.79-1.06%). Individuals in the age group 31-45 years had the highest prevalence among the different age groups (1.52%, 95% CI = 1.23-1.86%). The prevalence map showed patients clustered within the central and north-eastern part of the locality, while villages in the south-western part had few or no cases. In conclusion, this clinical epidemiological study is pioneering and shows that mycetoma is prevalent in certain parts of Sudan. This data obtained will support the design of measures to reduce the disease burden in the state. The survey procedures and protocols can be adopted for further studies in Sudan and beyond.

Modelling the spatial distribution of mycetoma in Sudan

BACKGROUND

Mycetoma is a neglected tropical disease that is reported worldwide and Sudan has the highest reported number of mycetoma infections across the globe. The incidence, prevalence and burden of mycetoma globally are not precisely known and its risk factors remain largely unelucidated.

METHODS

This study aimed to identify the environmental predictors of fungal and bacterial mycetoma in Sudan and to identify areas of the country where these niche predictors are met. Demographic and clinical data from confirmed mycetoma patients seen at the Mycetoma Research Centre from 1991 to 2018 were included in this study. Regression and machine learning techniques were used to model the relationships between mycetoma occurrence in Sudan and environmental predictors.

RESULTS

The strongest predictors of mycetoma occurrence were aridity, proximity to water, low soil calcium and sodium concentrations and the distribution of various species of thorny trees. The models predicted the occurrence of eumycetoma and actinomycetoma in the central and southeastern states of Sudan and along the Nile river valley and its tributaries.

CONCLUSION

Our results showed that the risk of mycetoma in Sudan varies geographically and is linked to identifiable environmental risk factors. Suitability maps are intended to guide health authorities, academic institutes and organisations involved in planning national scale surveys for early case detection and management, leading to better patient treatment, prevention and control of mycetoma.

Modifications to Hepatopancreatobiliary surgical services during COVID-19 partial lockdown in a hospital in northern Malaysia

Maintaining hepatopancreatobiliary (HPB) services during the initial phase of a pandemic in a state referral hospital for COVID-19 presents a few challenges, especially when a nationwide, government-issued partial lockdown is in enforcement. We describe the adaptations to our practice to maintain the services whilst ensuring safety of patients and staff, by postponing non-urgent clinic cases, grouping our staff to two mutually exclusive teams that work on alternate shifts and selecting HPB operative cases according to the modified Risk Urgency Decision Matrix.

Human actinomycetoma caused by Actinomadura mexicana in Sudan: the first report

Mycetoma is a localized, chronic, granulomatous disease that can be caused by fungi (eumycetoma) or bacteria (actinomycetoma). Of the 70 different causative agents implicated in mycetoma worldwide, Actinomadura madurae is the only one that causes multiple cases on all continents. Recently, new Actinomadura species were described as causative agents of human mycetoma. One of these new causative agents was Actinomadura mexicana, which was identified in Latin America. Here we demonstrate that this causative agent is not confined to Latin America and that it is also a causative agent of actinomycetoma in Sudan. The disease was managed by antibiotic treatment alone and resulted in complete cure after 6 months of treatment, which is quick when compared with actinomycetoma cases caused by other Actinomadura species.

POS1276 LONG TERM OUTCOME OF MULTIPLE ULTRASOUND GUIDED SUPRASCAPULAR NERVE BLOCK IN TREATMENT OF FROZEN SHOULDER IN DIABETIC PATIENTS

Background:

Frozen shoulder is prevalent among diabetic patients, and usually has aggressive course, with more tendency to be bilateral and resistant to treatment. Suprascapular nerve block (SSNB) is used with increasing frequency by anesthetists and rheumatologists in the management of frozen shoulder. We previously introduced a protocol of nine injections for SSNB with better short term outcome than single SSNB injection (1). Long term outcome of SSNB in management of frozen shoulder is still not detected.

Objectives:

To evaluate the long term effect of multiple (nine) ultrasound guided supra-scapular nerve block in treatment of diabetic frozen shoulder.

Methods:

A retrospective cohort study followed up 40 diabetic patients who received a course of ultrasound guided multiple supra-scapular nerve block (9 injections) on 2014. In this study we retrospectively assessed the patients from previously recorded data at a mean duration of 6 years after completing the 9 injection course SSNB clinically by measuring the shoulder active range of motion (using a goniometer in three planes: abduction, internal, and external rotation). Visual analogue scale and Functional assessment by shoulder pain and disability index (SPADI).

Results:

Thirty four patients (85% of original cohort) completed the long term follow up.

The patients were 19 (55.9%) females, 60.6 y mean age, and the mean of disease duration was 85.6 months. The majority of patients (33 patients 97.05%) continues improvement and gained within normal complete range of motions in all directions and excellent grades of shoulder function (Table 1).

Table 1.Clinical ParametersAt base lineAt 4 monthsLast follow up at (72months±4)**P valueSPADI pain score (100)(68.8 ± 0.5)a(10.3 ± 7.4)b(0.9±1.9)c0.00*SPADI disability score (100)(69.2 ± 7.7)a(6.25 ± 2.25)b(0.4±0.8)c0.00*SPADI total (100)(69.1 ± 8.5)a(8.15 ± 5.4)b(1.1±0.9)c0.00*Patient global assessment (100)(90.2 ± 8.2)a(8.2 ± 4.2)b(0.4±2.1)c0.00*Night pain (100)(55.4±10.2)a(10.3 ± 4.9)b(2.3±1.1)c0.00*Abduction (180°)(77.5 ± 4.7)a(170.3 ± 10.3)b(174.2±6.2)b0.00*External rotation (100 °)(46 ± 12.6)a(80.1 ± 10.2)b(86.4±10.3)b0.00*Internal rotation (70 °)(34.5 ± 2.4)a(55.4 ± 10.1)b(60.2±9.5)b0.00*

* P <0.05 there was a statistical significant difference

•A,b,c--- the alphabet of different symbols ---means a significant statistical difference between groups

SPADI: shoulder pain and disability index

Conclusion:

The multiple injection courses for supra-scapular nerve block has an excellent long term efficacy as treatment of diabetic frozen shoulder. This method should be the treatment of choice in patients of diabetic frozen shoulder who do not respond to physiotherapy.

References:

[1]Mortada, M. A., Ezzeldin, N., Abbas, S. F., Ammar, H. A. & Salama, N. A. Multiple versus single ultrasound guided suprascapular nerve block in treatment of frozen shoulder in diabetic patients. J. Back Musculoskelet. Rehabil. 30, 537–542 (2017).

Disclosure of Interests:

None declared

Association of interleukin-17A rs2275913 polymorphism with rheumatoid arthritis susceptibility in Sudanese population

Objectives:

Rheumatoid arthritis is a chronic inflammatory autoimmune disease. This study aimed to determine the association of interleukin-17A-197G/A polymorphism with rheumatoid arthritis in Sudanese patients.

Methods:

A case–control study was conducted between March and December 2018. Clinical and demographic data of the study participants were collected and analyzed. Polymerase chain reaction restriction fragment length polymorphism molecular technique was done to investigate interleukin-17A-197G/A polymorphisms. All statistical tests were considered statistically significant when p < 0.05.

Results:

The study population included 266 participants aged between 1 and 85 years, with an average of 40 years, classified into 85 (31.2%) cases (mean age 48.5 ± 11.3 years), and 181 (68.8%) controls (mean age 35.3 ± 15.9 years). The interleukin-17A homozygote AA genotype was more frequent among the control group compared to the case group; 95 (52.5%) and 7 (8.2%), respectively. The homozygote GG and the heterozygote AG genotypes were proportionally not different among the cases and control groups; 13 (54.2%) and 11 (45.8%), and 65 (46.4%) and 75 (53.6%), respectively. According to the distribution of interleukin-17A genotypes, a statistically significant difference was observed among cases with the interleukin-17A AA and AG genotypes, p values 0.001 and 0.004, respectively. For the association interleukin-17A genotypes and family history a negatively significant association was reported (95% confidence interval, –0.219, p value = 0.001). There was also a negatively significant association of interleukin-17A genotypes and anti-cyclic citrullinated peptide (95% confidence interval, −0.141, p value = 0.002).

Conclusion:

This study is the first study in Sudan established the association between interleukin-17A-197G/A (rs2275913) polymorphisms and susceptibly to rheumatoid arthritis. These findings appeal for further research in Sudan to investigate the exact role of IL-17A in immunopathology and disease severity among Sudanese rheumatoid arthritis

Emergency Laparotomy in a COVID-19 patient with acute abdomen

We describe here the first laparotomy involving a COVID-19 patient in Malaysia. A 60-year-old man screened positive for SARS-CoV-2 in March 2020 and developed acute abdomen in the ward in Hospital Sultanah Bahiyah, Kedah. He underwent laparotomy and cholecystectomy for gangrenous cholecystitis. All personnel adhered to infectious control precautions, donning full personal protective equipment (PPE) throughout the surgery. Post-operatively, due to raised septic parameters, he was carefully diagnosed with and treated empirically for superimposed bacterial sepsis instead of cytokine release syndrome, with confirmed blood culture of Klebsiella pneumoniae. Patient was discharged well later. None of the staff involved in his care developed COVID-19 infection.

Molecular detection of human papillomavirus-16 among Sudanese patients diagnosed with squamous cell carcinoma and salivary gland carcinoma

OBJECTIVE

Human papillomavirus (HPV) gained momentum as a potential etiological factor for many types of cancers. Therefore, the aim of this study was to assess the prevalence of HPV-16 infection among Sudanese patients diagnosed with Squamous Cell Carcinoma (SCC) and Salivary Gland Carcinoma. A descriptive, hospital-based study was conducted. 150 formalin-fixed paraffin-embedded blocks were collected.

RESULTS

The study population included a total of 150 patients aged between 18 to 87 years with a mean age of 48.8 ± 11.9 years. Based on gender, females constituted 46.7% while males constituted 53.3%. The 150 patients were classified into 40 (26.0%) esophageal, 30 (20.0%) nasopharyngeal, 18 (12.0%) conjunctival, 18 (12.0%) tongue 12 (8.0%) laryngeal, 8 (5.3%) lip, 6 (4.0%) oropharyngeal, 6 (4.0%) mucoepidermoid, and 6 (4.0%) adenoid cystic, and 6 (4.0%) myoepithelial carcinomas. Odds ratio for male and female diagnosed with carcinoma was 1.025 [0.439-2.394, 95% CI]. Molecular detection of HPV-16 revealed a prevalence of 26 (17.3%) patients were positive for HPV-16. According to cancer diagnosis, esophageal SCC patients showed a high proportion of HPV-16; 14/40 (35.0%). A statistically significant difference was seen for the distribution of HPV-16 positive patients based on cancer diagnosis, P value 0.001.

Clinical implications of conventional cytogenetics, fluorescence in situ hybridization (FISH) and molecular testing in chronic myeloid leukaemia patients in the tyrosine kinase inhibitor era - A review

Chronic myeloid leukaemia (CML) provides an illustrative disease model for both molecular pathogenesis of cancer and rational drug therapy. Imatinib mesylate (IM), a BCR-ABL1 targeted tyrosine kinase inhibitor (TKI) drug, is the first line gold standard drug for CML treatment. Conventional cytogenetic analysis (CCA) can identify the standard and variant Philadelphia (Ph) chromosome, and any additional complex chromosome abnormalities at diagnosis as well as during treatment course. Fluorescence in situ hybridization (FISH) is especially important for cells of CML patients with inadequate or inferior quality metaphases or those with variant Ph translocations. CCA in conjunction with FISH can serve as powerful tools in all phases of CML including the diagnosis, prognosis, risk stratification and monitoring of cytogenetic responses to treatment. Molecular techniques such as reverse transcriptase-polymerase chain reaction (RT-PCR) is used for the detection of BCR-ABL1 transcripts at diagnosis whereas quantitative reverse transcriptase-polymerase chain reaction (qRTPCR) is used at the time of diagnosis as well as during TKI therapy for the quantitation of BCR-ABL1 transcripts to evaluate the molecular response and minimal residual disease (MRD). Despite the excellent treatment results obtained after the introduction of TKI drugs, especially Imatinib mesylate (IM), resistance to TKIs develops in approximately 35% - 40% of CML patients on TKI therapy. Since point mutations in BCR-ABL1 are a common cause of IM resistance, mutation analysis is important in IM resistant patients. Mutations are reliably detected by nested PCR amplification of the translocated ABL1 kinase domain followed by direct sequencing of the entire amplified kinase domain. The objective of this review is to highlight the importance of regular and timely CCA, FISH analysis and molecular testing in the diagnosis, prognosis, assessment of therapeutic efficacy, evaluation of MRD and in the detection of BCR-ABL1 kinase mutations which cause therapeutic resistance in adult CML patients.

Prevalence of Helicobacter pylori among Sudanese patients diagnosed with colon polyps and colon cancer using immunohistochemistry technique

Objectives

Infection with the bacteria Helicobacter pylori has been classified as class one carcinogen associated with increasing susceptibility of gastritis and gastric carcinoma. This study is aiming at investigating the prevalence of H. pylori among colon polyps and colon cancer patients. A descriptive cross-sectional hospital-based study was conducted between February and June 2017. Sixty-nine formalin-fixed paraffin blocks collected from colon polyps and colon cancer patients to detect H. pylori using immunohistochemistry technique.

Results

Of the 69 patients included in the study, 39 (56.5%) males and 30 (43.5%) were females, their age ranged from 21 to 80 years with a mean age of 47.1 ± 19.7. Of the 69 colon polyps and colon cancer patients, 44 (63.8%) were diagnosed as adenocarcinoma, 10 (14.5%) colitis, 15 (21.7%) juvenile polyposis syndrome. The results of immunohistochemistry technique showed the presence of 16 (23.2%) positive patients for H. pylori infection. Of these 16, 13 (81.3%) patients were diagnosed with adenocarcinoma and 3 (18.7%) patients were diagnosed with juvenile polyps. The results of H. pylori detection among the different colon polyps and colon cancer patients were showing a statistically significant association for H. pylori infection and adenocarcinoma, P value 0.028.

Immunohistochemical expression of Cyclin D1 among Sudanese patients diagnosed with benign and malignant prostatic lesions

Objectives

Prostate cancer (PC) is common cancer worldwide. Several markers have been developed to differentiate between benign prostatic hyperplasia (BPH) from PC. A descriptive retrospective hospital-based study aimed at determining the expression of Cyclin D1 in BPH and PC. The study took place at different histopathology laboratories in Khartoum state, Sudan, from December 2016 to January 2019. Formalin-fixed paraffin-embedded blocks were sectioned and fixed in 3-aminopropyltriethoxysilane coated slides incubated into primary antibody for Cyclin D1. The assessment of immunoreactivity of Cyclin D1 of each section was done using the Gleason scoring system.

Results

A total of 153 males’ prostate sections included in this study, of them, 120 (78.4%) were PC, and 33 (21.6%) were BPH. Their age ranged from 45 to 88 years, mean age was 66.19 ± 8.599. 142 (92.8%) did not have a family history of PC, while 11 (7.2%) patients reported having a family history. The Gleason scoring showed a total of 81 (52.9%) patients with high-grade and 39 (25.5%) with low-grade. 118 (97.5%) patients had PC showed positive results for Cyclin D1, while BPH was 3 (2.5%). P value < 0.001. Cyclin D1 staining was associated with high-grade Gleason score and perineural invasion, P value 0.001.

AB0177 RHEUMATOID ARTHRITIS SAUDI DATABASE (RASD): A SINGLE CENTER EXPERIENCE

Background:

National Registries are essential to direct current practice and design appropriate management strategies1. Rheumatoid arthritis (RA) registries in the middle east and north Africa remain scarcely represented2.

Objectives:

Our objective is to describe the Saudi RA population and to compare the findings to internationally reported data.

Methods:

This is a cross sectional, analytical study that was conducted at Doctor Soliman Fakeeh Hospital (DSFH). The study ran from December of 2014 and concluded in December of 2018 using a pool of 433 patients. Inclusion criteria included adults older than 18 years of age who fulfilled the 2010 American College of Rheumatology criteria for diagnosis of RA3. Data were collected from patients and entered in a specially designed program for this registry. They included main demographic details,, lag times to final disease diagnosis. Disease Activity Score-28-C Reactive Protein (DAS-28-CRP) was calculated on presentation and on subsequent visits with intervals ranging from three to six months between them. Multiple regression model was used to assess the predictors of disease activity. We charted the lines of medications given, including conventional and biologic disease modifying antirheumatic drugs (DMARDs), following treat to target strategies4.

Results:

Out of 430 patients, 76.68% were female, while only 23.32% were male and the mean age was found to be 49.26 years with SD±11.

At initial presentation, 45.5% had demonstrated active disease (moderate or high disease activity) based on DAS-28-CRP scores while 54.5% were in remission or low disease activity. Out of the total number of clinic visitors, 330 had regular follow ups for more than 1 year while 103 patients were either irregularly visiting the rheumatology clinic or had lost follow up. The remission rates after 1 year had increased to 79.7% (263 patients), while 9.7% (32 patients) had low disease activity and no patients had sustained high disease activity at the end of follow up. It was also found that the female gender, higher Health Assessment Questionnaire-Disability Index (HAQ-DI) and a longer lag1/lag2 period were associated with higher disease activity in our population. Biologic medications had been used by 129 patients (29.7%) while conventional DMARDs were given to 304 patients (70.3%).

Conclusion:

We described a population of RA patients in a single center in SA. We detected higher remission rates at one year of follow up. This could be attributed to many factors, including good referral systems and treat to target strategies with easier access to biologic medications.

References:

[1]Singh JA, Saag KG, Bridges SL Jr, Akl EA, Bannuru RR, Sullivan MC, Vaysbrot E, McNaughton C, Osani M, Shmerling RH, Curtis JR, Furst DE, Parks D, Kavanaugh A, O’Dell J, King C, Leong A, Matteson EL, Schousboe JT, Drevlow B, Ginsberg S, Grober J, St Clair EW, Tindall E, Miller AS, McAlindon T. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis.Arthritis Rheumatol.2016 Jan;68(1):1-26.

[2]Smolen, Josef S., et al. “EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update.”Annals of the rheumatic diseases73.3 (2014): 492-509.

[3]Saag KG, Teng GG, Patkar NM, Anuntiyo J, Finney C, Curtis JR, et al. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis.Arthritis Rheum2008;59: 762–84.

[4]Hussain W, Noorwali A, Janoudi N. From symptoms to diagnosis: an observational study of the journey of rheumatoid arthritis patients in Saudi Arabia.Oman Med J.2016;31(1):29.

Disclosure of Interests:

Rola Hassan Grant/research support from: Pfizer pharmaceuticals, Mohamed Cheikh Grant/research support from: Pfizer pharmaceuticals, Hani Almoallim Grant/research support from: Pfizer pharmaceuticals, Hanan Faruqui Grant/research support from: Pfizer pharmaceuticals, Reem AlQuraa Grant/research support from: Pfizer pharmaceuticals, Ayman Eissa Grant/research support from: Pfizer pharmaceuticals, Aous Alhazmi Grant/research support from: Pfizer pharmaceuticals, Nahid Janoudi Grant/research support from: Pfizer pharmaceuticals

Is Procalcitonin more superior to hs-CRP in the diagnosis of infection in diabetic foot ulcer?

INTRODUCTION

Procalcitonin (PCT) has recently emerged as a marker for diagnosing infection. This study aimed to compare the performance of PCT and other infection markers in diagnosing infected diabetic foot ulcer (IDFU).

MATERIALS AND METHODS

A total of 128 diabetic patients with foot ulcers were recruited and divided into two groups, consisting of 73 patients in the IDFU group and 55 in the non-infected diabetic foot ulcer (NIDFU). The severity of infection in IDFU patients was graded based on the Infectious Disease Society of America-International Working Group on the Diabetic Foot classification. Blood samples from all the patients were collected for measurement of PCT, high sensitivity C-reactive protein (hs-CRP) and white cell count (WBC). The area under the receiver operating curves (AUC) were then constructed and analysed.

RESULTS

PCT, hs-CRP and WBC levels were significantly higher in the IDFU group compared to NIDFU with hs-CRP demonstrated the highest AUC (0.91; p <0.001) followed by PCT (0.814; p < 0.001) and lastly WBC (0.775; p < 0.001). The best cut off value, sensitivity and specificity for the presence of infection in diabetic foot, were 3.47 mg/dL, 80% and 89% for hs-CRP, 0.11 ng/ml, 70% and 87% for PCT and 11.8x109/L, 60% and 90% for WBC. All the infection markers showed significant positive correlations with infection severity of DFU.

CONCLUSION

This study showed that hs-CRP is a more sensitive marker for diagnosing IDFU. Although PCT is useful in differentiating IDFU from NIDFU, the use of PCT is not necessary as it adds little value to the current practice.

Jejunal metastasis of Merkel cell carcinoma: case report

Merkel cell carcinoma (MCC) of the skin is a rare but aggressive cutaneous neuroendocrine-derived malignancy that predominantly affects elderly white males. The presence of distant nodal metastases significantly impacts survival. Typical metastatic sites of MCC are liver, bone, brain and skin. Gastrointestinal metastases are uncommon and small bowel is the most common site followed by stomach. We report a case of symptomatic MCC jejunal metastasis.

Mirizzi syndrome: a challenging diagnosis. Case report

Mirizzi Syndrome (MS) is an uncommon complication of chronic gallstone disease defined as a common bile duct (CBD) obstruction secondary to gallstone impaction in the cystic duct or gallbladder neck. MS is still a challenging clinical situation: preoperative diagnosis of MS is complex and can be made in 18-62.5% of patients. Over 50% of patients with MS is diagnosed during surgery. In most of cases, laparotomy is the preferred surgical approach. We report the case of a 70-year-old woman with a history of asthenia, jaundice, abdominal pain and preoperative imaging that suggest the presence of biliary stones with a choledocal stenosis. Intraoperatively, a MS with cholecysto-biliary fistula involving less than two-thirds of the circumference of the bile duct was diagnosed and successfully treated.

Pseudomixoma peritonei associated with appendiceal cistoadenoma rupture: case report

Appendiceal mucocele represents specimen finding in 0.2-0.3% out of appendectomies. The rupture or perforation in peritoneal cavity might cause pseudomixoma peritonei (PMP), with multiple mucinous deposits in the abdominal cavity. We report a case of PMP caused by a perforated appendiceal cistoadeonoma.

Intrathecal administration of autologous bone marrow stromal cells improves neuropathic pain in patients with spinal cord injury

Neuropathic pain (NP) is highly disabling, responds poorly to pharmacological treatment, and represents a significant cause of decreased quality of life in patients suffering from spinal cord injury (SCI). In recent years, cell therapy with autologous mesenchymal stromal cells (MSCs) has been considered as a potential therapeutic weapon in this entity. Ten patients suffering chronic SCI received 100 million MSCs into subarachnoid space by lumbar puncture (month 1 of the study) and this procedure was repeated at months 4 and 7 until reaching a total doses of 300 million MSCs. Intensity of NP was measured by standard numerical rating scale (VAS) from 0 to 10, recording scores previous to the first MSCs administration and monthly, until month 10 of follow-up. Months 1, 4, 7 and 10 of the study were selected as time points in order to a statistical analysis by the nonparametric Wilcoxon rank test. Our results showed significant and progressive improvement in NP intensity after the first administration of MSCs (p: 0.003). This study supports the benefit of intrathecal administration of autologous MSCs for the treatment of NP in patients with SCI.

Potential use of cord blood for Hb E hemoglobinopathy screening programme using capillary electrophoresis

BACKGROUND

Thalassemia and hemoglobinopathies are inherited red blood cell disorders found worldwide. Hemoglobin (Hb) E disorder is one of the hemoglobinopathies known to have the high prevalence in South East Asia. Most of transfusion-dependent thalassemias were genotypically compound heterozygous Hb E/ β-thalassemia. In Malaysia, the national screening program for thalassemia was implemented for early pregnancy or secondary school girls; however many participants do not turn-up and missed the screening test. Screening for thalassemia using samples from cord blood is an alternative choice as it is a readily available source of blood and hence early detection of the disease. The purpose of this study was to determine the potential use of cord blood for the screening of HbE hemoglobinopathy by using capillary electrophoresis (CE).

METHODS

Cord blood samples were collected from 300 newborns of healthy mothers. Hematological parameters were determined and hemoglobin quantitation for all cord blood samples were performed using capillary electrophoresis system (CES) and high performance liquid chromatography (HPLC).

RESULTS

Majority of cord blood samples (63%) revealed Hb AF followed by Hb AFA2 (20%). Hb AFE was detected in 10.7% with the mean value of Hb E ranging from 2.3%-11.1%.

CONCLUSION

Hemoglobin E was detected in cord blood using capillary electrophoresis system. It can be recommended in areas where Hb E/β is prevalent. Implementation of a screening strategy using CE on cord blood sampling will identify the disease early. With regular follow-up on these patients, the status of their disease can be determined earlier and appropriate management implemented.

The burden of HPV associated cancers in two regions in Nigeria 2012-2014

INTRODUCTION

HPV attributable cancers are the second most common infection-related cancers worldwide, with much higher burden in less developed regions. There are currently no country-specific estimates of the burden of these cancers in Nigeria just like many other low and middle income countries.

METHODS

In this study, we quantified the proportion of the cancer burden in Nigeria that is attributable to HPV infection from 2012 to 2014 using HPV prevalence estimated from previous studies and data from two population based cancer registries (PBCR) in Nigeria. We considered cancer sites for which there is strong evidence of an association with HPV infection based on the International Agency for Research on Cancer (IARC) classification. We obtained age and sex-specific estimates of incident cancers and using the World Standard Population, we derived age standardized incidence (ASR) rates for each cancer type by categories of sex, and estimated the population attributable fractions (PAF).

RESULTS

The two PBCR reported 4336 new cancer cases from 2012 to 2014. Of these, 1627 (37.5%) were in males and 2709 (62.5%) in females. Some 11% (488/4336) of these cancers were HPV associated; 2% (38/1627) in men and 17% (450/2709) in women. Of the HPV associated cancers, 7.8% occurred in men and 92.2% in women. The ASRs for HPV associated cancers was 33.5 per 100,000; 2.3 and 31.2 per 100,000 in men and women respectively. The proportion of all cancers attributable to HPV infection ranged from 10.2 to 10.4% (442-453 of 4336) while the proportion of HPV associated cancers attributable to HPV infection ranged from 90.6% to 92.8% (442-453 of the 488 cases). In men, 55.3% to 68.4% of HPV associated cancers were attributable to HPV infection compared to 93.6% to 94.8% in women. The combined ASR for HPV attributable cancers ranged from 31.0 to 31.7 per 100,000. This was 1.4 to 1.7 per 100,000 in men and 29.6 to 30.0 per 100,000 in women. In women, cervical cancer (n=392, ASR 28.3 per 100,000) was the commonest HPV attributable cancer, while anal cancer (n=21, ASR 1.2 per 100,000) was the commonest in men.

CONCLUSIONS

HPV attributable cancers constitute a substantial cancer burden in Nigerian women, much less so in men. A significant proportion of cancers in Nigerian women would be prevented if strategies such as HPV DNA based screening and HPV vaccination are implemented.

Generation and characterisation of human umbilical cord derived mesenchymal stem cells by explant method

Mesenchymal stem cells (MSCs) derived from human umbilical cord (UC) have been considered as an important tool for treating various malignancies, tissue repair and organ regeneration. Umbilical cord-derived mesenchymal stem cells (UC-MSCs) are better alternative to MSCs that derived from bone marrow (BM-MSCs) as they are regarded as medical waste with little ethical concern for research and easily culture-expanded. In this present study, the foetal distal end of human UC was utilised to generate MSC by explant method. Upon in vitro culture, adherent cells with fibroblastic morphology were generated with rapid growth kinetics. Under the respective inductive conditions, these cells were capable of differentiating into adipocytes and osteocytes; express an array of standard MSC's surface markers CD29, CD73, CD90, CD106 and MHC-class I. Further assessment of immunosuppression activity revealed that MSCs generated from UC had profoundly inhibited the proliferation of mitogen-activated T lymphocytes in a dosedependent manner. The current laboratory findings have reinforced the application of explant method to generate UCMSCs thus, exploring an ideal platform to fulfil the increasing demand of MSCs for research and potential clinical use.

Risk factors for hospitalisation and associated costs among patients with hepatitis A associated with imported pomegranate arils, United States, 2013

OBJECTIVES

To assess hospitalisation risk factors and economic effects associated with a multistate hepatitis A outbreak in 2013.

STUDY DESIGN

Retrospective case series.

METHODS

Eligible outbreak-related cases confirmed by September 1, 2013, were defined as acute hepatitis symptoms and positive IgM anti-hepatitis A during March 15-August 12 among patients who consumed the food vehicle or had the outbreak genotype. We reviewed medical records, comparing demographic and clinical characteristics among hospitalized and non-hospitalized patients; we used logistic regression analysis to identify factors associated with hospitalization. We interviewed patients regarding symptom duration and healthcare usage and estimated per-patient and total costs. Health departments reported outbreak-related personnel hours.

RESULTS

Medical records were reviewed for 147/159 (92%) eligible patients; median age was 48 (range: 1-84) years, and 64 (44%) patients were hospitalized. Having any chronic medical condition was independently associated with hospitalisation (odds ratio, 3.80; 95% confidence interval, 1.68-8.62). Interviews were completed for 114 (72%) eligible patients; estimated per-patient cost of healthcare and productivity loss was $13,467 for hospitalized and $2138 for non-hospitalized patients and $1,304,648 for all 165 outbreak-related cases. State and local public health personnel expenditures included 82 h and $3221/outbreak-related case.

CONCLUSIONS

Hospitalisations in this outbreak were associated with chronic medical conditions and resulted in substantial healthcare usage and lost productivity. These data can be used to inform future evaluation of expansion of hepatitis A vaccination recommendations to include adults with chronic medical conditions.

Genetic aberrations in multiple myeloma characterized by cIg-FISH: a Brazilian context

Genetic abnormalities are critical prognostic factors for patients diagnosed with multiple myeloma (MM). This retrospective, multicenter study aimed to contribute with the genetic and clinical characterization of MM patients in a country with continental dimensions such as Brazil. Genetic abnormalities were assessed by cIg-fluorescent in situ hybridization (cIg-FISH) in a series of 152 MM patients (median age 55 years, 58.5% men). Overall, genetic abnormalities were detected in 52.7% (80/152) of patients. A 14q32 rearrangement was detected in 33.5% (n=51), including t(11;14), t(4;14) and t(14;16) in 18.4, 14.1, and 1% of cases, respectively. del(13q) was identified in 42.7% (n=65) of patients, of whom 49.2% (32/65) presented a concomitant 14q32 rearrangement. del(17p) had a frequency of 5.2% (n=8). del(13q) was associated with high plasma cell burden (≥50%, P=0.02), and del(17p) with advanced ISS stages (P=0.05) and extramedullary disease (P=0.03). t(4;14) was associated with advanced Durie-Salmon stages (P=0.008), renal insufficiency (P=0.01) and was more common in patients over 60 years old. This study reports similar frequencies of genetic abnormalities to most series worldwide, whereas the t(14;16) and del(17p), two high risk factors for newly diagnosed patients, exhibited lower frequencies. Our results expand the knowledge on the molecular features of MM in Brazil, a country where innovative therapies that could overcome a poor prognosis for some genetic abnormalities are not always available.