Chromosome-1 abnormalities in Childhood B-Lymphoblastic Leukemia - An analysis with reference to clinical variables and survival outcome

Background

Chromosome-1 abnormalities (C1As) are common genetic aberrations in hematological malignancies. We sought to evaluate significance of these abnormalities with reference to clinical characteristics and survival outcome in a pediatric B-Lymphoblastic Leukemia (B-ALL) cohort.

Methods

This is a retrospective study conducted in cytogenetic section of Indus Hospital and Health Network. Data was retrieved from October 2020 to July 2022 for childhood B-ALL cases exhibiting C1As. Chromosome analysis was performed on Cytovision MB8 using G-banded metaphases derived from unstimulated bone marrow culture. Results were recorded according to the International System for Human Cytogenetic Nomenclature (ISCN-2020). Data analyzed using SPSS, version 24.0.

Results

C1As were observed in 60/450 (13.3%) cases of B-ALL. Among C1As, 29 (48%) cases had t(1;19). There were 13 (45%) balanced and 16 (55%) unbalanced translocations. The aberrations without t(1;19) were seen in 31 (52%) cases including 1q duplication with hyperdiploidy in 14 (45%) cases. The median age for C1As with and without t(1;19) was eight years and six years while the median leukocyte count was 32 x 109/L vs. 17 x 109/L. Event-free survival (EFS) for cases with and without t(1;19) was 69% and 74.2% respectively.

Conclusion

Despite the fact that the t(1;19) positive group had a higher median age, a higher white cell count and more CNS positives, the difference in EFS is statistically insignificant when compared to the t(1;19) negative cases. Furthermore, we found a survival difference between balanced and unbalanced t(1;19) groups, which is statistically insignificant but warrants large-scale prospective studies for further understanding.

Degree of blood safety of voluntary non-remunerated versus replacement blood donations: A multi-centre study of the large cohort of blood donors from two provinces of Pakistan

BACKGROUND AND OBJECTIVES

Voluntary non-remunerated blood donors (VNRBDs) are recognized as being crucial for the safety and sustainability of national blood supplies. Systems based on replacement donors (RDs) pose high risks of transfusion transmissible infections (TTIs). Currently, only 10%-13% of blood donations are voluntary in Pakistan. No large-scale studies have been conducted to objectively evaluate the impact of the mode of donation on the frequency of TTIs, a gap this study aimed to fill.

MATERIALS AND METHODS

The study was conducted at the Indus Hospital, Karachi. Data from a total of 591,820 blood donations were included from 1 October 2017 to 30 May 2021 and evaluated for type of donations and results of TTI testing, primarily performed on Architect i2000SR (Abbott). The TTIs tested include hepatitis B virus, hepatitis C virus, human immunodeficiency virus, syphilis and malaria.

RESULTS

A total of 477,938 (80.7%) RDs and 113,882 (19.3%) VNRBDs were screened. Among these, 53,590 (9.06%) were positive for TTIs. There were 10.2% positive RDs (10.08-10.25 95% confidence interval [CI]) while 4.4% in VNRBDs (4.29-4.53 95% CI). Co-infections were observed in 2367 (0.4%) RDs, while 159 (0.02%) in VNRBDs. Geographically, the highest frequency of TTIs was observed in semi-urban areas of Sindh (11.2%) and Punjab (9.6%). A site-wise comparison of TTIs in RD versus VNRBD showed significant differences (p-value 0.00).

CONCLUSION

RDs are associated with higher frequencies of TTIs, compared with VNRBD. However, the study was unable to assess whether the significant difference was related to individual risk or repeat/first time status of the donors. Other important variables affecting frequency are the catchment area of the blood donors in Pakistan. Urban areas have less prevalence than semi-urban areas.

Plasmablastic Lymphoma in a Human Immunodeficiency Virus-positive Child With a Suspicion of Concomitant Primary Immunodeficiency Disorder

Plasmablastic lymphoma (PBL) occurs in the setting of immunodeficiency, in association with human immunodeficiency virus (HIV) infection, in elderly patients, and in the posttransplantation state. It is exceptionally rare in children. PBL is an aggressive lymphoma with a poor prognosis. We present a case of pediatric PBL in an HIV-positive child with suspicion of a concomitant underlying immune deficiency state other than HIV. A 7-year-old girl presented to the pediatric emergency department with complaints of fever and painful swelling on the left side of her face for 15 days, associated with headache, snoring, and difficulty in breathing. She had a history of watery diarrhea, oral thrush, recurrent fever, and hospitalizations for skin infections since the age of 1 year. Histopathological findings were consistent with PBL. Her HIV RNA polymerase chain reaction was positive. She was offered chemotherapy based on the FAB/LMB 96 protocol. This case demonstrates an aggressive presentation of a rare entity, HIV-associated PBL, in a child, with underlying immunodeficiency and highlights the issues which caused a significant challenge in making the diagnosis. The presence of HIV infection and contradicting other immunologic investigations posed a dilemma in establishing an association of PBL in this child. The outcome of patients with this tumor is associated with high mortality.

Point prevalence probing of antimicrobial prescription patterns from a developing country

BACKGROUND

Irrational use of antibiotics intensifies resistance and jeopardizes advances made in modern medicine. We aimed to conduct a baseline gap analysis survey on antibiotic prescription practices across Pakistan.

RESEARCH DESIGN AND METHODS

This multi-centered cross-sectional survey was conducted at six public sector tertiary care hospitals from February 2021 to March 2021. Data related to various variables including hospital infrastructure, policies and practices, monitoring and feedback, and epidemiological, clinical, and antibiotic prescription for surveyed patients was collected using World Health Organization (WHO) Point Prevalence Survey (PPS) methodology.

RESULTS

In a survey of 837 inpatients, 78.5% were prescribed antibiotics. Most commonly prescribed antimicrobial was ceftriaxone (21.7%), followed by metronidazole (17.3%), cefoperazone-sulbactam (8.4%), amoxicillin-clavulanate (6.3%), and piperacillin/tazobactam (5.9%). Surgical prophylaxis (36.7%) and community-acquired infections (24.7%) were the main reasons for antibiotic prescriptions. Single antibiotics were given to 46.7% of patients, 39.9% received a combination of two antibiotics, and 12.5% were prescribed three or more antibiotics. Among six hospitals surveyed, two had drug and therapeutic committees, three had infection prevention and control committees, and one had an antibiotic formulary.

CONCLUSION

Findings demonstrate high consumption of broad-spectrum antimicrobials and emphasize the importance of expanding antimicrobial stewardship programs among hospitals. Mentoring clinical teams could help rationalize antimicrobial use.

Cytogenetic Profiling In Paediatric Acute Leukaemia; A Report On 746 Newly Diagnosed Paediatric Cases Analyzing The Spectrum Of Recurring Chromosomal Rearrangements In B Cell Lymphoblastic And Acute Myeloid Leukaemia

Background

Cytogenetics is evolving and different molecular mechanisms we know now have proved to be of diagnostic and prognostic significance in both acute lymphoid (ALL) and myeloid leukaemia (AML). This study aims to find out and compare the occurrence of different cytogenetics in paediatric acute leukaemia.

Methods

This is a cross-sectional study of diagnosed B-ALL and AML patients presenting at The Indus Hospital. We studied FISH and karyotype in BALL and FISH in AML patients. FISH analysis shows a total of 69 (12.8%) of B ALL patients had cytogenetic abnormalities. BCR-ABL1 was positive in 5.1%, ETV6/RUNX1T1 in 8.6% and KMT2A in 2.3% individuals. Karyotype reveals hyper diploidy in 24.3%, Monosomy in 1.94%, and t (1:19) and t (17:19) were observed in 5.8% and 0.24% cases respectively. FISH analysis in AML cases reveal positivity of t (8:21) in 26.4%, INV (16) in 6.1% while PML-RARA t(15:17) was done on morphological suspicion in 17 cases; all of which showed positivity; making 7.9% of the total AMLs. The study demonstrated a wide spectrum of heterogeneity in paediatric acute leukaemia.

Conclusion

Hyperdiploidy was the most common cytogenetic abnormality. We report a lower incidence of t (12:21), compared to the world. We showed a higher prevalence of RUNX1/RUNX1T1 in young children. The prevalence of core binding factor AML was 32.5%.

Monocyte Distribution Width, a Novel Biomarker for Early Sepsis Screening and Comparison with Procalcitonin and C-Reactive Protein

Objectives Monocyte distribution width (MDW) can be used for the early recognition of sepsis. The study compared the diagnostic accuracy of the MDW with two well-known sepsis biomarkers, procalcitonin (PCT) and C-reactive protein (CRP).

Materials and Methods A study was conducted from July 2021 to October 2021, on 111 patients admitted to the Indus Hospital and Health Network. Patients from the ages of 1 to 90 years were enrolled if hospitalized for more than 24 hours for suspected sepsis to avoid inclusion of patients who had short-term stay in the emergency department. According to the Sequential Organ Failure Assessment score, the clinical team did the characterization of cases as with sepsis or without sepsis. SPSS version 24 was used, and the diagnostic accuracy of MDW was assessed and compared using the area under the curves (AUCs) acquired from receiver operating characteristic curves. Pearson's chi-square/Fisher's exact test (as per need) was applied to determine the association. A p-value of less than 0.05 was considered significant.

Results Among 111 patients, 81 (73%) patients were labeled with sepsis and 30 (27%) were without sepsis. We have reported significantly higher MDW, PCT, and CRP levels in septic patients (p < 0.001). The AUC of MDW was comparable with PCT (0.794). Significant cutoff value for the MDW was greater than 20.24 U with 86% sensitivity and 73% specificity.

Conclusion MDW may have a predictive ability similar to PCT and CRP in terms of sepsis and, thus, can be used as a standard parameter for the timely diagnosis of sepsis.

Myoepithelial Carcinoma arising in a background of pleomorphic adenoma

Carcinoma ex pleomorphic adenoma is a neoplasm of the salivary gland that causes 3.6% of salivary gland tumours and 12% of salivary gland malignancies. It is a myoepithelial or epithelial neoplasm that arises from pleomorphic adenoma, whether primary or recurrent. Historically carcinoma ex pleomorphic adenoma is considered a high-grade malignancy. Salivary duct carcinoma and high-grade adenocarcinoma are the histologic types that most commonly arise in the background of Pleomorphic adenoma. However, 15% of tumours arising in Pleomorphic adenoma are considered low grade and have sluggish growth. Low-grade carcinoma ex pleomorphic adenoma can be difficult to differentiate from cellular pleomorphic adenoma. The case of a 56-year-old female patient who had neck swelling is being presented. The biopsy showed spindle cell component with mild atypia, invasion into surrounding tissue, and increased mitotic activity on the basis of which a diagnosis of Low-grade carcinoma ex pleomorphic adenoma developing in a background of pleomorphic adenoma was made. The morphological and immunohistochemical features confirmed the carcinoma component to be myoepithelial.

Association of Seroconversion Status with Outcome in Admitted Covid-19 Patients

OBJECTIVE

To determine the association between seroconversion status and outcome in admitted COVID-19 patients and compare inflammatory markers amongst them.

STUDY DESIGN

Single cohort observational study.

PLACE AND DURATION OF STUDY

Indus Hospital and Health Network between 10th May and 10th July 2020.

METHODOLOGY

All admitted patients were tested serially for anti-COVID-IgM and IgG until their sera showed positive results. This was continued until their expiry or discharge. Those patients who remained negative for both anti-COVID-19-IgG and IgM were labeled as non-seroconverts. Demographics, comorbidities, inflammatory marker levels and outcome (alive/expired) were compared between seroconverts and non-seroconverts.

RESULTS

In 224 admitted patients, the median seroconversion time of IgM and IgG was six and seven days in survivors and non-survivors respectively. Expired patients displayed higher levels of procalcitonin (maximum), C-reactive protein, and Interleukin-6 (baseline and maximum). Of 34 non-seroconverts, 17 (50%) expired. Non-seroconverts significantly failed to develop fever and had lower levels of ferritin, CRP, and LDH.

CONCLUSION

Non-seroconversion in hospitalised COVID-19 infected patients indicated muted immune and acute phase response and was associated with poor outcomes. Hence these patients need to be carefully evaluated and managed.

KEY WORDS

Antibody response, Corticosteroids, Immunosuppression, SARS-Cov-2, Seroconversion.

Extramedullary hematopoiesis in an inguinal lymph node: an unusual presentation of primary myelofibrosis

Background

Extramedullary hematopoiesis (EMH) is a proliferation of hematopoietic tissue outside of the bone marrow medullary space. It is a pathophysiologic response, more often associated with either a benign reactive hematological disease or a myeloproliferative neoplasm (MPN). Identification of EMH in adults is always pathologic. It is highly unlikely for a myeloproliferative neoplasm to present with inguinal lymphadenopathy. An unusual and complex case can be precisely diagnosed via a multidisciplinary approach involving experts from various modalities of laboratory. In this regard, the present case highlights the importance of an integrated approach in establishing the diagnosis.

Case presentation

We report a case of a 61-year-old male patient of primary myelofibrosis who presented with extramedullary hematopoiesis in an inguinal lymph node. The patient initially presented with generalized symptoms including anemia, fatigue, abdominal pain, and weight loss. On examination, massive splenomegaly. Chest X-ray revealed consolidation which was secondary to right-sided pleural effusion. Therefore, he was suspected to have a lung carcinoma. However, lymph node biopsy revealed extensive fibrosis, consequently effacing the nodal architecture. An abnormal blood picture raised the possibility of bone marrow infiltration. Extensive panel of markers is tested on lymph node and bone trephine. Cytogenetic studies with G-banding analysis and fluorescence in situ hybridization (FISH) played a significant role in deriving clinical decision. Translocations identified in conventional cytogenetic workup led to the diagnosis of primary myelofibrosis. The case is being reported due to unusual presentation of PMF.

Conclusion

In conclusion, it is a distinctive case of myeloproliferative disorder initially presented with extramedullary hematopoiesis and through multidisciplinary workup successfully diagnosed as primary myelofibrosis. Awareness of unique clinical presentations and integrated approach towards diagnosis is the key to such challenging cases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-022-02660-9.

POS1361 THE CANADIAN RESEARCH GROUP OF RHEUMATOLOGY IN IMMUNO-ONCOLOGY (CanRIO): A NATIONWIDE MULTI-CENTER PROSPECTIVE COHORT

Background

Immune Checkpoint Inhibitors (ICI) have altered the landscape of cancer therapy. However, toxicities are common and up to 80% of patients will develop immune-related adverse events (irAE), including rheumatic irAEs (Rh-irAE), which can often limit their cancer treatment. Our knowledge of clinical manifestations and optimal management of patients with Rh-irAE continues to evolve as these agents are being used to treat a wider variety of cancers. Currently available data is limited to retrospective case series and case reports. There is also scarce data on the use of ICI in patients with pre-existing autoimmune disease (PAD) as these patients are often excluded from clinical trials.

Objectives

To describe the clinical presentation, management and early outcomes of patients exposed to ICI with Rh-irAE or PAD recruited and followed prospectively from multiple sites across Canada.

Methods

Adult patients with Rh-irAE from cancer immunotherapy (CTLA-4, PD-1 or PDL-1 inhibitors) or those with PAD exposed to cancer immunotherapy are prospectively recruited across 9 academic sites in Canada. Standardized clinical and biologic data are also collected. We describe clinical characteristics and management of patients recruited between January 2020 and October 2021, stratified based on the presence or absence of PAD.

Results

103 patients were recruited from 9 sites. From those, 85 had Rh-irAE, 47 had pre-existing musculoskeletal and rheumatic diseases, and 20 had other PAD. The most frequent Rh-irAE were joint manifestations (n = 73). Other Rh-irAE included muscle symptoms (n = 7), connective tissue disease (n = 6), vasculitis (n=2) and sarcoid (n = 3). Prednisone was the most common treatment (n = 53). Intraarticular corticosteroids were used in 7 patients. Eleven patients required conventional synthetic disease-modifying anti-rheumatic drugs (DMARD) and only one required biologic DMARD to control the Rh-irAE. Anti-PD-1 therapies were the most used ICI (56.3%), followed by combination therapy (35.9%). Response to index immunotherapy at 6 months was available for 21 patients. Most patients had partial response (57.1%) and only 4 patients had tumor progression (19.1%). The ICI was permanently discontinued due to an irAE in 21 patients (38.1% with PAD and 61.9% without PAD). There were no deaths related to Rh-irAE.

Conclusion

The initial sample of the CanRIO prospective national cohort suggests that demographic characteristics and tumor representation in people with PAD and without PAD is similar. Patients with PAD are less likely to receive combination therapy (n= 12 vs. n=25) and are less likely to have tumor progression on ICI (n=1) compared to those without PAD (n=3). Selection bias is noted in this initial sample since half of recruited patients have PAD. The CanRIO cohort provides valuable insight into real-world spectrum and management of Rh-irAE secondary to immunotherapy for cancer.

Disclosure of Interests

Shahin Jamal Grant/research support from: CanRIO has received financial support from BMS and Organon, Lourdes Gonzalez Arreola: None declared, Julia Tan: None declared, Carrie Ye: None declared, Janet Roberts: None declared, Aurore Fifi-Mah: None declared, Marie Hudson: None declared, Sabrina Hoa: None declared, Janet Pope: None declared, Ines Colmegna: None declared, C. Thomas Appleton: None declared

Re-Evaluating the Merits of Decentralisation as a Core Strategy for Effective Delivery of Drug-Resistant Tuberculosis Care in Pakistan

Decentralized, person-centred models of care delivery for drug-resistant tuberculosis (DR-TB) continue to be under-resourced in high-burden TB countries. The implementation of such models—made increasingly urgent by the COVID-19 pandemic—are key to addressing gaps in DR-TB care. We abstracted data of rifampicin-resistant (RR)/multidrug-resistant tuberculosis (MDR-TB) patients initiated on treatment at 11 facilities between 2010 and 2017 in Sindh and Balochistan provinces of Pakistan. We analysed trends in treatment outcomes relating to programme expansion to peri-urban and rural areas and estimated driving distance from patient residence to treatment facility. Among the 5586 RR/MDR-TB patients in the analysis, overall treatment success decreased from 82% to 66% between 2010 and 2017, as the programme expanded. The adjusted risk ratio for unfavourable outcomes was 1.013 (95% confidence interval 1.005–1.021) for every 20 km of driving distance. Our analysis suggests that expanding DR-TB care to centralized hubs added to increased unfavourable outcomes for people accessing care in peri-urban and rural districts. We propose that as enrolments increase, expanding DR-TB services close to or within affected communities is essential.

Correlation of clinical and radiological predictors of retinoblastoma with high-risk histopathological features

INTRODUCTION

Retinoblastoma (RB) tumors having high-risk histopathologic features (HRFs) have an increased risk of metastasis and disease relapse. However, RB has not been studied widely in Pakistan. Therefore, we evaluated the association of clinical, histopathologic, and radiological findings with HRFs in patients with RB who were treated at the Indus Health & Hospital Network in Karachi, Pakistan.

METHODS

We enrolled treatment-naïve patients with RB who received upfront enucleation from September 2017 to February 2021. We evaluated enucleated eyes with the Intraocular Classification of Retinoblastoma system and classified HRFs as invasion of the anterior chamber, including the iris and ciliary body, or massive invasion of the choroid, sclera, or optic nerve (postlaminar and/or up to the transection line).

RESULTS

Of 117 patients with RB treated at our institution during the study period, 54 received upfront enucleation. Unilateral disease was present in 92.6% of cases. The most frequent disease signs and symptoms included the presence of vitreous seeds (30.6%) and leukocoria (100%), respectively. The most frequent HRFs and radiological findings comprised massive choroidal invasion (15.1%) and anterior chamber enhancement (66.7%), respectively. The majority (62.9%) of patients did not exhibit any HRFs. Female sex, pseudohypopyon, iris neovascularization, buphthalmos, and glaucoma had significant predictive ability for HRF occurrence.

CONCLUSION

Pseudohypopyon, iris neovascularization, buphthalmos, and glaucoma are important clinical factors that should be taken into consideration before the management of RB. Early recognition of high-risk histopathological and radiological features is essential for appropriate treatment of RB.

Initiation of Molecular Pathology FCPS in Pakistan Is Urgent!

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Neutralizing Antibody Response to BBIBP-CorV in Comparison with COVID-19 Recovered, Unvaccinated Individuals in a Sample of the Pakistani Population

Fifty five percent of the Pakistani population is still unvaccinated with the two-dose protocol of COVID-19 vaccines. This study was undertaken to determine the seroconversion rate and antibody titers following the two-dose BBIBP-CorV protocol, and to compare these variables in unvaccinated, COVID-19 recovered individuals (total n = 180) at Indus Hospital and Health Network, Karachi. Pseudotyped lentivirus antibody neutralization assays and SARS-CoV-2 IgG Quant II (Abbott) immunoassays were performed 4-8 weeks following the second dose of the BBIBP-CorV or PCR positivity/onset of symptoms of COVID-19. Seroconversion rate, using neutralization assays, in vaccinated individuals was lower (78%) than that in unvaccinated, COVID-19-recovered individuals with moderate to severe infection (97%). Prior PCR positivity increased serocoversion rate to 98% in vaccinated individuals. Immunoassays did not, however, reveal significant inter-group differences in seroconversion rates (≥95% in all groups). Log10 mean antibody neutralizing titers following the two-dose BBIBP-CorV protocol (IC50 = 2.21) were found to be significantly less than those succeeding moderate to severe COVID-19 (IC50 = 2.94). Prior SARS-CoV-2 positivity significantly increased post-vaccination antibody titers (IC50 = 2.82). Similar inter-group titer differences were obtained using the immunoassay. BBIBP-CorV post-vaccination titers may, thus, be lower than those following natural, moderate to severe infection, while prior SARS-CoV-2 exposure increases these titers to more closely approximate the latter.

COVID-19 Testing Crisis Management Through a Public-Private Partnership in Sindh, Pakistan

Building upon an existing public-private partnership enabled the rapid and effective implementation of province-wide COVID-19 testing in the Sindh province of Pakistan.

As the coronavirus disease (COVID-19) pandemic spread, meeting the testing needs to control the spread of infection became a major challenge worldwide. In Pakistan, the lack of the requisite infrastructure and training compounded the acute shortage of testing kits and other consumables. Against this backdrop and to urgently improve province-wide access to high-quality COVID-19 polymerase chain reaction (PCR) testing with rapid turnaround times, the Government of the Sindh (GoS) province of Pakistan entered into a public-private partnership with Indus Hospital & Health Network (IHHN). Under this partnership, the GoS undertook sample collection and Indus Hospital in Karachi, Sindh, centralized testing. We describe the implementation strategies adopted by the partnership, as well as the challenges, opportunities, and lessons learned. Notably, up to 40% and 22% of total COVID-19 PCRs done in Sindh in the first 2 months of the pandemic, respectively, were performed at Indus Hospital in Karachi, though this percentage declined gradually as other centers caught up with their testing capacities. The rapid scaling up was achieved through a combination of mechanisms and factors including building on preexisting partnerships between the GoS and IHHN, pooling resources and harnessing distinct and complementary roles, relocating existing resources, introducing automation and information technology system changes, establishing risk mitigation strategies, and introducing quality measures within testing processes. The primary outcome of the partnership was rapid province-wide access to quality COVID-19 PCR testing with short turnaround times and at no cost to the patient. Furthermore, implementation of the partnership goals established new mechanisms as well as strengthened existing ones to enable rapid response to the future global health security challenges in Sindh, Pakistan.

Duration of respiratory sample stability at -80ºC for SARS-CoV-2 PCR

Objective:

To determine the stability of respiratory samples for SARS-CoV-2 PCR at standard laboratory ultra-freezer temperatures (-80°C).

Methods:

Five hundred and sixty-five archived, SARS-CoV-2 PCR positive patient specimens received at the Pathology Department of the Indus Hospital & Health Network between January 2021 and June 2021 were retested in June 2021. Samples had been stored at -70°C or below throughout this duration. Sample integrity following storage was assessed as the percentage of samples with reproducible results, and as consistency of cycle threshold (Ct) values between the original testing and the repeat testing.

Results:

Of the 565 samples evaluated in this study, 86% gave reproducible results upon retesting. However, there was no correlation between the duration of storage and result reproducibility, though the majority (69% for PCR Target-I and 78% for PCR Target-II respectively) of non-reproducible results had Ct values above 30. Similarly, there was a consistent increase of Ct values upon storage at ultra-freezer temperatures, though the effect again was more contingent upon freezing the sample in the ultra-freezer rather than the duration of storage.

Conclusion:

SARS-CoV-2 positive respiratory specimens for PCR can be stored for up to six months at -70°C or below without loss of sample integrity, though there is some loss of PCR-detected viral targets as evidenced by an immediate increased in the PCR-generated Ct values. In addition, samples with initial Ct values above 30 are more likely to give non-reproducible results.

High risk histopathological factors in retinoblastoma in upfront enucleated eyes: An experience from a tertiary care centre of Pakistan

Background & Objectives:

The assessment of histopathological risk factors (HRFs) in retinoblastoma in upfront enucleated eyes is important in deciding treatment protocols. Limited data is available from the developing countries as very few studies were conducted on retinoblastoma. The study aims to report this data from Pakistan.

Methods:

This cross-sectional study included treatment naïve retinoblastoma patients who underwent upfront enucleation between 2017 to 2021. Various tumor characteristics i.e. laterality, size, histologic grade, anaplasia grade, growth pattern, extent and length of optic nerve invasion, pathologic staging, tumor involvement of ocular structures were assessed. High-risk factors such as involvement of anterior chamber, choroidal, scleral, extrascleral, and optic nerve were also noted.

Results:

A total number of 54 patients were enrolled, out of which 53.7% were females while remaining were males. Median age at presentation was 24 months. Unilateral tumor was seen in 92.6% cases. Most frequent histologic grade was G2 (64.7%) and moderate anaplasia was observed in 59.2% cases. Vitreous involvement was seen in (86.5%). Pathologic staging of most of the tumors was pT1 (39.2%). Assessment of high-risk factors revealed that optic nerve involvement (35.1%) was the most common finding with retrolaminar tumor invasion seen in 75% cases. Choroidal invasion (≤3mm) was seen in 55.6% of patients. Limited involvement of anterior chamber (3.8%), sclera (7.4%), and extrascleral (3.8%) tissue was also observed.

Conclusion:

The presence of high risk histopathological factors in enucleated eyes diagnosed with retinoblastoma are known to have a profound impact on the risk stratification as well as decision of future treatment plan.

Chemotherapy induced histopathological changes in retinoblastoma, assessment of high risk predictive factors & its correlation with comorbid conditions

Background & Objectives: Retinoblastoma is a malignant intraocular tumor and its treatment requires a multidisciplinary approach. Chemotherapy is an important modality in treatment of retinoblastoma. The purpose of this study was to assess the histopathological changes in retinoblastomas treated with chemotherapy along with correlation of comorbid conditions with high risk histopathological factors (HRF). Methods: All post-chemotherapy enucleated eye specimens received in the pathology department between 2017 to 2021 were included in the study. Slides were retrieved and reviewed for chemotherapeutic effects, tumor regression, and for assessment of HRF. Patient demographic data, information regarding chemotherapy and co-morbid conditions were retrieved through the hospital database. Chi-square was used to analyze the relation between comorbid conditions and HRF. Results: Chemotherapeutic effects were seen in all eyes with varying degrees of responses. Necrosis, calcification, and gliosis were the most common findings. The majority of eyes showed tumor occupying less than 50% of the eye whereas complete regression was noted in one eye only. Retinal detachment, glaucoma, and buphthalmos were the most common comorbid conditions at the time of diagnosis. Patients with glaucoma were more likely to have ciliary body invasion. Kaplan Meier analysis showed that patients with more than two HRF had decreased survival rates in comparison to those with one or no HRF. Conclusion: Histopathological evaluation of chemotherapy-treated eyes shows varying degrees of response to chemotherapy. Post enucleation histopathological evaluation of the globe plays an important role in assessing disease activity and guiding further treatment to prevent metastasis. doi: https://doi.org/10.12669/pjms.38.ICON-2022.5786 How to cite this:Yaqoob N, Mansoor S, Zia N, Aftab K, Kaleem B, Jamal S. Chemotherapy induced histopathological changes in retinoblastoma, assessment of high risk predictive factors & its correlation with comorbid conditions. Pak J Med Sci. 2022;38(2):362-368.  doi: https://doi.org/10.12669/pjms.38.ICON-2022.5786 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

399 Complex Limb Injuries – Limb Salvage vs Amputation: An Overview of the Factors Influencing Decision-Making and Outcomes

Aim

Complex limb injuries usually comprise of a combination of osseous, soft tissue, vascular and neural damage, necessitating prompt and accurate initial examination and decision-making to maximise optimal patient outcomes. We present the factors affecting the decision-making as well as the outcomes following primary limb amputation or salvage of complex extremity injuries, with an emphasis on the various scoring systems present that endeavour to offer prognostic and therapeutic guidance to orthopaedic surgeons.

Method

We performed the literature search on PubMed and Embase, and collated the relevant data comprising of demographics, injury, scoring system, primary and secondary outcome metrics and complications.

Results

Many scoring systems, each with variable factors, have been proposed to predict limb salvage vs amputation in complex extremity injury (MESS, PSI, LSI, NISSSA, HFS-97), however the landmark LEAP trial concluded in its final analysis that they could not validate them. Whilst the scores were useful in predicting limb salvage, they were inaccurate and unreliable in predicting amputation with low sensitivities

Conclusions

Many scoring systems attempt to provide guidance regarding decision-making in limb salvage vs primary amputation, however the LEAP study has shown poor predictive standards of these systems. As such, there is no gold standard algorithmic approach or scoring system when making this difficult decision – instead, the poor predictors of limb salvage have been identified, and the surgeons need to be judicious and make a joint decision considering these variables and other patient factors (social, economic, and psychological status).

358 Surgical Management of Spinal Cord Injuries: An Overview of Controversies

Aim

Spinal Cord Injuries (SCI) are incredibly debilitating injuries associated with significant morbidity and financial burden, with an incidence of 12-16 per million population in the UK. There is currently no cure for SCI, with majority of interventions focusing on primary prevention of SCI or of further damage once SCI is sustained. We present an overview of the role of closed reduction, timing of surgery and role of steroids, and provide an algorithm for management of SCI.

Method

A search was carried out on PubMed, looking at notable reviews, consensus statements and trends in management of spinal cord injuries. This was cross-referenced with the NICE and BOAST guidelines for SCI.

Results

The efficacy of closed reduction in cervical fractures and necessity of pre-reduction MRI is still equivocal and remains a source of major debate amongst spinal surgeons. The timing of surgery remains controversial as studies have not consistently shown improved outcomes with early, aggressive surgery but there have been trends noted in the newer studies with some benefit of early surgery. The use of steroids in acute SCI has fallen out of favour with most guidelines not recommending them due to their equivocal benefit and unequivocal side-effect profile.

Conclusions

Prevention and pre-hospital management are crucial in the management of SCI, along with early spinal alignment restoration, decompression and stabilisation augmented by good long-term rehabilitation measures. There is a need for new randomised controlled trials assessing the role of closed reduction, need for pre-reduction MRI and timing of surgery in SCI.

Burkitt Lymphoma With Aberrant Immunophenotype Imposing Diagnostic Challenge

Burkitt lymphoma (BL) exhibits a characteristic immunophenotype that is positive for pan-B-cell antigens and germinal center markers while negative for immature markers. A deviation from classic immunophenotype can cause diagnostic confusion and might result in false exclusion of BL. In some cases, overlapping clinical, morphological and immunophenotypic features of BL and B lymphoblastic lymphoma (B-LL) can be of diagnostic challenge. However, definitive delineation is of paramount importance due to difference in treatment. We describe a case of BL in a child with atypical features including absence of L3 morphology in diagnostic tissue and aberrant expression of CD34, CD99 and BCL2 on immunohistochemistry. These findings led to the interpretation of B-LL which was later on excluded by detection of t (8;14). This unorthodox case not only highlights the importance of cytogenetic testing but also emphasizes the correlation of all the diagnostic tools before making a definitive diagnosis. Therefore, reporting this case will help in eliciting the high index of suspicion among pathologists for this exceptionally unusual immunophenotype.

Sensitivities and specificities of Anti-SARS CoV2 detection kits - comparison and agreement between fifteen assays

The correct and rapid diagnosis of COVID-19 is vital for proper care and identification of affected individuals. This led to the early availability of many serological assays in the market but with limited validations. This study aimed to assess the validation of the serological assays based on different techniques. We evaluated fifteen assays based on four different immunoassay techniques on 235 patients. The most sensitive kit employing different techniques were as follows: immunochromatography (Zybio SARS CoV-2 IgM/IgG Antibody Assay Kit: 83%), ELISA (Aeskulisa SARS-CoV-2 NP IgG -88.1%), chemiluminescence (Alinity SARS-CoV-2 IgG - 82.2%) and immunofluorescence (Lifotronic FA160 [Shenzhen SARS-CoV-2 Assay Kit (IgG)] -88.9%). 100% specificity was seen in kits by Uniper (Singuway Biotec COVID-19 IgM/IgG Presumptive Kit), Genrui 2019-nCoV IgM/IgG Test Kit, Wondfu SARS CoV-2 Antibody Test and Aeskulisa SARS-CoV-2 NP IgG while IgG assay on Lifotronic FA160 (Shenzhen SARS-CoV-2 Assay Kit) showed the lowest specificity at 58%. Maximum agreement was observed between Aeskulisa SARS-CoV-2 NP IgG and Alinity SARS-CoV-2 IgG at 94%. Serological tests are practical alternatives but their reliability requires critical validation. The pandemic pointed a need for investment in health research on both national and international levels.

Distribution of subtypes and immunophenotypic characterization of 1379 cases of paediatric acute leukaemia

Objectives:

Acute leukaemia is the most common and highly curable childhood malignancy; subtyping and identification of antigens via immunophenotyping helps in treatment plan as well as minimal residual disease monitoring.

Methods:

This retrospective study was conducted at the Haematology section of the clinical laboratories of Ziauddin University Hospital and The Indus Hospital, Karachi conducted at January 1st, 2012 to December 31^st, 2017. The study included 1379 cases of de novo acute leukemia from 2012 to 2017. Among these, 80% were diagnosed by using four color flowcytometry (FACS Calibur), 9% and 11% via immunohistochemistry on bone marrow trephine biopsy samples and morphological examination respectively.

Results:

The mean age of patients was 7.4 ± 4.3 years while male to female ratio was 1.75:1. Lymphoblastic leukaemia accounted for 77.2% and myeloid leukaemia 21.2%. Amongst lymphoblastic lineage, B-ALL was 80.4% while T-ALL was 19.6%. Among the phenotypic expression of B-ALL, CD79a (99.8%) had the highest positivity. In B-ALL, CD13 (29.8%) was the most common aberrant myeloid marker. Aberrant expression of CD79a observed in 11.1% of T-ALL cases. In non APL AML, aberrant expression of CD79a and CD19 was observed in 6.6% and 5.5% of cases respectively.

Conclusion:

Overall immunophenotypic profile, expression of aberrant phenotypes and subtype distribution in our patients was similar to international literature except for a relatively high frequency of T-ALL which was discordant from the western data.

COVID-19 recovery: tackling the 2-week wait colorectal pathway backlog by optimising CT colonography utilisation

AIM

To review the indications for computed tomography colonography (CTC) performed on patients referred via the 2-week wait colorectal pathway (2WWCP).

MATERIALS AND METHODS

A retrospective study was performed on all patients referred through the 2WWCP between October 2018 and September 2019. The referrals were audited against the National Institute for Health and Care Excellence (NICE) NG12/DG30 guidelines for referral to the 2WWCP, and against the Royal College of Radiologists (RCR) 2017 guidelines for CTC.

RESULTS

Over the study period, there were 1,707 2WWCP referrals, and 362 (21.2%) of these patients underwent CTC. The median age was 66 years, and 55% were female. Forty-six patients did not meet the NICE NG12/DG30 guidelines for referral to the 2WWCP, and a further 268, although meeting the NICE guidelines, did not meet the RCR 2017 guidelines for CTC. In total, only 13% of CTCs performed complied with both guidelines.

CONCLUSION

This audit demonstrated a significant opportunity to reallocate CTC resources in the recovery stage of the COVID-19 pandemic. To improve outcomes for colorectal cancer (CRC) in the UK, establishing a selective straight-to-test CTC 2WWCP should be considered. Documented consent detailing the risks and benefits of CTC versus colonoscopy should take place in order to assist the patient in making an informed choice.

Association between known risk factors and colorectal cancer risk in Indigenous people participating in the Ontario Familial Colon Cancer Registry

Introduction

Colorectal cancer is one of the most common cancers in Ontario and imposes a high burden on many Indigenous populations. There are two aims for this short communication: ■ Highlight colorectal risk factor findings from a population-based case-control study■ Highlight trends and challenges of colorectal cancer research in Indigenous populations in Ontario.

Methods

Prevalences of cigarette smoking, obesity, fruit and vegetable consumption, and family history of colorectal cancer were estimated using the Indigenous identifier in the Ontario Familial Colon Cancer Registry for 1999-2007 and then compared for cases and controls using age-adjusted odds ratios (ors) with 95% confidence intervals (cis).

Results

The registry search identified 66 Indigenous cases and 23 Indigenous controls. Cigarette smoking (or: 1.88; 95% ci: 0.63 to 5.60) and obesity (or: 2.16; 95% ci: 0.72 to 6.46) were higher in cases, but not statistically significantly so.

Conclusions

Findings were consistent with previous literature describing Indigenous populations. A small sample size and poor Indigenous identification questions make it challenging to comprehensively understand cancer risk factors and burden in Indigenous populations.

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.

Her-2/neu Oncogene Amplification by Fluorescence In Situ Hybridization and Protein Overexpression on Immunohistochemistry in Breast Cancer

OBJECTIVE

To investigate the concordance and discordance between the test results of Her-2/neu by immunohisto-chemistry (IHC) and flourescence In Situ hybridization (FISH) in breast cancer cases.

STUDY DESIGN

Descriptive cross-sectional study.

PLACE AND DURATION OF STUDY

Department of Histopathology, Dr. Ziauddin Hospital, Karachi, from 2011 to 2016.

METHODOLOGY

Forty-three specimens of invasive ductal carcinoma of breast were evaluated for grade and Her-2/neu status using IHC and FISH methods. Concordance and discordance between their results was determined.

RESULTS

There is 100% concordance between FISH and IHC in cases scoring 0, 1+ (negative) and 3+ (positive) immunostaining. Tumour cases scoring 2+ immunostaining showed amplification in 69.2% cases. All grade-I tumours were non-amplified on FISH, while most of the grade-III tumours showed Her-2/neu amplification on FISH. There is significant association of Her-2/neu IHC with tumour grade and FISH (p<0.05). A fairly high proportion i.e. 69.7% of cases showed Her-2/neu gene amplification. There was high concordance between Her-2/neu testing on IHC and FISH, (Kappa co-efficient 0.466, p <0.001).

CONCLUSION

Her-2/neu amplification increases with increasing grade of breast cancer. A high proportion of Her-2/neu gene amplified cases indicates aggressive disease in that area and need for FISH testing on large scale, which is the gold standard for equivocal cases on immunohistochemistry.

Invasive Ductal Carcinoma: Correlation of Immunophenotypic Features with Age

OBJECTIVE

To evaluate the frequency of hormone receptors and Her2neu expression and their correlation with age in patients of carcinoma breast.

STUDY DESIGN

Descriptive, cross-sectional study.

PLACE AND DURATION OF STUDY

Department of Histopathology, Dr. Ziauddin Hospital, Karachi, between the period 2006 - 2013.

METHODOLOGY

Estrogen receptors, progesterone receptors and Her2neu immunohistochemical staining was performed on all specimens of carcinoma breast of female patients. Allred scoring was followed using normal epithelium as internal control. Age was determined in years. Results were described as percentages.

RESULTS

Three hundred and forty-six cases of infiltrating ductal carcinoma of breast between the age of 20 - 90 years (mean= 49 ±14 years) were studied. Seventy-nine (23%) cases were below the age of 40 years. ER +ve cases were 210 (61%), PR +ve were 190 (55%), and 78 (23%) were Her2neu +ve. Three were 12 (3%) triple positive cases and 58 (17%) triple negative cases. One hundred and seven (31%) cases were ER/PR+ve and Her2neu -ve. Most of the breast cancer cases were aged between 41 - 50 years. Estrogen receptor positivity was maximum between 41 - 60 years. Fifty percent cases of carcinoma breast below 30-year age were also ER positive.

CONCLUSION

A high proportion of breast cancer in young Pakistani females is alarming. Younger age harbours aggressive clinicopathologic characteristics. There is a due need for identifying high risk individuals/families including BRCA1 and BRCA2 testings, biologically driven trials devoted specifically to this group.

Primary tuberculosis of palate

Primary tuberculosis (TB) of the hard palate is very rare. A 74-year-old man was presented with 6-month history of dysphagia along with an irregular mass in the hard and soft palate. Magnetic resonance imaging (MRI) revealed thickened and increased signal intensity within hard and soft palate. Tissue biopsy showed focal caseating granulomatous-like lesion and the histochemical staining using Ziehl-Neelsen stain for acid-fast bacilli was positive. Positive histochemical studies provided evidences that the hard palate mass was most likely due to TB. Thus, the patient was started on antituberculous therapy.

Is universal sample processing methodology better than conventional techniques for detection of tuberculosis?

BACKGROUND

The identification of infectious cases is a crucial first step for tuberculosis control programmes worldwide. It relies exclusively on the detection of acid-fast bacilli in sputum by smear microscopy. Therefore, there is an urgent and definite need to improve the sensitivity of smear microscopy.

OBJECTIVE

The USP method was compared with the two most commonly used conventional methods of smear microscopy namely; direct smear microscopy and the microscopy by modified Petroff's method.

MATERIALS AND METHODS

Two samples from each patient were taken from 197 patients of presumptive tuberculosis. One smear was made for direct Ziehl-Neelsen staining and two smears were made after processing by two concentration methods i.e., modified Petroff's and USP solution. LJ media were inoculated for culture after processing by both concentration methods.

RESULTS

Among 197 cases 93 were culture positive by either method. Out of 93 culture-positive sample, 78.5% were direct smear positive, 89% were 4%NaOH smear positive and 96% were USP smear-positive samples but difference in diagnostic accuracy of USP (96%) and modified Petroff method (93%) is not statistically significant (P>0.01).

CONCLUSION

The present study evaluated the smear microscopy by USP method with two conventional methods, direct microscopy and microscopy by modified Petroff's method. The study concludes that although USP method is more sensitive than conventional methods, it is not feasible to include it in diagnosis of early tuberculosis within RNTCP.

A novel approach to analyzing concentration polarization of polysaccharide solutions

This paper describes a novel approach to analyzing the concentration polarization (CP) in the short-time constant flux filtration of polysaccharide solutions. With application of the pearl-necklace model based polymer solution permeability correlation, a transmembrane pressure (TMP) increase rate model was developed to relate the linear TMP increase rate measured in the short-time constant flux filtration to the solid concentration at the membrane surface, the polymer critical overlapping concentration, and the radius of gyration of the polymer molecules. Establishment of such a theoretical model allows analysis of the gelation propensity of the CP layer formed by polysaccharides based on the experimentally determined linear TMP increase rate.

Reticular type parotid myoepithelial carcinoma: an intriguing variant and mimicker

Myoepithelial carcinoma, the malignant counterpart of benign myoepithelioma, is one of the rarest salivary gland neoplasms. It is composed almost exclusively of tumour cells with myoepithelial differentiation, characterized by infiltrative growth and potential for metastasis. We herein, report a case of myoepithelial carcinoma in a 50 years old male with reticular morphology. Reticular variant of myoepithelial carcinoma may be mistaken for a variety of benign and malignant epithelial and mesenchymal tumours including mixed tumour (pleomorphic adenoma), adenoid cystic carcinoma, basal cell adenoma and epithelial myoepithelial carcinoma. Complete surgical excision is the mainstay of therapy. The role of radiation therapy and chemotherapy is not yet established. Awareness of this variant is emphasized to prevent misdiagnosis.

Spindle cell rhabdomyosarcoma of the tongue – A rare entity

Spindle cell variant of Rhabdomyosarcoma is a rare malignant tumor in adults but even more so in tongue. We report a case of a 17 year old boy who presented with a polypoidal swelling on the tip of the tongue. The mass was excised and the specimen was sent to the Histopathology Department of Armed Forces Institute of Pathology for Histomorphological diagnosis. The histological evaluation showed a malignant spindle cell tumor. On the basis of morphological features and immunohistochemistry findings a final diagnosis of Rhabdomyosarcoma, Spindle cell variant was made. Journal of College of Medical Sciences-Nepal,2011,Vol-7,No-4, 63-66 DOI: http://dx.doi.org/10.3126/jcmsn.v7i4.6814

A clinical decision rule to enhance targeted bone mineral density testing in healthy mid-life women

SUMMARY

The rates of bone mineral density testing for osteoporosis among healthy mid-life women are high, although their osteoporosis or fracture risk is low. To reduce unnecessary testing, we created and evaluated a tool to guide bone density testing based on the woman's age, weight, fracture history, and menopausal status.

INTRODUCTION

This study aims to improve case finding of mid-life women with low bone mass on bone mineral density (BMD) assessment.

METHODS

Among healthy women aged 40-60 years having their first BMD test, osteoporosis risk factors were assessed by questionnaire and BMD by dual-energy X-ray absorptiometry. The combination of risk factors that best discriminated women with/without low bone mass (T-score ≤ -2.0) was determined from the logistic regression model area under the curve (AUC) and internally validated using bootstrapping. Using the model odds ratios, a clinical prediction rule was created and its discriminative properties assessed and compared with that of the osteoporosis self-assessment tool (OST). Sensitivity analyses examined results for pre-/peri- and post-menopausal women, separately.

RESULTS

Of 1,664 women referred for baseline BMD testing, 433 with conditions known to be associated with bone loss were excluded. Of 1,231 eligible women, 944 (77%) participated and 87 (9.2%) had low bone mass (35 pre-/peri- and 52 post-menopausal). Four risk factors for low bone mass were identified and incorporated into a clinical prediction rule. Selecting women for BMD testing with weight of ≤70 kg or any two of age >51, years' post-menopause of ≥1, and history of fragility fracture after age 40 was associated with 93% sensitivity to identify women with low bone mass, compared with 47% sensitivity for an OST score of ≤1 (AUC 0.75 versus OST AUC 0.69, p = 0.04). Results restricted to post-menopausal women were similar.

CONCLUSIONS

Among healthy mid-life women receiving a baseline BMD test, few had low bone mass, supporting the need for guidance about testing. A prediction rule with four risk factors had improved sensitivity over the OST. Further validation is warranted.