Comparison of All-Polyethylene Tibial Versus Metal-Backed Tibial Component in Total Knee Replacement Surgery

Introduction: Total knee replacement (TKR) is the most successful procedure in Orthopedics. The selection of an ideal implant relies on better survivorship, restoration of functional activities and cost-effectiveness. This study compared the effectiveness of all-polyethylene (AP) versus metal-backed tibial (MTB) implant in TKR patients in terms of objective and subjective patient related outcomes. Objectives: To compare the effectiveness of all-polyethylene tibial implants versus metal-backed tibial implants in total knee replacement patients in terms of improvement in the American Knee Society Score (AKSS). Methodology: It was a nonrandomized controlled trial done in the Orthopaedic Department of the Sharif Medical City Hospital, Lahore, after approval by the institutional ethical committee. Fifty patients of grade IV knee joint osteoarthritis for greater than six months were included by nonprobability convenient sampling technique. The patients were allocated equally into standard treatment and intervention groups; patients underwent TKR with MTB implants in the standard group and AP implants in the intervention group after taking informed written consent. The AKSS score was calculated pre-operatively, 3 months and 6 months after surgery by the team member not involved in surgical planning. Results: A statistically significant improvement was observed in pre-operative to post-operative knee scores (p-value = 0.004) and functional scores (p-value = 0.001) with TKR. When the means of knee scores were compared between AP and MTB implants, there was no significant difference between the two groups between pre-operative and post-operative knee scores and functional scores. Practical implication Conclusion: There is no significant difference in knee score between the all-polyethylene and metal-backed implants regarding pain and functional status. All-polyethylene implants are a better substitute for MTB implants due to their cost-effectiveness, particularly in countries with financial constraints. The most practical implication of the current study is health economics. In a developing country with a low per capita income, expensive implants can be swapped with low cost implants to bring the cost of the procedure down. Keywords: All-polyethylene tibial, Metal-backed tibial, Total knee replacement, American Knee Society Score, AKSS.

Plasma Proteomics Unveil Novel Immune Signatures and Biomarkers upon SARS-CoV-2 Infection

Several elements have an impact on COVID-19, including comorbidities, age and sex. To determine the protein profile changes in peripheral blood caused by a SARS-CoV-2 infection, a proximity extension assay was used to quantify 1387 proteins in plasma samples among 28 Finnish patients with COVID-19 with and without comorbidities and their controls. Key immune signatures, including CD4 and CD28, were changed in patients with comorbidities. Importantly, several unreported elevated proteins in patients with COVID-19, such as RBP2 and BST2, which show anti-microbial activity, along with proteins involved in extracellular matrix remodeling, including MATN2 and COL6A3, were identified. RNF41 was downregulated in patients compared to healthy controls. Our study demonstrates that SARS-CoV-2 infection causes distinct plasma protein changes in the presence of comorbidities despite the interpatient heterogeneity, and several novel potential biomarkers associated with a SARS-CoV-2 infection alone and in the presence of comorbidities were identified. Protein changes linked to the generation of SARS-CoV-2-specific antibodies, long-term effects and potential association with post-COVID-19 condition were revealed. Further study to characterize the identified plasma protein changes from larger cohorts with more diverse ethnicities of patients with COVID-19 combined with functional studies will facilitate the identification of novel diagnostic, prognostic biomarkers and potential therapeutic targets for patients with COVID-19.

Proteomics approaches to characterize the immune responses in cancer

Despite the dynamic development of cancer research, annually millions of people die of cancer. The human immune system is the major 'guard' against tumor development. Unfortunately, cancer cells have the ability to evade the immune system and continue to grow. The proper understanding of the intricate immune response in tumorigenesis remains the holy grail of cancer immunology and designing effective immunotherapy. To decode the immune responses in cancer, in recent years, proteomics studies have received considerable attention. Proteomics studies focus on the detection and quantification of proteins, which are the effectors of biological functions, and as such, are proven to reflect the cell state more accurately, in comparison to genomic or transcriptomic studies. In this review, we discuss the proteomics studies applied to characterize the immune responses in cancer and tumor immune microenvironment heterogeneity. Further, we describe emerging single-cell proteomics approaches that have the potential to be applied in cancer immunity studies.

Identification and Characterization of Splicing Defects by Single-Molecule Real-Time Sequencing Technology (PacBio)

Although DNA-sequencing is the most effective procedure to achieve a molecular diagnosis in genetic diseases, complementary RNA analyses are often required.Reverse-Transcription polymerase chain reaction (RT-PCR) is still a valuable option when the clinical phenotype and/or available DNA-test results address the diagnosis toward a gene of interest or when the splicing effect of a single variant needs to be assessed.We use Single-Molecule Real-Time sequencing to detect and characterize splicing defects and single nucleotide variants in well-known disease genes (DMD, NF1, TTN). After proper optimization, the procedure could be used in the diagnostic setting, simplifying the workflow of cDNA analysis.

A case report of Munchausen syndrome presenting with bleeding from ear: a rare factitious disorder

Munchausen syndrome is a rare psychiatric illness that includes mimicking a group of medical conditions, in which a person repeatedly harms him or herself or falsely misinterprets any medical condition when he or she is not actually sick, in order to achieve health care attention. Underdiagnosis of this syndrome leads to irrelevant use of medical assets. Here, we document an interesting and rare case of a young girl presented in the outpatient department of the Otolaryngology department of Patel Hospital with episodes of bleeding from her ear, which is a rare presentation of Munchausen syndrome. Her complete physical, otolar yngological, haematological and radiological examination failed to reveal any clue towards a particular diagnosis. Hence a diagnosis of Munchausen syndrome was made by exclusion of other possibilities of ear bleeding, and it was considered as a case report after taking duly signed written consent from the patient. This report will help in increasing the self-knowledge and perception of different clinical based presentations of this syndrome in medical practitioners, in order to avoid overlooking such cases. Further exploratory work is required in this regard to discover the etiology and predisposing factors and to develop new treatment strategies.

Organophosphate Poisoning: Demographics, Severity Scores and Outcomes From National Poisoning Control Centre, Karachi

Introduction

Organophosphate ingestion is the commonest cause of self-harm encountered at poison control centers in Pakistan. It usually affects a young populous. Organophosphates are found in various forms and formulations that are easily accessible to the general public. These compounds are extremely potent poisons causing rapid clinical deterioration with minimal ingestion or exposure.

Signs and symptoms can range from mild or none to severe such as bradycardia, miosis, fasciculations, seizures and altered level of consciousness. Poisoning severity is measured using the Peradeniya Organophosphorus Poisoning (POP) scale. Mortality rates are relatively low for mild to moderate disease. Severe disease as calculated by the POP carries an exceptionally high mortality rate.

The National Poisoning Control Centre (NPCC) at Jinnah Postgraduate Medical Centre, Karachi treats an extraordinary number of poisoning cases on a daily basis. Despite this data pertaining specifically to OP ingestion is nearly absent. There have been no studies analyzing the various aspects of organophosphate poisoning in the last 30 years to the best of our knowledge. Here, we look to rectify this.

Aims

To evaluate the demographics, severity scores and outcomes of organophosphate poisoning cases in the last year from the NPCC, Karachi.

Methods

This was a retrospective study. It was held from 1^st January 2019 to 31^st December 2019. All data was recorded from patients admitted to the NPCC with a proven diagnosis of organophosphate poisoning.

Results

Three thousand and three hundred patients were inducted into this study. Over 3/4th of the patients were teenagers or aged less than 30 years. Almost all referrals were made from within the city. Overall survival rate at 28 days was 89.45%. Most patients presented with mild to moderate disease as calculated by the POP; severe disease had a mortality rate of nearly 50%.

Conclusion

Organophosphates make up a significant portion of all cases of poisoning treated at the NPCC. The POP is an excellent tool to evaluate disease severity. Overall survival rates are good but mortality rate is high for severe disease even in young patients.

Epidemiological, Poisoning Characteristics and Treatment Outcomes of Patients Admitted to the National Poisoning Control Centre at Karachi, Pakistan: A Six Month Analysis

INTRODUCTION

 Any substance if taken in enough quantity can be defined as a poison provided it causes physiological or anatomical harm. It can range from food products to therapeutic medications to toxins and chemicals. Animals, plants, and insects also produce toxins, which are poisonous. While any route of ingestion is dangerous, most poisons are either taken by mouth or inhaled. Rarely intravenous access as in the case of heroin/opoids overdose is seen as well. Poisoning whether deliberate or otherwise is a growing problem of the modern world. Young people are disproportionally affected by it. Mostly household products such as insecticides, bleach, acid, etc. are used. Harmful ingestion of prescription meds, recreational drugs, psychiatric medicines, and opoids has been on the rise in recent times. This is one of the major sources of poisoning these days. Data with respect to Sindh and Pakistan is scarce. As the largest referral center in the country, Jinnah Postgraduate Medical Centre sees its fair share of poisoning cases. Here we evaluate the trends and increasing burden of poisoning cases seen at this center.

AIMS

To evaluate the epidemiological, poisoning characteristics and treatment outcomes of patients admitted to the National Poisoning Control Centre (NPCC) at Karachi, Pakistan.

MATERIALS AND METHODS

 This is a retrospective study, held from July 1^st to December 31^st 2018. Data were recorded from all patients admitted to the NPCC after complete medico-legal work up.

RESULTS

 A total of 2546 patients were inducted into the study. The mean age of presentation was 26.57 ± 11.82 years. Nearly 80% of patients were aged 40 years or younger. Both genders were equally affected and most cases were referred from within the city. Organophosphates (OPs) were the most frequent (46.11%) cause of poisoning seen. Overall mortality was 3.61%.

CONCLUSION

 The burden of poisoning cases has risen sharply. Mostly young adults and teenagers are affected without gender bias. Mortality is high considering the young population involved.

2854 High Resolution Esophageal Manometry Findings in Patients With Esophageal Symptoms After Head and Neck Radiation Therapy

INTRODUCTION:

Head and neck radiation therapy is known to cause esophagitis and esophageal strictures as early and late effects after radiation exposure, respectively. The negative effects of radiation on esophageal motor function have been speculated in case reports but have not been studied in a larger population with high resolution manometry (HRM). The aim of this study was to evaluate HRM findings in patients who received head and neck or mediastinal radiation and presented with esophageal symptoms.

METHODS:

There were a total of 718 patients who received HRM from 2010 to 2018 at the Michael E. DeBakey VA Medical Center. Patients were excluded if they had undergone esophageal surgery, found to have oro-pharyngeal dysphagia, or if they had a mechanical cause on esophagogastroduodenoscopy of esophageal symptoms. Among the cohort, 14 patients met our inclusion criteria of receiving head and neck or mediastinal radiation prior to HRM. Chicago Classification v3.0 was used for HRM diagnoses.

RESULTS:

The most common symptom for which HRM was performed was esophageal dysphagia in 8 patients. Regurgitation and chest pain were each reported in 3 patients. Heartburn (n = 2), odynophagia (n = 1), and hoarseness (n = 1) were also reported symptoms. Seven of 14 patients (50.0%) were found to have abnormal findings on HRM (Table 1). Findings included hypotensive lower esophageal sphincter (LES) (n = 2), hypertensive LES (n = 1), hypotensive upper esophageal sphincter (UES) (n = 1), UES stricture (n = 1), spastic achalasia (n = 1), and ineffective esophageal motility (n = 1). There was no difference in HRM findings based on radiation dose received (Figure 1). There was an association towards increased HRM abnormalities with time since last radiation (Figure 2).

CONCLUSION:

This is one of the largest studies to show the effects of head and neck radiation on esophageal motility using HRM. Fifty percent of patients in this cohort exposed to head and neck radiation had abnormalities on HRM. We have also shown an association towards increased abnormal HRM findings with time, especially greater than five years after radiation exposure. Similar to our study, achalasia and ineffective peristalsis have been reported both early and late after head and neck radiation. Despite reports of esophageal motility complications with increasing doses of radiation, we were unable to demonstrate this. Our findings suggest that patients with esophageal symptoms after radiation exposure should be investigated for esophageal motor dysfunction.

Improving Anemia in Inflammatory Bowel Disease: Impact of the Anemia Care Pathway

BACKGROUND

Anemia is a common complication of inflammatory bowel disease (IBD). Despite existing guidelines for anemia in IBD, it is frequently under-treated and the prevalence of anemia has remained high. To address this gap, the Crohn's and Colitis Foundation developed the Anemia Care Pathway (ACP).

AIMS

To implement the ACP in a managed care setting and identify where it improves practice habits and where barriers remain.

METHODS

The ACP was implemented from July 2016 through June 2017 and retrospectively studied. Run charts were used to identify shifts in iron deficiency screening and treatment as well as anemia prevalence. Results were compared to those of other providers in the same center not using the ACP.

RESULTS

640 IBD encounters were studied. In the ACP clinic (n = 213), anemics received iron therapy in only 30% of encounters at baseline but improved to 80%. Concurrently, anemia prevalence decreased from 48 to 25%. Screening for iron deficiency, however, did not improve. No shifts were seen in the non-ACP clinics (n = 427) across the same period despite awareness of the ACP and other guidelines.

CONCLUSIONS

Across 1 year, we observed gaps in the screening and treatment of anemia in IBD. Although screening rates did not improve, the ACP appeared to reduce missed opportunities for iron therapy by about half. Most importantly, this was associated with an overall decrease in anemia prevalence. Future refinements to the ACP should be focused on enhanced screening and follow-up.

Expert consensus on a train-the-trainer curriculum for robotic colorectal surgery

AIM

Robotic techniques are being increasingly used in colorectal surgery. There is, however, a lack of training opportunities and structured training programmes. Robotic surgery has specific problems and challenges for trainers and trainees. Ergonomics, specific skills and user-machine interfaces are different from those in traditional laparoscopic surgery. The aim of this study was to establish expert consensus on the requirements for a robotic train-the-trainer curriculum amongst robotic surgeons and trainers.

METHOD

This is a modified Delphi-type study involving 14 experts in robotic surgery teaching. A reiterating 19-item questionnaire was sent out to the same group and agreement levels analysed. A consensus of 0.8 or higher was considered to be high-level agreement.

RESULTS

Response rates were 93-100% and most items reached high levels of agreement within three rounds. Specific requirements for a robotic faculty development curriculum included maximizing dual-console teaching, theatre team training, nontechnical skills training, patient safety, user-machine interface training and telementoring.

CONCLUSION

A clear need for the development of a train-the-trainer curriculum has been identified. Further research is needed to assess feasibility, effectiveness and clinical impact of a robotic train-the-trainer curriculum.

Efficacy and Safety of Sofosbuvir and Ribavirin for Treating Chronic Hepatitis C, Genotype 3: Experience of a Tertiary Care Hospital at Karachi, Pakistan

Background

It is estimated that approximately 10 million individuals in Pakistan are infected with hepatitis C virus (HCV). Historically, it was very difficult not just to cure but even treat HCV as available options did not have desirable outcomes. However, the approval of directly acting antiviral (DAA) drugs has revolutionized treatment and management. These are specific proteases and polymerase inhibitors with profound capability for accomplishing elimination and overtime eradication of the virus.

Objective

The aim of this study was to evaluate the efficacy and safety of sofosbuvir (SOF) in combination with ribavirin (RIB) for the treatment of chronic hepatitis C virus with genotype 3.

Materials and methods

This prospective observational study was conducted at the gastroenterology section of Medical Unit IV, Jinnah Post-graduate Medical Center, Karachi and Medical Unit II, Dow University of Health Sciences, Ojha Campus, Karachi from January 2016 to December 2016. Patients aged 18 years or older of either gender having chronic active HCV infection as demonstrated by a positive Anti-HCV (ELISA) test and a qualitative polymerase chain reaction (PCR) analysis along with genotype analysis showing only type 3 were inducted into the study.

Treatment was initiated with either 12-week or 24-week regimen of SOF 400 mg once daily along with weight-adjusted RIB orally. Successful treatment was indicated by the elimination of the virus, i.e., undetectable viral load/levels by PCR qualitative analysis. Rapid virological response (RVR), end of treatment response (ETR), and sustained virological response (SVR) were defined as the undetectable viral load at four, 12, and 24 weeks, respectively.

Results

A total of 300 patients were inducted into the study, predominantly female (57%). The mean age of presentation was 41.14 ± 11.48, and most (70.33%) were treatment naïve. The mean alanine transaminase (ALT), aspartate aminotransferase (AST), and gamma-glutamyl transferase (GGT) levels at presentation were 41.89 ± 46.23 IU/l, 68.57 ± 83.62 IU/l, and 54.52 ± 77.57 IU/l, respectively.

ALT, AST, and GGT levels at 24 weeks were 33.84 ± 13.60 IU/l, 32.44 ± 16.16 IU/l, and 37.59 ± 22.41 IU/l, respectively, showing significant improvement. ETR was achieved in 99.1% (209) treatment-naïve patients and 98.9% (88) treatment-experienced patients. SVR rates were almost similar with 98% (208) achieving it in the treatment-naïve group and 96.6% (86) achieving it in the treatment-experienced group.

Conclusion

SOF in combination with RIB is safe and remarkably efficacious in the treatment of chronic HCV, genotype 3. Not only is this regimen associated with the elimination of viral replication but it also improved transaminase levels. Outcomes are rarely, if ever, affected by previous use of antiviral medications.

Epidemiology, Clinical Characteristics, and Management Status of Hepatitis B: A Cross-sectional Study in a Tertiary Care Hospital at Karachi, Pakistan

Background

Hepatitis B virus (HBV) infection is a serious health problem in Pakistan. In view of the serious socioeconomic consequences, identifying patient characteristics and the current treatment for the disease will enhance HBV regulation and its medical management.

Aims

To describe the epidemiology, clinical characteristics, and current management status of patients infected by HBV.

Methods

We undertook an observational, cross-sectional, and epidemiological study at the Jinnah Postgraduate Medical Centre, Karachi, during the period from January 2014 to November 2017. Male and female patients of any age and with documentation for an HBV infection were eligible for inclusion in the study. An HBV infection was defined as a positive hepatitis B surface antigen test.

Results

A total of 500 patients were analyzed. The mean age at presentation was 29.86±13.68 years. The majority of the patients (25.6%) were ethnically Sindhi followed by Pathan (24.4%), indicating a high prevalence among the rural-based population of Pakistan. The mean duration of the disease was 3.51±4.46 years. The most common cause for the spread was positive family history (40.4%) followed by roadside barbers (30.0%). Most patients were Child-Pugh (CP) class A (84.6%) and the median Modified End-Stage Liver Disease (MELD) score was 7. Upper gastrointestinal bleeding was the most frequent hepatic complication (6.2%). Antiviral medications had been received by 18.6% of patients previously. Peg-interferon (6.0%) was the major antiviral medication prescribed to treatment-experienced patients.

Conclusions

This observational, real-life study has identified some gaps between clinical practice and guideline recommendations in Pakistan. To achieve better health outcomes, several improvements, such as disease monitoring and optimizing antiviral regimens, should be made to improve disease management.

Evolution of sinonasal symptoms and mucosal healing after minimally invasive pituitary surgery

BACKGROUND

Minimally invasive pituitary surgery (MIPS) via endoscopy has become widely accepted as the surgical paradigm of choice for pituitary pathology. The objective of the current study was to analyze the evolution of symptom scores and mucosal healing after MIPS.

METHODS

The 22-item Sino-Nasal Outcome Test (SNOT-22) scores and objective endoscopic data of 52 patients were reviewed in a longitudinal manner. Scaled averages of the SNOT-22 and endoscopic scores from different time points were compared with baseline scores by using nonparametric testing. The time to baseline for endoscopic examinations was also analyzed by using Kaplan-Meier curves.

RESULTS

The rhinologic symptoms subdomain of the SNOT-22 scores showed statistically significant worsening between baseline and 2 weeks after surgery (p = 0.03). Follow-up SNOT-22 scores after 2 weeks showed no significant differences compared with baseline scores, with an overall trend toward improvement in patient symptoms during the subsequent period. Similar analysis for the endoscopic data illustrated statistically significant differences from the baseline scores up to 16 weeks after surgery. The overall trend showed a worsened endoscopic examination, initially with a spike at ∼8 to 10 weeks (p = 0.03) and with a subsequent return to baseline. The Kaplan-Meier estimate curve demonstrated a median time to return to baseline endoscopy at 18.9 weeks (95% confidence interval, 14.9-38.3 weeks).

CONCLUSION

The longitudinal data exhibited subjective improvement of patient outcomes based on SNOT-22 scores within 2-4 weeks after MIPS. However, the objective endoscopic data revealed a lag in improvement of the examination, typically at 16-20 weeks, which underscores ongoing careful endoscopic assessment and management to ensure proper mucosal healing beyond just subjective symptoms as the gauge to postoperative recovery.

Nuclear transportation of exogenous epidermal growth factor receptor and androgen receptor via extracellular vesicles

Epidermal growth factor receptor (EGFR) plays a central role in the progression of several human malignancies. Although EGFR is a membrane receptor, it undergoes nuclear translocation, where it has a distinct signalling pathway. Herein, we report a novel mechanism by which cancer cells can directly transport EGFR to the nucleus of other cells via extracellular vesicles (EVs). The transported receptor is active and stimulates the nuclear EGFR pathways. Interestingly, the translocation of EGFR via EVs occurs independently of the nuclear localisation sequence that is required for nuclear translocation of endogenous EGFR. Also, we found that the mutant receptor EGFRvIII could be transported to the nucleus of other cells via EVs. To assess the role of EVs in the regulation of an actual nuclear receptor, we studied the regulation of androgen receptor (AR). We found that full-length AR and mutant variant ARv7 are secreted in EVs derived from prostate cancer cell lines and could be transported to the nucleus of AR-null cells. The EV-derived AR was able to bind the androgen-responsive promoter region of prostate specific antigen, and recruit RNA Pol II, an indication of active transcription. The nuclear-translocated AR via EVs enhanced the proliferation of acceptor cells in the absence of androgen. Finally, we provide evidence that nuclear localisation of AR could occur in vivo via orthotopically-injected EVs in male SCID mice prostate glands. To our knowledge, this is the first study showing the nuclear translocation of nuclear receptors via EVs, which significantly extends the role of EVs as paracrine transcriptional regulators.

Learning curve for the transsphenoidal endoscopic endonasal approach to pituitary tumors

INTRODUCTION

The transsphenoidal endoscopic approach is a relatively new procedure compared to the microscopic approach in pituitary adenoma resection. The endoscopic approach has shown to significantly decrease the rate of complications, time in the operating room and hospital, and patient post-op discomfort. However, this procedure requires the surgeon to make use of different visual and tactile clues that must be developed with experience. Therefore, it is important to understand the learning curve that the surgeon must overcome to become proficient with the endoscopic approach.

METHODS

Retrospective review of a single-surgeon consecutive series of 78 patients undergoing endoscopic pituitary tumor surgery from 2006 to 2012 at Rush University Medical Center has been used in this study. Patients were grouped according to an early (n = 9) and late group (n = 68) determined by a significant difference in outcomes. Our primary outcome measures were: duration of operation, CSF leak, hospital length of stay, visual field improvement, diabetes insipidus, panhypopituitarism, and subtotal resection.

RESULTS

There was a significant reduction in OR time and intraoperative CSF leaks between the early and late groups. There was no difference in hospital LOS or visual field improvement between the groups. With regards to complication rates, there was no difference found for DI, panhypopituitarism, lumbar drain placement, sinusitis, or subtotal resection between the two groups.

CONCLUSION

This study indicates that there may be a learning curve of approximately 9 cases before a surgical team can decrease OR times and reduce the rate of intraoperative CSF leaks for the endonasal endoscopic approach to pituitary adenoma resection.

A systematic review and meta-analysis evaluating the role of laparoscopic surgical resection of transverse colon tumours

OBJECTIVES

A meta-analysis of published literature comparing outcomes after laparoscopic resection (LR) with open resection (OR) for transverse colon tumours.

METHODS

Medline, PubMed, CINAHL, EMBASE and Cochrane were searched from inception to October 2013. The text words "minimally invasive", "keyhole surgery" and "transverse colon" were used in combination with the medical subject headings "laparoscopy" and "colon cancer". Outcome variables were chosen based upon whether the included articles reported results. A meta-analysis was performed to obtain a summative outcome.

RESULTS

Six comparatives involving 444 patients were analysed. Of them 245 patients were in the LR group and 199 in the OR group. There was a significant increase in operative time in the LR group compared with the OR group [random effects model: SMD = -0.65, 95% CI (-1.01, -0.30), z = -3.60, p < 0.001] but there was significant heterogeneity amongst trials (Q = 15.51, df = 5, p = 0.008, I(2) = 68). There was less blood loss in the LR group [fixed effects model: SMD = 0.70, 95% CI (0.47, 0.93), z = 6.01, p < 0.001] and patients returned to oral diet earlier [random effects model: SMD = 0.78, 95% CI (0.40, 1.16), z = 4.01, p < 0.001] and had a reduced time to functioning bowel [fixed effects model: SMD = 0.86, 95% CI (0.60, 1.11), z = 6.63, p < 0.001]. No difference was seen for overall morbidity (p = 0.76) or mortality (p = 0.58).

CONCLUSIONS

LR of transverse colon tumours is a safe and effective technique. Although there is an increase in operating time, operative and clinical outcomes of intraoperative blood loss and faster recovery are seen with laparoscopic procedures.

Regulation of the tumor suppressor PTEN through exosomes: a diagnostic potential for prostate cancer

PTEN is a potent tumor-suppressor protein. Aggressive and metastatic prostate cancer (PC) is associated with a reduction or loss of PTEN expression. PTEN reduction often occurs without gene mutations, and its downregulation is not fully understood. Herein, we show that PTEN is incorporated in the cargo of exosomes derived from cancer cells. PTEN is not detected in exosomes derived from normal, noncancerous cells. We found that PTEN can be transferred to other cells through exosomes. In cells that have a reduction or complete loss of PTEN expression, the transferred PTEN is competent to confer tumor-suppression activity to acceptor cells. In PC patients, we show that PTEN is incorporated in the cargo of exosomes that circulate in their blood. Interestingly, normal subjects have no PTEN expression in their blood exosomes. Further, we found that the prostate-specific antigen (PSA) is incorporated in PC patients’ and normal subjects’ blood exosomes. These data suggest that exosomal PTEN can compensate for PTEN loss in PTEN deficient cells, and may have diagnostic value for prostate cancer.

Abstract 2455: Molecular targeted imaging of vascular endothelial growth factor receptor (VEGFR)-2 and anti-NMP autoantibodies detect ovarian tumor at early stage

Background: Although several serum markers of ovarian cancer (OVCA) have been suggested, none can detect OVCA at early stage specifically because of the lack of a corresponding marker in the ovary. Ovarian malignant cellular transformation is an early event followed by tumor-associated neoangiogenesis (TAN). Malignant cellular transformation results in shedding of nuclear matrix proteins (NMPs) in circulation and anti-NMP autoantibody production. VEGFR-2, an ovarian TAN marker, may also be an imaging marker for early OVCA detection. Thus VEGFR-2 in association with anti-NMP antibodies may constitute an early detection test for OVCA. Objectives: The goal of this study was to examine (i) whether VEGFR-2 targeted ultrasound imaging detects ovarian TAN vessels and (ii) whether the frequency of TAN vessels is associated with serum anti-NMP antibodies at early stage of OVCA in laying hens model of human OVCA. Materials and Methods: Mature White Leghorn laying hens with normal or low egg laying rates or no egg laying were scanned by transvaginal ultrasound before and after intravenous injection with VEGFR-2 targeted microbubbles. All images were archived and analyzed offline. Serum samples were collected, hens were euthanized, ovarian tissues were processed for paraffin or frozen sections and NMP extraction. Ovarian tumors were confirmed by gross morphology and routine histology. Sera were tested for anti-NMP antibodies and VEGFR-2 levels by immunoassay and 1- and 2D-Western blot (WB). The frequencies of VEGFR-2 expressing TAN vessels were determined by immunohistochemistry (IHC). Results: VEGFR-2 targeted microbubbles bounded with ovarian tumors and appeared as a ring of irregular shape on the ovarian surface. Compared with non-targeted, VEGFR-2 targeted imaging increased the visualization of TAN vessels remarkably. VEGFR-2 expressing TAN vessels confirmed targeted ultrasound imaging predictions. Serum levels of VEGFR-2 were higher in OVCA hens than in normal hens and associated with the frequencies of ovarian TAN vessels. None of the hens with normal egg laying rates was positive for anti-NMP antibodies. Immunoreactive tumor antigens (NMP) of 50-60kDa were detected by 2D-WB. The frequencies of VEGFR-2 expressing TAN vessels were higher in hens with serum anti-NMP antibodies than in normal hens. Conclusion: VEGFR-2 targeted ultrasound imaging enhanced the visualization of ovarian TAN vessels remarkably. The intensity of targeted imaging was associated with serum VEGFR-2 levels and anti-NMP antibodies. Thus, VEGFR-2 targeted imaging together in association with serum anti-NMP antibodies may improve OVCA detection at early stage. These results will form a foundation for a clinical study. Support: DOD-(OC0100192), Elmer and Sylvia Sramek Foundation, NCI-POCROC (P50 CA83636).

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 2455. doi:1538-7445.AM2012-2455

The magnetism of surgery: small bowel obstruction in an 8-year-old boy

An 8-year-old boy with Asperger's syndrome presented with right-sided abdominal pain, which was consistent with a probable appendicitis, but revisiting the history with a high index of suspicion confirmed multiple foreign body ingestion to be the cause of his symptoms. An emergency laparotomy was performed. Multiple toy magnets and other metal objects were found, which were causing small bowel obstruction with interloop fistulation. Following removal and repair, the patient made an excellent recovery.

Evaluation of nested polymerase chain reaction, pepsin/trypsin digest, and histology for the detection of Myxobolus cerebralis in salmonid fishes of Indiana and Michigan

The objectives of this study were to survey fish from state hatcheries in Indiana and Michigan and to compare the nested polymerase chain reaction (PCR) test with pepsin/trypsin digest (PTD) and histopathology for the diagnosis of whirling disease (WD). One group of 40 and 9 groups of 60 fish heads, for a total of 580 samples, were submitted from hatcheries in Indiana and Michigan. These samples were examined for myxozoan spores using histopathology, PTD, and PCR tests. The heads were hemisectioned, and one half was fixed in 10% neutral-buffered formalin for histopathologic examination. The other half was processed for PTD. Some of the sediment was examined for the presence of myxozoan spores, and the rest was prepared for the nested PCR. Histologic examinations did not reveal Myxobolus cerebralis in any of the 580 samples. One hundred serial step sections, taken at 5-microm intervals, were evaluated for samples with positive spore identification by PTD. Histologic examination of these sections failed to reveal any myxozoan parasites. Myxozoan spores were observed in 16.9% (98/580) of samples in sediment after PTD. Spores morphologically similar to those of M. cerebralis were observed in 1.0% of PTD samples (n = 6). The nested PCR indicated that M. cerebralis spores were present in 0.5% of samples (n = 3). All 3 nested PCR-positive samples came from the same hatchery, however, spores of M. cerebralis were seen in 1 sample, spores of other myxozoan species were seen in the second sample, and spores were not seen in the third sample. When comparing the PTD to the nested PCR test, the PTD diagnosed 1 true positive, 5 false positives, 2 false negatives, and 572 true negatives, for a sensitivity of 33% and a specificity of 99.1%. Screening for M. cerebrallis infection in this study indicated a low prevalence of the disease. Histopathology was a very insensitive indicator of WD. The PCR test was highly specific and was used to differentiate spores of M. cerebralis from similar spores of other species.

Management of patients with intermediate (C3) cytology and a solitary breast lump

The records of all patients who had a C3 result on fine needle aspiration cytology (FNAC) over a 3-year period were reviewed. Clinical and mammographic findings at presentation were correlated with histopathological diagnosis. Of 43 patients, 32 patients underwent excision biopsy. Histology was benign in 25 patients, eight patients had an invasive breast carcinoma, two a phyllodes tumour and one had widespread ductal carcinoma in situ (DCIS). All but two of the patients with invasive tumours had abnormalities on clinical examination or imaging. In two patients there was no clinical or mammographic suspicion of malignancy. A C3 breast cytology result must be taken seriously as it is frequently an indicator of underlying malignancy. These results suggest that definite histology should be obtained in all patients because of the unacceptably high false-negative rate of clinical and radiological assessment in this group.

Cockayne syndrome

We report four cases of Cockayne Syndrome in a family of seven children. Apart from the usual clinical and laboratory features, sparse eye lashes and high arched palate in two patients, conjunctival and corneal edema in one, and proximal muscle weakness in one patient were noticed as additional findings.

Transmission ofMycobacterium bovisfrom experimentally infected ferrets to non-infected ferrets (Mustela furo)

AIMS

To demonstrate the transmission of Mycobacterium bovis infection from experimentally infected ferrets (Mustela furo) to non-infected ferrets in a laboratory setting, using three different isotypes of M. bovis, and to observe ferret behaviour that might be implicated in disease transmission.

METHODS

Three female ferrets, each experimentally infected with a unique strain of M. bovis, were housed together with six female and two male non-infected ferrets in an isolation facility. Transmission of infection was monitored clinically, serologically (using an ELISA test), bacteriologically, histologically, and by isotype analysis of M. bovis isolates using spoligotyping to determine whether or not transmission of each strain occurred. Ferret behaviour was observed using a time-lapse video recorder.

RESULTS

Transmission of M. bovis infection was confirmed in two male and four female ferrets. Isotype analysis showed that of the experimentally infected females, one did not infect any other ferret, another transmitted M. bovis to one ferret before it died prematurely 49 days post-infection, and the third, which was cannibalised, appears to have transmitted M. bovis to both males and three females. However, two of these latter three females had died before the event of cannibalism took place. One female was infected with two strains. Several behavioural interactions were observed that could have resulted in M. bovis transmission, including den sharing, sniffing of orifices and faeces, cannibalism and aggressive breeding behaviour.

CONCLUSIONS

Horizontal transmission of M. bovis infection was demonstrated in ferrets under experimental housing conditions. Routes of transmission may involve cannibalism and factors such as den sharing, playing, fighting, mating, and sniffing of faeces.

Genetic resistance to experimental infection with Mycobacterium bovis in red deer (Cervus elaphus)

Tuberculosis (Tb) caused by Mycobacterium bovis is a worldwide threat to livestock and humans. One control strategy is to breed livestock that are more resistant to Mycobacterium bovis. In a 3-year heritability study 6 farmed red deer stags were selected from 39 on the basis of their differing responses to experimental challenge via the tonsillar sac with approximately 500 CFU of M. bovis. Two stags remained uninfected, two were moderately affected, and two developed serious spreading Tb. Seventy offspring, bred from these six stags by artificial insemination using stored semen, were similarly challenged with M. bovis. The offspring showed patterns of response to M. bovis challenge similar to those of their sires, providing evidence for a strong genetic basis to resistance to Tb, with an estimated heritability of 0.48 (standard error, 0.096; P < 0. 01). This is the first time the heritability of Tb resistance in domestic livestock has been measured. The breeding of selection lines of resistant and susceptible deer will provide an ideal model to study the mechanisms of Tb resistance in a ruminant and could provide an additional strategy for reducing the number and severity of outbreaks of Tb in farmed deer herds. Laboratory studies to identify genetic and immunological markers for resistance to Tb are under way. Preliminary studies showed no associations between NRAMP or DRB genes and resistance to Tb in deer. Patterns of immune responses seen in resistant animals suggest that both innate and acquired pathways of immunity are necessary to produce the resistant phenotype.

Partial protection against oral challenge with Mycobacterium bovis in ferrets (Mustela furo) following oral vaccination with BCG

SETTING

Ferrets (Mustela furo) are important wildlife vectors of bovine tuberculosis (TB) in New Zealand. Protective vaccination of ferrets may limit the potential of transmission to livestock.

OBJECTIVE

To determine whether orally-delivered Mycobacterium bovis BCG can confer protection against oral challenge with virulent M. bovis.

DESIGN

Ten ferrets were vaccinated by feeding measured doses of live BCG, and subsequently challenged with virulent M. bovis via the oral route. Ten non-vaccinated (control) ferrets were similarly challenged. Live body weights and lymphocyte reactivity were monitored longitudinally, and ferrets were killed 20 weeks following challenge. Necropsy, histological examination and bacterial culture of alimentary tract lymphatic tissues were undertaken.

RESULTS

There was a significant reduction in the incidence of gross tuberculous lesions among vaccinated ferrets compared to control animals, and fewer vaccinated ferrets had histologically-detectable acid-fast organisms in mesenteric lymph node (LN) tissues. There were significantly fewer vaccinated ferrets with culture-positive retropharyngeal LNs, and the mean bacterial burden was significantly lower for retropharyngeal LNs isolated from vaccinated animals than from controls.

CONCLUSION

These results demonstrate that oral BCG vaccination of ferrets can confer partial protection against M. bovis, and suggest that systemic immune responses may be less important in mediating this degree of protection than local immunity.

Experimental infection of white-tailed deer with rangiferine brucellosis

Experimental infections of white-tailed deer (Odocoileus virginianus) with Brucella suis biovar 4 were evaluated over a period of 6 wk. Five adult male hand-raised white-tailed deer were inoculated with 1 x 10(7) colony forming units of B. suis biovar 4 in the conjunctiva and serologically evaluated over 6 wk by the card test (CARD), rivanol test (RIV), serum agglutination test (SAT), complement fixation test (CFT), particle concentration fluorescence immunoassay (PCFIA), and competitive enzyme linked immunosorbent assay (cELISA), as routinely used for bovine samples. Six weeks postinoculation the animals were euthanized and cultured for B. suis biovar 4. One deer became serologically positive 4 wk postinoculation on CFT, CARD, PCFIA, and cELISA. At 6 wk postinoculation, CFT was positive in four infected deer, CARD was positive in three deer; RIV, SAT, and PCFIA was positive in two deer; and cELISA was positive in one deer. Only the CFT was 100% sensitive. At necropsy B. suis biovar 4 was isolated from four of five deer, and representative colonies were biologically similar to the challenge organism.

Oxidative responses in ferret macrophages

Although the basic function of T and B lymphocytes in ferrets has been known for some time, the function of mononuclear phagocytes has not been described in this species. The present study has characterised basic oxidative responses in ferret macrophages, and has investigated the effects of endogenous and exogenous modulators of macrophage function on oxidative capacity in vitro. Macrophages derived from the blood or lungs of ferrets were shown capable of generating the reactive oxygen intermediate (ROI) molecules superoxide and hydrogen peroxide, and secreting a lysosomal enzyme (acid phosphatase), in response to appropriate stimuli. A T cell supernatant (derived from mitogen-stimulated peripheral blood lymphocytes) was able to activate both blood- and lung-derived macrophages for enhanced ROI production, while specific ROI inhibitors (superoxide dismutase and catalase) were able to partially ablate ROI activity. The accumulation of nitrite in culture supernatants, as an indicator for the production of reactive nitrogen intermediates, could not be demonstrated by ferret macrophages derived from either tissue source. In contrast to the enhancing effects of TCS on the oxidative function of blood-derived macrophages, exposure to bacterial LPS caused marked suppression of ROI and lysosomal enzyme production by these cells. Finally, the generation of superoxide anion, following phagocytosis of live or heat-killed Mycobacterium bovis or zymosan, indicated that ROI production in response to phagocytic stimulation was relatively weak in ferret blood-derived macrophages. These results are discussed in relation to the study of immune function in a novel species, and with particular reference to research into tuberculosis (Tb), since ferrets are important wildlife vectors of bovine Tb in New Zealand.