Multiregion whole-exome sequencing of matched primary and metastatic tumors revealed genomic heterogeneity and suggested polyclonal seeding in colorectal cancer metastasis.

BACKGROUND: Distant metastasis accounts for 90% of deaths from colorectal cancer (CRC). Genomic heterogeneity has been reported in various solid malignancies, but remains largely under-explored in metastatic CRC tumors, especially in primary to metastatic tumor evolution. PATIENTS AND METHODS: We conducted high-depth whole-exome sequencing in multiple regions of matched primary and metastatic CRC tumors. Using a total of 28 tumor, normal, and lymph node tissues, we analyzed inter- and intra-individual heterogeneity, inferred the tumor subclonal architectures, and depicted the subclonal evolutionary routes from primary to metastatic tumors. RESULTS: CRC has significant inter-individual but relatively limited intra-individual heterogeneity. Genomic landscapes were more similar within primary, metastatic, or lymph node tumors than across these types. Metastatic tumors exhibited less intratumor heterogeneity than primary tumors, indicating that single-region sequencing may be adequate to identify important metastasis mutations to guide treatment. Remarkably, all metastatic tumors inherited multiple genetically distinct subclones from primary tumors, supporting a possible polyclonal seeding mechanism for metastasis. Analysis of one patient with the trio samples of primary, metastatic, and lymph node tumors supported a mechanism of synchronous parallel dissemination from the primary to metastatic tumors that was not mediated through lymph nodes. CONCLUSIONS: In CRC, metastatic tumors have different but less heterogeneous genomic landscapes than primary tumors. It is possible that CRC metastasis is, at least partly, mediated through a polyclonal seeding mechanism. These findings demonstrated the rationale and feasibility for identifying and targeting primary tumor-derived metastasis-potent subclones for the prediction, prevention, and treatment of CRC metastasis.

Ultrasound-guided infraclavicular axillary vein cannulation: a useful alternative to the internal jugular vein.

BACKGROUND: Ultrasound (US) guidance reduces complications and increases accuracy during internal jugular vein (IJV) cannulation. The subclavian vein (SCV) is popular but is less amenable to US guidance. The axillary vein (AxV), a direct continuation of the SCV, is an alternative, but to date, experience with US is limited to small case series. METHODS: Retrospective procedural data were collected on 2586 sequential patients referred for insertion of tunnelled central venous access at a UK tertiary centre from 2004 to 2011. RESULTS: A total of 99.8% of patients tolerated the procedure with local anaesthesia ± sedation; six patients had general anaesthesia. Twenty-six (1%) patients had uncorrected coagulopathy or thrombocytopenia. A total of 2572 (99.5%) of patients were cannulated successfully: right AxV 1644 cases, left AxV 279, right IJV 547, left IJV 89, other techniques 13, and 14 (0.5%) cases failed. The initial site chosen was successful in 96%. In patients who previously underwent long-term cannulation, 93.3% of lines were sited easily. Forty-eight (1.9%) procedural complications occurred. CONCLUSIONS: In this large analysis of US-guided central venous access in a complex patient group, the majority of patients were cannulated successfully and safely. The subset of patients undergoing AxV cannulation demonstrated a low rate of complications. The AxV route of access appears to be a safe and effective alternative to the IJV.

A comparison of Rapydan® patch and Ametop® gel for venous cannulation.

Ametop(®) gel (4% tetracaine) is used to provide topical anaesthesia for venous cannulation. Rapydan(®) patch (7% lidocaine and 7% tetracaine) has been developed to provide topical anaesthesia by a different mechanism, that of heat assisted delivery. We compared the topical anaesthetic effect of these agents for venous cannulation. One hundred healthy adults undergoing day-case surgery were randomly assigned to receive either Rapydan (n = 50) or Ametop (n = 50) before venous cannulation. Pain on insertion was scored on a visual analogue scale between 0 and 100 (where 100 = unbearable pain). Median(IQR[range]) pain scores were not different between groups with 11 (5-20 [0-72]) for Rapydan and 10 (5-24 [0-95]) for Ametop (p = 0.63). Adequate topical anaesthesia was achieved in over 90% of patients in both groups. Rapydan produces topical anaesthesia comparable with Ametop for venous cannulation.

Mastoid cavity obliteration using bone pâté versus bioactive glass granules in the management of chronic otitis media (squamous disease): a prospective comparative study.

OBJECTIVE: To compare the efficacy of bone pâté versus bioactive glass in mastoid obliteration. METHOD: This randomised parallel groups study was conducted at a tertiary care centre between September 2017 and August 2019. Sixty-eight patients, 33 males and 35 females, aged 12-56 years, randomly underwent single-stage canal wall down mastoidectomy with mastoid obliteration using either bone pâté (n = 35) or bioactive glass (n = 33), and were evaluated 12 months after the operation. RESULTS: A dry epithelised cavity (Merchant's grade 0 or 1) was achieved in 65 patients (95.59 per cent). Three patients (4.41 per cent) showed recidivism. The mean air-bone gap decreased to 16.80 ± 4.23 dB from 35.10 ± 5.21 dB pre-operatively. The mean Glasgow Benefit Inventory score was 30.02 ± 8.23. There was no significant difference between the two groups in these outcomes. However, the duration of surgery was shorter in the bioactive glass group (156.87 ± 7.83 vs 162.28 ± 8.74 minutes; p = 0.01). CONCLUSION: The efficacy of both materials was comparable.

Escheriosomes entrapped DNA vaccine co-expressing Cu-Zn superoxide dismutase and IL-18 confers protection against Brucella abortus.

In the present study, we evaluated prophylactic prospective of liposome based DNA vaccine co-expressing Cu-Zn superoxide dismutase (SOD) along with interleukin-18 (IL-18) against experimental murine brucellosis. The immunization schedule involves liposome-mediated delivery of pVsod (encoding SOD of Brucella abortus) and pVIL18-sod (encoding IL-18 of mouse and SOD of B. abortus) DNA constructs. The data highlight potential of Escherichia coli lipid liposome (escheriosome) based DNA delivery vehicle to induce SOD specific humoral and cellular immune responses in the immunized mice. The co-expression of SOD along with IL-18 ensued in higher lymphoproliferative response and IFN-gamma production in comparison to the group of animals that were immunized with free form of SOD-DNA. Antibody response developed upon immunization with both DNA vaccines was of IgG2a type mainly. The results of the present study show that co-expression of IL-18 along with SOD polarized the antigen specific immune responses toward Th-1 direction, a desirable feature to control intracellular pathogens.

An investigation into the length of standard tracheostomy tubes in critical care patients.

A number of problems have been reported with the use of standard length tracheostomy tubes in adult critical care patients. We measured the depth from the skin surface to the tracheal wall and the angle of the tracheal stoma during percutaneous tracheostomy. In vitro measurements were also performed on standard tracheostomy tubes. Comparison of in vivo and in vitro dimensions demonstrated that standard length tracheostomy tubes are too short for the average critical care patient. We recommend that both the stomal and intratracheal lengths should be made longer by approximately 1 cm and tubes should be redesigned to an angle of 110-120 degrees to allow optimal tracheal placement.

Pre-emptive Novalung-assisted carbon dioxide removal in a patient with chest, head and abdominal injury.

A young man sustained traumatic lung, head and abdominal injuries. Despite mechanical ventilation, deteriorating respiratory function resulted in severe hypoxia and hypercapnia, with high P(a)co(2) compounding an already raised intracranial pressure (ICP). The Novalung was pre-emptively used without anticoagulation, prior to laparotomy, to remove carbon dioxide and to allow for cerebral and lung protective strategies. This facilitated control of ICP thereby limited possible secondary brain injury.

Modified rush pin technique for two- or three-part proximal humeral fractures.

PURPOSE: To report the outcomes of modified Rush pin fixation for proximal humeral fractures. METHODS: 42 men and 20 women aged 19 to 94 (mean, 64) years with 2- or 3-part proximal humeral fractures underwent reduction and fixation using the modified Rush pin technique. 11 patients died from reasons unrelated to the surgery. RESULTS: Of 40 (out of 51) patients completing a subjective functional assessment using an Oxford Shoulder Questionnaire, 28 (70%) had 2-part and 10 (25%) had 3-part displaced fractures, and the remaining 2 (5%) had fracture-dislocations (one being 2-part and one 3-part). 25 (63%) patients were very satisfied (including one with a 3-part fracture after 6 months of rehabilitation), 7 (17%) were moderately satisfied, and 8 (20%) were not satisfied. There were 8 complications, including pin cut-out from the proximal fragment (n=2), proximal pin migration (n=2), distal pin migration (n=1), cortical perforation during surgery (n=1), mild ulnar nerve symptoms (n=1). No patients had non-union, myositis ossificans, avascular necrosis of the humeral head, or axillary nerve injury. CONCLUSION: The modified Rush pin fixation minimises tissue dissection; the implants are cheap and readily available; and the technical expertise is easily learnt. This technique is a suitable alternative of fixing proximal humeral fractures, especially in the elderly.

Preparation and in vitro evaluation of ethyl cellulose microspheres containing stavudine by the double emulsion method.

The aim of this study was to formulate and evaluate microspheres of stavudine by water-in-oil-in-oil (w/o/o) double emulsion solvent diffusion method using ethyl cellulose and ethyl cellulose in combination with polyvinyl pyrrolidone. A mixed solvent system consisting of acetonitrile and dichloromethane in an 1: 1 ratio and light liquid paraffin was chosen as primary and secondary oil phase, respectively. Span 80 was used as surfactant for stabilizing the secondary oil phase. The influence of formulation factors like stirring speed, surfactant concentration on particle size and polymer:drug ratio and combination of polymers on drug release characteristics of the microspheres was investigated. The prepared microspheres characterized by micrometric properties, drug loading, Fourier transform infrared spectroscopy, X-ray powder difractometry and scanning electron microscopy. The prepared microspheres were white, free flowing and spherical in shape, stable in nature, with 41-65% of drug entrapment efficiency. The best-fit release kinetics was achieved with Higuchi plot followed by first order and zero order. The release of stavudine was influenced by the drug to polymer ratio, particle size and polymer combination.

Caregiver's perception of epilepsy treatment, quality of life and comorbidities in an international cohort of CDKL5 patients.

OBJECTIVE: CDKL5 is a genetic condition associated with drug-resistant epilepsy and intellectual disability. There is limited information on its natural history. We investigated the natural history, complications, and the effectiveness of current treatment strategies. METHODS: This study was conducted in conjunction with the CDKL5-UK Charity, with patients recruited from the USA and Europe. Online questionnaires were completed by parents/carers and included information relating to demographics, growth, development, epilepsy, comorbid conditions, and efficacy and side effects of antiepileptic treatments. RESULTS: Thirty-nine of the 44 patients were female. Median age was five years (range five months to 31 years), and all had a history of epilepsy. All patients had developmental delay, with 4/21 able to run and 4/22 able to climb. Gastrointestinal problems were reported in 31/43. Cardiac arrhythmia was seen in 11/29. Over one-quarter of the patients had tried ten or more antiepileptic medications. Vigabatrin was reportedly the most effective AED (antiepileptic drug) in 12/23; clobazam (most effective in 6/14); sodium valproate (most effective in 5/27), and levetiracetam (most effective in 3/27). VNS (Vagal Nerve Stimulator) was reported to be effective in 9/12. One year after VNS insertion, 9/12 reported improved (QoL), and there were improvements in mood, school achievement and concentration in (9/11). The ketogenic diet was considered effective and to have improved QoL in (12/23). CONCLUSION: Vigabatrin appears to be more effective than other AEDs. VNS and ketogenic diet are also relatively effective. Gastrointestinal and cardiovascular system complications are common. The results may help to guide management of epilepsy in CDKL5. It highlights a possible link between CDKL5 and potentially treatable life-threatening complications such as cardiac arrhythmia. More research in this area may help us develop a more systematic approach to treating these patients. HIPPOKRATIA 2017, 21(3): 130-135.

[Discontinuation or tapering strategies of biologics in rheumatoid arthritis in remission]. / Stratégies d'arrêt ou de réduction des biomédicaments dans la polyarthrite rhumatoïde en rémission.

The arrival of new drugs and new therapeutic strategies allowed to reach sustained remission in an increasing number of patients with rheumatoid arthritis. The study of biologic disease-modifying anti-rheumatic drugs (bDMARDs) adaptation strategies is a need to optimize the benefit/risk balance and cost/effectiveness ratio of these molecules. Current recommendations such as EULAR 2016 propose tapering bDMARDs, especially when combined with a csDMARD, when the patient is in remission after stopping persistent glucocorticoids. The analysis of literature comprising 22 studies shows that a bDMARD adaptation is possible in established rheumatoid arthritis when clinico-biological and ultrasound remission is maintained over six months. Priority should be given to a progressive tapering strategy doses controlled by disease activity while maintaining "tight control" to identify and effectively treat a relapse, a retreatment being usually favorable.

Chronic Recurrent Multifocal Osteomyelitis: A Diagnostic Dilemma: A Case Report and Review of the Literature.

CASE: Chronic recurrent multifocal osteomyelitis, a misnomer in itself, is a rare disorder that presents infrequently to orthopaedic units. The differential diagnosis is wide, including neoplastic lesions and infection, which may lead to unnecessary interventional and surgical procedures. We present a case that exhibited the hallmark features of this condition-recurrent, multifocal, aseptic osteitis in a 9-year-old girl-and our rationalized management including imaging, nonsteroidal anti-inflammatory drugs, and bisphosphonates. CONCLUSION: With increased awareness by orthopaedic surgeons, patients may be diagnosed and managed appropriately, enabling a benign course and limiting morbidity.

ENT Disabilities in Candidates for Recruitment.

BACKGROUND: Recruitment in the Army is subject to medical fitness as per laid down standards. A study of the frequency of referral and rejection gives us an understanding as to where to lay stress in the Ear Nose Throat Examination during recruitment medical. METHOD: A three year analysis of candidates reporting for review of ENT disabilities was carried out from January 1999 to December 2001. RESULTS: Of the 1156 candidates, 888(76.8%) were found to be fit. The commonest cause for rejection was Wax in ears in 496 cases (43%). 428(86.3%) were found to be fit on review. Chronic suppurative otitis media (21.9%) and tympanosclerosis (21.3%) were the other causes for rejection. CONCLUSION: The desirable situation is wherein the evaluation by the specialist is in minimal variation with that of the initial recruitment medical examination. Awareness to have ears cleaned for wax before appearing for the examination, provision of better examination ambiance and equipment and a short training capsule will be beneficial to reduce the number of review cases to referral hospitals.

Hypoglycemia due to 3ß-Hydroxysteroid Dehydrogenase type II Deficiency in a Newborn.

BACKGROUND: 3ß-hydroxysteroid dehydrogenase type II deficiency results in decreased production of all three groups of adrenal steroids. Recurrent hypoglycemia as a presenting feature of this disorder has not been reported earlier. CASE CHARACTERISTICS: A genotypically and phenotypically normal female newborn delivered by in-vitro fertilization presenting with recurrent hypoglycemia. Primary adrenal insufficiency with insignificant mineralocorticoid deficiency and slightly elevated levels of 17-hydro-xyprogesterone, dehydroepian-drosterone sulphate and testosterone. OUTCOME: Successfully managed only with corticosteroid replacement. MESSAGE: Congenital adrenal hyperplasia can rarely cause recurrent hypoglycemia in newborns.

In vitro and in vivo evaluation of 2-chloroethylnitrosourea derivatives as antitumor agents.

AIM: To evaluate potential of Naphthal-NU, Napro-NU and 5-Nitro-naphthal-NU, 2-chloroethylnitrosourea compounds with substituted naphthalimide in the pre-clinical studies. MATERIALS AND METHODS: In vitro cytotoxicity of three nitrosoureas was determined in human and mouse tumor cell lines by MTT assays. In vivo anti-tumor potential was evaluated in Sarcoma-180 (S-180) and Ehrlich's carcinoma (EC) solid tumors. Apoptosis in S-180 cells was analyzed by using Annexin V-Propidium Iodide (PI). Histological analysis of liver and kidney was performed at optimum dose (50 mg/kg). Expression status of CD4(+), CD8(+) and CD25(+) cells in treated mouse were also examined. RESULTS: Significant tumor growth retardation by the compounds was noted in early and advanced disease groups, as the life span of drug treated mice increased considerably. Drug induced killing was observed by induction of apoptosis. Naphthal-NU and 5-Nitro-naphthal-NU were effective to normalize the tumor induced structural abnormalities of liver and kidney. The compounds have no immunotoxic effect on CD4(+) and CD8(+) T cells and down regulate CD4(+)CD25(+) regulatory T cells. CONCLUSION: Overall data holds promise for the antitumor activity with lower toxicity of the compounds that can be utilized for the treatment of human malignant tumors.

Ocular infections caused by Candida species: Type of species, in vitro susceptibility and treatment outcome.

PURPOSE: To report clinical and microbiological profile of patients with ocular candidiasis. MATERIALS AND METHODS: Patients with ocular candidiasis were retrospectively identified from microbiology records. Significant isolates of Candida species were identified by Vitek 2 compact system. Minimum inhibitory concentration (MIC) of antifungal agents such as amphotericin B, itraconazole, voriconazole, fluconazole and caspofungin was determined by E test and of natamycin by microbroth dilution assay. Data on treatment and outcome were collected from medical records. RESULTS: A total of 42 isolates of Candida were isolated from patients with keratitis-29, endophthalmitis-12 and orbital cellulitis-1. The most common species isolated was Candida albicans (12-keratitis, 4-endophthalmitis, 1-orbital cellulitis). All except one isolate were susceptible to amphotericin B. MIC of caspofungin was in the susceptible range in 28 (96.5%) corneal isolates while 12 out of 29 (41.3%) corneal isolates were sensitive to fluconazole. Resistance to voriconazole was seen in four corneal isolates. All isolates were susceptible to natamycin and all except two isolates were resistant or susceptible dose-dependent to itraconazole. Outcome of healed ulcer was achieved in 12/18 (66.6%) patients treated medically, while surgical intervention was required in 11 patients. Among the isolates from endophthalmitis patients, 11/12 were susceptible to amphotericin B, 6/12 to voriconazole and all to natamycin. Ten out of 11 patients (one patient required evisceration) with endophthalmitis were given intravitreal amphotericin B injection with variable outcome. CONCLUSIONS: Ocular candidiasis needs early and specific treatment for optimal results. Candida species continue to be susceptible to most commonly available antifungals including amphotericin B, voriconazole and natamycin.

Multiple organ damage caused by tumor necrosis factor and prevented by prior neutrophil depletion.

The effect of TNF on nonpulmonary multiple organ damage (MOD) was studied. Since polymorphonuclear leukocytes (PMN) are thought to play an important role in septic or TNF-induced MOD, we investigated both neutrophil sufficient (PMN+) and neutropenic (PMN-) guinea pigs. Sepsis was induced by Escherichia coli administration (2 x 10(9)/kg) or recombinant human TNF (1.4 x 10(6) U/kg) was infused into PMN+ and PMN- guinea pigs. During necropsy, the PMN+/TNF and PMN+/E coli animals exhibited marked damage in the adrenal glands, kidneys and liver as evidenced by hemorrhage, congestion, and PMN sequestration on histopathologic examination. There was also increased tissue albumin accumulation in the adrenal glands, kidneys, spleen, heart, and liver as demonstrated by 125I-labeled albumin determinations. In contrast, the PMN-/TNF group did not reveal histopathologic damage in any organ system and there was no abnormal organ accumulation of 125I-albumin. However, in PMN-/E coli animals, marked histopathologic damage in the adrenal glands and liver was evident. Furthermore, there were marked accumulations of 125I-albumin in the adrenals, heart, kidneys, liver, and spleen. Moreover, the PMN-/E coli guinea pigs had a much greater accumulation (p less than 0.01) of 125I-albumin in the kidneys than any other group including the PMN+/E coli group. Thus, nonpulmonary MOD in guinea pigs is caused by TNF administration and can be prevented by PMN depletion. However, while E coli administration also caused marked nonpulmonary MOD in neutrophil sufficient guinea pigs, equivalent or greater damage was produced in neutropenic animals. This suggests that while TNF-induced MOD may be primarily mediated by PMN, E coli-induced MOD seems to be mediated by more than PMN.

Comparison of air tonometry with gastric tonometry using saline and other equilibrating fluids: an in vivo and in vitro study.

OBJECTIVE: 1) To compare saline gastric tonometry monitoring with air tonometry (Tonocap) in a group of general ICU patients. 2) An in vitro investigation of the performance of other fluids used in gastric tonometry and to assess the effects of variation of temperature and carbon dioxide concentration within the range encountered in clinical use. DESIGN: a) A prospective, observational study in ICU patients b) A comparative laboratory study. SETTING: The general Intensive Care Unit (ICU) and the laboratory at Leeds General Infirmary. PATIENTS AND PARTICIPANTS: Nine patients in the general ICU with severe sepsis or septic shock. MEASUREMENTS AND RESULTS: In vivo comparison of saline and air tonometry demonstrated a difference between the two techniques. Bland & Altman analysis showed a mean bias in the measurement of gastric PCO2 of 1.88 kPa with a precision of 1.22 kPa, with saline giving the lower result. In vitro, saline, air (Tonocap), gelatin and heparinised blood were used, at temperatures of 33-42 degrees C and at carbon dioxide concentrations of 4-8 kPa. While gelatin and blood gave unpredictable results, dependent on temperature and carbon dioxide concentration, air tonometry gave highly reproducible results. A consistent bias between the results with saline and air tonometry was seen over the range of temperatures and carbon dioxide (CO2) concentrations studied. The mean bias was 0.85 kPa with a precision of 0.40 kPa, saline consistently giving lower results. CONCLUSIONS: There are clinically significant differences in values for gastric mucosal PCO2 measured by air tonometry and saline tonometry both in vivo and in vitro.

Co-administration of immunomodulator tuftsin and liposomised nystatin can combat less susceptible Candida albicans infection in temporarily neutropenic mice.

In order to develop a prospective chemotherapeutic agent against opportunistic infections, it is important to know that host factors such as degree of immunological debility as well as recovery of immune functions to normality may contribute significantly to a successful elimination of the pathogens. We demonstrated previously that concomitant delivery of antimicrobial agents and immunomodulators to the pathogen harbouring-host contributes to the complete elimination of the deep-seated fungal infections (aspergillosis and candidiasis) in animals with normal immune status. Considering that neutropenic hosts are the main targets of such infections, it can be argued about the potential of the immunomodulator-based therapy in subjects with non-functional immune system. To resolve the hypothesis, we studied the role of immunomodulator tuftsin against experimental murine candidiasis in temporarily neutropenic Balb/c mice. The neutropenic mice were challenged with an isolate of Candida albicans that was showing less susceptibility to both free and liposomised-amphotericin B. The co-administration of tuftsin increased the efficiency of liposomised-polyene antibiotics (nystatin and amphotericin B) against experimental murine candidiasis in immunocompromised Balb/c mice. Pretreatment with liposomised tuftsin prior to C. albicans infection clearly enhanced protection against candidiasis, suggesting a prophylactic role of tuftsin in normal and temporarily neutropenic animals.