Correlation between intestinal stem cell niche changes and small bowel crypt failure in patients with treatment-naïve celiac disease.

OBJECTIVES: We hypothesized that crypt failure in the small bowel results in villous flattening in patients with celiac disease (CeD). We investigated whether alterations in the stem cell niche (ISC) are responsible for this phenomenon. MATERIALS AND METHODS: We included 92 duodenal (D2/3) biopsies from treatment-naive patients of CeD and 37 controls. All underwent screening for serum anti-tissue transglutaminase and endoscopic upper small bowel biopsy. Immunohistochemical markers were used to investigate ISC niche alterations, including LGR5 for crypt basal cells (CBC), Bmi1 for position 4+ cells, ß-Defensin for Paneth cells, R-spondin1 as WNT activator, transcription factor-4 as WNT transcription factor, BMP receptor1A as WNT inhibitor, fibronectin-1 as periepithelial stromal cell marker, H2AX as apoptosis marker, and Ki67 as proliferation marker. We also analyzed IgA anti-tTG2 antibody deposits by using dual-color immunofluorescence staining. RESULTS: We found that in biopsies from patients with treatment-naive CeD with modified Marsh grade 3a-3c changes, the epithelial H2AX apoptotic index was upregulated than in controls. LGR5+ crypt basal cells were upregulated in all modified Marsh grades compared to controls. However, the Ki67 proliferation index, expressions of WNT-activator RSPO1, and position-4 cell marker Bmi1 did not significantly alter in patients' biopsies as compared to controls ( P = 0.001). We also observed depletion of pericrypt stromal fibronectin-1 in patients with CeD compared to controls. In addition, we identified IgA anti-TG2 antibody deposits in pericrypt stroma. CONCLUSIONS: Our data suggests that ISC niche failure is a plausible hypothesis for villous flattening in patients with CeD, resulting from pericrypt IgA anti-TG2 antibody complex-mediated stromal depletion.

Procalcitonin for Detecting Culture-Positive Sepsis in Neonates: A Prospective, Multicenter Study.

INTRODUCTION: It is unclear if serum procalcitonin (PCT) estimated at sepsis suspicion can help detect culture-positive sepsis in neonates. We evaluated the diagnostic performance of PCT in culture-positive sepsis in neonates. METHODS: This was a prospective study (February 2016 to September 2020) conducted in four level-3 units in India. We enrolled neonates suspected of sepsis in the first 28 days of life. Neonates with birth weight <750 g, asphyxia, shock, and major malformations were excluded. Blood for PCT assay was drawn along with the blood culture at the time of suspicion of sepsis and before antibiotic initiation. The investigators labeled the neonates as having culture-positive sepsis or "no sepsis" based on the culture reports and clinical course. PCT assay was performed by electrochemiluminescence immunoassay, and the clinicians were masked to the PCT levels while assigning the label of sepsis. Primary outcomes were the sensitivity, specificity, and likelihood ratios to identify culture-positive sepsis. RESULTS: The mean birth weight (SD) and median gestation (IQR) were 2,113 (727) g and 36 (32-38) weeks, respectively. Of the 1,204 neonates with eligible cultures, 155 (12.9%) had culture-positive sepsis. Most (79.4%) were culture-positive within 72 h of birth. The sensitivity, specificity, and positive and negative likelihood ratios at 2 ng/mL PCT threshold were 52.3% (95% confidence interval: 44.1-60.3), 64.5% (60.7-68.1), 1.47 (1.23-1.76), and 0.74 (0.62-0.88), respectively. Adding PCT to assessing neonates with 12.9% pretest probability of sepsis generated posttest probabilities of 18% and 10% for positive and negative test results, respectively. CONCLUSION: Serum PCT did not reliably identify culture-positive sepsis in neonates.

Chemotherapy response evaluation using diffusion weighted MRI in Ewing Sarcoma: A single center experience.

BACKGROUND: Non-invasive biomarkers for early chemotherapeutic response in Ewing sarcoma family of tumors (ESFT) are useful for optimizing existing treatment protocol. PURPOSE: To assess the role of diffusion-weighted magnetic resonance imaging (MRI) in the early evaluation of chemotherapeutic response in ESFT. MATERIAL AND METHODS: A total of 28 patients (mean age = 17.2 ± 5.6 years) with biopsy proven ESFT were analyzed prospectively. Patients underwent MRI acquisition on a 1.5-T scanner at three time points: before starting neoadjuvant chemotherapy (baseline), after first cycle chemotherapy (early time point), and after completion of chemotherapy (last time point). RECIST 1.1 criteria was used to evaluate the response to chemotherapy and patients were categorized as responders (complete and partial response) and non-responders (stable and progressive disease). Tumor diameter, absolute apparent diffusion coefficient (ADC), and normalized ADC (nADC) values in the tumor were measured. Baseline parameters and relative percentage change of parameters after first cycle chemotherapy were assessed for early detection of chemotherapy response. RESULTS: The responder:non-responder ratio was 21:7. At baseline, ADC ([0.864 ± 0.266 vs. 0.977 ± 0.246]) × 10-3mm2/s; P = 0.205) and nADC ([0.740 ± 0.254 vs. 0.925 ± 0.262] × 10-3mm2/s; P = 0.033) among responders was lower than the non-responders and predicted response to chemotherapy with AUCs of 0.6 and 0.735, respectively. At the early time point, tumor diameter (27% ± 14% vs. 4.6% ± 10%; P = 0.002) showed a higher reduction and ADC (75% ± 44% vs. 52% ± 72%; P = 0.039) and nADC (81% ± 44% vs. 48% ± 67%; P = 0.008) showed a higher increase in mean values among responders than the non-responders and identified chemotherapy response with AUC of 0.890, 0.723, and 0.756, respectively. CONCLUSION: Baseline nADC and its change after the first cycle of chemotherapy can be used as non-invasive surrogate markers of early chemotherapeutic response in patients with ESFT.

Contrast-enhanced computed tomography abdomen versus diagnostic laparoscopy-based management in patients with penetrating abdominal trauma: a randomised controlled trial.

PURPOSE: Penetrating abdominal trauma was traditionally managed by mandatory exploration, which led to high rates of non-therapeutic surgery and prolonged hospital stay. Diagnostic laparoscopy (DL) is a less-invasive alternative; however, it requires general anaesthesia and carries a potential risk of iatrogenic injuries. Contrast-enhanced computed tomography (CECT)-guided selective non-operative management (SNOM) may avoid surgery altogether, but there is apprehension of missed injury. Randomised trials comparing these two modalities are lacking. This study is aimed at comparing outcomes of these two management approaches. METHODS: Hemodynamically stable patients with penetrating trauma to anterior abdominal wall were randomised in 1:1 ratio to DL or CECT-based management. Primary outcome was length of hospital stay (LOS). Secondary outcomes were rate of non-therapeutic surgery, complications, and length of intensive care unit (ICU) stay. RESULTS: There were 52 patients in DL group and 54 patients in CECT group. Mean LOS was comparable (3 vs 3.5 days; p = 0.423). Rate of non-therapeutic surgery was significantly lower in CECT group (65.4 vs 17.4%, p = 0.0001). Rate of complications and length of ICU stay were similar. Selective non-operative management based on CECT findings was successful in 93.8% of patients; 2 patients had delayed surgery. CONCLUSION: In patients with penetrating trauma to anterior abdominal wall, DL and CECT-based management led to comparable hospital stay. Significant reduction in non-therapeutic surgery could be achieved using a CECT-based approach. TRIAL REGISTRATION: Clinical trials registry-India (CTRI/2019/04/018721, REF/2019/01/023400).

Can portable Colposcopes Replace Standard-of-care Colposcopes? A Crossover Trial of Two Portable Colposcopes with a Standard-of-Care Video Colposcope.

BACKGROUND: Screen positive women need to be triaged by colposcopy which is a major challenge in low-middle income countries. Portable colposcopes may overcome many challenges, reduce referrals and enable a single visit approach. This study assessed the performance of portable colposcopes and potential to reduce referral. METHOD: This crossover randomised study enrolled women aged 25 to 65 years with abnormal screening result or cervical symptoms. All women underwent visual inspection with acetic acid (VIA), HPV test, colposcopy with two portable colposcopes (Gynocular®, Gynius, Sweden, and Pocket® transvaginal colposcope, Duke University, NC, USA) and a standard video colposcope, and biopsy. Colposcopic Swede score agreement between portable and video colposcopes, as well as agreement of Swede score with histology were calculated for each device. The potential impact of portable colposcopes in a single visit approach was assessed based on the final diagnosis. RESULTS: Among 250 subjects, 27(10.80%) had high-grade cervical intraepithelial neoplasia (CIN2+) lesions. Swede scores for Pocket and Gynocular colposcopes were similar to video colposcope in 248 (99.20%) and 247 (98.80%) subjects, respectively (agreement scores 0.9969 and 0.9954, respectively). At a Swede score cut-off of ≥5, all three devices had identical sensitivity, specificity, positive and negative predictive value of 96.30%, 92.30%, 60.50% and 99.50,. Ablative treatment offered at field setting would result in optimal treatment in 52.0% and 85.1% cases when screened with VIA and HPV test respectively; using Pocket colposcope could improve this to 94.0% and 95.9%, respectively. Overtreatment and referral rates reduced from 46.8% and 12.4% to 4.8% and 6.0%, respectively, when VIA test is followed by triage with pocket colposcope. These outcomes were comparable to screening with HPV followed by colposcopy triage. CONCLUSIONS: Pocket colposcope performed comparably to the video colposcope. Used by healthcare providers in the field setting, they can augment the results of VIA significantly.

Serial Evaluation of T cell Subsets in Paediatric Acute Myeloid Leukaemia- a Prospective Study.

PURPOSE: There is paucity of data regarding T-cells in paediatric AML patients. The aim of this prospective study was to evaluate trend of T-cell subset during disease course of paediatric AML patients and to see its correlation with patient characteristics and survival outcome. METHODS: T-cell subsets (CD3, CD4 and CD8) were evaluated by flow-cytometry at diagnosis, post-induction, post-treatment completion, at 3 months and 6 months post-treatment completion, and relapse in 29 pediatric AML patients. Trend of T-cells was plotted between group A (those in continuous remission) and group B (those who relapsed) patients. RESULTS: Patients with high WBC count had significantly higher number of CD3, CD4 and CD8 cell. Baseline Tcell subsets did not affect CR, EFS and OS; however, higher than median CD4 count predicted improved DFS [58% vs 25%; HR = 0.306 (0.10-0.93); P = 0.037]. On serial follow-up from post-induction till 3 months after completion of therapy, there was no difference in the absolute values of T cell subsets between group A and B patients. CONCLUSION: Our study demonstrated T cell subsets are increased in AML subjects with high WBC count. CD4 cells have a positive impact on DFS. Serial follow-up has no impact on T cell subsets. Further studies in larger patient cohorts are needed to evaluate if CD4 population may serve as an immune biomarker for AML.

Vitamin D status among Kashmiri tribal population: A cross-sectional community-based study.

Background & objectives: Vitamin D deficiency (VDD) is prevalent across all age groups in general population of India but studies among tribal populations are scanty. This study aimed to evaluate the prevalence of VDD in the indigenous tribal population of the Kashmir valley and examine associated risk factors. Methods: In this cross-sectional investigation, a total of 1732 apparently healthy tribal participants (n=786 males and n=946 females) were sampled from five districts of Kashmir valley by using probability proportional to size method. Serum 25-hydroxy vitamin D (25(OH)D) levels were classified as per the Endocrine Society (ES) recommendations: deficiency (<20 ng/ml), insufficiency (20-30 ng/ml) and sufficiency (>30 ng/ml). The serum 25(OH)D levels were assessed in relation to various demographic characteristics such as age, sex, education, smoking, sun exposure, body mass index and physical activity. Results: The mean age of the male participants was 43.79±18.47 yr with a mean body mass index (BMI) of 20.50±7.53 kg/m[2], while the mean age of female participants was 35.47±14.92 yr with mean BMI of 22.24±4.73 kg/m2. As per the ES guidelines 1143 of 1732 (66%) subjects had VDD, 254 (14.71%) had insufficient and 334 (19.3%) had sufficient serum 25(OH)D levels. VDD was equally prevalent in male and female participants. Serum 25(OH)D levels correlated positively with serum calcium, phosphorous and negatively with serum alkaline phosphatase. Gender, sun exposure, altitude, physical activity and BMI did not seem to contribute significantly to VDD risk. Interpretation & conclusions: VD deficiency is highly prevalent among Kashmiri tribals, although the magnitude seems to be lower as compared to the general population. These preliminary data are likely to pave way for further studies analyzing the impact of vitamin D supplementation with analysis of functional outcomes.

Histologic Changes in Core-Needle Liver Biopsies From Patients With Acute-on-Chronic Liver Failure and Independent Histologic Predictors of 28-Day Mortality.

CONTEXT.­: The histologic features in patients with acute-on-chronic liver failure (ACLF) are evolving, and histologic indicators of patients' poor prognosis are not yet fully established. OBJECTIVE.­: To evaluate the independent histologic predictors of 28-day mortality in ACLF patients on core-needle liver biopsies. DESIGN.­: Core-needle biopsies from patients with a diagnosis of ACLF (n = 152) as per the European Association for the Study of the Liver criteria were included during 8 years. Liver biopsies from 98 patients with compensated chronic liver disease were included as disease controls for histologic comparison. Features of ongoing changes, such as hepatic necrosis, hepatic apoptosis, cholestasis, hepatocyte degeneration, bile ductular proliferation, Mallory-Denk bodies, steatosis, and extent of liver fibrosis, were analyzed for predicting short-term mortality (28 days). A P value of <.05 was considered significant. RESULTS.­: In our cohort of ACLF patients, the following etiologies for acute decompensation were identified: alcohol, 47 of 152 (30.9%); sepsis, 24 of 152 (15.7%); hepatotropic viruses, 20 of 152 (13.1%); drug-induced liver injury, 11 of 152 (7.2%); autoimmune flare, 9 of 152 (5.9%); mixed etiologies, 5 of 152 (3.2%); and cryptogenic, 36 of 152 (23.6%). On histologic examination, hepatic necrosis (P < .001), dense lobular inflammation (P = .03), cholestasis (P < .001), ductular reaction (P = .001), hepatocyte degeneration (P < .001), and absence of advanced fibrosis stages (P < .001) were identified significantly more othen in ACLF patients than in disease controls on univariate analysis. On multivariate Cox regression analysis, the absence of advanced Ishak histologic activity index fibrosis stages (P = .02) and the presence of dense lobular inflammation (P = .04) were associated with increased 28-day mortality in ACLF patients. After adjusting the clinical causes of acute decompensation, only dense lobular inflammation was found as an independent predictor of short-term mortality (P = .04) in ACLF patients. CONCLUSIONS.­: Dense lobular necroinflammatory activity is a clinically independent histologic predictor of 28-day short-term mortality in patients with ACLF.

Comparison of hazard models with and without consideration of competing risks to assess the effect of neoadjuvant chemotherapy on locoregional recurrence among breast cancer patients.

CONTEXT: While analyzing locoregional recurrences (LRRs), it is necessary to consider distant metastasis as a competing event. Because, later one is more fatal than LRR. It may change ongoing treatment of breast cancer and may alter the chance of LRR. Although some earlier studies assessed the effect of neoadjuvant chemotherapy (NACT) on LRR, they did not use competing risk regression model for it. AIMS: To identify the risk factors and predict LRR using competing risk hazard model and to compare them with those using conventional hazard model. SETTINGS AND DESIGN: This was a retrospective study from a tertiary care cancer hospital in India. SUBJECTS AND METHODS: Data of 2114 breast cancer patients undergoing surgery were used from patient's record files (1993-2014). STATISTICAL ANALYSIS: Fine and Gray competing risk regression was used to model time from surgery to LRR, considering distant metastasis and death as the competing events. Further, cause-specific Cox regression was used to model time from surgery to LRR without considering competing risk. RESULTS: Greater than ten positive nodes (hazard ratio [HR] [95% confidence interval (CI)]: 2.19 [1.18-4.03]), skin involvement (HR [95% CI]: 2.75 [1.50-5.05]), NACT (HR [95% CI]: 1.90 [1.06-3.40]), invasive tumor in inner quadrant (HR [95% CI]: 1.78 [0.98-3.24]), and postoperative radiotherapy (HR [95% CI]: 0.52 [0.29-0.94]) were found to be significantly associated with LRR. However, conventional survival analysis ignoring competing risk overestimated cumulative incidence function and underestimated survival. Competing risk regression provided relatively more precise CI. Conclusions: Competing risks, if any, need to be incorporated in the survival analysis. NACT was found to be associated with higher risk for LRR, which may be because of administering it mainly to patients with bad prognosis. CONCLUSIONS: Competing risks, if any, need to be incorporated in the survival analysis. NACT was found to be associated with higher risk for LRR, which may be because of administering it mainly to patients with bad prognosis.

Late effects in pediatric Hodgkin lymphoma survivors after uniform treatment with ABVD with or without radiotherapy.

PURPOSE: ABVD (doxorubicin, bleomycin,vinblastine, and dacarbazine) is not a standard regimen in children due to concerns regarding late effects. However, no studies have evaluated long-term toxicities of ABVD in children. METHODS: Total 154 pediatric Hodgkin lymphoma (HL) survivors uniformly treated with ABVD were clinically followed up as per institutional protocol. All participants were evaluated for cardiac, pulmonary, and thyroid function abnormalities by multigated acquisition scan (MUGA) scan, spirometry with diffusion capacity of lung for the uptake of carbon monoxide (DLCO), and thyroid profile test, respectively, at a single time point. Predictors of toxicity were also analyzed. RESULTS: The median duration of follow-up of the cohort was 10.3 years (6.04-16.8). No secondary malignant neoplasm (SMN) or symptomatic cardiac/pulmonary toxicities were detected. Nine patients (5.9%) had left ventricular ejection fraction (LVEF) <55%. Subclinical and overt hypothyroidism were observed in 78 (50.6%) and 16 (10.4%) survivors, respectively. Abnormal spirometry and reduced DLCO was observed in 43.2% and 42.0% survivors, respectively. Receiving neck radiation was significantly associated with thyroid dysfunction (odds ratio [OR] 16.04, p < .001); age ≥10 years predicted reduced DLCO (OR 4.12, p = .001). Sixty-three and 33 patients had one and two late adverse effects, respectively; receiving neck radiation predicted development of multiple late effects (proportional OR 4.72, p < 0.001). Cumulative dose of chemotherapy did not predict toxicity. CONCLUSIONS: Overall, ABVD appears safe in children at a relatively short follow-up. Long-term safety data are required before it can be adopted for treating pediatric HL patients. Children receiving neck radiation require close follow-up.

Expression patterns and prognostic significances of RRM1 and ERCC1 in pancreatic carcinoma and cholangiocarcinoma.

BACKGROUND: Aggressive pancreatobiliary tumors often require oxaliplatin-based therapies, instead of standard gemcitabine-based therapy and biomarker studies at diagnosis to decide the appropriate therapeutic regimen. The ribonucleotide Reductase catalytic subunit M1 (RRM1) and excision repair cross-complementing gene-1 (ERCC1) are related to DNA synthesis and repair and essential in this regard. However, apart from the therapeutic benefit, their prognostic implication is controversial. METHODS: In this retrospective study, paraffin-embedded tissue from 51 cases of pancreatic cancer and 29 cases of cholangiocarcinoma were evaluated for RRM1 and ERCC1 expression by immunohistochemical technique along with 18 control pancreatic and biliary tissues. The semiquantitatively H score was calculated based on stain distribution and stain intensities. RESULTS: Both RRM1 and ERCC1 expression were high in tumor epithelium than in controls (RRM1: the difference was statistically significant in cholangiocarcinoma (P = 0.008); ERCC1: the difference was statistically significant both in pancreatic and cholangiocarcinoma (P < 0.05)]. However, no correlation was noted between RRM1 and ERCC1-low and high tumors with histological markers of prognosis and overall survival in these patients. CONCLUSIONS: The present study adds further evidence against the controversy that if RRM1 and ERCC1 expression in pancreatic and biliary carcinomas have any prognostic significance apart from their proven therapeutic benefits in these tumors.

An Open-Label Randomized Controlled Trial Comparing the Efficacy and Safety of Pemetrexed-Carboplatin versus (Weekly) Paclitaxel-Carboplatin as First-Line Chemotherapy in Advanced Non-Squamous Non-Small Cell Lung Cancer.

BACKGROUND: Before the approval of first-line immune checkpoint inhibitors, platinum doublets were the standard of care in patients with treatment-naïve advanced non-small cell lung cancer (NSCLC) without targetable driver mutations. Pemetrexed-platinum combinations are preferred in non-squamous NSCLC. However, there has been no direct comparison to paclitaxel-carboplatin. METHODS: This open-label randomized trial was designed to compare pemetrexed-carboplatin with (weekly) paclitaxel-carboplatin in treatment-naïve advanced/metastatic non-squamous NSCLC without driver mutations. Patients received either pemetrexed 500 mg/m2 and carboplatin AUC 5 every 3 weeks, or paclitaxel 80 mg/m2 on day 1, day 8, and day 15 with carboplatin AUC 5 every 4 weeks for 4 cycles. Patients in both arms were allowed to receive pemetrexed maintenance. RESULTS: A total of 180 patients were enrolled. The study was terminated early; however, at the time of analysis 75.8% of the required events had occurred. Finally, 164 patients were evaluable, 83 in the pemetrexed arm and 81 in the paclitaxel arm. After a median follow-up of 17 months, progression-free survival (PFS) rates at 6 months were not different in the two treatment arms (47.45 vs. 48.64%, p = 0.88). The median PFS values were 5.67 months (95% CI 3.73-7.3) and 5.03 months (95% CI 2.63-7.43) in each arm, respectively (HR 1.13, 95% CI 0.81-1.59, p = 0.44). The median overall survival was also not different: 14.83 months (95% CI 9.5-18.73) and 11.3 (95% CI 8.3-19.7; HR 1.19, 95% CI 0.8-1.78, p = 0.37). All grade toxicities were similar except for alopecia and peripheral neuropathy, which were higher in the paclitaxel arm. CONCLUSION: Pemetrexed-carboplatin is not superior to (weekly) paclitaxel-carboplatin as the first-line regimen in advanced non-squamous NSCLC in terms of PFS.

Clinical and molecular epidemiology of vancomycin-resistant Enterococcus faecium bacteremia from an Indian tertiary hospital.

We determined the clinical and molecular epidemiology of emerging nosocomial vancomycin-resistant Enterococcus faecium (VREfm)-causing serious bloodstream infections (BSIs) and the correlations between antibiotic resistance and virulence determinants among isolates. All isolates were confirmed by molecular methods (16SrRNA and E. faecium ddl genes) and tested for disk diffusion. PCR was used to detect aac(6')-aph(2″), vanA and vanB resistance genes, and asa1, cylA, ace, esp, gelE and hyl virulence genes. VREfm and high-level gentamicin-resistant (HLGR) representative isolates were selected to characterize by pulsed-field gel electrophoresis (PFGE) and multi-locus sequence typing (MLST). Of 173 isolates, 73 (42.2%), 146 (84.4%), and 0 (0.0%) were vanA-containing VREfm, aac(6')-aph(2″)-positive HLGR, and vanB-positive. Independent predictors of VREfm infection were hematological malignancies (P = 0.001) and previous hospitalizations (P = 0.007). Observed mortality rate was 34.7%. Independent predictors of BSI-related mortality were endotracheal intubations (P < 0.001), gastrointestinal diseases (P = 0.002), and pulmonary disease (P < 0.001). All VREfm were resistant to vancomycin, teicoplanin, ciprofloxacin, and erythromycin. The esp, hyl, ace, asa1, cylA, and gelE genes were detected at 55.9, 22.5, 2.9, 2.3, 1.7, and 1.2%, respectively. The esp gene was significantly associated with VREfm compared to VSEfm (P = 0.001). PFGE analysis revealed 23 clones, with 7 major clones. The MLST analysis revealed the following five sequence types: ST80, ST17, ST117, ST132, and ST280, all belonging to CC17. The emergence and expansion of VREfm CC17 with limited antibiotic options in our hospital present a serious public health menace and represent challenges to infection control.

Early Discontinuation versus Continuation of Antimicrobial Therapy in Low Risk Pediatric Cancer Patients with Febrile Neutropenia, Before Recovery of Counts: A Randomized Controlled Trial (DALFEN Study).

OBJECTIVE: To determine if early discontinuation of antimicrobials in pediatric patients with low risk febrile neutropenia is as effective as continuing therapy before recovery of counts, in an outpatient setting. METHODS: In an open label, non-inferiority, randomized controlled phase 3 trial at a tertiary cancer center, patients aged 3-18 y, with low risk febrile neutropenia were started on empirical intra-venous antibiotics in an outpatient setting. Randomization was done when the patients became afebrile for at least 24 h; standard arm consisted of oral antibiotics, while antibiotics were stopped in the experimental arm. Enrolled patients were followed for re-appearance of fever and rate of re-admission, until ANC ≥ 500. A pilot feasibility randomized study with similar design preceded this trial. RESULTS: From Jan 2017-Dec 2018, 75 patients were randomized: 38 to stoppage arm while 37 patients received oral antibiotics. Baseline characteristics were equally matched. Success rates were 94.6% in the continuation arm vs. 94.7% in the stoppage arm; absolute risk difference was 0.1% (95% CI: -10.0% to +10.3%), thus suggesting that the experimental arm is non-inferior to the standard arm. There was no re-admission on failure in any arm. CONCLUSIONS: Antimicrobial therapy in low risk afebrile neutropenic patients can be stopped early. This approach can lead to significant cost and resource benefits.

Stroke in Coronavirus Disease 2019: A Systematic Review.

BACKGROUND AND PURPOSE: Various neurological findings including stroke in patients with coronavirus disease 2019 (COVID-19) have been described, although no clarity exists regarding the nature and pattern of this association. This systematic review aims to report the characteristics of stroke in patients with COVID-19. METHODS: Three authors independently searched Web of Science, Embase, Scopus, and PubMed starting from inception up to May 22, 2020. The data for individual patients was extracted where available from published reports including clinical and laboratory parameters and analysed for any significant associations between variables. RESULTS: We identified 30 relevant articles involving 115 patients with acute or subacute stroke with COVID-19. The mean±standard deviation age was 62.5±14.5 years. Stroke was ischemic in majority of the patients (101 [87.8%]). Hypertension (42 [42%]), dyslipidaemia (24 [26.1%]), and diabetes (23 [23.2%]) were the major vascular risk factors. Most of the patients (80 [85.1%]) had COVID-19 symptoms at the time of stroke with a median interval of 10 days to stroke from the diagnosis of COVID-19. Three-fourths (86 [74.8%]) of the patients were critically ill which frequently delayed the diagnosis of stroke. High levels of D-dimer, and ferritin were observed in these patients. Patients with COVID-19 and stroke had a high mortality (47.9%). Factors associated with mortality were intensive care unit admission, having two or more vascular risk factors, particularly smoking and high levels of D-dimer, C-reactive protein, and lactate dehydrogenase. CONCLUSIONS: The association between stroke and COVID-19 is probably multifactorial including an amalgamation of traditional vascular risk factors, proinflammatory and a prothrombotic state. Prospectively collected data is required in the future to confirm this hypothesis.

Regulatory T cells in pediatric AML are associated with disease load and their serial assessment suggests role in leukemogenesis.

BACKGROUND: Regulatory T cells (Tregs) modulate immune system by suppressing other immune cells. In current exploratory era of immunotherapy, the detailed enumeration data of Tregs cells in pediatric AML is lacking. AIM: Serial assessment of Treg absolute values in pediatric AML at diagnosis and follow-up; and correlating with outcome. STUDY DESIGN: Prospective study. METHODS: Study objectives were determining Tregs (CD4+CD25+Foxp3+) were assessed at diagnosis, post-induction, post-consolidation, 3 and 6 months follow-up and relapse in 30 consecutive pediatric AML patients. RESULTS: Patients with AML had higher baseline Treg frequencies than controls (P=0.0001). Female patients, WBC > 50,000 × 103/L and hypoalbuminemia were significantly associated with high Treg absolute values. Baseline Tregs were not associated with DFS, EFS and OS. Tregs significantly decreased after induction chemotherapy (P=0.028). Using generalized-estimating-equation regression model, Treg absolute numbers continued to decrease at each assessment time point from post-induction till 6 months follow-up (P=0.029) in those who are in continuous CR; however, in those patients who relapsed, Tregs did not change from post-induction till last follow-up preceding relapse (P=0.39). CONCLUSIONS: This first study in pediatric AML demonstrates that Tregs are increased at diagnosis; the increased number is significantly associated with female gender and high WBC count. Tregs decrease after induction chemotherapy as compared to their baseline value. Post CR, Treg absolute values continue to decrease significantly in those who stay in CR but not so in those who relapse; this suggests their possible role in leukemogenesis.

Outpatient ADE (cytarabine, daunorubicin, and etoposide) is feasible and effective for the first relapse of pediatric acute myeloid leukemia: A prospective, phase II study.

BACKGROUND: Approximately 40% children with acute myeloid leukemia (AML) invariably relapse, after attaining the first complete remission (CR), with dismal long-term outcome. There is little consensus regarding choice of optimal induction chemotherapy regimen for relapsed pediatric AML. PROCEDURE: A prospective single arm phase II study (CTRI/2017/02/007757) was carried out at our center to evaluate the safety and efficacy of outpatient cytarabine, daunorubicin, and etoposide (ADE) regimen in pediatric AML (≤18 years) at the first relapse. Response evaluation was done by bone marrow aspiration morphology along with minimal residual disease (MRD) assessment. All adverse events including need and duration of hospitalization, transfusion support, and antimicrobial use were recorded. RESULTS: Total 45 patients were included with median age of 12 years. The CR rate of the cohort was 66% and 54% of patients were MRD negative. The estimated 2-year event-free survival (EFS) and overall survival (OS) were 29% (±7%) and 34% (±7%), respectively. The presence of fever at relapse was associated with inferior CR rate (P = .001), positive MRD (P = .01), and inferior EFS (P = .02), while not achieving nadir absolute neutrophil count of zero during induction was associated with inferior CR rate (P = .03) and inferior OS (P = .04). Approximately all patients developed ≥Grade 3 cytopenia and febrile neutropenia. Twenty-six (59%) patients required hospitalization for management of toxicity and there were four (9%) deaths attributed to infection. CONCLUSION: ADE is an effective induction regimen for pediatric AML patients at the first relapse with reasonable toxicity profile. Outpatient administration of the regimen is feasible in the presence of proper support structure and rigorous follow up.

Evaluation of Vascular Endothelial Growth Factor (VEGF) and Thrombospondin-1 as Biomarkers of Metronomic Chemotherapy in Progressive Pediatric Solid Malignancies.

OBJECTIVE: We compared Vascular Endothelial Growth factor (VEGF) and Thrombospondin-1 between patients with progressive paediatric malignancies randomized to metronomic chemotherapy versus placebo to determine their role as biomarker. METHODS: In this double-blinded, placebo-controlled randomized study of 108 progressive pediatric malignancies, serum VEGF and thrombospondin-1 levels were evaluated using ELISA at baseline, A2 (week-9 or earlier if progressed) and A3 (week-18 or earlier if progressed). RESULTS: Mean VEGF and thrombospondin-1 at baseline, A2 and A3 and the change from baseline to A2 were not different between two groups. In metronomic arm, responders (those completing 3 cycles) had significantly lower mean (SD) baseline VEGF levels [659.7(362.1) vs 1143.9 (622.0) µg/mL] (P=0.002) and significant decrease in thrombospondin-1 from baseline to A2 [-4.43(8.0) µg/mL vs 1.7(11.3) µg/mL] (P=0.04), as compared to non-responders. Similar changes were not observed in responders on placebo arm. No consistent trend of these biomarkers was observed. CONCLUSIONS: VEGF and thrombospondin-1 are not reliable biomarkers for response to metronomic chemotherapy.

The Promising Signatures of Circulating microRNA-145 in Epithelial Ovarian Cancer Patients.

BACKGROUND: Epithelial ovarian cancer continues to be a deleterious threat to women as it is asymptomatic and is typically detected in advanced stages. Cogent non-invasive biomarkers are therefore needed which are effective in apprehending the disease in early stages. Recently, miRNA deregulation has shown a promising magnitude in ovarian cancer tumorigenesis. miRNA-145(miR- 145) is beginning to be understood for its possible role in cancer development and progression. In this study, we identified the clinicopathological hallmarks altered owing to the downexpression of serum miR-145 in EOC. METHODS: 70 serum samples from histopathologically confirmed EOC patients and 70 controls were collected. Total RNA from serum was isolated by Trizol method, polyadenylated and reverse transcribed into cDNA. Expression level of miR-145 was detected by miRNA qRT-PCR using RNU6B snRNA as reference. RESULTS: The alliance of miR-145 profiling amongst patients and controls established itself to be conspicuous with a significant p-value (p<0.0001). A positive conglomeration (p=0.04) of miR-145 profiling was manifested with histopathological grade. Receiver Operating Characteristic (ROC) curve highlights the diagnostic potential and makes it imminent with a robust Area Under the curve (AUC). A positive correlation with the ROC curve was also noted for histological grade, FIGO stage, distant metastasis, lymph node status and survival. CONCLUSION: Our results propose that miR-145 down-regulation might be a possible touchstone for disease progression and be identified as a diagnostic marker and predict disease outcome in EOC patients.

Genetic Landscape of Mitochondrial Regulatory Region in Pediatric Acute Myeloid Leukemia: Changes from Diagnosis to Relapse.

This prospective study aimed to compare the pattern of mitochondrial deoxyribonucleic acid D-loop (mt-DNA D-loop) variations in 41 paired samples of de novo pediatric acute myeloid leukemia (AML) (baseline vs. relapse) patients by Sanger's sequencing. Mean mt-DNA D-loop variation was 10.1 at baseline as compared with 9.4 per patients at relapse. In our study, 28 (68.3%) patients showed change in number of variations from baseline to relapse, 11 (26.8%) patients showed increase, 17 (41.6%) patients showed decrease, and 7 (17.1%) patients who suffered a relapse had a gain at position T489C. No statistically significant difference was observed in the mutation profile of mt-DNA D-loop region from baseline to relapse in the evaluated population of pediatric AML.