Optimization of tissue microarray technique for breast cancer patients: a short communication.

Background: Tissue microarray (TMA) is a novel technique for studying different types of cancer tissues in one block. TMA is not yet established in Syria, so we aimed in this project to apply and set the most optimal conditions of TMA creation of breast cancer tissues at the Pathology Department of our institute. Materials and Methods: Eighty-eight blocks of breast cancer tissues were selected, considering the inclusion criteria. The tissue specimens of breast cancer patients were manually placed in the block by punching a core from a paraffin block, which was then released into a recipient block using a small trocar. Three different conditions were tested on the constructed TMA block. Results: We determined the most effective parameters that proved high quality: incubating the newly constructed block at a temperature of 43°C for 24 h in the oven and then cutting it the next day after cooling it to room temperature; also, cutting with a 5 µm thickness created the preferable stained slides later. CD3 staining showed high expression of tumor-infiltrating lymphocytes among triple-negative breast cancer patients and high expression of CD3 in triple-negative cancer patients. Conclusion: The optimization of parameters presented in our study resulted in perfect TMA generation and successful immunohistochemistry staining for cancer research at our institution.

The First Documented Ibuprofen-Induced Toxic Epidermal Necrolysis in the Middle East and North Africa Region: A Case Report, Complications, and Management.

INTRODUCTION: Stevens-Johnson syndrome (SJS), Stevens-Johnson/toxic epidermal necrolysis overlap syndrome (SJS/TEN) and toxic epidermal necrolysis (TEN) are rare, acute, potentially lethal conditions, considered to be part of the severe cutaneous adverse reactions (SCARs) spectrum, with TEN being the most life-threatening. The distinction between these three entities is based on the extent of total skin surface involvement, with SJS involving < 10%, SJS/TEN involving 10-30% and TEN involving > 30% of total body surface area. These mucocutaneous reactions are most commonly caused by a hypersensitivity reaction to a drug, with infections and vaccines being possible, less common etiologies. CASE PRESENTATION: In the following case report, we summarize a rare case of a 43-year-old, previously healthy male patient who presented with TEN after taking ibuprofen, a non-steroidal anti-inflammatory drug. According to PubMed literature, this is the first documented case of ibuprofen-induced TEN in the Middle East and North Africa (MENA) region. DISCUSSION: TEN is an autoimmune bullous disorder that results in the death of keratinocytes, leading to complete dermo-epidermal separation. In the case of our patient, the desquamation was extensive, involving 70% of the total body surface area, and was complicated by a triple bacterial infection with Acinetobacter baumannii, Klebsiella pneumoniae, and Pseudomonas aeruginosa. The patient was treated with colistin and meropenem, in addition to supportive management, hydration and nutritional support. CONCLUSION: In the case of TEN, early diagnosis and hospitalization in a burn centre are crucial to allow rapid healing, and improve the quality of life of the affected patients. Immediate cessation of the causative mediation is critical. Supportive management, hydration, nutritional support, and maintenance of aseptic conditions are highly encouraged to reduce the mortality and morbidity associated with TEN.

Evaluation of Outcomes in Patients Receiving Amantadine to Improve Alertness After Traumatic Brain Injury.

Background: Amantadine has been used off-label to improve alertness after traumatic brain injury (TBI). The goal of this study is to assess the mean change at 72 hours and in course of therapy (COT) Glasgow Coma Scale (GCS) score after amantadine initiation and to correlate the change in GCS score with participation in physical therapy (PT) and occupational therapy (OT) among patients with TBI receiving amantadine during the first hospitalization. Methods: This single-center, retrospective, cohort study included patients ≥18 years old hospitalized for a TBI from August 2012 to February 2018 and received ≥1 dose of amantadine to increase alertness. The primary endpoint is the mean change in 72-hour GCS score after amantadine initiation. The secondary endpoint is the mean change in COT GCS score after amantadine initiation and the correlation between the change in GCS score and percent PT and OT participation at 72 hours and during the COT. Results: Seventy-nine patients were included. The mean age of patients was 41 years, and 79.8% of the patients were men. The mean change in 72-hour GCS score was +0.75 (95% confidence interval [CI] = 0.09-1.42, P = .027), and the mean change in COT GCS score was +2.29 (95% CI = 1.68-2.90, P < .001). There was no significant correlation between the increase in GCS score and percent PT/OT session participation at 72 hours and during the COT, r = -0.15 (P = .24) and r = -0.02 (P = .74), respectively. The percent PT/OT session participation at 72-hour post-amantadine initiation was 61.3% compared with 65.9% during the COT. Conclusion: There were small but statistically significant increases in the mean change at 72 hours and in COT GCS score; however, they were not correlated with percent PT/OT participation. Other studies are needed to determine the appropriate time and GCS score to initiate amantadine along with the optimal dose in the inpatient setting.

Evaluation of serum calcium differences in hypertensive crises and control patients: A randomly matched case-control study.

The role of calcium in blood pressure has been widely studied among hypertensive patients; however, no study has explored the role of calcium in hypertensive crises. The primary objective of this study is to evaluate the differences in serum calcium levels between hypertensive crises patients and a 1:1 random matched controls (age-, sex-, race-, diabetes, and body mass index matched). This study is a single-center, retrospective, chart review, case-control study of patients with hypertensive crises (case group) and patients without hypertensive crises (control group). Patients were included in the case group if they were 18 years of age or older with hypertensive crises and have a documented calcium level. The control group patients were required to be 18 years of age or older, have a documented calcium level, and have no diagnosis of hypertensive crises. The primary outcome of the study was to compare the mean serum calcium in patients with hypertensive crises vs patients without hypertensive crises. Five hundred and sixty-six patients were included in the study: 283 patients in both the case group and control group. The primary outcome results showed that serum calcium concentration was not significantly different between the case group (8.99 ± 0.78 mg/dL) and control group (8.96 ± 0.75 mg/dL) (P = .606). This study found no significant difference in serum calcium levels in patients with hypertensive crises compared to a random matched control group. Larger observational or experimental studies may be useful to evaluate the effect of calcium on blood pressure in hypertensive crises.

Evaluation of serum magnesium differences in hypertensive crises and control patients: A randomly matched case-control study.

Although the role of magnesium in blood pressure has been well studied among hypertensive patients, no study has explored the role of magnesium in hypertensive crises. The primary objective of this study is to evaluate the differences in serum magnesium levels between hypertensive crises patients and matched controls (age-, sex-, race-, and diabetes-matched) in a 1:1 random match. This study is a single-center, retrospective, chart review, case-control study of patients with hypertensive crises (case group) and patients without hypertensive crises (control group). Patients were included in the case group if they were 18 years of age or older with hypertensive crises and have a documented magnesium level. The control group patients were required to be 18 years of age or older, have no diagnosis of hypertensive crises, and have a documented magnesium level. The primary outcome of the study was to compare the mean serum magnesium in patients with hypertensive crises versus patients without hypertensive crises. Three hundred and fifty-eight patients were included in the study: 179 patients in both the case group and control group. The primary outcome results showed that serum magnesium concentration was not significantly different between the case group (1.89 ± 0.29 mg/dl) and control group (1.90 ± 0.31 mg/dl) (p = .787). This study found no significant difference in serum magnesium levels in patients with hypertensive crises compared to a random matched control group. Larger observational or experimental studies may be useful to evaluate the effect of magnesium on blood pressure in hypertensive crises.

Depressive symptoms in adolescent girls at-risk for type 2 diabetes and their parents.

Few studies have characterized the relation between parent's depression symptoms and adolescent's depression symptoms in adolescents at-risk for type 2 diabetes (T2D). We evaluated the associations of parental depression symptoms with the depression symptoms and metabolic functioning of adolescent offspring at-risk for T2D. One-hundred sixteen parents and adolescent girls with a family history of diabetes completed surveys of depression symptoms. Adolescents' degree of metabolic risk for T2D was estimated from body mass index (BMI; kg/m2) standard score, percent adiposity from dual-energy x-ray absorptiometry scan, and whole body insulin sensitivity index determined from glucose/insulin concentrations during a two-hour oral glucose tolerance test. Parents' and adolescents' depression symptoms were significantly associated, even after accounting for race/ethnicity, age, puberty, body composition, and parental diabetes/BMI. Adjusting for similar covariates, parent depression symptoms also were positively related to adolescents' BMI standard score and had a trend-level association with adiposity. There was an inverse relation between parental depression symptoms and adolescent insulin sensitivity, which was entirely accounted for by adolescent body composition. The associations of parental depression symptoms with more elevated depression symptoms and higher BMI in adolescents at-risk for T2D has potential implications for interventions addressing these co-morbid health conditions.

[Percutaneous angioplasty of renal artery stenosis: Short- and long-term results]. / Angioplastie des sténoses de l'artère rénale : résultats à court et à long termes.

INTRODUCTION: Renal artery stenosis (RAS) may be symptomatic. The treatment of these lesions is primarily medical but may sometimes require surgical or endovascular revascularization. RAS angioplasty is well controlled but its results are discussed. The objective of this work was to report the short- and long-term results of the endovascular treatment of renal arteries in our center. METHODS: We report a retrospective study between 2013 and 2018, including patients who received endovascular treatment for severe symptomatic RAS (≥75%). RESULTS: Our population consisted of 17 patients. Mean age was 51.1 years [18-76], sex ratio 2.4. RAS was discovered during work-up for severe renovascular hypertension resistant to medical treatment for 16 patients and rapidly progressive renal failure for one patient. The etiology retained was: atherosclerosis (9 cases), fibromuscular dysplasia (6 cases) and Takayasu's disease (2 cases). The average stenosis rate was 85.9% [75-97%]. We performed simple angioplasty in 47% of the cases and stenting in 53%. The technical success rate was 100%. At 1 month, morbidity-mortality rates were zero. Mean follow-up was 12 months [6-36 months]. Patients with renovascular hypertension experienced a decrease in blood pressure, with discontinuation of antihypertensive therapy in 62.5% of cases and reduction of doses in 37.5% of cases. The permeability rate was 100% at 1 year, 94% at 2 years and 94% at 3 years. One patient had asymptomatic stent thrombosis at the 18th month. The restenosis rate was zero. CONCLUSION: Angioplasty of symptomatic RAS may be indicated as first-line treatment. It is associated with satisfactory results in the short and long terms.

Oral Metolazone Versus Intravenous Chlorothiazide as an Adjunct to Loop Diuretics for Diuresis in Acute Decompensated Heart Failure With Reduced Ejection Fraction.

Background: Thiazide diuretics are often utilized to overcome loop diuretic resistance when treating acute decompensated heart failure (ADHF). In addition to a large cost advantage, several pharmacokinetic advantages exist when administering oral metolazone (MTZ) compared with intravenous (IV) chlorothiazide (CTZ), yet many providers are reluctant to utilize an oral formulation to treat ADHF. The purpose of this study was to compare the increase in 24-hour total urine output (UOP) after adding MTZ or CTZ to IV loop diuretics (LD) in patients with heart failure with reduced ejection fraction (HFrEF). Methods and Results: From September 2013 to August 2016, 1002 patients admitted for ADHF received either MTZ or CTZ in addition to LD. Patients were excluded for heart failure with preserved ejection fraction (HFpEF) (n = 469), <24-hour LD or UOP data prior to drug initiation (n = 129), or low dose MTZ/CTZ (n = 91). A total of 168 patients were included with 64% receiving CTZ. No significant difference was observed between the increase in 24-hour total UOP after MTZ or CTZ initiation (1458 [514, 2401] mL vs 1820 [890, 2750] mL, P = .251). Conclusions: Both MTZ and CTZ similarly increased UOP when utilized as an adjunct to IV LD. These results suggest that while thiazide agents can substantially increase UOP in ADHF patients with HFrEF, MTZ and CTZ have comparable effects.

Pleural empyema due to Salmonella: a case report.

Pleuropulmonary involvement of salmonella infection is very rare and only two cases of salmonella empyema have been reported in Korea. We report the case of a 70-year-old female diabetic patient who presented with right flank pain and right lower chest pain. The chest radiographs revealed fibrostreaky and hazy density at right lower lung field and blunting of right costophrenic angle. Thoracentesis revealed turbid yellowish fluid. Salmonella group B was identified from the cultures of blood and pleural fluid. After antimicrobial therapy and repeated therapeutic thoracentesis, the patient was improved.

A case of Cushing's syndrome in ACTH-secreting mediastinal paraganglioma.

Paragangliomas are unusual neuroendocrine cell tumors arising from paraganglia, of which ACTH-secreting cases in the mediastinum are extremely rare. A 51-year-old woman was admitted for generalized edema and weakness which began 5 months ago. Chest X-ray and CT scan revealed a tumor mass in the anterior mediastinum. The plasma cortisol and ACTH levels were very high. Other sources secreting ACTH, except mediastinal mass, were not found. Surgical excision of mediastinal mass and left supraclavicular lymph node was performed. The postoperative microscopic finding and immunohistochemical staining revealed organoid tumor cell nests (zellballen) and S-100 protein positive sustentacular cells which are characteristics of paraganglioma. This was thus a case of Cushing's syndrome resulting from ectopic ACTH production in anterior mediastinal paraganglioma.

Torsade de pointes induced by terfenadine in a patient with long QT syndrome.

Torsade de pointes is a form of polymorphic ventricular tachycardia that is associated with prolongation of the QT interval. Although torsade de pointes is found in many clinical settings, it is mostly drug induced. Similar problems have been described with nonsedating H1-receptor antagonists, such as astemizole and terfenadine. Terfenadine is a widely used antihistamine. The authors report a case of torsade de pointes in a patient with a possible congenital sporadic form of QT interval prolongation who was receiving a therapeutic dose of terfenadine.

Evidence that activation of the Egr-1 promoter by v-Raf involves serum response elements.

The constitutively active serine/threonine kinase encoded by the v-raf oncogene, v-Raf, activates the Egr-1 promoter in transient expression assays. To characterize the v-Raf-responsive transcriptional control elements, deletion mutants of the Egr-1 promoter were used in transient expression assays. A v-Raf expression vector was co-transfected into NIH3T3 cells with reporter chloramphenicol acetyl transferase (CAT) expression vectors under the control of the Egr-1 promoter or the Egr-1 promoter containing various deletions. Responsiveness to v-Raf was restricted to a region that contained repeated CC(A/T)6GG sequences, known as CArG boxes. CArG boxes form the core of serum response elements (SREs). v-Raf-induced Egr-1 promoter activation was lost by removal of the four tandemly repeated SREs. This region, between -425 and -250, which was necessary for v-Raf responsiveness, was also found to be sufficient for maximal Egr-1 induction by v-Raf when placed upstream from a minimal heterologous promoter. Three out of four SREs from this region were able to respond to v-Raf, however the activation of the individual SREs was lower than the clustered SREs. This cluster of SREs has previously been shown to be responsive to several mitogenic stimuli and the oncogene v-src. Thus, the SREs contained in this cluster may be an important target for cell division signals.

Evidence that Ha-Ras mediates two distinguishable intracellular signals activated by v-Src.

v-Src activates promoters under the control of 12-O-tetradecanoylphorbol-13-acetate (TPA) response elements (TREs) and serum response elements (SREs) via two distinguishable intracellular signaling mechanisms. The induction of TRE- and SRE-mediated gene expression by v-Src could be distinguished by a differential sensitivity to depleting cells of protein kinase C (PKC) and to a dominant negative Raf-1 mutant. Thus, PKC depletion and the dominant negative Raf-1 mutant were able to distinguish two intracellular signaling mechanisms activated by v-Src. Both of these v-Src-induced intracellular signals were sensitive to a dominant negative mutant of Ha-Ras. These data suggest that Ha-Ras functions to coordinately regulate multiple intracellular signaling mechanisms activated by v-Src.

v-Fps-responsiveness in the Egr-1 promoter is mediated by serum response elements.

Egr-1, a mitogen-responsive transcription factor, is rapidly induced by v-Fps in the absence of protein synthesis. Thus, Egr-1 is a primary response to the protein-tyrosine kinase activity of v-Fps. To determine the v-Fps-responsive elements in the Egr-1 promoter, deletion mutants of the Egr-1 promoter were used in transient expression assays. A v-Fps expression vector was contransfected into NIH 3T3 cells with chloramphenicol acetyl transferase (CAT) gene expression vectors under the control of the Egr-1 promoter or the Egr-1 promoter containing various deletions. Responsiveness to v-Fps was restricted to a region that contained repeated CC(A/T)6GG sequences, known as CArG boxes. CArG boxes form the core of serum response element (SREs). v-Fps-induced Egr-1 promoter activation was lost by sequential removal of four tandemly repeated SREs. This region, containing four SREs, was found to be sufficient for maximal Egr-1 induction by v-Fps when placed upstream from a heterologous promoter. Individual SREs from this region were able to respond to v-Fps, however, the activation of the individual SREs was lower than that observed for the clustered SREs. These data suggest that v-Fps-responsiveness in the Egr-1 promoter is mediated by SREs.

Sustained induction of egr-1 by v-src correlates with a lack of fos-mediated repression of the egr-1 promoter.

Serum stimulation of quiescent fibroblasts leads to a transient induction of the transcription factor egr-1. However, the induction of egr-1 by v-src was found to be sustained rather than transient. The proto-oncogene fos has been reported to be co-regulated with egr-1 and to repress serum-induced egr-1 expression. We found that c-fos prevents v-src-induced gene expression regulated by the egr-1 promoter. Thus, the sustained induction of egr-1 by v-src could be explained by a lack of c-fos induction by v-src. Consistent with this hypothesis, egr-1 and c-fos were co-induced by serum, but not by v-src, in Balb/c 3T3 cells; v-src did not induce c-fos expression in these cells. We propose that sustained expression of egr-1 induced by v-src in Balb/c 3T3 cells is due to a lack of c-fos down-regulation of egr-1.

An inhibitory mutant of c-Raf-1 blocks v-Src-induced activation of the Egr-1 promoter.

The protein-tyrosine kinase activity of v-Src leads to the transcriptional activation of the mitogen-responsive transcription factor Egr-1. c-Raf-1 is a serine/threonine protein kinase that has been implicated in the transduction of signals induced by mitogens. The involvement of c-Raf-1 in v-Src-induced Egr-1 expression was investigated using an inhibitory mutant of c-Raf-1. We report here that expression of a kinase-defective mutant of c-Raf-1 inhibits v-Src-induced activation of the Egr-1 promoter. This inhibition is reversed by overexpression of wild type c-Raf-1. Consistent with an involvement of c-Raf-1 in a signaling pathway leading to Egr-1 expression, we find that v-Raf induces Egr-1 promoter activation. These data suggest that c-Raf-1 is a component in an intracellular signaling pathway initiated by v-Src leading to the induction of the mitogen-responsive transcription factor Egr-1.

v-Src activates both protein kinase C-dependent and independent signaling pathways in murine fibroblasts.

Activating the protein-tyrosine kinase activity of v-Src rapidly induced expression of the two 'primary response' genes, TIS10 and Egr-1, in Balb/c 3T3 cells. Depleting cells of protein kinase C (PKC) by prolonged exposure to 12-O-tetradecanoylphorbol 13-acetate (TPA), blocked v-Src-induced TIS10 expression, but had no effect on v-Src-induced Egr-1 gene expression. In addition, the induction of TIS10 and Egr-1 by v-Src could be distinguished using protein kinase inhibitors. Thus, v-Src induced gene expression in murine fibroblasts via two distinguishable signaling pathways: one dependent upon PKC and another that is independent of PKC. Consistent with the use of PKC-mediated signaling pathway by v-Src in murine fibroblasts, we found that activating the kinase activity of v-Src led to increased phosphorylation of a major PKC substrate. Thus, data presented here suggest that v-Src-induced transformation involves the activation of multiple signalling pathways, one of which requires PKC.