bluuebunny/crossref_metadata_2025 huggingface dataset:
A case of NTRK-rearranged Spindle cell tumor in a Pediatric patient
Authors: Reddy A C , Reddy K S
Published: October 2021

Introduction/Objective

Recent studies continue to demonstrate that NTRK fusions occur more frequently in pediatric than in adult patients involving a broader panel of fusion partners as well as a wider range of pediatric tumors than previously recognized. The identification of these NTRK fusions has facilitated precision cancer diagnosis and TRK inhibitor targeted therapy. With the recent FDA approval of larotrectinib and entrectinib for the treatment of adult and pediatric NTRK-positive, unresectable solid tumors, identification of these fusions directly impacts patient care.

Methods/Case Report

Our patient, a 10 year old female presented with a large right sided buttock mass and pressure effects from the tumor. An incisional biopsy showed a moderately moderately cellular tumor with a collagenous and partially myxoid stroma. The atypical cells had ovoid nuclei with vesicular chromatin, minimal to no atypia, and rare mitotic activity (<2/30 high-power fields), as well as fibrous tissue that appeared as ropy collagen. Some of the blood vessels were rimmed by a hyalinized cuff. A mild inflammatory component, namely scattered lymphocytes and fewer plasma cells were noted. Immunohistochemistry showed: SMA(faint+), S100(+), CD34(+), CD31(+), FLI1(+), NTRK(+). Negative for ALK1, desmin, SOX10, EMA, keratin AE1/3, CAM5.2, D2-40, myogenin, MUC4, TLE1, STAT6, BCOR, ERG. Both INI1 and H3K27me3 were retained. Proliferative rate by Ki-67 was low, showing <2% positivity.

Next generation sequencing revealed the following: LMNA-NTRK1 fusion; CD36 N53fs*24 and CDKN2A/B CDKN2A loss exon 1. Thus, the histologic, immunophenotypic, and molecular findings together supported a diagnosis of NTRK-rearranged spindle cell tumor. This entity has alternately been termed lipofibromatosis-like tumor. Following confirmation of NTRK fusion, she was treated with oral TRK inhibitor with near total response. With this NTRK-rearranged spindle cell tumor’s minimal mitotic activity, absence of necrosis, and low cellularity, the behavior of this tumor was expected to be indolent rather than aggressive. However, the patient was presented for assessment and management at a recent tumor board about 8 months after her initial diagnosis as she had residual/recurrent tumor.

Results (if a Case Study enter NA)

NA

Conclusion

Our case highlights the clinical utility of screening for NTRK fusions in all pediatric tumors.
Identifiable Mutations in Pancreatic Adenocarcinoma in the Veteran Population: Molecular Testing Guidelines by NCCN 2020
Authors: Petersen J M , Jhala D
Published: October 2021

Introduction/Objective

In 2019 and 2020, the National Comprehensive Cancer Network (NCCN) advanced a recommendation that all patients with metastatic, recurrent, or locally advanced pancreatic adenocarcinoma should undergo tumor gene profiling (TGP). Prior to these recommendations, TGP in targeted patients have demonstrated a high frequency of KRAS (>90%), TP53 (60-70%), CDKN2A (>50%), SMAD4, TGF- βR1, and TGF- βR2 mutations or alterations. Even less frequent mutations such as the homologous recombination repair (HRR) genes impact treatment by predicting tumor response to platinum-based therapies. However, the literature is sparse for the frequency of these mutations in patients with pancreatic adenocarcinoma undergoing generalized testing as part of the standard of care per NCCN guidance, particularly for veterans.

Methods/Case Report

For a quality assurance study, a retrospective review was performed to identify patients with pancreatic adenocarcinoma at a tertiary medical center serving veterans from January 2019 to February 2021 with TGP performed as part of their care. All of the TGP had been sent to Foundation Medicine (Cambridge MA), and the identifiable tumor mutations from the test reports were recorded to document the frequency of KRAS, TP53, CDKN2A, SMAD4, TGF- βR1, TGF- βR2 and HRR mutations or alterations.

Results (if a Case Study enter NA)

There were a total of 11 patients with pancreatic adenocarcinoma who had a tumor specimen for TGP during the study period. All 11 patient tumors had KRAS mutation. 10 out of 11 had a mutation or alteration in TP53. 8 of 11 patients had a CDKN2A mutation or alteration. 7 of 11 patients had a mutation or alteration of SMAD4 though none had TGF- βR1 or TGF- βR2. 2 of 11 patients had HRR mutations (1 with FANCA and 1 with ATM).

Conclusion

Tumor mutations on generalized gene profiling per NCCN guidelines continue to identify important mutations in pancreatic adenocarcinoma for veteran patients.
Pancreatic Gangliocytic Praganglioma: A Rare Case and Literature Review
Authors: Goyal G , Harris J
Published: October 2021

Introduction/Objective

Gangliocytic paraganglioma, GP is a morphologically distinct tumor first reported by Dahl in 1957, most often in second portion of duodenum near ampulla of Vater. GP mostly present as single tumors, but occasionally may be multiple, when seen in association with Von Recklinghausen disease and carcinoid tumors. Rare cases have been reported at other sites in gastrointestinal tract including esophagus, pylorus, jejunum and extra- gastrointestinal tract in the nasopharynx, thymus, lung and ovary. Pancreatic GP is extremely rare with five cases reported till date.

Methods/Case Report

A 42- year- old male presented with abdominal pain. Physical exam showed no abnormalities. The significant findings on labs were raised amylase levels in the range of 1262 U and mild hyperglycemia with blood glucose of 178mg/dl. CA 19-9 was found to be 8.0 U/ml. Coronal CT Abdomen showed hypodense well circumscribed nodule 1.5 cm in body of pancreas. Gross specimen of pancreas showed a circumscribed 1.5 cm nodule in body of Pancreas.The microscopic sections of pancreatic mass show epithelioid appearing neuroendocrine cells in nests, with spindle shaped schwann cells or sustentacular cells in periphery, and scattered ganglion cells. The immunohistochemical staining positive for synaptophysin in epithelioid cells, S100 in spindled schwann cells and CK in epithelioid cells and Ganglion cells. Based on the microscopic findings, a diagnosis of Gangliocytic Paraganglioma, GP arising in Pancreas was made.

Results (if a Case Study enter NA)

NA

Conclusion

Pancreatic GP, are often misdiagnosed as Pancreatic Neuro endocrine tumors, Grade1. The accurate differentiation and precise diagnosis is crucial for appropriate clinical management. WHO classification of 2010, classifies gangliocytic paragangliomas as benign. Duodenal GP has a benign behavior with lymph node metastasis in only 5-7% cases, and no evidence of distant metastasis. In comparison, Pancreatic GP show an more aggressive behavior with lymph node metastasis observed in 2/6 cases and one case with sternal bone metastasis, emphasizing the importance of the primary location of origin of GP as prognostic factor. Our understanding is limited due to the scarcity of literature; more published data shall be instrumental in further explaining the clinical behavior of this rare entity.
Chronic Histiocytic Intervillositis: A Placental Histopathologic Feature in Vertical Transmission of Maternal Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)
Authors: Oentoro J , Jalali-Farahani S , Davis J , Zee S
Published: October 2021

Introduction/Objective

Vertical transmission of severe acute respiratory syndrome associated with coronavirus-2 (SARS-CoV-2) infection has been reported as a rare occurrence. The purpose of this study is to identify any specific placental histopathologic abnormalities associated with SARS-CoV-2 infection, compare differences between mothers with symptomatic and asymptomatic coronavirus disease 2019 (COVID-19), and determine the frequency of vertical transmission.

Methods/Case Report

Placentas from mothers diagnosed with COVID-19 during pregnancy and delivered at Stony Brook University Hospital were identified. A control group of mothers with a negative COVID-19 test was selected from the same period. The frequency of histopathologic characteristics defined by the Amsterdam Placental Workshop Group Consensus was compared using chi-square tests between the following cohorts: COVID-19 positive mothers against COVID-19 negative mothers and symptomatic COVID-19 mothers against asymptomatic COVID-19 positive mothers.

Results (if a Case Study enter NA)

A retrospective study reviewed 23 placentas from mothers with COVID-19 for features of maternal vascular malperfusion, fetal vascular malperfusion, and inflammatory changes. 11 mothers displayed symptomatic COVID-19, and 12 mothers were asymptomatic. One neonate tested positive for SARS-CoV-2. No significant differences were identified in the frequency of the examined placental histopathologic characteristics between COVID-19 positive and negative mothers. The degree of COVID-19 severity did not significantly impact the frequency of examined histopathologic features. Interestingly, in the case with vertical transmission, the placenta demonstrated the only finding of chronic histiocytic intervillositis (CHI) with associated trophoblast necrosis.

Conclusion

Comparing across groups based on COVID-19 status, this study found no specific placental histopathologic features associated with maternal SARS-CoV-2 infection, regardless of symptom severity. However, in one case of vertical transmission, CHI was a unique histopathologic feature. These findings are consistent with the current literature. Further large-scale investigations are needed to establish additional patterns of specific placental histopathology, incidence and contributing factors of vertical transmission of COVID-19, and the impact of CHI in future pregnancies of affected women.
A case report of an uncommon presentation of Nephroblastoma (Wilms tumor): in an older child with polycythemia and elevated erythropoietin
Authors: Danyal K , Sybenga A
Published: October 2021

Introduction/Objective

Wilms tumor (nephroblastoma), is a neoplasm that has a prevalence of 1 per 10,000 before the age of fifteen, with 50% occurring before age 3. WT1 (11p13) gene, a zinc finger transcription factor, is expressed in early urogenital system development and mutations here represent one of the primary pathways to the development of Wilms tumor. Although mouse model studies have shown that WT1 may be a transcriptional activator of erythropoietin (EPO) gene, increases in serum erythropoietin are rarely seen in patients with Wilms tumor. Concurrent polycythemia is a further rarity with only 11 such reports in literature. This is intriguing since WT1 mutations represent the most common mutation pathway in Wilms Tumor. Interestingly, other tumor types associated with elevated serum EPO and polycythemia (e.g. renal cell carcinoma and metanephric adenoma) are thought to do so through the generation of hypoxia inducible factor, and induction of VEGF.

Methods/Case Report

Here we present a case of Wilms tumor in a 7-year-old female who was establishing care after moving to Vermont. Physical examination showed possible splenomegaly ultimately discovered to be a large LUQ abdominal mass with a concurrent discovery of polycythemia. Subsequent serum EPO was 308 (Ref: 2.6-18.5 mIU/mL).). The mass was surgically removed with resolution of polycythemia. Histological evaluation showed a triphasic, blastema predominant Wilms tumor with favorable histology. Heterologous, vascular differentiation was seen in the stroma, positive for CD34 and CD31, and negative for D2-40.

Results (if a Case Study enter NA)

NA

Conclusion

Based on these findings, this phenomenon may be related to increased VEGF expression resulting in this patient’s increased serum EPO and polycythemia, and heterologous vascular differentiation within the tumor stroma. This is the first report of histology in a case of Wilms tumor associated with high serum EPO and polycythemia and may indicate an alternative pathway for the generation of EPO in Wilms tumor.
Outcome of primary pulmonary salivary gland-type carcinoma
Authors: Deb P Q , Suster D
Published: October 2021

Introduction/Objective

Primary pulmonary salivary gland-type carcinomas are rare malignancies that arise from minor salivary gland tissue present within seromucinous submucosal glands within the lower respiratory tract. Due to their rarity (~ <1% of all primary lung malignancies), the epidemiological features and outcome of these malignancies are not well documented. Data from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) database was analyzed to identify cases of primary pulmonary salivary gland carcinoma. The most common tumor types included mucoepidermoid carcinoma (MEC), adenoid cystic carcinoma (ADCC), and epithelial-myoepithelial carcinoma (EMEC). The tumors were analyzed for overall survival across various epidemiological factors.

Methods/Case Report

All patients diagnosed with MEC, ADCC, and EMEC with the lung designated as the primary site between the period of 1975 to 2017 were analyzed. We calculated overall survival and disease-specific survival with Kaplan-Meier curves and Cox proportional hazards models using SPSS v25.

Results (if a Case Study enter NA)

323 cases of MEC, 284 cases of ADCC, and 6 cases of EMEC diagnosed as primary lung carcinoma were identified. Age distribution analysis of the patients showed a unimodal distribution for both MEC and ADCC with most patients being diagnosed after the age of 40. 54% of MEC patients were male, while 48% of ADCC patients were male. The majority of patients were Caucasians (77% for MEC and 83% for ADCC patients). Both disease-specific and overall survival were worse for patients diagnosed at the age of 60 years or above. Race or sex did not significantly affect patients’ survival. High-grade MEC showed significantly worse prognosis than low or intermediate grade MEC. EMEC cases were too few (n=6) to perform reliable survival analysis, however, the age of diagnosis was higher (45 and above) with a higher incidence among black population (50%).

Conclusion

Comprehensive review of clinical and epidemiological features of primary salivary gland-type lung carcinoma show that the age of diagnosis and tumor grade are the most significant factor in determining the survival of these patients.
Quality improvement Initiative to eliminate silver precipitate during Periodic Acid Silver Methenamine Stain (PAMS) automated protocol of renal biopsies at McGill University Health Centre
Authors: Kuk M , Chicoine D , Maedler C , Bernard C
Published: October 2021

Introduction/Objective

Annually, about 400 renal biopsies are processed at the McGill University Health Centre (MUHC) pathology laboratory located in Montreal, Canada. One of the stains used to visualize the glomerular basement membrane is Periodic Acid Silver Methenamine Stain (PAMS). In August 2020, a strong, granular precipitate of silver was noted during PAMS automated staining resulting in uninterpretable results and delay in the diagnosis. Based on a sample analysis, this problem affected 21 % of kidney biopsies.

Methods/Case Report

A cause-and-effect workflow was developed for systematic assessment of potential causes of the granular precipitate including pre-analytical and analytical factors. Some of the pre-analytical factors included length of time spent in transport before fixation and patient factors that predisposed precipitate formation. Analytical factors were categorized as fixation problems (temperature, pH, duration), embedding problems (parafilm temperature, cooling method, type of parafilm), slide preparation (temperature, water bath pH, dehydration and further processing steps), microtone parameters (microtone calibration, thickness, laboratory technologist expertise), automatic staining parameters (cartridge age, hematoxylin counterstain duration, wash-out period etc.) and coverslip placement (adhesive type, temperature, drying).

Results (if a Case Study enter NA)

Following our systematic approach, the cause of granular precipitate was identified as the timing of hematoxylin counterstain. A portion of renal biopsy tissue was taken from parafilm blocks of previouslly reported cases of patients with membranous glomerulonephritis to further test the hypothesis by introduction of various incubation times with the hematoxylin counterstain.

Conclusion

Best PAMS staining was attained when no hematoxylin counterstain was employed (instead, neutral red counterstain for 70 seconds was used). PAMS staining with hematoxylin counter stain for no more than 60 seconds was found to be acceptable for the interpretation of glomerular pathology.
GATA3 Is a Useful Immunohistochemical Marker to Differentiate Variants of Renal Tubular Lesions from Different Segments of Renal Tubules
Authors: Deebajah M , Qu Z , Zhang P
Published: October 2021

Introduction/Objective

GATA3 is found in glomerular mesangial cells, and the distal tubules & collecting ducts in metanephros and eventual kidneys, but not associated with the proximal tubules and loops of Henle. We hypothesize that GATA3 can be used as a marker to identify the origin of tubular differentiation in most renal tumors.

Methods/Case Report

Ten negative controls and 43 renal mass lesions (RCC, papillary, clear cell papillary, and chromophobe carcinomas, oncocytoma, and polycystic kidney disease). GATA3 nuclear stain was graded as negative (absent stain), equivocal and positive (< 5 and > 5% cells, respectively). Details of their GATA3 nuclear expression was analyzed for identifying their tubular segmental origins.

Results (if a Case Study enter NA)

In 10 normal renal parenchyma, GATA3 was positive in mesangial cells, distal tubules, and collecting ducts, but was negative in the proximal tubules and loop of Henle. The cystic lining of glomerulocystic renal disease was stained negatively for GATA3 (proximal tubular origin), whereas pediatric and adult variants of polycystic kidney diseases was positive for GATA3 staining (distal tubular origin). 1/10 ten clear cell RCC and papillary RCC showed focal positive GATA3 stain. GATA3 showed weakly positive staining in some oncocytomas (4/11) and some chromophobe RCC (4/11), indicating that they might be derived from the junctional segment between the loop of Henle and the distal tubules. By contrast, all clear cell papillary RCC (distal tubule origin) were diffusely positive.

Conclusion

Our results indicate that GATA3 is a useful immunohistochemical marker to determine the developmental origin in the specific renal tubular segment for the majority of renal mass lesions. Thus, it may be useful for routine differential diagnosis of these lesions.
The Correlation between Serum Creatinine and PTH Levels in Dialysis Patients in Egypt
Authors: Boraik A S , Abdelmonem M , Shedid M , Abd Elaal H M , Elhusseny A , Mohamed M M , Wasim H
Published: October 2021

Introduction/Objective

Chronic kidney disease (CKD) is affecting about 14% of the general population. CKD is associated with a decrease in calcium level in the body. In the early stages of (CKD), dialysis may not be needed. The late stages of CKD will require dialysis or a kidney transplant to save a life.

Secondary hyperparathyroidism is a crucial disorder in CKD patients. It explains why the illness causes a significant change in bone and mineral metabolism. This study aims to study renal hyperparathyroidism (rHPT) in dialysis patients with late-stage of chronic kidney disease (CKD).

Methods/Case Report

A total of 55 subjects were enrolled in this study for late-stage dialysis patients from Egypt. Serum creatinine and PTH levels were measured. Among the 55 subjects; 41 subjects (74.5%) were males, 14 subjects (25.5%) were females with a mean age of 52.7 and 34.3 years for males and females, respectively.

Subjects were divided into two groups; Study group I consists of 33 dialysis patients; three patients were females (9%) while 30 patients were males (91%), and control group II consists of 22 healthy individuals, 11 subjects were females (50%), and 11 subjects were males (50%).

Results (if a Case Study enter NA)

In our study, in comparison between two groups as regards blood investigations. The means of creatinine and PTH in the study group I were 8.93 mg/dl and 316.8, while in the control group II were 0.9, and 38.4 respectively.

Comparing the two groups shows that mean of Creatinine and PTH in the study group was statistically significantly higher than the control group (p-value less than 0.001).

Conclusion

In patients with CKD, accurate measurement of (PTH) is critical for treatment decision-making to reduce the risk of bone and cardiovascular diseases.

We recommend that patients with diabetes and high blood pressure be aware that they must take their medications consistently to avoid kidney problems.
Service Learning is Action Learning: A Novel Way to Increase Classroom Learning Retention
Authors: Brunson-Pitt E
Published: October 2021

Introduction/Objective

As educators, how do we ignite students to become effective and engaging ambassadors for the medical laboratory profession while making learning difficult concepts fun? This case study explores the use of service learning as an effective tool in nurturing advocacy for issues affecting the health and longevity of minority populations within the community, while learning hematological and blood banking concepts.

Methods/Case Report

Four MLT student cohorts comprised of twelve to sixteen students each participated in a ten- week, service-learning assignment as part of their Medical Laboratory Technician Curriculum. Assignment objectives were to: (1) understand racial /cultural history that preclude individuals from participating in hematopoietic stem cell donation and transplant; and, (2) develop and implement a strategy to recruit donors for the screening event. Students actively recruited across their college campus and surrounding communities to enroll one hundred new stem cell donors, with over fifty percent of these donors identifying as people of color. This activity represented ten percent of their course grade. Examples of assignments students were required to complete included: creating and implementation a donor recruitment strategy; reflection journal entries; host an in-person /virtual stem cell donor drive; and submission of an outcome assessment summarizing goal achievement along with lessons learned.

Results (if a Case Study enter NA)

N/A

Conclusion

As a result, students enrolled over 300 new stem cell donors into Be The Match™ - National Marrow Donor Program® resulting in seven successful transplants. Students learned how to effectively inform their community of the importance of clinical laboratory scientists, raising awareness of the need for clinical laboratory professionals and the need of genetically diverse individuals to volunteer as donors to provide the life-saving therapies.
Bleeding Patient with Anti-PP1Pk – Revisiting Autologous Frozen Red Blood Cells
Authors: Pacheco M C , Fedda F , Mignogna D , Meena-Leist C
Published: October 2021

Introduction/Objective

A 34-year-old Amish woman G11P8A2L8, with a known PP1Pk antibody, presented to her OB with vaginal hemorrhage secondary to an incomplete spontaneous abortion. Despite medical treatment, her hemoglobin decreased from 12 g/dL to 8.4 g/dL. She was air transferred to a tertiary care hospital for further management and antigen negative RBC transfusion.

Upon arrival, her hemoglobin had decreased to 7.1 g/dL and her BP decreased to 92/64 mm Hg. Additional blood draws were discontinued to save blood wastage. Her blood pressure continued to decrease over the next several hours to a low of 78/36. The patient was briefly stabilized, and a successful dilation and curettage was performed.

Methods/Case Report

A national search was conducted for PP1Pk antigen negative blood. Her RBC phenotype: C+, c-, E-, e+, K-k-, Fy(a + b-), Jk(a+ b+), MN+, p, Le(a-b-). There was no history of blood product transfusion and the prior miscarriages where thought to be the source of alloimmunization. There was no known family history of the p (P- P1- Pk-) phenotype.

Results (if a Case Study enter NA)

One unit of PP1Pk antigen negative PRBCs was located approximately 48 hours after the patient’s admission, however, the consulting hematology team suggested withholding transfusion due the possibility of alloimmunization from other blood groups complicating future transfusions. She was treated with IV iron and discharged four days later with a hemoglobin level of 6 g/dL. She was asymptomatic upon discharge.

Conclusion

Anti-PP1Pk is a rare antibody (5.8 per 1 million people). In the Amish population, the incidence is approximately 1 in 5000 individuals. Our patient is planning for future pregnancies. Upon our suggestion, the patient was encouraged to consider frozen autologous blood donation after recovery and before the next pregnancy as well as close monitoring in high-risk maternal fetal medicine settings.

In a patients and donors with anti PP1PK, we recommend advance planning including frozen autologous blood donation and family members RBC antigen studies. They should be encouraged to become regular blood donors for themselves and others.
Identification of Wasted Blood Products at Staten Island University Hospital in 2020 and Institutional Efforts to Reduce Wastage
Authors: Toprak M , Asuzu I M , Morvillo G , Kiran F , Chae B , Desai D S , Opitz L M
Published: October 2021

Introduction/Objective

Blood products are precious resources obtained from donors who donate with the intention to help people. These blood products however do not always go to the patients, instead sometimes ending up in the waste. It is inevitable to have some degree of the wastage due to limited blood product shelf life, the inherent need to have stock on hand at all times, and the often unpredictable demand of these products. However, it is possible to minimize the wastage of blood products with careful management of inventories, proper documentation, and education1. In this study, we aim to identify the amount and cost of wasted blood products at Staten Island University Hospital in 2020, the reasons behind the wastage, and solutions to reduce the wastage.

Methods/Case Report

A retrospective statistical analysis of blood product waste data in 2020 was performed manually with Microsoft Excel. Wastage rate and average cost was calculated, the reasons behind the wastage were identified, and low cost interventions to reduce wastage were planned.

Results (if a Case Study enter NA)

Total number of the wasted blood product is 425 which represents 3.8% of the total inventory at a total cost of $ 97,309.46 which does not include the hours spend by the lab personnel for the wasted products. The most wasted blood component is fresh frozen plasma (FFP) (Table 1). Thawing the frozen blood products (FFP and cryoprecipitate) significantly shortens the shelf life and triggers a lot of wastage through expiration (Table 2). 32.5 % of the wasted products are wasted due to expiration on the shelf (Diagram 1). Other reasons for the wastage includes patient unreadiness, patient refusal, late return of unused products etc. (Graph 1).

Conclusion

Educating clinical and laboratory team members about the reasons for wasted blood products and strategies to reduce it might significantly reduce the wastage. Appropriate activation and immediate deactivation of massive transfusion protocol (MTP) would be one of the most important aspect of this education. Expired thawed blood product is the largest contributor to wastage, and MTP is the main reason for thawing. Preventing unnecessary MTP activation minimizes over-thawing and therefore minimizes the expiration and wastage. Documentation of the wasted blood product should be improved to better identify the reasons behind wastage.
Leukostasis aggravated by red blood cell transfusion in a chronic lymphocytic leukemia patient
Authors: Jum’ah H , Chitsaz M , Kundrapu S
Published: October 2021

Introduction/Objective

Leukostasis/symptomatic hyperleukocytosis is commonly seen in acute leukemias and is characterized by high blast counts and symptoms of decreased tissue perfusion with a one-week mortality of 20-40%, if left untreated. It is a rare complication in chronic lymphocytic leukemia (CLL) and is seen in CLL patients with white blood cell (WBC) counts > 500x10^9/L. Studies have shown that transfusion of blood products prior to decreasing the WBC count may lead to increased blood viscosity and worsen leukostasis. We report a CLL patient with a lower WBC count presenting with symptoms of leukostasis, further worsened by a red blood cell (RBC) transfusion prior to leukapheresis.

Methods/Case Report

A 73-year-old male with history of CLL for 5 years, hypertension and chronic kidney disease presented with acute dyspnea for 1 day. The WBC count was 208x10^9/L, hemoglobin was 6.5 g/dL, troponin I was 1.554 ng/mL, creatinine was 1.68 mg/dL and chest x-ray showed bilateral interstitial lung edema. The patient was diagnosed with acute hypoxic respiratory failure, acute kidney injury and myocardial infarction due to leukostasis. He received RBC transfusion, shortly after which his dyspnea worsened. There were no other signs or symptoms that could suggest a transfusion reaction. A single leukapheresis was performed following which there was a significant improvement in symptoms with a drop in WBC count to 123.1x10^9/L and creatinine to 1.3 mg/dL.

Results (if a Case Study enter NA)

NA

Conclusion

CLL may present with symptomatic hyperleukocytosis at lower leukocyte counts than has been described in the literature. Symptoms due to leukostasis can be precipitated/worsened by transfusion of blood products due to increased blood viscosity. It is critical to identify the signs and symptoms of this medical emergency as prompt diagnosis and management with leukapheresis significantly reduces the leukocyte count and blood products should be transfused slowly during or after leukapheresis.
Effects of Fasting Blood Glucose on the Progression of Arterial Stiffness in Nondiabetic Population
Authors: Han Xu , Liu Qian , Ma Yi-han , Zheng Xiao-ming , Ruan Chun-yu , Cui Kai , Song Ming-zhu , Wu Shou-ling , Wu Yun-tao
Published: October 2021

Background

To investigate the relationship between baseline fasting blood glucose levels and the progression of arterial stiffness in nondiabetic population.

Methods

In this research, the individuals participated in the Kailuan research cohort and completed 2 tests of brachial–ankle pulse wave velocity (baPWV) from 2010 to 2018 and were not diabetic at the first baPWV testing were included. A multiple linear regression was applied to analyze the impact of baseline fasting blood glucose levels on baPWV and its progress during the follow-up.

Results

A total of 16,875 with 10,453 male (61.94%) subjects met the inclusion criteria. The average age at baseline (the first baPWV measurement) was (45.9 ± 13.0) years old and the average baPWV was (1,439.0 ± 309.3) cm/s. During the follow-up (the second baPWV measurement), the average age was (49.6 ± 13.3) years old, and the average baPWV was (1,494.6 ± 334.3) cm/s. The baPWV progression in the observed subjects was (55.7 ± 233.4) cm/s. After adjusted for other confounding factors, multiple linear regression analysis found that there was a positive correlation between the baseline fasting blood glucose levels and the follow-up baPWV. With every 1 mmol/l baseline fasting blood glucose increase, the follow-up baPWV increased 16.89 cm/s. With every 1 mmol/l fasting blood glucose level increase, the progress of baPWV increased by 3.70 cm/s.

Conclusions

Fasting blood glucose levels in nondiabetics affect arterial stiffness during follow-up. Elevated fasting blood glucose levels during the follow-up period are a risk factor that may increase the progression of arterial stiffness.
Seasonal reproduction and gonadal function: a focus on humans starting from animal studies
Authors: Beltran-Frutos Ester , Casarini Livio , Santi Daniele , Brigante Giulia
Published: October 2021

Photoperiod impacts reproduction in many species of mammals. Mating occurs at specific seasons to achieve reproductive advantages, such as optimization of offspring survival. Light is the main regulator of these changes during the photoperiod. Seasonally breeding mammals detect and transduce light signals through extraocular photoreceptor, regulating downstream melatonin-dependent peripheral circadian events. In rodents, hormonal reduction and gonadal atrophy occur quickly and consensually with short-day periods. It remains unclear whether photoperiod influences human reproduction. Seasonal fluctuations of sex hormones have been described in humans, although they seem to not imply adaptative seasonal pattern in human gonads. This review discusses current knowledge about seasonal changes in the gonadal function of vertebrates, including humans. The photoperiod-dependent regulation of hypothalamic–pituitary–gonadal axis, as well as morphological and functional changes of the gonads is evaluated herein. Endocrine and morphological variations of reproductive functions, in response to photoperiod, are of interest as they may reflect the nature of past population selection for adaptative mechanisms that occurred during evolution.
EP.WE.28Routine histopathology examination of the sleeved stomach after sleeve gastrectomy - significance and comparison with preoperative endoscopy
Authors: Omar Islam , Hafez Ahmed , Freear Josephine
Published: October 2021

Background

Sleeve gastrectomy (SG) is one of the most commonly performed bariatric procedures. However, the available literature on histological examination of the resected sleeved stomachs is widely inconsistent. This study aimed at assessing the histopathological findings after SG performed in our center compared to the routinely performed preoperative esophagogastroduodenoscopy (OGD) and the intraoperative findings.

Material and methods

We conducted a retrospective cohort study using the bariatric unit database of all patients who had SG procedures from June 2007 to December 2019.

Results

Out of the 620 SG performed, there were 219 patients with complete data, including preoperative OGD reports, operative notes, and postoperative histopathology reports. We found normal specimens in 43.83% (n = 96) and evidence of inflammation in 50.68% (n = 111) of cases. There were 10 (4.56%) specimens with evidence of inflammation and other lesions and two (0.91%) specimens with lesions only. Twenty-five patients had inflammation, and 10 had lesions on preoperative OGD with negative histopathology reports.

Conclusion

Routine histopathology examination after SG does not change the management, and preoperative OGD can detect inflammatory changes and lesions, which could have been missed with histology analysis only.
EP.WE.46Stentolith as an uncommon complication of loss to follow up after endoscopic biliary stenting
Authors: Ng Sherwin , Lam Mark , Gill Nina , Shamali Awad
Published: October 2021

Introduction

Endoscopic biliary stenting is a common procedure, with indications from malignant obstruction to benign stone disease. We discuss a patient who re-presented after endoscopic stenting having been lost to follow up, with a large ‘stentolith’ requiring open CBD exploration.

Case Presentation

A 56-year-old female presented in 2013 with obstructive jaundice and a 2-week history of abdominal pain. She was a smoker, but otherwise had no past medical, surgical, or relevant family history. After initial workup, ERCP with sphincterotomy and pigtail stent placement was performed with interval laparoscopic cholecystectomy in 2014. Post-operative follow up was not arranged, the patient subsequently re-presented in 2020 with fatigue. MRCP confirmed a proximal CBD stone and linear artefact. Open exploration facilitated removal of the stone-stent complex.

Discussion

Complications of stenting include cholangitis, stent occlusion and migration. Stenting for failed biliary stone extraction is considered a temporary measure, with removal or exchange at three months. However, patients may be lost to follow up and return with non-specific symptoms. A rare cause is de novo formation of a gallstone calculus encasing the stent, a phenomenon termed “stentolith”. Proposed pathophysiology is through promotion of bacterial proliferation by the stent, with biofilm formation and calcium bilirubinate precipitation. Variation in formation has been described, with plastic stents developing circumferential stones, due to potential space between the wall and stent.

Conclusion

This highlights the importance of robust inter-disciplinary working, careful patient follow up and implementation of a mandatory registry at all hospitals for stented patients.
EP.WE.47Cholecystectomy During COVID-19: A Single Centre Experience
Authors: Ghassemi Nader , Rathod Sneha , Salgaonkar Hrishikesh , Nnaji Martin , Athwal Tejinderjit , Cheruvu Chandra
Published: October 2021

Background

The COVID-19 pandemic has significantly impacted healthcare delivery globally with consequent restructuring of surgical services during the peak period and prioritisation of emergency and cancer surgery over elective operations.

We present outcomes for laparoscopic cholecystectomy during the peak period for COVID-19 in the UK and compare this with data for the same period in 2019

Methodology

This is a prospectively study. Analysis of collected data on patients who underwent laparoscopic cholecystectomy during the peak period for COVID-19 from 1st March 2020 – 30th June 2020 (study cohort) at the Royal Stoke University Hospital. Data from the same period in 2019 (control cohort) was compared and analysed.

Results

104 patients underwent a laparoscopic cholecystectomy during the peak period compared to 217 during the same period in 2019.

Median age in the study cohort was 51.5 years (15-84 years) and 52 years (19-91 years) in the control cohort (p = 0.49). Male to Female ratio was 1:2 in the study cohort and 1:2.2 in the control cohort (p = 0.67)

Emergency admissions constituted the majority of cases and there was no statistically significant difference between both groups (61.5% vs 61.8%, p = 0.49). Most cholecystectomies were for biliary colic (41.3% vs 35.5%) and cholecystitis (37.5% vs 43.8%), and there was no statistically significant difference between both groups (p = 0.31 and p = 0.29 respectively).

Conclusion

This study demonstrates that laparoscopic cholecystectomy was feasible and safe in patients with symptomatic gall bladder disease during the peak period for COVID-19 when compared to a historic cohort in 2019.
EP.WE.117Colovaginal fistula from neglected vaginal pessary; Fallouts from the COVID-19 pandemic
Authors: Tawfik Ahmed , Oyewole Bankole , Elzaafarany Ahmed , Gilbert Catherine , Campbell-Smith Tim
Published: October 2021

An 86 year old lady was admitted with a one week history of feeling unwell, polyuria, dysuria, urinary and faecal incontinence. She had previously been treated for recurrent UTIs by her GP. On examination she had suprapubic tenderness but no peritonism. Observations revealed tachycardia of 122bpm with a temperature of 36.3*C. Inflammatory markers were raised with a white cell count of 22.0x106/L and CRP 129 mg/L. Urine cultures grew Pseudomonas aeruginosa. She was managed for urosepsis with intravenous antibiotics.

Past medical history included vaginal pessary for uterine prolapse, congestive cardiac failure, hypertension, polymyalgia and osteoporosis.

She lived alone with no package of care.

On admission she improved with intravenous antibiotics however she had a perineal examination due to ongoing faecal and urinary incontinence and was noticed to be passing faeces per vaginam. A colo-vaginal fistula was suspected and she was reviewed by the gynaecologist who noted her pessary had been in-situ for up to a year and her routine appointment to have it changed was cancelled due to the COVID-19 pandemic.

An MRI Pelvic scan confirmed a 3x2cm rectovaginal fistula.

She was reviewed by the general surgery team and the decision was made for her to be defunctioned to prevent her episodes of recurrent UTIs and improve her quality of life. She successfully had a laparoscopic end colostomy with an uneventful post-operative period.

This case highlights the harms caused from the cancellation of appointments and demonstrates a rare cause of rectovaginal fistula.
EP.WE.213Short-term impact of COVID-19 on surgical services in a tertiary hospital
Authors: Hamer N , Brown A , Sharma V , Jha T , Garg D , Jha M
Published: October 2021

Aim

Since December 2019, SARS-CoV-2 has dramatically impacted the global landscape. One of the biggest challenges has been the additional strain put on healthcare systems. Although there are numerous studies on the effects of COVID-19 on intensive care beds and ventilator availability, there has been little exploration into the wider impacts of COVID-19 on the provision of other services. This study was designed to explore how COVID-19 has impacted surgical service provision at a large NHS hospital.

Methods

We compared the number and types of general surgical procedures carried out in a tertiary centre in the six months prior to the UK COVID-19 outbreak (September 2019-February 2020) and the six months after (March 2020-August 2020).

Results

We found that since March 2020 there has been a 70% decrease in the amount of operations taking place, with numbers dropping from a pre-COVID total of 1761 to a post-COVID total of 529. This mainly affected elective procedures with emergency surgeries remaining relatively constant (48 pre-COVID vs 44 post-COVID).

Conclusion

COVID-19 has caused a significant decrease in the number of surgeries being undertaken. This is due to a combination of factors including staffing issues, reduced investigative capacity, and national mandates on the cessation of non-urgent procedures. Although this mainly affected elective operations, it will have wider implications on future NHS workload and training. The knock on effects will inevitably result in a rise in delayed and emergency presentations with worse patient outcomes.
EP.WE.227YouTube as a source of patient information on elective surgery safety during the COVID-19 pandemic
Authors: Dawidziuk Aleksander , Gandhewar Rishikesh , Shah Kamal , Vemulapalli Kalyan
Published: October 2021

Aims

To evaluate the understandability, actionability and quality of perioperative patient information conveyed by YouTube videos covering safety of elective surgery during the COVID-19 pandemic.

Methods

YouTube search strategy was optimised using a combination of “COVID”, “safety”, and “surgery” terms. Each video was screened by two independent reviewers. The search was conducted on 9 January 2021. The understandability and actionability of videos were evaluated using validated Patient Education Materials Assessment Tool (PEMAT). Quality of perioperative patient information was determined with a novel 4-point checklist based on recommendations by the National Institute for Health and Care Excellence. The effect of video type on PEMAT and quality scores was assessed with Kruskal-Wallis Test. Scores were correlated with video metrics using Spearman's Rank.

Results

The primary search revealed 594 videos. After deduplication and exclusions, 108 materials were analysed. Majority of videos (n = 89) originated from the USA, with only 4 produced in the UK. Hospital-produced videos had the highest understandability scores [median (IQR): 83.33% (18.40%)] and patient testimonies the lowest [55.91% (33.24%)] (p=0.002). Hospital materials were also most actionable [2.25 (2.40)], with news reports scoring lowest [0.0 (0.8)] (p=0.049). Social distancing, preoperative COVID-19 testing, and wearing face masks were mentioned in 46, 41, and 48 videos respectively. Only 9 materials recommended self-isolation before surgery. There was no significant correlation between video metrics (e.g., length) and scores.

Conclusions

Short UK-specific videos should be created to outline accurate patient instructions for elective surgery during the COVID-19 pandemic and provide reassurance to help reduce the surgical backlog.
EP.WE.264How much are we spending on Botulinum Toxin A injections for functional Upper Gastrointestinal conditions?
Authors: Afzal Zeeshan , Sreedharan Loveena , Hasan Ibtisam , Corbett Gareth , Hardwick Richard
Published: October 2021

A number of Oesophagogastric (OG) conditions such as Achalasia, Gastroparesis, Oesophageal dysmotility (OD) and Pyloric dysfunction (PD) can be treated with Botulinum Toxin A (BTxA). The aim of our study was to assess the use and costs of Botulinum Toxin A endotherapy within a tertiary Oesophagogastric unit.

We performed a retrospective analysis of data collected over a 2-year period at a tertiary Oesophagogastric unit from November 2015 to November 2017.

We found 68 eligible patients with Achalasia, Gastroparesis, Oesophageal dysmotility, Pyloric dysfunction. The median number of treatment sessions were Achalasia 2 (1-3), Gastroparesis: 2 (1-9), Oesophageal dysmotility: 1 (1-5) and Pyloric dysfunction: 1.5 (1-3). The mean number of units of BTxA used per procedure (Unit) were Achalasia 200, Gastroparesis 170, Oesophageal dysmotility 190 and Pyloric dysfunction 270. A total of 126 vials containing 63000 units (£19530) were opened. 25520 units were used, and 37480 2. Vbn vcfunits were wasted (£11618) over 2 years. On average, 67% of each vial of Dysport was wasted.

The local annual wastage was £5810 per year, which roughly equates to a national wastage cost of £348,600 per year for these 4 OG conditions alone (assuming we serve population of around 1 million people and therefore multiplying by 60). An option for cost saving would be to consider using smaller volume vials to reduce wastage. We would recommend that guidelines are produced in order to standardise the optimal dose required and the vial sizes to stock for treatment of these conditions and avoid unnecessary expenditure.
EP.WE.334Value of including CT chest in the management of acute abdominal emergencies: Experience during first wave of COVID-19 pandemic at a District General Hospital
Authors: Patel Maitreyi , Jebamani Jennifer , Mohapatra Shrabani Das
Published: October 2021

Aims

The aim of this retrospective study was to assess the incidence of positive findings on CT chest in patients presenting with acute abdomen, who underwent CT thorax as part of the Intercollegiate General Surgical Guidance on COVID-19 during the first wave. To correlate CT chest findings with confirmed cases on RT-PCR; and to determine its influence on surgical management of abdominal emergencies.

Methods

A retrospective observational study of adult emergency surgical referrals (excluding trauma) for acute abdomen over a ten week period was performed. COVID changes on CT Chest were categorized as per the BSTI CT reporting criteria. Patient demographics, COVID RT-PCR, management and outcome were recorded. Statistical analysis was performed using Microsoft Excel with p value significant at ≤ 0.05.

Results

Of the 160 patients included, only 111(69.38%) had COVID RT-PCR. Of 24 (15%) patients with CT chest features of COVID, 45.83% demonstrated classic/probable CT features of COVID of which 36.36% had positive RT PCR. 54.17% had indeterminate pattern and none tested positive for COVID. There was a significant association between positive CT abdomen with normal CT chest findings (p = 0.03). Of 25 (15.63%) patients with normal CT abdomen, 7(28%) had CT features of COVID. Only 43(34.4%) patients needed surgical intervention of which 18.6% had COVID changes on CT, confirmed by positive RT PCR in 12.5%.

Conclusions

CT chest as an additional investigation modality in acute abdomen had clinically helped in triaging of patients to appropriate specialties but did not influence emergency surgical management.