1. health and fitness
2. disease
3. cancer

199
Annals of Clinical & Laboratory Science, vol. 39, no. 2, 2009
Abstracts of Presentations at the
Association of Clinical Scientists’ 129th Meeting
at Tampa, Florida, on 13 to 17 May 2009
[1] Claude P. Brown Memorial Lecture: Frontiers of ovarian
cancer. Santo V. Nicosia, University of South Florida College
of Medicine, Tampa, FL.
Ovarian cancer represents the fifth most frequent
malignancy in American women and the fourth leading cause
of death in 40 to 59 year old women, with an estimated overall
incidence of 21,650 cases and 15,520 deaths and a dismal
diagnosis: death ratio of 1.4 in 2008. Eighty-five to 90% of
ovarian malignancies are of so-called epithelial type although
the nature of the epithelial cell of origin in still controversial.
Approximately 90% of ovarian epithelial cancers (OEC)
occur sporadically while 10% are genetically linked. Patients
with OEC have a short median survival time after diagnosis
and, even when the tumor is clinically localized, their 5-year
relative survival rate is less than 40% regardless of therapy.
Early stage OEC accounts for 30% of all malignancies and
clearly represents an important target for screening as it is
lethal in 25-30% of cases. This lecture will provide an
overview of the current status and future vistas of basic and
translational research in a disease defined as “insidious” and
“silent killer” by both researchers and patient advocates. To
establish the foundation of the topic, the lecture will begin by
visiting key embryological, anatomical, and histological
features of the human ovary. To review the topic in perspective
and recognizing the educational value imparted by history,
the lecture will then touch upon some of the key events in the
discovery of the ovary and in the history of ovarian pathology.
The main presentation will focus on OEC biology since
meaningful progress in molecular biology must be based on a
solid comprehension of cell, tissue, and organ biology.
Translational aspects of OEC will be addressed by reviewing
issues of current ovarian cancer management and detection,
focusing on the most relevant characteristics of early, sporadic,
and familial OEC and on the current status of cancer
screening. The lecture will conclude by exploring the areas of
future investigation, including current efforts at unraveling
the natural history of OEC, which may shed light into the
mechanisms responsible for the transformation of a tiny but
important organ into a neoplastic mass not infrequently
exceeding 5 to 10 inches in diameter at initial presentation.
Upon completion of this presentation, participants
should be able to discuss the pathobiology of ovarian epithelial
cancer and describe current research on its detection and
management.
[2] Frontiers of research on Alzheimer’s disease. Huntington
Potter, University of South Florida College of Medicine,
Tampa, FL.
Alzheimer’s disease is the most common neurodegenerative disease of the elderly, affecting 10% of individuals
over age 65 and some 40% over age 85. Currently the available
treatments merely slow the inevitable decline by perhaps a
year or two. With the developing understanding of the
genetics of Alzheimer’s disease and the role that environmental
factors play in its development, it has become possible to
create animal models of Alzheimer’s disease in the form of
transgenic mice. These mice have been extensively studied in
order to elucidate the pathogenic pathway that leads to
Alzheimer’s disease and to develop more effective therapies.
Several of these new therapies are able to completely prevent
and in some case reverse Alzheimer’s pathology and cognitive
decline in the mouse models and, as will be discussed, are
now in or are being prepared for human clinical trials. It is
highly likely that the results will show that no single approach
will be best for all individuals and that a combination of
drugs and lifestyle changes may be most efficacious.
Upon completion of this presentation, participants
should be able to describe the pathological features of
Alzheimer’s disease, the cholinergic hypothesis of Alzheimer’s
disease, and the cleavage of amyloid precursor protein into
the A beta peptide.
[3] Signal transduction pathways: A goldmine of anticancer
drug targets. Said M. Sebti, University of South Florida
College of Medicine, Tampa, FL
It is believed that human cancer develops as a consequence
of accumulations of genetic alterations that lead to activation
of oncogenes and inactivation of tumor suppressor genes.
These genetic alterations results in aberrant signal transduction
pathways, which in turn, result in several hallmarks of cancer
including: uncontrolled cell division, resistance to programmed cell death (apoptosis), and angiogenesis and metastasis.
This lecture will describe innovative ways to discover and
develop novel anticancer drugs based on interfering with the
above mentioned aberrant signal transduction pathways.
Specifically, the design of farnesyl and geranylgeranyl
transferase inhibitors that target small GTPases such as Ras
and Rho will be described. The effects of these novel anticancer drugs on signal transduction pathways in cancer cells
will also be described. The speaker will discuss the discovery
of other novel anti-cancer drugs based on interfering with
pivotal signaling circuits in the cancer cell such as the PI3
kinase/Akt, the JAK/STAT3 and the BCLxL/Bax pathways.
Examples will be given where laboratory discoveries from the
bench were translated to hypothesis-driven clinical trials.
Upon completion of this presentation, participants
should be able to explain how aberrant signal transduction
pathways contribute to malignant transformation of normal
cells and how anti-cancer drugs can interfere with these
pathways.
200 Annals of Clinical & Laboratory Science, vol. 39, no. 2, 2009
[4] Teratogenic causes for malformations. Enid GilbertBarness, Tampa General Hospital, Tampa, FL.
Crucial morphogenetic processes ongoing during the
blastogenesis period, which extends through the first 4 weeks
of development, from fertilization until the end of the
gastrulation stage (days 27 to 28 postconception), can be
altered and result in several structural abnormalities, including
patterns of multiple congenital anomaly (MCAs) resulting
from developmental field defects. Severe damage may cause
the death of the product of conception or, because of the
pluripotential nature of the cells, the damage may be
compensated allowing development to continue in a normal
fashion. Most investigators believe that the all-or-none rule
applies to the first 2 weeks of development. Because the fetus
is less susceptible to morphologic alterations, because the
development process of the majority of organs has been
completed, the most common anomalies associated with
teratogenic exposures during the fetal period are fetal growth
restriction (intrauterine growth retardation) and mild errors
of morphogenesis (abnormalities of phenogenesis), such as
epicanthic folds, clinodactyly, and others. Thus, teratogenic
exposures may result in a wide variety of effects that range
from infertility, prenatal onset growth restriction, structural
defects, or functional CNS abnormalities to miscarriage or
fetal death.
Upon completion of this presentation, participants
should be able to delineate the FDA criteria for fetal risk,
point out times during development when a specific substance
may be teratogenic, and identify the developmental anomalies
caused by certain drugs and chemicals.
[5] Geriatric oncology: Integrating biologic variability into
clinical research. Martine Extermann, Moffitt Cancer
Center, University of South Florida, Tampa, FL.
Personalized Cancer Care are buzzwords in oncology.
Large efforts are poured into improving the targeting of
cancer treatments by analyzing the molecular biology of the
heterogeneous cancers that most solid tumors are. As most
cancers occur beyond the age of 65, geriatric oncology is here
to address the other component of Personalized Cancer Care:
patient variability. Traditionally, clinical trials have sought to
minimize patient variability in order to detect more sensitively
treatment effects. This has resulted in underrepresentation of
older patients in clinical trials. Furthermore, 60% of American
retirees have at least one geriatric syndrome, and 90% have at
least one comorbidity. Therefore variability is inescapable for
an increasing proportion of patients in cancer trials. ECOG
performance status is an insensitive adjustment factor in the
elderly. Comorbidity is rarely recorded, yet its prognostic
impact is as high as performance status. Furthermore,
comorbidities can influence the behavior of the cancer itself,
such as diabetes increasing the risk of relapse from colon
cancer. The effect size is large enough to confound the impact
of chemotherapy. As comorbidity is a complex concept, it
would be desirable to identify biological markers to assess a
patient’s functional reserve and level of fitness. Markers such
as IL-6, D-dimers, albumin, and hemoglobin, are altered by
aging and frailty. Comorbidities can alter levels of molecules
such as VEGF and IGF-1. In an age of increasing use of
targeted therapies, there is need for integrating better analyses
of the patient side of the equation, if we want clinical trials to
have optimal relevance for the majority of cancer patients.
Upon completion of this presentation, participants
should be able to recognize potential confounders that are not
addressed by traditional oncology trial designs and list key
biological markers that are relevant to aging and cancer.
[6] Implementation of advanced molecular diagnostics at
the James A. Haley Veterans Hospital. Stephen Mastorides,
James A. Haley Veterans Affairs Medical Center, Tampa, FL
The Pathology and Laboratory Medicine Service at the
James A. Haley VAMC is the busiest and most complex
laboratory in the VA Healthcare system, performing over
twenty five thousand tests daily. The Molecular Diagnostics
Section is part of a medical network of inpatient and outpatient
facilities, providing molecular testing services for numerous
VA medical centers in Florida. The laboratory performs over
two thousand nucleic acid extractions per month and offers
molecular infectious disease testing as well as pharmacogenomic testing. Our infectious disease menu includes PCRbased qualitative testing for hepatitis B, Chlamydia trachomatis
and Neisseria gonorrhea, quantitative testing for hepatitis C
and HIV, as well as hepatitis C and HIV genotyping. We
routinely offeri to our clinicians cytochrome P450 2C9 and
VKORC1 genotyping as recommended by the FDA for
warfarin (coumadin) patients. The coumadin clinic serves
1874 patients with a total of 15382 visits annually. Individuals
carrying variants in the CYP2C9 and VKORC1 genes are
susceptible to reduced warfarin clearance leading to serious
adverse effects, including life-threatening hemorrhage. This
testing helps clinicians to optimize warfarin therapy while
reducing serious side-effects.
Upon completion of this presentation, participants
should be able to explain pharmacogenomics testing
modalities and their impact on patient care and cite examples
of pharmacogenomics testing.
[7] Atypical teratoid/rhabdoid tumor: Morphoproteomics
defines its biology and exposes therapeutic targets. Robert
E. Brown, Janet M. Bruner, and Johannes Wolff, UTHSC–
Medical School at Houston and University of Texas-MD
Anderson Cancer Center, Houston, TX.
The atypical teratoid/rhabdoid tumor (AT/RT) is a highly
aggressive central nervous system tumor that occurs in infants
and young children. It is generally fatal with a mean
postoperative survival of only 11 mo. AT/RT is associated
with inactivation (deletion or mutation) of the hSNF5/INI1/
SMARCB1/BAF47, tumor suppressor gene resulting in upregulation of the cyclin D1 gene . The purpose of this study
was to do morphoproteomic analysis on a case of AT/RT to
define its biology and expose therapeutic targets. Immunohistochemical probes were applied to detect protein analytes
related to the following: signal transduction pathways and
their state of activation; cell cycle promoters and inhibitors;
antiapoptotic/tumorigenic/angiogenic/chemoradioresistant
factors; and tumoral stem cell markers. Results: correlative
absence of INI1 protein with upregulation of cyclin D1;brisk
G1 to S phase cell cycle progression associated with high Skp2
Abstracts, 2009 Annual Meeting of the Association of Clinical Scientists 201
expression in the nuclei, reduced cell cycle inhibitor expression
(i.e., low p27Kip1 and p16INK4a nuclear proteins) and with
a high mitotic index (20 mitotic figures/10 h.p.f ’s); constitutive
activation of the Akt/mTOR/extracellular signal-regulated
kinase (ERK)/beta-catenin and NF-kappaB pathways, all of
which contribute to cyclin D1 expression; correlative
expression of protein analytes associated with the transcriptional activation of their corresponding genes by p-NFkappaBp65 (i.e., VEGF-A, Bcl-2, GST-pi, and P-glycoprotein),
the latter of which contribute to chemoradioresistance; and
tumoral stem cell/endothelial precursor markers (ie, CD133,
nestin, CD34 and CD44). These data show genomic and
morphoproteomic correlates associated with upregulation of
cyclin D1 and cell cycle progression in ATRT but also
opportunities for therapeutic interventions targeting the cell
cycle, the differentiation of the tumoral stem cells and the use
of antiangiogenic agents to enhance tumoral necrosis.
Upon completion of this presentation, participants
should be able to discuss genomic and proteomic aspects of
atypical teratoid/rhabdoid tumors and understand the
application of morphoproteomics in exposing therapeutic
targets in an individual patient’s tumor.
[8] Overexpression of cancer stem cell markers in
fibrolamellar hepatocellular carcinoma. Maryam J. Zenali,
Dongfeng Tan, Robert E. Brown, and Wei Li., The University
of Texas-Health Science Center at Houston, and The
University of Texas-MD Anderson Cancer Center, Houston,
TX.
Fibrolamellar hepatocellular carcinoma (FL-HCC)
remains a highly aggressive neoplasm due to high resistance
to chemotherapy and radiation therapy. Cancer stem cells
(CSCs) have been recognized responsible for the formation
and growth of cancer tissue and are naturally resistant to
chemotherapy and radiation therapy. Although involvement
of CSCs in tumorigenesis and progression has been studied in
many malignant tumors, the existence and role of CSCs in
FL-HCC has not been explored. Formalin-fixed paraffinembedded tissue sections of 8 FL-HCC and 6 normal liver
were selected. Mouse anti-human antibodies directed against
CSCs markers (CD133 and CD44) were used. Expression
levels of CD133 and CD44 were evaluated by immunohistochemistry using standard avidin-biotin techniques.
Slides were scored using a semi-quantitative scoring scale
based on intensity (weak +1, mild 2+, moderate 3+, strong 4+)
and % immunoreactive cells (low = <25%, moderate 25 75%,
and high >75%).The number of CD133 and CD44 positive
cells and the intensity of immunostaining were significantly
increased in FL-HCC compared with normal liver tissues (p
< 0.001). Majority of FL-HCC tissue showed moderate (3+)
to strong (4+) staining. In contrast, majority of normal liver
parenchyma exhibited weak (1+) to mild (2+) staining. The
immunostaining pattern was characterized by membranous
as well as cytoplasmic stains.CD133 and CD44 are found and
highly expressed in FL-HCC. These findings suggest that
CSCs may play a potential role in FL-HCC formation. Our
data could provide new insight into the FL-HCC tumorigenesis and bear better therapeutic implications. Additional
studies are needed to characterize the role of CSCs in FL-HCC
initiation and progression.
Upon completion of this presentation, participants
should be able to define the activation and possible role of
stem cell marker upregulation in fibrolamellar hepatocellular
caricnoma.
[9] Morphoproteomics defines the NF-kappaB pathway in
fibrolamellar hepatocellular carcinoma. Wei Li, Maryam J
Zenali, Dongfeng Tan and Robert E Brown. The University
of Texas Health Science Center-Medical School at Houston
and The University of Texas-M.D. Anderson Cancer Center,
Houston, TX.
Fibrolamellar hepatocellular carcinoma (FL-HCC) is an
aggressive neoplasm with high recurrence after surgical
resection and with chemoradioresistance. The activation of
the NF-KB pathway has been recognized for involvement in
cellular proliferation and anti-apoptosis, and its constitutive
activation is related to progression of various malignant
neoplasms. Studies have demonstrated that NF-KB activation
is an important mechanism for chemotherapy resistance, and
that inhibition of NF-KB significantly enhances tumor cell
response to chemotherapeutic agents. The purpose of this
study was to determine whether the NF-KB pathway is
constitutively activated and overexpressed in FL-HCC.
Archival, paraffin-embedded tissue sections of 8 FL-HCC
and 6 normal livers were selected. Phosphospecific antibody
directed against NF-KBp65 (Ser 536) was used in an
immunohistochemical assay. Expression levels of p-NFKBp65 (Ser 536) were scored by bright-field microscopy in
tumor cells and non-neoplastic hepatocytes. These were
categorized into 4 grades: 0 (background), 1+ (weak), 2+
(moderate), or 3+ (strong), based on intensity of intranuclear
staining. The expression of p-NF-KBp65 was further assessed
using 2 scales: high expression (2+ or 3+) and low expression
(0 or 1+).High expression of NF- KBp65 was found in 88 %
(7/8) of FL-HCC tissue. In contrast, only 17 % (1/6) of
normal liver parenchyma showed high expression for NFKBp65 (p < 0.01). Increased expression of p-NF-KBp65 (Ser
536) in FL-HCC tissue suggests that constitutive activation
and overexpression of this pathway may play a role in the
biology of FL-HCC. This finding may have significant
implications in the development and application of targeted
therapy.
Upon completion of this presentation, the participants
should be able to explain the morphoproteomic assessment of
the constitutive activation and overexpression of the NF-KB
pathway in fibrolamellar hepatocellular carcinoma.
[10] What we forgot to teach in medical school and why it
matters. Stephen K. Klasko, University of South Florida
College of Medicine, Tampa, FL.
The future of academic health care is up for grabs. The
very selection and educational biases that serve physicians
and scientists well in their clinical and research role may be
hindering our efforts to be leading change in quality, service
and technology. Strategies to overcome these gaps in our
faculty, resident, and student knowledge base and steps
toward an optimistic future in health care will be outlined
202 Annals of Clinical & Laboratory Science, vol. 39, no. 2, 2009
and discussed, with the following objectives: (a) to understand
the educational and selection mechanisms that have created
biases which limit physicians and physician leaders from
being successful in a changing healthcare environment; (b) to
realize the power of creative thought in assisting health care
leaders as they confront an ever changing environment; (c ) to
understand how quality improvement/error reduction can be
leveraged in negotiations and how changes in other service
sectors will affect health care; (d) to recognize the revolution
occurring in ambulatory health care delivery and how each
physician will either be a leader or follower in that reform;
and (e) to understand the current barriers to significant
quality improvement impeding our movement to an optimistic
health care future
Upon completion of this presentation, participants
should be motivated to initiate changes in the quality, service,
and technology of academic health care.
[11] Dysfunctional regulation of extracellular matrix
assembly: Transgenic mice as a model of classic EhlersDanlos syndrome. David E. Birk, University of South Florida
College of Medicine, Tampa, FL.
The purpose of this work was to elucidate the
mechanism(s) whereby alterations in type V collagen result in
dysfunctional connective tissue biogenesis associated with the
classic form of Ehlers-Danlos syndrome (EDS). EDS is
associated with mutations in type V collagen genes. Type V
collagen is a fibril-forming collagen that co-assembles with
type I collagen regulating connective tissue structure and
function. A mouse model with a targeted mutation in Col5a1
was analyzed. Null animals fail to assemble collagen fibrils
and die during organogenesis. Heterozygous animals display
features characteristic of the classic EDS phenotype. These
mice are haploinsufficient with a 50% reduction in Col5a1
mRNA and type V collagen levels. The aortas from Col5a1+/mice have decreased stiffness and tensile strength. The skin
was hyperextensible, demonstrating decreased tensile strength
in wounded and unwounded skin. Col5a1+/- mice demonstrate
defective collagen fibril formation. Dermal structure is
disorganized and fibril number is reduced. Heterozygous
animals assemble two subpopulations of fibrils. One is
relatively normal with cylindrical profiles and a second
consists of structurally aberrant fibrils with irregular shapes.
As the dermis matures the subpopulations intermix. The data
indicate that a reduction in type V collagen reduces the
initiation of fibril assembly. Therefore, in dermis where type
V collagen content is limiting, fewer fibrils are assembled into
two subpopulations: one containing relatively normal fibrils
with type I/V interactions; and a second with an unregulated
sequestration of type I collagen. The presence of the aberrant
fibril subpopulation disrupts fibril maturation. Therefore,
abnormal fibril nucleation, dysfunctional fibril growth, and
potential disruption of cell directed fibril organization lead to
the disruption of function associated with the EDS
phenotype.
Upon completion of this presentation, participants
should be able to define the structural alterations associated
with type V collagen mutations and the functional
consequences; characterize the relationship between structural
abnormalities and clinical phenotype in classic EDS; identify
tissue-specific differences in structural/function dysfunction
as a result of the disease phenotype; and define the regulatory
mechanism of type I/V collagen interaction in extracellular
matrix assembly and function.
[12] A good ending makes a good beginning: The telomere
theory of reproductive aging. David L. Keefe, University of
South Florida College of Medicine, Tampa, FL.
Infertility, miscarriage, and aneuploid offspring increase
with age in women, and meiotic dysfunction underlies
reproductive aging. How aging disrupts meiotic function in
women remains unclear, but as women increasingly delay
attempts at childbearing, solving this problem becomes an
urgent priority. Telomeres, which mediate aging in mitotic
cells, also may mediate aging during meiosis. Telomeres
shorten both during DNA replication and from the response
to oxidative DNA damage. Oocytes do not divide in adult
mammals, but their precursors did replicate during fetal
oogenesis, and eggs ovulated from older females traversed
more mitotic cell cycles before entering meiosis during fetal
oogenesis than eggs ovulated from younger females. Telomeres
also would be expected to shorten from the DNA repair
response to oxidative damage, because the interval between
fetal oogenesis and ovulation is exceptionally prolonged in
women. We have tested the hypothesis that telomere
shortening disrupts meiosis by experimentally shortening
telomeres in mice, which normally do not exhibit age-related
meiotic dysfunction. Interestingly, mouse telomeres are much
longer than human telomeres, but genetic or pharmacologic
shortening of mouse telomeres recapitulates in mice the
human reproductive aging phenotype as the mouse telomeres
reach the length of telomeres from older women. These
observations led us to propose a telomere theory of reproductive
aging. Finally, if telomeres shorten with aging, how do they
reset across generations? Telomerase could not play a
significant role in telomere elongation during early
development, because this enzyme is not active until the
blastocyst stage, well after the stage when telomere elongation
takes place. Rather, telomeres lengthen during the early cell
cycles of development by a novel mechanism involving
recombination and sister chromatid exchange.
Upon completion of this presentation, participants
should be able to discuss the effects of meiotic non-disjunction
on female reproductive aging, explain the role of telomeres in
meiosis, and summarize the data that support the telomere
theory of reproductive aging.
[13] Congenital hepatorenal fibrocystic syndromes:
Advances in molecular pathology and genetics. Consolato
Sergi, University of Alberta Hospital, Edmonton, Canada.
The hepatorenal fibrocystic (HRFC) syndromes are a
heterogeneous group of severe monogenic conditions that
may be detected before birth. Commonly, HRFC syndromes
present in the neonatal and pediatric age, with consistent
developmental abnormalities mostly involving the liver and
kidney. HRFC disease is characterised by changes in the
parenchymal tissues of the liver, kidney, and sometimes
pancreas or other organs. They include the proliferation and
Abstracts, 2009 Annual Meeting of the Association of Clinical Scientists 203
dilatation of epithelial ducts, and proliferative changes in the
extracellular matrix of stromal connective tissue. One of the
manifestations that has received intensive study is related to
the ductal plate malformation of the liver and comprises
proliferation and dilation of peripherally-located intrahepatic
biliary structures, with a variable degree of fibrosis and cyst
formation. The clinical features and differential diagnoses of
this group of syndromes, including autosomal recessive
polycystic kidney disease (ARPKD), juvenile nephronophthisis (NPHP), Meckel-Gruber syndrome (MKS),
Bardet-Biedl syndrome (BBS), and Jeune asphyxiating
thoracic dystrophy (JATD) are reviewed. Extrahepatic
manifestations include mostly bone and central nervous
system abnormalities, dysmorphic features, and developmental
delay. The longest open reading frame of PKHD1 (polycystic
kidney and hepatic disease 1), the autosomal recessive
polycystic kidney disease (ARPKD) gene, encodes a singlepass, integral membrane protein named polyductin or
fibrocystin. A fusion protein comprising its intracellular Cterminus, FP2, was previously used to raise a polyclonal
antiserum shown to detect polyductin in several human
tissues, including liver. The expression of polyductin in several
HRFC syndromes and liver diseases is reported.
Upon completion of this presentation, participants
should be able to describe the molecular pathology and
genetics of the common hepato-renal fibrocystic diseases and
discuss the expression of polyductin in these diseases.
[14] Promises and challenges in cancer immunotherapy.
Dimitry I. Gabrilovich, H. L. Moffitt Cancer Center and
University of South Florida College of Medicine, Tampa,
FL.
Cancer immunotherapy is a treatment strategy utilizing
a unique set of antigens able to discriminate between normal
and neoplastic cells. There are numerous examples of
successful generation of immune responses against tumorassociated antigens. However, clinical results so far have been
discouraging. One of the main limitations of cancer
immunotherapy is the existence of numerous mechanisms
that allow tumor cells to escape immune system control.
Novel strategies to counter the effect of these mechanisms
have been developed and some of them have demonstrated
promise in clinical trials.
Upon completion of this presentation, participants
should be able to summarize the successes and failures of
current immunotherapy regimens and evaluate the different
mechanisms of tumor induced immune suppression.
[15] Overview on the evolution of the innate and adaptive
immune systems culminating in adoptive immune
lymphocyte therapy. Joseph G. Sinkovics, St. Joseph
Hospital’s Cancer Institute, H. L. Moffitt Cancer Center, and
University of South Florida College of Medicine, Tampa, FL
Virally-mediated fusion of ancient archaebacterial and
prokaryotic protoplasts might have created the first eukaryotes.
Extant fusogenic phages may re-induce these primordial
events. The relationship of the first eukaryotes with viruses
evolved under mutual genetic pressures resulting in siRNA
defense reactions, or early apoptotic deaths, of the cell,
occurring before the maturation of the viral progeny. In
response, viral genes encoding anti-apoptotic proteins
evolved. After the first multicellular organisms acquired the
machinery of interferon generation, viruses developed gene
product proteins to neutralize interferons. The first
multicellular hosts recognized pathogens by Toll-like receptors
and chemokines and by the variable lymphocyte receptors
consisting of leucine-rich repeats. They defended themselves
throughout millennia by mobilization of phagocytes and by
secretion of bactericidal substances (defensins). Superimposed
on the faculties of the innate immune system (phagocytes,
dendritic cells, NK cells), the adaptive immune system
emerged with specific immunoglobulin-producing B, and
cytokine-producing cytolytic immune T lymphocytes.
Horizontal acquisition of retrotransposons might have
encoded the entire adaptive immune system. Placentation
compromised the adaptive immune system, forcing it to
accept the semiallogeneic fetus. In mammalian hosts the
placenta mobilizes Th2-type immune reactions in the mother;
so do a number of pathogens and malignantly transformed
cells in their hosts. Pathogens under genetic pressure learned
how to survive in the infected host. Malignant cells often
immunosuppress their hosts and are able to induce subverted
host reactions (chemokines, cytokines) for the promotion of
their own growth. Yet monoclonal antibody and adoptive
immune lymphocyte therapy could eliminate pathogens and
malignant cell populations and secure complete remissions,
maybe cures, of the afflicted hosts.
Upon completion of this presentation, participants
should be able to review the evolution of the immune systems
and explain adoptive immune lymphocyte therapy.
[16] Myeloproliferative neoplasms: Role of JAK2 mutations.
John Lazarchick, Medical University of South Carolina,
Charleston, SC 29425
Myeloproliferative neoplasms are clonal disorders of
hematopoietic progenitor cells and include chronic myelogenous leukemia (CML), polycythemia vera (P Vera), essential
thrombocythemia (ET), and primary myelofibrosis (PMF),
in addition to chronic eosinphilic leukemia and systemic
mastocytosis. Each of these is characterized by distinct but
not exclusive clinicopathologic features. Mutant alleles
resulting in constitutive activation of tyrosine kinase activity
are the hallmark of CML but had not been noted in P Vera,
ET, or PMF until the recent identification of mutations that
activate JAK2 signaling in patients with these neoplasms.
JAK2 is a member of the Janus kinase family of intracellular
non-receptor tyrosine kinases that transduce cytokinemediated signaling via the JAK-STAT pathway. The
pathophysiologic role of JAK2V617 mutation in these
disorders and possible treatment with JAK2 inhibitors will be
discussed.
Upon completion of this presentation, participants
should be able to tabulate the clinical-pathologic spectrum of
myeloproliferative neoplasms by the WHO classification,
discuss the role of mutation of JAK2 kinase (JAKV617F) in
development of polycythemia vera, essential thrombocythemia, and primary myelofibrosis, and speculate about the
potential role of JAK2 inhibitors in their therapy.
204 Annals of Clinical & Laboratory Science, vol. 39, no. 2, 2009
{17] Morphoproteomics of multiple signaling pathways in
anaplastic thyroid carcinoma. Jing Liu and Robert E.
Brown, University of Texas Health Science Center at Houston
Medical School, Houston, TX.
Anaplastic thyroid carcinoma (ATC) is a highly
aggressive tumor resistant to radiation and chemotherapy.
Individualized targeted therapies may be an effective strategy
against ATC. However, signaling pathways involved in its
tumorigenesis are not quite understood. Studies reported in
the literature are limited to scattered genes and their products.
We studied multiple signaling pathways in 2 patients with
ATC using archival paraffin-embedded tissue. For comparison, 30 normal thyroid tissue sections from 30 patients were
studied. Immunohistochemical stains were performed for
detection of following antigens: p-p38 MAPK, p-ERK1/2
(Thr202/Tyr 204), p-Akt (Ser 473), p-mTOR (Ser 2448), pp70S6K (Thr 389), p-NF-κBp65 (Ser536), PLD1, IL-8, GSTpi, p27, Skp2, Ki-67, and cyclin D1. Both staining intensity
(0 to 3+) and extensiveness (0 to 100%) were evaluated.
Positivities for p27, Skp2, Ki-67 and cyclin D1 were calculated
by an automatic imaging system, as measured by percentages
of tumor cell nuclear immunostaining. Mitotic index (MI)
was calculated as the number of mitoses per 10 high power
fields (10HPF). Moderate or strong (2+ or 3+) and extensive
(≥50%) expressions of p-NF-κBp65, p-mTOR, PLD1, pERK1/2, p-Akt, p-p38 MAPK, p-p70S6K, IL-8 and GST-pi
were present in both ATCs. Nuclear translocation of p-NFκBp65, p-mTOR and p-ERK1/2 was noted. There were
increases in Ki-67 (32%), Skp2 (51%), cyclin D1 (36%) and
MI (8/10HPF) and a decrease in p27 (0%) in ATCs in
comparison with normal controls. The results indicate
constitutive activation of multiple signaling pathways
including MAP kinase, mTOR, and PLD (phospholipase
D1)/ p70S6K pathways in ATCs, which converge on the NFκB pathway. The activations of such pathways promote
progression from G1 to S and mitotic phases as evidenced by
increased Ki-67, Skp2, cyclin D1 and mitotic indices in
ATC’s. This is a pilot study and the results warrant future
studies on a large series of cases in order to provide molecular
basis of signal transduction pathways for clinical therapy.
Upon completion of this presentation, participants
should be able to list some of the signaling transduction
pathways that may be upregulated in anaplastic thyroid
carcinoma.
[18] Modulation of survival and death pathways by
sanguinarine in neuroblastoma cells. Priya Weerasinghe,
Tushar Acharya, and Robert E. Brown. University of Texas
Medical School at Houston, Houston, TX.
Neuroblastoma is predominantly a disease in children.
It is the most common cancer among patients less than one
year of age, accounting for 15% of all pediatric cancer
fatalities. Natural products have greatly influenced the
development of antitumor agents. Sanguinarine, a naturally
occurring benzophananthridine alkaloid extracted from
plants of the papaveraceae family, has been well studied in the
laboratory despite having no documented use as a conventional
chemotherapeutic agent in the clinic. We set out to investigate
the effects of sanguinarine on neuroblastoma cells. Cells
treated with 0.375 µg/ml of sanguinarine for 24 hr revealed
classic morphological apoptosis when examined using light
and electron microscopy. Western blotting of sanguinarinetreated cells showed a dose-dependent decrease in p-AKT
(Ser 473) and p-p70S6K (Thr 389), while showing proteolytic
activation of caspase-3. This study provides the first evidence
of sanguinarine’s being effective against neuroblastoma cells
via inhibition of pathways involved in survival (ie, AKT and
p70 S6K). Molecular characterization of sanguinarine-treated
cells could reveal important molecular targets for effective
adjuvant therapeutics for neuroblastoma patients.
Upon completion of this presentation, participants
should be able to explain how specific signaling molecules
might be used as drug targets to design effective therapies to
combat neuroblastoma.
[19] New trends in liquid chromatography–tandem mass
spectrometry. Joseph P. Laurino, The University of Tampa,
Tampa, FL.
Liquid chromatography–tandem mass spectrometry
(LC/MSMS) is an emerging technology in the clinical
laboratory. LC/MSMS has been used to measure a broad
range of compounds, such as androgens (testosterone and
dihydroxytestosterone), proteins (thyroglobulin), 25-hydroxy
vitamin D, low molecular weight organic acids (methylmalonic
acid), and both therapeutic and illegal drugs. Recent advances
in instrument automation and reliability have facilitated the
entry of this analytical technique into the clinical laboratory.
This presentation will summarize the major classes of mass
analyzers and the frequently used modes of ionization, with
special emphasis given to the benefits and limitations
associated with each process. An overview of the common
analytes measured by LC/MSMS in the clinical laboratory
will be presented, and the implementation of LC/MSMS
methods in the clinical laboratory will be outlined.
Upon completion of this presentation, participants
should be able to describe the various mass analyzers, the
various ionization techniques, and the advantages and
limitations of each method for use in clinical laboratories.
[20] A chemistry analyzer is much the same as any other
chemistry analyzer, or is it? Clive R. Hamlin, Case Western
Reserve School of Medicine, Cleveland, OH.
Leonard Skeggs and his colleagues, through ingenuity
and serendipity, created the first automated clinical chemistry
analyzer. This continuous-flow technique was commercialized
by a single company, but is no longer in common use. Another
unique slide-based technique was conceived and
commercialized by another single company, and is still
commonly used. Tests performed in a spectrophotometer’s
cuvette predate both the former techniques, and many
companies in several countries attempted to automate this
procedure. Improvements in design have improved the
cuvette-based technique such that it now dominates clinical
chemistry worldwide. A few companies in Japan manufacture
most of the instruments, all using components from single
manufacturers. Despite this, these companies have unique
histories and the companies’ expertise is incorporated into
Abstracts, 2009 Annual Meeting of the Association of Clinical Scientists
each company’s product. These differences can become
important when choosing one analyzer versus another.
Upon completion of this presentation, participants
should be able to choose an appropriate chemistry analyzer
for their clinical laboratory.
[21] Determination of urinary myo-inositol on an automated
chemistry analyzer. Zak K. Shihabi, Krista J. Garrison, and
Barry I. Freedman, Wake Forest University School of
Medicine, Winston-Salem, NC.
The objective of this work is to adapt an enzymatic method
for myo-inositol (MI) determination on the Beckman DX
800 chemistry analyzer. MI is synthesized from glucose
through isomerization and it is also derived from the diet. It
is mainly incorporated into cell membranes. MI is decreased
in the nerves of patients with diabetic neuropathy and it is
also decreased in the cerebrospinal fluid of patients with
affective disorders. MI has been sugggessted as a screening
method for impaired glucose tolerance. Existing methods for
analyzing MI are based on chromatographic methods that are
difficult to use routinely. Herein, we describe the adaptation
of an enzymatic method for urinary MI (Lucica MI, Asahi
Kasei Pharma Corporation, Chiyoda-ku, Tokyo, Japan) on
the Beckman DXC 800. This method is based on conversion
of MI to myo-inosose by the enzyme MI dehydrogenase, with
formation of thio-NADH from thio-NAD. After urine
samples were mixed with the reagents on the instrument, two
readings were recorded at 4 and 10 min at 410 / 670 nm. The
test was linear between 0 and 775 µmol/L of MI (r = 0.995).
The mean ± SD of 10 samples of urine from normal patients
was 22 ± 15 µmol/g creatinine (n = 12), compared to 507 ±
730 (n=10) from patients with nephropathy, and 751 ± 796
(n= 12) µmol/g creatinine in diabetic non-nephropathy
patients. MI increased 1.4 fold after 2 hr of ingestion of 75 g
of glucose in normal individuals (n = 7) vs 13.9 fold in diabetic
subjects (n = 7). Common interfering substances, such as
glucose (20 g/L), ascorbate (10 g/L), uric acid (1 g/L), and
sorbitol (1 g/L) did not interfere with this test. The
cerebrospinal fluid (CSF) MI can be assayed directly by this
method. The mean ± standard deviation for CSF samples was
111 ± 26 µmol/L (n = 20). In conclusion, the new enzymatic
method for determination of urine MI on the Beckman
instrument is fully automated, specific, and easy to perform,
compared to chromatographic methods
Upon completion of this presentation, participants
should be able to discuss the enzymatic analysis of myoinositol and its clinical applications in diabetic patients.
[22] Using an automated camera system to rapidly inspect
for mislabeled specimens. Charles D. Hawker, ARUP
Laboratories and University of Utah, Salt Lake City, UT.
Clinical laboratory automation vendors are now
incorporating systems to inspect specimens for correct
specimen type, serum volumes above packed red cells, and
interferences such as fibrin, hemolysis, icterus, and lipemia.
These systems are generally known in industry as machine
vision systems. Depending on design, some are capable of
inspecting specimens through the sides of tubes covered with
labels. They usually require extensive computer software for
205
analysis and data interpretation. As cost reduction pressures
on laboratories increase and the supply of medical technologists
continues to diminish, automated inspection will become
increasingly important. One very critical area for laboratory
inspection is mislabeled specimens. Most laboratories are
aware that they have mislabeled specimens, and require
employees to carefully inspect all specimens. A recent CAP
Q-Probe study (Arch Path Lab Med, 2008;130:1662-1668)
found an average incidence in 147 reporting laboratories of 1
mislabeled specimen per 1000 specimens processed. We have
developed an automated system for camera inspection of the
patient’s name on the client’s label to determine if a specimen
has been mislabeled. The system employs one camera to
determine tube dimensions and four equidistant cameras to
create a two-dimensional image of the entire tube
circumference. It uses optical character verification (OCV)
software to find a character string within the total image, but
outside the zone of our laboratory label, that matches our bar
coded computer record of patient name. Only 3 sec are needed
for image acquisition and assembly and for OCV analysis.
After a year of validation (proof-of-principle), pass-fail
messages from the inspection computer will direct routing on
our automated track system of all “fail” tubes to human
inspection stations.
Upon completion of this presentation, participants
should be able to design strategies to reduce the incidence of
mislabeled samples in their clinical laboratories.
[23] Minor metabolic products of opiate metabolism:
potential for misinterpretation of urine drug testing results.
Roger L. Bertholf and Gary M. Reisfield. University of
Florida Health Science Center, Jacksonville, FL.
Urine drug testing is a prominent feature in the current
practice of chronic pain management. In patients prescribed
opioids, evidence indicates that the potential for drug abuse is
high. Additionally, the street value of prescription opioids
raises concerns about their diversion. Therefore, physicians
treating patients with chronic opioid therapy often test their
patients’ urine to verify adherence with the prescribed
regimen, as well as to detect the use of illicit or unauthorized
licit drugs. Unexpected results on the urine drug screen may
lead to termination of opioid privileges or dismissal from the
medical practice. Concerns have been raised regarding the
ability of physicians to correctly interpret the results of urine
drug screens; in this context, knowledge of the anticipated
metabolic products of commonly prescribed opioids is
essential for correct interpretation. The metabolic conversions
of codeine to morphine, and of heroin to 6-acetylmorphine
and morphine, have been widely reported. Metabolism of
hydrocodone to hydromorphone also has been described.
However, there have been recent reports of the detection of
hydromorphone in the urine of patients purported to be only
taking morphine, and hydrocodone in the urine of patients
only taking codeine. These purported metabolic conversions,
if validated, would be important because hydromorphone and
hydrocodone are themselves prescription opioids, and
historically, their presence in urine has been taken as evidence
of use of those drugs, rather than as expected metabolites of
morphine and codeine, respectively. We present a case in
206 Annals of Clinical & Laboratory Science, vol. 39, no. 2, 2009
which hydromorphone was detected in the urine of a woman
on high dose morphine therapy, who had been sequestered in
an inpatient hospice unit for the 12 weeks prior to her death,
effectively eliminating the possibility of exposure to nonprescribed opioids.
Upon completion of this presentation, participants
should be able to describe the common pathways of opiate
metabolism, list two minor metabolites of morphine and
codeine, and explain how opiate metabolism influences the
interpretation of urine drug testing results.
[24] Estimated average glucose: Why? Frederick L. Kiechle,
Memorial Regional Hospital, Hollywood, FL
The Diabetes Control and Complications Trial (DCCT)
and United Kingdom Prospective Diabetes Study clearly
demonstrate the relationship between the risk for diabetes
complications and Hb A1C . These two studies set the stage
for establishment of specific diabetes treatment goals using
Hb A1C as an index of mean glycemia. Recently, a linear
relationship between the estimated average glucose and Hb
A1C has been established: eAG (mg/dL) = 28.7 x Hb A1C –
46.7 (Nathan DM, et al. Diabetes Care 2008;31:1-6.) To
evaluate the clinical value of this calculation, the literature
and physicians were queried. Approximately 50% of physicians
interviewed used Hb A1C for screening and diagnosis of
diabetes mellitus. Most Hb A1C assays have a CV <2%. The
estimated average glucose derived from Hb A1C in the DCCT
was greater than the 2008 linear regression or A1C -derived
average glucose (ADAG) formula (3.1%, 97 mg/dl to 15.2%,
269 mg/dl). This difference is attributable to improvements
in Hb A1C methods from 1993 to 2008. The ADAG formula
was derived from glucose meter and interstitial fluid glucose
measurements. The latter were scaled up 5% since interstitial
fluid glucose is 5% lower than simultaneously collected
capillary glucose values. The primary incentive for providing
the eAG with the H A1C on one report is to aid in patient
education regarding the direct relationship between serum
glucose and glycated hemoglobin. In conclusion, estimated
average glucose (ADAG) calculated from HbA1C levels
provides a value a diabetic patient can relate to his/her daily
glucose monitoring practice.
Upon completion of this presentation, participants
should be able to estimate the average daily blood glucose
levels of their patients, based on measurements of Hb A1C .
[25] Improving detection in capillary electrophoresis:
Example of serum mycophenolic acid. Zak K. Shihabi, Wake
Forest University and Baptist Medical Center, WinstonSalem, NC.
The objective of this study is to improve the detection
limits in capillary electrophoresis (CE) using the analysis of
mycophenolic acid as an example. One of the main practical
shortcomings of CE in routine clinical analysis is the poor
light absorbency detection limits, which are about 30-60
times less sensitive when compared to HPLC. Several
strategies have been described to remedy this problem but
none alone is sufficient to bring along the detection limits of
the CE to those of HPLC. In order to overcome this problem,
three simple and general strategies were combined to increase
the amount of the sample injected and to increase the light
path: (a) a long capillary to hold extra sample, (b) stacking
(acetonitrile), which concentrates the sample based on
transient pseudo-isotachophoresis and (c ) using at the same
time a wide capillary for better signal to noise ratio. The
combination of these strategies yielded sensitivity comparable
or better than that of HPLC with good peak resolution and
better theoretical plate number. The analysis of mycophenolic
acid, a common immunosuppressant drug, in serum was used
as an example to illustrate this enhanced detection and its
applicability to therapeutic drug monitoring. Acetonitrile
was used to remove serum proteins and induce sample
concentration on the capillary, followed by direct injection
filling 5-21% of the capillary volume with sample and
separation in a borate buffer. The minimum detection level
for mycophenolic was 95 µg/L for CE vs 125 µg/L for HPLC.
Also, in this case, the apparent theoretical plate number for
MPA peak is much better by the CE compared to HPLC,
53,265 vs. 4,620, respectively. In conclusion, the overall CE
method for mycophenolic acid compared well to an assay by
HPLC as far as sample preparation, correlation coefficient,
and especially sensitivity of detection.
Upon completion of this presentation, participants
should be able to list three ways to enhance the detection
limits of capillary electrophoretic analysis.
[26] Liquid chromatography-tandem mass spectrometry
workshop. Scott Allen, University of Tampa, Tampa, FL.
Participants will prepare a therapeutic drug sample for
analysis, tune the mass spectrometer on the analyte of interest,
and evaluate the mass spectral data obtained from the analysis.
Optimization parameters, modes of ionization, sample
concentration limitations, and carryover restrictions will be
discussed and evaluated. Unknown compounds will be
identified using a data base program containing representative
mass spectra.
Upon completion of this presentation, participants
should be able to tune the mass analyzer on the compound of
interest, optimize instrument parameters, interpret mass
spectra and identify spectral matches in a library database.
[27] Inductively coupled plasma–atomic emission
spectroscopy workshop. Joseph P. Laurino, University of
Tampa, Tampa, FL.
Inductively coupled plasma–atomic emission spectrometry (ICP-AES) is a frequently used technique for elemental
analysis. This method has several advantages over traditional
flame atomic absorption spectrometry. Due to the high degree
of stability associated with the plasma source, the ability to
overcome depressive interference effects caused by the
formation of stable compounds, the ability to excite several
elements that are not excited in traditional chemical flames,
and the increased sensitivity of detection, this technique is
generally favored over flame photometry. Participants in this
workshop will prepare representative standard curves and
simultaneously analyze digested tissue samples for calcium,
sodium, and zinc. Analysis of spectral curves, determination
of potential interfering substances, and the use of internal
standards will be demonsstrated.
[29] Surgical pathology tutorial on cancers of the colon and
breast. Domenico Coppola and Geza Acs, with case
presentations by pathology residents and fellows (Evita
Henderson-Jackson, Rahel Mathew, and Masoumeh
Ghayouri), H. Lee Moffitt Cancer Center and University of
South Florida College of Medicine, Tampa, FL.
Interesting and challenging cases of colon and breast
cancer will be presented by pathology residents and fellows
for discussions of histologic findings, tumor classifications,
prognoses, and therapeutic considerations by two expert
surgical pathologists and by the participants.
Upon completion of this presentation, participants
should be able to hone their diagnostic skills in surgical
pathology of the colon and breast.
[30] Integration of histology and molecular biology in the
therapeutic planning for colon cancer. Domenico Coppola,
H. Lee Moffitt Cancer Center, Tampa, FL.
[28] Workshop on instrumental advances in molecular
diagnostics. Maura Pieretti, BayCare Health System,
Clearwater, Florida
Until approximately 20 years ago molecular technologies
were almost exclusively found in research, academic, and
specialized laboratories. DNA and RNA extractions were
tedious and labor intensive procedures, fraught with
inconsistencies and low level reproducibility. As molecular
technologies become increasingly utilized in several clinical
disciplines, we are witnessing automation and simplification
of molecular tests. Automation is now available for nucleic
acid extraction, amplification, and detection, as well as various
sample handling steps. Examples of automated instruments
that are currently utilized in clinical molecular laboratories
will be presented during the workshop. An automated
platform for the detection of Enterovirus (EV) in cerebrospinal fluid (CSF) will be demonstrated. This platform utilizes
real time PCR and automates the extraction, amplification,
and detection steps of the assay. The utilization of this
technologically advanced, yet simple and rapid test within
our health care system allows the rapid diagnosis of EV
meningitis. Turn-around times improved dramatically after
implementation of this rapid test at two of our Microbiology
Departments; clinician and patient satisfaction have also
significantly increased. Length of hospital stay for patients
with suspected viral/bacterial meningitis was studied before
and after implementation of this test and a reduction from an
average stay of 4.2 days to 2.2 days was observed.
Upon completion of this presentation, participants
should be able to describe the trend from manual to automated
technologies in clinical molecular diagnostics, list examples
of automated instruments used in clinical molecular
laboratories, and describe the automated detection of EV by
real time PCR.
Upon completion of this presentation, participants
should be able to prepare a suitable standard curve for ICPAES analysis, detect potential interfering substances, describe
the use of internal standards, and determine the concentrations
of various elements in a tissue sample.
Abstracts, 2009 Annual Meeting of the Association of Clinical Scientists
207
Recent studies have shown that a gamut of different
molecular pathways may be responsible for colon cancer. Each
of the molecular pathways relates to specific histopathological
findings. Here we describe molecular alterations characteristic
of the microsatellite instable pathway, and of the APC
pathway. In addition, we review the use of important predictor
markers of therapeutic response and survival. These markers,
including among others, thymidylate synthase, ERCC1,
topoisomerase 1, uridine diphosphate glucoronosyl-transferase (UGT1A1), and K-Ras, illustrate the attempt to provide
targeted/personalized therapy. We also present recent
developments in the identification of gene and protein
signatures capable of predicting tumor response to therapy.
Finally, we present an overview of the Total Cancer Care
program, a Moffitt Cancer Center initiative furthering the
vision for a personalized/tailored cancer care for each patient
to maximize efficacy and minimize toxicity of therapy.
Upon completion of this presentation, participants
should be able to recognize the features of hyperplastic polyp
and sessile serrated adenoma, list the components of the MSI
and APC pathways, identify the targets for the most common
chemotherapeutic agent used for the therapy of colon cancer,
and discuss recent developments in gene and protein profiling
for colon cancer.
[31] Constitutively active erythropoietin receptors in the
growth of human cancer. Geza Acs, H. Lee Moffitt Cancer
Center, Tampa, FL
Human recombinant erythropoietin (Epo) is widely
used in the management of cancer and therapy related anemia
in patients with malignant neoplasms. Although Epo is
effective in correcting anemia and improving quality of life,
recent clinical trials suggest that its use may be associated
with earlier tumor recurrence/progression and decreased
survival. Various human cancer cells were recently shown to
express Epo receptor (EpoR) and in vitro studies suggested
that Epo can stimulate signaling mechanisms and proliferation
in some cancer cells. Other studies, however, found that
exogenous Epo failed to stimulate tumor growth in in vivo
tumor models. Given the lack of biologic response to Epo
despite the presence of high levels of EpoR in some tumor
cells, we tested the hypothesis that EpoR is constitutively
active and contributes to tumor growth independent of Epo
in such tumors. We found that despite expression of high
levels of EpoR, exogenous Epo fails to stimulate EpoR-related
signaling mechanisms, proliferation, or invasiveness in A2780
human ovarian carcinoma cells. We have down-regulated
EpoR expression in A2780 cells using a short hairpin RNA
(shRNA) expression plasmid, which resulted in markedly
suppressed cell proliferation and invasiveness in vitro, and
abrogation of tumor growth in vivo. Western blot analysis
revealed decreased activation status of EpoR signaling
pathway components in A2780/EpoR shRNA tumors
compared to controls. In order to examine the potential
mechanisms of constitutive EpoR signaling in breast and
ovarian cancer cells, we measured the mRNA expression
levels of the EpoR gene exons. We found that mRNA regions
coding for the extracellular portion of EpoR were expressed at
significantly lower levels compared to C-terminal regions,
208 Annals of Clinical & Laboratory Science, vol. 39, no. 2, 2009
suggesting the presence of altered EpoR mRNA species in
these cancer cells. Increased ratio of C- vs N-terminal EpoR
mRNA levels determined by qualitative RT PCR in breast
cancer samples significantly correlated with lymphatic
invasion and nodal metastasis. A SMART RACE PCR assay
confirmed the presence of altered EpoR mRNA variants in
breast and ovarian cancer cells. Our findings suggest that
variant forms of EpoR may be constitutively active in some
cancer cells and provide the first evidence for the potential
role of an Epo independent EpoR mediated pathway in tumor
growth.
Upon completion of this presentation, participants
should be able to describe our current understanding of the
role of erythropoietin receptor in the biology of malignant
neoplasm and the potential role of constitutively active altered
erythropoietin receptor variants in the growth of tumors.
[32] Granulomatous prostatitis secondary to M. tuberculosis
complex. Frank M. Taylor, III, Salim Afridi, Bienvenido
Yangco, and A. John Saranko, South Florida Baptist Hospital,
Plant City, FL.
We report a rare case of infectious granulomatous
prostatitis that was diagnosed in a 69-yr-old African-American
man. The patient presented with severe lower back pain and
was found to have lytic lesions of the lumbar spine, an enlarged
prostate gland, and elevated serum level of prostate-specific
antigen. Despite our strong initial suspicion of prostate
adenocarcinoma with metastases, tissue studies revealed
granulomatous prostatitis and orchitis secondary to M.
tuberculosis complex, as determined by PCR. Salient clinical
and laboratory features are discussed.
Upon completion of this presentation, participants
should be able to distinguish the various subtypes of
granulomatous prostatitis and related disorders.
[33] Iron in neurodegeneration. Joseph C. Parker, Jr.,
University of Louisville School of Medicine, Louisville, KY.
Iron distributed throughout the human body plays a
major role in the production of free radicals. Too much
dietary iron causes hemosiderosis; too little produces altered
hematopoiesis with iron deficiency anemia, a major worldwide
nutritional problem. Behavior and cognitive developmental
delays with iron deficiency are related to abnormal neurotransmission, decreased myelin formation, and altered brain
energy metabolism. Iron concentrations in the normal brain
are most prevalent in the basal ganglia, substantia nigra, and
deep cerebellar nuclei. Iron appears high in the brain at birth
and decreases through the first year of life increasing with
myelination and increased transferrin. With aging, iron
increases in a random distribution in the brain. In hereditary
and sporadic neurodegenerative disesases such as
Hallervorden-Spatz syndrome (neurodegeneration with brain
iron accumulation), Alzheimer’s disease, and Parkinson’s
disease damage to neurons occurs with accumulated free
radicals associated with the iron catalytic Fenton reaction
(H2O2 + Fe2+ → Fe3+ + OH- + OH•) in mitochondria.
Over-expression of iron uptake from transferrin receptors has
been found with excessive iron deposition related to increased
hydroxyl radicals (OH•), mitochondrial insufficiency, and
apoptotic neurons. Altered brain iron metabolism in
neurodegenerative diseases has multiple causes that include
genetic and non-genetic factors related to altered iron uptake,
release, storage, and metabolism. Iron induced free radicals
seem to play a major role in many neurodegenerative disorders
with oxidative stess being a central feature. Chelation (desferrioxamine) and antioxidant treatment (CoQ10) slow the
neurodegenerative process while altering proteins involved
with iron absorption and transport such as hepcidin may
help.
Upon completion of this presentation, participants
should be able to identify the neurological disorders that are
associated with disturbed iron metabolism and free radicals.
[34] Papillary tumor of the pineal region: Two unique case
studies. Kyle Rickard, John R. Parker, Stephanie Wagner,
Todd Vitaz, and Joseph C. Parker, Jr., University of Louisville
School of Medicine, Louisville, KY.
Papillary tumor of the pineal region (PTPR) is a newly
recognized distinct entity in the 2007 World Health Organization nomenclature; it is characterized by epithelialappearing areas with papillary features and more densely
cellular areas that often display ependymal-like differentiation.
Ultrastructurally, this rare neuroepithelial tumor possesses
secretory and ependymal organelles that likely originate from
the subcommisural organ. Forty described cases worldwide
have been recognized, with ages ranging from 5 to 66 yr
(mean age = 32 yr). Clinical presentation most often includes
headache and obstructive hydrocephalus. The tumor, which is
well circumscribed, may be cystic and grossly is usually
considered a pineocytoma. Microscopic evaluation often
demonstrates a lesion with atypical small and intermediate
size epitheloid tumor cells with scattered eosinophilic
cytoplasm found in sheets and perivascular clusters in a
papillary pattern. Perivascular, neuroblastic, and true rosettes
may be identified. Distinctive immunohistochemical features
including reactivity for keratins (AE1/AE3, CAM 5.2, CK18)
in the papillary structures help distinguish this neoplasm
from an ependymoma. The relative paucity of data compiled
for this tumor makes giving an accurate diagnosis as well as a
subsequent prognosis a daunting task. We discuss two cases
of PTPR that were presented to us within a 3-mo span in
order to elucidate the possible presentations of this extremely
rare entity. Furthermore, we examine the 40 reported cases of
PTPR in order to compare and contrast treatment modalities
and to offer insight into the long-term prognosis of this
unusual neoplasm.
Upon completion of this presentation, participants
should be able to describe the presentations of the rare entity,
papillary tumor of the pineal gland, as well as the treatment
modalities and prognosis of this unusual neoplasm.
[35] Mechanism of brain edema following intracerebral
hemorrhage. Jiping Qi, Harbin Medical University, Harbin,
Heilongjiang, China.
Intracerebral hemorrhage (ICH) can cause brain damage
through inflammation-related pathways. In order to identify
how the inflammatory mediators released from the blood
after ICH cause edema formation, we tested the hypothesis
Abstracts, 2009 Annual Meeting of the Association of Clinical Scientists 209
that thrombin activates the inflammatory cascade, which
might play an important role in forming the brain edema
after ICH. We produced ICH in adult Sprague Dawley rats
by direct injection of autologous blood (50 µl) into the caudate
nucleus. Patients with injured hippocampus were also enrolled
in this study. Different expression levels of thrombin, protease
activated receptor-1 (PAR-1), nuclear factor-kappa B (NFκB), macrophage inflammatory protein-2 (MIP-2), matrix
metalloproteinase-9 (MMP-9), and aquaporin-4 (AQP-4)
were detected in rat and human brain by immunohistochemistry, in situ hybridization, and quantitative real-time
RT-PCR. Brain water content of the rats was also measured.
We found that all of the inflammatory mediators showed
dynamic changes according to the time of ICH. Their
changing tendencies were in conformity with brain water
content on the whole. Taken together, our findings indicate
that: (a) thrombin activates an inflammatory cascade that
may play an important role in the pathogenesis of brain edema
after ICH; (b) NF-κB signaling is a key requirement for
thrombin-induced inflammatory activation cascade after
ICH; and (c) ICH-activated thrombin at PAR receptors may
activate NF-κB, which, in turn, activates MIP-2 and MMP-9
to disrupt the blood–brain barrier, and then AQP-4 to induce
brain edema formation.
Upon completion of this presentation, participants
should be able to diagram the proposed pathway for the
pathogenesis of brain edema after cerebral hemorrhage.
[36] Collagenous colitis in the pediatric population. Nina
Tatevian, Sagar A. Dhamne, and William Klish, University
of Texas–Houston Medical School and Baylor College of
Medicine, Houston, TX.
Collagenous colitis is a disease of unknown etiology
predominantly seen in adults, with few cases reported in the
pediatric age group. Clinical presentation in children is
similar to that in adults, ie, chronic watery diarrhea with or
without abdominal pain. The colonic mucosa is grossly
normal by endoscopy. Histology reveals a collagenous band
of varying thickness in the subepithelial region with occasional
intraepithelial lymphocytes. No specific treatment other than
symptomatic therapy is recommended. Here we report 9
children who presented in the years 2000-2008 with chronic
watery diarrhea. Endoscopy showed a grossly normal colon.
Colonic biopsies stained with H&E revealed a subepithelial
collagen band in all the cases. This was confirmed using
Masson’s trichrome stain. A systematic morphometric study
to measure the maximum and minimum thickness of the
subepithelial collagen band including the basal membrane
was carried out on trichrome-stained sections using 40X
magnification. The thickness of the band averaged 6.02 to
9.53 µm, with a range in individual cases from 4.7 to 12.73
µm. Minimal lymphocytic infiltrate was present in the
glandular and surface epithelium. No acute inflammation or
increased eosinophils were seen. In normal children, the
collagenous plate is practically absent with a very thin
basement membrane. The mere presence of a thickened
collagen band is abnormal. In the presence of the clinical
symptoms noted above, we conclude that these children have
the pediatric counterpart of adult collagenous colitis.
Upon completion of this presentation, participants
should be able to diagnose collagenous colitis in pediatric
subjects.
[37] Pulmonary-renal syndrome: IgA nephropathy
presenting with renal failure and pulmonary hemorrhage.
Ewa Elenberg, Baylor College of Medicine, Houston, Texas.
IgA nephropathy (IgAN) is the most common glomerular
disease worldwide, usually renal limited. The pulmonary–
renal syndrome (PRS) is defined as the combination of a
diffuse alveolar hemorrhage and rapidly progressive glomerulonephritis. PRA is characterized by a fulminant course,
thus early diagnosis is essential for correct therapy. The
differential diagnosis commonly includes ANCA- associated
vasculitides, Goodpasture syndrome, and systemic lupus
erythematodes. IgAN presenting with renal failure and
pulmonary hemorrhage is an extremely rare cause of PRS.
There are only few cases reported worldwide. Mortality rate
is high. The youngest previously reported patient was 17-yrold. We report a 14-yr-old male presenting with end stage
renal disease (ESRD) due to IgAN and recent onset of dyspnea
and hemoptysis. He gave a history of progressive orthopnea
over a few days, with blood tinged sputum, gross hematuria,
and anemia. Chest x-ray revealed an enlarged heart and
pulmonary edema. CT scan of the lung revealed multiple illdefined nodular opacities and pulmonary capillaritis with
interstitial thickening. The lung biopsy (Bx) revealed features
suggestive of acute hemorrhage, fibrin, patchy organizing
pneumonia, multifocal increased mucus, goblet cell
hyperplasia, and mild anthracosis. The kidney Bx revealed
IgAN with diffuse global sclerosis. Therapy (Rx) consisted of
monthly iv cytoxan for 6 mo and pulses of solumedrol (1 g, iv,
initially daily, then weekly). After 6 mo of Rx, cytoxan was
replaced by methotrexate for 1 yr and the iv solumedrol was
slowly weaned to every mo. With Rx, the patient did not have
additional hemophtysis or pulmonary hemorrhage. The
patient remains on chronic HD. This is the first report of an
adolescent patient with IgA nephropathy presenting as ESRD
and PRS.
Upon completion of this presentation, participants
should be able to itemize the differential diagnosis of
pulmonary-renal syndrome and delineate the therapy for
pulmonary-renal syndrome with IgA nephropathy.
[38] Death of the autopsy and its underestimated utility in
modern medicine. Gwendolin J. Godfrey and Joseph C.
Parker, Jr., University of Louisville School of Medicine,
Louisville, KY.
The rate of post-mortem examination of hospital
decedents has substantially declined in recent years. Reasons
for this decline have involved every facet of medicine, from
the decedents’ family, clinical medicine teams, hospital
attorneys, and even the pathologists themselves. This overview
illustrates how a complete post-mortem examination is
conducted in a teaching institution through an interesting
case study of an actual hospital autopsy. In addition, current
research on the reasons for the declining autopsy rate and the
benefits from performing autopsies will be reviewed.
210 Annals of Clinical & Laboratory Science, vol. 39, no. 2, 2009
Upon completion of this presentation, participants should be
able to identify the common excuses for not requesting an
autopsy and provide specific examples of how post-mortem
examinations significantly contribute to understanding
diseases and establishing the cause, manner, and mechanism
of death.
[39] Virtual cadavers for 21st century medical education
and research. Donald Hilbelink, University of South Florida
College of Medicine, Tampa, FL.
Virtual cadaver development had its start with initiation
of the Visible Human Project (VHP) by the National Library
of Medicine in the early 1990’s. Visualization toolkits and
software developed in conjunction with this project provide a
means to produce accurate, high resolution virtual models of
human anatomy. Although first limited to a small number of
cadaver specimens provided by the VHP, advances in medical
imaging and computer technology now permit high resolution
imaging and modeling of any cadaveric specimen. During the
past year all cadavers used for medical education by the USF
College of Medicine were CT-scanned prior to use in the
dissection laboratories. State-of-the-art software has been
obtained and tested for use in 3D visualization and virtual
dissection activities. Virtual cadaver images provide not only
the opportunity for immediate cross-sectional anatomic
correlation during the dissection, but also provide for a digital
data base of virtual models of a wide range of anatomical
variations and pathologies. The natural progression is to
extend this technology to living patient medical image data to
broaden the quality and quantity of virtual anatomical models
for use in medical education and research. With this purpose
in mind, the Human Morphoinformatics Research Center
was established in 2008 in the College of Medicine at USF.
Upon completion of this presentation, participants
should be able to describe the nature of a virtual cadaver, how
virtual cadavers are produced, and how virtual cadavers can
be used in medical education and research.
[40] Standardization of bioinformatics. Philip R. Foulis,
James A. Haley Veterans Hospital and University of South
Florida College of Medicine, Tampa, FL.
Diagnostic medicine increasingly utilizes recent advances
in genomics to diagnosis, classify, monitor, and treat patients.
Clinical information systems need to manage these results
and support the exchange of data based on genomics-related
findings. Most current medical vocabularies lack rich terms
to describe findings generated by molecular diagnostic and
cytogenetic techniques. SNOMED-CT (College of American
Pathologists) is ontology but lacks both significant granularity
for detailed description of chromosomal structures and terms
for the accurate description of molecular findings. Ontology
comprises the concepts and relationships that describe
molecular medicine. The Online Mendelian Inheritance in
Man (National Library of Medicine and Johns Hopkins
University) is clinically oriented. It is not provided in a
machine-readable format suitable for integration with
relational databases and applies inconsistent methods of
describing genetic positional information. The Clinical
Bioinformatics Ontology (CBO) is a construct that assists in
codifying molecular medicine. The CBO addresses the gaps
in current codification schemas by covering the areas of
molecular genetics, molecular pathology, cytogenetics, and
infectious disease, utilizing a semantically structured
vocabulary for clinical molecular diagnostics. The attributes
of the vocabulary provide standardized naming conventions
and coded values describing clinically relevant molecular
biological entities. The CBO contains a vocabulary, which is
controlled by an oversight organization, and has uniquely
identified concepts. This paradigm results in a codified
representation of molecular medicine with a standardized
terminology allowing extensive clinical and research
possibilities as an added benefit because of its controlled
scope. The standardization of laboratory test names, enhanced
result interpretation, and completeness of reporting will assist
with the delivery of healthcare. The capabilities of the CBO
will be most beneficial in the areas of microbiology, anatomic
pathology, and molecular pathology.
Upon completion of this presentation, participants
should be able to discuss the pros and cons of current
codification methodologies with emphasis on molecular
medicine, explain how a detailed molecular codification
schema assists in the delivery of healthcare, and list the
requirements for comprehensive bioinformatics ontology.
[41] Recent algorithmic developments in content-based
image retrieval systems in support of realizing clinicallydeployed solutions for surgical pathology. Jerome Y. Cheng
and Ulysses J. Balis, University of Michigan Health System,
Ann Arbor, Michigan.
The investigation of content-based image retrieval
(CBIR) has largely been an academic topic of interest for
computer scientists and those active in automated evaluation
of remote-sensing-based earth imagery. CBIR’s utility in the
health sciences has been limited owing to two general factors:
computational expense and limited use-cases where comprehensive digital imagery workflow is available for query. With
the increasing availability of digital content for pathology, the
challenge has essentially been confined to the need for
improved computational methods. In this report, we present
a novel set of algorithmic approaches targeted at solving the
computational limitation for real-time CBIR applications in
surgical pathology, based in particular on translationally and
rotationally invariant vector ring kernel forms. This approach
differs fundamentally from prior efforts in vector-based image
classification in that the total possible degrees of freedom
with the rotationally-invariant ring model are literally several
million-fold less than prior constructs (with this decrement
similarly representing an opportunity for commensurate
improvements in computational performance). Representative
digital histopathologic imagery data sets were selected for
qualitative presence of one or more archetypal features
(malignancy, unique cell type, structural configuration) and
then analyzed with a discovery tool specifically designed to
test the utility of individually-selected prototypic vectors.
Results of vector matching performance analysis confirmed
the utility of the spatially invariant hypothesis, with as few as
even single vectors constituting a complete search kernel for
both structural and cellular components within selected
Abstracts, 2009 Annual Meeting of the Association of Clinical Scientists
imagery. In many cases, computational times for feature
matching were <1 min for representative fields of view, with
extrapolation of this metric indicating that it is computationally
possible to extend such approaches to image-library-wide
pattern matching, in a real-time support model. These
preliminary results demonstrate a possible algorithmic
approach that will ultimately allow image-based query in
surgical pathology as a routine imaging informatics tool.
Upon completion of this presentation, participants
should be able to discuss the prospect of using the computer
for image-based queries in surgical pathology.
[42] Method for analysis of signaling pathways in multiple
organ failure. Mary F. McGuire, M. Sriram Iyengar, and
David W. Mercer. University of Texas Health Science Center
at Houston, Houston, TX.
Multiple organ failure (MOF) is the leading cause of inhospital mortality following trauma. Pro- and anti-inflammatory cytokines have been implicated in MOF and their
signaling pathways can potentially yield important
information on the cellular mechanisms leading to MOF. We
present a method for analysis of these signaling pathways over
time and across clinical outcomes (MOF or Non-MOF).
Eleven serum cytokines from 48 patients sustaining major
torso trauma (excluding severe head injuries) who met
standardized criteria were assayed and grouped in time
periods (t = 2-6 hr, 6-10 hr, 10-14 hr, 14-18 hr, 18-22 hr, and
22-24 hr) by outcome. A significance set, S(t), the statistically
significant cytokines differentiating outcomes, was derived
using the one-sided Wilcoxon rank sum test with p <0.05.
Ingenuity pathway analysis (IPA) generated molecular
pathways for each time period t and for each outcome based
on S(t). A time dependency matrix (TDM) was then generated
with rows representing signaling molecules and columns
showing time periods. Each cell contains a 1 or 0 depending
on presence/absence of the signaling molecule in that time
period. TDM enables mathematical analysis for questions of
biological interest. This study identified 132 potentially
significant signaling molecules. The analysis showed 67 in
both outcomes in the same time periods; 31 in both outcomes
at different times; 33 molecules appeared only in MOF or in
NMOF at a single time, and one molecule implicated in
apoptotic cell death appeared solely in two MOF time periods.
In conclusion, our technique can provide detailed insights
into molecular mechanisms evoked by trauma, with
identification of potential drug targets and optimal time
frames for therapy.
Upon completion of this presentation, participants
should be able to appraise the application of computer
programs for ingenuity pathway analysis (IPA) and timedependency matrix (TDM) to generate mathematical
solutions to questions of clinical interest, such as the signaling
pathways in multiple organ failure.
[43] Computer monitoring of quality in anatomic pathology.
Myra L. Wilkerson, Geisinger Medical Laboratories, WilkesBarre, PA.
We needed a software package to monitor quality in
anatomic pathology that would encompass the entire work
211
unit, starting with clinician ordering and ending with final
coding and billing. Data flow and specimen workflow were
evaluated and a list of quality indicators was generated for
each step. We then designed a database using Sybase, allowing
us to retreive information from our anatomic pathology lab
information system (CoPath v2.7, Cerner Corp.) into this
new database without translationn. Other database tables
were designed in MS SQL so that our software would have
auditing capability. Web application windows were designed
in Flex 2.0 (Adobe). Data were collected over the first 9 mo
after deployment of the software with 3050 process errors
recorded. Analysis shows that 70.4% of these errors occurred
in the prelaboratory/preanalytic phase and included problems
with incomplete information on requisitions, incorrect
specimen labeling, and improper specimen packaging. The
other top 2 categories where process errors occurred were
histology (15.1%) and the grossing bench (13.3%). The data
suggest that most delays in specimen processing result from
prelaboratory errors and that we should focus on this area for
quality improvement.
Upon completion of this presentation, participants
should be able to delineate the software requirements for
monitoring and implementing a quality control program in
anatomic pathology.
[44] Personalized medicine will be the future. Pai C. Kao,
Mayo Clinic, Rochester, MN.
The human genome project, accomplished in 2001,
revealed that many adverse drug reactions are caused by gene
polymorphisms of drug metabolizing enzymes in patients.
Phamacogenomics has been applied as personalized medicine.
For many years, dentists wondered why codeine did not stop
pain in some patients. In current knowledge, codeine has no
pain-killing effect itself and requires hydroxylation to remove
a methyl group at the 3-position, converting codeine to
morphine by a cyp2D6 enzyme. Polymorphism of the gene
causes some patients to lack the hydroxylating enzyme. A
classic case of phamacogenomics/personalized medicine is
codeine intoxication: a 62-year-old man hospitalized for
pneumonia received the standard dose of 25 mg codeine tid
for cough suppression. After 4 days, he fell into a coma. His
blood morphine levels were 20 times the expected level.
Genetic tests showed that he had more than 2 copies of the
gene for the cyp2D6 enzyme. Fortunately, the patient was
revived by iv infusion of naloxone. Pre-testing the patient’s
genotype is the best way to prevent such severe adverse drug
reactions. The reactions of a drug in patients can be divided
into 3 groups: (a) ultra-rapid metabolizer, about 1-7%, the
drug is metabolized rapidly from the body and has little
therapeutic effect; (b) extensive metabolizer, about 80%, the
drug is metabolized at a normal rate and has optimal
therapeutic effect; (c ) poor metabolizer, about 5-10%, adverse
drug reactions mostly occur in this group. It is estimated that
each year, 2 million hospitalized patients have adverse drug
reactions resulting in 100,000 deaths. Personalized medicine
can minimize drug adverse reactions; the economic saving
might cover the uninsured patients in the USA. The FDA is
considering including genetic information on drug labels;
212 Annals of Clinical & Laboratory Science, vol. 39, no. 2, 2009
drug companies are also targeting the market for personalized
medicine.
Upon completion of this presentation, participants
should be able to discuss various applications of pharmacogenomics to minimize drug adverse reactions.
[45] Plasma BNP as a biochemical marker for patent ductus
arteriosus in pre-term neonates. Vaneet K. Kalra, F. M.
Kiblawi, A. Zauk and Vincent A. DeBari, Children’s Hospital
at St. Joseph’s Regional Medical Center, Paterson, NJ, and
School of Health and Medical Science, Seton Hall University,
South Orange, NJ.
Among pre-term neonates (PTN), patent ductus
arteriosus (PDA) is highly prevalent and has been recognized
as a significant cause of neonatal co-morbidity. The purpose
of this study was to determine if levels of brain (or beta-type)
natriuretic peptide (BNP), a peptide secreted by ventricular
myocytes in response to volume or pressure overload, correlate
with the size of the PDA. In a prospective design, 48 PTN
(no PDA: n = 20; PDA: n = 28) were studied after obtaining
parental consent. Those with genetic anomalies and congenital
heart disease except for PDA and patent foramen ovale were
excluded. Echocardiographic estimates of the diameters of
the PDA (or absence of PDA) were made concurrently (within
4 hr) of capillary blood collection for BNP assay. BNP levels
in samples from PTN without PDA were 27.4±8.6 pg/ml,
with small PDA (n = 10), 62.3±34.4pg/ml, with moderate
PDA (n = 11), 542.1±297 pg/ml, and with large PDA (n = 7),
2141.6±1699.7 pg/ml (p < 0.0001 for ANOVA; groupwise: p
<0.05 for both no PDA vs moderate and large PDA and small
PDA vs large PDA); trend analysis suggested a strong
association of BNP with size of PDA (p <0.001). No correlation
was found between BNP and either gestational age or birth
weight. Logistic regression analysis of clinically relevant
distinctions among size of PDA yielded a strong association
(p <0.0001) with a cut-off of 119 pg/ml for the treat/no treat
options. Assay of BNP may obviate the need for repeated
echocardiography after treatment or to monitor the course of
respiratory distress in PTN.
Upon completion of this presentation, participants
should be able to interpret BNP levels in patients with patent
ductus arteriosus.
[46] Association of D-dimer levels with clinical outcomes in
patients presenting with acute pulmonary embolism. Maria
Alfakir, J. Blamoun, A. I. Sedfawy, M. Q. Moammar, M.
Maroules, M. A. Khan, and Vincent A. DeBari, St. Joseph’s
Regional Medical Center, Paterson, NJ, and School of Health
and Medical Science, Seton Hall University, South Orange,
NJ.
The D-dimer fragment of fibrin degradation has been a
useful adjunct in the diagnosis of venous thromboembolism
(VTE). In conjunction with predictive algorithms, the high
negative predictive value (NPV) of D-dimer measurements
has provided this analyte with a prominent position in the
diagnosis of pulmonary embolism (PE). The purpose of this
study was to determine if D-dimer levels correlate with
ventilation/perfusion (V/Q) derangements as assessed by the
alveolar-arterial oxygen tension gradient (ΔA-a) and to
ascertain if quantitative measurements of D-dimer on
admission have prognostic value in terms of during-admission
mortality and recurrence over a 60-wk period. The study
utilized a retrospective cohort of 108 subjects admitted to a
single institution and studied longitudinally. The cohort was
divided into 4 groups representing degree of severity assessed
by CT-angiography: mild, moderate, severe, and very severe.
Differences among D-dimer levels among these groups were
significant (p <0.0001). Strong correlation was observed
between D-dimer concentration and ΔA-a (p <0.0001).
Logistic methods were used to calculate a “cut-off” level that
would distinguish mild-moderate from severe-very severe PE.
At a concentration of 12.35 μg/ml, this level yielded an odds
ratio (OR) = 12.64 (p = 0.006) for during-admission mortality
and a hazard ratio (HR) = 0.13 (p <0.0001) for 60-wk
recurrence. These data suggest that D-dimer levels have utility
beyond their NPV and should be considered as potential
prognostic markers in subjects presenting with acute PE.
Upon completion of this presentation, participants
should be able to interpret the prognostic significance of Ddimer levels in patients with acute pulmonary embolism.
[47] Poloxamer 188 prolongs survival of hypotensive
resuscitation and decreases vital tissue injury after full
resuscitation. Robert L. Hunter, Jr., Rongzhen Zhang,
Ernest A Gonzalez, and Frederick A Moore, University of
Texas-Houston Medical School and The Methodist Hospital,
Houston, TX.
Hypotensive resuscitation prolongs survival of patients
with severe bleeding until they can undergo hemorrhage
control. However, its value is limited by continuing ischemic
injury. Purified poloxamer 188 (P188), a copolymer with
rheologic and cytoprotective activities, was known to reduce
mortality of hemorrhagic shock when used as an adjunct to
full resuscitation with fresh whole blood and crystalloid.
Studies were undertaken to determine if it could prolong
survival and reduce reperfusion injury during prolonged
hypotensive resuscitation when added to the best regimen
currently available. Unanesthetized rats were bled to a mean
arterial pressure (MAP) of 30 mmHg for 30 min under
computer control. They then received hypotensive resuscitation
with Hextend or Hextend + P188 to maintain a MAP of 60
mmHg until death. P188 improved auto-resuscitation,
reduced fluid requirements, and increased the survivable
duration of hypotensive resuscitation by over 3 hr (p <0.01).
Additional studies assessed tissue damage after shock and
hypotensive resuscitation with Hextend followed by full
resuscitation with crystalloid. In these studies, P188 blunted
the no reflow phenomenon and largely prevented myocardial
injury, pulmonary inflammation, small bowel damage, renal
tubular necrosis, hepatic central lobular necrosis, and
apoptosis of splenic germinal centers that occurred during
full resuscitation. Additional studies demonstrated that P188
increased survival from 0% to 75% in 50% volume controlled
hemorrhage (p <0.001). Finally, P188 did not increase
bleeding in uncontrolled hemorrhage produced by 75% tail
amputation. Since, P188 prolongs survival, decreases fluid
requirements, and reduces tissue damage, it deserves further
Abstracts, 2009 Annual Meeting of the Association of Clinical Scientists
consideration as an adjunct to hypotensive resuscitation.
Supported by US Army Grant W81XWH-06-1-0570.
Upon completion of this presentation, participants
should be able to comment on the potential utility of
Poloxamer 188 as a therapeutic adjunct during resuscitation.
[48] Unique properties of aluminum maltolate in
experimental studies of neurodegeneration. John Savory,
University of Virginia Medical School, Charlottesville, VA.
It is over 40 years since Klatzo et al reported that the
intracisternal administration of aluminum (Al) phosphate to
New Zealand white rabbits produced intraneuronal protein
aggregates which on silver staining appeared remarkably
similar to the neurofibrillary tangles of Alzheimer’s disease.
Most subsequent studies of Al-induced neurodegeration have
followed Klatzo’s work and used inorganic Al compounds
that are highly insoluble at physiological pH, making it
difficult to reproduce dose (Al3+)-response data. The choice
of an appropriate Al compound is important for obtaining
consistent results since at neutral pH many of these compounds
form insoluble precipitates. The chemistry of Al is complex
and should be understood in assessing investigations
employing Al as a toxic agent. Most studies carried out in the
author’s laboratory have employed Al maltolate, which is
soluble at neutral pH and can be delivered to brain tissue via
the intracisternal route of administration without the
complications of Al(OH)3 precipitation. The primary
constituent of paired helical filaments in human neurofibrillary
tangles is tau, although other proteins are present. Studies in
the author’s laboratory have provided insight into the
mechanisms of apoptosis involved in the neurodegenerative
process including mitochondrial and endoplasmic reticulum
stress involving caspase-12 and caspase-3 activation. Overall,
the Al/rabbit model system has provided useful information
on several processes that could share a common mechanism
with the development of neurodegeneration in Alzheimer’s
disease and this model should continue to be valuable as more
mechanistic schemes are uncovered. The model could be of
value in identifying early diagnostic markers and preventative
or therapeutic strategies for Alzheimer’s disease.
Upon completion of this presentation, participants
should be able to compare the neurodegeneration induced in
rabbits by intracisternal infusion of aluminum maltolate with
that seen in patients with Alzheimer’s disease.
[49] Anti-tumor effect of ent-11a-hydroxy-15-oxo-kaur-16en-19-oic-acid in mouse models of liver and lung tumors.
George G. Chen,1 Jackie Leung,1 Nian Ci Liang,2 Michael
K.Y. Hsin,1 Kefen Wu, 2 Yi Feng Deng,2 Johnson H.Y. Yip,1
Xianling Gong,2 Yingnian Lu,2 Naomi M.W. Choi,1
Malcolm J. Underwood,1 and Paul B.S. Lai.1 1The Chinese
University of Hong Kong, Shatin, Hong Kong; 2Guangdong
Medical College, Zhanjiang, Guangdong, China
Ent-11α-hydroxy-15-oxo-kaur-16-en-19-oic-acid (5F) is
a chemical compound extracted from Pteris semipinnata L.
Apoptotic effect induced by 5F has been documented in
several in vitro tumor cell lines but not yet been tested in vivo.
In this study, the therapeutic effects of 5F were investigated in
mouse models of hepatocellular carcinoma (HCC) and lung
213
cancer. Diethylnitrosamine was used to induce HCC in
C3H/HeJ mice. 4-(N-methyl-N-nitrosamino)-1-(3-pyridyl)1-butanone was administrated to induce lung tumor in A/J
mice. Tumor-bearing mice were given 5F with 12, 24, 48 mg/
kg of 5F daily ip, and control mice were given vehicle. It was
found that mice receiving 48 mg/kg of 5F alone, and those
receiving 12, 24 mg/kg plus 5-fluorouracil (5-FU) had a
significant decrease in target organ weights, surface tumor
number, and total tumor volume in both groups. Cell
proliferation index revealed that all liver tissues from mice
receiving 5F treatment were less proliferative than the nontreatment group. Mice with 48 mg/kg treatment had highest
value of TUNEL among all groups. Pro-apoptotic proteins
Bax and Bak were strongly expressed in the 48 mg/kg alone
group, and 12, 24 mg/kg plus 5-FU group. Nuclear factor
kappaB (NF-kB) was highly suppressed in the above stated
groups. Suppression of Bcl-2 was observed in all 5F treatment
groups. 5F treatment increased Bax and Bak expression but
decreased Bcl-2 and NF-kB levels compared with the tumorbearing non-treatment group. Collectively, 5F alone has a
therapeutic effect on both liver and lung tumors, especially at
the higher doses and 5-FU in combination with the lower
doses (12-24 mg/kg) of 5F may have an additive effect on the
inhibition of tumor. Therefore, 5F is a promising novel antitumor agent. (This study was supported by ITF of Innovation
and Technology Commission, the Government of the Hong
Kong Special Administration Region, GHP/022/06.)
Upon completion of this presentation, participants
should be able to discuss how the herbal-extracted compound
ent-11a-hydroxy-15-oxo-kaur-16-en-19-oic-acid inhibits the
growth of liver and lung tumors in mouse models.
[50] Mercury in the environment. Ernest M. Walker, Jr.,
Sandra M. Walker, Kevin Rice, and Eric R. Blough, Marshall
University School of Medicine and Marshall Community and
Technical College, Huntington, WV.
Mercury, a highly toxic and hazardous environmental
contaminant, exists naturally and as a human-introduced
contaminant, progressively increasing the amount of
atmospheric mercury, which may enter atmospheric-soilwater distribution cycles and be circulated for years. Mercury
poisoning (hydrargaria or mercurialism) results from exposure
to mercury or its compounds and the toxic effects depend on
its chemical form and route of exposure. Ingested elemental
mercury is usually absorbed relatively slowly and may pass
through the digestive system without causing damage.
Ingested inorganic compounds may damage the gastrointestinal tract and cause kidney failure. Organic mercurials,
such as methylmercury, can irreversibly damage the immune,
genetic, metabolic, and nervous systems, particularly in
developing embryos, who are five to ten times more sensitive
than adults. Certain bacteria in the environment take up
inorganic mercury and convert it to methylmercury. These
bacteria may be consumed by the next higher level in the food
chain, or release methylmercury into water, where it can
adsorb to plankton and work up the food chain. People are
exposed to methylmercury largely by eating contaminated
fish, seafood, and wildlife that are at the top of food chains.
Ingested mercury may undergo bioaccumulation leading to
214 Annals of Clinical & Laboratory Science, vol. 39, no. 2, 2009
progressive increases in body burdens. Many toxic effects of
mercury are partially or wholly reversible through specific
therapy, decreased exposure, and natural elimination of the
metal after exposure has been discontinued. Treatment of
mercury poisoning is difficult. Only DMSA (2,3-dimercaptosuccinic acid) is FDA-approved to treat inorganic mercury in
children. Other agents sometimes used include DMPS (2,3dimercapto-1-propanesulfonic acid), DPCN (D-penicillamine), or BAL (dimercaprol). No FDA-approved chelator
exists for methylmercury or ethylmercury treatment although
oral DMSA is the most frequently used.
Upon completion of this presentation, participants
should be able to explain the health hazards and toxic
mechanisms, especially to developing fetuses, following
exposures to mercurial compounds, especially methylmercury,
[51] Deferasirox and iron removal in the iron overloaded
gerbil model. Rabaa M. Al-Rousan, Ernest M. Walker,
Joseph P. Laurino, Satyanarayana Paturi, and Eric R.
Blough, Marshall University School of Medicine, Huntington,
WV, and University of Tampa, Tampa, FL.
Transfusional iron overload in thalassaemia and other
conditions is the most common metal-related toxicity disorder
with the highest mortality rate worldwide. Iron overload leads
to iron deposition in the heart, liver, and endocrine tissues
resulting in serious disease states including cardiomyopathy,
hepatic fibrosis, and diabetes mellitus. Deferasirox is a novel
tridentate oral iron chelator that was recently approved for the
treatment of transfusional iron overload. The objective of this
study is to evaluate the ability of deferasirox to remove stored
tissue iron and prevent or reverse iron-induced tissue injury.
Adult male Mongolian gerbils were randomly divided into 3
groups: control, iron overload, and iron overload + deferasirox
treatment (n = 8/group). Iron-dextran was given 100 mg/kg/
5d ip for 10 wk. Deferasirox treatment was undertaken postiron loading and was given at 100 mg/kg/d po. Iron levels in
heart, liver, and pancreas were determined by inductively
coupled plasma atomic emission spectrometry (ICP-AES)
and Prussian blue iron staining was performed to examine
iron deposition in the corresponding tissues. Hydroethidine
fluorescence, oxyblot, and immunoblotting analyses were
used to evaluate indices of cardiac and hepatic oxidative
stress. Compared to the untreated group, the data show that
deferasirox treatment for three mo resulted in 23.5%, 43.5%,
and 38% reductions in cardiac, hepatic, and pancreatic iron
levels, respectively (p <0.05). Histological examination
revealed reduced iron deposition and superoxide production
with deferasirox treatment. Deferasirox-mediated reductions
in tissue iron levels were associated with decreases in tissue
ferritin and diminished indices of oxidative stress. Taken
together, these results demonstrate that deferasirox removes
excess tissue iron and has a protective effect against ironinduced cellular insult.
Upon completion of this presentation, participants
should be able to weigh the strength of the experimental
evidence and speculate about the potential clinical use of
deferasirox for therapy of iron-overload in patients.
[52] Overview of iron metabolism and hemochromatosis.
Donald J. Cannon, The University of Tampa, Tampa, FL.
Iron is critical to our industries and indispensable to
many functions in the human body, including its role in the
transport of oxygen as a constituent of hemoglobin. We
continually ingest iron in our diet and lose some every day.
Maintaining a balance in this element depends on the
processes of iron absorption, transport. storage, erythrocyte
turnover, and the individual’s genetic makeup. Pathological
conditions arise from both deficiencies and excesses of iron.
Among the latter is hemochromatosis, a disease that can
either be acquired or caused by an autosomal genetic disorder.
Primary hemochromatosis is hereditary with a genetic defect
in the HFE gene or other genes that regulate absorption,
transport, and storage of iron. Hemochromatosis can become
manifest at any age, but it is seen chiefly between the ages of
30 and 50 yr in men and after the age of 50 yr in women.
Hemochromatosis is treatable, under-diagnosed, and may
contribute to the development of cancer and diabetes. Various
clinical laboratory tests of iron metabolism will be reviewed,
as well as tthe genetic tests for hemochromatosis. Continual
education of the public and health care professionals about
hemochromatosis is needed to increase awareness of this
relatively common and sometimes fatal disease.
Upon completion of this presentation, participants
should be able to describe the silent and occult nature of iron
buildup in hemochromatosis and discuss steps to ameliorate
this condition.
[53] HLA sequence-based typing. Kaaron Benson, H. Lee
Moffitt Cancer Center, Tampa, FL.
HLA typing has evolved from use of serologic to
molecular methods. Of the molecular methods commonly
employed, sequence-based typing (SBT) allows for high
resolution typing and allele-level results. Stem cell
transplantation programs have expanded the number of HLA
loci typed from three (HLA-A, B, DRB1) to five (HLA-A, B,
Cw, DRB1, DQB1) to allow for improved engraftment and
reduced graft-vs-host disease rates, particularly when
unrelated donors are necessary. When HLA-matched, related
donors are not available, HLA-matched, unrelated donors
offer potential cures to patients with previously incurable
diseases.
Upon completion of this presentation, participants
should be able to list 2-3 advantages of molecular HLA typing
over use of serologic methods, outline the basic steps in
molecular HLA assays, and select the best donor from a roster
of HLA-mismatched, unrelated donors.
[54] Hereditary thrombophilia and the molecular
pathogenesis of Factor V Leiden. M. Kent Froberg, Saint
Mary’s Duluth Clinic, Duluth, MN
Hereditary thrombophilia affects 5-8% of the USA
population, causing deep venous thrombosis (DVT) and
pulmonary emboli leading to 60,000 deaths annually.
Congenital causes of thrombogenic disease include deficiencies
in Proteins C, S, and anti-thrombin III; and mutations in
enzymes of homocysteine metabolism, prothrombin, and
Factor V. Normally Factor V is a cofactor for activation of
Abstracts, 2009 Annual Meeting of the Association of Clinical Scientists
Factor X which leads to conversion of thrombin from
prothrombin and the ultimate production of fibrin from
fibrinogen, Activated Factor V is inactivated by activated
Protein C as a major step in anticoagulation. Factor V Leiden
mutation leads to activated protein C resistance and accounts
for more than 50% of hereditary thrombophilia. The most
common genetic change in Factor V Leiden involves an
arginine to glutamine substitution at amino acid position 506
making Factor V resistant to proteolysis by activated protein
C. This arginine residue is the preferred catalytic site for
activated Protein C degradation of Factor V. This mutation
prevents inactivation of Factor V, but does not prevent its
activation, hence the accumulation of activated Factor V leads
to a procoagulant state and increased risk of DVT. Factor V
Leiden is likely when activated Protein C resistance is present.
Factor Va levels remain increased and the clotting time is
shortened. Molecular diagnosis of Factor V Leiden mutation
may be confirmed by PCR assay using a restriction enzyme
that specifically cleaves Factor V at the 506 position and
facilitates automated diagnosis from small blood samples.
Upon completion of this presentation, participants
should be able to name the most common causes of hereditary
thrombophilia, explain the role of Factor V in normal clotting,
discuss the role of activated Protein C in anticoagulation, and
tell how Factor V Leiden mutation leads to activated Protein
C resistance and an increased risk of deep vein thrombosis.
[55] Feto-maternal hemorrhage detection techniques.
Jonathan S. Krauss, The Medical College of Georgia,
Augusta, GA
The incidence of hemolytic disease of the newborn
(HDN) has been dramatically reduced due to tests that both
identify and quantify, to dose Rh(0)(D) immune globulin,
feto-maternal hemorrhage (FMH) in Rh-negative (-) mothers.
Tests for fetal red blood cells (RBCs) in the maternal
circulation recognize either (a) hemoglobin F (Hb F)
containing RBCs, or (b) Rh-positive (+) RBCs. The
identification of HbF cells in the maternal circulation for
FMH quantification is restricted by maternal hereditary
persistence of fetal hemoglobin (HPFH) and other
hemoglobinopathies, which can elevate the maternal Hb F
level. The categorization of Rh+ RBCs in the maternal
circulation for FMH is limited by the need for fetal Rh
phenotype determination, which can be elucidated by
molecular methods, thus lessening the utility of this strategy,
antenatally, however. Acid elution of Hb A (Betke-Kleihauer;
B-K) is the most traditional technique, however, its accuracy
and precision are suboptimal, and interpretation of the B-K
blood smear requires expertise. An automated cytometric/
morphometric method has improved the coefficient of
variation (CV) of the B-K test. Immunologic Hb F
identification methods are primarily flow cytometric; accuracy
and precision may be improved by dual-staining for carbonic
anhydrase (CA), which is absent antenatally; fetal cells are
Hb F+/CA-; adult cells are Hb F-/CA+. Dual color flow
cytometry of Hb F and Rh(0)(D) recognizes Rh+ fetal RBCs.
Flow cytometry can also be used to pinpoint Rh(0)(D) alone;
also, an automated hematology analyzer has been adapted to
quantify anti-Rh(0)(D) labeled cells. Rh+ cells can be
215
identified by rosette and agglutination methods, which
require less instrumentation than flow cytometry. Techniques
for quantification of FMH have gradually improved, primarily
due to advances in flow cytometry.
Upon completion of this presentation, participants
should be able to describe the limitations and advantages of
the different methods for quantitation of fetomaternal
hemorrhage in Rh-negative mothers.
[56] Dermatopathologic manifestations of biowarfare
agents. Michael B. Morgan, University of South Florida
College of Medicine, Tampa, FL.
Although the potential cutaneous manifestations of the
various biowarfare/terrorist agents are manifold, key clinical
and pathologic alterations can be expected in their setting.
The most important and potentially deadly biowarfare agents
include anthrax and smallpox. Anthrax is caused by the
bacterium Bacillus anthracis, a Gram-positive spore-forming
bacillus. Endogenous principally to cattle producing countries
such as Scotland, the United States, and Argentina, among
others, this organism is considered to be zoonotic among
cows with man being occasionally infected following
accidental inhalation of the infective spores or handling of
contaminated furs/hides. The principal forms of the disease
include inhalational disease, producing hemorrhagic
pneumonia and associated with poor prognosis, gastrointestinal disease, and cutaneous disease. The cutaneous
lesions consist initially of a hemorrhagic papule usually seen
on or around the hands that evolves within days to a blackened
ulcer referred to as an eschar. Associated regional lymphadenopathy is commonly observed. The pathogenesis involves
the engulfment of the organisms within macrophages that
may remain localized or proceed to the lymph nodes. B.
anthracis produces 3 important pathogenic factors responsible
for enhancing its virulence: a protective capsule, an edema
factor, and a lethal factor. The diagnosis of anthrax follows
isolation of the organism where a presumptive diagnosis can
be rendered on the basis of the characteristic Gram-staining
attributes, or confirmed with the characteristic medusa-head
colonial morphology seen.
Smallpox, otherwise referred to as variola, is a deadly
microbe known throughout recorded history. The cause is a
orthopox virus last seen naturally in the early 1970’s and since
relegated to biowarfare laboratories in the former USSR and
the CDC in Atlanta. The virus is obtained following
respiratory inhalation of infective droplets and produces a
localized infection of the airways followed by viremia and
later, cutaneous disease. The cutaneous lesions occur as a
single crop producing hemorrhagic macules followed by
papules that ulcerate finally leaving depressed (varioloform)
scars. Unlike chickenpox (varicella) with which it may be
confused, the lesions are concentrated upon the extremities
and face and show lesions that are temporally and
isomorphically related. Pathology of the lesions shows a
combination of reticular and balooning epithelial degeneration
with characteristic intra-cytoplasmic viral inclusions referred
to as Guarneri bodies. The case fatality rate of smallpox is
high, with most complications stemming from pneumonia,
encephalitis, and disseminated intravascular coagulation.
216 Annals of Clinical & Laboratory Science, vol. 39, no. 2, 2009
Diagnosis can be achieved by biopsy, serology, culture, or
electron microscopy. Treatment with antivirals is available.
Patients diagnosed with the disease should be immediately
isolated and public health authorities notified. The implications
of diagnosis of smallpox are ominous and should engender
consideration of biowarfare or terrorist attack.
Upon completion of this presentation, participants
should be able to distinguish between the important
biowarfare microbes that present with cutaneous
manifestations and describe the pathogenesis of the histologic
and clinical attributes of these organisms.
[57] Influenza: Considerations in children and adolescents.
Armand Glassman, Medical University of South Carolina,
Charleston, SC.
The purpose of this work is to examine the role of
influenza in morbidity and mortality of children and
adolescents (C&A). Data from the Centers for Disease
Control & Prevention (CDC) for the 2006-2007 influenza
season were reviewed to provide information regarding deaths
in C&A. A total of 76 deaths for this group were reported in
this time period. The predominant organism was influenza
A/New Caledonia, a type H1N1 strain. This strain was
included in the trivalent vaccine that year. It is estimated that
vaccine efficacy ranges from 70 to 90 % assuming that there
is a good match of the vaccine antigen(s) and the epidemic
virus. Two types of vaccines are available. The more commonly
used one is the trivalent inactivated vaccine (TIV), which
must be injected. A live attenuated influenza vaccine (LAIV)
administered by nasal spray is available. LAIV is more
effective than TIV in young children. The Advisory
Committee on Immunization Practices (ACIP) recommends
influenza vaccination for all children 6 mo to 18 yr of age.
Influenza variants that were not part of vaccines have been the
cause of 80% of epidemics in the last few years. The present
TIV contains one H1N1, one H3N2, and one influenza B
viral antigen. Diagnosing outbreaks includes clinical
presentation and a variety of on site rapid tests. Viral cultures
are necessary to characterize the specific virus & antigens.
Antiviral drug selection for the treatment of influenza presents
challenges. Amantadine and rimantadine are ineffective for
H3N2 strains. Oseltamivir, a neuraminidase inhibitor, is not
effective against many H1N1 strains. Influenza is associated
with significant disease and death in C&A. Universal
vaccination of C&A has been recommended by the ACIP.
Vaccination and therapy for influenza have limitations.
Upon completion of this presentation, participants
should be able to recount the current status of vaccines against
influenza strains and the antiviral drugs that are available for
treatment of influenza infection in children and adolescents.
[58] Multi-drug resistant Acinetobacter infections in Iraq
veterans: The Tampa VA experience. L. Brannon Thomas,
A.A. Borkowski, M.J. Kasper, A.V. Heal, F.J. Kinney, J.
N.Burgett, R.L. Oehler, S.G. Scott, B. Neugaard, and S.M.
Mastorides, James A. Haley Veterans Hospital, Tampa, FL.
Infections with multi-drug resistant Acinetobacter
(MDR-Acb) are an increasing problem in hospitals worldwide, and these infections are extremely common among
casualties of Operation Iraqi Freedom (OIF). We will review
our current understanding of MDR-Acb infections in veterans
of OIF, and explore problems and potential solutions to
developing rapid detection (PCR based) screening tests for
these infections. Emphasis will be on the findings from
patients admitted to the James A. Haley Veterans Hospital in
Tampa, FL. This facility is one of the nation’s largest veterans’
hospitals, and one of only four designated VA poly-trauma
rehabilitation centers. We performed a retrospective chart
review tracking OIF veterans admitted to our facility from
injury through rehabilitation, finding that 56% had cultures
positive for Acb. Of these, 85% were with MDR strains
(defined as resistant to ≥4 classes of commonly tested
antibiotics). In 25% of these veterans, at least one culture was
resistant to all antibiotics tested. The most common
mechanism of injury was from improvised explosive devices
(IEDs), although patients with non-penetrating injuries were
colonized and/or infected as well. Most positive cultures were
from the skin, respiratory tract, or wounds, with many
additional sites encountered. Veterans with MDR-Acb
infections had lengthened hospital and rehabilitation stays
(128.6 days compared to 89.2 days in patients without MDRAcb infections). Furthermore, these admissions coincided
with a greater than 6-fold increase of multi-drug resistance in
Acb infections in non-OIF patients admitted to our facility.
MDR-Acb infections produce challenges in both treatment
and containment, and, due to diverse mechanisms of drug
resistance, difficulties with developing rapid screening tests.
Upon completion of this presentation, participants
should be able to define multi-drug resistant Acinetobacter
infections, discuss the basic mechanisms involved in drug
resistance, summarize current theories regarding the origin of
these infections in casualties of Operation Iraqi Freedom,
delineate the dissemination risk of these infections in the
hospital setting, and describe the difficulty of developing
rapid screening tests.