Unusual presentation of disseminated cryptococcal infection complicated by myocarditis in a heart transplant recipient.

BACKGROUND: Cryptococcus neoformans is the third most common cause of invasive fungal infection in solid organ transplant (SOT) recipients. While cryptococcal infection can involve any organ, cases of myocarditis are exceedingly rare. METHODS: A retrospective chart review was completed for this case report. RESULTS: We present the case of a 21-year-old heart transplant recipient who developed disseminated cryptococcal infection with biopsy-proven cryptococcal myocarditis. CONCLUSIONS: Cryptococcal disease in SOT recipients poses diagnostic and therapeutic challenges. There are no current guidelines for the duration of cryptococcal myocarditis treatment. Repeat myocardial biopsy may play a role in guiding length of therapy.

Addressing Academic Concerns: A Survey of Primary Care Providers.

Given new clinical recommendations, we sought to better understand the perspectives and practices of primary care providers (PCPs) around pediatric academic concerns. Practicing PCPs were recruited to complete an 8-item self-report survey; 163 PCPs were included in the final analysis. Results indicated that 84% of PCPs perceived their role in addressing patients' academic concerns as highly important; yet there was variability in the frequency with which PCPs reported engaging in activities around these educational needs. There was a significant positive relationship between perception of role importance and engagement in clinical supports. Some differences were present in responses across PCP specialty area. More information about practice differences between provider types, rural versus urban practices, and how perceptions/practices differ based on provider demographics are likely to be useful areas for future consideration. Our findings highlight the need to advance PCP instruction for practical implementation to increase rates of engagement in these activities.

Endothelium-in Versus Endothelium-out Insertion With Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To determine whether graft orientation during insertion affects Descemet membrane endothelial keratoplasty (DMEK) outcomes. METHODS: This was a retrospective analysis of 754 consecutive DMEK cases performed by 2 experienced surgeons to treat Fuchs dystrophy. Both surgeons used an intraocular lens insertor. One surgeon always inserted the tissue scrolled endothelium outward (group 1, n = 245). The other surgeon tested 3 methods: endothelium-outward scroll configuration (group 2, n = 161), endothelium-inward trifold configuration (group 3, n = 172), and trifold configuration with concurrent use of an anterior chamber maintainer (group 4, n = 176). The main outcome measures were rebubbling rate, regrafting or failure within 6 months, and 6-month endothelial cell loss. The tissue unfolding time from graft insertion to air fill was measured in a subset of 120 cases by 1 surgeon. RESULTS: The rebubbling rates were comparable across groups (ie, 12%, 10%, 10%, and 13% for groups 1, 2, 3, and 4, respectively, P = 0.21). The 6-month graft failure/replacement rates were comparable across groups (ie, 0.8%, 1.2%, 2.3%, and 0.6%, respectively, P = 0.18). Similarly, the 6-month endothelial cell loss did not differ significantly between groups (ie, 28% ± 11%, 30% ± 13%, 28% ± 15%, and 27% ± 13%, respectively, P = 0.019). In the subset analysis, the tissue unfolding time was similar for scroll and trifold configurations (6.0 ± 3.5 vs. 5.4 ± 3.0 minutes, respectively, P = 0.43). CONCLUSIONS: The outcomes were similar for endothelium-out and endothelium-in (trifold) insertion methods with DMEK, suggesting that the choice is a matter of surgeon preference.

Five-Year Graft Survival of Descemet Membrane Endothelial Keratoplasty (EK) versus Descemet Stripping EK and the Effect of Donor Sex Matching.

PURPOSE: To determine whether the reduced risk of immunologic rejection with Descemet membrane endothelial keratoplasty (DMEK) results in a 5-year survival advantage relative to Descemet stripping endothelial keratoplasty (DSEK) and to determine whether matching the donor and recipient sex affects the rejection episode and graft survival rates. DESIGN: Retrospective cohort study. PARTICIPANTS: Patients with Fuchs' endothelial corneal dystrophy treated with DSEK or DMEK. METHODS: This study reviewed 2017 consecutive cases (1312 DSEK and 705 DMEK) performed by 13 surgeons between 2003 and 2012 and included the surgeons' first cases. Survival rates were calculated by Kaplan-Meier analysis. MAIN OUTCOME MEASURES: Immunologic rejection episodes, graft failure or replacement for any reason, and endothelial cell loss. RESULTS: The 5-year rejection episode rate was lower with DMEK (2.6% vs. 7.9% with DSEK, relative risk, 0.29; 95% confidence interval, 0.16-0.53) despite early reduction of topical corticosteroids in 25% of the DMEK cases. African Americans (n = 46) had a higher risk of rejection episodes than other races (relative risk, 4.4; 95% confidence interval, 2.0-9.6). The cumulative 5-year survival rate was 93% with DSEK and DMEK (P = 0.86). Forty-four DMEK and 69 DSEK grafts failed or were replaced within 5 years, but only 1 DMEK and 4 DSEK failures followed a rejection episode. Rejection episodes increased endothelial cell loss (P = 0.004) but were not a significant risk factor for graft failure within 5 years (P = 0.90). The mean 5-year endothelial cell loss was similar between DMEK (48%±19%) and DSEK (47%±19%) (P = 0.22). Graft rejection episode and survival rates were not significantly influenced by whether the sex of the donor matched that of the recipient (rejection episodes: P = 0.07 for female recipients and P = 0.33 for male recipients; graft survival: P = 0.67 for female recipients and P = 0.17 for male recipients). CONCLUSIONS: Five-year graft survival was similar between DMEK and DSEK. Although DMEK had a significantly lower risk of immunologic rejection, rejection episodes rarely resulted in graft failure within 5 years with either procedure. Sex matching the donor and recipient provided no survival advantage with DSEK or DMEK.