Freeze artifact on full-field optical coherence tomography skin imaging.

BACKGROUND/PURPOSE: Full-field optical coherence tomography (FFOCT) is an emerging imaging technique for rapid histological analysis. As FFOCT is introduced into the Mohs workflow, it is important to document the effect of tissue freezing on FFOCT images and any effect FFOCT has on frozen sections. Our study aimed to evaluate the changes on FFOCT images after tissue freezing as well as FFOCT imaging effects on frozen sectioning. METHODS: Six normal skin specimens were imaged using FFOCT and subsequently frozen using a cryostat. The specimens were then reimaged using FFOCT and compared for any differences. To evaluate the effect of FFOCT imaging on frozen sections, five normal skin specimens were bisected and one half was imaged using FFOCT. Both halves underwent frozen sectioning and analysis. RESULTS: Significant changes in the fat, sebaceous glands, eccrine glands, and dermal collage and minimal changes in the epidermis were seen after freezing. No effect on frozen sectioning was seen after FFOCT imaging. CONCLUSION: As FFOCT is studied for use in Mohs, clinicians should be aware that freezing prior to imaging introduces significant artifact in the FFOCT image. If possible, specimens should undergo imaging prior to being frozen.

Recommendations for Solid Organ Transplantation for Transplant Candidates With a Pretransplant Diagnosis of Cutaneous Squamous Cell Carcinoma, Merkel Cell Carcinoma and Melanoma: A Consensus Opinion From the International Transplant Skin Cancer Collaborative (ITSCC).

Advancements in solid organ transplantation successfully extend the lives of thousands of patients annually. The tenet of organ stewardship aims to prevent the futile expenditure of scarce donor organs in patient populations with high mortality risk, to the detriment of potential recipients with greater predicted life expectancy. The development of skin cancer posttransplantation portends tremendous morbidity, adversely affecting quality of life for many transplant recipients. This special article, provided by of members of the International Transplant Skin Cancer Collaborative (ITSCC), will provide the transplant professional with a consensus opinion and recommendations as to an appropriate wait period pretransplantation for transplant candidates with a history of either cutaneous squamous cell carcinoma, malignant melanoma, or Merkel cell carcinoma.

Sirolimus conversion regimen versus continued calcineurin inhibitors in liver allograft recipients: a randomized trial.

A large prospective, open-label, randomized trial evaluated conversion from calcineurin inhibitor (CNI)- to sirolimus (SRL)-based immunosuppression for preservation of renal function in liver transplantation patients. Eligible patients received liver allografts 6-144 months previously and maintenance immunosuppression with CNI (cyclosporine or tacrolimus) since early posttransplantation. In total, 607 patients were randomized (2:1) to abrupt conversion (<24 h) from CNI to SRL (n = 393) or CNI continuation for up to 6 years (n = 214). Between-group changes in baseline-adjusted mean Cockcroft-Gault GFR at month 12 (primary efficacy end point) were not significant. The primary safety end point, noninferiority of cumulative rate of graft loss or death at 12 months, was not met (6.6% vs. 5.6% in the SRL and CNI groups, respectively). Rates of death at 12 months were not significantly different, and no true graft losses (e.g. liver transplantation) were observed during the 12-month period. At 52 weeks, SRL conversion was associated with higher rates of biopsy-confirmed acute rejection (p = 0.02) and discontinuations (p < 0.001), primarily for adverse events. Adverse events were consistent with known safety profiles. In conclusion, liver transplantation patients showed no demonstrable benefit 1 year after conversion from CNI- to SRL-based immunosuppression.

[Hydatid disease of the first rib treated surgically by the Roos approach]. / Hydatidose de la première côte opérée par voie de Roos.

Hydatid disease is a parasitic infection due to Echinococcus granulosus. Since involvement of the ribs and in particular the first rib is rare, diagnosis and treatment in these locations can pose special problems. The purpose of this report is to describe the case of a 27-year-old man in whom an apical left opacity was discovered by chance. Clinical examination was normal. Thoracic ultrasound demonstrated multilocular cyst in the left apical region of the thorax. Thoracic computed tomography (CT) demonstrated a hydatid cyst originating from the first rib. The patient was operated using the technique known as the Roos approach. The procedure consisted of cystectomy with resection of the first rib. The multiloculated appearance of the lesion and erosion at the first rib was consistent with hydatid cyst. The Roos approach is the technique of choice for the treatment of the first rib.

Liver retransplantation: a single-center outcome and financial analysis.

Retransplantation of the liver (re-OLTx) accounts for approximately 10% of all liver transplants in the United States. The decision to offer a patient a second liver transplant has significant financial, ethical, and outcome implications. This large, single-center experience describes some outcome and financial data to consider when making this decision. One thousand three liver transplants were performed in 921 patients at our center. Patients were divided into adult and pediatric groups, and further by whether they received a single transplant or more than one. Overall survival, variation in survival by timing of re-OLTx, and survival in adults with hepatitis C were investigated, as were hospital charges and cost of re-OLTx. Adults, but not children, had a significant decrement in survival following a second transplant. Second transplants more than double the cost of the initial transplant, but there is a significantly higher cost associated with early retransplantation compared to the cost associated with late retransplantation (costs of first and second transplants included in both cases). This difference is due to a longer length of stay and associated cost in the ICU. Adult patients retransplanted early have the same overall survival compared to those done late. The sample size of the adult HCV re-OLTx population was too small to reach statistical significance despite their observed poorer outcome.

[Mediastinal localisation of a thoracic duct lymphocele--account of a surgical case]. / Localisation médiastinale d'une lymphocèle du canal thoracique: apropos d'un cas opéré.

INTRODUCTION: Lymphocele of the thoracic duct is a rare pathological entity occurring as a consequence of deterioration and cystic dilation wall of this vessel. It may be of congenital or degenerative origin. OBSERVATION: We report the case of a 47 year old patient, operated on for a symptomatic cyst localised by CT scan to the inferoposterior mediastinum. At postero-lateral thoracotomy it was identified as a lymphocele and completely resected. Chemical analysis of the liquid and histopathology study of the cystic wall confirmed the diagnosis. The patient's post operative course was uneventful. CONCLUSION: This case demonstrates the clinical characteristics of this entity and describes diagnostic techniques and surgical management.

[Pulmonary myofibroblastoma: the role of primary surgery]. / Tumeur myofibroblastique pulmonaire: intérêt de la chirurgie première.

INTRODUCTION: Myofibroblastic tumours or pulmonary pseudotumours are rare and, though benign, they may become invasive and recur after excision. CASE REPORT: We report the case of a child aged 14, presenting with mild haemoptysis, who had a solitary nodule at the base of the left lung. CT scanning suggested a hypervascular tumour. Fibreoptic bronchoscopy was normal and it was not possible to perform percutaneous biopsy on account of its proximal situation. A lobectomy was performed via a postero-lateral thoracotomy with a successful outcome. Histological examination revealed a myofibroblastic tumour. CONCLUSION: Recourse to primary surgery is essential to confirm the diagnosis of a myofibroblastic pulmonary tumour. Complete resection is the only guarantee to prevent recurrence.

Rectal bleeding from a mucous fistula secondary to a Dieulafoy's lesion.

Dieulafoy's lesion is a submucosal artery associated with a minute mucosal defect, and it is an extremely rare cause of profuse but intermittent gastrointestinal bleeding. Most cases have occurred in the proximal stomach within 6 cm of the gastroesophageal junction. Less commonly, cases are encountered in the antrum, duodenum, jejunum, colon, and rarely the rectum. Only three cases of rectal Dieulfoy's lesion have been reported in the English medical literature: one in a child and two in otherwise healthy young men. We report a case of a rectal Dieulafoy's lesion in an elderly man with a mucous fistula. Successful treatment was administered with a combination of injection therapy and heater-probe coagulation followed by elective surgical oversewing. Rectal Dieulafoy's lesions should be included in the differential diagnosis of unexplained rectal bleeding in the elderly.

Two cases from the spectrum of nonalcoholic steatohepatitis.

Nonalcoholic steatohepatitis is a poorly understood disease that mimics alcoholic liver disease histologically. Its natural history is not well defined, although gradual progression to cirrhosis has been described. Most patients with this condition have been obese, with or without associated diabetes or hyperlipidemia. No known effective treatment exists for nonalcoholic steatohepatitis, although weight loss may have a beneficial effect. We report two cases of nonalcoholic steatohepatitis. One patient with well-established nonalcoholic steatohepatitis had cirrhosis with a complete loss of fat on subsequent liver biopsy despite a gain in weight, simulating cryptogenic cirrhosis. In another patient, the condition improved after use of ursodeoxycholic acid; this agent may be a potential therapeutic agent for the treatment of nonalcoholic steatohepatitis. We believe these two cases represent the spectrum of this condition: on the one end is a progressive liver disease that in some instances may be a cause of cryptogenic cirrhosis; at the other end, a potentially treatable liver condition.

Betaine, a promising new agent for patients with nonalcoholic steatohepatitis: results of a pilot study.

OBJECTIVES: No effective therapy currently exists for patients with nonalcoholic steatohepatitis (NASH). Betaine, a naturally occurring metabolite of choline, has been shown to raise S-adenosylmethionine (SAM) levels that may in turn play a role in decreasing hepatic steatosis. Our aim was to determine the safety and effects of betaine on liver biochemistries and histological markers of disease activity in patients with NASH. METHODS: Ten adult patients with NASH were enrolled. Patients received betaine anhydrous for oral solution (Cystadane) in two divided doses daily for 12 months. Seven out of 10 patients completed 1 yr of treatment with betaine. RESULTS: A significant improvement in serum levels of aspartate aminotransferase (p = 0.02) and ALAT (p = 0.007) occurred during treatment. Aminotransferases normalized in three of seven patients, decreased by >50% in three of seven patients, and remained unchanged in one patient when compared to baseline values. A marked improvement in serum levels of aminotransferases (ALT -39%; AST -38%) also occurred during treatment in those patients who did not complete 1 yr of treatment. Similarly, a marked improvement in the degree of steatosis, necroinflammatory grade, and stage of fibrosis was noted at 1 yr of treatment with betaine. Transitory GI adverse events that did not require any dose reduction or discontinuation of betaine occurred in four patients. CONCLUSIONS: Betaine is a safe and well tolerated drug that leads to a significant biochemical and histological improvement in patients with NASH. This novel agent deserves further evaluation in a randomized, placebo-controlled trial.

Whipple's arthritis: direct detection of Tropheryma whippelii in synovial fluid and tissue.

We describe 2 patients presenting with polyarthritis in whom the synovial fluid (1 patient) or synovial tissue (1 patient) was positive for Tropheryma whippelii, the Whipple's disease-associated bacillus, when examined by polymerase chain reaction (PCR) and DNA sequencing. Histopathologic findings were consistent with articular Whipple's disease in the synovial fluid of 1 patient and the synovial tissue of the other. In both patients, bowel mucosal specimens were negative for Whipple's disease features by histologic and PCR methods. One patient was positive for T whippelii in the peripheral blood. Control synovial fluid specimens from 40 patients with other arthritides, including Lyme arthritis, were negative. Sequencing of a 284-basepair region of the 16S ribosomal RNA gene confirmed that the sequence is closely related to the known T whippelii sequence. Both patients responded to treatment with antibiotics.

Anti-interleukin-2 receptor therapy in combination with mycophenolate mofetil is associated with more severe hepatitis C recurrence after liver transplantation.

The pathogenesis of hepatitis C virus (HCV) recurrence after liver transplantation (LT) is poorly understood, but the cellular immune response is likely to have a major role. Daclizumab, an interleukin-2 receptor (IL-2R) antibody that blunts T-cell activation, leading to a decreased risk for cellular rejection, is used frequently in transplant recipients. The aim of this study is to evaluate the effect of daclizumab therapy on the incidence and severity of recurrent HCV. Forty-one liver transplant recipients (21 patients, HCV positive; 20 patients, HCV negative) at high risk for neurological or renal complications of calcineurin inhibitors were administered daclizumab, mycophenolate mofetil (MMF), and steroids in the early post-LT period, followed by tacrolimus and a steroid taper. All patients were followed up prospectively for graft function and disease recurrence with protocol liver biopsies day 7, month 4, and yearly. Compared with patients without HCV, patients with HCV administered daclizumab had greater 4-month serum alkaline phosphatase, total bilirubin, and alanine aminotransferase (ALT) levels. These biochemical differences resolved by 12 months, except for persistent elevation of ALT levels. Compared with a well-matched HCV control population, patients with HCV administered daclizumab were more likely to have an earlier onset of hepatitis, jaundice, and greater histological activity. Recurrent hepatitis progressed more rapidly in the daclizumab group; 45% developed advanced disease within 1 year. HCV viral load in the daclizumab group was significantly greater at both 4 months and 1 year. Results of this study suggest that the use of adjuvant IL-2R antibodies in combination with MMF in the early peritransplantation period may be associated with early recurrence of hepatitis C and more rapid histological progression of disease.

Tropheryma whippelii DNA is rare in the intestinal mucosa of patients without other evidence of Whipple disease.

BACKGROUND: Little is known about the pathogenesis of Whipple disease, the reservoirs of Tropheryma whippelii, and the proportion of persons harboring the bacterium without "classic" intestinal abnormalities. OBJECTIVE: To assess the presence of T. whippelii in patients undergoing upper endoscopy for a variety of indications. DESIGN: Prospective and routine diagnostic examination of patients. SETTING: Three academic medical centers in California; Minnesota; and Heidelberg, Germany. PATIENTS: 342 patients undergoing endoscopy for evaluation of dyspepsia or possible peptic ulcer (group A, 173 patients), malabsorption (group B, 37 patients), or clinical suspicion of Whipple disease (group C, 132 patients). MEASUREMENTS: Small-intestinal biopsy specimens were tested by polymerase chain reaction for T. whippelii DNA and examined for histopathologic abnormalities. RESULTS: All patients with negative histologic findings also had negative results for T. whippelii DNA. CONCLUSIONS: T. whippelii occurs only rarely in intestinal mucosa that lacks histopathologic evidence of Whipple disease. The human small intestinal mucosa is an unlikely reservoir for this organism.

Treatment of chronic hepatitis C with interferon with or without ursodeoxycholic acid: a randomized prospective trial.

The only effective and approved therapy for chronic hepatitis C is interferon-alpha. Because sustained response rates with interferon alone are disappointingly low, multidrug treatment regimens are currently being investigated. Ursodeoxycholic acid has been used in other chronic liver diseases and can limit hepatocyte injury. To evaluate the potential benefit of ursodeoxycholic acid in combination with interferon-alpha for the treatment of chronic hepatitis C, we conducted a prospective, double-blinded, randomized, placebo-controlled trial comparing the combination therapy of interferon-alpha 2b and ursodeoxycholic acid with interferon alone. Thirty-one patients with chronic hepatitis C were randomized to receive 3 million units of interferon-alpha 2b subcutaneously three times per week and either 13 to 15 mg/kg/day ursodeoxycholic acid or placebo orally for 6 months. The 6-month treatment period was followed by 6 months of observation. Biochemical normalization at the end of treatment occurred in 5 of 14 (36%) patients receiving monotherapy versus 8 of 15 (53%) patients (p = 0.34) receiving combination therapy. No patient treated with interferon alone had a sustained biochemical response 6 months after therapy; however, 3 of 12 patients (25%) treated with combination interferon and ursodeoxycholic acid maintained biochemical normalization at 6 months after therapy (p = 0.08). No difference in liver histology or clearance of hepatitis C viral RNA was noted 6 months after treatment. We conclude that combination therapy with ursodeoxycholic acid and interferon-alpha 2b was no more effective than interferon monotherapy in inducing a biochemical response in previously untreated patients with chronic hepatitis C. Ursodeoxycholic acid, however, may be useful in prolonging the biochemical response to interferon therapy.