Vaccine-associated varicella and rubella infections in severe combined immunodeficiency with isolated CD4 lymphocytopenia and mutations in IL7R detected by tandem whole exome sequencing and chromosomal microarray.

In areas without newborn screening for severe combined immunodeficiency (SCID), disease-defining infections may lead to diagnosis, and in some cases, may not be identified prior to the first year of life. We describe a female infant who presented with disseminated vaccine-acquired varicella (VZV) and vaccine-acquired rubella infections at 13 months of age. Immunological evaluations demonstrated neutropenia, isolated CD4 lymphocytopenia, the presence of CD8(+) T cells, poor lymphocyte proliferation, hypergammaglobulinaemia and poor specific antibody production to VZV infection and routine immunizations. A combination of whole exome sequencing and custom-designed chromosomal microarray with exon coverage of primary immunodeficiency genes detected compound heterozygous mutations (one single nucleotide variant and one intragenic copy number variant involving one exon) within the IL7R gene. Mosaicism for wild-type allele (20-30%) was detected in pretransplant blood and buccal DNA and maternal engraftment (5-10%) demonstrated in pretransplant blood DNA. This may be responsible for the patient's unusual immunological phenotype compared to classical interleukin (IL)-7Rα deficiency. Disseminated VZV was controlled with anti-viral and immune-based therapy, and umbilical cord blood stem cell transplantation was successful. Retrospectively performed T cell receptor excision circle (TREC) analyses completed on neonatal Guthrie cards identified absent TREC. This case emphasizes the danger of live viral vaccination in severe combined immunodeficiency (SCID) patients and the importance of newborn screening to identify patients prior to high-risk exposures. It also illustrates the value of aggressive pathogen identification and treatment, the influence newborn screening can have on morbidity and mortality and the significant impact of newer genomic diagnostic tools in identifying the underlying genetic aetiology for SCID patients.

Anchoring barbs and balloon expandable stents: what is the risk of perforation and failed stent deployment?

PURPOSE: Balloon expandable stents may on occasion be deployed in close proximity to the anchoring barbs of endovascular grafts. The aim of this study was to determine the risk and effect of balloon perforation by anchoring barbs and to assess whether these risks are different if the balloon is protected by a covered stent mounted upon it. METHODS: A bench-top model was developed to mimic the penetration of anchoring barbs into the lumen of medium sized blood vessels. The model allowed variation of angle and depth of vessel penetration. Both bare balloons and those with covered stents mounted upon them were tested in the model to determine whether there was a risk of perforation and which factors increased or decreased this risk. RESULTS: All combinations of barb angle and depth caused balloon perforation but this was most marked when the barb was placed perpendicular to the long axis of the balloon. When the deployment of covered stents was attempted balloon perforation occurred in some cases but full stent deployment was achieved in all cases where the perforation was in the portion of the balloon covered by the stent. The only situation in which stent deployment failed was where the barb was intentionally placed in the uncovered portion of the balloon. This resulted in only partial deployment of the stent. CONCLUSIONS: Balloon rupture is a distinct possibility when deploying balloon-expandable stents in close proximity to anchoring barbs. Care should be taken in this circumstance to ensure that the barb is well away from the uncovered portion of the balloon.

Fascial closure following percutaneous endovascular aneurysm repair.

INTRODUCTION: There are potential benefits of percutaneous over open femoral access for endovascular aneurysm repair (EVAR). Subsequent arterial closure using percutaneous devices is costly, whilst open repair risks potential wound complications and delayed discharge. The technique of fascial closure has perceived advantages but its efficacy is unclear. The aim of this study was to assess the safety and durability of fascial closure after EVAR. METHODS: Patients undergoing EVAR using devices up to 24 French were considered. Exclusion criteria included morbid obesity, high bifurcation, previous surgery, inadvertent high puncture, arteries < 5 mm and surgeon preference. The primary outcome measure was immediate technical success. All patients were followed-up clinically and with duplex at one and twelve months to determine secondary complications. RESULTS: Over a one-year period fascial closure of 69 common femoral arteries was attempted in 38 patients undergoing EVAR. Nine primary failures were due to haemorrhage in eight arteries and thrombosis in one artery; all had immediate, uncomplicated open revision. Of the 60 (87%) successful procedures, all had duplex surveillance at one month. Four pseudoaneurysms were identified, all treated conservatively. At one year, 61 fascial closures (88%) were imaged, four patients had died and two were lost to follow-up. Three of the pseudoaneurysms had resolved, the fourth patient had died (unrelated). No other complication attributable to fascial closure was found at either one or twelve months. CONCLUSION: Fascial closure is a safe, durable and cost-effective method of arterial closure following EVAR. Success and complication rates are comparable to other techniques.

Surveillance after EVAR based on duplex ultrasound and abdominal radiography.

INTRODUCTION: Computed tomography angiography (CTA) is considered the gold standard imaging technique for surveillance following endovascular aneurysm repair (EVAR). Limitations of CTA include cost, risk of contrast nephropathy and radiation exposure. A modified surveillance protocol involving annual duplex ultrasound (DUS) and abdominal radiography (AXR) was introduced, with CTA performed only if abnormalities were identified or DUS was undiagnostic. METHODS: Prospective records were maintained on patients undergoing infra-renal EVAR at a UK, tertiary referral centre. All patients enrolled with at least one-year follow-up were reviewed. Primary outcomes identified were aneurysm rupture and aneurysm-related complications. Secondary outcomes included number of CTAs avoided and cost. RESULTS: Median follow-up was 36 months (range 12-57) for 194 patients. The total number of sets of surveillance imaging was 412 of which 70 (17%) required CTA. Abnormalities were found in 30 patients, 18 confirmed by CTA. Eleven patients required secondary intervention, three initially identified by AXR, three by DUS, three by both DUS and AXR, and two by CTA following undiagnostic DUS. No patient presented with rupture or aneurysm-related complications not identified by modified surveillance. Mean annual savings were €223. CONCLUSION: EVAR surveillance based on DUS and AXR is feasible and safe. The complimentary nature of AXR and DUS is demonstrated.

Altered perception and report of fatigue and recovery in veteran athletes.

AIM: This study investigated whether ageing effects perceived and reported ratings of fatigue and total quality of recovery following high-intensity training in athletes. We hypothesized that veteran (V) athletes would report greater changes in perceived measures of fatigue and recovery than training-matched younger athletes. METHODS: Perceptions of muscle soreness (SOR), fatigue, and recovery were recorded in young (Y) and V (>35 years) well-trained cyclists in response to 3 days of repeated cycling time trials. Nine Y (24+/-5 years) and 9 V (45+/-6 years) cyclists performed 3 consecutive days (T1-T3) of 30-min cycling time trials (TT30) intended to induce fatigue leading to decreased performance. Physiological and performance variables were measured before, during, and after each time trial. Subjective measures of SOR, fatigue, and recovery were recorded each day. RESULTS: There was no change in performance at the TT30 from T1 to T3 for either group. SOR, fatigue, and recovery significantly changed over the 3 days in the V group, but not in the Y group. The change in SOR from T1 to T3 was significantly greater in the V group than in the Y group (22+/-14 mm vs 9+/-12 mm, respectively; P=0.04). CONCLUSION: It was concluded that 3 days of cycling time trials induce perceptions of muscle pain/SOR, fatigue and reduced recovery in well-trained V cyclists with no corresponding decline in physical performance.

Extracellular adenosine levels and cellular energy metabolism in ischemically preconditioned rat heart.

OBJECTIVE: Microdialysis and 31P-NMR spectroscopy were used to test opposing hypotheses that ischemic preconditioning inhibits adenine nucleotide degradation and purine efflux, or that preconditioning activates cardiovascular adenosine formation to provide enhanced cardioprotection. METHODS: 31P-NMR spectra and matching interstitial fluid (ISF) or venous effluent samples were obtained from Langendorff perfused rat hearts. Control hearts (n = 9) underwent 30 min of global normothermic ischemia and 30 min reperfusion. Preconditioned hearts (n = 6) were subjected to a 5 min ischemic episode and 10 min reflow prior to 30 min ischemia and 30 min reperfusion. Effects of repetitive ischemia-reperfusion (3 x 5 min ischemic episodes) on adenosine levels and energy metabolism were also assessed (n = 8). RESULTS: Preconditioning improved post-ischemic recovery of heart rate x left ventricular developed pressure (71 +/- 5 vs 43 +/- 8%, P < 0.05) and end-diastolic pressure (14 +/- 3 vs 29 +/- 4 mmHg, P < 0.05) compared with control hearts, respectively. Preconditioning did not alter intracellular ATP, phosphocreatine (PCr), inorganic phosphate (Pi), H+ or free Mg2+ during global ischemia, but improved recoveries of PCr, Pi, and delta GATP on reperfusion. ISF adenosine increased more than 20-fold during 30 min ischemia. The 5 min preconditioning episode increased ISF adenosine 3-fold, and reduced ISF adenosine and inosine during subsequent prolonged ischemia by up to 75%. Venous purine levels during reperfusion were also reduced by preconditioning. Accumulation of adenosine in ISF and venous effluent during repetitive ischemia was progressively reduced despite comparable changes in substrate for adenosine formation via 5'-nucleotidase, (5'-AMP), and in allosteric modulators of this enzyme (Mg2+, H+, Pi, ADP, ATP). CONCLUSIONS: (i) Ischemic preconditioning reduces interstitial and vascular adenosine levels during ischemia-reperfusion, (ii) reduced ISF adenosine during ischemia is not due to reduced ischemic depletion of adenine nucleotides in preconditioned rat hearts, (iii) preconditioning may inhibit adenosine formation via 5'-nucleotidase in ischemic rat hearts, and (iv) improved functional recovery with preconditioning is unrelated to metabolic/bioenergetic changes during the ischemic insult, but may be related to improved post-ischemic recovery of [Pi] and delta GATP in this model.

A biphasic response to adenosine in the coronary vasculature of the K(+)-arrested perfused rat heart.

Biphasic vasodilatory responses to adenosine and 5'-N-ethylcarboxamidoadenosine (NECA) were observed in the coronary vasculature of K(+)-arrested perfused rat hearts. Dose-response data for both agonists were best represented by two-site models. For adenosine, two sites with negative log ED50 (pED50) values of 8.1 +/- 0.1 (mean +/- S.E.M) and 5.2 +/- 0.1 were obtained, mediating 31 +/- 2% and 69 +/- 2% of the total response. In the presence of 8-phenyltheophylline, the vasodilatory response to adenosine remained best fitted to a two-site model with pED50 values of 7.0 +/- 0.2 and 5.4 +/- 0.2. The relative contribution of each site to the total response remained unchanged. For NECA, pED50 values of 9.6 +/- 0.1 and 6.8 +/- 0.2 were obtained, representing 48 +/- 3% and 52 +/- 3% of the sites, respectively. In contrast, ATP produced a monophasic response with a pED50 value of 8.8 +/- 0.1. These results provide evidence of adenosine receptor and response heterogeneity in the in situ coronary vasculature.

Deleterious effects of hydrogen peroxide on the function and ultrastructure of cardiac muscle and the coronary vasculature of perfused rat hearts.

OBJECTIVE: To examine the effect of hydrogen peroxide on the function and ultrastructure of cardiac muscle and the coronary vasculature in an isovolumic rat heart preparation perfused at constant flow. DESIGN: Ventricular function was monitored via a balloon placed in the left ventricle and the response of the coronary vessels to vasodilators was assessed in hearts arrested with 35 mM potassium and treated with 5 microM phenylephrine to contract the coronary resistance vessels. Changes in coronary perfusion pressure reflect changes in resistance vessel tone. SETTING/ANIMALS: This experimental study consisted of 14 heart preparations, six control and eight treated hearts. INTERVENTIONS: Hydrogen peroxide was included in the perfusate at a final concentration of 250 microM for 20 mins. MAIN RESULTS: Hydrogen peroxide reduced rate-pressure product by 42%, caused a fivefold increase in end-diastolic pressure and increased coronary perfusion pressure by 33%. Also, the response of the coronary vasculature to the endothelium-dependent vasodilator, histamine, and endothelium-independent vasodilator, sodium nitrite, was decreased by 55% and 53%, respectively. Electron microscopy of hydrogen peroxide-treated hearts showed damage to both capillaries and arterioles. Endothelial cells were distorted and contained pinocytotic vesicles, endothelial cell junctions were disrupted and blood vessels were detached from surrounding tissue. A comparatively small amount of injury was seen in the myocyte population. CONCLUSIONS: The greater amount of ultrastructural damage seen in blood vessels compared with cardiac muscle suggests that the smooth muscle and endothelial cells of the vasculature are more susceptible to oxidant injury than the myocytes.

Myocardial sarcocystosis in a grand eclectus parrot (Eclectus roratus) and a Moluccan cockatoo (Cacatua moluccensis).

Cardiac sarcocystosis is described in a grand eclectus parrot and a Moluccan cockatoo. Many cysts containing metrocytes were observed within cardiac muscle fibers on tissue sections stained with hematoxylin and eosin. Characteristic ultrastructural features of the cyst walls included the presence of villous projections containing microtubules. Compartmentalization of the cysts resulted from inward extensions of the cyst wall. The differential diagnosis of sarcocystosis, the life cycle of the parasite, and control measures are discussed.

A new stain for identification of avian leukocytes.

Differential staining of avian leukocytes was achieved within 6 min following brief fixation in a methanolic solution of C.I. acid red 360 followed by immersion in a mixture containing C.I. basic blue 41, C.I. basic blue 141, and C.I. acid red 52. Heterophils contained black angular and punctate granules. Eosinophils contained bright purple granules. Lymphocytes displayed red nuclei and blue cytoplasm. Monocytes contained red-brown nuclei and lavender cytoplasm. Basophils showed red-orange granules. Thrombocytes stained deep purple. Compared to traditional panoptic stains like Wright's or Giemsa's, the new staining method provides brighter colors, more precise details of cellular structures, and shorter staining time. Significantly, it facilitates identification of avian leukocyte species based on differences in color as well as differences in size and shape.

Survey of congenital cytomegalovirus (cCMV) knowledge among medical students.

BACKGROUND: Congenital cytomegalovirus (cCMV) is a leading cause of congenital infection worldwide and the most common congenital infection in the United States, affecting 30,000-40,000 US newborns each year and causing permanent disabilities in 8000-10,000. In contrast to how commonly it occurs, physicians and medical students have little knowledge of cCMV. OBJECTIVES: To test the hypothesis medical students have little awareness about cCMV infection, and to collect data on medical students' knowledge about cCMV. The long-term goal of this project is to establish medical student awareness of cCMV infection and educate students about available treatments and strategies for prevention in at-risk populations. STUDY DESIGN: Medical students at one institution were surveyed by questionnaire to assess their knowledge of cCMV. Responses were described, quantified, and compared between groups. RESULTS: 751 surveys were sent and 422 completed responses were received. Respondents were well distributed over all 4 medical school (MS) class years. Only 34% MS1 had heard of cCMV compared to 100% MS2-4 (P<0.0001). All MS2-4 who reported being "very familiar" with CMV learned about it in medical school, 80% in one lecture. MS1 respondents were significantly less knowledgeable about cCMV than MS2-MS4 respondents. CONCLUSION: A baseline lack of knowledge about cCMV was documented in first year medical students. A sharp increase in knowledge of cCMV occurred between MS1 and MS2 years, likely due to preclinical medical student curriculum. However, significant knowledge gaps regarding transmission and treatment were observed in all MS years, representing opportunities for medical education.

Patch variability following carotid endarterectomy: a survey of Great Britain and Ireland.

INTRODUCTION: Evidence suggests a clinical benefit with patch angioplasty after carotid endarterectomy (CEA). The UK National Vascular Database has demonstrated variation in practice but does not record technical details. This study was intended to define indications and technique of patching after CEA. METHODS: An electronic questionnaire was emailed to all 402 members of the Vascular Society of Great Britain and Ireland. The email could not be received by 23 and 14 did not perform CEA. Some questions allowed multiple answers. Fisher's exact test was used for statistical analysis. RESULTS: There were 187 responses (51%). Fifteen members (8%) performed eversion CEA, which obviates patching. Of all the respondents, 121 surgeons (65%) always use a patch. Seventy of these (58%) use the full patch width (median: 8 mm, range: 4-10 mm). Fourteen (12%) variably trimmed the patch (median: 7.5 mm, range: 5-10 mm) and 34 (28%) routinely trimmed (median: 6 mm, range: 3-20 mm). Selective patching, dependent on internal carotid artery diameter, was performed by 48 respondents (26%), 23 of whom specified a median artery threshold diameter of 5 mm (range: 3-8 mm). General anaesthesia was always or usually used by 83 surgeons (45%), local anaesthesia by 77 (41%) and the remainder followed patient choice. Obligatory patching is performed by 68 of the 83 respondents (82%) who prefer general anaesthesia whereas only 40 of the 77 surgeons (52%) who use local anaesthesia always patch (p<0.0001). CONCLUSIONS: There is a variable rate of patching after CEA in the UK, which appears dependent on the vessel size and mode of anaesthesia. There are also differences in the patch width adopted.