Proliferative Glomerulonephritis with Monoclonal Immunoglobulins in a Child with Recurrence in the Allograft.

Proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID) is among the spectrum of monoclonal protein-associated renal diseases, with only about 15 case reports in children. We report a 7-year-old boy with biopsy-proven crescentic PGNMID who progressed to end-stage renal disease within a few months of presentation. He then received a renal transplant with his grandmother as a donor. Proteinuria was detected at 27 months post-transplant and an allograft biopsy revealed a recurrent disease.

A novel amnion-chorion allograft membrane combined with a coronally advanced flap: a minimally invasive surgical therapy to regenerate interdental papillary soft tissue recession - a six-month postoperative image analysis-based clinical trial.

OBJECTIVES: Loss of the interdental papilla is multi-factorial and creates a multitude of problems. Autogenous connective tissue/biomaterial-based regeneration has been attempted for decades to reconstitute the black space created due to the loss of papilla. The aim of this present study was to regenerate papillary recession defects using an amnion-chorion membrane (ACM) allograft and to evaluate the clinical outcome up to six months postoperatively. MATERIALS AND METHODS: Twenty patients with 25 Nordland and Tarnow's Class I/II interdental papillary recession defects were treated with ACM and coronal advancement of the gingivo-papillary unit via a semilunar incision on the labial aspect followed by a sulcular incision in the area of interest. A photographic image analysis was carried out using the GNU Image Manipulation software program from the baseline to three and six months postoperatively. The black triangle height (BTH) and the black triangle width (BTW) were calculated using the pixel size and were then converted into millimeters. The mean and standard deviation values were determined at baseline and then again at three and six months postoperatively. The probability values (P <0.05 and P≤0.01) were considered statistically significant and highly significant, respectively. An analysis of variance and post hoc Bonferroni test were carried out to compare the mean values. RESULTS: Our evaluation of the BTH and BTW showed a statistically and highly significant difference from the baseline until both three and six months postoperatively (P=0.01). A post hoc Bonferroni test disclosed a statistically significant variance from the baseline until three and six months postoperatively (P <0.05) and a non-significant difference from three to six months after the procedure (P≥0.05). CONCLUSION: An ACM allograft in conjunction with a coronally advanced flap could be a suitable minimally invasive alternative for papillary regeneration.

Giant Dental Calculus: A Rare Case Report and Review.

Inadequate oral hygiene is the root cause of the initiation and establishment of the periodontal disease. Dental calculus serves as plaque retentive area, thereby contributing to gingivitis and periodontitis. The present unusual case is of a 55-year-old female patient reported to the department of periodontology with a chief complaint of hard deposit at the right maxillary and mandibular posterior region. The patient was found to have very heavy calculus deposition with respect to right maxillary and mandibular posterior teeth, and the patient was using the left side for mastication and avoiding chewing from the right side mainly due to some periodontal problem. The extraction of the hopeless teeth along with dental calculus was done. Dimensions of dental calculi at maxillary and mandibular teeth was 4 cm × 3 cm each.

A Case Report of a Gingival Plasma Cell Granuloma in a Patient on Antihypertensive Therapy: Diagnostic Enigma.

The aim of the present report was to discuss a unique case of gingival plasma cell granuloma (PCG) in a hypertensive patient on Amlodipine therapy. Also, we attempt to emphasize the importance of considering primary and advance investigations before making a definite diagnosis. PCG is an extremely rare, reactive, non-neoplastic lesion characterized by the predominance of polyclonal plasma cells. Drug-induced gingival overgrowth is a known side effect of Amlodipine. A hypertensive 60-year-old female patient reported with a chief complaint of swollen gums and discomfort in the upper front teeth region. A provisional diagnosis of Amlodipine-induced gingival overgrowth, combined gingival overgrowth, and fibroma was suggested. Surprisingly, histopathology revealed it to be a plasma cell lesion which was confirmed by advanced investigations, thereby establishing a confirmatory diagnosis of PCG.

Interventional Radiology Private Practice Patterns.

Private practice interventional radiology (IR) in the US takes many forms - from specialty coverage withing traditional diagnostic radiology (DR) models and hybrid IR/DR practices, to multispecialty groups and independent IR practitioners. The purpose of this article is to understand the value each of these current IR models offer and predict their future viability.

Advanced Practice Professionals and an Outpatient Clinic: Improving Longitudinal Care in an Interventional Radiology Practice.

The field of interventional radiology (IR) has made tremendous advances in both scope and practice since its inception in the early 1960s. With these advances, it has solidified itself as a valuable subspecialty to the medical community and, most importantly, to the patients who receive IR care. Expanding clinical services to improve care in both the pre- and postprocedural setting is a logical step in IR maturation. The use of advanced practice professionals, in the form of physician assistants and nurse practitioners, can add value in both quality of the patient experience and exposure to other subspecialties. Furthermore, a dedicated outpatient clinic provides a centralized site to evaluate patients and communicate with referring services. These additions can be a challenging value proposition, particularly when working in a combined diagnostic radiology and IR practice, but given the benefits, these are well worth the time and monetary investments.

A Rare Case of Plasma Cell Gingivitis with Cheilitis.

BACKGROUND: Plasma cell gingivitis (PCG) is a rare condition of the gingiva, characterized histopathologically by infiltration of plasma cells in connective tissue. Hypersensitivity reaction due to antigen is considered as primary etiological factor. CASE PRESENTATION: The present case is of an 18-year-old male patient suffering from gingival enlargement along with cheilitis. Histopathological and immunohistochemistry of tissue revealed lesion as plasma cell gingivitis. After gingivectomy, the follow up of the patient was done for 8 months. Gradual reduction of lip swelling was observed after gingivectomy during subsequent visits. CONCLUSION: Early diagnosis is essential as plasma cell gingivitis has similar pathologic changes seen clinically as in leukemia, multiple myeloma, discoid lupus erythematosus, atrophic lichen planus, desquamative gingivitis, or cicatricial pemphigoid which must be differentiated through hematologic examination.

Is there a role for Ytrrium-90 in the treatment of unresectable and metastatic intrahepatic cholangiocarcinoma?

BACKGROUND: Selective internal radiation therapy (SIRT) with Ytrrium-90 (Y-90) has been used to treat hepatic malignancies with success. This study focuses on the efficacy and safety of Y-90 in the treatment of unresectable and metastatic intrahepatic cholangiocarcinoma (ICC). METHODS: A single-institution retrospective case review was performed for patients with unresectable and metastatic ICC treated with Y-90 between 2006 and 2016. RESULTS: Seventeen patients with ICC underwent 21 Y-90 treatments. Four patients had undergone prior liver resection, and six patients had extrahepatic disease at the time of treatment. Five year overall survival was 26.8%, with a median survival of 33.6 months. One patient underwent margin negative liver resection after a single treatment. Complications were appreciated in two cases. Ninety-day mortality was 0%. CONCLUSION: Treatment of ICC using Y-90 is a safe and promising procedure. Further research is needed to clarify its role in the treatment of unresectable and metastatic ICC.

Prostate Multiparametric Magnetic Resonance Imaging Program Implementation and Impact: Initial Clinical Experience in a Community Based Health System.

INTRODUCTION: Magnetic resonance imaging of the prostate is increasingly being performed at academic centers but implementation in community based health systems has lagged and literature regarding clinical impact in this setting is limited. We describe our experience developing a community based prostate magnetic resonance imaging program, including the evolution of interpretation and reporting methods, and the resulting clinical impact during a period of more than 5 years (August 2010 to December 2015). METHODS: Data collected for prostate magnetic resonance imaging included demographic, clinical, scanning, pathology and treatment/management information. Suspicion level on prostate magnetic resonance imaging was correlated with pathology results when available. Outcomes were compared across 3 reporting eras, ie early, mid and Prostate Imaging Reporting and Data System, version 2. RESULTS: A total of 537 prostate magnetic resonance images were obtained for diagnosed prostate cancer (60%) or screening (37%). During the study period the number of scans and ordering physicians increased. The proportion of patients with suspected extraprostatic extension (17.5%), lymph node metastasis (6.9%) and bone/other metastasis (4.3%) on prostate magnetic resonance imaging remained relatively constant. When stratified by era, there was a significant increase in low suspicion studies (p = 0.0002) and a trend toward a significant increase in cancer detection at biopsy (p = 0.09), reflecting increased specificity in the Prostate Imaging Reporting and Data System, version 2 era. CONCLUSIONS: While staging information with prostate magnetic resonance imaging was accurate early in the implementation of the program, lesion characterization improved with use of Prostate Imaging Reporting and Data System, version 2 criteria and standardized reporting. Regular multidisciplinary participation in community based prostate magnetic resonance imaging programs may maximize clinical impact.

Liver Resection After Selective Internal Radiation Therapy with Yttrium-90 is Safe and Feasible: A Bi-institutional Analysis.

BACKGROUND: Treatment with yttrium-90 (Y90) microspheres has emerged as a viable liver-directed therapy for patients with unresectable tumors and those outside transplantation criteria. A select number of patients demonstrate a favorable response and become candidates for surgical resection. METHODS: Patients who underwent selective internal radiation therapy (SIRT) with Y90 microspheres at two institutions were reviewed. Patients who underwent liver resection were included in the study. The data gathered included demographics, tumor characteristics, response to Y90, surgical details, perioperative outcomes, and survival. RESULTS: The inclusion criteria were met by 12 patients. The diagnoses included metastatic disease from colorectal adenocarcinoma (n = 6), neuroendocrine tumor (n = 1), and ocular melanoma (n = 1) in addition to hepatocellular carcinoma (n = 4). The median time from liver disease diagnosis to Y90 treatment was 5.5 months (range 2-92 months). The median time from Y90 treatment to surgery was 9.5 months (range 3-20 months). The surgical approach included right hepatectomy (n = 3), extended right hepatectomy (n = 5), extended left hepatectomy (n = 1), segmentectomy with ablation (n = 2), and segmentectomy with isolated liver perfusion (n = 1). The hospital stay was 7 days (range 4-31 days), and 67% of the patients were discharged home. The readmission rate was 42%. The 90-day morbidity and mortality rates were respectively 42 and 8%. At this writing, the median overall survival has not been reached at 25 months. CONCLUSION: Liver resection after Y90 SIRT is a challenging surgical procedure with high rates of perioperative morbidity and hospital readmission. However, for properly selected patients, potential exists for extending disease-free and overall survival in the current era of multimodal therapy for malignant liver disease.

Increased transfusion-free survival following auxiliary pig liver xenotransplantation.

BACKGROUND: Pig to baboon liver xenotransplantation typically results in severe thrombocytopenia and coagulation disturbances, culminating in death from hemorrhage within 9 days, in spite of continuous transfusions. We studied the contribution of anticoagulant production and clotting pathway deficiencies to fatal bleeding in baboon recipients of porcine livers. METHODS: By transplanting liver xenografts from α1,3-galactosyltransferase gene-knockout (GalT-KO) miniature swine donors into baboons as auxiliary organs, leaving the native liver in place, we provided the full spectrum of primate clotting factors and allowed in vivo mixing of porcine and primate coagulation systems. RESULTS: Recipients of auxiliary liver xenografts develop severe thrombocytopenia, comparable to recipients of conventional orthotopic liver xenografts and consistent with hepatic xenograft sequestration. However, baboons with both pig and native livers do not exhibit clinical signs of bleeding and maintain stable blood counts without transfusion for up to 8 consecutive days post-transplantation. Instead, recipients of auxiliary liver xenografts undergo graft failure or die of sepsis, associated with thrombotic microangiopathy in the xenograft, but not the native liver. CONCLUSION: Our data indicate that massive hemorrhage in the setting of liver xenotransplantation might be avoided by supplementation with primate clotting components. However, coagulation competent hepatic xenograft recipients may be predisposed to graft loss related to small vessel thrombosis and ischemic necrosis.

Up to 9-day survival and control of thrombocytopenia following alpha1,3-galactosyl transferase knockout swine liver xenotransplantation in baboons.

BACKGROUND: With standard miniature swine donors, survivals of only 3 days have been achieved in primate liver-transplant recipients. The recent production of alpha1,3-galactosyl transferase knockout (GalT-KO) miniature swine has made it possible to evaluate xenotransplantation of pig organs in clinically relevant pig-to-non-human primate models in the absence of the effects of natural anti-Gal antibodies. We are reporting our results using GalT-KO liver grafts. METHODS: We performed GalT-KO liver transplants in baboons using an immunosuppressive regimen previously used by our group in xeno heart and kidney transplantation. Post-operative liver function was assessed by laboratory function tests, coagulation parameters and histology. RESULTS: In two hepatectomized recipients of GalT-KO grafts, post-transplant liver function returned rapidly to normal. Over the first few days, the synthetic products of the donor swine graft appeared to replace those of the baboon. The first recipient survived for 6 days and showed no histopathological evidence of rejection at the time of death from uncontrolled bleeding, probably caused by transfusion-refractory thrombocytopenia. Amicar treatment of the second and third recipients led to maintenance of platelet counts of over 40 000 per µl throughout their 9- and 8-day survivals, which represents the longest reported survival of pig-to-primate liver transplants to date. Both of the last two animals nevertheless succumbed to bleeding and enterococcal infection, without evidence of rejection. CONCLUSIONS: These observations suggest that thrombocytopenia after liver xenotransplantation may be overcome by Amicar therapy. The coagulopathy and sepsis that nevertheless occurred suggest that additional causes of coagulation disturbance must be addressed, along with better prevention of infection, to achieve long-term survival.

Giant lipoma of posterior neck with bleeding decubitus ulcer: a rare entity.

Giant lipomas are benign soft tissue tumours. They are found relatively rarely on the posterior part of the neck. Bleeding pressure ulcer in this giant tumour is a rare presentation. Surgical interventions in these tumours are very challenging because, sometimes, extension to the spinal cord and malignant change may occur, especially in old age. Knowledge of the anatomy and meticulous surgical techniques are needed for such giant lipomas.

The Chait Trapdoor cecostomy catheter: an alternative access device to pigtail catheters for chronic cholecystostomy drains.

Acute cholecystitis is a well known complication in the critically ill patient population. These patients are often at high risk for morbidity and mortality associated with cholecystectomy. Percutaneous cholecystostomy has been shown to be an effective procedure in the treatment of acute cholecystitis in this patient population. Some patients require prolonged catheter drainage before definitive therapy. In four patients with patent cystic ducts, standard drainage catheters were exchanged for 10.2-F Chait pediatric cecostomy catheters. The low profile of the catheter and the "Trapdoor" feature allow maintenance and increased patient satisfaction while maintaining drainage and access.

Management of intraabdominal hypertension by percutaneous catheter drainage.

The authors report a case of an 18-year-old man with T-cell acute lymphocytic leukemia who developed hemorrhagic pancreatitis after chemotherapy. He subsequently developed abdominal compartment syndrome (ACS). Computed tomography showed a large fluid-filled mass in the area of the pancreas. As a result of the instability of his condition, surgical decompression, the standard therapy for ACS, was believed to carry significant morbidity and potential mortality. The patient underwent ultrasound-guided drainage of the peripancreatic fluid, which decreased his abdominal pressures and improved his clinical status. Without this procedure, the patient may not have tolerated subsequent surgery.