Predictors of hematological abnormalities in multiple sclerosis patients treated with fingolimod and dimethyl fumarate and impact of treatment switch on lymphocyte and leukocyte count.

BACKGROUND: There is limited data regarding the predictors of hematological abnormalities in multiple sclerosis (MS) patients treated with dimethyl fumarate (DMF) or fingolimod (FNG), and the impact of treatment switch on lymphocyte and leukocyte count METHODS: We identified 405 patients on DMF and 300 patients on FNG (treatment duration: at least 12 month) within a large prospective study of MS patients conducted at the Partners MS Center, Brigham and Women's Hospital (CLIMB study) between Jan 2011 to Feb 2016. Patients had complete blood counts with differentials at baseline and every 6 months while on treatment. Most participants had a clinical visit with complete neurologic examinations every 6 months and brain MRI scan every 12 months. T cell subset profile was available for subgroup of patients (n = 116). RESULTS: In the FNG group, the risk of developing lymphopenia grade 4 (< 200) was higher in female patients (p = 0.0117) and those who were previously treated with natalizumab (p = 0.0116), while the risk of lymphopenia grade 3b+4 (< 350) was higher in female patients (p = 0.0009). DMF treated patients with lower baseline lymphocyte count had a higher chance of developing lymphopenia grade 2 (< 800) (p < 0.0001) or 2+3 (< 500) (p < 0.0001). We examined the effect of treatment switch between DMF and FNG. No significant recovery in lymphocyte and leukocyte count was observed after treatment switches. Reduced dosing of FNG in patients with lymphopenia led to increase in lymphocyte count but also increased disease activity in 25% of patients. CONCLUSION: Female sex and prior exposure to natalizumab increased the probability of lymphopenia on FNG, while low absolute lymphocyte count was associated with increased risk of lymphopenia on DMF. Parallel switch did not lead to recovery from hematological abnormalities. Long-term studies with larger number of patients are required to confirm our findings and to establish guidelines for prediction and management of hematological abnormalities.

Laparoscopic antegrade continent enema through VQ stoma skin flaps using two ports: Long-term follow-up.

PURPOSE: To introduce a simple technique for laparoscopic appendicostomy using two ports through "V" and quadrilateral "Q"-shaped skin flaps to create antegrade continent enemas in children with a neuropathic bowel incontinence or intractable constipation. PATIENTS AND METHODS: Laparoscopic appendicostomy was performed in 19 children through a V-shaped skin flap at McBurney's point. The first port was inserted into the peritoneal cavity under direct vision, and the second port was inserted after peritoneal insufflation. The appendix was brought to the abdominal surface, and its distal tip was resected and intubated. The spatulated appendix was used to create an anastomosis to the V-shaped skin flap. The appendix was then covered by a quadrilateral skin flap. RESULTS: All patients were discharged from the hospital within 3 days (range 1-3 days) after surgery with a catheter in place. An irrigation regimen was initiated 3 weeks after surgery. All but one patient became continent without constipation and diaper free. The duration of follow-up ranged from 15 to 54 months (mean 35.8 months). CONCLUSION: The laparoscopic antegrade continent enema through the VQ stoma skin flaps using two ports ensures rapid recovery, an excellent cosmetic appearance, and minimal complications in long-term follow-up. This is the first report of this technique, which shows promising results in stoma reconstruction.

Fetus in fetu.

Fetus in fetu (FIF) is a very rare condition, with a reported incidence of one in 500,000 live births. It most likely represents a monozygotic diamniotic twin that implants itself and grows within the body of its normal karyotypically identical sibling, which typically manifests as a fetiform abdominal mass in a newborn or infant. The mass is located in the retroperitoneum in most cases, including our example, and is commonly surrounded by encapsulated fluid. However, FIF has been reported to occur in other locations, such as within the cranium, the scrotum, and the oral cavity. Usually only one fetus is present but very rarely multiple fetuses may also be present. Five fetuses in the cranium of a 1-day-old female infant with hydrocephalus (although three of these fetuses were composed of extremities only) had been reported. The fetus itself is incomplete, containing a variable number of identifiable organs. The lung, the liver, the adrenal gland, the pancreas, and the genital organs may be seen in the more complex specimens. The presence of a head with eyes, hair, and teeth has been reported, but most of these fetuses are anencephalic. We are presenting a FIF mimicking a solid and cystic renal mass in a 6-month-old boy.