A 16-year multi-institutional study of the role of age and EBV status on PTLD incidence among pediatric heart transplant recipients.

The objective was to determine the incidence and hazard for posttransplant lymphoproliferative disease (PTLD) in a study of 3170 pediatric primary heart transplants between 1993 and 2009 at 35 institutions in the Pediatric Heart Transplant Study. 147 of 151 reported malignancy events were classified as PTLD. Overall freedom from PTLD was 98.5% at 1 year, 94% at 5 years and 90% at 10 years. Freedom from PTLD was lowest in children (ages 1 to < 10 years) versus infants (<1 year) and adolescents (10 to < 18 years) with children at highest risk for PTLD with a relative risk of 2.4 compared to infants and 1.7 compared to adolescents. Positive donor EBV status was a strong risk factor for PTLD in the seronegative recipient, but risk magnitude was dependent on recipient age at the time of transplantation. Nearly 25% of EBV seronegative recipients of EBV+ donors at ages 4-7 at transplantation developed some form of PTLD. The overall risk for PTLD declined in the most recent transplant era (2001-2009, p = 0.003). These findings indicate that EBV status and the age of the recipient at the time of transplantation are important variables in the development of PTLD in the pediatric heart transplant recipient.

Increased incidence and mortality associated with skin cancers after cardiac transplant.

Skin cancer incidence has been shown to be increased in the context of transplant-associated immunosuppression. There is, however, limited information specifically about the incidence of skin cancer after cardiac transplantation in the United States. A 10-year retrospective cohort study of 6271 heart transplants at 32 US transplant centers revealed increased postprocedure incidence of nonmelanoma and melanoma skin cancers, especially cutaneous squamous cell carcinoma, for which the incidence increased from 4- to 30-fold compared to the age and gender equivalent general population. Incidence of skin cancer in this study was consistent with prior single-center data regarding cardiac transplant patients. Comparison of all-cause mortality statistics for patients with basal cell carcinoma, squamous cell carcinoma and melanoma, respectively, demonstrated increased mortality associated with melanoma. Skin cancer screening and prophylaxis may be of some utility in reducing morbidity and mortality in cardiac transplant patients.

Pregnancy outcomes and ultrasonographic diagnosis in patients with histologically-proven placental chorioangioma.

OBJECTIVE: To evaluate pregnancy outcome and ultrasound diagnosis in patients with histologically-confirmed placental chorioangioma. STUDY DESIGN: Placentas with histological diagnosis of chorioangioma were identified and medical charts were reviewed for findings of ultrasound examinations. Pregnancy outcomes were compared with all singleton deliveries without chorioangioma in the same time period. MAIN OUTCOME MEASURES: Primary outcome was Neonatal Intensive Care Unit admission rate. Secondary outcome was ultrasound detection rate of chorioangioma. RESULTS: Among 14,725 singleton deliveries, 23 placentas were diagnosed with chorioangioma (0.16%). The control group included all singleton deliveries without chorioangioma (n = 14702). Neonates in the study group were more likely to be admitted to the Neonatal Intensive Care Unit (OR = 4.45) and to have smaller birth weight (p = 0.006). Only 2 of 7 larger chorioangiomas (≥ 2 cm) with available ultrasound reports were identified by ultrasound (29% detection rate). All cases demonstrated normal fetal growth and wellbeing. CONCLUSION: Chorioangiomas are not always identified by routine prenatal sonography. Even in the absence of ultrasonic abnormalities, neonatal morbidity, as measured by NICU admission rate, is increased.

Controlled synthesis of core-shell iron-silica nanoparticles and their magneto-dielectric properties in polymer composites.

Low loss core-shell iron-silica nanocomposites with improved magneto-dielectric properties at radio frequencies (1 MHz-1 GHz) were successfully fabricated. A new simple method was developed to synthesize metallic iron (Fe) nanoparticles with uniform size distribution in an aqueous environment at room temperature. Citric acid and oleic acid served as surface-capping agents to control the particle size of the synthesized Fe nanoparticles. Smaller Fe nanoparticles with narrower particle size distribution were obtained as the concentration ratio of iron ions to carboxylic acid groups decreased. The Fe nanoparticles were subsequently coated with silica (SiO(2)) layers to prevent the iron cores oxidizing. Polymer composites were prepared by incorporating Fe@SiO(2) nanoparticles with polydimethylsiloxane (PDMS) elastomers. Experimental results showed that the dielectric permittivity (ε) and magnetic permeability (µ) of the polymer composite increased with increasing amount of Fe@SiO(2) nanoparticle doping. The dielectric loss (tanδ) was near 0.020 at a frequency of 1 GHz.

Spatial analysis of the exposure of dogs in rural north-coastal California to vectorborne pathogens.

Between 0 and 50 per cent of the dogs in eight rural villages in far northern California with a high risk of tickborne diseases were seropositive for Anaplasma phagocytophilum and Bartonella vinsonii subspecies berkhoffii, and between 0 and 10 per cent were seropositive for Borrelia burgdorferi. The odds ratio for the co-exposure of individual dogs to B vinsonii berkhoffii and A phagocytophilum was 18.2. None of the diseases was associated with the sex of the dogs, whether they slept out of doors, or whether tick-preventive measures were taken. When the villages were assessed for landscape risk factors, a particularly high seroprevalence for B vinsonii berkhoffii and A phagocytophilum was observed in a village at a relatively high altitude and greater distance from the Pacific coast, and montane hardwood conifer woodland was most associated with a high seroprevalence for these two pathogens.

Utility of long-term surveillance endomyocardial biopsy: a multi-institutional analysis.

BACKGROUND: The utility of long-term endomyocardial biopsy surveillance in heart transplant recipients has been questioned. This study was undertaken to identify risk factors for late rejection and to examine the impact of different biopsy surveillance protocols on outcomes using the registry of the Cardiac Transplant Research Database. METHODS: The study group consisted of all adult patients who underwent heart transplantation at the 33 centers participating in this investigation between January 1, 1993 and January 1, 2002, survived past the second post-transplant year, and were followed-up by a defined surveillance biopsy protocol. RESULTS: During a follow-up that consisted of 24,137 patient-years, 1,626 late rejections occurred. Shorter time since transplant, history of rejection, younger age and African-American ethnicity of the recipient were strong risk factors for late rejection. The practice of surveillance biopsy varied among institutions. Continued surveillance increased the rate of diagnosis of late rejection (RR = 1.3, p = 0.002). There was no reduction in the incidence of hemodynamically compromising rejection and no increase in survival in patients with long-term vs intermediate-term surveillance. Short-term surveillance was associated with an increased incidence of hemodynamically compromising rejection, particularly among high-risk patients, and increased mortality in African-American patients. CONCLUSIONS: There are no apparent benefits from surveillance biopsy beyond 5 years post-transplant. Surveillance biopsy between 2 and 5 years post-transplant was found to reduce mortality in African-American recipients. Non-African-American recipients at high risk for late rejection will likely benefit from surveillance up to 5 years post-transplant.

Sylvatic maintenance of Borrelia burgdorferi (Spirochaetales) in Northern California: untangling the web of transmission.

Lyme borreliosis is associated with several genospecies of Borrelia burgdorferi sensu lato (s.l.) (Spirochaetales), but human disease has been associated only with Borrelia burgdorferi sensu stricto (s.s.) Johnson, Schmid, Hyde, Steigerwalt & Brenner in the western United States. Restriction fragment length polymorphism (RFLP) analysis of rrf-rrl amplicons from 124 tick and mammalian isolates from various habitats yielded 13 RFLP patterns. Of these patterns, six were patterns previously associated either with Borrelia bissettii Postic, Marti Ras, Lane, Hendson & Baranton or Borrelia burgdorferi s.s., and the remaining seven patterns belonged to diverse and previously uncharacterized Borrelia spp. Uncharacterized Borrelia spp. were cultured most frequently from Ixodes spinipalpis Hadwen & Nuttall and California kangaroo rats, Dipodomys californicus Merriam, inhabiting grasslands, and B. bissettii from I. spinipalpis and dusky-footed woodrats, Neotoma fuscipes Baird, associated with oak woodlands or chaparral. B. burgdorferi s.s. typically was isolated from host-seeking Ixodes pacificus Cooley & Kohls collected in dense oak woodlands, woodland-grass, or redwood forests. Although some isolates of B. burgdorferi s.s. were cultured from woodrats, there was no clear association of this human pathogen with any vertebrate host. These findings, along with recent evidence indicating that the western gray squirrel, Sciurus griseus Ord, may be an important reservoir of B. burgdorferi s.s. in Californian oak woodlands, suggest that our earlier hypothesis implicating an enzootic cycle involving woodrats and I. spinipalpis is insufficient to account for observed patterns of infection in nature.

Rejection with hemodynamic compromise: objective evidence for efficacy of photopheresis.

BACKGROUND: Photopheresis therapy (photo) has been advocated as a therapy to improve outcome after recalcitrant or severe rejection, but objective evidence of a beneficial effect has been elusive. This study examined the hypothesis that photo provides protection against rejection, rejection with hemodynamic compromise (HC), and death from rejection after cardiac transplantation. METHODS: Between 1990 and 2003, 36 adult patients (from 343 adult transplant recipients) received at least 3 months of photo (2-day treatment every 3 to 6 weeks for a target of 18 months) after HC rejection (n = 12), recurrent/recalcitrant rejection (n = 20), or as prophylaxis in the presence of anti-donor antibodies (n = 4). Survival and risk factors were examined by analysis using multivariate hazard function modulated renewal function. RESULTS: Patients selected for photo were at greater risk for rejection (p < 0.0001) and HC rejection (p < 0.0001) than non-photo patients. After 3 months of photo therapy, rejection risk was decreased (p = 0.04). More importantly, the hazard for subsequent HC rejection or rejection death was significantly reduced toward the risk-adjusted level of lower-risk non-photo patients (p = 0.006). CONCLUSIONS: This study provides objective evidence that photo reduces the risk of subsequent HC rejection and/or death from rejection when initiated for patients with high rejection risk. Photopheresis is recommended as an important therapeutic modality after rejection with hemodynamic compromise, although further studies are needed to define the precise mechanism of the effect and the potential for benefit in other patient sub-sets.

To induce or not to induce: do patients at greatest risk for fatal rejection benefit from cytolytic induction therapy?

BACKGROUND: Induction immunosuppression utilizing lymphocytolytic agents in the early peri-operative period has a number of theoretical and practical advantages and disadvantages. However, the efficacy of cytolytic agents as induction therapy remains unproven. METHODS: To assess the current impact of induction therapy in heart transplantation, we queried a multi-institutional database regarding the frequency of use, type of agent, duration of therapy and outcomes of 6,553 patients transplanted from 1990 to 2001. A study group of 5,897 patients were identified who survived the first 48 hours post-transplant and received either no induction therapy (n = 4,161) or induction with OKT3 or anti-thymocyte preparations (n = 1,736). RESULTS: By multivariate analysis, risk factors for rejection death were identified and then applied to a model of overall mortality. Among patients with a 1-year risk of rejection death at >5%, induction therapy provided a survival advantage, but survival with induction was decreased when the risk of rejection death was <2%. Specific patient sub-sets that received a survival benefit in the current era with induction included younger patients of black race with >/=4 HLA mismatches and long-term (>6 months) support on a ventricular assist device (VAD). CONCLUSIONS: Use and application of induction therapy continues to be controversial in heart transplantation. At present, this approach appears to be beneficial in selected patients who are at high risk for rejection death, but likely detrimental in patients who are at low risk for rejection death. Those with a combination of longer term VAD support, of black ethnicity, and having extensive HLA mismatching are most likely to benefit from cytolytic induction therapy.

RAPD markers linked to eastern filbert blight resistance in Corylus avellana.

A total of 1,110 decamer primers were screened for RAPD markers linked to a dominant allele in hazelnut ( Corylus avellana) that confers resistance to eastern filbert blight caused by Anisogramma anomala. Twenty RAPD markers linked in coupling, and five markers linked in repulsion, were found. A seedling population was used to construct a linkage map of the region flanking the resistance locus. The map spans 46.6 cM, with 14 markers on one side of the resistance locus and eight on the other side. Eleven markers showed less than 3% recombination with resistance, including three that showed no recombination. Seven of these 11 markers are sufficiently robust to allow their use in marker-assisted selection. These include AA12(850) which shows no recombination, and six markers on one side of the resistance locus: 173(500), 152(800), 122(825), 275(1130), H19(650) and O16(1250). Marker 268(580), which flanks the resistance locus on the other side, is also suitable for use in marker-assisted selection, but shows 5.8% recombination with resistance. Other markers are less suitable for marker-assisted selection because of sensitivity to changes in primer or MgCl(2) concentration, or the long time required for electrophoresis to separate bands of similar size. The 16 markers closest to the resistance locus were cloned and sequenced. The W07(365) marker, which showed no recombination with the resistance locus but is difficult to score, includes a CT microsatellite repeat. The sequence information will allow the design of SCAR primers and eventual map-based cloning of the resistance allele.

Increased fetal nuchal translucency: possible association with esophageal atresia.

We describe a case in which in-utero diagnosis of an esophageal atresia with a tracheo-esophageal fistula in the third trimester followed the finding of an increased nuchal translucency in the first trimester and suggest a mechanism by which these two findings might be associated.

Differences in the epidemiology of theileriosis on smallholder dairy farms in contrasting agro-ecological and grazing strata of highland Kenya.

A prospective cohort study was conducted in five purposively-sampled agro-ecological zone (AEZ)-grazing system strata in Murang'a District, Kenya, between March 1995 and June 1996. The study strata were selected based on a preliminary characterization study to represent the widest range of risks to East Coast fever (ECF) in the District and included zero-grazing and open-grazing farms. In total, 225 calves from 188 smallholder farms were examined from birth to 6 months of age and visited within the first 2 weeks of life and thereafter at bi-weekly intervals for up to 14 visits. The purpose of the study was to characterize the differences in epidemiology (risks of infection, morbidity and mortality) and potential control of ECF between the selected strata. Evidence of Theileria parva infection was assessed by increased antibody levels as measured in an indirect ELISA assay by the percent positivity (PP) of serum samples relative to a strong positive reference serum. Sero-conversion risks of T. parva were highest in the open-grazing strata. Antibody prevalence in adult cattle and ECF morbidity and mortality risks were also highest in open-grazing strata. While different, all five AEZ-grazing strata were considered to be endemically unstable for ECF. East Coast fever challenge was low in all zero-grazing strata and this challenge is likely to remain low due to continuing intensification of smallholder farming in the central highlands. In the open-grazing strata, there was higher challenge and a greater impact of ECF.

First trimester umbilical venous Doppler sonography in chromosomally normal and abnormal fetuses.

In 342 singleton pregnancies in which the patients were undergoing chorionic villus sampling at 11 to 14 weeks of gestation, color Doppler sonography was used to obtain waveforms from the umbilical cord. The prevalence of pulsatile flow in the umbilical vein was higher in the 18 fetuses with trisomy 18 or 13 (16 of 18; 88.9%) than in the 18 fetuses with trisomy 21 (6 of 18; 33.3%) or the 302 chromosomally normal fetuses (73 of 302; 24.2%).

Ixodes (Ixodes) jellisoni and I. (I.) neotomae (Acari:Ixodidae): descriptions of the immature stages from California.

Nymphal and larval stages of Ixodes (Ixodes) jellisoni Cooley & Kohls and I. (I.) neotomae Cooley are described for the first time. These 2 tick species occur only in the western United States, predominantly in California. The primary host for I. jellisoni is the California kangaroo rat, Dipodomys californicus (Merriam); that for I. neotomae is the dusky-footed woodrat, Neotoma fuscipes Baird. The etiologic agent of Lyme disease Borrelia burgdorferi Johnson, Schmidt, Hyde, Steigerwalt & Brenner has recently been isolated from both tick species, and I. neotomae was proven a competent enzootic vector of the Lyme disease spirochete.