Outcomes of adults with lymphoma treated with nonmyeloablative TLI-ATG and radiation boost to high risk or residual disease before allogeneic hematopoietic cell transplant.

We evaluated the impact on survival of antithymocyte globulin conditioning (TLI-ATG) with radiation (RT) boost to high risk or residual disease before allogeneic hematopoietic cell transplant (allo-HCT) for adults with lymphoma (excluding mycosis fungoides and low-grade NHL other than SLL/CLL). Of 251 evaluable patients, 36 received an RT boost within 3 months of allo-HCT at our institution from 2001 to 2016. At the time of TLI-ATG, patients who received boost vs no boost had a lower rate of CR (11% vs 47%, p = 0.0003), higher rates of bulky disease (22% vs 4%, p < 0.0001), extranodal disease (39% vs 5%, p < 0.0001), and positive PET (75% vs 28%, p < 0.00001). In the boost group, the median (range) largest axial lesion diameter was 5.2 cm (1.8-22.3). Median follow-up was 50.2 months (range: 1-196). There was no significant difference in OS, time to recurrence, or time to graft failure with vs without boost. A trend toward higher percent donor CD3+ chimerism was seen with vs without boost (p = 0.0819). The worst boost-related toxicity was grade 2 dermatitis. RT boost may help successfully mitigate the risk of high risk or clinically evident residual disease in adults with lymphoma undergoing allo-HCT.

Infectious diseases consult improves vaccination adherence in kidney transplant candidates.

BACKGROUND: Vaccines prevent infections and avoid related complications. Low rates in immunocompromised patients are concerning due to increased morbidity. Vaccinations are less effective when administered post-transplant and should be administered prior. We describe pre-transplant vaccination rates among kidney or kidney-pancreas transplant recipients. METHODS: Retrospective review including adults receiving kidney or kidney-pancreas allografts at Cleveland Clinic from October 2013 to October 2016. Pre-transplant vaccinations, serologies, and transplant data were collected. RESULTS: 393 patients were included; median age was 53 years with most (46%) being Caucasian males. Influenza vaccination rate was 48%; receipt of at least one pneumococcal vaccine was 77%. Vaccination rates were higher among dialysis patients for pneumococcal, hepatitis B, and varicella vaccines; rates were also higher with infectious diseases consults. CONCLUSIONS: Vaccination rates at our institution for kidney or kidney-pancreas transplant candidates are consistent with previous literature. Rates were higher for candidates with infectious diseases consults or receiving dialysis.

Risk factors associated with Clostridium difficile infection in kidney transplant recipients.

BACKGROUND: Solid organ transplant recipients are especially vulnerable to Clostridium difficile infection (CDI) due to cumulative risk factors including increased exposure to healthcare settings, persistent immunosuppression, and higher rates of antimicrobial exposure. We aimed to identify risk factors associated with CDI development in kidney transplant recipients including implications of immunosuppressive therapies and acid-suppressing agents. METHODS: This was a single-center, non-interventional, retrospective case-control study of adult subjects between June 1, 2009 and June 30, 2013. During this time, 728 patients underwent kidney transplantation. Overall, 22 developed CDI (cases) and were matched 1:3 with 66 controls. Cases and controls were also matched for induction agent, kidney allograft type (living or deceased), and time from transplant to CDI result (±60 days). RESULTS: The majority of subjects received a deceased donor kidney (77.3%) and basiliximab induction therapy (86.4%). The overall CDI incidence was 3%. Factors independently associated with CDI were average tacrolimus trough (AOR = 1.25, 95% CI = 1.00-1.56, P = .048) and antibiotic exposure for urinary tract infections (UTI) (AOR = 4.17, 95% CI = 1.12-15.54, P = .034). Proton pump inhibitor use was not associated with CDI (OR = 0.81, 95% CI = 0.29-2.29, P = .691). CONCLUSION: Maintaining a clinically appropriate tacrolimus trough and judicious antibiotic use and selection for UTI treatment could potentially reduce CDI in the kidney transplant population.

En Bloc Multivisceral and Kidney Transplantation in an HIV Patient: First Case Report.

The continual improvement in outcome with highly active antiretroviral therapy (HAART) for human immunodeficiency virus (HIV) infection and visceral transplantation for gut failure stimulated our interest in lifting HIV infection as a contraindication for intestinal and multivisceral transplantation. This report is the first to describe visceral transplantation in a patient with HIV infection. A HAART regimen was introduced in the setting of short-gut syndrome with successful suppression of HIV viral load. The indication for en bloc multivisceral and kidney transplantation was end-stage liver failure with portomesenteric venous thrombosis and chronic renal insufficiency. The underlying hepatic pathology was alcoholic and home parenteral nutrition-associated cirrhosis. Surgery was complicated due to technical difficulties with excessive blood loss and long operative time. The complex posttransplant course included multiple exploratory laparotomies due to serious intra-abdominal and systemic infections. Heavy immunosuppression was required to treat recurrent episodes of severe allograft rejection. Posttransplant oral HAART successfully sustained undetectable viral load. Unfortunately, the patient succumbed to sepsis 3 months posttransplant. With new insights into the biology of gut immunity, mechanisms of allograft tolerance, and HIV-associated immune dysregulation, successful outcome is anticipated, particularly in patients who are in need of isolated intestinal and less-organ-contained visceral allografts.

Diversity of functional microornamentation in slithering geckos Lialis (Pygopodidae).

The skin of geckos is covered with countless microscopic protuberances (spines). This surface structure causes low wettability to water. During evolution, representatives of the recent gekkotan clade Pygopodidae started slithering on the ground. This manner of locomotion affected limb reduction resulting in a snake-like body. Regarding abrasion and frictional properties, a surface covered with gekkotan spines is a topography that hampers the snake-like locomotion mode. Using scanning electron microscopy, we investigated the shed skins of two pygopodid lizards, Lialis jicari (Papua snake lizard) and Lialis burtonis (Burton's legless lizard), in order to show epidermal adaptations to limbless locomotion. Our data showed that Pygopodidae differ from their relatives not only anatomically, but also in their epidermal microstructure. Scales of L. jicari have five different structural patterns on various body regions. Ventral scales have nanoridges, similar to those found on the ventralia of snakes. Surfaces of scales covering the jaw bones, have flattened spine-like microstructures that might be an adaptation to reduce abrasion. Dorsal scales have oblong microscopic bulges covered with nanoridges. Spines cover the undersides and the interstices of scales over the entire body of both species and in L. jicari also the top of dorsal head scales. Our measurements of surface wettability (surface free energy) show superhydrophobic properties of the spiny surfaces in comparison with the other microstructural patterns of other body parts.

Neurofilament light chain levels in ventricular cerebrospinal fluid after acute aneurysmal subarachnoid haemorrhage.

PURPOSE: The contribution of axonal injury to brain damage after aneurysmal subarachnoid haemorrhage (aSAH) is unknown. Neurofilament light chain (NF-L), a component of the axonal cytoskeleton, has been shown to be elevated in the cerebrospinal fluid of patients with many types of axonal injury. We hypothesised that patients with aSAH would have elevated cerebrospinal fluid (CSF) NF-L levels and sought to explore the clinical correlates of CSF NF-L dynamics. METHODS: Serial ventricular CSF (vCSF) samples were collected from 35 patients with aSAH for up to 15 days. vCSF NF-L measurements were determined by enzyme-linked immunosorbent assay. NF-L levels were analysed in relation to acute clinical status, radiological findings and 6-month outcomes. RESULTS: vCSF NF-L concentrations were elevated in all patients with aSAH. Patients with early cerebral ischaemia (ECI), defined as a CT hypodense lesion visible within the first 3 days, had higher acute vCSF NF-L levels than patients without ECI. These elevated NF-L levels were similar in patients with ECI associated with intracranial haemorrhage and ECI associated with surgical/endovascular complications. vCSF NF-L levels did not differ as a function of acute clinical status, clinical vasospasm, delayed cerebral ischaemia or 6-month Glasgow Outcome Scale. CONCLUSIONS: Elevated vCSF NF-L levels may in part reflect increased injury to axons associated with ECI. However, our results suggest that axonal injury after aSAH as reflected by release of NF-L into the CSF may not play a major role in either secondary adverse events or long-term clinical outcomes.

Detection and identification of mammalian reoviruses in surface water by combined cell culture and reverse transcription-PCR.

Reoviruses are a common class of enteric viruses capable of infecting a broad range of mammalian species, typically with low pathogenicity. Previous studies have shown that reoviruses are common in raw water sources and are often found along with other animal viruses. This suggests that in addition to the commonly monitored enteroviruses, reoviruses might serve as an informative target for monitoring fecal contamination of drinking water sources. Mammalian reoviruses were detected and identified by a combined cell culture-reverse transcription-PCR (RT-PCR) assay with novel primers targeting the L3 gene that encodes the lambda3 major core protein. Five of 26 (19.2%) cytopathic effect-positive cell culture lysates inoculated with surface water were positive for reoviruses by RT-PCR. DNA sequence analysis of RT-PCR products revealed significant sequence diversity among isolates, which is consistent with the sequence diversity among previously characterized mammalian reoviruses. Sequence analysis revealed persistence of a reovirus genotype at a single sampling site, while a sample from another site contained two different reovirus genotypes.

Age-of-onset classification of conduct disorder: reliability and validity in a prospective cohort study.

OBJECTIVE: To test in a prospective clinical cohort study the reliability and validity of the age-of-onset subtyping of conduct disorder. METHOD: Participants were adolescents referred to psychiatric clinics who met DSM-III-R criteria for conduct disorder by structured diagnostic interview. Age of onset was the reported age of the first conduct disorder symptom. The reliability of age-of-onset report was tested by assessing agreement within informant on interviews 2 to 4 weeks apart. Age-of-onset groups were compared within informant on rates of correlates and symptom and social functioning outcomes over a period of 3 years. RESULTS: The reliability of age-of-onset report was low (kappa of 0.1 and 0.4 by adolescent and parent informant, respectively). Although the early-onset group had elevated rates of attention-deficit/hyperactivity disorder, family disadvantage, and aggressive and nonaggressive antisocial behaviors at inclusion, growth curve analysis showed that age-of-onset subtyping had no predictive validity. CONCLUSIONS: The reliability of ascertainment of age of onset of antisocial behavior requires further study. While age-of-onset subtyping has heuristic value with respect to the study of the causal pathways to conduct disorder, it is premature to use this system in clinic settings.

Tardy posterior interosseous nerve palsy due to childhood osteomyelitis: a case report.

A partial posterior interosseous nerve (PIN) paralysis developed in a patient more than 2 decades after having childhood osteomyelitis of the metaphysis of the radius. In previous reports of tardy PIN palsy, the radial head was dislocated (frequently in cases of unrecognized Monteggia fracture-dislocations), causing compression at the arcade of Frohse. In the patient whose case is discussed here, the radial head was located; compression of the PIN at the arcade of Frohse, in combination with traction against inflamed periosteum, likely resulted in the late development of clinical symptoms and signs.

Superficial radial nerve compression following flexor digitorum superficialis opposition transfer: a case report.

A patient is reported with a lesion of the radial branch of the superficial radial nerve following opposition transfer. The ring finger flexor digitorum superficialis slip was responsible for the neural compression near its thumb insertion.

Predicting the one-year course of adolescent major depression.

OBJECTIVE: To identify specific clinical and social functioning variables that predict persistence of major depression over a 1-year period of follow-up. METHOD: The sample consisted of 67 adolescents with major depression, drawn from consecutive referrals to psychiatric clinics in a defined, geographic catchment area. Clinical interviews and questionnaires measuring behaviors, symptoms, and social functioning were administered to both the adolescent and a parent at inception and at follow-up. Discriminant function analyses were used to identify inception variables that predicted clinical course independent of severity of depressive symptoms and global functioning. RESULTS: At 1-year follow-up, major depression remitted in 66% of subjects. Persisters were characterized at inception as older, more likely to have substance use or anxiety disorders, less involved with fathers, and less responsive to mother's discipline compared with remitters. The effect of these prognostic factors was independent of symptom severity and global functioning. CONCLUSION: These variables appear to reflect perpetuating and ameliorating factors influencing the short-term course of major depression. The findings suggest that treatments for adolescent depression that aim to enhance parent-adolescent relationships, and that specifically target coexisting disorders, should be evaluated for effectiveness.

Posterior interosseous nerve compression due to an enlarged bicipital bursa confirmed by MRI.

Posterior interosseous nerve compression is a well-described clinical entity with many aetiologies. Fewer than 12 documented cases of the condition due to an enlarged bicipital bursa exist in the literature. We describe a case in which magnetic resonance imaging (MRI) was used in the preoperative assessment of a mass in the proximal forearm with a clinical diagnosis of partial posterior interosseous nerve compression.

Infraclavicular ulnar nerve entrapment due to a chondroepitrochlearis muscle.

The chondroepitrochlearis muscle is an extremely rare muscle, arising from the pectoralis major, crossing over the neurovascular bundle in the axilla and inserting into the brachial fascia and medial epicondyle of the humerus. This paper presents the first known neurological complication due to the chondroepitrochlearis muscle.

Partial median nerve entrapment in the distal arm because of an accessory bicipital aponeurosis.

We present a newly described entrapment of the median nerve caused by compression in the distal arm because of an accessory bicipital aponeurosis. It is characterized by the paresis or paralysis of muscles innervated by the anterior interosseous branch of the median nerve--the flexor pollicis longus, the flexor digitorum profundus, and the pronator quadratus--as well as other more proximal median nerve innervated muscles, namely, the pronator teres and flexor carpi radialis. Sensibility is intact. The site of the Tinel's sign in the distal arm and the clinical appearance of an accessory bicipital aponeurosis help to localize the lesion. Electrodiagnostic studies are also important in establishing the site of the entrapment. The clinical and surgical findings are correlated with the internal topography of the median nerve at its site of compression. It is important to differentiate this syndrome from the classic anterior interosseous syndrome and other nerve entrapments at the elbow and arm. Surgical exploration is indicated if there is no clinical or electromyographic improvement in three to four months after the onset of symptoms.

An anatomic factor significant in transposition of the ulnar nerve.

Anterior subcutaneous or submuscular transposition of the ulnar nerve are recommended treatments for the cubital tunnel syndrome. Commonly encountered findings at submuscular transposition are the presence of a distinct fibrous septum within the main flexor-pronator origin, which arises from the proximal ulna and medial epicondyle and requires release to accomplish the transposition. Cadaver dissections were conducted to study the intermuscular fascial anatomy of the flexor-pronator origin. The surgical findings were confirmed. The fascial structure is the common aponeurosis between the flexor digitorum superficialis of the ring finger and the humeral head of the flexor carpi ulnaris. Failure to release this structure from the proximal ulna caused kinking and tethering of the nerve when transposition was attempted.

Anatomic variations in the motor and sensory supply of the thumb.

Variations in the motor and sensory nerve supply to the thumb exist despite stereotyped descriptions in modern anatomy texts. A careful dissection of ten specimens under high magnification has been made with special reference to the nature and incidence of anatomic variations. Transligamentous passage of the recurrent motor branch of the median nerve was noted in six dissections; two of these included multiple motor branches to the thenar musculature. The Riche-Cannieu anastamosis was observed in three specimens. Variations in the branch pattern of the median nerve fibers supplying sensation to the thenar eminance and palmar thumb were also noted. No dorsal (superficial radial nerve) to palmar communications were detected, although this pattern has been described clinically. The differences give rise to an element of diagnostic uncertainty in treating the nerve-injured patient; functional deficits and therapeutic consequences are discussed in relation to the authors' observations and a review of the literature.