A 79-year-old male presented to our institution with a fever of 100.9oF, shaking, chills, altered mental status, and 2 episodes of seizures. His prior medical history is significant for dementia, myasthenia gravis, type 2 diabetes mellitus, hypertension, right frontal hemorrhagic stroke, benign prostatic hyperplasia, and 2 simple kidney cysts. He was diagnosed 6 weeks earlier with an Escherichia coli bacteremia with no known source and with acute cystitis and hematuria caused by Klebsiella pneumoniae. Both organisms were pansensitive, and he was treated for 4 days with piperacillin–tazobactam and for 10 days with cefdinir. Follow-up blood cultures after 2 days showed no growth. His current urinalysis results showed negative nitrite, positive leukocyte esterase, and the presence of both red and white blood cells (WBC >50 and RBC >50/high-powered field). Blood and urine cultures were sent to the laboratory. The patient was started on empiric vancomycin and piperacillin–tazobactam but expired less than 24 hours later. The anaerobic blood culture bottle flagged positive after 98 hours of incubation, with the Gram stain showing long, gram-variable filaments containing bulbous inclusions (Figure 1).
Πέμπτη 30 Αυγούστου 2018
Erratum
An error appeared in the 15 January 2017 issue of the journal [Lockhart S.R., Etienne K.A., Vallabhaneni S., et al. Simultaneous Emergence of Multidrug-Resistant Candida auris on 3 Continents by Whole-Genome Sequencing and Epidemiological Analyses. Clin Infect Dis 2017; 64(2):134–40. https://doi.org/10.1093/cid/ciw691]. The Erg11 amino acid substitution associated with South African isolates is F126L, not F126T, as originally stated. The authors regret this error.
A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2018 Update by the Infectious Diseases Society of America and the American Society for Microbiologya
Abstract
The critical nature of the microbiology laboratory in infectious disease diagnosis calls for a close, positive working relationship between the physician/advanced practice provider and the microbiologists who provide enormous value to the healthcare team. This document, developed by experts in laboratory and adult and pediatric clinical medicine, provides information on which tests are valuable and in which contexts, and on tests that add little or no value for diagnostic decisions. This document presents a system-based approach rather than specimen-based approach, and includes bloodstream and cardiovascular system infections, central nervous system infections, ocular infections, soft tissue infections of the head and neck, upper and lower respiratory infections, infections of the gastrointestinal tract, intra-abdominal infections, bone and joint infections, urinary tract infections, genital infections, and other skin and soft tissue infections; or into etiologic agent groups, including arthropod-borne infections, viral syndromes, and blood and tissue parasite infections. Each section contains introductory concepts, a summary of key points, and detailed tables that list suspected agents; the most reliable tests to order; the samples (and volumes) to collect in order of preference; specimen transport devices, procedures, times, and temperatures; and detailed notes on specific issues regarding the test methods, such as when tests are likely to require a specialized laboratory or have prolonged turnaround times. In addition, the pediatric needs of specimen management are also emphasized. There is intentional redundancy among the tables and sections, as many agents and assay choices overlap. The document is intended to serve as a guidance for physicians in choosing tests that will aid them to quickly and accurately diagnose infectious diseases in their patients.Erratum
An error appeared in the 1 February 2018 issue of the journal [Muñoz L, Santin M, Alcaide F, et al. QuantiFERON-TB Gold In-Tube as a Confirmatory Test for Tuberculin Skin Test in Tuberculosis Contact Tracing: A Noninferiority Clinical Trial. Clin Infect Dis 2018; 66(3):396–403. https://ift.tt/2MIeTIs]. A Biostatistics Unit – IDIBELL team member (Cristian Tebé) name was inadvertently omitted. In the Appendix, after "Department of Microbiology: Fernando Alcaide, Raquel Moure." should appear the following "Biostatistics Unit, Bellvitge Biomedical Research Institute (IDIBELL): Cristian Tebé Codormi." The authors regret this error.
Drawing Inferences: Thinking with 6B (and Sketching Paper)
Abstract
This article discusses the epistemology of design as a process, arguing specifically that sketching and drawing are essential modes of thinking and reasoning. It demonstrates that the commonly accepted notion of a spontaneous and intuitive vision in the mind's eye—encapsulated in the cliché of the napkin sketch—obscures the exploratory inferences that are made while scribbling with a pencil on a sheet of paper. The draughtsperson, along with their work tools (such as the 6B), modes of notation, specific techniques, and epistemic strategies as well as the resulting design artefacts form milieus of reflection that facilitate complex processes of exploration. Case studies, including the genesis of the Mini by Alec Issigonis, samples of work by Alvar Aalto, and a reinterpretation of student sketches from a classical design study by Gabriela Goldschmidt, serve to illustrate how drawing inferences with pencil and paper occurs.
Dominant dystrophic epidermolysis bullosa pruriginosa with a COL7A1 exon 87 c.6898C>T mutation
Clinical and Experimental Dermatology, EarlyView.
Subacute cutaneous lupus erythematosus and systemic lupus erythematosus associated with abatacept
Subacute cutaneous lupus erythematosus (SCLE) is a subtype of cutaneous lupus erythematosus (CLE) with distinct clinical and immunologic features. It can be associated with Sjogren syndrome and rheumatoid arthritis (RA) as well as several classes of medications. Here we present a patient with new-onset SCLE and systemic lupus erythematosus (SLE) after treatment with abatacept. There is one other case of SCLE and one of SLE associated with abatacept described in the literature.1,2
The impact of diaper design on mitigating known causes of diaper dermatitis
Pediatric Dermatology, EarlyView.
Balance of tofacitinib efficacy and disease flare in the treatment of alopecia universalis: A case report and review of the literature
Alopecia areata (AA) is one of the most prevalent autoimmune diseases with 1.7% lifetime risk.1 AA is a nonscarring hair loss, typified by alopecic patches that can encompass the entire scalp in alopecia totalis (AT) or body in alopecia universalis (AU). The cause of AA is multifactorial, including an immune-mediated destruction of hair follicles2 in conjunction with genetic predisposition.3 There are currently no US Food and Drug Administration–approved treatments for alopecia areata, and treatment regimens are empiric, although topical, intralesional, and systemic steroids are commonly offered.
Reticular rash in drug reaction with eosinophilia and systemic symptoms syndrome: A clue to parvovirus B19 reactivation?
The term drug reaction with eosinophilia and systemic symptoms (DRESS) refers to a complex syndrome characterized by cutaneous lesions, eosinophilia, and systemic symptoms that may be triggered by different medications. The reaction takes place 2 to 6 weeks after the initial exposure to the culprit drug.1 Even after appropriate diagnosis and treatment have been conducted, patients may experience isolated or sequential relapses and slow clinical resolution that may be associated with viral reactivations of herpesvirus.
A case of subungual tumors of incontinentia pigmenti: A rare manifestation and association with bipolar disease
Incontinentia pigmenti (IP), or Bloch-Sulzberger syndrome, is an X-linked dominant disorder with male lethality caused by mutations in the IKBKG gene (also known as IKK-γ or NEMO), which is essential for nuclear factor-κB (NF-κB) activation and protects cells against tumor necrosis factor-α–induced apoptosis.1 In addition to the 4 cutaneous stages of IP (vesiculo-bullous, verrucous, hyperpigmented, and atrophic/hypopigmented), IP is also associated with ectodermal abnormalities, such as pegged teeth, alopecia, and anodontia as well as neurologic and ocular abnormalities.
Generalized familial benign chronic pemphigus (Hailey-Hailey disease) treated successfully with low-dose naltrexone
Familial benign chronic pemphigus or Hailey-Hailey disease (HHD) is an autosomal dominant genodermatosis with complete penetrance that was initially described by dermatologists and brothers Howard and Hugh Hailey.1 This disorder results from mutations in the ATP2C1 gene on chromosome 3q21, which encodes the Golgi-associated Ca2+ ATPase. Mutations in this gene lead to abnormal intracellular Ca2+ signaling leading to impaired processing of junctional proteins needed for cell-cell adhesion.
Subclinical granulomas in benign skin lesions heralding the onset of BRAF and MEK inhibitor–associated granulomatous dermatitis in a patient with metastatic melanoma
A 48 year-old white woman presented with melanoma, metastatic to the mediastinum. The primary lesion was ulcerated with a Breslow depth of 2.6 mm. The lesion was excised with appropriate margins. Right axillary sentinel lymph node biopsy was positive in 1 node, whereas a full lymph node dissection failed to find additional nodal involvement. She was treated with adjuvant interferon-β2, which was poorly tolerated and discontinued after 2 weeks. One year later, she presented with a 1-cm subcutaneous nodule above the excision scar, a biopsy of which confirmed metastatic melanoma.
Pancreatic acinar cell carcinoma–induced panniculitis
Pancreatic cancer is the fourth most common cause of cancer-related death among men and women in the United States. Every year, an estimated 43,090 people die of pancreatic cancer nationally.1 Pancreatic acinar cell carcinoma (ACC) is a rare form of pancreatic cancer that accounts for 1% to 2% of all pancreatic neoplasms.2 ACCs are generally asymptomatic and may be discovered incidentally when patients undergo work-up for general complaints such as abdominal pain. In the literature, investigators have reported a variety of systemic presentations of ACC.
Dehydrated human amnion/chorion membrane allograft as an aid for wound healing in patients with full-thickness scalp defects after Mohs micrographic surgery
Large surgical defects after Mohs micrographic surgeries (MMS) often require rotation or advancement flaps, skin grafts, or delayed reconstruction after use of tissue expanders. For patients with limited tissue redundancy, wounds may also heal by secondary intention. Elderly patients undergoing MMS with full-thickness defects exposing bone pose a unique set of healing barriers, such as immunosuppression, increased infection risk, poor tolerance to bone chiseling for exposing pinpoint bleeding, and difficulty in reaching wounds to apply dressings successfully.
Giant condyloma acuminatum of the vulva: Successful management with imiquimod
Giant condyloma acuminata (GCA) is a large condyloma of the anogenital region with a cauliflowerlike appearance. The tumor is extremely rare and is related to human papilloma virus (HPV) infection (HPV type 6 and 11 in 90% of cases).1 The definitive treatment is wide surgical excision, but topical medical treatment can be effective in selected cases.2,3 Here we report the first case, to our knowledge, of complete regression of vulvar GCA after treatment with topical imiquimod (5% cream) therapy, with no recurrence reported over a 3-year follow-up period.
Cutaneous metastases of malignant peripheral nerve sheath tumor: Ineffectiveness of intralesional methotrexate
Malignant peripheral nerve sheath tumor (MPNST) is an uncommon, aggressive sarcoma that arises from peripheral nerves and metastasizes hematogenously, most often to lung and bone.1 Approximately half of MPNSTs arise from plexiform neurofibromas in patients with neurofibromatosis type I (NF1).1 The remaining half occur sporadically, 10% of which arise from previously irradiated tissue.1 The epithelioid variant of MPNST is uncommon, accounting for less than 5% of cases.1 The most important aspect of treatment for MPNST is achieving clear surgical margins, as survival decreases dramatically with positive margins.
Successful treatment of cutaneous metastatic breast cancer with topical treatments that potentially synergize with systemic therapy: A case series
Breast cancer is the second most common malignancy after melanoma to metastasize to skin.1 Approximately 30% of individuals with metastatic breast cancer (MBC) go on to have cutaneous metastases, frequently presenting as firm nodules, diffuse infiltrative or ulcerative lesions, often in proximity to an old mastectomy scar.2,3 Cutaneous metastases of breast cancer (CMOBC) is a therapeutic challenge and is associated with increased morbidity. Progression of disease often results in severe pain, chest wall ulceration, bleeding, and superinfection.
Multiple reactive keratoacanthomas treated with zinc oxide wraps and intralesional corticosteroids
Keratoacanthoma (KA), a neoplasm of epidermal cells from the hair follicle unit,1 is often present on chronic sun-exposed skin.2 Many facets of this neoplasm are controversial, including its epidemiology, etiology, and biologic behavior, including malignant potential and recommendations for treatment.2 This case presents a treatment option for multiple reactive KAs that is both conservative and noninvasive.
Multiple acantholytic dyskeratotic acanthomas in an organ transplant recipient
Organ transplant recipients are known for carrying a high risk of various benign and malignant tumor development, particularly of the skin. Therapeutic immunosuppression in association with a variety of (co-)carcinogenic factors are held responsible for the high tumor incidence.
Pure testicular choriocarcinoma presenting as a friable hemorrhagic nodule on the lip
Here we present a case of metastatic cutaneous choriocarcinoma presenting as a lesion on the upper lip. This report briefly discusses choriocarcinoma, cutaneous manifestations, and prognosis.
Hepatitis C mixed cryoglobulinemia with undetectable viral load: A case series
Mixed cryoglobulinemic vasculitis is caused by circulating cold-precipitable immunoglobulins, or cryoglobulins, composed of monoclonal (type II) or polyclonal (type III) IgM directed against a polyclonal IgG. It causes palpable purpura and has long been associated with hepatitis C virus (HCV) infection. The initial theory regarding the new antiviral medications, which have been so successful in treating hepatitis C, was that once the HCV was treated, the mixed cryoglobulinemic vasculitis would also resolve.
Erythrodermic presentation of psoriasis in a patient treated with dupilumab
Dupilumab is an interleukin (IL)-4 receptor α (IL-4Rα) antagonist that inhibits IL-4 and IL-13 signaling, key mediators of T-helper (Th)2-mediated inflammation.1 Whereas an immune shift toward Th2 drives atopic dermatitis and thus a blockade in the Th2 inflammatory cascade is an effective treatment, the opposing shift toward Th1 and Th17 cells is implicated in the pathogenesis of psoriasis.2 We present an erythrodermic presentation of psoriasis in a patient treated with dupilumab for a dermatitis that was clinically diagnosed as atopic dermatitis.
Checkpoint inhibitor–associated cutaneous small vessel vasculitis
Under physiologic conditions, immune checkpoints provide negative signals to control T-cell activation and prevent inflammation-associated tissue destruction. Cytotoxic T-lymphocyte–associated antigen 4 (CTLA-4), a principal negative regulator of T-cell activation, binds to CD80/CD86 on antigen-presenting cells, dampening the stimulatory signal of CD28 on T cells. Programmed cell death 1 receptor (PD-1) is another inhibitive co-regulator of the CD28/CTLA4 pathway. Excessive activity of either of these checkpoints is one of the underlying mechanisms for cancers, such as melanoma, to evade the immune system.
Neglected basal cell carcinoma presenting with diffuse skeletal metastases
Metastatic basal cell carcinoma (mBCC) is exceedingly rare, with an estimated incidence of 0.0028% to 0.55%.1 Although the behavior of mBCC is poorly understood, the primary tumor typically exhibits aggressive histopathology, such as morpheaform, infiltrating, or basosquamous features. Basal cell carcinoma (BCC) usually metastasizes to regional lymph nodes (53%), lungs (33%), and bone (20%). Until a few years ago, the median survival after diagnosis was only 8 to 10 months. After the demonstration that more than 90% of BCC expressed abnormal Hedgehog signaling, 2 Hedgehog pathway inhibitors, vismodegib and sonidegib, were approved for advanced BCC.
Potential for overlooked melanoma in solid organ donors with a severely dysplastic nevus
Current or recent malignancy is a contraindication to organ donation because of the risk of transmission. Given the profound organ shortage in the United States, transplant surgeons frequently consider potential deceased organ donors with a remote history of malignancy. However, a diagnosis of melanoma, at any time, is an absolute contraindication to organ donation.1 Melanoma is one of the cancers most commonly transmitted from donor to recipient, which is likely related to its pathophysiology. The behavior of melanoma can be modulated by immunity; melanoma can remain dormant in the donor and then reactivate in the recipient because of the intense immunosuppression required to prevent rejection.
Negative Predictive Value of NI-RADS Category 2 in the First Posttreatment FDG-PET/CT in Head and Neck Squamous Cell Carcinoma [HEAD & NECK]
BACKGROUND AND PURPOSE:
FDG PET/CT has a high negative predictive value in patients with head and neck squamous cell carcinoma who responds completely to non-operative therapy. However, the treatment failure rate in patients with a partial but incomplete response is unclear. Our aim was to investigate the negative predictive value of the first posttreatment FDG-PET/CT in patients with head and neck squamous cell carcinoma with incomplete response interpreted as Neck Imaging Reporting and Data System (NI-RADS) category 2.
MATERIALS AND METHODS:We retrospectively identified patients with head and neck squamous cell carcinoma treated with chemoradiation or radiation therapy with curative intent in our institution between 2008 and 2016. We included patients whose first posttreatment FDG-PET/CT was interpreted as showing marked improvement of disease but who had a mild residual mass or FDG avidity in either the primary tumor bed or lymph nodes (NI-RADS 2). The negative predictive value of FDG-PET/CT was calculated, including the 95% CI, using the Newcombe method. Two-year disease-free survival was the reference standard.
RESULTS:Seventeen of 110 patients (15%) experienced locoregional treatment failure within 2 years of completing treatment, yielding a negative predictive value of 85% (95% Cl, 77%–90%). The most common location of tumor recurrence was the cervical lymph nodes (59%). The median time interval between completion of therapy and treatment failure was 10 months (range, 5–24 months).
CONCLUSIONS:In patients with an incomplete response after treatment of head and neck squamous cell carcinoma, the negative predictive value of the first posttreatment FDG-PET/CT was 85%, which is lower than the 91% negative predictive value of FDG-PET/CT in patients with an initial complete response. Patients with an incomplete response (NI-RADS 2) should undergo more frequent clinical and imaging surveillance than patients with an initial complete response (NI-RADS 1).
Multiple Brain Developmental Venous Anomalies as a Marker for Constitutional Mismatch Repair Deficiency Syndrome [PEDIATRICS]
BACKGROUND AND PURPOSE:
Biallelic constitutional mutations in DNA mismatch repair genes cause a distinct syndrome, constitutional mismatch repair deficiency syndrome (CMMRD), characterized by cancers from multiple organs, most commonly brain tumors, during childhood. Surveillance protocols include total and brain MR imaging among other modalities to enable early detection of tumors. Brain surveillance scans revealed prominent brain developmental venous anomalies (DVAs) in some patients. DVAs are benign vascular anomalies, and their incidence in the general population is 2.6%–6.4%. Most developmental venous anomalies are asymptomatic and are found incidentally. Our purpose was to assess the prevalence of DVAs in CMMRD patients and describe their phenotype.
MATERIALS AND METHODS:A retrospective descriptive analysis of brain MR imaging studies from 10 patients from 3 families with CMMRD was performed. Analysis included the number of developmental venous anomalies, location, draining vessels, and associated vascular anomalies (ie, cavernomas), with clinical correlation of symptoms and tumors.
RESULTS:All 10 patients had ≥2 developmental venous anomalies, and 2 had, in addition, non-therapy-induced cavernomas. There was no clinically symptomatic intracranial bleeding from developmental venous anomalies. Six patients had malignant brain tumors. The location of brain tumors was not adjacent to the developmental venous anomalies. No new developmental venous anomalies developed during follow-up.
CONCLUSIONS:The occurrence of multiple developmental venous anomalies in all our patients with CMMRD suggests that developmental venous anomalies may be a characteristic of this syndrome that has not been previously described. If confirmed, this quantifiable feature can be added to the current scoring system and could result in early implementation of genetic testing and surveillance protocols, which can be life-saving for these patients.
Radiologic-Pathologic Correlation of Tumor Thickness and Its Prognostic Importance in Squamous Cell Carcinoma of the Oral Cavity: Implications for the Eighth Edition Tumor, Node, Metastasis Classification [HEAD & NECK]
BACKGROUND AND PURPOSE:
Addressing the performance of an imaging-based parameter compared to a "gold standard" pathologic measurement is essential to achieve accurate clinical T-classification. Our aim was to determine the radiologic-pathologic tumor thickness correlation and its prognostic value in oral squamous cell carcinoma.
MATERIALS AND METHODS:All pathologic T1–T3 (seventh edition of the Cancer Staging Manual of the American Joint Committee on Cancer) oral squamous cell carcinomas diagnosed between 2010 and 2015 were reviewed. Radiologic tumor thickness was measured on preoperative CT or MR imaging blinded to pathology. The radiologic-pathologic tumor thickness correlation was calculated. The impact of the imaging-to-surgery time interval and imaging technique on the correlation was explored. Intra-/interrater reliability on radiologic tumor thickness was calculated. The correlation of radiologic-versus-pathologic tumor thickness and its performance as the seventh edition T-category modifier was evaluated. Multivariable analysis assessed the prognostic value of the radiologic tumor thickness for overall survival adjusted for age, seventh edition T-category, and performance status.
RESULTS:For 354 consecutive patients, the radiologic-pathologic tumor thickness correlation was similar for the image-to-surgery interval of ≤4.0 weeks ( = 0.76) versus 4–8 weeks ( = 0.80) but lower in those with more than an 8-week interval ( = 0.62). CT and MR imaging had similar correlations (0.76 and 0.80). Intrarater and interrater reliability was excellent (0.88 and 0.84). Excluding 19 cases with an imaging-to-surgery interval of >8 weeks, 335 patients were eligible for further analysis. The radiologic-pathologic tumor thickness correlation was 0.78. The accuracy for upstaging the T-classification based on radiologic tumor thickness was 83% for pathologic T1 and 74% for pathologic T2 tumors. Multivariable analysis confirmed the prognostic value of radiologic tumor thickness (hazard ratio = 1.5, P = .02) for overall survival.
CONCLUSIONS:This study demonstrates a good radiologic-pathologic tumor thickness correlation. Intrarater and interrater reliability for radiologic tumor thickness was excellent. Radiologically thicker tumor was predictive of inferior survival.
Thrombus Permeability on Dynamic CTA Predicts Good Outcome after Reperfusion Therapy [INTERVENTIONAL]
BACKGROUND AND PURPOSE:
Thrombus permeability assessed on conventional CTA is associated with neurologic outcome in patients with acute ischemic stroke. We aimed to investigate whether dynamic CTA can improve the accuracy of thrombus permeability assessment and its predictive value for outcome.
MATERIALS AND METHODS:We reviewed consecutive patients with acute ischemic stroke who had occlusion of the M1 segment of the middle artery cerebral artery and underwent pretreatment perfusion CT. Thrombus permeability, determined by thrombus attenuation increase (TAI), was assessed on 26-phase dynamic CTA derived from perfusion CT. TAImax was defined as the maximum TAI among phases; TAIpeak, as TAI of peak arterial phase; TAIcon, as TAI on phase 13. Good outcome was defined as a 3-month mRS score of ≤2.
RESULTS:One hundred four patients were enrolled in the final analysis. The median TAImax, TAIpeak, and TAIcon were 30.1 HU (interquartile range, 13.0–50.2 HU), 9.5 HU (interquartile range, –1.6–28.7 HU), and 6.6 HU (interquartile range, –5.1–24.4 HU), respectively. Multivariable regression analyses showed that TAImax (OR = 1.027; 95% CI, 1.007–1.048; P = .008), TAIpeak (OR = 1.029; 95% CI, 1.005–1.054; P = .020), and TAIcon (OR = 1.026; 95% CI, 1.002–1.051; P = .037) were independently associated with good outcome. The areas under the ROC curve of TAImax, TAIpeak, and TAIcon in predicting good outcome were 0.734, 0.701, and 0.658, respectively.
CONCLUSIONS:Thrombus permeability assessed on dynamic CTA could be a better predictor of outcome after reperfusion therapy than that assessed on conventional single-phase CTA.
Reasons for Reperfusion Failures in Stent-Retriever-Based Thrombectomy: Registry Analysis and Proposal of a Classification System [INTERVENTIONAL]
BACKGROUND AND PURPOSE:
In 5%–10% of patients with acute ischemic stroke with an intention to treat with mechanical thrombectomy, no reperfusion can be achieved (Thrombolysis in Cerebral Infarction score = 0/1). Purpose of this analysis was a systematic assessment of underlying reasons for reperfusion failures.
MATERIALS AND METHODS:An intention-to-treat single-center cohort (n = 592) was re-evaluated for all patients in whom no reperfusion could be achieved (n = 63). Baseline characteristics of patients were compared between patients with and without reperfusion failures. After qualitative review of all cases with reperfusion failures, a classification system was proposed and relative frequencies were reported. In a second step, occurrence of delayed recanalization at 24 hours after reperfusion failure and dependency on IV-tPA were evaluated.
RESULTS:In 63/592 patients with an intention to perform stent-retriever thrombectomy, no reperfusion was achieved (TICI 0/1, 10.6%, 95% CI, 8.2%–13.1%). Older patients (adjusted OR per yr = 1.03; 95% CI, 1.01–1.05) and patients with M2 occlusion (adjusted OR = 3.36; 95% CI, 1.82–6.21) were at higher risk for reperfusion failure. In most cases, no reperfusion was a consequence of technical difficulties (56/63, 88.9%). In one-third of these cases, reperfusion failures were due to the inability to reach the target occlusion (20/63, 31.7%), while "stent-retriever failure" occurred in 39.7% (25/63) of patients. Delayed recanalization was very rare (18.2%), without dependence on IV-tPA pretreatment status.
CONCLUSIONS:Reasons for reperfusion failure in stent-retriever thrombectomy are heterogeneous. The failure to establish intracranial or cervical access is almost as common as stent-retriever failure after establishing intracranial access. Systematic reporting standards of reasons may help to further estimate relative frequencies and thereby guide priorities for technical development and scientific effort.
Comparison of Advanced Imaging Resources, Radiology Workforce, and Payment Methodologies between the United States and Canada [PRACTICE PERSPECTIVES]
SUMMARY:
The purpose of this Practice Perspectives was to review the United States and Canadian approaches to health care access and payment for advanced imaging. The historical background, governmental role, workforce, coding, payment, radiologic challenges, cost, resource intensity, and overall outcomes in longevity are reviewed.
Identification of Hostile Hemodynamics and Geometries of Cerebral Aneurysms: A Case-Control Study [INTERVENTIONAL]
BACKGROUND AND PURPOSE:
Hostile hemodynamic conditions and geometries are thought to predispose aneurysms for instability and rupture. This study compares stable, unstable, and ruptured aneurysms while controlling for location and patient characteristics.
MATERIALS AND METHODS:The hemodynamics and geometries of 165 stable, 65 unstable, and 554 ruptured aneurysms were compared. Hemodynamics was modeled using image-based computational fluid dynamics. Case-control pairs were selected matching aneurysm location, patient age, and sex. Paired Wilcoxon tests were used to compare hemodynamic and geometric variables among different aneurysm groups. The pairing was repeated 100 times, and the combined P values were calculated and adjusted for multiple testing.
RESULTS:Ruptured aneurysms had lower minimum wall shear stress (P = .03), higher maximum wall shear stress (P = .03), more concentrated (P = .03) and mean oscillatory shear stress (P = .03), higher maximum velocity (P = .03), and more complex flows (vortex core-line length, P = .03) than stable aneurysms. Similarly, unstable aneurysms had more concentrated shear stress (P = .04) and more complex flows (vortex core-line length, P = .04) than stable aneurysms. Compared with stable aneurysms, ruptured aneurysms were larger (size ratio, aneurysm size/vessel size, P = .03), more elongated (aspect ratio, P = .03), and irregular (nonsphericity index, P = .03). Similarly, unstable aneurysms were larger (size ratio, P = .04), more elongated (aspect ratio, P = .04), and irregular (bulge location, P = .04; area-weighted Gaussian curvature; P = .04) than stable aneurysms. No significant differences were found between unstable and ruptured aneurysms.
CONCLUSIONS:Unstable and ruptured aneurysms have more complex flows with concentrated wall shear stress and are larger, more elongated, and irregular than stable aneurysms, independent of aneurysm location and patient sex and age.
Teaching with Stories: Ecology, Haraway, and Pedagogical Practice
Abstract
Haraway foregrounds many stories that we, in a late capitalist era, tell ourselves in order to justify, or not even notice, actions that are harmful to all living things. While I am mindful of Haraway's excellent attention to the ways that 'stories tell stories, thoughts think thoughts, and knots knot knots,' I argue that we must take great care when we, as educators, blur the lines between facts and fiction; reality and art. When everything becomes a story—with some stories simply being more compelling than other stories—we run the risk of contributing to the very sense of unmooring (from each other, from all living, from the earth) that has led us to the status quo where arctic icecaps are melting, living things are becoming extinct, and humans are suffering from man-made pollution. In this paper, I trouble the use of stories to draw attention to the ecological harm we have done to our earth. While stories can be powerful, there are risks associated with how we tell stories; and particular risks when we blur the lines between critical storytelling and the idea of something as 'factual'. Storytelling, and blurring the lines between stories and facts, can have negative implications for our quest to generate a sense of 'response-ability' for our planet and all who live on it. In order to make that argument, I first talk about my own story and the ways that I have used stories in the classroom. I then touch on Haraway and her particular use of (and argument for the use of) stories. I then foreground the practice of telling truths with stories by exploring the use of critical fiction and narrative inquiry. I conclude with implications for pedagogy.
Exploring an Alternative Justification for the Importance of Curiosity in Education: Social Curiosity and Løgstrup’s Sovereign Expression of Life
Abstract
There seems to be a broad agreement that curiosity is important in education. However, current research often seeks to answer the question of how best to nurture curiosity and fails to ask the normative question of why this should be done. A closer look reveals that the reasons for justifying the importance of curiosity vary, with some theorists pointing to its role in cognitive development as a starting point for learning, and others praising it as an element of democracy and a child's right to participation. Most of these approaches understand curiosity as an individual urge or desire for knowledge. In contrast, this article will examine a relational understanding of the concept by focussing on social curiosity. Instead of following a cognitive developmentalist, intellectual virtue or emancipatory approach to valuing curiosity, I will employ relational ethical theory. The argument then explores a possible analogy between social curiosity and the concept of sovereign expressions of life, as developed by the Danish philosopher and theologian K.E. Løgstrup. By drawing on his relational ethics, the article aims to expand the theoretical grounds on which curiosity can be normatively legitimised in education. With children spending longer and longer hours in educational, structured and adult-led settings, I conclude with a twofold normative claim: Social curiosity should be a part of all relations in education and its absence should lead to an ethical demand. In addition, an awareness of the actual deeds through which social curiosity is realised is also a topic that must be addressed by educators.
Topical 3-bromopyruvate is a novel targeted therapy for melanoma in a preclinical model
Targeting cancer metabolism is a promising strategy in improving cancer treatment.
Treatment of alopecia universalis with topical Janus kinase inhibitors – a double blind, placebo, and active controlled pilot study
International Journal of Dermatology, EarlyView.
Three-dimensional analysis of cutaneous nervous system in pruritic atopic dermatitis and psoriasis skin
Introduction: Intraepidermal nerve fiber (IENF) count in skin biopsies has been used as a reflection of the innervation density of itch-transmitting C nerve fibers in the skin. Changes in IENF densities in pruritic conditions such as eczema and psoriasis has been studied previously, but conflicting results have been reported. In these studies, IENF count is defined as the number of PGP9.5-positive nerve fibers crossing the basement membrane per unit length in 50-μm-thick histologic sections. However, this 2-dimensional approach is limited by the thickness of the section examined.
Introduction: Allergy Special Issue
Vascular wall imaging in reversible cerebral vasoconstriction syndrome – a 3-T contrast-enhanced MRI study
Limited histopathology studies have suggested that reversible cerebral vasoconstriction syndromes (RCVS) does not present with vascular wall inflammation. Previous vascular imaging studies have had inconsisten...
Satisfying your neuro-oncologist: a fast approach to routine molecular glioma diagnostics
Diffuse gliomas are the most common primary brain tumors in adults. Discrimination between astrocytic and oligodendroglial lineage differentiation has been subject to substantial intra- and interobserver variability, impairing prognostic and predictive stratification. Therefore, the 2016 WHO Classification of Tumors of the Central Nervous System introduced molecular markers, notably isocitrate dehydrogenase (IDH) mutation and loss of heterozygosity 1p/19q status, to reduce diagnostic bias.1 Nevertheless, standardized protocols for diagnostic (eg, IDH1/2 mutation, loss of heterozygosity 1p/19q) and predictive markers (eg, O6-methylguanine-DNA methyltransferase [MGMT] promoter methylation) are lacking. In addition, practical implementation of routine molecular workup of these tumors may be compromised by impractically long turnaround times and economic restraints, including lack of required equipment.
Facial Animation Surgery for Long-standing Facial Palsy: Opportunities for Shared Decision Making
This Viewpoint discusses the shared patient-physician decision-making process and suggests a 6-step approach for implementing the practice before surgical treatment of long-standing facial palsy in adults and children.
Anesthesia Duration Does Not Exist in a Surgical Vacuum
To the Editor Brady et al performed a novel retrospective investigation into outcomes after prolonged, otherwise intermediate-risk surgery. We take issue with the wording of their conclusion. From our perspective, they studied duration of surgery not anesthesia duration because it is for the prolonged surgery that prolonged anesthesia was administered. Obviously having a control group for similar surgery and similar duration without anesthesia would be practically impossible. One possible imaginary control group would be being anesthetized for a similarly prolonged number of hours without any surgery. From practical experience we can say with almost absolute certainty that the imaginary control group is very unlikely to see any complications. It is well established that perioperative entities like MINS (myocardial injury after noncardiac surgery) can affect mortality and outcome, especially after longer surgeries, from the extreme inflammation and prothrombogenic processes getting stimulated exits. Although the authors reported the incidence of myocardial infarction (MI), MINS is diagnosed using a high-sensitivity troponin assay, and most likely was not recorded in the National Surgical Quality Improvement Program database. Other studies have associated blood loss and blood transfusion with an increased risk of cardiac complications after surgery. In our experience, when we provide anesthesia for these patients it is often a vexing problem to maintain an adequate blood pressure for graft perfusion given the slow but persisting blood loss while simultaneously trying to avoid transfusion. To us, this is one more of the several studies showing that a prolonged surgical procedure, compounded by anesthesia and ongoing inflammatory processes may contribute to increased complications as observed in this study.
Anesthesia Duration Does Not Exist in a Surgical Vacuum
To the Editor In a recent retrospective database analysis, Brady et al dramatically opined in the title and repeatedly in the article that anesthesia duration is directly associated with several adverse outcomes in patients undergoing microvascular reconstruction procedures. This is a misleading and alarming claim which may lead to physician and lay public misunderstanding of the effects of general anesthesia.
Health Utility of Facial Palsy and Facial Reanimation
This survey study examines the societal perception of facial deformities and surgical facial reanimation.
The calcium-binding type III repeats domain of thrombospondin-2 binds to fibroblast growth factor 2 (FGF2)
Abstract
Thrombospondin (TSP)-1 and TSP-2 share similar structures and functions, including a remarkable antiangiogenic activity. We have previously demonstrated that a mechanism of the antiangiogenic activity of TSP-1 is the interaction of its type III repeats domain with fibroblast growth factor-2 (FGF2), affecting the growth factor bioavailability and angiogenic activity. Since the type III repeats domain is conserved in TSP-2, this study aimed at investigating whether also TSP-2 retained the ability to interact with FGF2. The FGF2 binding properties of TSP-1 and TSP-2 and their recombinant domains were analyzed by solid-phase binding and surface plasmon resonance assays. TSP-2 bound FGF2 with high affinity (Kd = 1.3 nM). TSP-2/FGF2 binding was inhibited by calcium and heparin. The FGF2-binding domain of TSP-2 was located in the type III repeats and the minimal interacting sequence was identified as the GVTDEKD peptide in repeat 3C, corresponding to KIPDDRD, the active sequence of TSP-1. A second putative FGF2 binding sequence was also identified in repeat 11C of both TSPs. Computational docking analysis predicted that both the TSP-2 and TSP-1-derived heptapeptides interacted with FGF2 with comparable binding properties. Accordingly, small molecules based on the TSP-1 active sequence blocked TSP-2/FGF2 interaction. Binding of TSP-2 to FGF2 impaired the growth factor ability to interact with its cellular receptors, since TSP-2-derived fragments prevented the binding of FGF2 to both heparin (used as a structural analog of heparan sulfate proteoglycans) and FGFR-1. These findings identify TSP-2 as a new FGF2 ligand that shares with TSP-1 the same molecular requirements for interaction with the growth factor and a comparable capacity to block FGF2 interaction with proangiogenic receptors. These features likely contribute to TSP-2 antiangiogenic and antineoplastic activity, providing the rationale for future therapeutic applications.
Understanding the evolving phenotype of vascular complications in telomere biology disorders
Abstract
Vascular complications such as bleeding due to gastrointestinal telangiectatic anomalies, pulmonary arteriovenous malformations, hepatopulmonary syndrome, and retinal vessel abnormalities are being reported in patients with telomere biology disorders (TBDs) more frequently than previously described. The international clinical care consortium of telomere-associated ailments and family support group Dyskeratosis Congenita Outreach, Inc. held a workshop on vascular abnormalities in the TBDs at the National Cancer Institute in October 2017. Clinicians and basic scientists reviewed current data on vascular complications, hypotheses for the underlying biology and developed new collaborations to address the etiology and clinical management of vascular complications in TBDs.
Angiogenesis in pancreatic cancer: current research status and clinical implications
Abstract
Pancreatic cancer is one of the most lethal malignancies worldwide. Although the standard of care in pancreatic cancer has improved, prognoses for patients remain poor with a 5-year survival rate of < 5%. Angiogenesis, namely, the formation of new blood vessels from pre-existing vessels, is an important event in tumor growth and hematogenous metastasis. It is a dynamic and complex process involving multiple mechanisms and is regulated by various molecules. Inhibition of angiogenesis has been an established therapeutic strategy for many solid tumors. However, clinical outcomes are far from satisfying for pancreatic cancer patients receiving anti-angiogenic therapies. In this review, we summarize the current status of angiogenesis in pancreatic cancer research and explore the reasons for the poor efficacy of anti-angiogenic therapies, aiming to identify some potential therapeutic targets that may enhance the effectiveness of anti-angiogenic treatments.
L’album des résultats
Publication date: Available online 30 August 2018
Source: Annales de Chirurgie Plastique Esthétique
Author(s): C. Bruant Rodier, F. Bodin, C. Huttin, V. Duquennoy, E. Delay, C. Dissaux
Résumé
Cet album est à l'usage du chirurgien pour faciliter l'information de la patiente. Des résultats cliniques y sont présentés, déclinés en fonction de la technique de reconstruction envisagée ; reconstruction prothétique, mixte ou autologue, par lambeau ou lipomodelage et en prenant en compte des femmes de morphologies diverses. Sans constituer un catalogue, ni une promesse de résultat, le but de cet album est d'assister le chirurgien et sa patiente dans un choix avisé de l'indication technique par le biais d'un support visuel.
Summary
This document is meant to be a practical guide for the surgeon, to assist him in informing the patient more easily. Different clinical results with different reconstructive techniques and different morphologies are presented. This document is not meant to be a catalogue, or to guarantee any result to the patient, but truly to assist as best as it can the surgeon and the patient in choosing together the most appropriate techniques on a visual basis.
Sentinel lymph node biopsy in melanoma: Which hot nodes should be harvested and is blue dye really necessary?
Publication date: September 2018
Source: Journal of Plastic, Reconstructive & Aesthetic Surgery, Volume 71, Issue 9
Author(s): JM Ranson, NM Pantelides, D Gharpuray Pandit, JKG Laitung
Abstract
Objectives
The '10% rule' has become widely accepted by surgeons performing sentinel lymph node biopsy (SLNB) for melanoma. The purpose of this study was to compare the '10% rule' with alternative node harvesting criteria. In particular, we were interested to see whether the use of blue dye had any impact on the sensitivity of the test and whether it is necessary to remove all hot nodes.
Methods
We reviewed 537 SLNBs performed for primary melanoma from 2009–2015. SLNB was offered to all patients with 1–4 mm Breslow thickness melanoma and sentinel nodes were harvested according to the '10% rule'.
Results
One hundred sixteen patients (22%) had at least one positive sentinel node and there were 45 positive nodal basins from which more than one sentinel node had been harvested. Excluding blue dye and sampling only hot nodes would have enabled a 5% reduction in nodes harvested, without any compromise in the sensitivity of the test. However, applying harvesting criteria whereby not all hot nodes are taken was associated with a loss of sensitivity, with positive sentinel nodes being missed and patients understaged.
Conclusions
Our data do not support the continued use of blue dye in SLNB for melanoma, as it does not improve the sensitivity of the test. This series adds to growing evidence, suggesting that the '10% rule' with the inclusion of blue nodes should be reconsidered and that radiocolloid tracer alone is sufficient for sentinel node localisation.
The Effect of Endothelial Cells on UVB‐induced DNA Damage and Transformation of Keratinocytes In 3D Polycaprolactone Scaffold Co‐culture System
Photochemistry and Photobiology, Volume 0, Issue ja, -Not available-.
De novo design of biosynthetic pathways for bacterial production of bulk chemicals and biofuels
Abstract
Recent advances in DNA synthesis and computer science have enabled the de novo design of biosynthetic pathways. Numerous computational tools are currently available for searching biosynthetic pathways and ranking them on the basis of multiple criteria for installation into microbial chassis strains. This new framework allows the design of artificial biosynthetic pathways without expert knowledge of the specific biochemical reactions involved. Moreover, genetic apparatuses with quantitative and predictable properties enable rational construction of gene circuits. Thus, our ability to construct microbial cells specialized for bio-production is accelerating. However, many synthetic biology tools have not yet been fully applied to metabolic engineering owing to the lack of interdisciplinary collaboration between metabolic engineers and synthetic biologists. Therefore, we have focused on discussing how synthetic biology tools can be applied to de novo design of biosynthetic pathways.RpoS controls the expression and the transport of the AlgE1-7 epimerases in Azotobacter vinelandii
Abstract
Azotobacter vinelandii produces differentiated cells, called cysts, surrounded by two alginate layers, which are necessary for their desiccation resistance. This alginate contains variable proportions of guluronate residues, resulting from the activity of seven extracytoplasmic epimerases, AlgE1-7. These enzymes are exported by a system secretion encoded by the eexDEF operon; mutants lacking the AlgE1-7 epimerases, the EexDEF or the RpoS sigma factor produce alginate, but are unable to form desiccation resistant cysts. Herein, we found that RpoS was required for full transcription of the algE1-7 and eexDEF genes. We found that the AlgE1-7 epimerases proteins were diminished in the rpoS mutant strain. In addition, the alginate produced in the absence of RpoS was more viscous in the presence of proteases, a phenotype similar to that of the eexD mutant. Primer extension analysis located two promoters for the eexDEF operon, one of them RpoS dependent. Thus, during encysting conditions, RpoS coordinates the expression of both the AlgE1-7 epimerases and the EexDEF protein complex responsible for their transport.Lactic acid bacteria: from starter cultures to producers of chemicals
Abstract
Lactic acid bacteria constitute a diverse group of industrially significant, safe microorganisms that are primarily used as starter cultures and probiotics, and are also being developed as production systems in industrial biotechnology for biocatalysis and transformation of renewable feedstocks to commodity- and high value chemicals, and health products. Development of strains, which was initially based mainly on natural approaches, is also achieved by metabolic engineering that has been facilitated by the availability of genome sequences and genetic tools for transformation of some of the bacterial strains. The aim of this paper is to provide a brief overview of the potential of lactic acid bacteria as biological catalysts for production of different organic compounds for food and non-food sectors based on their diversity, metabolic- and stress tolerance features, as well as the use of genetic/metabolic engineering tools for enhancing their capabilities.Utility of a sensor‐based technology to assist in the prevention of pressure ulcers: A clinical comparison
International Wound Journal, EarlyView.
Surgery, radiotherapy or a combined modality for jugulotympanic paraganglioma of Fisch class C and D
Clinical Otolaryngology, Volume 0, Issue ja, -Not available-.
Foreign body granuloma treatment with 22‐MHz ultrasound‐guided corticoid infiltration
Journal of Cosmetic Dermatology, EarlyView.
Effects of four soaps on skin trans‐epidermal water loss and erythema index
Journal of Cosmetic Dermatology, EarlyView.
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Publication date: Available online 25 July 2018 Source: Journal of Photochemistry and Photobiology B: Biology Author(s): Marco Ballestr...
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Editorial AJR Reviewers: Heartfelt Thanks From the Editors and Staff Thomas H. Berquist 1 Share + Affiliation: Citation: American Journal...
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