Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00306932607174: 06/26/17

Δευτέρα 26 Ιουνίου 2017

Diagnostic utility of distal nerve conduction studies and sural near-nerve needle recording in polyneuropathy

Nerve conduction studies (NCS) are a very useful tool in diagnosing polyneuropathy (PNP) both with respect to confirming the PNP and classifying it as primarily demyelinating or axonal (Donofrio and Albers, 1990; Tankisi et al., 2005). Since most PNPs follow a length dependent pattern, the sensory nerves of the feet are usually affected in the early stages (Oh et al., 2001; Park et al., 2003; Singleton et al., 2008; Singleton, 2005). The sural nerve is the most frequently examined nerve in the electrodiagnosis of PNP (Burke et al., 1974).

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The neural bases of ictal tachycardia in temporal lobe seizures

Temporal lobe epilepsy (TLE) can lead to intense changes in cardiac autonomic functions during both interictal and ictal periods (Lotufo et al., 2012; Eggleston et al., 2014). Tachycardia, defined as a decrease in the ECG R-R intervals (RR) (increase in heart rate), is the most common cardiac change occurring during epileptic seizures (Opherk and Hirsch, 2002; O'Regan and Brown, 2005; Toth et al., 2010) whereas bradycardia occurs in only 2% of them (Moseley et al., 2010). Tachycardia was proposed as a biomarker providing a somatic indicator of temporal lobe (TL) seizure onset (Osorio, 2014; Schiecke et al., 2014; Osorio and Manly, 2014; Jeppesen et al., 2015; Osorio and Manly, 2015; Behbahani et al., 2016; Van de Vel et al., 2016), opening the way to automatized and noninvasive seizure detection and treatment delivery prior to, or at the onset of, a TL seizure.

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Reversal of long term potentiation-like plasticity in primary motor cortex in patients with progressive supranuclear palsy

Progressive Supranuclear Palsy (PSP) is a neurodegenerative disorder due to the deposition of tau-protein aggregates in several brain regions leading to parkinsonism, oculomotor abnormalities, early postural instability and falls. To date, the pathophysiological mechanisms of PSP are still poorly understood (Colosimo et al., 2014; Wenning et al., 2013).

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Female Runner with Painful Left Thigh Swelling: A Case of May-Thurner Syndrome

We present a case of a female runner who presented with burning left groin and thigh pain and positional swelling following a long run. The workup revealed May-Thurner syndrome. May-Thurner syndrome anatomy is a common anatomical variant present in approximately 20% of the population. Compression of the iliac vein may result in venous stasis in the lower limb with a predisposition to deep venous thrombosis. We identify four reported cases of May-Thurner syndrome in female runners and review the importance of diagnosis and appropriate treatment of this condition.

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Measuring physical and cognitive fatigue in people with Post Polio Syndrome: development of the Neurological Fatigue Index for Post Polio Syndrome (NFI-PP)

Fatigue in Post Polio Syndrome (PPS) has been shown to adversely affect quality of life. There is currently no disease-specific measure of fatigue for PPS.

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Change of an Injured Corticospinal Tract During 3 Weeks' Rehabilitation After Putaminal Hemorrhage.

No abstract available

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Regarding: Radial Extracorporeal Shockwave Therapy Is No More Effective Than Placebo in the Management of Lateral Epicondylitis: A Double-Blind, Randomized, Placebo-Controlled Trial.

No abstract available

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What Is the Effect of Strength Training on Pain and Sleep in Patients With Fibromyalgia?.

Objective: The study aimed to investigate the effect of an 8-wk structured strength training program on pain and sleep quality in patients with fibromyalgia. Design: Fifty-two patients with fibromyalgia were evaluated; 31 submitted to strength training and 21 comprised the control group. The instruments used were the Fibromyalgia Impact Questionnaire and The Pittsburgh Sleep Quality Index. The questionnaires were applied before the first training session, at 12 sessions, and after 24 sessions. Descriptive statistics (mean, SD, and frequency) and inferential tests were used. Results: After 8 wks of intervention, significant differences were found between groups in subjective quality of sleep (P = 0.03), sleep disturbance (P = 0.02), daytime dysfunction (P = 0.04), and total sleep score (P

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Effects of Transcranial Direct Current Stimulation Plus Physical Therapy on Gait in Patients With Parkinson Disease: A Randomized Controlled Trial.

Objective: The aim of the study was to study the combined effects of transcranial direct current stimulation (tDCS) and physical therapy on the walking ability of patients with Parkinson disease (PD). Study Design: The study used an experimental, double-blinded, randomized controlled trial. Results: After intervention, group 1 (only tDCS) demonstrated a significant increase in gait speed by 0.13 to 0.14 m/sec (17.8%-19.2%) and an increase in step length by 5.9 to 6.1 cm (14.0%-14.5%), whereas group 2 (tDCS and physical therapy) revealed a significant increase in gait speed by 0.10 to 0.13 m/sec (14.9%-19.4%) and step length by 4.5 to 5.4 cm (10.6%-12.8%) and group 3 (sham tDCS and physical therapy) showed a significant increase in gait speed by 0.09 to 0.14 m/sec (13.0%-20.3%) and step length by 3.0 to 5.4 cm (6.8%-12.3%). All these results lasted for at least 8 wks after intervention. Upon comparing the parameters of gait among the three groups at every follow-up visit, no significant difference was observed. Conclusions: Anodal tDCS or physical therapy could be used alone or together as a combination treatment to improve the walking speed of patients with Parkinson disease. The effects lasted for approximately 8 wks. The combination treatment was not superior to the use of tDCS or physical therapy alone. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Moving into poverty during childhood is associated with later sleep problems

A social gradient in sleep has been demonstrated across the life span, but previous studies have been cross-sectional and used self-reported socioeconomic status (SES) indicators. Using registry-based data on family income trajectories, the current study examined the association between relative poverty in childhood and subsequent sleep in adolescence.

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Utility of new-generation pacemakers in sleep apnea screening

Patients with cardiac pacemakers present a high prevalence of undiagnosed sleep apnea syndrome (SAS). New-generation pacemakers have algorithms that identify sleep respiratory events. Our aim was to evaluate their accuracy in the diagnosis of SAS.

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Validation of the screening tool ApneaLink® in comparison to polysomnography for the diagnosis of sleep-disordered breathing in children and adolescents

While out-of-center testing was introduced as an alternative for the diagnosis of obstructive sleep apnea in adults, polysomnography (PSG) is still considered mandatory in the diagnosis of sleep-disordered breathing (SDB) in children. The purpose of this study was to validate the outpatient screening device ApneaLink® in comparison to PSG in children and adolescents for the diagnosis of SDB.

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Relationship between stress coping and sleep disorders among the general Japanese population: a nationwide representative survey

To clarify the prevalence of stress, and examine the relationship between sleep disorders and stress coping strategies among highly stressed individuals in the general Japanese population.

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Relationship between obstructive sleep apnea and neuroimaging signatures of cerebral small vessel disease in community-dwelling older adults. The Atahualpa Project

/Objectives: Evidence of a relationship between obstructive sleep apnea (OSA) and neuroimaging signatures of cerebral small vessel disease (SVD) is limited. The present study aimed to evaluate this association in older adults living in rural Ecuador, where small vessel disease is a major pathogenetic mechanism underlying stroke.

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Post-traumatic headache in patients with minimal traumatic intracranial hemorrhage after traumatic brain injury: a retrospective matched case-control study

No evidence is available on the risks of neurologically asymptomatic minimal traumatic intracranial hemorrhage (mTIH) in patients with traumatic brain injury (TBI) for post-traumatic headache (PTH). The purpos...

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Pain Management in Abdominal Wall Reconstruction.

Background: In abdominal wall reconstruction, adequate pain control and minimization of narcotic consumption are essential to improving patient outcomes and satisfaction. Previous studies have examined the role of individual strategies, such as neuraxial analgesia and multimodal analgesia. However, there has not been a study that examined all potential determinants of postoperative narcotic requirements, including intraoperative strategies. Methods: Consecutive patients who underwent abdominal wall reconstruction were reviewed. Preoperative factors (chronic preoperative narcotic usage, indication for abdominal wall reconstruction, administration of neuraxial analgesia), intraoperative factors (intraoperative narcotics administered, method of mesh fixation), and postoperative factors (multimodal analgesia, complications) were collected. The main outcomes were daily amount of opioids used and length of hospital stay. Results: Ninety-three patients were included in the study. Patients who had an epidural required lower doses of opioids postoperatively, while those on chronic preoperative opioids, those whose mesh was fixated using transfascial sutures, and those who received large doses of opioids intraoperatively required higher doses of postoperative opioids. Hospital length of stay was longer in patients who received transfascially sutured mesh and those on chronic opioids preoperatively. Conclusions: This study provides potential strategies to improve pain control and minimize narcotic consumption postoperatively in patients undergoing abdominal wall reconstruction. Intraoperative administration of opioids should be minimized to avoid the development of tolerance. Epidural analgesia reduces postoperative narcotic requirement and may be especially beneficial in patients at highest risk for postoperative pain, including those on chronic opioids, and those in whom transfascial sutures are used for mesh fixation. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Copyright (C) 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.

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Tissue Expanders and Proton Beam Radiotherapy: What You Need to Know.

Summary: Proton beam radiotherapy (PBR) has gained acceptance for the treatment of breast cancer because of unique beam characteristics that allow superior dose distributions with optimal dose to the target and limited collateral damage to adjacent normal tissue, especially to the heart and lungs. To determine the compatibility of breast tissue expanders (TEs) with PBR, we evaluated the structural and dosimetric properties of 2 ex vivo models: 1 model with internal struts and another model without an internal structure. Although the struts appeared to have minimal impact, we found that the metal TE port alters PBR dynamics, which may increase proton beam range uncertainty. Therefore, submuscular TE placement may be preferable to subcutaneous TE placement to reduce the interaction of the TE and proton beam. This will reduce range uncertainty and allow for more ideal radiation dose distribution. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Copyright (C) 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.

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Using the Venous Pectoral Branch from the Thoracoacromial System as a Lifeboat in Autologous Breast Reconstruction.

Summary: The most common recipient vessels for autologous free flap breast reconstruction are the internal mammary vessels. At times, there are problems with the exposed internal mammary vein (IMV) that require other options such as using the contralateral IMV, superior rib resection to access proximal IMV, retrograde IMV use, and thoracodorsal vein access with or without a vein graft. This case demonstrates using the pectoral branch of the thoracoacromial venous system without a vein graft as a lifeboat option when the IMV is not suitable for anastomosis. C.W. was a 65-year-old female who underwent right-sided mastectomy with placement of a tissue expander. After adjuvant radiation therapy, C.W. underwent deep inferior epigastric perforator free flap breast reconstruction. During exposure of the internal mammary artery and IMV, an iatrogenic venotomy occurred that precluded the use of this vessel as a reliable recipient. The deep inferior epigastric perforator flap pedicle was then dissected proximal to isolate the artery and vein, and the vein was successfully anastomosed to the venous pectoral branch of the thoracoacromial system. The postoperative course was uneventful and patient was discharged home on postoperative day 4. Using the venous pectoral branch of the thoracoacromial is a safe and valuable option that can be considered in difficult situations when the IMV is not a suitable option. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Copyright (C) 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.

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A Unique Lymphaticovenous Supermicrosurgery Training Curriculum: Reflections on Validation and Competency Thresholds.

Summary: Supermicrosurgery is becoming a commonly used technique in various subspecialties of reconstructive surgery. However, there is a lack of standardization and validation in novel supermicrosurgical training. Current simulation training programs are not adequately focused on the challenges encountered during clinical supermicrosurgery practice. This article describes the authors' experience utilizing a supermicrosurgery competency-based training curriculum, in a simulation-based environment, toward safe clinical practice for lymphatic submillimeter supermicrovascular surgery. This article demonstrates the senior authors' (I.K.) Halstedian competency-based curriculum for lymphaticovenous anastomosis training. Further, a step-by-step training utilizing the chicken thigh and the living rat high fidelity simulation models, which subsequently allows supervised one-to-one clinical training with verified clinical competency outcomes, are demonstrated. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Copyright (C) 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.

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Gender Confirmation Surgery: Cosmetic or Reconstructive Procedure?.

No abstract available

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Unilateral Internal Mammary Recipient Vessels for Bilateral DIEP Flap Breast Reconstruction.

Summary: The deep inferior epigastric perforator flap has become increasingly popular for breast reconstruction with the most common recipient vessels being the internal mammary artery and vein. In certain cases, however, these recipient vessels are inadequate due to an absent or diminutive vein. Moreover, patients at high risk for future coronary artery disease may sacrifice the best conduit for coronary revascularization if the internal mammary recipients are used. Alternative recipient vessels, including the thoracodorsal, thoracoacromial, external jugular, and cephalic vessels have significant limitations. In this report, we describe a novel technique using unilateral internal mammary recipient vessels for bilateral free flap breast reconstruction. Two cases are presented that represent distinct indications for this technique: (1) absence or inadequacy of unilateral recipient vessels and (2) preservation of the left internal mammary system for future bypass in patients at high risk for coronary artery disease. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Copyright (C) 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.

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Angiotensin 1-7 inhibits angiotensin II-stimulated head and neck cancer progression

Angiotensin II (Ang II) is the product of the proteolytic action of angiotensin-converting enzyme (ACE) on the precursor peptide, angiotensin I (Ang I). In addition to its vasoactive properties, Ang II is able to stimulate angiogenesis and act as a mitogen, promoting cellular proliferation. Recently, evidence has emerged that Ang II is also able to promote tumour invasion, a key step in the metastatic cascade, although the mechanisms by which it does so remain largely obscure. Here we show that Ang II is able to promote the invasion and migration of head and neck squamous cell carcinoma (HNSCC) cells both in an autocrine manner and by triggering stromal tumour-paracrine interactions. The effects of Ang II on autocrine and paracrine signalling pathways are mediated by angiotensin receptor 1 (AT₁R) and inhibited by angiotensin 1-7 (Ang 1-7), a peptide produced from Ang II by the action of angiotensin-converting enzyme 2 (ACE2). These data are the first to demonstrate a role for the renin–angiotensin system in oral carcinogenesis and raise the possibility of utilizing AT₁R receptor antagonists and/or Ang 1-7 as novel therapeutic agents for HNSCC.

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Oral problems and quality of life of preschool children: self-reports of children and perception of parents/caregivers

The purpose of this study was to evaluate the association between oral health problems and oral health-related quality of life (OHRQoL) of preschool children according to both self-reports and the reports of parents/caregivers. A school-based, cross-sectional study was conducted with 769 preschool children and their parents/caregivers. The OHRQoL was evaluated using the Scale of Oral Health Outcomes for Five-Year-Old Children (SOHO-5). Based on logistic regression for complex samples, the following variables were found to be associated with poorer OHRQoL in the parent/caregiver version: toothache (OR = 6.77; 95% CI: 3.95–11.59); consequences of untreated dental caries (OR = 2.69; 95% CI: 1.27–5.70); and anterior open bite (OR = 2.01; 95% CI: 1.13–3.56). The following variables were associated with poorer OHRQoL in the child self-report version: toothache (OR = 3.34; 95% CI: 2.11–5.29); cavitated lesions (anterior teeth) (OR = 2.20; 95% CI: 1.26–3.84); occurrence of traumatic dental injury (OR = 1.77; 95% CI: 1.19–2.61); and anterior open bite (OR = 1.95; 95% CI: 1.16–3.29). We conclude that children with dental caries (or its sequelae) had poorer OHRQoL. Having experienced a traumatic dental injury and having a malocclusion were also associated with a poorer OHRQoL.

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Antibiotic-prescribing habits among Norwegian dentists: a survey over 25 years (1990–2015)

Bacterial antibiotic resistance is a steadily growing global problem, which today is compared with issues such as global warming, ozone depletion, and extinction of species. Consequently, calls come from global, Pan-European, and national authorities to gain insight into, limit, and stringently qualify the use of antibiotics in human and veterinary medicine, as well as in food production. Dentists are not considered to be frequent prescribers of antibiotics. However, few studies have identified how much, and in which situations, dentists prescribe such drugs. The aims of the present study were to survey Norwegian dentists' antibiotic-prescribing habits in 2015 and to compare the findings with previous studies (1990 and 2004) and with the actual numbers of dispensed prescriptions obtained from the 'Norwegian National Prescription Register'. The results from 1990 to 2004 show that there was a general increase in antibiotic prescriptions by Norwegian dentists, followed by a reduction or flattening of the prescription volume curve from 2004 to 2015. Despite this, possibilities for further improvements have been identified and recommendations given for targeted campaigns to reduce the prescription volume in dentistry by a further 30%, which has been ordered by the Norwegian National Assembly.

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Treatment of laryngopharyngeal reflux using a sleep positioning device: A prospective cohort study

Laryngopharyngeal reflux (LPR) symptoms are often resistant to management and cause significant quality of life impairment to patients with this disease. This study assesses the utility of a sleep-positioning device (SPD) in treating LPR.

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Lateral cervical approach for supracricoid partial laryngectomy

The supracricoid partial laryngectomy has been described for the treatment of T3 laryngeal glottic and supraglottic tumors as well as upfront and salvage surgery. Good oncological and functional outcomes are expected, while the post-operative rehabilitation can be quite difficult for the patient. Early and late complications can occur especially in salvage surgery. Neck dissection according to the T stage is often associated with the resection of the primary tumor.

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Oral problems and quality of life of preschool children: self-reports of children and perception of parents/caregivers

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Angiotensin 1-7 inhibits angiotensin II-stimulated head and neck cancer progression

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Antibiotic-prescribing habits among Norwegian dentists: a survey over 25 years (1990–2015)

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Persistent distress increases mortality in patients with coronary artery disease, study finds

Persistent, moderate to severe psychological distress is associated with significantly increased mortality in patients with stable coronary artery disease, a large follow-up study has shown.1Previous...

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Eating fish regularly is linked to reduced rheumatoid arthritis, study finds

Eating fish at least twice a week was associated with reduced disease activity in patients with rheumatoid arthritis (RA) in a study that found higher levels of joint swelling and tenderness in...

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Persistent distress increases mortality in patients with coronary artery disease, study finds

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Eating fish regularly is linked to reduced rheumatoid arthritis, study finds

Eating fish at least twice a week was associated with reduced disease activity in patients with rheumatoid arthritis (RA) in a study that found higher levels of joint swelling and tenderness in...

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Panton-Valentine Leukocidin–producing Staphylococcus aureus

Emerg Infect Dis.

doi: 10.3201/eid1211.060726

PMCID: PMC3372361

Amos Adler,^* Violeta Temper,^* Colin S. Block,^* Nitsa Abramson,^† and Allon E. Moses^*

^*Hadassah-Hebrew University Medical Center, Jerusalem, Israel;

^†Ministry of Health, Jerusalem, Israel

Corresponding author.

Address for correspondence: Allon E. Moses, Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, Kiryat-Hadassah, Jerusalem, Israel; email: li.ca.ijuh.dm@asesom

To the Editor: Panton-Valentine leukocidin (PVL) is a cytotoxin produced by Staphylococcus aureus that causes leukocyte destruction and tissue necrosis (1). Although produced by 5% of S. aureus strains, the toxin is detected in large percentages of isolates that cause necrotic skin lesions and severe necrotizing pneumonia (2). Although commonly associated with community-acquired methicillin-resistant S. aureus (CA-MRSA) (3), several outbreaks due to methicillin-susceptible S. aureus (MSSA) have also been reported (4–6). We describe an outbreak of cutaneous infections caused by PVL-producing MSSA that affected 6 of 11 members of 2 related families.

During a period of 6 months, a cluster of S. aureus skin and soft tissue infections occurred in 2 families in Jerusalem, Israel, that were related through the mothers, who are sisters. The event started with the 4-year-old boy of family A, who had 5 episodes of skin infections, including 2 episodes of perianal abscesses that required drainage and hospitalization. Culture of pus grew MSSA that was resistant to erythromycin and clindamycin. Subsequently, recurrent abscesses and cellulitis developed in the boy's father's legs, and his mother had severe periorbital cellulitis that required hospitalization and surgical drainage. Approximately 1 month later, a 9-year-old boy in family B had severe cellulitis and abscess around his knee that required hospitalization and surgical drainage. Subsequently, infections developed in 2 more children in family B: 1 had a finger pulp-space infection and the other cellulitis of the lower abdomen. All pus cultures grew S. aureuswith identical susceptibility patterns. The cases are summarized in the Table.

Table

Clinical and microbiologic data of the outbreak*

Following these events, the families consulted the infectious diseases clinic at the Hadassah-Hebrew University Medical Center in Jerusalem. Since the clinical isolates were not available, nasal cultures were obtained from all family members. S. aureus was isolated from all the affected members of family A and from the parents and the 2 boys in family B. All 7 isolates were subjected to pulsed-field gel electrophoresis (PFGE) after digestion with SmaI. All except 1 had identical band patterns and the same antimicrobial drug susceptibilities as the clinical isolates. The presence of PVL genes was examined by PCR as previously described (2) and was detected only in the isolates with identical PFGE patterns. The families were advised to apply mupirocin nasal ointment twice a day for 5 days and to bathe with 4% chlorhexidine scrub for 1 week (7). At 7 months of follow-up, no new cases of skin infection had occurred in either family. An epidemiologic investigation was undertaken by the local department of health to determine if 3 kindergartens and 2 schools attended by the 7 children had an increased incidence of staphylococcal skin disease. No evidence of unusual disease was found.

We describe here the first confirmed cases of PVL-producing S. aureus infections in Israel. Maier et al (8) recently described 2 cases of similar infections that occurred in German tourists after visiting the Dead Sea area, but since these infections were caused by MRSA, it is probable that the isolates were genetically distinct from the strain described here. In addition, to the best of our knowledge this is the first description of transmission of PVL-producing MSSA between related families. Previous reports described community-related outbreaks that occurred within families (6,8,9), between schoolmates (4), and between football team players (10). The exact route of transmission was not identified in some of these cases but it was presumed to have been close contact leading to skin (10) or nasal (4) colonization and subsequent active infection. In our report, the PVL-producing S. aureus clone was detected in nasal cultures in 6 of the 11 members of the 2 families. In this niche, it was able to persist and cause a series of infections in a relatively large number of family members. Even though the S. aureus isolated from active lesions were not available for testing, the recovery of identical PVL-positive organisms from nasal cultures strongly suggests the presence of a pathogenic clone that probably caused the recurrent infections in the 6 affected family members. Our investigation highlights the high transmissibility of this PVL-producing S. aureus clone, its high attack rate, and its virulence. The intervention in this outbreak might have prevented not only subsequent recurrences of cutaneous infections but also further spread of this clone and the manifestation of even more serious infections such as necrotizing pneumonia. Increasing awareness among community-based healthcare providers of PVL-producing S. aureus infections is important to facilitate rapid and adequate response in similar clinical events in the future.

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Footnotes

Suggested citation for this article: Adler A, Temper V, Block CS, Abramson N, Moses AE. Panton-Valentine leukocidin–producing Staphylococcus aureus [letter]. Emerg Infect Dis [serial on the Internet]. 2006 Nov [date cited]. http://ift.tt/2thnmIt

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References

1. Genestier AL, Michalete MC, Prévoset G, Bellot G, Chalabreysse L, Peyrol S, et al. Staphylococcus aureus Panton-Valentine leukocidin directly targets mitochondria and induces Bax-independent apoptosis of human neutrophils. J Clin Invest. 2005;115:3117–27 10.1172/JCI22684 [PMC free article] [PubMed][Cross Ref]

2. Lina G, Piémont Y, Godail-Gamot F, Bes M, Peter MO, Gauduchon V, et al. Involvement of Panton-Valentine leukocidin–producing Staphylococcus aureus in primary skin infections and pneumonia. Clin Infect Dis. 1999;29:1128–32 10.1086/313461 [PubMed] [Cross Ref]

3. Vandenesch F, Naimi T, Enright MC, Lina G, Nimma GR, Heffernan H, et al. Community-acquired methicillin-resistant Staphylococcus aureus carrying Panton-Valentine leukocidin genes: worldwide emergence. Emerg Infect Dis. 2003;9:978–84 [PMC free article] [PubMed]

4. Boubaker K, Diebold P, Blanc DS, Vandenesch F, Praz G, Dupuis G, et al. Panton-Valentine leukocidin and staphylococcal skin infections in schoolchildren. Emerg Infect Dis. 2004;10:121–4 [PMC free article][PubMed]

5. Österlund A, Kahlmeter G, Bieber L, Runehagen A, Breider JM Intrafamilial spread of highly virulentStaphylococcus aureus strains carrying the gene for Panton-Valentine leukocidin. Scand J Infect Dis. 2002;34:763–87 10.1080/00365540260348554 [PubMed] [Cross Ref]

6. Le Thomas I, Mariani-Kurkdjian P, Collignon A, Gravet A, Clermont O, Brahimi N, et al. Breast milk transmission of a Panton-Valentine leukocidin–producing Staphylococcus aureus strain causing infantile pneumonia. J Clin Microbiol. 2001;39:728–9 10.1128/JCM.39.2.728-729.2001 [PMC free article][PubMed] [Cross Ref]

7. Morreilon P, Que YA, Glauser MP Staphylococcus aureus. In: Mandell GL, Bennett JE, Dolin R, editors. Principles and practice of infectious diseases. 6th ed. Philadelphia: Elsevier Churchill Livingstone; 2005. p. 2338.

8. Maier J, Melzl H, Reischl U, Drubel I, Witte W, Lehn N, et al. Panton-Valentine leukocidin-positive methicillin-resistant Staphylococcus aureus in Germany associated with travel or foreign family origin. Eur J Clin Microbiol Infect Dis. 2005;24:637–9 10.1007/s10096-005-0008-8 [PubMed] [Cross Ref]

9. Jones TF, Creech CB, Erwin P, Baird SG, Woron AM, Schaffner W Family outbreaks of invasive community-associated methicillin-resistant Staphylococcus aureus infection. Clin Infect Dis. 2006;42:e76–8 10.1086/503265 [PubMed] [Cross Ref]

10. Begier EM, Frenette K, Barrett NL, Mshar P, Petit S, Boxrud DJ, et al. A high-morbidity outbreak of methicillin-resistant Staphylococcus aureus among players on a college football team, facilitated by cosmetic body shaving and turf burns. Clin Infect Dis. 2004;39:1446–53 10.1086/425313 [PubMed] [Cross Ref]

Articles from Emerging Infectious Diseases are provided here courtesy of Centers for Disease Control and Prevention

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An amazing cause of false pet positivity: Diagnosed after a lung cancer surgery

Abstract

Fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) has an effective role in both diagnosis and management of patients with lung cancer. There are many reasons could cause false positivity on PET/CT.A 60-year-old man was admitted a mass on thorax CT and diagnosed as squamous cell carcinoma. Lobectomy with lymph node dissection was performed after evaluation of distant metastases. There were pathological lymph nodes detected on PET/CT at six month following period. Endobronchial ultrasonography guided transbronchial needle aspiration was performed for differantial diagnosis. The pathologic diagnosis was granuloma which developed in response to suture material. We interpreted this granulomatous reaction as gossypiboma which developed against long-left or forgotten suture material. In conclusion, based on this case, gossypiboma (or granulomatous inflammation in response to foreign bodies) should be also considered in differential diagnosis of intrathoracic lymph nodes with PET positivity in a previously operated patient.

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Radiation and PD-1 inhibition: Favorable outcomes after brain-directed radiation : ncorporation of palliative radiation does not preclude favorable outcomes in patients treated with PD-1 inhibitors; patients irradiated after the start of PD-1 inhibition can remain on therapy and demonstrate prolonged survival. Of note, patients irradiated for brain metastases demonstrate favorable outcomes compared with historical controls.

Radiation and PD-1 inhibition: Favorable outcomes after brain-directed radiation: Patients with metastatic melanoma, renal cell carcinoma (RCC) and non-small cell lung cancer (NSCLC) are increasingly treated with immune checkpoint blockade targeting the programed death (PD)-1 receptor, often with palliative radiation therapy. Outcome data are limited in this population.Background and purpose

Patients with metastatic melanoma, renal cell carcinoma (RCC) and non-small cell lung cancer (NSCLC) are increasingly treated with immune checkpoint blockade targeting the programed death (PD)-1 receptor, often with palliative radiation therapy. Outcome data are limited in this population.

Material and methods

We retrospectively reviewed consecutive patients with metastatic NSCLC, melanoma, and RCC who received radiation and anti-PD-1 therapy at four centers.

Results

We identified 137 patients who received radiation and PD-1 inhibition. Median survival from first PD-1 therapy was 192, 394, and 121 days for NSCLC, melanoma, and RCC patients. Among 59 patients who received radiation following the start of PD-1 blockade, 25 continued to receive PD-1 inhibition for a median of 179 days and survived for a median of 238 additional days. Median survival following first course of radiation for brain metastases was 634 days. Melanoma patients received brain directed radiation relatively less frequently following the start of PD-1 inhibitor treatment.

Conclusions

Incorporation of palliative radiation does not preclude favorable outcomes in patients treated with PD-1 inhibitors; patients irradiated after the start of PD-1 inhibition can remain on therapy and demonstrate prolonged survival. Of note, patients irradiated for brain metastases demonstrate favorable outcomes compared with historical controls.

Keywords:

Immunotherapy, Immune checkpoint inhibitor, Radiation therapy

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Current Controversies on Wernicke’s Area and its Role in Language

Abstract

Purpose of Review

The aim of the study is to assess historical anatomical and functional definitions of Wernicke's area in light of modern lesion and neuroimaging data.

Recent Findings

"Wernicke's area" has become an anatomical label usually applied to the left posterior superior temporal gyrus and adjacent supramarginal gyrus. Recent evidence shows that this region is not critical for speech perception or for word comprehension. Rather, it supports retrieval of phonological forms (mental representations of phoneme sequences), which are used for speech output and short-term memory tasks. Focal damage to this region produces phonemic paraphasia without impairing word comprehension, i.e., conduction aphasia. Neuroimaging studies in recent decades provide evidence for a widely distributed temporal, parietal, and frontal network supporting language comprehension, which does not include the anatomically defined Wernicke area.

Summary

The term Wernicke's area, if used at all, should not be used to refer to a zone critical for speech comprehension.

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Nocturnal awakenings and total sleep duration.Predictors of sleep disturbances in the first year of life

: a longitudinal study

στο Sleep Medicine

Μετάφραση άρθρου

Publication date: August 2017
Source:Sleep Medicine, Volume 36
Author(s): Stefania Sette, Emma Baumgartner, Raffaele Ferri, Oliviero Bruni
ObjectiveThe aim of this study was to identify early predictors of nocturnal awakenings and short sleep duration during the first year of life, in terms of sleep habits and patterns. We also analyzed the trend of nocturnal awakenings and total sleep duration from 3 to 12 months of age.MethodsThe parents of 704 infants (49.3% female) were interviewed during their first year of life. The interview included questions on infant sleep (eg, sleep habits, sleep duration, number of nocturnal awakenings) and maternal perception of infant sleep difficulties.ResultsThe study results indicate that most of the infants at risk, with three or more nocturnal awakenings or ≤10 h of total sleep duration in the early months of life, tend to display a similar pattern of sleep problems at 12 months. The main early predictors of sleep problems at 12 months were sleep duration, sleep initiation method, and nocturnal awakenings. More specifically, infants with three or more nocturnal awakenings or ≤10 h of total sleep duration at 12 months were those with a higher number of awakenings during the night and a shorter sleep duration, at both three and six months. In addition, infants at risk for sleep problems at 12 months had an independent sleep initiation method at three months, whereas these same infants had a nonindependent sleep initiation method at six months.ConclusionsOur study identified the early predictors of sleep problems at 12 months. Caregivers should identify these early symptoms in infants to prevent possible sleep difficulties in later years.

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An amazing cause of false pet positivity: Diagnosed after a lung cancer surgery

Abstract

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Apnea–hypopnea index, arterial oxyhemoglobin desaturation, flow-limitation, snoring or periodic leg movements.Transcutaneous carbon dioxide (TcCO2).Upper-airway flow limitation and transcutaneous carbon dioxide during sleep in normal pregnancy

Upper-airway flow limitation and transcutaneous carbon dioxide during sleep in normal pregnancy

στο Sleep Medicine

Μετάφραση άρθρου

Publication date: August 2017
Source:Sleep Medicine, Volume 36
Author(s): Ville Rimpilä, Riina Jernman, Katariina Lassila, Jukka Uotila, Heini Huhtala, Johanna Mäenpää, Olli Polo
ObjectiveSleep during pregnancy involves a physiological challenge to provide sufficient gas exchange to the fetus. Enhanced ventilatory responses to hypercapnia and hypoxia may protect from deficient gas exchange, but sleep-disordered breathing (SDB) may predispose to adverse events. The aim of this study was to analyze sleep and breathing in healthy pregnant women compared to non-pregnant controls, with a focus on CO2 changes and upper-airway flow limitation.MethodsHealthy women in the third trimester and healthy non-pregnant women with normal body mass index (BMI) were recruited for polysomnography. Conventional analysis of sleep and breathing was performed. Transcutaneous carbon dioxide (TcCO2) was determined for each sleep stage. Flow-limitation was analyzed using the flattening index and TcCO2 values were recorded for every inspiration.ResultsEighteen pregnant women and 12 controls were studied. Pregnancy was associated with shorter sleep duration and more superficial sleep. Apnea–hypopnea index, arterial oxyhemoglobin desaturation, flow-limitation, snoring or periodic leg movements were similar in the two groups. Mean SaO2 and minimum SaO2 were lower and average heart rate was higher in the pregnant group. TcCO2 levels did not differ between groups but variance of TcCO2 was smaller in pregnant women during non-rapid eye movement (NREM). TcCO2 profiles showed transient TcCO2 peaks, which seem specific to pregnancy.ConclusionsHealthy pregnancy does not predispose to SDB. Enhanced ventilatory control manifests as narrowing threshold of TcCO2 between wakefulness and sleep. Pregnant women have a tendency for rapid CO2 increases during sleep which might have harmful consequences if not properly compensated.

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Symptomatic brain metastases : Is there a role for prophylactic cranial irradiation ?

The incidence of symptomatic brain metastases from extra-pulmonary small cell carcinoma: Is there a role for prophylactic cranial irradiation in a clinically relevant population cohort?: To examine the incidence and outcomes of patients with brain metastases from extra-pulmonary small cell carcinoma (EPSCC) and assess the indication for prophylactic cranial irradiation (PCI).

Materials and methods

A Provincial cancer registry was used to conduct a retrospective, population-based study of patients diagnosed with EPSCC between January 1997 and December 2011. The primary end point was the incidence of brain metastases. The secondary endpoint was overall survival. A "PCI Eligible" cohort was defined to provide an estimation of the incidence of brain metastases in clinically relevant patients.

Results

In 287 patients, the primary sites were 21% gastrointestinal, 34% genito-urinary, 14% gynecologic, 5% head/neck and 25% unknown primary. Thirty-five (12.5%) patients had brain metastases: 12 (4.2%) at initial diagnosis and 23 (8%) later in the disease course. In PCI Eligible patients, the 3-year cumulative incidence of new brain metastases was 5.5% for M0 stage disease and 26.3% for M1 disease. There was no significant difference in the incidence of brain metastases between primary sites.

Conclusions

The incidence of brain metastases in patients with EPSCC is comparatively low, even in a cohort of patients that were suitable for PCI. Based on our analysis, we cannot recommend PCI for patients with EPSCC.

Keywords:

Extra-pulmonary small cell carcinoma, Prophylactic cranial irradiation, Brain metastasis

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The MSCs from the healthy controls and SS patients expressed characteristic MSC markers, including CD29, CD44, CD73, CD90, and CD105; they were negative for CD34, CD45, and CD106, and also negative for the salivary gland epithelium markers (CD49f and CD117).

Characteristics of Labial Gland Mesenchymal Stem Cells of Healthy Individuals and Patients with Sjögren's Syndrome: A Preliminary Study: Stem Cells and Development , Vol. 0, No. 0.

Author information

Shi-Qin Wang,¹ Yi-Xiang Wang,² and Hong Hua¹

¹Department of Oral Medicine, National Engineering Laboratory for Digital and Material Technology of Stomatology,Peking University School and Hospital of Stomatology, Beijing, China.

²Department of Oral Surgery, National Engineering Laboratory for Digital and Material Technology of Stomatology,Peking University School and Hospital of Stomatology, Beijing, China.

Address correspondence to:

Prof. Hong Hua

Department of Oral Medicine

National Engineering Laboratory for Digital and Material Technology of Stomatology

Peking University School and Hospital of Stomatology

22 South Zhongguancun Avenue, Haidian District

Beijing 100081

China
E-mail: honghua1968@aliyun.com

Dr. Yi-Xiang Wang

Department of Oral Surgery

National Engineering Laboratory for Digital and Material Technology of Stomatology

Peking University School and Hospital of Stomatology

22 South Zhongguancun Avenue, Haidian District

Beijing 100081

China
E-mail: kqwangyx@sina.com

ABSTRACT

Sjögren's syndrome (SS) is a systemic autoimmune disease that is characterized by focal lymphocytic infiltration into exocrine organs such as salivary and lacrimal glands, resulting in dry mouth and eyes, and other systemic injuries. There is no curative clinical therapy for SS, and stem cell therapy has shown great potential in this area. The mesenchymal stem cells (MSCs) in the salivary glands of healthy individuals and in patients with SS have not been extensively studied. The aim of this study was to elucidate the characteristics of MSCs from the labial glands of healthy controls and of those from patients with SS to elucidate the related pathogenesis and to uncover potential avenues for novel clinical interventions. Labial glands from patients with SS and healthy subjects were obtained, and MSCs were isolated and cultured by using the tissue adherent method. The MSC characteristics of the cultured cells were confirmed by using morphology, proliferation, colony forming-unit (CFU) efficiency, and multipotentiality, including osteogenic, adipogenic, and salivary gland differentiation. The MSCs from the healthy controls and SS patients expressed characteristic MSC markers, including CD29, CD44, CD73, CD90, and CD105; they were negative for CD34, CD45, and CD106, and also negative for the salivary gland epithelium markers (CD49f and CD117). Labial gland MSCs from both groups were capable of osteogenic and adipogenic differentiation. The CFU efficiency and adipogenic differentiation potential of MSCs were significantly lower in the SS group compared with the healthy controls. Cells from both groups could also be induced into salivary gland-like cells. Real-time polymerase chain reaction and immunofluorescence staining showed that the gene and protein expression of AMY1, AQP5, and ZO-1 in cells from the SS group was lower than that in cells from the healthy group. Thus, MSCs from the labial glands in patients with SS could lack certain characteristics and functions, especially related to salivary secretion. These preliminary data provided insights that could lead to the development of novel therapeutic strategies for the treatment of SS.

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Characteristics of Labial Gland Mesenchymal Stem Cells of Healthy Individuals and Patients with Sjögren's Syndrome: A Preliminary Study

Characteristics of Labial Gland Mesenchymal Stem Cells of Healthy Individuals and Patients with Sjögren's Syndrome: A Preliminary Study: Stem Cells and Development , Vol. 0, No. 0.

Author information

Shi-Qin Wang,¹ Yi-Xiang Wang,² and Hong Hua¹

¹Department of Oral Medicine, National Engineering Laboratory for Digital and Material Technology of Stomatology,Peking University School and Hospital of Stomatology, Beijing, China.

²Department of Oral Surgery, National Engineering Laboratory for Digital and Material Technology of Stomatology,Peking University School and Hospital of Stomatology, Beijing, China.

Address correspondence to:

Prof. Hong Hua

Department of Oral Medicine

National Engineering Laboratory for Digital and Material Technology of Stomatology

Peking University School and Hospital of Stomatology

22 South Zhongguancun Avenue, Haidian District

Beijing 100081

China
E-mail: honghua1968@aliyun.com

Dr. Yi-Xiang Wang

Department of Oral Surgery

National Engineering Laboratory for Digital and Material Technology of Stomatology

Peking University School and Hospital of Stomatology

22 South Zhongguancun Avenue, Haidian District

Beijing 100081

China
E-mail: kqwangyx@sina.com

ABSTRACT

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Prospective analysis of 231 elective neck dissections in oral squamous cell carcinoma with node negative neck—To decide the extent of neck dissection

Prospective analysis of 231 elective neck dissections in oral squamous cell carcinoma with node negative neck—To decide the extent of neck dissection: To evaluate the incidence of level IIB and IV lymph node metastases in patients of oral carcinoma with N0 necks. This study will help to decide the extent and need of routine comprehensive removal of these specific lymph node groups in selective neck dissection.

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Names and phenotypes of CD163 positive macrophages in oral precancerous lesions

Names and phenotypes of CD163 positive macrophages in oral precancerous lesions: We are quite interested in the recently published article entitled "Programmed death ligand 1 (PD-L1) expression and tumor microenvironment: Implications for patients with oral precancerous lesions" [1]. The authors had explored the PD-L1 expression in the stoma cells in oral precancerous lesions and investigated the relationships among PD-L1 positive cells and malignant transformation of these cells. We have two questions on this article.

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Letter in reply: Prognostic prediction by liver tissue proteomic profiling in patients with colorectal liver metastases

Future Oncology Ahead of Print.

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Adult cancer-related hemophagocytic lymphohistiocytosis

Michael A. Hust¹,
Boris R. A. Blechacz²,
Diana L. Bonilla³,
Naval Daver⁴ and
Cristhiam M. Rojas-Hernandez⁵Email author

Journal of Medical Case Reports201711:172

DOI: 10.1186/s13256-017-1344-x

Received: 23 March 2017

Accepted: 3 June 2017

Published: 27 June 2017

Open Peer Review reports

Abstract

Background

Adult hemophagocytic lymphohistiocytosis is a secondary immunopathologic phenomenon, mainly secondary to malignancy, infection, or autoimmune disorders.

The performance of diagnostic criteria, studied in the pediatric population, is yet to be validated in the adult population. Some of the criteria include cytopenias and organomegaly that are inherent features to malignant processes, thus making the diagnosis of hemophagocytic lymphohistiocytosis a challenge in patients with cancer.

Case presentation

We describe the case of a 54-year-old white man with history of metastatic maxillary sinus adenoid cystic carcinoma who had severe liver injury and cytopenias with progressive clinical deterioration. We performed an evaluation, by flow cytometry, of the expression of surface markers in his natural killer cells that revealed remarkable abnormalities. His syndrome eventually fulfilled criteria for hemophagocytic lymphohistiocytosis and he received therapy with steroids with interval clinical improvement. Unfortunately, he refused further cytotoxic treatment and died 2 weeks later.

Conclusions

The conventional criteria for the diagnosis of hemophagocytic lymphohistiocytosis are suboptimal for adult patients with cancer resulting in delays in diagnosis and timely initiation of treatment. The diagnostic criteria have to be re-evaluated in patients with cancer; novel, easily available, and accurate diagnostic methods are needed.

Keywords

Hemophagocytosis Cancer Diagnosis Adult

Background

Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening immunopathologic syndrome with increasing prevalence in adults, necessitating systematic characterization and development of adult-specific criteria. Early recognition and diagnosis is critical with <10% survival without prompt treatment [1]. The HLH-2004 criteria offer a basis for clinical consideration, yet lack validation in the adult population [2]. Criteria such as cytopenias and organomegaly are inherent to malignant processes, especially hematologic or metastatic disease or concomitant chemotherapy.

We present a case of malignancy-related HLH with clinical manifestations that represented diagnostic ambiguity and difficulty in therapy initiation. We also describe the potential use of the evaluation of surface markers in cytokine-producing natural killer (NK) cells and cytotoxic NK cells by flow cytometry for diagnosis of that entity. Finally, we synthetize a literature review exploring current and developing HLH diagnostic criteria, as well as barriers to therapy, in particular for malignancy-related HLH.

Case presentation

A 54-year-old white man with a past medical history of right maxillary sinus adenoid cystic carcinoma with metastatic lesions to lung and vertebrae, hypertension, hypothyroidism, and nonalcoholic steatohepatitis presented to our emergency room in June 2016 with mental status changes accompanied by abdominal pain, dyspnea, and fever. He was not on active therapy for his malignancy. He previously received a trial regimen of coenzyme Q10, 12 g every 3 days, from October 2015 to April 2016. His past medical history was remarkable for two prior episodes of ascites and 3 months of progressive liver dysfunction and coagulopathy (Table 1). He had atorvastatin-induced myalgias leading to its discontinuation in April 2016 although his creatine kinase levels were not elevated. He was taking increasing doses of acetaminophen (2 grams daily) prior to admission. His physical examination vital signs were stable with one recorded febrile episode. In general, he appeared ill and lethargic, and was only oriented to person. He exhibited diminished bibasilar breath sounds, ascites with guarding, hypoactive bowel sounds, right lower quadrant tenderness, and hepatosplenomegaly.

Table 1

Laboratory and diagnostic data

Characteristic (reference laboratory value)	Baseline	Peak of liver enzyme abnormalities	Admission	Steroid initiation	1 week post-steroid	2 weeks post-admission
White blood cell (4–11×10³/uL)	5.5	4.0	5.0	8.5	4.8	41.0
Hemoglobin (14.0–18.0 gm/dL)	11.0	9.0	11.1	10.8	9.5	13.1
Platelet (140–440 K/uL)	164	109	60	75	29	96
Prothrombin time (12.7–15.0 seconds)	15.7	20.6	22.5	35.7	24.6	26.3
International normalization ratio (0.90–1.20)	1.25	1.80	2.02	3.76	2.22	2.43
Partial thromboplastin time (24.7–35.9 seconds)	42.0	37.7	31.6	45.1	30.1	32.9
Fibrinogen (mg/dL)	452		166	141	173	155
Albumin (g/dL)	2.9	2.3	2.3	2.2	3.3	4.0
Aspartate aminotransferase (15–46 U/L)	150	807	395	314	136	145
Alanine aminotransferase (7–56 U/L)	67	319	54	53	26	39
Alkaline phosphatase (38–126 U/L)	123	139	432	350	182	187
Gamma-glutamyl transferase (8–78 U/L)	42			148	291	252
Serum lactate dehydrogenase (U/L)	2372	3879	3449		2769	3867
Ferritin (30–400 ng/mL)		28,942		10,283	6031	5863
Serum triglyceride level (≤1500 mg/dL)	167	212	101
NK-cell activity (7–125 LU30)						5
CD25 (<1033 pg/mL)				3910
IL-1 (<1.0 pg/mL)						1.8
IL-6 (<5.0 pg/mL)						27
IFN-y (<2.0 pg/mL)						<0.4
Tumor necrosis factor (1.2–15.3 pg/mL)						20.9

IFN interferon, IL interleukin, LU lytic unit, NK natural killer

Laboratory data were remarkable for hyperferritinemia, hypofibrinogenemia, anemia, and thrombocytopenia along with elevated transaminases and coagulopathy (Table 1). A peripheral blood smear showed neutrophilia, monocytosis, and reticulocytopenia. No microangiopathic changes were seen. Extensive platelet clumping was noted.

Imaging studies revealed small pleural effusions, ascites, and hepatosplenomegaly with no evidence of portal hypertension or splanchnic thrombosis. We were suspicious of HLH in light of laboratory and physical examination findings. Additional differential diagnosis workup – infectious, autoimmune, acetaminophen levels – yielded unremarkable results, including: serology for hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), hepatitis E virus (HEV), cytomegalovirus (CMV), Epstein–Barr virus (EBV), herpes simplex virus (HSV), alpha 1-antitrypsin levels, and antinuclear, anti-mitochondrial, anti-smooth muscle, and transglutaminase antibodies (immunoglobulin A (IgA) and immunoglobulin G (IgG)). ADAMTS 13 activity was >34%. HLH-specific laboratory studies were sent, including soluble CD25 (sCD25), NK cell activity studies, and bone marrow biopsy.

He continued to deteriorate with multiple organ failure including renal failure, myocardial injury, and respiratory failure requiring intubation. Empiric therapy, considering the evidence of liver injury and the possibility of HLH, with N-acetylcysteine on a 20-hour intravenous protocol and dexamethasone 8 mg intravenously administered three times daily was initiated. HLH chemotherapy was not done during this time as hepatotoxicity risk outweighed benefits and a definite diagnosis was not confirmed.

As an attempt to expedite the evaluation of possible HLH, we isolated mononuclear cells from peripheral blood and evaluated expression of surface markers in cytokine-producing NK cells and cytotoxic NK cells by flow cytometry. We compared the profile with normal controls. The results, available after 36 hours, were remarkable for an increased expression of CD69 in cytotoxic NK cells, and decreased NKG2A in cytokine-producing NK cells in our case. The expression of CD69 and NKG2A in NK cells was evaluated in four other normal donors and the results were similar to the one acquired in parallel to the HLH sample (Fig. 1). No differences in protein expression of other markers were observed by flow cytometry (data not shown). These findings included similar surface levels of OX40, GITR, 4-1BB, TIM-3, PD-1, CTLA-4, LAG-3, and ICOS in CD8+ CD3+ T cells, as well as effector (CD127+, FoxP3-) and regulatory (CD127-, FoxP3+) CD4+ CD3+ T cells; similar expression of NKp44, NKG2C, NKG2D, 4-1BB, NKp30, and NKp46 in NK cells (CD56+ CD3-); and similar expression of CD28, CD27, ICOS, Eomes, Blimp-1, Bcl-6, T-bet, Ki-67, and cMyc in naïve (CCR7+ CD45RA+), effector (CCR7- CD45RA+), effector memory (CCR7-CD45RA-), and central memory (CCR7+ CD45RA-) CD4+ and CD8+ T cells. The frequency of all the evaluated immune cell populations was also similar, when comparing cells from our patient with those ones from a healthy control.

Fig. 1

Natural killer cell flow cytometric analysis of peripheral blood mononuclear cells of patient with hemophagocytic lymphohistiocytosis. Natural killer cell gating was performed on live single CD56+ cells (a). Representation of CD69 and NKG2A surface expression in cytotoxic (CD56+ CD16+) and cytokine-secreting (CD56+ CD16-) natural killer cells (b). Results from the patient with hemophagocytic lymphohistiocytosis and a normal donor are shown. HLH hemophagocytic lymphohistiocytosis, NK natural killer

Our patient's bone marrow biopsy was performed 10 days after admission and delayed due to severe coagulopathy and demonstrated normocellularity (40 to 50%), megakaryocytic hypoplasia, and clusters of foamy histiocytes with ingested marrow cells. Fifteen days after admission, he fulfilled multiple HLH-2004 diagnostic criteria including hyperferritinemia, fever, splenomegaly, cytopenias, hemophagocytosis on biopsy of bone marrow, elevated CD25, and decreased NK cell activity by standardized studies (Table 1).

He steadily recovered with the steroid therapy instituted for 12 days and supportive measures. He was weaned off intubation and sedation. However, he refused further interventions for HLH, namely etoposide-based therapy and continuation of steroid treatment; he chose palliative care and died 2 weeks later.

Discussion

Adult onset HLH is mainly a secondary phenomenon, arising from four components of pathology: a susceptible host; intrinsic/acquired immune defects; a trigger resulting in immune activation; and immunopathology resulting in host end organ failure [3]. Adult patients with HLH are immunocompromised individuals with malignancy, infection, or autoimmune disorders. Ramos-Casals et al. [4] found that 48% of cases were triggered by neoplasms, especially hematologic malignancies. Furthermore, patients with active malignancy are at greatest risk [4, 5, 6]. Differentiation of HLH from other sequelae of hematologic malignancies is based upon degree of inflammation [7]. Allen and McClain hypothesized that the syndrome results from complex interactions of host genetics and extrinsic immune challenges [7]. Studies have shown that immune defects in genes affecting regulation of granule-dependent lymphocyte activity as well as intracellular granule trafficking, mutations in T cell functioning (CD27), and cytokine production, that is, interferon (IFN)-gamma and interleukin (IL)-6, by malignant cells play a key role in HLH evolution [5, 8]. Similar genes and inflammatory responses may become affected during neoplasm therapy, inciting an iatrogenic HLH in adults [9, 10, 11]. The HLH-2004 criteria, validated in the pediatric community, are consensus criteria developed to guide inclusion and enrollment to studies [7]. The sensitivity and specificity of these criteria in the adult population have yet to be validated through prospective studies. However, a recent study from the MD Anderson Cancer Center (MDACC) identified an "extended 18-point diagnostic criteria" of clinical and laboratory variables closely associated with a diagnosis of malignancy-associated HLH (M-HLH) in adults. Sensitivity analysis suggested that individuals with an underlying malignancy who met 5/18 criteria could be considered to have a high likelihood of M-HLH [6]. These extended criteria include available parameters at the community level such as serum albumin, serum transaminases, lactate dehydrogenase, and basic coagulation testing that may function as early effective surrogates of M-HLH. These 18 markers are currently being validated in a prospective clinical trial at MDACC (NCT02385110).

HLH consensus definitions implicate specific cell lines responsible for the severe inflammatory propagation, including: CD8+ T lymphocytes overactivation and uncontrolled expansion and NK cell dysfunction. Familial HLH (FHL) studies identified genetic deficiencies in these cell lines [3, 7, 12]. More recently, flow cytometry has been used to screen genetically predisposed patients, measuring intracellular perforin levels in NK cells [13]. To the best of our knowledge, similar flow cytometry studies, as described in our case, have not been conducted in adult patients with secondary HLH. Although well documented in patients with malignancies, NK cell line alterations may ultimately lead to secondary HLH. Various mechanisms of NK cell anti-tumor activity inhibition have been described, including: downregulation of NK-activating receptors, that is, natural cytotoxic receptors (NCRs) and NKG2D; upregulation of inhibitory receptors, that is, killer-cell immunoglobulin-like receptors (KIRs) and NKG2A; and modifications of expression of receptor-specific ligands. Ultimately, this inhibits NK cell-mediated anti-tumor surveillance, and impairs molecular crosstalk between NK cells and other immune cells [14]. Another study noted that excessive CD8+ T cells activation during FHL suppressed the regulatory T cell (Treg) population, allowing for rapid growth of CD8+ T-cell line and unchecked progression of persistent systemic inflammation. This resulted in an overall reduction of IL-2 and reversal in the IL-2 hierarchy of consumption by T cells, with pathologic preferential consumption by inflammatory CD8+ T cells via upregulated CD25, release of sCD25 by CD8+ T cells, reduction in Treg cell IL-2-induced anti-inflammatory properties, and reduction in Treg cell lines; this ultimately resulted in diverting "the normally anti-inflammatory IL-2 feedback loop into a proinflammatory circuit" [13].

Another major problem is the lack of effective therapy. Hurdles to therapy initiation, similar to our case report, include: (a) delayed recognition of HLH, (b) advanced stage of underlying disease, and (c) concurrent immunocompromised state with a need for further cytotoxic HLH-directed therapy. However, our experience with adult HLH suggests that early suspicion and treatment are of paramount priority as high mortality rate is secondary to the aggressive and rapid HLH process [6]. Emerging non-cytotoxic therapies such as IFN-gamma inhibitor (NI-0501), anti-IL-6 agents (tocilizumab), and JAK-inhibitors (ruxolitinib), either as single agents or in combination with traditional HLH therapies, hold promise for the therapy of M-HLH in adults.

Conclusions

The current diagnostic criteria of HLH might be suboptimal for adult patients and perhaps result in delays in its diagnosis and timely initiation of treatment. Given the high prevalence of cancer in an ageing population, current diagnostic criteria have to be re-evaluated in adult patients and novel, easily available, and highly specific diagnostic methods must be developed.

Declarations

Funding

This study was supported in part by the MD Anderson Cancer Centre Support Grant (CCSG) CA016672.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Authors' contributions

MAH jointly conceived the idea for the manuscript (with CMR, BRB, ND), searched the background literature, wrote the report, and refined the text in accordance with comments from all authors. BRB conceived the idea for the manuscript, contributed to drafting of the manuscript and final approval of the version to be published. DLB collaborated with acquisition and analysis of flow cytometry data, drafting of the manuscript, and final approval of the version to be published. ND conceived the idea for the manuscript, contributed to drafting of the manuscript and final approval of the version to be published. CMR was the lead physician responsible for the clinical care of the case, supplied all clinical details, drafting of the manuscript, and final approval of the version to be published. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Written informed consent was obtained from the patient's next of kin for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Ethics approval and consent to participate

Given the case report nature of the manuscript and according to institutional Human Subject Research regulations, the need for approval was waived.

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Authors' Affiliations

(1)

Department of Internal Medicine, The University of Texas Health Science Center

(2)

Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center

(3)

Department of Immunology, The University of Texas MD Anderson Cancer Center

(4)

Department of Leukemia, The University of Texas MD Anderson Cancer Center

(5)

Section of Benign Hematology, The University of Texas MD Anderson Cancer Center

References

Janka GE. Familial hemophagocytic lymphohistiocytosis. Eur J Pediatr. 1983;140:221–30.View ArticlePubMedGoogle Scholar
Henter JI, Horne A, Arico M, Egeler RM, Filipovich AH, Imashuku S, Ladisch S, McClain K, Webb D, Winiarski J, Janka G. HLH-2004: Diagnostic and therapeutic guidelines for hemophagocytic lymphohistiocytosis. Pediatr Blood Cancer. 2007;48:124–31.View ArticlePubMedGoogle Scholar
Jordan MB, Allen CE, Weitzman S, Filipovich AH, McClain KL. How I treat hemophagocytic lymphohistiocytosis. Blood. 2011;118:4041–52.View ArticlePubMedPubMed CentralGoogle Scholar
Ramos-Casals M, Brito-Zeron P, Lopez-Guillermo A, Khamashta MA, Bosch X. Adult haemophagocytic syndrome. Lancet. 2014;383:1503–16.View ArticlePubMedGoogle Scholar
Lehmberg K, Sprekels B, Nichols KE, Woessmann W, Muller I, Suttorp M, Bernig T, Beutel K, Bode SF, Kentouche K, et al. Malignancy-associated haemophagocytic lymphohistiocytosis in children and adolescents. Br J Haematol. 2015;170:539–49.View ArticlePubMedGoogle Scholar
Tamamyan GN, Kantarjian HM, Ning J, Jain P, Sasaki K, McClain KL, Allen CE, Pierce SA, Cortes JE, Ravandi F, et al. Malignancy-associated hemophagocytic lymphohistiocytosis in adults: Relation to hemophagocytosis, characteristics, and outcomes. Cancer. 2016;122:2857–66.View ArticlePubMedGoogle Scholar
Allen CE, McClain KL. Pathophysiology and epidemiology of hemophagocytic lymphohistiocytosis. Hematology Am Soc Hematol Educ Program. 2015;2015:177–82.PubMedGoogle Scholar
Zhang K, Jordan MB, Marsh RA, Johnson JA, Kissell D, Meller J, Villanueva J, Risma KA, Wei Q, Klein PS, Filipovich AH. Hypomorphic mutations in PRF1, MUNC13-4, and STXBP2 are associated with adult-onset familial HLH. Blood. 2011;118:5794–8.View ArticlePubMedPubMed CentralGoogle Scholar
Papadopoulou A, Krance RA, Allen CE, Lee D, Rooney CM, Brenner MK, Leen AM, Heslop HE. Systemic inflammatory response syndrome after administration of unmodified T lymphocytes. Mol Ther. 2014;22:1134–8.View ArticlePubMedPubMed CentralGoogle Scholar
Teachey DT, Rheingold SR, Maude SL, Zugmaier G, Barrett DM, Seif AE, Nichols KE, Suppa EK, Kalos M, Berg RA, et al. Cytokine release syndrome after blinatumomab treatment related to abnormal macrophage activation and ameliorated with cytokine-directed therapy. Blood. 2013;121:5154–7.View ArticlePubMedPubMed CentralGoogle Scholar
Grupp SA, Kalos M, Barrett D, Aplenc R, Porter DL, Rheingold SR, Teachey DT, Chew A, Hauck B, Wright JF, et al. Chimeric antigen receptor-modified T cells for acute lymphoid leukemia. N Engl J Med. 2013;368:1509–18.View ArticlePubMedPubMed CentralGoogle Scholar
Usmani GN, Woda BA, Newburger PE. Advances in understanding the pathogenesis of HLH. Br J Haematol. 2013;161:609–22.View ArticlePubMedGoogle Scholar
Lehmberg K, Ehl S. Diagnostic evaluation of patients with suspected haemophagocytic lymphohistiocytosis. Br J Haematol. 2013;160:275–87.View ArticlePubMedGoogle Scholar
Chretien AS, Le Roy A, Vey N, Prebet T, Blaise D, Fauriat C, Olive D. Cancer-Induced Alterations of NK-Mediated Target Recognition: Current and Investigational Pharmacological Strategies Aiming at Restoring NK-Mediated Anti-Tumor Activity. Front Immunol. 2014;5:122.View ArticlePubMedPubMed CentralGoogle Scholar

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