Clostridium difficile infection in hospitalized liver transplant patients: a nationwide analysis

The incidence of Clostridium difficile infection (CDI) is increasing among hospitalized patients. Liver transplantation (LT) patients are at higher risk for acquiring CDI. Small, single-center studies (but no nationwide analyses) have assessed this association. We used the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project (2004-2008) for this retrospective, cross-sectional study. Patients with any discharge diagnosis of LT composed the study population, and they were identified with International Classification of Diseases, Ninth Revision, Clinical Modification codes. Those with a discharge diagnosis of CDI were considered cases. Our primary outcomes were the prevalence of CDI and the effects of CDI on inpatient mortality. Our secondary outcomes included the length of stay and hospitalization charges. A regression analysis was used to derive odds ratios (ORs) adjusted for potential confounders. There were 193,174 discharges with a diagnosis of LT from 2004 to 2008. The prevalence of CDI was 2.7% in the LT population and 0.9% in the non-LT population (P < 0.001). Most of the LT patients were 50 to 64 years old. LT patients had higher odds of developing CDI [OR = 2.88, 95% confidence interval (CI) = 2.68-3.10]. Increasing age and increasing comorbidity (including inflammatory bowel disease and nasogastric tube placement) were also independent CDI risk factors. CDI was associated with a higher mortality rate: 5.5% for LT patients with CDI versus 3.2% for LT-only patients (adjusted OR = 1.70, 95% CI = 1.29-2.25). In conclusion, the prevalence of CDI is higher for LT patients versus non-LT patients (2.7% versus 0.9%). CDI is an independent risk factor for mortality in the LT population.     

Role of ultrasonography in detection of renal artery pseudoaneurysm caused by retroperitoneal malignant peripheral nerve sheath tumor in a patient with neurofibromatosis type 1

Malignant peripheral nerve sheath tumors (MPNSTs) are extremely uncommon neoplasms, predominantly seen within the deep soft tissues of the extremities, in close proximity to the nerve trunks. Retroperitoneal MPNSTs are exceedingly rare, usually seen in association with neurofibromatosis type 1 (NF-1), and often result from malignant degeneration of a plexiform neurofibroma. These tumors are highly malignant and the prognosis is worsened if they occur in association with NF-1. Metastasis is not uncommon, but local invasion by these tumors is rarely reported. Renal artery pseudoaneurysms are mostly iatrogenic and rarely result from invasion by retroperitoneal neoplasms. Ultrasonography is a valuable tool in early diagnosis of these neoplasms and vascular complications, particularly in emergency cases requiring immediate operative intervention. To the best of our knowledge, no case of renal artery pseudoaneurysm caused by retroperitoneal MPNST has been reported to date. We present a case of a middle-aged female with Von Recklinghausen disease, complaining of sudden onset of severe abdominal pain, where ultrasound accurately diagnosed renal artery pseudoaneurysm caused by a large retroperitoneal MPNST, and who was later treated by radical excision of the tumor and nephrectomy.     

Male gender and not the severity of hypertension is associated with end-organ damage in aged stroke-prone spontaneously hypertensive rats

BACKGROUND: It is well-known that gender affects the progression of kidney failure. Male patients exhibit faster development of age-dependent renal disease than do women. In the present study, we examined arterial blood pressure (BP), proteinuria, and end-organ damage in male and female retired breeders from our colony of stroke-prone spontaneously hypertensive rats (SHRSP). METHODS: Male (n = 7) and female (n = 11) SHRSP littermates maintained on Purina Laboratory Chow 5008 and water were studied starting at 53 weeks of age. Systolic BP was measured by tail-cuff plethysmography and 24-h urinary protein excretion was quantified while animals were housed in metabolic cages. Blood was obtained by retro-orbital bleeding. Mean arterial pressure (MAP) was then monitored by radiotelemetry. Organs were preserved for histopathologic assessment. RESULTS: Tail-cuff systolic BP did not differ between the sexes. Male SHRSP exhibited greater proteinuria (128 +/- 7 mg/d) than females (21 +/- 5 mg/d, P < .001). Blood urea nitrogen was higher in males (22 +/- 2 mg%) v females (15 +/- 1 mg%, P < .005). The MAP by radiotelemetry did not differ between the sexes (179 +/- 3 mm Hg in males v 192 +/- 6 mm Hg in females, 2 weeks after probe implantation). Stroke-related mortality was greater in males (83%) than females (10%). Renal vascular disease including thrombotic microangiopathy affecting glomeruli and microvessels and cardiac damage were more prominent in male SHRSP. CONCLUSIONS: These findings demonstrate that male gender is a major risk factor for multisystem end-organ damage associated with aging and hypertension in SHRSP, despite comparable degrees of hypertension among males and females.     

Surgical trends in glaucoma management: The current Indian scenario

International Ophthalmology - To assess the current trend in the surgical management of glaucoma in India. An anonymous online survey evaluating the preferred choices in the surgical management of...     

Outcomes of primary percutaneous coronary intervention in acute myocardial infarction due to unprotected left main thrombosis: The Asia‐Pacific Left Main ST‐Elevation Registry (ASTER)

Introduction

Prior studies of ULM STEMI have been confined to small cohorts. Recent registry data with larger patient cohorts have shown contrasting results. We aim to study the outcomes of patients with unprotected left main (ULM) ST‐elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI).

Methods

The Asia‐pacific left main ST‐Elevation Registry (ASTER) is a multicenter retrospective registry involving 4 sites in Singapore, South Korea, and the United States. The registry included patients presenting with STEMI due to an ULM coronary artery culprit lesion who underwent emergency PCI. The primary outcome was in‐hospital mortality. Secondary outcomes included major adverse cardiovascular events.

Results

A total of 67 patients (mean age 64.2 ± 12.8 years, 53 [79.1%] males) were included. The distal left main bifurcation was most commonly involved (85%, n = 57). Fifty one (76%) patients had TIMI 3 flow post‐PCI. The in‐hospital mortality rate was 47.8% (n = 32); 61% (n = 41) had cardiac failure, 4% (n = 3) had emergency coronary artery bypass grafting, 1% (n = 1) had a re‐infarction, 3% (n = 2) had stroke and 55% (n = 37) had malignant ventricular arrhythmias. On multivariate analysis, predictors of in‐hospital mortality included older age (odds ratio (OR) 1.085 (95% confidence interval (CI) 1.002‐1.175), P = 0.044), diabetes mellitus (OR 10.882 (95%CI 11.074‐110.287), P = 0.043) and absence of post‐PCI TIMI 3 flow (OR 71.429 (95%CI 2.985‐1000), P = 0.008).

Conclusions

STEMI from culprit unprotected left main coronary artery stenosis is associated with significant mortality and morbidity. Emergency PCI provides an important treatment option in this high‐risk group, but in‐hospital mortality remains high.     

Mucoepidermoid carcinoma may be devoid of squamoid cells by immunohistochemistry: expanding the histologic and immunohistochemical spectrum of MAML2- rearranged salivary gland tumours

Mucoepidermoid carcinoma (MEC) is historically defined by a mix of squamoid, intermediate, and mucous cells, but we have recently encountered several cases lacking immunoreactivity for squamous markers p40, p63, and CK5/6 despite MAML2 fusions. This study will characterise these unique tumours. Ten MEC were collected arising from the parotid gland (n = 4), submandibular gland (n = 2), nasopharynx (n = 1), base of tongue (n = 1), bronchus (n = 1), and trachea (n = 1). Six tumours were low-grade, two intermediate-grade, one high-grade, and one demonstrated low-grade areas with high-grade transformation. Four cases were oncocytic, four had clear-cell features, two had spindle cell features, and one high-grade MEC had prominent solid, cord-like, and micropapillary features. The tumours were negative for p40 (10/10), p63 (10/10), and CK5/6 (9/9). Targeted RNA sequencing demonstrated CRTC1::MAML2 in five cases, CRTC3::MAML2 in two, and a novel MAML2::CEP126 in the unusual high-grade case. In two cases with insufficient RNA, MAML2 fluorescence in situ hybridisation (FISH) showed rearrangement. Genetically-confirmed MEC may lack overt squamous differentiation by histology and immunohistochemistry. While most cases harboured canonical fusions and fit within the spectra of MEC variants with oncocytic, clear cell, and/or spindle cell features, one had a novel MAML2::CEP126 fusion and unusual morphology. In MEC without squamoid cells, the use of immunohistochemistry may hinder, rather than aid, the correct diagnosis. In such cases, MAML2 analysis is most useful. The historical definition of MEC as a carcinoma with squamoid, intermediate and mucous cells should be revisited.