POEMS syndrome treated with melphalan high-dose therapy and autologous blood stem cell transplantation: a single-institution experience

The acronym POEMS syndrome stands for a rare multi-system disorder, comprised of polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes. Here, we present a single-center report of a series of five POEMS patients treated with melphalan high-dose therapy (HDT) with subsequent autologous blood stem cell transplantation (ABSCT). After a median follow-up of 52 months from time of diagnosis (range, 15-192) and a median follow-up of 18 months after ABSCT (range, 11-120), all patients were alive. Overall, no severe transplantation-associated complications such as engraftment syndrome or peri- or post-transplant death were noted. In two cases, HDT followed by ABSCT resulted in a complete hematologic response; in the additional three cases, partial responses (PR) were achieved including one very good hematologic PR. Only one patient with initial PR developed progressive disease nearly 2.5 years after transplantation. Consequently, a second HDT with ABSCT was successfully applied resulting in clinical improvement and hematologic PR. In line with previous single-center reports, melphalan HDT followed by ABSCT proved to be a first-line treatment option with tolerable side effects in severely affected POEMS patients with progressing symptoms.     

Comparison study of full and subthreshold bulimia nervosa: Personality,clinical characteristics,and short-term response to therapy

Abstract

This study compared symptomatological and personality differences between individuals with threshold bulimia nervosa (BN; n=39) and those with subthreshold BN (n=39) and their short-term response to a brief outpatient intervention. Participants were matched using a pairwise matching procedure, taking into account age, age of onset, and duration of the disorder. Both groups received the same brief outpatient psychoeducational therapy. The same assessment measures were used before and after treatment. With the exception of some clinical and psychopathological symptoms (higher depression and phobic anxiety in threshold BN), there were no significant between-group differences on scales of general psychopathology or personality traits. At the end of treatment, there were no significant between-group differences on abstinence rates for binge eating and vomiting, number of sessions attended, or dropout rates. Threshold BN and subthreshold BN share common psychopathological symptoms and personality traits. No differences in therapy outcome were observed for the two groups after a brief group psychoeducational intervention.     

A Systematic Review of the Predictive Value of 18FDG-PET in Esophageal and Esophagogastric Junction Cancer After Neoadjuvant Chemoradiation on the Survival Outcome Stratification

Purpose

We studied the predictive value of [¹⁸?F]fluorodeoxyglucose-positron emission tomography (¹⁸FDG-PET) for assessing disease-free (DFS) and overall survival (OS) in esophageal and esophagogastric junction cancer.

Materials and methods

A literature search (PUBMED/MEDLINE, EMBASE, Cochrane) was performed to identify full papers with ¹⁸FDG-PET and survival data, using indexing terms and free text words. Studies with >10 patients with locally advanced esophageal cancer, presenting sequential or at least one post-adjuvant treatment ¹⁸FDG-PET data and Kaplan–Meier survival curves with >6 months median follow-up period were included. We performed a meta-analysis for DFS and OS using the hazard ratio (HRs) as outcome measure. Sources of heterogeneity study were also explored.

Results

We identified 26 eligible studies including a total of 1,544 patients (average age 62 years, 82 % males). The TNM distribution was as follows: stage I 7 %, II 24 %, III 53 % and IV 15 %. The pooled HRs for complete metabolic response versus no response were 0.51 for OS (95 % CI, 0.4–0.64; P?<?0.00001) and 0.47 for DFS (95 % CI, 0.38–0.57; P?<?0.00001), respectively. No statistical heterogeneity was present. To explore sources of clinical heterogeneity, we also realised subgroup and regression analyses. Taken into account the moderate correlation between OS and DFS (ρ?=?0.54), we used joint bivariate random regression model. These analyses did not show a statistically significant impact of study characteristics and PET modalities on the pooled outcome estimates.

Conclusion

Despite methodological and clinical heterogeneity, metabolic response on ¹⁸FDG-PET is a significant predictor of long-term survival data.     

The colitis of Behcet's disease: A separate entity?

Summary An additional case of Behcet's disease with colonic involvement has been presented. This association is rare, as only 13 prior cases with adequate data were available for comparison. Controversy exists as to whether these cases represented true involvement of the colon by Behcet's disease, coincidental inflammatory bowel disease and Behcet's disease, or merely autoimmune phenomena associated with inflammatory bowel disease. Unusual colonoscopic lesions noted in our patient and other features enumerated in the text suggested to us that at least some of these cases represented primary Behcet's disease involving the colon.     

New approach for inhibiting Rev function and HIV-1 production using the influenza virus NS1 protein.

The Rev protein of HIV-1, which facilitates the nuclear export of HIV-1 pre-mRNAs, has been a target for antiviral therapy. Here we describe a new strategy for inhibiting Rev function and HIV-1 replication. In contrast to previous approaches, we use a wild-type rather than a mutant Rev protein and covalently link this Rev sequence to the NS1 protein of influenza A virus, a protein that inhibits the nuclear export of mRNAs. The NS1 protein contains an RNA-binding domain mutation (RM), so that the only functional RNA-binding domain in the chimeric protein (NS1RM-Rev) is in the Rev protein sequence. In the presence of the NS1RM-Rev chimeric protein, HIV-1 pre-mRNAs were retained in, rather than exported from, the nucleus. In addition, this chimeric protein effectively inhibited Rev function in trans in transfection experiments and effectively inhibited the production of HIV-1 in tissue culture cells transfected with an infectious molecular clone of HIV-1 DNA. The inhibitory activities of the NS1RM-Rev chimera were at least equivalent to those of the Rev M10 mutant protein, which has been considered to be the prototype trans inhibitor of Rev function and is currently in phase I clinical trials for the treatment of AIDS patients. We discuss (i) the potential for increasing the inhibitory activity of NS1-Rev chimeras against HIV-1 and (ii) the need for additional studies to evaluate these chimeras for the treatment of AIDS.     

Long‐term retention of avulsed maxillary permanent incisors replanted after prolonged non‐physiological storage

Ankylosis and external replacement resorption (ERR) are two typical biological responses to delayed replantation of avulsed teeth in cases where adequate root canal treatment is performed. The patient's growth stage affects the progression of root resorption and the long‐term outcome of the affected teeth. This case report describes the long‐term outcome of an 18.5‐year‐old patient following an accident in which both of his maxillary central incisors were avulsed and replanted after four hours of non‐physiological storage. ERR and ankylosis of teeth 11 and 21 were detected clinically and radiographically during the second year of follow‐up. Sixteen years after replantation, replacement resorption was progressing very slowly, enabling functional tooth retention with favorable esthetics. Young adults, with delayed replantation of avulsed teeth, may benefit from tooth retention with slow ERR.     

Increased neural activity during overt and continuous semantic verbal fluency in major depression: mainly a failure to deactivate

Major depression is associated with impairments in semantic verbal fluency (VF). However, the neural correlates underlying dysfunctional cognitive processing in depressed subjects during the production of semantic category members still remain unclear. In the current study, an overt and continuous semantic VF paradigm was used to examine these mechanisms in a representative sample of 33 patients diagnosed with a current episode of unipolar depression and 33 statistically matched healthy controls. Subjects articulated words in response to semantic category cues while brain activity was measured with functional magnetic resonance imaging (fMRI). Compared to controls, patients showed poorer task performance. On the neural level, a group by condition interaction analysis, corrected for task performance, revealed a reduced task-related deactivation in patients in the right parahippocampal gyrus, the right fusiform gyrus, and the right supplementary motor area. An additional and an increased task-related activation in patients were observed in the right precentral gyrus and the left cerebellum, respectively. These results indicate that a failure to suppress potentially interfering activity from inferior temporal regions involved in default-mode network functions and visual imagery, accompanied by an enhanced recruitment of areas implicated in speech initiation and higher-order language processes, may underlie dysfunctional cognitive processing during semantic VF in depression. The finding that patients with depression demonstrated both decreased performance and aberrant brain activation during the current semantic VF task demonstrates that this paradigm is a sensitive tool for assessing brain dysfunctions in clinical populations.     

Internal Medicine Residents’ Perceptions of Virtual Morning Report: a Multicenter Survey

ImportanceThe COVID-19 pandemic disrupted graduate medical education, compelling training programs to abruptly transition to virtual educational formats despite minimal experience or proficiency. We surveyed residents from a national sample of internal medicine (IM) residency programs to describe their experiences with the transition to virtual morning report (MR), a highly valued core educational conference.ObjectiveAssess resident views about virtual MR content and teaching strategies during the COVID-19 pandemic.DesignAnonymous, web-based survey.ParticipantsResidents from 14 academically affiliated IM residency programs.Main MeasuresThe 25-item survey on virtual MR included questions on demographics; frequency and reason for attending; opinions on who should attend and teach; how the virtual format affects the learning environment; how virtual MR compares to in-person MR with regard to participation, engagement, and overall education; and whether virtual MR should continue after in-person conferences can safely resume. The survey included a combination of Likert-style, multiple option, and open-ended questions.ResultsSix hundred fifteen residents (35%) completed the survey, with a balanced sample of interns (39%), second-year (31%), and third-year (30%) residents. When comparing their overall assessment of in-person and virtual MR formats, 42% of residents preferred in-person, 18% preferred virtual, and 40% felt they were equivalent. Most respondents endorsed better peer-engagement, camaraderie, and group participation with in-person MR. Chat boxes, video participation, audience response systems, and smart boards/tablets enhanced respondents’ educational experience during virtual MR. Most respondents (72%) felt that the option of virtual MR should continue when it is safe to resume in-person conferences.ConclusionsVirtual MR was a valued alternative to traditional in-person MR during the COVID-19 pandemic. Residents feel that the virtual platform offers unique educational benefits independent of and in conjunction with in-person conferences. Residents support the integration of a virtual platform into the delivery of MR in the future.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-06963-7.KEY WORDS: graduate medical education, internal medicine residency, morning report, virtual     

Interscalene anesthesia for shoulder arthroscopy in a community-sized military hospital

The first 100 consecutive shoulder arthroscopic procedures performed under interscalene anesthesia at a small community-sized military hospital are the basis of this report. This method of anesthesia was compared with 100 shoulder arthroscopies performed in a previous 2-year time period under general anesthesia. A variety of arthroscopic and subsequent open reconstructive procedures about the shoulder were performed using both techniques. Using the interscalene method, 87 regional blocks were entirely successful. Thirteen patients required conversion to general anesthesia for adequate pain control; however, 4 of these had a complete block in the recovery room and required no postoperative narcotics. Seven patients required supplementation with local anesthetic when an open procedure became necessary. There were no major complications. Minor complications included 5 patients with transient Horner's syndrome, 4 patients who experienced anxiety, which was controlled with sedation, and 3 with nausea or pruritus. Interscalene anesthesia provided excellent intraoperative and postoperative analgesia with low morbidity. On a subsequent questionnaire, all patients with a successful block reported that they were extremely satisfied with their experience. Ten patients who had previous shoulder surgery under general anesthesia preferred the interscalene method. In summary, interscalene anesthesia proved to be an excellent method of anesthesia for shoulder arthroscopy. The technique is reproducible within the resources available in most community-level hospitals.     

Subcortical shape alterations in major depressive disorder: Findings from the ENIGMA major depressive disorder working group

Alterations in regional subcortical brain volumes have been investigated as part of the efforts of an international consortium, ENIGMA, to identify reliable neural correlates of major depressive disorder (MDD). Given that subcortical structures are comprised of distinct subfields, we sought to build significantly from prior work by precisely mapping localized MDD-related differences in subcortical regions using shape analysis. In this meta-analysis of subcortical shape from the ENIGMA-MDD working group, we compared 1,781 patients with MDD and 2,953 healthy controls (CTL) on individual measures of shape metrics (thickness and surface area) on the surface of seven bilateral subcortical structures: nucleus accumbens, amygdala, caudate, hippocampus, pallidum, putamen, and thalamus. Harmonized data processing and statistical analyses were conducted locally at each site, and findings were aggregated by meta-analysis. Relative to CTL, patients with adolescent-onset MDD (≤ 21 years) had lower thickness and surface area of the subiculum, cornu ammonis (CA) 1 of the hippocampus and basolateral amygdala (Cohen's d = ?0.164 to ?0.180). Relative to first-episode MDD, recurrent MDD patients had lower thickness and surface area in the CA1 of the hippocampus and the basolateral amygdala (Cohen's d = ?0.173 to ?0.184). Our results suggest that previously reported MDD-associated volumetric differences may be localized to specific subfields of these structures that have been shown to be sensitive to the effects of stress, with important implications for mapping treatments to patients based on specific neural targets and key clinical features.