Risk Factors and Management of Leukopenia After Kidney Transplantation: A Single-Center Experience

BackgroundLeukopenia is a common complication after kidney transplantation. The etiology is multifactorial, with medication adverse effects and cytomegalovirus infection as main causes. Optimal strategies to prevent or treat posttransplant leukopenia remain unknown. We aimed to identify risk factors for leukopenia and to investigate the benefit of switching the immunosuppressive therapy to hydrocortisone as a continuous infusion.MethodsWe retrospectively evaluated all patients with leukopenia after kidney transplantation between 2007 and 2017 at our center relative to age- and sex-matched controls.ResultsLeukopenia was associated with the degree of rejection therapy before leukopenia, the immunosuppressive therapy before transplantation, and an induction therapy with rabbit antithymocyte globulin. Patients with leukopenia exhibited increased mortality, an increased incidence of bacterial and viral infections, and more acute rejections. Switching to hydrocortisone as a continuous infusion in patients with severe leukopenia decreased the duration of leukopenia and the incidence of subsequent viral infections, especially with cytomegalovirus.ConclusionLeukopenia is a risk factor for infectious complications and mortality, and it is associated with acute rejection. Switching immunosuppressive therapy to hydrocortisone as a continuous infusion is a safe approach to reduce the duration of leukopenia and the incidence of viral infections.     

Measuring patient perceptions of surgeon communication performance in the treatment of thyroid nodules and thyroid cancer using the communication assessment tool

BackgroundThyroid surgeons are offering their patients less aggressive diagnostic and therapeutic management strategies for thyroid nodules and low-risk thyroid cancer in an effort to decrease overdiagnosis and overtreatment of indolent disease. Explaining the rationale for less aggressive management plans requires physicians to be effective communicators. We aimed to assess the communication skills of thyroid surgeons with the Makoul Communication Assessment Tool and to identify risk factors for poor communication.MethodsNew adult patients with thyroid nodules or thyroid cancer presenting to a single tertiary-referral endocrine surgery clinic were enrolled from July 2018 through December 2019. Patients were administered the Communication Assessment Tool immediately after their clinical encounter. Outlier communication scores were identified, and clinical characteristics were compared between outlier and nonoutlier groups.ResultsA total of 107 patients completed the Communication Assessment Tool. Mean (standard deviation) total and top box scores were 67 (6) and 86% (29%), respectively. Twenty-five patients (23%) were in the low-outlier group, defined by a total score below 67.5/70 or top box score below 82.25%. Other race and non-Hispanic patients (versus white race) were more likely low outliers (odds ratio 3.58, P = .048). The lowest scoring Communication Assessment Tool item overall was “the doctor encouraged me to ask questions” (78.5% top box).ConclusionWe found communication to be perceived as excellent in the majority of patients; however, an opportunity for improvement was identified in 29% of participants. Significant differences in race and ethnicity between low outlier and nonoutlier communication score patients were observed, which warrants additional investigation. These findings support the utility of the Communication Assessment Tool in studying the effectiveness of communication improvement initiatives.     

Site of metastatic recurrence impacts prognosis in patients with high-grade upper tract urothelial carcinoma

PurposeMetastatic recurrence occurs in over 25% of upper tract urothelial carcinoma patients treated with radical nephroureterectomy. While metastatic recurrence suggests poor prognosis, the impact of the specific site of recurrence on prognosis is not well documented.Materials and methodsWe retrospectively analyzed 188 patients who underwent radical nephroureterectomy for high-grade, node-negative upper tract urothelial carcinoma at our institution from 2003 to 2018 without receiving neoadjuvant or adjuvant chemotherapy. Competing-risks survival analysis was performed to evaluate the cumulative incidence and predictors of metastatic recurrence. The Kaplan-Meier method and log-rank test were used to estimate and compare recurrence site-specific survival probabilities following metastatic recurrence. Cox regression analyses were performed to assess site-specific prognoses.ResultsOf the 188 patients, 47 (25%) developed metastatic recurrence over a median follow-up of 30 months (interquartile range: 10.5–58.5 months). The 1- and 2-year cumulative incidences of metastatic recurrence were 13.6% and 23.6%, respectively. On multivariable analysis, lymphovascular invasion was significantly predictive of metastatic recurrence (subhazard ratio: 2.6, P = 0.01). Of the 47 patients who developed recurrence, 38 (80.9%) died over a median follow-up of 10 months (interquartile range: 5–20 months). Metastatic recurrence was most common in the lungs (n= 13, 28%) and at multiple sites (n= 14, 30%). Median time to recurrence was shorter for recurrences at multiple sites (6.5 months) and those in the liver (13 months) and bone (18 months) compared to other sites. Patients who recurred in the liver (hazard ratio: 6.3, P = 0.007), bone (hazard ratio: 4.9, P = 0.02), and multiple sites (hazard ratio: 4.6, P = 0.01) had significantly worse prognosis compared to those who recurred in lymph nodes. Statistical significance persisted after adjusting for treatment with salvage therapy.ConclusionsA significant proportion of high-grade upper tract urothelial carcinoma patients recur systemically after radical nephroureterectomy. Lymphovascular invasion is a predictor of metastatic recurrence and may inform decisions regarding perioperative chemotherapy. Hepatic and osseous recurrences have relatively quicker onset and less favorable prognosis compared to other sites. These findings may benefit future efforts to develop recurrence site-specific treatment plans and highlight the necessity of subsequent endeavors to explore the genetic associations of recurrence in upper tract urothelial carcinoma.     

Highly attenuated poxviruses induce functional priming of neutrophils in vitro

Summary Highly attenuated poxvirus samples were used to examine the influence of potential poxvirus expression vector systems on neutrophil function. Exposure to the viruses alters the number of membrane bound complement-and Fc-receptors and led to functional priming of neutrophils to subsequent stimuli.     

Dementia praecox and manic-depressive insanity in 1908: A Grade of Membership analysis of the Kraepelinian dichotomy

Grade of Membership (GoM) analysis, a multivariate classification technique based on fuzzy-set mathematics, was applied to the demographic, history, and mental-state data on 53 dementia praecox cases and 134 manic-depressive insanity cases admitted to Kraepelin's University Psychiatric Clinic in Munich in 1908. The original data recorded by Kraepelin and his collaborators on specialZählkarten (counting cards) were rated and coded in terms of the Present State Examination (PSE) Syndrome Check List. The statistical analysis resulted in a high degree of replication of Kraepelin's clinical entities. However, the dichotomy of dementia praecox and manic-depressive insanity was not fully supported. The catatonic syndrome tended to occupy an intermediate position between the two major psychoses. The possibility is discussed that catatonia in Kraepelin's time shared certain clinical features with the later diagnostic groupings of schizoaffective disorder, cycloid psychoses, and other atypical forms of psychotic illnesses.