Robotic Isolated Caudate Lobectomy for Solitary Colorectal Liver Metastasis

Background

Safety of liver resection for colorectal adenocarcinoma continues to improve due to decreased morbidity of resection. Minimally invasive techniques contribute greatly to this morbidity reduction. Isolated caudate lobectomy presents a unique technical challenge because of proximity to major vasculature. The video aims to review nuances of robotic isolated caudate lobectomy for metastatic colon adenocarcinoma.

     

S-100 protein and SOX10-positive breast carcinoma mimicking metastatic melanoma

We present a case detailing a 70-year-old female with a history of triple-negative breast carcinoma (TNBC) of the left breast and contralateral stage pT2a nodular melanoma of the right upper arm who underwent sentinel lymph node biopsy of the right axilla demonstrating a metastatic epithelioid tumor that was strongly positive for S-100 protein and SOX10. The tumor cells were negative for HMB-45 and Melan-A and positive for CK7 and other breast markers (GCDFP15, mammaglobin, and GATA3). While concerning for metastatic melanoma based on clinical history and initial immunohistochemistry, tumor morphology and subsequent immunohistochemistry was supportive of metastatic breast adenocarcinoma. This case demonstrates a rare but perilous diagnostic pitfall of triple-negative breast carcinomas that strongly and diffusely express S-100 protein and SOX10 mimicking melanoma.     

Mortality in HIV-infected and uninfected children of HIV-infected and uninfected mothers in rural Uganda

OBJECTIVE: To estimate 2-year mortality rates in HIV-1-infected and uninfected infants born to HIV and HIV mothers. METHODS: Data are from a prospective study in rural Rakai District, Uganda. Infant HIV status (determined by polymerase chain reaction) was evaluated at 1 to 6 weeks postpartum and during breast-feeding, and maternal HIV viral load and CD4 levels were measured at the postpartum visit. Multivariate Cox proportional hazards models and Kaplan-Meier survival analysis were used to assess survival of infants by maternal and infant HIV status and by quartiles of viral load. Log-rank tests were used to test the equality of survival functions. RESULTS: Of the 4604 pregnant women, 16.9% were HIV, and the proportion of children infected was 20.9%. Median survival of HIV-infected infants was 23 months. Two-year child mortality rates were 128 of 1000 children born to HIV mothers, 165.5 of 1000 uninfected children born to HIV mothers, and 540.1 of 1000 HIV-infected children (P < 0.0001). Compared with children of HIV mothers, the hazard of child mortality was 2.04 (P < 0.001) if the mother was HIV and 3.78 (P < 0.001) if the infant was also infected. In the adjusted model, the highest quartiles of log10 HIV viral load in infants and mothers were associated with significantly increased hazard of child mortality (hazard ratio [HR] = 8.54 and HR = 2.50, respectively). Maternal CD4 counts <200 cells/mL were also significant predictors of child mortality (HR = 2.61). A total of 67.6% of HIV-infected children with viral loads above the median died by the age of 2 years and are in need of early antiretroviral therapy (ART). CONCLUSIONS: More than half of HIV-infected infants died at less than 2 years of age. Therefore, ART may need to be initiated earlier in HIV-infected African children.     

Hemicrania Continua Responsive to Intravenous Methyl Prednisolone

Hemicrania continua (HC) is a strictly unilateral, continuous primary headache disorder with periodic exacerbations, usually accompanied by cranial autonomic disturbances. Exquisite and persistent effect of indomethacin is a fundamental property of HC. We report 2 patients of HC in which attacks were successfully eliminated by repeated infusion of methyl prednisolone.     

Calcineurin Inhibitor Withdrawal After Renal Transplantation with Alemtuzumab: Clinical Outcomes and Effect on T-Regulatory Cells

To address the results of calcineurin inhibitor (CNI) withdrawal after alemtuzumab induction relative to CNI continuation, we performed a pilot randomized clinical trial in renal allograft recipients on CNI, a mycophenolic acid derivative and steroids after the first 2 months posttransplantation. Forty patients were randomized to taper off CNI or to maintain it, and followed for at least 1 year. Four patients in the withdrawal group were treated for acute rejection while no patient received antirejection treatment in the control group. Two control patients withdrew CNI due to nephrotoxicity. Estimated GFR was similar in both groups after 1 year. Flow cytometry of CD4⁺CD25⁺CTLA-4⁺FoxP3⁺ regulatory T cells (Treg) demonstrated a significant increase in Treg percentages in the peripheral blood of alemtuzumab-treated patients on CNI early postransplant. Furthermore, the increased Treg percentages in the withdrawal cohort were unchanged at month 6 postenrollment, whereas they decreased significantly in those patients maintained on CNI. Patients withdrawn from CNI after alemtuzumab trend toward a higher rejection rate, but most patients can be weaned from a CNI using this regimen. With the exception of maintaining increased Treg levels, the benefits are not appreciable in this short follow-up, and a larger randomized trial is justified.     

Polygyny,maternal HIV status and child survival: Rakai,Uganda

The objective of this research was to assess the association of child mortality with polygyny and maternal HIV status through a prospective community-based study in Rakai district, Uganda. We sought to test whether there was an indirect evidence that polygynous households in an HIV prevalent area may divert resources away from the children of HIV-infected mothers in favor of children with better survival prospects. We test this theory using data from a follow-up study which collected detailed behavioral and medical information at 10-month intervals on a cohort of over 4000 pregnant women and their infants (5300 person years of observation). Cox proportional hazards models estimated the mortality hazard (RR) associated with polygyny for children of HIV-negative and HIV-positive mothers. HIV prevalence in the full cohort of mothers was 11.9%, and 23% of mothers lived in polygynous households. Multivariate analysis showed an increased hazard of child mortality if the mother was HIV-positive (RR = 1.75, p<0.001). Maternal education reduced mortality, whereas low birth weight increased mortality risk. Polygyny was associated with an increase in the hazard of child mortality in the full sample (RR = 1.36, p<0.001) and in mothers who were HIV-positive (RR = 2.17, p<0.001), but not in HIV-negative mothers. Being born to an HIV-positive mother increased mortality risk and polygyny accentuated a child's risk of death. Polygyny had no significant effect on the survival of children with HIV-negative mothers. Polygynous households, where not all wives may have HIV, could be diverting resources away from the children of the infected wives.     

Construction of stable LamB-Shiga toxin B subunit hybrids: analysis of expression in Salmonella typhimurium aroA strains and stimulation of B subunit-specific mucosal and serum antibody responses.

The complete Shiga toxin B subunit and two N-terminal segments of the B subunit have been inserted into a cell surface exposed loop of the LamB protein, and expression of the hybrid proteins from three different promoter systems, i.e., (i) an in vitro-inducible tac promoter that provides high-level expression, (ii) the iron-regulated aerobactin promoter presumably induced in vivo under the iron-limiting conditions of the intestinal mucosal environment, and (iii) a synthetic, modified beta-lactamase promoter providing moderate level constitutive expression, has been analyzed in Escherichia coli, Salmonella typhimurium, and attenuated antigen carrier strains of S. typhimurium (aroA mutants). The hybrid vaccine strains were used to immunize mice by the oral and intraperitoneal routes. S. typhimurium aroA mutants apparently have a membrane export defect which prevents the transport of LamB and its derivatives across the cytoplasmic membrane. High-level expression of hybrid proteins through use of the tac promoter proved deleterious to the vaccine strains and prevented the production of viable cells at reasonable cell densities. The lower levels of gene expression observed with the beta-lactamase and aerobactin promoters did not have this effect. Immunization of mice with S. typhimurium aroA strains carrying the hybrid genes expressed from these two promoters resulted in significant B subunit-specific mucosal and serum antibody responses. This suggests that such expression systems may be useful when incorporated into candidate antidysentery live oral vaccines for inducing protection against the effect of Shiga toxin in infections caused by Shigella dysenteriae 1 and other Shiga toxin-or Shiga-like toxin-producing pathogens.     

A narrative review on the effects of a ketogenic diet on patients with Alzheimer's disease

Alzheimer''s disease (AD) has been very difficult to prevent and cure using the medicine available today. However, there has been some hope with using a ketogenic diet (KD) to reduce the cognitive and quality of life decline experienced by patients with AD. In this review, the authors discuss the research done on the effect of a KD on AD to provide some potential avenues for future research and to determine a KD that can be best adopted by patients. The authors also go over the effects of KD''s and low-carbohydrate diets (LCDs) on the cognitive function of healthy patients and on patients without AD to determine the similar and dissimilar effects of the diets. The authors found that the KD was able to improve the cognitive abilities and quality of life of patients ranging from mild to severe AD. Several types of memory were improved as a result of the diets. Further research needs to be conducted to determine the cause behind these improvements. However, the several studies that were done were mostly in agreement that once ketosis was reached, cognitive improvements were observed in patients ranging from mild to severe AD or mild to moderate cognitive impairment. Through the use of a KD, potential mechanisms can be found to reduce the cognitive decline of patients with AD, and potentially even prevent the damaging effects of cognitive decline from AD altogether.     

Multi-Level Socioenvironmental Contributors to Childhood Asthma in New York City: a Cluster Analysis

Childhood asthma exacerbation remains the leading cause of pediatric emergency department visits and hospitalizations and disproportionately affects Latinx and Black children, compared to non-Latinx White children in NYC. Environmental exposures and socioeconomic factors may jointly contribute to childhood asthma exacerbations; however, they are often studied separately. To better investigate the multiple contributors to disparities in childhood asthma, we compiled data on various individual and neighborhood level socioeconomic and environmental factors, including education, race/ethnicity, income disparities, gentrification, housing characteristics, built environment, and structural racism, from the NYC Department of Health’s KIDS 2017 survey and the US Census’ American Community Survey. We applied cluster analysis and logistic regression to first identify the predominant patterns of social and environmental factors experienced by children in NYC and then estimate whether children experiencing specific patterns are more likely to experience asthma exacerbations. We found that housing and built environment characteristics, such as density and age of buildings, were the predominant features to differentiate the socio-environmental patterns observed in New York City. Children living in neighborhoods with greater proportions of rental housing, high-density buildings, and older buildings were more likely to experience asthma exacerbations than other children. These findings add to the literature about childhood asthma in urban environments, and can assist efforts to target actionable policies and practices that promote health equity related to childhood asthma.