Appropriateness of angiography for suspected coronary artery disease

The aim of this study was to assess the appropriate use of diagnostic catheterizations (DC) for the patients with suspected coronary artery disease performed in Iran. The Electronic Health Record System database and manual review of files were utilised to collect data between 2012 and 2014. Patients were categorized in three groups as appropriate, uncertain, and inappropriate usage of DC and the logistic regression was used to investigate the relationships between variables. One-quarter of the 2458 angiographies were rated as inappropriate, out of which 99% had no previous stress test. The rate of inappropriate DC between various hospitals were approximately the same. The regression showed that some risk factors (Sex, high cholesterol, smoking, chronic heart failure, renal failure, diabetes) were significantly associated with inappropriate rate.     

Scleral exposure alterations following Le Fort I osteotomy (with and without maxillary impaction) in skeletal class III patients: A before-and-after clinical trial

Purpose

Exposure of sclera below the iris in natural head positions is aesthetically undesirable. Studies on post-surgical changes in inferior scleral exposure following orthognathic surgery are scarce and mostly retrospective. The aim of this clinical trial is to examine the effect of Le Fort I osteotomy, a procedure for correction of malocclusion and maxillo-mandibular deformities, on the inferior scleral exposure and overall scleral surface area in skeletal class III patients.

Recalcitrant verrucous lesion: verrucous hyperplasia or epithelioma cuniculatum (verrucous carcinoma)

A 37-year-old woman originally presented in May 2003 with a nonhealing, painless ulcer on the plantar surface of her right foot that had been slowly increasing in size for the previous 1.5 years. Two weeks before presentation, a biopsy of the lesion, performed at another institution, had indicated a probable verrucous carcinoma. After preoperative workup, the patient underwent resection of the lesion, with clear margins and full-thickness skin grafting. The final pathologic findings were not consistent with verrucous carcinoma. A recurrent lesion was noted during a follow-up visit, and a second biopsy revealed a hyperkeratotic papillomatous verrucous lesion, type unclassified. No viral particles were isolated in the random biopsy samples. This recurrent lesion was refractory to treatment with topical acyclovir. Subsequent treatments consisted of imiquimod and CO(2) laser ablation, which succeeded in reducing the lesion. Verrucous lesions can be frustrating, and the diagnosis of epithelioma cuniculatum can be difficult to prove. We report a case highly suggestive of but not definitively diagnosed as epithelioma cuniculatum and summarize the literature on this entity.     

Alloimmunity in primate heart recipients with CD154 blockade: evidence for alternative costimulation mechanisms

BACKGROUND: CD154 mediates key facets of humoral and cellular immunity to alloantigens, and is tolerogenic to influenza antigens in primates. Barriers to CD154-based tolerance induction for primate cardiac allografts have not previously been defined. METHODS: Heterotopic cardiac allograft outcomes in cynomolgus monkeys treated with a CD154 inhibitor, IDEC-131 (n=27), were compared to no treatment (n=4) or cyclosporine A (n=6). RESULTS: CD154 blockade significantly prolonged median allograft survival, from 6.2 (range 6, 7, n=4) days in untreated controls, to 39 (8,112, n=16) days with intensive monotherapy and 93 (>25, 386; n=3) days with added antithymocyte globulin (ATG), but did not yield tolerance. Alloantibody production was delayed but not prevented by IDEC-131 alone or with ATG, and was exacerbated by infusion of donor bone marrow (n=8). Expression of ICOS was prominent in graft infiltrating lymphocytes, and preceded elaboration of antidonor antibody and vasculopathy. CONCLUSION: CD154 monotherapy modulates primate cardiac alloimmunity, but does not readily induce tolerance. Targeting alternative costimulation pathways, including ICOS, may facilitate tolerance induction based on CD154 blockade.     

Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis in Los Angeles County

Data on Epstein–Barr virus‐related hemophagocytic lymphohistiocytosis (EBV‐HLH) in adults in the United States remain very limited. A cluster of four cases of EBV‐HLH was observed in a 4‐month period at a tertiary center in Los Angeles County (LA County) and the clinical and molecular characteristics identified in these cases are being described. EBV typing, immunophenotypic and molecular genetic studies were performed. Diagnostic criteria that may be used to identify EBV as a cause of HLH in adults are also being suggested. Finally, the crude incidence rate for HLH in LA County was determined and was compared to the worldwide crude incidence rate for HLH. The cases each occurred in young male adult residents of California and were associated with evidence of EBV reactivation and ferritin levels of >20,000 µg/L. A higher rate of cases of EBV‐HLH in 2010 was found at UCLA Medical Center than for 2007–2009 (4.9/10,000 hospital discharges vs. 0.14/10,000 hospital discharges, respectively; P = 0.0017). The cases were associated with EBV type 1, and the insertion of the codon CTC (leucine) was found in numerous of the EBNA‐2 gene sequences. The annual incidence of secondary, non‐familial HLH was estimated to be 0.9 cases per million persons >15 years of age in LA County. Although EBV‐HLH is a rare disease, the incidence in adults in Western countries may be underestimated. J. Med. Virol. 84:777–785, 2012. © 2012 Wiley Periodicals, Inc.     

Improved clinical outcomes for multiple myeloma patients treated at a single specialty clinic

Despite recent advances made in its treatment, multiple myeloma (MM) remains an incurable B cell malignancy. Thus, the objective for treating these patients is to prolong overall survival (OS) and preserve patients’ quality of life. We have analyzed data from 264 consecutive MM patients who had their initial visit between July 1, 2004 and December 1, 2014 and have received treatment in a single clinic specializing in MM. We determined their progression-free survival (PFS, OS, and 5-year OS). The PFS for frontline (n = 165 treatments), salvage (n = 980), and all treatments (n = 1145) were 13.9, 4.6, and 5.5 months, respectively. The median OS of all patients was 98 months with a 5-year survival of 74%. The results of this study show a marked improvement in OS for unselected MM patients compared with historical data. There were no significant differences in OS between patients with different International Staging System (ISS) stages. Younger patients (<65 years old) showed a longer OS. The results of this study should help physicians predict outcomes for MM patients and be encouraging for patients with this B cell malignancy.     

Hyperglycemia Is a Strong Prognostic Factor of Lethality in Methanol Poisoning

Methanol poisoning is seen in the form of isolated episodes, or intentional ingestion and epidemics. Despite its efficient treatment, methanol poisoning has high morbidity and mortality rates. So far, several studies have been performed to identify the prognostic factors in methanol poisoning. Recently, during the treatment of patients with methanol poisoning, we observed that patients’ blood glucose levels were high on presentation to the hospital, particularly in those who expired. Through a literature search, we found that no studies have been performed on blood glucose levels or hyperglycemia in methanol poisoning. Therefore, the present retrospective study was done as a preliminary investigation to understand whether there was a meaningful relationship between methanol poisoning and blood glucose level on presentation, and also if hyperglycemia could be considered as a prognostic factor for mortality. In this retrospective study, a review of the hospital charts was performed for all patients who were treated for methanol poisoning from March 2003 to March 2010 in two hospitals in Tehran, Iran. Those with definitive diagnosis of methanol poisoning, no history of diabetes mellitus, and normal or low body mass index (<25) were included. Patients’ demographic information, clinical manifestations, time elapsed between ingestion and presentation, blood glucose level on presentation (before treatment), results of arterial blood gas analysis, and the clinical outcome were recorded. Statistical analysis was done using SPSS software (version 17, Chicago, Illinois, USA) and application of Mann–Whitney U test, Pearson's chi-square test, Pearson correlation coefficient (r), receiver operating characteristic (ROC) curve, and logistic regression. P values less than 0.05 were considered as the statistically significant levels. Ninety-five patients with methanol poisoning met the inclusion criteria and were included in the study. Of these, 91 (96%) were male and 4 (4%) were female. Mean age was 31.61?±?14.3 years (range, 13 to 75). Among the 95 patients, 68 survived (72%) and 27 expired (28%). Median blood glucose level was 144 mg/dL (range, 75 to 500). There was no significant statistical correlation between blood glucose level and time of treatment, age, pCO₂, or serum bicarbonate concentration, but blood glucose level had a statistically significant correlation with pH (r?=??0.242, P?=?0.02) and base deficit (r?=?0.230, P?=?0.03). The mean blood glucose level was 140?±?55 and 219?±?99 mg/dL in the survivor and non-survivor patients, respectively (P?<?001). Considering the cutoff level of 140 mg/dL for blood glucose and using logistic regression analysis, and adjusting according to the admission data with significant statistical difference in the two study groups, the odds ratio for hyperglycemia as a risk factor for death was 6.5 (95% confidence interval?=?1.59–26.4). Our study showed that blood glucose levels were high in methanol poisoning and even higher in those who died in comparison with the survivors. Therefore, hyperglycemia might be a new prognostic factor in methanol poisoning, but further studies are needed to determine whether controlling hyperglycemia has therapeutic consequences.     

Neurotrophin dependence domain

The mechanisms underlying neurotrophin dependence, and cellular dependent states in general, are unknown. We show that a 29 amino acid region in the intracellular domain of the common neurotrophin receptor, p75^NTR, is required for the mediation of apoptosis by p75^NTR. Furthermore, contrary to results obtained with Fas, monomeric p75^NTR is required for apoptosis induction, whereas multimerization inhibits the pro-apoptotic effect. Within the 29-residue domain required for apoptosis induction by p75^NTR, a 14-residue region is sufficient as a peptide inducer of apoptosis. This 14-residue peptide requires the positively charged carboxyterminal residues for its effect on cell death, and these same residues are required by the full-length p75^NTR. These studies define a novel type of domain that mediates neurotrophin dependence, and suggest that other cellular dependent states may be mediated by proteins displaying similar domains.