Adult Langerhans cell histiocytosis presenting with multisystem involvement and sarcomatoid features: a case report

Background

Langerhans cell tumors are rare clonal disorders characterized by neoplastic proliferation of dendritic cells that can be further classified into the subtypes Langerhans cell histiocytosis and Langerhans cell sarcoma, which are rare neoplasms exhibiting aggressive features and a poor prognosis. In addition to illustrating the refractoriness and poor outcomes of multisystem Langerhans cell histiocytosis in adults, specific events in this case highlight important characteristics of disease biology that warrant detailed discussion and exposition to a wider audience.

Case presentation

We describe the case of a 42-year-old Caucasian man with Langerhans cell histiocytosis diagnosed from a lesion on the left arm that presented with constitutional symptoms, early satiety, and weight loss. Esophagogastroduodenoscopy showed extensive esophageal and duodenal involvement by Langerhans cell histiocytosis with features of Langerhans cell sarcoma. He was initially treated for Langerhans cell histiocytosis with low doses of cytarabine until he eventually presented clear transformation to acute monoblastic leukemia with complex karyotype that could not be properly controlled, leading eventually to death.

Conclusions

Langerhans cell histiocytosis remains an exceedingly rare entity in adults, frequently presenting as multisystem disease with risk organ involvement. Langerhans cell sarcoma represents an aggressive subtype with extremely poor prognosis for which intensive acute myeloid leukemia induction should be strongly considered.

Ablative therapies for hepatic and biliary tumors: endohepatology coming of age

Ablative therapies refer to minimally invasive procedures performed to destroy abnormal tissue that may arise with many conditions, and can be achieved clinically using chemical, thermal, and other techniques. In this review article, we explore the different ablative therapies used in the management of hepatic and biliary malignancies, namely hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA), with a particular focus on radiofrequency ablation (RFA) and photodynamic therapy (PDT) techniques.

Vedolizumab-Induced De Novo Extraintestinal Manifestations

Background: Vedolizumab is an α4β7 integrin antagonist with gut-specific effects on lymphocyte and monocyte trafficking. Although the treatment is beneficial for inflammatory bowel disease (IBD), the effects of vedolizumab on extraintestinal manifestations (EIMs) have not been well described. The gut-specific effects of the medication may have diverse outcomes on EIMs. We hypothesize that EIMs may be unmasked by systemic availability of gut-homing effector cells. Aim: The goal of this study is to describe de novo EIMs of IBD patients who were started on vedolizumab. Methods: A retrospective chart review of 71 patients from January 2011 to October 2017, including clinical and medication history and colonoscopy results, was performed. Results: EIMs occurred in 26.7% of patients who were started on vedolizumab. The most common EIMs were arthralgias, perianal fistula, and pyoderma gangrenosum. There was a trend toward a greater occurrence of EIMs in patients with Crohn's disease compared to ulcerative colitis. Conclusion: Our retrospective study suggests that inhibition of gut-specific effector cells results in activated lymphocytes and/or monocytes that cause inflammation in other tissues. More studies are needed to confirm these observations and to develop biomarkers that predict patients at risk for EIMs and perianal fistulas while on vedolizumab.

Systematic review with meta-analysis: mycophenolate mofetil as a second-line therapy for autoimmune hepatitis

BACKGROUND

First-line treatment for autoimmune hepatitis (AIH) typically includes corticosteroids in combination with azathioprine. Mycophenolate mofetil (MMF) is often used as a rescue therapy in patients who are intolerant of, or nonresponsive to, standard therapy.

AIM

To systematically review studies and perform a meta-analysis on the efficacy and safety of MMF as a second-line therapy for AIH patients.

METHODS

MEDLINE, EMBASE and Cochrane Central were searched for studies that reported data on efficacy and safety of MMF as a second-line therapy in AIH. We calculated the pooled response rate, adverse events rate and discontinuation rate due to side effects, with their corresponding 95% confidence intervals.

RESULTS

Twelve studies comprising 397 patients, followed for a median of 34 months (range, 12-47 months), were included. MMF doses ranged from 0.5-4.0 g/d. Pooled response rate was 0.58 (95% CI 0.54-0.63). Pooled adverse events rate was 0.14 (95% CI 0.11-0.17), and pooled discontinuation rate due to side effects was 0.08 (95% CI 0.06-0.11). Five studies (n = 309) specified response rates according to reason for using MMF. Pooled response rate in the subgroup with intolerance to standard therapy was 0.82 (95% CI 0.77-0.87) and pooled response rate among nonresponders was 0.32 (95% CI 0.24-0.39).

CONCLUSIONS

The overall efficacy of MMF as second-line therapy in AIH was high. Response rate was greater in patients who started the medication due to intolerance to standard therapy as opposed to nonresponse. Overall, MMF was well tolerated, with a low discontinuation rate due to side effects.

Endoscopic Resection of Ampullary Tumours: Long-term Outcomes and Adverse Events

Background

The management of ampullary lesions has shifted from surgical approach to endoscopic resection. Previous reports were limited by small numbers of patients and short follow-up. The aim of this study is to describe short- and long-term outcomes in a large cohort of patients undergoing endoscopic ampullectomy.

Methods

Retrospective study of endoscopic ampullectomies performed at a tertiary center from January 1999 to October 2016. Information recorded includes patient demographics, clinical outcomes, lesion pathology, procedural events, adverse events and follow-up data.

Results

Overall, 103 patients underwent endoscopic resection of ampullary tumours (mean age 62.3 ± 14.3 years, 50.5% female, mean lesion size 20.9 mm; 94.9% adenomas, with a majority of lesions exhibiting low-grade dysplasia (72.7%). Complete endoscopic resection was achieved in 82.5% at initial procedure. Final complete endoscopic resection was achieved in all patients with benign pathology on follow-up procedures. Final pathology showed that 11% had previously undiagnosed invasive carcinoma. Delayed postprocedure bleeding occurred in 21.4%, all of which were managed successfully at endoscopy. Acute pancreatitis complicated 15.5% of procedures (mild in 93.8%). Perforation occurred in 5.8%, all treated conservatively except for one patient requiring surgery. Piecemeal resection was associated with significantly higher recurrence compared to en-bloc resection (54.3% versus 26.2%, respectively, P = 0.012). All recurrences were treated endoscopically.

Conclusion

Endoscopic ampullectomy appears both safe and effective in managing patients with ampullary tumours in experienced hands. Most adverse events can be managed conservatively. Many patients develop recurrence during long-term follow-up but can be managed endoscopically. Recurrence rates may be reduced by performing initial en-bloc resection.

Quality of life in mucopolysaccharidoses: construction of a specific measure using the focus group technique

OBJECTIVE

To describe the perceptions of patients, their caregivers, and their healthcare providers to the development of a new specific instrument for assessment of the quality of life (QoL) in patients with mucopolysaccharidoses (MPS) using a qualitative focus group (FG) design. FGs were held in two Brazilian states (Rio Grande do Sul and Rio de Janeiro).

RESULTS

Three versions of the new instrument were developed, each for a different age group: children (age 8-12 years), adolescents (age 13-17), and adults (age ≥ 18). The FGs mostly confirmed the relevance of items. All FGs unanimously agreed on the facets: School, Happiness, Life Prospects, Religiosity, Pain, Continuity of Treatment, Trust in Treatment, Relationship with Family, Relationship with Healthcare Providers, Acceptance, and Meaning of Life. The overall concept of QoL (as proposed by the WHO-World Health Organization) and its facets apply to this patient population. However, other specific facets-particularly concerning clinical manifestations and the reality of the disease-were suggested, confirming the need for the development of a specific QoL instrument for MPS.

Prophylactic rectal indomethacin may be ineffective for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis in general patients: A meta-analysis

BACKGROUND AND AIM

Efficacy of prophylactic indomethacin for prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in general patients remains controversial. To address this, we conducted a meta-analysis of clinical trials specifically on rectal indomethacin in prevention of PEP in consecutive patients undergoing ERCP.

METHODS

We searched MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials databases to identify randomized, double-blind, controlled clinical trials on rectal indomethacin in the prevention of PEP in consecutive patients undergoing ERCP. Primary outcome was the overall rate of PEP. Secondary outcomes were the overall rates of moderate to severe PEP and mild PEP.

RESULTS

Six studies, with a total of 2473 patients, were included. Overall rate of PEP was 7% (95% CI, 6-9%). No statistical difference was observed in overall rates of PEP (OR, 0.67; 95% CI, 0.46-1.00, P = 0.050) and, additionally, rates of moderate to severe (OR, 0.66; 95% CI, 0.28-1.56, P = 0.345) or mild (OR, 0.71; 95% CI, 0.45-1.10, P = 0.127) PEP between indomethacin and placebo.

CONCLUSION

In a contemporary meta-analysis of available randomized controlled trials of consecutive patients undergoing ERCP, rectal indomethacin did not show significant prevention effect of post-ERCP pancreatitis.

A randomized, controlled clinical trial to evaluate the immunogenicity of a PreS/S hepatitis B vaccine Sci-B-Vac™, as compared to Engerix B®, among vaccine naïve and vaccine non-responder dialysis patients

BACKGROUND

Dialysis patients have a suboptimal response to hepatitis B (HBV) vaccination. This study aimed to compare the immunogenicity of two vaccines: the third-generation Sci-B-Vac™ vs. the second-generation Engerix B^®. The cohort included two groups of dialysis patients: naïve and previously vaccinated non-responders. Primary endpoints were antibody titers ≥10 IU/L at 3 and 7 month post-vaccination. Secondary objectives were seroprotection rates in vaccine-naïve patients and in previously vaccinated non-responders.

METHODS

Eighty-six patients were assigned to vaccine (Sci-B-Vac™ or Engerix B^®) using computer-generated randomization, stratified by age, gender, diabetes, and previous HBV vaccination. Sci-B-Vac™ was administered in three doses, 10 μg, at 0, 1, and 6 months in naïve patients; or 20 μg in previously vaccinated non-responders. Engerix B^® included four doses, 40 μg at 0, 1, 2, and 6 months.

RESULTS

Each group had 43 patients. Seroconversion was 69.8% with Engerix B^® vs. 73.2% with Sci-B-Vac™. Antibody titers at 7 months were higher with Sci-B-Vac™ (266.4 ± 383.9, median 53.4) than with Engerix^® (193.2 ± 328.9, median 19). However, these differences were not significant, perhaps due to a suboptimal sample size.

CONCLUSIONS

This study suggests comparable immunogenicity for both vaccines. Thus, we cannot reject the null hypothesis that there is no difference in seroconversion by vaccine type. It is noteworthy that naïve patients were vaccinated with a standard dose of Sci-B-Vac™, while Engerix B^® was administered at a double dose. Similarly, although mean antibody titer levels in the Sci-B-Vac™ group were higher than in the Engerix^® group, this difference did not reach significance. Consequently, a future clinical trial should recruit a larger cohort of patients, using a standard double-dose protocol in both groups.

SCFMO Study of the Tautomerism of Anilino-Thiazole and Related Compounds

SCFMO study of the tautomerism of anilino-thiazole, anilino-oxazole, and anilino-oxadiazole shows that amino form predominates.

Balance is an important predictive factor for quality of life and function after primary total knee replacement

We investigated the extent to which improved balance relative to pain relief correlates with the success of total knee replacement (TKR). A total of 81 patients were recruited to the study: 16 men (19.8%) and 65 women (80.2%). Of these, 62 patients (10 men, 52 women) with a mean age of 73 (57 to 83) underwent static and dynamic assessment of balance pre-operatively and one year post-operatively. The parameters of balance were quantified using commercially available and validated equipment. Motor function and self-reported outcome were also assessed. There was a significant improvement in dynamic balance (p < 0.001) one year after TKR, and better balance correlated with improved mobility, functional balance and increased health-related quality of life. As it seems that balance, and not only pain relief, influences the success of TKR, balance skills should be better addressed during the post-operative rehabilitation of patients who undergo TKR.

Rehabilitation outcomes of stroke patients treated with multi-modal endovascular reperfusion therapy

AIM

The aim of this study was to investigate the influence of multi-modal endovascular reperfusion therapy (MMRT) on functional outcomes following rehabilitation.

METHODS

Data from 14 MMRT-treated patients were analyzed and compared to MMRT-ineligible, age and stroke severity-matched patients treated at the same Neurological and Rehabilitation departments. Neurological evaluation was assessed with the NIH stroke scale (NIHSS). Activity of daily living was measured using the FIMTM instrument. Functional outcome was measured using the modified Rankin scale (mRS).

RESULTS

The baseline characteristics of both groups were similar. NIHSS scores were lower in the MMRT group and they had slightly better functional and rehabilitation scores on admission to rehabilitation. At the end of rehabilitation, more MMRT-treated patients reached functional independence (mRS≤2; 50% vs. 7% respectively P=0.03). FIM scores were also higher in the MMRT group (mean score 93.3 vs. 87.7, respectively) but the difference did not reach significance. The delta in FIM and NIHSS scores obtained during rehabilitation did not significantly differ between the groups. MMRT remained a significant modifier of good outcome after regression analysis (OR 21.5 95% CI 1.1-410).

CONCLUSION

MMRT-treated patients have better chances of attaining independence after rehabilitation therapy. However, the additional improvements gained while in active rehabilitation were independent of reperfusion status.

Quantitation of cell-associated borrelial DNA in the blood of Lyme disease patients with erythema migrans

Bloodstream invasion is an important event in the pathogenesis of the more serious manifestations of Lyme disease. The number of spirochetes in the blood of infected patients, however, has not been determined, and, therefore, it is unknown whether the number of spirochetes can be correlated with particular clinical or laboratory features. This study was designed to measure the level of Borrelia burgdorferi in the plasma of Lyme disease patients and correlate these levels with selected clinical and laboratory findings. Nested and quantitative polymerase chain reaction (qPCR) was employed to detect cell-associated flaB gene DNA in the plasma of untreated early Lyme disease patients with erythema migrans (EM). Twenty-nine (45.3%) of 64 patients had evidence of B. burgdorferi in their plasma by at least one of the PCR methods. For the 22 qPCR-positive patients, the mean number of flaB gene copies per mL of plasma was 4,660, with a range of 414 to 56,000. The number of flaB gene copies did not significantly correlate with any of the clinical, demographic, or laboratory variables assessed. For reasons discussed, we suggest caution in extrapolating an estimate of the number of viable Borrelia in plasma from the observed number of flaB copies.

Dyadic coping among breast cancer patients treated with radiotherapy

e20589

Background: Cancer poses a major stressor for patients and their partners. Understanding dyad coping is useful for determining if one partner's involvement is beneficial or harmful to the other. We sought to evaluate whether dyadic coping enhances resilience in the context of other risk and protective factors for coping with serious illness. Methods: An IRB-approved questionnaire was offered to breast cancer patients and their spouses. Consent was obtained from 21 dyads who were queried prior to initiation of breast irradiation and within 2 weeks of completing treatment. The nature of dyadic coping (positive or negative), level of posttraumatic stress, functional impairment, depression, and markers of resiliency were assessed for each partner at the beginning and conclusion of therapy. Results: Depression was significantly higher in patients than in their spouses (df = 1, 13; F = 6.13; p = 0.028). Over the course of the radiotherapy, partner's depression improved while the patient's depression worsened (df=1,13; F=5.46; p=0.030). The patient's negative dyadic coping assessment before radiation therapy was positively associated with depression (β = 0.78; df = 31.3; t = 2.15; p = 0.04), as well as the partner's depression (β = 0.92; df = 31.3; t = 2.52; p = 0.017) and posttraumatic stress (β = 0.74; df = 31.7; t = 2.10; p = 0.04). Patient's pre-radiation negative dyadic coping was negatively associated with the partner's flexibility (β = -.21; df = 19; t = -2.28; p = 0.03) and self efficacy (β = 0.46; df = 21.8; t = 2.96; p = 0.007) at completion of therapy. Positive dyadic coping assessment was not associated with negative coping behaviors on the part of either the patient or partner. Conclusions: The results of this pilot study support interventions incorporating dyadic support to enhance the resilience of patients and partners. Intervention should promote flexibility and self-efficacy while providing tools for altering negative dyadic coping patterns.

No significant financial relationships to disclose.

New evidence for the role of TNF-alpha in liver ischaemic/reperfusion injury

BACKGROUND

Tumour necrosis factor-alpha (TNF-alpha) plays a key role in causing ischaemia/reperfusion (I/R) injury. I/R also causes activation of xanthine oxidase and dehydrogenase (XDH + XO) system that, via generated free radicals, causes organ damage. We investigated the effect of ischaemia, reperfusion and non-ischaemic prolonged perfusion (NIP) on TNF-alpha and XDH + XO production in an isolated perfused rat liver model.

MATERIALS AND METHODS

Rat livers underwent 150 min NIP (control group) or two hours of ischaemia followed by reperfusion (I/R group). TNF-alpha (TNF-alpha mRNA and protein level), XDH + XO production and bile secretion were determined in tissue and effluent at baseline, at 120 min of ischaemia, after 30 min of reperfusion (I/R group) and after 120 and 150 min of prolonged perfusion (control).

RESULTS

Unexpectedly, neither ischaemia nor reperfusion had any effect on TNF-alpha production. TNF-alpha in effluent was 11 +/- 4.8 pg mL(-1) at baseline, 7 +/- 3.2 pg mL(-1) at the end of ischaemia, and 13 +/- 5.3 pg mL(-1) after 30 min of reperfusion. NIP, however, caused a significant increase of TNF-alpha synthesis and release. TNF-alpha effluent level after 120 and 150 min of perfusion was 392 +/- 78.7 pg mL(-1) and 408 +/- 64.3 pg mL(-1), respectively. TNF-alpha mRNA in tissue was also significantly elevated compared to baseline levels (1.31 +/- 0.2 P < 0.001 and 1.38 P < 0.002, respectively). Decrease of liver function (expressed by bile secretion) during I/R and NIP was accompanied by significant XDH + XO elevation.

CONCLUSION

This is the first evidence that NIP, and not I/R, is the decisive trigger for TNF-alpha production. This study leads to a better understanding of pathogenesis of liver I/R and perfusion damage.

eToims twitch relief method in chronic refractory myofascial pain (CRMP)

INTRODUCTION

CRMP management involves electrical stimulation of motor points.

OBJECTIVE

To demonstrate that Electrical Twitch-Obtaining Intramuscular Stimulation (eToims) using ET127 system for noninvasive motor point stimulation is safe and efficacious in CRMP management.

METHOD

Longitudinal observation of consecutive self-pay outpatients treated from 10/06 through 4/08, divided into Preferred Group ("PG", N = 49, 3 Hz, 4 stimuli/site) and Basic Group ("BG", N = 43, 1 Hz stimulation, 1 stimulus/site). PG and BG had comparable ages, symptom durations, treatment session durations and treatment intervals. Each session involved treatment to large muscles of C4-C7 and L3-S1 myotomes. Outcome measures include prior week's verbal pain levels, pre and immediate post-session pain levels, blood pressure (BP), pulse rate (PR), symptomatic (S) and asymptomatic (A) side range-of-motion (ROM) for neck rotation (NR), shoulder external rotation (ER), shoulder internal rotation (IR), straight leg raising (SLR) and FABERE testing.

RESULTS

PG and BG showed significant improvements (p < 0.01) in immediate post-session pain levels and measured ROM. Significantly higher ERS (pre and post session percentage changes) noted for BG over PG (p < 0.05). Post-session PR decreased in both groups, more so in PG Systolic BP was mildly elevated in PG but was mildly reduced in BG Both groups showed no diastolic BP changes. Significant negative correlation noted between increasing number of treatments and pain level only in PG (r = -0.3, p = 0.00). Increasing number of treatments in PG correlated significantly with improvement in NRS, NRA, IRS, SLRS, LRA, FABERES and FABEREA whereas BG significantly correlated only for improvement in LRS. PG had lower average pain levels than BG (3.4 +/- 1.9 vs. 4.3 +/- 2.5, p < 0.02).

CONCLUSION

eToims using ET127 electrical stimulator appears safe and efficacious in CRMP management.

Infectious disease associations in advanced stage, indolent lymphoma (follicular and nonfollicular): developing a lymphoma prevention strategy

BACKGROUND

Eradication of Helicobacter pylori in gastric mucosa-associated lymphoid tumor can result in lymphoma remission. We prospectively identified/treated infections in nonbulky, advanced stage indolent lymphoma (follicular; nonfollicular lymphoma) eligible for observation.

MATERIALS AND METHODS

Stool H. pylori, hepatitis C and Borrelia serologies, Borrelia and Chlamydia fixed tissue PCR, Chlamydia peripheral blood mononuclear cell PCR and hydrogen breath test for small bowel bacterial overgrowth (SBBO) were obtained.

RESULTS

Fifty-six patients were enrolled. Positive infections: H. pylori (13); hepatitis C (3); SBBO (11). Negative: Borrelia (13); Chlamydophila psittaci (12, except one PCR). Lymphoma responses to antimicrobial therapy: H. pylori [one complete response (CR), 24+ months; one transient near CR]; hepatitis C [two CRs, 18+ and 30+ months; one partial response (PR) but hepatitis C virus persistent]; SBBO (one PR, 30+ months). Patients with associated infections, but without lymphoma CR, have required lymphoma treatment sooner than those without initial infections (treatment-free survival at 23.4 months median follow-up, 40.5% versus 74.7%, P = 0.01), indicating a different biology.

CONCLUSION

Infections are common in advanced stage indolent lymphoma (37.5% in our series). Anecdotal lymphoma responses have been seen and three have been durable CRs (18 to 30+ months) with infection eradication alone. The identification and treatment of associated infections may be a first step towards developing a lymphoma prevention strategy.

26 EFFECTS OF SOMATIC CLONING ON THE IMMUNE RESPONSE IN YOUNG AND ADULT CATTLE

Somatic cloning in cattle is associated with important gestational abnormalities, including implantation delay during the first 2 months of pregnancy and abnormal fetal and placental growth (known as large offspring syndrome, or LOS) in the third trimester. In our laboratory, between 3 and 25% of the cloned blastocysts transferred to recipient cows reach term, depending on genotype. About 20% of the newborns die rapidly due to various causes that appear to be direct consequences of the LOS. We previously reported on a thymic atrophy resulting from nuclear transfer (Renard et al. 1999 Lancet 353, 1459-1491) and have further diagnosed distinct pathological events occurring in the infancy and adult age of clones, including death due to apparently benign infections (despite treatment) and also thymic atrophy in approximately 20% of the postmortem cases. These observations in clones have led us to investigate the immune function of apparently normal bovine clones. Holstein cows housed in the same farm were used. Circulating lymphocyte populations during the resting state were marked, counted in 17 clones and 17 contemporary controls ranging from 15 days to 5 years of age, and allotted to one of three groups: 1 (0.5-2 months, n = 4 clones, n = 6 controls), 2 (3-9 months, n = 7 clones, n = 5 controls) and 3 (1.5-5 years, n = 6 clones, n = 6 controls). Clones originated from adult fibroblast cells from four different genotypes distributed in the three groups. Peripheral mononuclear blood cells (PMBCs) were collected, marked, and counted by flow cytometry. The specific markers were CD2, CD3, CD4, CD8, CD14, CD11b, CD25, CD45RO, P46 (NK cells), ��, PanB, MHC1, and MHC2. In a second experiment, six clones from three different genotypes and six controls aged 8-9 months were vaccinated with 10 mg ovalbumin in alum to evaluate the na�ve immune response. The cell subset proportions were not different between clones and controls. There was no difference between groups for antibody response to vaccination. However, T cell restimulation with specific antigens after immunization with evalbumin was significantly lower in clones compared to controls (P < 0.05). Furthermore, nonspecific stimulation with phytohemagglutinin (PHA) was also lower in clones (P < 0.05). These results show that lymphocyte populations are normally represented in apparently healthy clones. Bovine clones presented, however, a reduced capacity to build up a cellular immune response against a newly encountered antigen, such as ovalbumin. It remains to be determined whether these functional alterations are a result of defective reprogramming of immune functions during the cloning process or the consequence of an abnormal placental development leading to altered feto-placental interactions during pregnancy and fetal programming. Previous work by others has shown that there may be an abnormal expression of MHC1 in the placenta of bovine clones (Hill et al. 2002 Biol. Reprod. 67, 55-63), and this may well be part of the same phenomenon affecting overall immune regulation in clones.

Quantitative motor unit action potentials (QMUAP) in whiplash patients with neck and upper-limb pain

INTRODUCTION

Needle EMG studies in patients with whiplash symptoms to document presence of neural injury, such as cervical radiculopathy, are not available.

OBJECTIVE

To document presence of motor unit action potential (MUAP) parameter changes compatible with neurogenic involvement in symptomatic-limb muscles in whiplash induced acute and chronic pain states.

DESIGN

Retrospective review.

SETTING

Out patient quantitative electromyography (QEMG) laboratory.

PARTICIPANTS

72 consecutive patients (mean age 43.6 years) who underwent QEMG between 1/2001 - 12/2004 for electrodiagnosis of neck and upper-limb pain related to auto-accidents (mean symptom duration 15.3 months).

INTERVENTIONS

QEMG with MUAP parameter analysis.

MAIN OUTCOME MEASURES

Amplitude, duration, size-index (SI), percentage of polyphasic units and firing rate analysis in chosen bilateral muscles representing C3-C8 myotomes.

RESULTS

No spontaneous activity noted in muscles examined. Without subsetting symptom duration, symptomatic-side: asymptomatic-side MUAP parameter comparison showed significant increase in MUAP frequency on the symptomatic-side C6-muscle (10.4 +/- 1.3 vs. 9.7 +/- 1.4, p = < 0.05), and C7 muscle (10.0 +/- 1.2 vs. 9.1 +/- 1.1, p < or = 0.01). The symptomatic-side C6-muscle also showed increased percentage of polyphasic-MUAPs (23.7 +/- 13.1 vs. 15.9 +/- 12.7, p < 0.001). Patients with acute symptom duration (< 6 months, mean duration 3.4 +/- 1.4 months, N=26), showed increased percentage of polyphasic MUAPs in the symptomatic-side C6-muscle (27.0 +/- 12.3% vs. asymptomatic 22.2 +/- 17.6%, p < or = 0.05). In patients with chronic symptom duration (> or =6 months, mean duration 22.0 +/- 17.9 months, N=46), symptomatic-side C6-muscle showed increased polyphasic MUAPs (22.2 +/- 13.2%) vs. asymptomatic (15.5 +/- 11.6%), p < or = 0.02, and higher firing rates (10.3 +/- 1.7 vs. 9.6 +/- 1.3 respectively, p < or = 0.003).

CONCLUSIONS

QEMG changes suggest neural injury in symptomatic side C6 and C7 innervated muscles, even in the absence of spontaneous activity. In acute and chronic pain patients a higher percentage of polyphasic MUAPs is noted in the symptomatic side C6 muscle. In chronic pain patients higher MUAP frequencies are noted in the symptomatic side C6 muscle.

Motor unit action potential (MUAP) parameters affected by editing duration cursors

INTRODUCTION

Quantitative electromyography (QEMG) allows fast analysis of motor unit action potential (MUAP) parameters such as amplitude, duration, size index (SI), phases, turns and firing rate. When automated duration cursor placement is incorrect, the electrodiagnostician will manually edit this function potentially introducing bias to the final results.

OBJECTIVE

To identify that (1) size index is the MUAP parameter least affected by manually editing duration cursors and (2) MUAP amplitude will influence the manual cursor correction rate.

MATERIALS AND METHODS

Included were twenty-one consecutive patients who had QEMG with monopolar needle electrode for diagnostic evaluation of their myofascial pain symptoms. Evaluated for neck pain included 6 bilateral upper limb and cervical paraspinal muscles and for lower back pain were 5 bilateral lower limb and lower back muscles. Twenty MUAPs were recorded from each muscle and hardcopies of data obtained before and after manual edit.

RESULTS

Of a total of 5360 MUAPs analyzed 1764 (33%) required manual editing of duration cursors. Cursor correction rate 120 MUAP s/individual muscle analyzed was also similar at 33+/-17%. Percentage change in duration more so than turns, before and after correction, was significantly larger than that of other parameters. No significant differences in percentage changes noted between SI and phases.

CONCLUSIONS

SI and phases are least influenced by the manual correction of duration cursors since there is insubstantial amplitude and area at the tail-end of the MUAP.

In vivo and in vitro studies on Anaplasma phagocytophilum infection of the myeloid cells of a patient with chronic myelogenous leukaemia and human granulocytic ehrlichiosis

AIMS

The occurrence of human granulocytic ehrlichiosis (HGE) in a patient with chronic myelogenous leukaemia (CML) provided an opportunity to study whether Anaplasma phagocytophilum, the aetiological agent of HGE, infects mature or immature cells, both in vivo and in vitro.

METHODS

Diagnosis of HGE was confirmed by culture, polymerase chain reaction (PCR), detection of intragranulocytic inclusions, and serology. The infection rates of different myelogenous stages of granulocytic differentiation were determined by microscopy. Anaplasma phagocytophilum infection of the bone marrow was analysed by PCR, culture, and microscopy. In addition, the in vitro growth of A phagocytophilum in the patient's granulocytes and in HL-60 cells (a promyelocytic leukaemia cell line) was compared.

RESULTS

Pretreatment blood smears showed that mature granulocytic cells had a higher infection rate with A phagocytophilum than did immature cells. In the original inoculation of the patient's cells into HL-60 cells to isolate A phagocytophilum, the bacterium grew faster in the patient's leukaemic cells than in HL-60 cells. Anaplasma phagocytophilum inclusions were rarely seen in bone marrow granulocytes and PCR was negative. In vitro, two A phagocytophilum isolates grew faster in the patient's granulocytes than in HL-60 cells.

CONCLUSIONS

The superior growth in CML cells compared with HL-60 cells suggests that A phagocytophilum preferentially infects mature granulocytes. The higher infection rate of the patient's mature versus immature granulocytes before treatment and the minimal level of infection of the patient's bone marrow support this. It is possible that the primary site of infection in HGE is the peripheral mature granulocytic population.

Effect of montelukast pretreatment on inducible nitric oxide synthase mRNA expression in the lungs of antigen-challenged allergic mice

BACKGROUND

Growing evidence suggests that inducible nitric oxide synthase (iNOS) is the main source of the high output of exhaled nitric oxide (NO) in asthma. Treatment of asthmatic patients with glucocorticoids reduces high levels of exhaled NO mainly by inhibiting the transcription of iNOS. A similar reduction in exhaled NO was recently observed in patients treated with the leukotriene receptor antagonists, but the exact interaction between these drugs and iNOS remains obscure.

OBJECTIVE

The purpose of this study was to evaluate the effect of a leukotriene receptor antagonist, montelukast, on the expression and activity of iNOS in a murine model of allergic asthma.

METHODS

Twenty-four BALB/c mice were sensitized to OVA and were equally divided into 3 groups (Groups 1-3). Eight additional mice were sham sensitized and served as a negative control group (Group 4). Group 1 received montelukast 1 mg/kg/day in their drinking water, Group 2 received dexamethasone 1 mg/kg/day in their drinking water and Groups 3 and 4 received plain tap water. After 1 week, the animals were challenged by inhalation of OVA and, 3 h later, they were killed and their lung cells were isolated by enzymatic tissue digestion. NO generation was measured by a Griess assay, and iNOS mRNA was studied by RT-PCR.

RESULTS

A significant increase in iNOS mRNA expression and in NO generation was evident after allergen challenge compared with the controls. Pretreatment with montelukast mildly decreased NO production without producing a concomitant significant decrease in iNOS mRNA expression.

CONCLUSION

Unlike pretreatment with glucocorticoids, we failed to find compelling evidence for a major role for montelukast treatment in the modulation of iNOS mRNA in a murine model of acute asthma.

Skill and selection bias has least influence on motor unit action potential firing rate/frequency

INTRODUCTION

Motor unit action potential (MUAP) rise time in quantitative electromyography (QEMG) using multi-MUAP analysis may influence neuromuscular disease diagnosis.

OBJECTIVE

To demonstrate in QEMG that MUAP firing rate/frequency (FR) is the parameter least dependent on electrodiagnostician skill (EDXc) skill and selection bias.

METHODS AND MATERIALS

During minimal contraction (< 6 MUAPs/4.8 s analysis period) of tibialis anterior, 20 MUAPs were selected for QEMG at each of the 3 insertion sites. There were three EDXcs (professor & two fellows), each an independent MUAP selector + EMG machine itself (EMGM), for a total of four independent MUAP selectors. EDXc and selector order variation at each site involved the following. At insertion site1, during EMG by EDXc 1, the MUAP selector order was EDXc 1, EMGM, EDXc 2 and EDXc 3. At the following two sites, the previous 1st selector was sequentially rotated to become the last selector during EMG by the subsequent EDXc. The protocol was repeated in two subjects. MUAP inclusion criteria by EDXcs was MUAP rise time < 1 ms by visual inspection and, by the EMGM, any and all MUAPs during the 4.8 s analysis period.

RESULTS

The reproducibility of measurements between MUAP selectors for mean frequency was satisfactory (correlation coefficient for inter-EDXc was 0.57, and 0.66 between the most experienced EDXc and EMGM. Inter- EDXc correlation coefficient was poor for amplitude (0.10), duration (0.34), size index (0.35), phases (-0.13) and turns (-0.22). Of the MUAPs collected by EMGM, the mean amplitude was smaller and mean duration was longer than those collected by the other 3 selectors with no significant differences for the other parameters.

CONCLUSIONS

FR was the only satisfactorily reproduced parameter from QEMG of MUAPs between selectors, and least dependent on skill and/or selection bias. From this, FR appears a relatively objective parameter, while other parameters appear unduly influenced by EDXc skill and/or MUAP selection bias.

The efficacy of automated/electrical twitch obtaining intramuscular stimulation (atoims/etoims) for chronic pain control: evaluation with statistical process control methods

INTRODUCTION

Automated and/or electrical twitch-obtaining intramuscular stimulation (ATOIMS & ETOIMS) evoke twitches at/or near motor end plate zones to relieve muscle pain.

OBJECTIVES

To demonstrate that pain levels recorded daily by patients enable statistical process control (SPC) analysis of ATOIMS & ETOIMS effects over time.

METHODS

Four chronic fibromyalgic patients received ATOIMS & ETOIMS treatments to bilateral C3-C8 and L3-S1 myotomes and recorded daily pain on a visual analogue scale. Mechanical stimulation with ATOIMS involved a custom device to insert, oscillate and retract a monopolar needle (MN) at 2 Hz x2s. ETOIMS involved manual insertion of the MN and stimulating with 5 Volts, 0.5 ms pulse duration at 2 Hz for 2s to multiple sites. Positive outcome measures include two pain scales reduction.

RESULTS

Patient 1-4 had 89, 38, 40, 36 treatments during a follow-up time of 625, 1018, 378, 466 days with 5.4 +/- 3.7, 8.0 +/- 4.9, 4.2 +/- 2.4 and 4.6 +/- 2.7 days between treatments (DBT) during the first 6 months and 4.7 +/- 3.0, 21.8 +/- 15.6, 6.2 +/- 4.4 and 4.3 +/- 2.5 DBT respectively in the latter phase of the therapy. The average pain level (APL) in 1st week of treatment for patient 1-4 were 6.4 +/- 1.1, 3.7 +/- 1.1, 6.6 +/- 2.8 and 7.5 +/- 0.4 and in the last week of treatment were 4.5 +/- 0.4, 1.2 +/- 0.1, 4.2 +/- 1.0 and 4.7 +/- 0.7 respectively. APL correlated negatively with time during the first 6 months for patients 2-4 and also after 6 months for patients 4 & 1 who had unchanged and reduced DBT respectively. APL correlated positively with time for patient 2 with no correlation for patient 3 (both had increased DBT) after 6 months.

CONCLUSIONS

Patients will chronically record their pain scales daily enabling analysis by SPC. ATOIMS & ETOIMS applied periodically can be helpful in relieving fibromyalgic pain.

Twitch-obtaining intramuscular stimulation in reflex sympathetic dystrophy

BACKGROUND

Reflex Sympathetic Dystrophy (RSD) remains a painful disease entity of undetermined etiology and variable response to therapy.

FINDINGS

Presented is a patient with left leg early RSD and chronic musculoskeletal back pain who received automated and electrical twitch-obtaining intramuscular stimulation (ATOIMS & ETOIMS) treatments. Diagnosis combined clinical symptoms of pain and allodynia, signs of motor/trophic changes and electromyographic evidence of especially of left L5 root level irritation, with chronic bilateral, multiple level partial lumbosacral nerve root involvement. Signs and symptoms of early RSD resolved with therapy.

CONCLUSIONS

ATOIMS-ETOIMS have a promising role in the treatment of early RSD associated with neuropathic pain resulting from spondylotic radiculopathy.

The muscle twitch in myofascial pain relief: effects of acupuncture and other needling methods

Proposed is that needling methods such as acupuncture, primarily effect pain relief in myofascial pain through a local mechanism, elicitation of muscle twitches. Occasionally, diagnostic needling procedures such as electromyography (EMG) can relieve such pain through insertional intramuscular movements of the needle electrode. This results in stimulation of the motor end-plate zones (MEPZs), eliciting muscle twitches. As needle elicitation of muscle twitches is a common diagnostic technique to identify myofascial trigger points (MTrPs), muscle twitches elicited at such points may be therapeutic, not just diagnostic. Occasionally evoked small local muscle twitches are observed in pain relieving methods using needle penetration or manipulation, such as classical or electrical acupuncture and intramuscular stimulation (IMS). Twitch elicitation has been observed to be essential to obtain myofascial pain relief associated with the needling methods of automated and electrical twitch-obtaining intramuscular stimulation (ATOIMS and ETOIMS). These two methods facilitate the elicitation of larger force twitches by mechanical or electrical stimulation respectively at motor end-plate zones.

ErbB-4 expression in limb soft-tissue sarcoma: correlation with the results of neoadjuvant chemotherapy

ErbB-4 is a recently described growth factor receptor. Relatively little is known about its expression in human tumours. In this study, we assessed the possible role of erbB-4 as a tissue marker for soft-tissue sarcomas (STS) and its correlation with the response to chemotherapy. The histological specimen of 29 patients with STS of a limb who had received preoperative doxorubicin (ADR)-based chemotherapy were studied for the degree of necrosis and the expression of erbB-4 (by an avidin-biotin-peroxidase technique). ErbB-4 expression in the preoperative tissue samples was compared with the expression in the postchemotherapy resected tumour. The true objective response rate to preoperative chemotherapy was 34%. Wide resection of the tumour was done in 12 patients, marginal in 14, amputation in 2 and no surgery in 1. The tumour necrosis was above 90% in 9 patients, 60-90% in 12, and less than 60% in 7 patients. An increase in erbB-4 expression was more common in cases with no response to chemotherapy, while no change or a decrease in erbB-4 was more common in responsive tumours (P=0.004). No correlation could be found between the degree of necrosis or the chemotherapeutic regimen and the change in expression of erbB-4. The median disease-free survival (DFS) was longer for patients with a decrease or no change in expression of erbB-4 than for patients with increased expression. It is believed that postchemotherapy new expression or no downregulation of the erbB-4 molecule represents tumour aggressiveness and increased capability of growth and spread.

Laboratory diagnostic techniques for patients with early Lyme disease associated with erythema migrans: a comparison of different techniques

Recently, a number of refinements in diagnostic modalities for detection of Borrelia burgdorferi infection have been developed. These include large-volume blood cultures, quantitative polymerase chain reaction (PCR) techniques, and 2-stage serologic testing. In the present study, we compared 6 diagnostic modalities in 47 adult patients who had a clinical diagnosis of erythema migrans. Quantitative PCR on skin biopsy-derived material was the most sensitive diagnostic method (80.9%), followed by 2-stage serologic testing of convalescent-phase samples (66.0%), conventional nested PCR (63.8%), skin culture (51.1%), blood culture (44.7%), and serologic testing of acute-phase samples (40.4%). Results of all assays were negative for 3 patients (6.4%). We conclude that the clinical diagnosis of erythema migrans is highly accurate in an area where B. burgdorferi is endemic if it is made by experienced health care personnel, but some patients with this diagnosis may not have B. burgdorferi infection. No single diagnostic modality is suitable for detection of B. burgdorferi in every patient with erythema migrans.

Asymptomatic Borrelia burgdorferi infection

Little is known about the natural history of asymptomatic Borrelia burgdorferi infection. Our analysis of the asymptomatic infections diagnosed serologically in a recent OspA vaccine trial conducted in the United States (N Engl J Med 1998;339: 209-215), suggests that the natural history of this event is more benign than that reported for untreated patients with erythema migrans (Ann Intern Med 1987;107: 725-731). We hypothesize that this is due either to incorrect diagnosis since the specificity of the serologic criteria used to diagnose asymptomatic infection in the vaccine study is unknown, or to infection with non-pathogenic strains of B. burgdorferi. Increasing evidence indicates that the invasive potential of strains of B. burgdorferi varies according to the specific subtype. Theoretically, a serologic testing method could be devised which would distinguish infection with invasive versus non-invasive strains of B. burgdorferi, and allow testing of the second hypothesis.

Genetics and regulation of chitobiose utilization in Borrelia burgdorferi

Borrelia burgdorferi spends a significant proportion of its life cycle within an ixodid tick, which has a cuticle containing chitin, a polymer of N-acetylglucosamine (GlcNAc). The B. burgdorferi celA, celB, and celC genes encode products homologous to transporters for cellobiose and chitobiose (the dimer subunit of chitin) in other bacteria, which could be useful for bacterial nutrient acquisition during growth within ticks. We found that chitobiose efficiently substituted for GlcNAc during bacterial growth in culture medium. We inactivated the celB gene, which encodes the putative membrane-spanning component of the transporter, and compared growth of the mutant in various media to that of its isogenic parent. The mutant was no longer able to utilize chitobiose, while neither the mutant nor the wild type can utilize cellobiose. We propose renaming the three genes chbA, chbB, and chbC, since they probably encode a chitobiose transporter. We also found that the chbC gene was regulated in response to growth temperature and during growth in medium lacking GlcNAc.

Characterization of Borrelia burgdorferi isolated from erythema migrans lesions: interrelationship of three molecular typing methods

Genetic diversity among Borrelia burgdorferi isolates recovered from the skin of Lyme disease patients was assessed by ribosomal DNA (rDNA) spacer restriction fragment length polymorphism analysis, genomic restriction site polymorphism analysis, and plasmid content analysis. There was a significant association between the three rDNA spacer types, the six pulsed-field gel types, and plasmid content (P < 0.001). The association between distinct chromosomal and plasmid markers implies a clonal origin for each genotype.

Lumbosacral radiculopathic pain presenting as groin and scrotal pain: pain management with twitch-obtaining intramuscular stimulation. A case report and review of literature

BACKGROUND

Chronic groin and scrotal pain is a common entity plaguing a significant population of young athletic individuals. Aside from urologic and visceral etiologies, there is a vast array of underlying musculoskeletal and spinal abnormalities that may be found in these individuals.

FINDINGS

Presented is a patient found to have chronic, spine-related groin and scrotal pain diagnosed with lower lumbar discogenic disease by physical examination findings, imaging studies and multi-level chronic radiculopathy by electrodiagnostic studies who was treated with twitch-obtaining intramuscular stimulation (TOIMS). Symptoms of groin and scrotal pain abated with therapy.

CONCLUSION

Twitch-obtaining intramuscular stimulation has a promising role in the treatment of groin and scrotal pain of radiculopathic origin.

Impact of genotypic variation of Borrelia burgdorferi sensu stricto on kinetics of dissemination and severity of disease in C3H/HeJ mice

Various genotypes of Borrelia burgdorferi sensu stricto have been previously identified among a large collection of isolates cultured from patients with Lyme disease in the United States. Furthermore, association of specific genotypes with hematogenous dissemination early in the disease course has been observed. The present study assessed kinetics of spirochete dissemination and disease severity in C3H/HeJ mice infected with two different genotypes of B. burgdorferi. Spirochete load in plasma and ear and other tissue samples of infected mice was measured by quantitative PCR, and these data were compared to those obtained by culture and histopathologic analysis. In mice infected with isolate BL206 (a type 1 strain), the peak number of spirochetes was observed in plasma between day 4 and 7, in heart and ear tissue on day 14, and in joints on day 28 postinoculation. There was a correlation between the peak number of spirochetes in plasma on day 4 or 7 and that in ear biopsy and joint specimens on day 14. By contrast, spirochete burdens in plasma of mice infected with isolate B356 (a type 3 strain) were 16- and 5-fold lower than those of BL206-infected mice on days 7 and 14 of infection, respectively. Similarly, approximately 6- and 13-fold fewer spirochetes were detected in the heart tissues of B356-infected mice compared to BL206-infected mice. Histopathologically, severe arthritis and aortitis were noted only in mice infected with isolate BL206. Spirochete dissemination and disease severity vary significantly in mice infected with distinct genotypes of B. burgdorferi, suggesting that genotypic differences in the infecting spirochetes play a key role in the pathogenesis and development of clinical disease.

Borrelia lonestari infection after a bite by an Amblyomma americanum tick

Erythematous rashes that are suggestive of early Lyme disease have been associated with the bite of Amblyomma americanum ticks, particularly in the southern United States. However, Borrelia burgdorferi, the causative agent of Lyme disease, has not been cultured from skin biopsy specimens from these patients, and diagnostic serum antibodies usually have not been found. Borrelia lonestari sp nov, an uncultured spirochete, has been detected in A. americanum ticks by DNA amplification techniques, but its role in human illness is unknown. We observed erythema migrans in a patient with an attached A. americanum tick. DNA amplification of the flagellin gene flaB produced B. lonestari sequences from the skin of the patient that were identical to those found in the attached tick. B. lonestari is a probable cause of erythema migrans in humans.

Primary papillary serous carcinoma of the peritoneum in a man

BACKGROUND

Primary papillary serous carcinoma of the peritoneum is a well-known entity in women. The tumour is derived from the extraovarian mesothelium and the pelvis and lower abdomen mesothelia. The treatment strategies are similar to ovarian serous papillary carcinoma.

PATIENTS AND METHODS

A case of primary serous papillary carcinoma of the peritoneum in a man is presented. The patient, 53 years old, died 2 months after diagnosis.

RESULTS

The histologic and immunohistochemical studies of the tumour will be presented. These studies, made during lifetime and at autopsy of the patient, confirm a diagnosis of primary serous papillary carcinoma of the peritoneum.

CONCLUSIONS

primary serous papillary carcinoma of the peritoneum can occur in men, and should be considered in the differential diagnosis in cases of abdominal carcinomatosis of unknown origin. Treatment options remain to be determined.