Demonstrating Agreement between Radio and Fluorescence Measurements of the Depth of Maximum of Extensive Air Showers at the Pierre Auger Observatory

We show, for the first time, radio measurements of the depth of shower maximum (X_{max}) of air showers induced by cosmic rays that are compared to measurements of the established fluorescence method at the same location. Using measurements at the Pierre Auger Observatory we show full compatibility between our radio and the previously published fluorescence dataset, and between a subset of air showers observed simultaneously with both radio and fluorescence techniques, a measurement setup unique to the Pierre Auger Observatory. Furthermore, we show radio X_{max} resolution as a function of energy and demonstrate the ability to make competitive high-resolution X_{max} measurements with even a sparse radio array. With this, we show that the radio technique is capable of cosmic-ray mass composition studies, both at Auger and at other experiments.

Balancing anticoagulation and hemostasis in an infant with severe hemophilia A during cardiac transplantation: Review of the literature and development of a surgical protocol

Hemophilia A is a disorder resulting in a deficiency of clotting factor VIII that can lead to life-threatening bleeding. Evidence-based guidelines for surgical interventions like cardiac surgery are limited. Anticoagulation is necessary for cardiac bypass, thus risk of bleeding in a patient with hemophilia is increased and requires careful attention to maintain hemostasis. We report the first infant with severe hemophilia A and dilated cardiomyopathy who underwent successful cardiac transplantation, and review the literature on previous cardiac transplant cases in congenital hemophilia. To ensure safe and effective management, a multidisciplinary approach was used to develop the surgical protocol for transplant.

Pathway Mutations are Associated with Clinical Outcomes in Localized Pancreatic Cancer Treated with Neoadjuvant Chemoradiation Followed by Surgery

PURPOSE/OBJECTIVE(S)

The purpose of this study was to determine if mutations in biological pathways are associated with clinical outcomes in patients with localized pancreatic cancer who undergo neoadjuvant chemoradiation followed by surgical resection.

MATERIALS/METHODS

Patients treated with neoadjuvant chemoradiation followed by oncologic resection from 2015-2019 who also underwent next generation sequencing (NGS) of the primary tumor were included in this retrospective analysis. NGS was done using either Foundation One (n = 20), in-house Solid Tumor Panel (n = 121), or Tempus XT (n = 1). Genes were included in pathway analysis if at least one patient harbored a mutation in the gene. Pathways were defined from the Molecular Signatures Database Hallmark, KEGG, and Reactome gene sets. A pathway was deemed mutated if at least one gene within the pathway was mutated. Univariable Cox regression was performed to determine the association between pathway mutation status and overall survival (OS) as well as progression-free survival (PFS).

RESULTS

In total, 142 patients met criteria for study inclusion. For pathway analysis, 329 genes met inclusion criteria. Patients were typically treated with neoadjuvant chemotherapy (either 5-fluorouracil-based or gemcitabine-based) followed by radiation. Patients received SBRT (n = 104, most commonly 33 Gy in 5 fractions) or conventionally fractionated radiation (n = 38, most commonly 50.4 Gy in 28 fractions). For clinical variables, worse OS was significantly associated with T stage (p = 0.036), N stage (p = 0.044), and lymphovascular invasion (LVI, p = 0.011); worse PFS was significantly associated with T stage (p = 0.0008), N stage (p = 0.022), LVI (p = 0.026), and conventional RT (p = 0.007). Mutations in major pathways were associated with worse OS, notably hedgehog signaling (p = 0.001), chromatin modifying enzymes (p = 0.002), WNT/beta-catenin signaling (p = 0.005), mismatch repair (0.006), E2F targets (p = 0.008), FLT signaling (p = 0.012), VEGF signaling (0.025), innate immune system (p = 0.026), and NOTCH signaling (p = 0.029). Pathway mutations associated with worse PFS included mismatch repair (p = 0.007) and hedgehog signaling (p = 0.013).

CONCLUSION

For pancreatic cancer patients that undergo neoadjuvant chemoradiation followed by oncologic resection of the primary tumor, mutations in key biological pathways are associated with OS and PFS. Characterizing the importance of common pathway mutations may become increasingly valuable to help categorize less commonly mutated genes assayed by NGS.

Characterization of DNA Damage Response-Associated Somatic Mutations in Borderline Resectable and Locally Advanced Pancreatic Cancer

PURPOSE/OBJECTIVE(S)

The role of radiation for pancreatic cancer remains controversial, with recent studies showing conflicting results, highlighting the need to develop biomarkers of radiation response. Despite its potential utility in predicting radiosensitivity, the landscape of somatic mutations in borderline resectable pancreatic cancer (BRPC) and locally advanced pancreatic cancer (LAPC), as related to DNA damage response (DDR), has not been well characterized. This study aimed to characterize the frequency of such mutations in a cohort of patients with BRPC/LAPC treated with neoadjuvant chemotherapy and stereotactic body radiotherapy (SBRT).

MATERIALS/METHODS

Mutational data was collected from patients with BRPC/LAPC treated at a single institution with neoadjuvant chemotherapy and SBRT, followed by surgical resection from 2016-2021. Chemotherapy consisted of modified FOLFIRINOX or gemcitabine/nab-paclitaxel, and patients were treated with SBRT in 33 Gy in 5 fractions. Genomic data was obtained from either endoscopic biopsy or surgical specimens, and next-generation sequencing was performed either in-house with a Solid Tumor Panel or with FoundationOne CDx. Specific emphasis was placed on the characterization of double-strand DNA break (DSB) repair genes, as this is the type of tumor cell damage traditionally induced by radiation therapy. Genes associated with the two main pathways of DSB repair, non-homologous end joining (NHEJ) and homologous repair (HR), were analyzed. Specific HR pathway mutations assessed were BLM, BRCA1/2, MRE11, NBN, PALB2, RAD50, RAD51B-D, and RAD54L, while PRKDC mutations were assessed for the NHEJ pathway. Mutations in ATM, an important initiator of DDR pathways, were also analyzed. Additionally, the frequency of mutations in TP53, CDKN2A and SMAD4 in patients with concomitant KRAS mutations was assessed.

RESULTS

Eighty-five patients were included in the study. Five (5.9%) patients had mutations in the NHEJ pathway of the PRKDC gene. Twenty (23.5%) patients had mutations in the HR pathway, including BRCA2 (10/85; 11.8%), PALB2 (5/85; 5.9%), BRCA1 (3/85; 3.5%), and RAD50 (1/85; 1.2%). Six (7.1%) patients had mutations in ATM. No patients were found to have mutations in BLM, RAD51B-D, RAD54L, or NBN. Amongst patients with KRAS mutations (72/85), concomitant mutations were observed in TP53 (47/85; 55.3%), CDKN2A (16/85; 18.8%), and SMAD4 (9/85; 10.6%).

CONCLUSION

Herein, we characterized the frequency of somatic mutations associated with DSB repair genes in patients with BRPC/LAPC. Data analysis on outcomes related to radiation response in patients with mutations in DDR pathways is ongoing, but will likely also benefit from multi-institutional efforts to increase the power to answer this question.

Utilization of the Triangle Volume in Patients with Localized PDAC Undergoing Pre-Operative SBRT: Report of Early Outcomes

PURPOSE/OBJECTIVE(S)

In patients with borderline resectable or locally advanced pancreatic adenocarcinoma (BRPC/LAPC), advances in neoadjuvant therapy have led to an increased proportion of patients undergoing margin negative resection. Nevertheless, locoregional recurrence rates remain high. We have previously reported that the location of locoregional recurrences in this setting map to the "Triangle Volume (TV)," the anatomical space between the celiac artery, superior mesenteric artery, common hepatic artery, and portal vein, which is enriched in extrapancreatic perineural tracts at risk for microscopic residual disease after resection. At the beginning of 2021, we systematically changed our target volume to include the TV, in addition to gross disease and involved vasculature. Herein, we report early locoregional failure outcomes after resection in the setting of BRPC or LAPC treated with pre-operative stereotactic body radiation therapy (SBRT) to the TV, as compared to historical rates.

MATERIALS/METHODS

Patients who received a diagnosis of BRPC or LAPC and who were treated at our institution with neoadjuvant chemotherapy (CTX) and SBRT between 2016 and 2022 were retrospectively reviewed. Between 2016 and 2020, the SBRT clinical tumor volume (CTV) included gross disease and full circumference of involved vasculature at the level of involvement. From 2021 onward, the CTV also included the TV. Survival was estimated using the Kaplan-Meier method. Statistical analyses were performed using scientific 2-D graphing and statistics software.

RESULTS

From January 2016 to December 2022, 204 patients with localized PDAC underwent neoadjuvant CTX followed by SBRT. After completion of SBRT, all patients proceeded with surgical exploration. Of these patients, 111 (54%) had LAPC and 92 (45%) had BRPC disease. All patients were treated with induction CTX, mostly commonly with FOLFIRINOX (N = 166, 81%). Following CTX, the most frequently used SBRT regimen was 33 Gy in 5 fractions (N = 191, 94%). 155 (67%) patients were treated between 2016 and 2020 to the traditional CTV, while 49 (24%) patients were treated after 2020 to a CTV that included the TV. The 2-year local progression free survival rate of patients treated with SBRT using the TV was 77.6% as compared to 47.5% in patients treated with the traditional CTV. Over a median follow up of 15.7 months (range: 1 to 78.2 months), 47% (N = 73 out of 155) of patients who underwent SBRT with the traditional CTV developed locoregional recurrence, but only 12% (N = 6 out of 49) treated with SBRT to the TV have thus far developed locoregional recurrence (p<0.0001).

CONCLUSION

In patients with localized PDAC who undergo pre-operative SBRT for BRPC/LAPC, targeting the TV may help reduce locoregional recurrence. More data and longer follow-up are needed to verify these findings and inform whether the TV may serve as a new standard for target volume delineation in this setting.

Visceral Artery Pseudoaneurysm Rates after Pancreatoduodenectomy in Patients Who Received Pre-Operative Radiation for Pancreatic Cancer

PURPOSE/OBJECTIVE(S)

The role of pre-operative radiation therapy (RT) for localized pancreatic ductal adenocarcinoma (PDAC) with peri-pancreatic vascular involvement remains controversial, with two recent randomized controlled trials, namely PREOPANC-1 and Alliance A021501, showing conflicting results. Opponents of pre-operative radiation point towards the unclear oncologic benefit and potential added toxicity. While hemorrhage from a pseudoaneurysm (PsA) rupture is a known rare but potentially fatal complication after pancreaticoduodenectomy (PD), with published incidence rates of around 2 to 5%, it has been increasingly common in the pancreatic cancer surgical community for pre-operative RT to be cited as a risk factor for PsA development, despite the absence of data supporting this notion. Certainly, accurate characterization of relevant RT-related toxicities is critical to prevent inaccurate decision-making regarding foregoing its use. As such, we aim to report on the incidence of PsA in a cohort of patients with PDAC who underwent pre-operative RT prior to PD at a high-volume center.

MATERIALS/METHODS

Consecutive patients treated with pre-operative RT via stereotactic body radiation therapy (SBRT) or intensity modulated radiation therapy (IMRT) prior to PD for borderline resectable or locally advanced PDAC were retrospectively reviewed. Incidence of radiographic or clinically apparent PsA was reported. We also characterized the timing of PsA identification in relation to surgery and RT, the artery in which the PsA developed, and the clinical outcomes of patients after PsA identification.

RESULTS

One hundred seventy-five patients met eligibility criteria for our analysis. Most of our cohort (163 patients, 93%) received SBRT to a median dose of 6.6 Gy x 5 (median BED10 54.78 Gy, range: 48 Gy - 61.92 Gy), and only 12 patients (7%) received IMRT in various fractionation and dose patterns (median BED10 62.94 Gy, range 59.47 Gy - 97.5 Gy). The median time between surgery and last contrast-enhanced abdominal imaging was 17 months (range: 0.23 - 68 months). There were fourteen visceral arteries among thirteen patients (7%) that were found to have a PsA on routine follow-up imaging or after a post-PD hemorrhage. The median time between completion of radiation and surgery to PsA were 19.5 weeks (range: 8.6 to 98.1 weeks) and 13 weeks (range: 1.6 to 87.9 weeks), respectively. The two most commonly involved arteries were the gastroduodenal and superior mesenteric arteries. Rate of PsA development was similar among patients treated with SBRT (7%) and IMRT (8%). In terms of Clavien-Dindo classification of complications, there were six patients with grade 3a complications, five patients with grade 4b complications, and two patients with grade 5 complications.

CONCLUSION

Compared to historical data, pre-operative RT does not appear to significantly increase the risk of PsA development after PD. More data on the impact of pre-operative radiation dose-fraction regimen and longer follow-up are needed.

High Time to Consider the Role of Thyroid Function in Single Ventricle Heart Disease

Herein we respond to the controversial United States Food and Drug Administration (FDA) recommendation to perform thyroid function testing in children up to 3 years of age within 3 weeks of exposure to iodinated contrast media (ICM). Considering the many effects of thyroid hormone on the cardiovascular system, the increased risk of thyroid disease in patients with congenital heart disease, the hemodynamic consequences of the Fontan circulation on the thyroid gland, and the potential clinical significance of subclinical hypothyroidism, we share our perspective that the cardiovascular effects of thyroid hormone may carry more influence for patients with single ventricle heart disease. In our opinion, the FDA statement prompts us to consider routine thyroid hormone surveillance testing in the long-term management of patients with single ventricle heart disease.

Limits to Gauge Coupling in the Dark Sector Set by the Nonobservation of Instanton-Induced Decay of Super-Heavy Dark Matter in the Pierre Auger Observatory Data

Instantons, which are nonperturbative solutions to Yang-Mills equations, provide a signal for the occurrence of quantum tunneling between distinct classes of vacua. They can give rise to decays of particles otherwise forbidden. Using data collected at the Pierre Auger Observatory, we search for signatures of such instanton-induced processes that would be suggestive of super-heavy particles decaying in the Galactic halo. These particles could have been produced during the post-inflationary epoch and match the relic abundance of dark matter inferred today. The nonobservation of the signatures searched for allows us to derive a bound on the reduced coupling constant of gauge interactions in the dark sector: α_{X}≲0.09, for 10^{9}≲M_{X}/GeV<10^{19}. Conversely, we obtain that, for instance, a reduced coupling constant α_{X}=0.09 excludes masses M_{X}≳3×10^{13}  GeV. In the context of dark matter production from gravitational interactions alone, we illustrate how these bounds are complementary to those obtained on the Hubble rate at the end of inflation from the nonobservation of tensor modes in the cosmological microwave background.

Efficacy and Safety of Reirradiation with Stereotactic Body Radiation Therapy for Locally Recurrent Pancreatic Adenocarcinoma

AIMS

The purpose of this study was to report on outcomes of a cohort of patients who were treated with reirradiation with stereotactic body radiation therapy (SBRT) for locally recurrent pancreatic adenocarcinoma.

MATERIALS AND METHODS

Patients treated with SBRT reirradiation for locally recurrent pancreatic adenocarcinoma from December 2009 to April 2020 were included in the study. Descriptive statistics were used to record patient demographics, tumour and treatment characteristics. Kaplan-Meier analysis was used to evaluate overall survival, local progression-free survival (LPFS), distant metastasis-free survival and progression-free survival (PFS).

RESULTS

In total, 27 patients were included in the study. The median follow-up time from local recurrence was 19.7 months (range 4.2-43.1 months). Most patients received five-fraction SBRT (26/27, 96%). The median overall survival after local recurrence treatment was 18.3 months (range 3.0-42.6 months), with 6-month, 1-year and 2-year overall survival rates of 88.5%, 73.1% and 33.6%. The median LPFS after local recurrence treatment was 16.2 months (range 2.3-33.6 months), with 6-month, 1-year and 2-year LPFS rates of 95.8%, 62.9% and 27.2%. Peri-SBRT chemotherapy improved LPFS (median 17.5 versus 8.5 months; P = 0.010) and overall survival (median 19.3 versus 5.5 months; P = 0.049). Tumours ≤ 3 cm in the greatest dimension showed better local control (median LPFS 19.2 versus 10.2 months; P = 0.130). There was one case (4%) of acute grade 3 pain and one case (4%) of late grade 3 gastrointestinal toxicity.

CONCLUSIONS

Reirradiation with five-fraction SBRT is safe, but local control remains suboptimal. Patients with smaller tumours experienced improved outcomes, as did patients whose treatment plan included the administration of peri-SBRT chemotherapy.

Emergency Department Management of Pediatric Heart Transplant Recipients: Unique Immunologic and Hemodynamic Challenges

BACKGROUND

Since the first heart transplant in 1967, there has been significant progress in this field of cardiac transplantation. Approximately 600 pediatric heart transplants are performed every year worldwide. With the increasing number of pediatric heart transplant patients, and given the few tertiary care pediatric transplant centers, adult and pediatric emergency department (ED) providers are increasingly engaged in the care of pediatric heart transplant recipients in the ED.

OBJECTIVE

The aim of this article is to review common ED scenarios pertinent to the pediatric heart transplant patients.

DISCUSSION

There are complications unique to this population, such as rejection, opportunistic infections, and medication side effects, that require special considerations, and it is helpful for the emergency medicine (EM) provider to have knowledge about them.

CONCLUSIONS

The unique immunological challenges in these patients, including rejection and medication side effects and opportunistic infections, make this population fragile, and the knowledge of these challenges is helpful for EM providers.

302 Migratory Foreign Body in The Neck- How A Fishbone Morphed into A Piece of Glass In 18 Months

Background

Foreign body (FB) ingestion is a common presentation to ear, nose, and throat (ENT) surgeons. Usual culprits include fish or chicken bones, steak, or non-organic items. FBs can be categorised into batteries, hard objects, and soft boluses. Hard objects that have not passed beyond the post-cricoid region require removal to minimise perforation risk. In rare cases FBs are reported to migrate extra-luminally into surrounding tissues of the neck necessitating cross-sectional imaging ahead of neck exploration.

Case Report

A 70-year-old lady presented to A&E with a sensation of FBs in her throat. She was aphagic without dyspnoea. Home-cooked fish ingestion was the precursor. Panendoscopy was clear. The patient was discharged once tolerating fluids and soft diet. She presented 14 months later to the ENT clinic with a persistent FB sensation in her throat. A computed-tomography scan of neck showed a right sided, radio-opaque, 3 cm foreign body sitting just anterior to the carotid sheath, behind the right superior thyroid lobe. An elective external neck exploration revealed a 3 cm shard of glass which was successfully removed without complications.

Conclusions

Extra-luminal migration of FBs is extremely rare. They may present with life-threatening suppurative or vascular complications. A literature review revealed that migratory FBs tend to be sharp and long such as needles, wires, or fishbones. To allow prompt diagnosis and management, we propose a low threshold for CT imaging in instances with a clear history and persistent symptoms even when panendoscopy is negative.

Clinical course and surgical outcomes in middle-age adults with anomalous aortic origin of a coronary artery

Funding Acknowledgements

Type of funding sources: None.

Background

Patients with anomalous aortic origin of a coronary artery (AAOCA) present with a wide range of clinical manifestations, including ischemic symptoms (chest pain or dyspnea) and sudden cardiac death (SCD). Studies have identified coronary anatomic characteristics associated with a higher risk of SCD. However, most of the published literature consists of studies in adolescents and young adults. There is a paucity of data regarding outcomes in middle-aged patients. Current guidelines reveal gaps in evidence for identification of adults are at risk for SCD, and for whom surgery is beneficial.

Purpose

To study the clinical course and rate of major adverse cardiac events (MACE) in middle-aged adults with AAOCA based on presenting symptoms, coronary anatomy on coronary computed tomography angiography (CCTA), stress test results, and surgical management.

Methods

We included all patients from January 2013 to December 2019 age &gt; 18 at our institution who were found to have AAOCA.  Patients with the following were excluded to minimize confounding factors which could cause MACE: coronary artery disease (CAD) with &gt;50% stenosis in any coronary vessel, CAD requiring revascularization, heart failure with ejection fraction &lt;40%, history of heart transplant, and non-AAOCA congenital heart disease. All patient charts were reviewed for demographics, coronary anatomy on CCTA, presenting symptoms, rationale for pursuing stress testing and CCTA, nature of surgical interventions, post-surgical course, and MACE (cardiovascular death, myocardial infarction, and need for coronary revascularization). All patients underwent PET as well as treadmill stress testing.

Results

Of 19,367 patients who underwent CCTA, 47 met inclusion criteria, with median age at diagnosis of 54 and median follow-up of 48 months. No patients suffered MACE. Twenty-five patients had AAORCA and 22 had AAOLCA (Table 1). Ten patients with AAORCA and 8 patients with AAOLCA presented with ischemic symptoms and had coronary anatomy characteristics associated with higher risk of SCD, as well as ischemia corresponding to the anomalous artery on stress testing and did not undergo surgery due to personal preference. Five symptomatic patients with stress-induced ischemia corresponding to the anomalous artery underwent surgery and all achieved symptom relief over a median follow up of 5 years.

Conclusion

As AAOCA is a significant cause of SCD in young adults, it is compelling to observe this adult cohort in which no patients experienced MACE, including 18 symptomatic patients with high-risk anatomy and stress-induced ischemia, as well as a Class I recommendations for surgery.  The results suggest that although surgery may be beneficial for symptom relief, it does not necessarily improve mortality over an intermediate follow-up period.  Future studies should examine surgical outcomes in middle-aged cohorts with larger sample sizes.

A Multicenter Prospective Registry Study of Lung Transplant Recipients Hospitalized with COVID-19

Purpose

Outcomes of lung transplant recipients (LTR) hospitalized for COVID-19 and comparisons to non-lung solid organ transplant recipients (SOTR) are incompletely described.

Methods

Using a multicenter prospective registry of SOTR, we examined 28-day outcomes (mortality [primary outcome], intensive care unit (ICU) admission, mechanical ventilation, and bacterial pneumonia) among both LTR and non-lung SOTR hospitalized with laboratory-confirmed COVID-19 diagnosed between March 1, 2020 and September 21, 2020. Data were analyzed using Stata (StataCorp, College Station, TX); chi-square tests were used to compare categorical variables and multivariable logistic regression was used to assess risk factors for mortality.

Results

The cohort included 72 LTR and 392 non-lung SOTR (Table 1). Overall, 28-day mortality trended higher in LTR vs. non-lung SOTR (27.8% vs. 19.9%, P=0.136). Other 28-day outcomes were similar between LTR and non-lung SOTR: ICU admission (45.8% vs. 39.1%, P=0.28), mechanical ventilation (32.9% vs. 31.1%, P=0.78), and bacterial pneumonia (15.3% vs. 8.2%, P=0.063). Congestive heart failure, diabetes, age >65 years, and obesity (BMI >= 30) were independently associated with mortality in non-lung SOTR, but not in LTR (Table 2).

Conclusion

In this large prospective cohort comparing lung and non-lung SOTR hospitalized for COVID-19, there were high but not significantly different rates of short-term morbidity and mortality. Baseline comorbidities appeared to drive mortality in non-lung SOTR but not LTR. Further studies are needed to identify risk factors for mortality among LTR.

CTA Evaluation of Basilar Septations: An Entity Better Characterized as Aberrant Basilar Fenestrations

BACKGROUND AND PURPOSE

A basilar artery intraluminal septation is an exceedingly rarely reported, presumed congenital abnormality. In our clinical practice, we have occasionally noticed an intraluminal band within the inferior aspect of the basilar artery on CTA. Furthermore, we have noticed, at times, the presence of a punctate calcification associated with this finding. We hypothesized that what previous studies have called "basilar septations" in fact represent miniature and thus aberrant basilar fenestrations.

MATERIALS AND METHODS

We retrospectively reviewed CTA studies obtained between January 1, 2017, and August 31, 2019. Identified intraluminal basilar abnormalities were classified as either basilar septations or basilar fenestrations. Association with other posterior circulation abnormalities was documented.

RESULTS

A total of 3509 studies were examined. A basilar intraluminal abnormality was evident in 80 patients (2.3%). Of these 80 patients, 59 were classified as having a basilar fenestration (1.7%) and 21 were classified as having basilar septations (0.6%). Associated calcification was evident in 3 of the basilar fenestration cases and 13 of the basilar septation cases.

CONCLUSIONS

Basilar septations most likely represent and should be referred to as aberrant basilar fenestrations. They should be interpreted as benign congenital incidental findings and should not be misinterpreted as focal dissections or arterial webs. Important variations in the morphology of aberrant basilar fenestrations exist, including areas of thinning, varying thickness, and nodularity. Therefore, when associated with calcification or nodularity, aberrant basilar fenestrations should not be confused with focal intraluminal thrombi or calcified or noncalcified emboli.

Pneumocystis pneumonia with hypogammaglobulinemia in a pediatric patient who underwent heart transplantation

A 23-month-old Caucasian female who had heart transplantation (HT) at 11 days of age was diagnosed with Pneumocystis pneumonia (PCP) in the setting of secondary hypogammaglobulinemia (HGG). She was diagnosed with HGG at 5 months of age and had been receiving monthly intravenous immunoglobulin infusion. This is the first case report describing the clinical course of PCP in a pediatric patient with HGG. She developed PCP 23 months after HT even when she was off steroids and was receiving timely IVIG. The case posed some clinical questions regarding PCP prophylaxis and HGG management.

ADENOID CYSTIC CARCINOMA MISINTERPRETED AS ANTROCHOANAL POLYP: A RARE PRESENTATION

Adenoid cystic Carcnoma (ACC) is an uncommon malignant tumour accounting for <1% of all oral and maxillofacial tumors. However, in the sinonasal tract, ACC is the most common salivary gland tumor. The sinonasal ACC is asymptomatic initially or causes non-specific symptoms that are similar to those caused by inflammatory sinus disease and local neurological symptoms such as trigeminal neuralgia in advance stage due to perineural invasion by the tumour.We present a case of 35-year-old female who presented with complaints of nasal obstruction and headache. CT scans revealed an antrochoanal polyp without any bony involvement. The histopathological examination revealed unremarkable respiratory epithelium with underlying sheets and acini of small hyperchromatic cells with hyaline-like material in the lumina, confirming adenoid cystic carcinoma. The highlight of this case is that sinonasal polyps are not always inflammatory in origin, these can be neoplastic also.

Numerical analysis of subcritical Hopf bifurcations in the two-dimensional FitzHugh-Nagumo model

It had been shown that the transition from a rigidly rotating spiral wave to a meandering spiral wave is via a Hopf bifurcation. Many studies have shown that these bifurcations are supercritical, but, by using simulations in a comoving frame of reference, we present numerical results which show that subcritical bifurcations are also present within FitzHugh-Nagumo. We show that a hysteresis region is present at the boundary of the rigidly rotating spiral waves and the meandering spiral waves for a particular set of parameters, a feature of FitzHugh-Nagumo that has previously not been reported. Furthermore, we present a evidence that this bifurcation is highly sensitive to initial conditions, and it is possible to convert one solution in the hysteresis loop to the other.

Left ventricular adaptation following orthotopic heart transplantation in children: A speckle tracking echocardiographic imaging study

BACKGROUND

Evolution of left ventricle (LV) function in the pediatric OHT population has not been well described. Our hypothesis was that, in children following OHT without any rejection, there would be progressive normalization of LV size and function over 2 years.

METHODS

LV function was evaluated using STE and conventional echo parameters at five time points in pediatric OHT patients without any rejection in the first 2 years following OHT and normal controls. LV global peak systolic longitudinal strain (LVPLS) and strain rate, LV peak systolic radial and circumferential strain (LVRS and LVCS), and strain rate were analyzed.

RESULTS

We had twenty two patients with median age at OHT of 1.27 years ( IQR 0.19, 5.6 years). The LVPLS (mean ± SD) was abnormal in the post-OHT echocardiograms at 1 week (-12.4 ± 3.7) and 1 month (-13.9 ± 3.7) and significantly improved at 6 months (-15.8 ± 3.2), 1 year (-15.7 ± 3.1), and 2 years (-17.8 ± 2.8). However, LVPLS remained below the normal group even at 2 years following OHT (-21.3 ± 1.76).

CONCLUSION

In children following OHT, despite the absence of rejection, strain values are significantly impaired in the initial months, improve progressively over the first 2 years but remain abnormal compared with healthy controls.

Anaemia and thyrotoxicosis: The need to look for an alternative cause

OBJECTIVES

Anaemia and thyrotoxicosis are both relatively common. It is unclear whether thyrotoxicosis results in anaemia in the absence of other causes. The aim of this study was to determine the prevalence and characteristics of anaemia in patients with thyrotoxicosis.

DESIGN

A prospective cohort study of patients with thyrotoxicosis.

PATIENTS

353 patients referred to a regional endocrinology centre in New Zealand from March 2013 to November 2014 for new-onset thyrotoxicosis.

MEASUREMENTS

Detailed assessment including thyroid function tests, full blood count, inflammatory markers, haematological parameters and coeliac serology. Anaemia was defined as a haemoglobin value <115 g/L (woman) or <130 g/L (men).

RESULTS

Anaemia was present in 31 (8.7%) patients at diagnosis. Of these, pre-existing anaemia was present in 10, and a further 11 had one or more identifiable underlying cause(s) for the anaemia. Only 10 patients (2.8% of the entire cohort) had anaemia not clearly attributable to another cause. Median free thyroid hormone levels were higher in those with anaemia of unknown cause compared to patients with thyrotoxicosis alone. The median duration of anaemia was shorter in patients with thyrotoxicosis-associated anaemia compared to those with anaemia due to an underlying cause (1 vs 6 months, P = .001). In all patients with thyrotoxicosis-associated anaemia, the anaemia resolved, either prior to, or on becoming euthyroid.

CONCLUSION

Anaemia coexisting with thyrotoxicosis is less common than previously reported and is mild and transient. Patients with thyrotoxicosis and significant anaemia should be investigated for other potential causes, particularly when anaemia persists.

Heart Transplant in Children: What a Primary Care Provider Needs to Know

Heart transplantation is offered to children with heart failure that is not amenable to medical or surgical therapy. Indications for heart transplant include unrepairable congenital heart disease, failed palliation of congenital heart disease, and cardiomyopathies. There has been tremendous progress in this field since the first heart transplant was performed in 1967. Each year, approximately 500 pediatric heart transplants take place worldwide. Pediatric heart transplant survivors are living longer with their initial transplant. Many pediatric practitioners are faced with caring for these patients before as well as after the heart transplant and, therefore, they should be knowledgeable about basic principles related to heart transplant. There are certain complications that are unique to this population, and medication side-effects, evaluation and management of a febrile illness, opportunistic infections, vaccination, pregnancy, and exercise recommendations are areas that require special consideration. [Pediatr Ann. 2018;47(4):e172-e178.].

Right Ventricular Dysfunction as an Echocardiographic Measure of Acute Rejection Following Heart Transplantation in Children

Noninvasive biomarkers of acute allograft rejection (AAR) following orthotopic heart transplantation (OHT) are needed. The aim of this study was to investigate the accuracy of echocardiographic (ECHO) right ventricular (RV) global functional and resistance indices in the detection of AAR. This retrospective chart review included children with biopsy-proven AAR (grade ≥ 2R cellular or CD4 + antibody-mediated rejection) following OHT and an ECHO within 12 h of the biopsy. ECHO measures: (a) ratio of systolic to diastolic duration (S/D), (b) RV myocardial performance index (MPI) and (c) tricuspid regurgitant gradient to RV outflow tract velocity time integral ratio (TRG/VTI), were derived at baseline, during AAR and at two follow-ups. Sixteen patients [56% male, mean (SD) age at OHT 3.5 (4.3) years] had 16 AAR episodes. S/D (1.15 vs. 1.60, p < 0.01), RV MPI (0.19 vs. 0.39, p < 0.01) and TRG/VTI (1.05 vs. 1.7, p = 0.01) deteriorated during AAR and, except for diastolic duration, improved significantly at first follow-up. The negative predictive values for S/D, RV MPI and TRG/VTI at cutoffs of 1.3, 0.31 and 1.3 were 97, 97 and 87%, respectively. RV S/D, MPI and TRG/VTI deteriorated during AAR. Their excellent negative predictive values suggest that their incorporation in surveillance may obviate the need for routine biopsies.

New-onset diabetes mellitus after heart transplantation in children - Incidence and risk factors

Diabetes mellitus is a recognized complication of SOT in adults and is associated with decreased graft and patient survival. Little is known about NOD in pediatric HT recipients. We aimed to characterize the incidence and describe risk factors for development of NOD after HT in children. Children who developed diabetes after HT were identified from the OPTN database. Demographic and clinical data before and after transplant were compared between patients with and without NOD. A total of 2056 children were included, 56% were male, 54% were Caucasian, and 62% had cardiomyopathy prior to HT. NOD developed in 219 children (11%) after HT. The incidence of NOD was 2.4, 9.0, and 10.4% at one, five, and 10 yr after HT, respectively. Obesity (HR: 4.32), dialysis prior to transplant (HR: 2.38), African American race (HR: 1.86), transplant before year 2000 (HR: 1.82), female gender (HR: 1.68), and older age at transplant (HR: 1.28) were independent predictors of NOD. The major modifiable risk factor for NOD is obesity, imparting the maximum hazard. Improved surveillance for diabetes in high-risk patients and specific prevention and intervention strategies are imperative in this population.

Dilated cardiomyopathy with cardiogenic shock in a child with Kearns-Sayre syndrome

Kearns-Sayre syndrome (KSS) is a mitochondrial myopathy resulting from mitochondrial DNA deletion. This syndrome primarily involves the central nervous system, eyes, skeletal muscles and the heart. The most well-known cardiac complications involve the conduction system; however, there have been case reports describing cardiomyopathy. We describe a case of a child with KSS who presented with decompensated cardiac failure from dilated cardiomyopathy representing cardiomyocyte involvement of KSS. Our patient had a rapidly progressing course, despite maximal medical management, requiring emergent institution of extracorporeal membrane oxygenation and transition to a ventricular assist device. To the best of our knowledge, this is the youngest patient in the literature to have dilated cardiomyopathy in KSS.

Epidemiology, Clinical Presentation, and Outcomes of Kawasaki Disease Among Hospitalized Children in an Inner City Hospital Before and After Publication of the American Academy of Pediatrics/American Heart Association Guidelines for Treatment of Kawasaki Disease: An 11-Year Period

The effect of 2004 Kawasaki disease (KD) guidelines on diagnosis and outcome of KD is lacking. We studied the epidemiology of KD in our region and compared the incidence, presentation, and outcome of KD before and after publication of the guidelines. A retrospective chart review was conducted for patients admitted with a diagnosis of KD. Demographics, laboratory data, and clinical data were collected. Comparison was made between 2 groups: prepublication (2000-2004) and postpublication (2005-2009) of guidelines. A total of 312 children were included; 64% were African American, 23% White, and 2% Asian; 61% were boys; 79% were complete KD, and 66% were in winter/spring. There was a significant increase in KD cases over the 11 years. There was no significant difference in clinical findings and outcome between the 2 groups. KD admissions in our region significantly increased during the postpublication period. There was no difference in clinical presentation, laboratory findings, or outcome between the 2 groups.

Strain and strain rate imaging using speckle tracking in acute allograft rejection in children with heart transplantation

Acute allograft rejection is a major cause of morbidity and mortality following heart transplantation. There is no reliable noninvasive test to diagnose rejection. We aimed to investigate the accuracy of strain by speckle tracking echocardiography in the detection of acute rejection. We identified acute rejection episodes in patients followed at a single transplant center. Data were collected at baseline, during rejection and two follow-up points. Peak systolic radial and circumferential strain at the level of papillary muscles and peak systolic longitudinal strain from apical four-chamber view were analyzed offline. ANOVA was used for comparison between groups. p value ≤0.05 was considered significant. Fifteen rejection episodes were identified. There were no differences in the fractional shortening, LV posterior wall thickness, E/A, septal E/E', septal S', lateral E/E', lateral S', or MPI during rejection, compared to baseline. There was a significant increase in the LV mass during a rejection episode (47.5 vs. 34.4 g/ht(2.7) [p = 0.03]). The peak systolic radial strain (18.3 vs. 26.5; p = 0.03), longitudinal strain (-11.7 vs. -14.6; p = 0.05), and circumferential strain (-14.4 vs. -21.7; p = 0.05) declined significantly during rejection. In conclusion, peak systolic radial, longitudinal and circumferential strain decline and LV mass increases during an episode of rejection.

Cytological Diagnosis of Primary Thyroid Tuberculosis

Primary thyroid tuberculosis is an extremely rare disease, even in countries where other forms of tuberculosis are abundant. TT has no age bar but usually affects women in fourth and fifth decade. Hereby, we report a case of 16-years-old girl presented with complaint of progressively increasing, painful thyroid swelling. Diagnosis of TT was made on cytology and there was no evidence of involvement of any other organ by tuberculosis. Despite of its rarity, TT is usually misdiagnosed. So, a clinician should always consider this entity in the differential diagnosis of thyroid swelling. Fine needle aspiration cytology is the best diagnostic method and can result in the avoidance of unnecessary thyroid surgeries.

Nutritional composition of ginger powder prepared using various drying methods

A study was undertaken to prepare ginger powder using various drying methods and their nutritional evaluation was carried out. Ginger (Zingiber officinale) was dried using shade, solar, oven and microwave drying methods. All the samples were ground in grinder to make fine powder. Sensory analysis indicated that acceptability of all types of ginger powders were in the range of 'liked very much' to 'liked moderately' by the panelists. The mean score obtained for colour was higher in shade dried ginger powder i.e., 8.20 as compared to oven dried (7.60), solar dried (7.70) and microwave dried ginger powder (7.80). Moisture content ranged from 3.55 % in solar dried ginger powder to 3.78 % in shade dried ginger powder. Slightly higher moisture content was found in shade dried ginger powder. Protein, crude fiber, fat and ash contents ranged from 5.02 to 5.82, 4.97 to 5.61, 0.76 to 0.90 and 3.38 to 3.66 %, respectively. β-carotene and ascorbic acid content was found maximum in shade dried ginger powder i.e., 0.81 mg/100 g and 3.83 mg/100 g, respectively. Polyphenol content was almost similar in all the samples whereas calcium was slightly higher in the shade dried ginger powder i.e., 69.21 mg/100 g. Results have shown that ginger powder prepared from various drying methods had good sensory and nutritional profile.

Relevance of opt-out screening for HIV in emergency and pre-surgery patients in a tertiary care center in Northern India: a pilot study

OBJECTIVE

A preliminary opt-out screening study for HIV was conducted in a tertiary care hospital in India according to Center for Disease Control (CDC) guidelines. A total of 876 cases were screened for HIV during August 2007 to December 2007 using tests approved by the National AIDS Control Organization (NACO).

RESULTS

Data indicates that the prevalence of HIV in emergency and pre-surgical setting was 21 per thousand at the tertiary care center. Positivity rate in the pediatric population was 20.9 per thousand while in adults it was 21.4 per thousand. Most patients were totally unsuspected. Nearly 40000 patients seek admission annually to the emergency department alone. Thus nearly 700 to 800 patients may be missed every year if one does not resort to such a practice.

CONCLUSION

Since India has the second largest number of HIV cases in the world, opt-out screening program and testing in an emergency setting, as recommended by CDC, is extremely relevant. Logistics of implementation of this policy need to be worked out at a national level.

High incidence of Epstein Barr virus infection in childhood acute lymphocytic leukemia: a preliminary study

INTRODUCTION

Epstein Barr virus (EBV) has a unique association with several human malignancies, especially lymphoproliferative disorders, mainly lymphomas in adults. There is paucity of data pertaining to EBV association with various cancers in India .

OBJECTIVE

The study aims to investigate the association of EBV in childhood leukemia.

MATERIAL AND METHODS

Patients attending pediatric oncology services of the referral center have been included in the study. Twenty-five consecutive pediatric patients with acute lymphocytic lukemia (ALL) were subjected to EBV studies employing sensitive polymerase chain reaction followed by hybridization for presence of Bam H1-W region of EBV genome and detection of anti Z EBV replication activator (ZEBRA) antibodies using Western blot. Positive control included a case of Burkitt's lymphoma and infectious mononucleosis each. Raji cells were used as positive control with each test.

RESULTS

The PCR for EBV was positive in 8/25 patients of ALL. Western blot test using anti ZEBRA antibodies was positive in 5/25(20%) cases of ALL. Considering PCR as the gold standard, 32% of the children with ALL had evidence of active EBV replication. The positive controls were consistently positive. None of the 30 healthy laboratory controls, 22 age matched disease controls, 12 cases of AML and 15 cases of multiple myeloma were positive either by PCR or Western blots assays (P < 0. 01). There was no statistically significant correlation between duration of therapy and EBV positivity (P > 0.05).

CONCLUSION

These studies indicate that a significant number of patients with ALL show evidence of active EBV replication.