Clinical and sociodemographic characteristics as predictors for quality of life in transmasculine and transfeminine individuals receiving gender-affirming hormone therapy

Healthcare systems and providers have increasingly acknowledged the role and impact of social determinants in overall health. However, gender-diverse individuals face persistent health disparities due to their identities. There is limited research on the impact of clinical and sociodemographic characteristics on mood and quality of life (QoL) for transgender (TG) individuals. Our study aims to understand and better elucidate social and clinical characteristics of transmasculine (TM) and transfeminine (TF) individuals and their impact on quality of life and depressive symptoms. In this cross-sectional study, 298 TF and TM individuals on gender-affirming hormone therapy (GAHT) were surveyed about their demographic characteristics (age, gender identity, body mass index (BMI), and education), social needs, mood, and quality of life. Multivariable regression modelling was performed to assess the effect of each variable listed above on three domains of QoL (psychological, environmental, and physical) as well as depressive symptoms. We find that QoL scores are similar between TM and TF individuals, with scores in the psychological domain particularly low in both cohorts. TM individuals report higher rates of stress and restroom avoidance than TF individuals. In particular, psychological well-being (measured by the psychological domain of QoL and depressive symptoms) is significantly associated with increased BMI, financial instability, and stress in TM individuals while for TF individuals, psychological well-being is associated with stress and social integration. These data suggest that social circumstances are key drivers of QoL and psychological well-being among gender-diverse individuals receiving GAHT with specific differences between TF and TM individuals. This information may be utilized by healthcare providers and policymakers to address and improve clinical care and social policies to improve health equity for gender-diverse individuals.

Fatal Allograft Rejection and Cardiac Allograft Vasculopathy After Treatment With Pembrolizumab for Metastatic Melanoma in a Heart Transplant Recipient: A Case Report

Checkpoint inhibitors decrease the progression of many cancers. However, the experience in immunosuppressed patients is limited, with reports of possible serious adverse events. We present a heart transplant recipient treated with pembrolizumab for metastatic melanoma who developed fatal rejection. The patient was a 29 year-old man who underwent heart transplantation at the age of 10 years for congenital heart disease. Seventeen years after transplant, he was diagnosed with scalp melanoma pT3a, N2a, M0, Stage IIIA, positive for BRAF V600E mutation treated with excision, which metastasized to his lungs and brain a year later. Dabrafenib and trametinib were started with transient response. Additional options and their risks were discussed, and pembrolizumab was started 4 months later due to the incomplete response to previous therapy. Five days after initiation the patient presented with moderate cellular rejection and possible antibody mediated rejection (ISHLT Grade 2R, pAMR 1H). Pembrolizumab was discontinued, and he was treated with steroids. Seven months later he presented in cardiogenic shock and severe coronary allograft vasculopathy. Biopsy was negative for cellular rejection, but suspicious for antibody mediated rejection (ISHLT Grade 0R, pAMR 1H), and he had a new serum alloantibody. Despite steroids and plasmapheresis he remained in refractory cardiogenic shock and died of cardiac arrest.

Multifocal Multisystem Langerhans Cell Histiocytosis in an Adult Female Atypically Presenting With Multiple Abdominopelvic Abscesses

Introduction: Langerhans Cell Histiocytosis (LCH) is a condition of malignant clonal proliferation of myeloid bone marrow cells that more commonly affects children than adults. Furthermore, its presentation remains variable ranging from single organ to multisystem involvement including bone, skin, lymph, liver, spleen, lung, and central nervous system. We report an unusual case of multisystem LCH in an adult female presenting with multiple soft tissue abscesses.

Case: We report a case of a 38-year-old female with a past medical history of polysubstance abuse, type 2 diabetes, polycystic ovarian syndrome, and isolated central diabetes insipidus who had multiple hospitalizations for recurrent soft tissue abscesses treated with incision and drainage and antibiotics. Imaging studies revealed multiple osteolytic lesions involving the bilateral iliac crests, acetabulum and femur, as well as an iliopsoas abscess. Given her prior history of isolated central diabetes insipidus, the possibility of LCH as the cause was entertained. Histological evaluation performed on an inguinal soft tissue sample stained positive for CD1a and S100, and a formal diagnosis of Langerhans Cell Histiocytosis (LCH) was made. The patient was treated with chemotherapy with good results.

Conclusion: This report presents a rare and unusual case of adult onset multisystem LCH involving bone, skin, lymph, and central nervous system presenting with recurrent large abdominopelvic abscesses. These abscesses may represent a rare and unrecognized form of soft tissue involvement of LCH.

Comatose within 6 weeks, but still alive after 3 years, Creutzfeldt-Jakob disease with unusual progression

Creutzfeldt-Jakob disease (CJD) should still be considered in a patient presenting with rapidly progressive dementia and negative CSF 14-3-3 protein and RT-QulC. Treatable causes of encephalopathy must be ruled out. Neurodegenerative diseases must also be considered.

Rigor prophylaxis in stage IV melanoma and renal cell carcinoma patients treated with high dose IL-2

BACKGROUND

Rigors are a significant adverse event during interleukin-2 (IL2) therapy for metastatic melanoma and renal cell carcinoma. Meperidine has been a mainstay for rigor prophylaxis but there is a paucity of data regarding possible alternatives.

METHODS

Ninety one patients receiving IL2 therapy for metastatic renal cell carcinoma and melanoma at Huntsman Cancer institute (HCI), Utah from May 2009 to October 2016 were retrospectively evaluated for rigor prophylaxis. Forty two patients received meperidine and 49 received tramadol. Rigors were tabulated using the proxy of number of doses of as needed (PRN) rigor medications and normalized by IL2 doses. Other outcomes of fever, hypotension, and renal insufficiency were noted on a binary scale and normalized by cycles. Statistical analysis was performed utilizing univariate and multivariate negative binomial models.

RESULTS

Ninety one patients were identified with metastatic melanoma or RCC who received high dose IL2 therapy. Forty two received meperidine and 49 received tramadol prophylaxis for rigors. Univariate negative binomial analysis shows incidence rate ratios (IRR): fever 0.41 (95% CI 0.28-0.62, p-value < 0.001), hypotension 1.7 (95% CI 1.11-2.61, p-value 0.015), renal insufficiency 0.58 (95% CI 0.35-0.98, p-value 0.041), rigors per all PRN meds 1.01 (95% CI 0.79-1.28, p-value 0.964), and rigors via opioid PRN meds 0.85 (95% CI 0.67-1.07, p-value 0.168). Multivariate negative binomial analysis shows IRR: fever 0.59 (95% CI 0.28-1.24, p-value 0.163), hypotension 0.93 (95% CI 0.43-2.03, p-value 0.864), renal insufficiency 1.1 (95% CI 0.52-2.32, p-value 0.807), rigors per al PRN meds 0.92 (95% CI 0.67-1.26, p-value 0.604), and rigors via opioid PRN 0.9 (95% CI 0.65-1.26, p-value 0.554).

CONCLUSION

Univariate models indicated meperidine pre-treatment was associated with significantly lower rates of fever and renal insufficiency whereas tramadol was associated with significantly lower rate of hypotension. However, when controlled for demographics and other treatment differences, these differences were no longer significant.

Salvage treatment for locally recurrent nasopharyngeal carcinoma (NPC)

BACKGROUND

It is important to determine the outcomes of retreatment in patients with locally recurrent nasopharyngeal carcinoma.

METHODS

We reviewed the records of patients treated for local recurrence at Stanford and Shantou Universities. The end points were local relapse-free survival (LRFS) and overall survival after retreatment.

RESULTS

Fifty-six patients from Stanford and 98 from Shantou qualified. For the Stanford patients, 33 had surgery alone (S group), 12 had surgery plus radiotherapy±chemotherapy (CMT group), and 22 had radiotherapy±chemotherapy (RT Stanford group). All Shantou patients received radiotherapy±chemotherapy (RT Shantou group). The 5-year LRFS rates were: 57% for S group, 25% for CMT group, 53% for RT Stanford group, and 41% for RT Shantou group (P>0.05) for rT1-2 tumors; they were 29% for S group, 25% for CMT group, 39% for RT Stanford group, and 9% for RT Shantou group for rT3-4 tumors (P>0.05). For RT patients, 5-year overall survival rates were 49% for Stanford and 25% for Shantou patients (P=0.026).

CONCLUSIONS

Similar and durable LRFS rates were attained for both S and RT groups when stratified by rT-stage.

Human papillomavirus 16 detected in nasopharyngeal carcinomas in white Americans but not in endemic Southern Chinese patients

BACKGROUND

We evaluated the relationship of human papillomavirus (HPV) and Epstein-Barr virus (EBV) with race in endemic and nonendemic cohorts of patients with nasopharyngeal carcinoma (NPC), and with smoking status in the nonendemic cohort.

METHODS

Tissue microarrays (TMAs) were constructed using samples from 86 patients treated in southern China and 108 patients from Stanford, California. TMAs were stained with p16, HPV in situ hybridization (ISH), and EBV ISH. Polymerase chain reaction (PCR) was used to confirm EBV(-) cases and HPV status in p16(+) cases. Survival data was available for the Stanford cohort only.

RESULTS

No HPV(+) cases were detected in the Chinese cohort. In the Stanford cohort, 5 of 11 EBV(-) cases harbored HPV-16, 10 of 10 occurred in whites, and 8 of 11 were smokers. Patients with EBV(-) NPC also showed a trend toward worse survival.

CONCLUSION

EBV(-) NPC shows an association with the presence of HPV, white race, and smoking. In contrast, EBV(-) NPC shows no association with HPV in the endemic cohort.

A novel aldehyde dehydrogenase-3 activator leads to adult salivary stem cell enrichment in vivo

PURPOSE

To assess aldehyde dehydrogenase (ALDH) expression in adult human and murine submandibular gland (SMG) stem cells and to determine the effect of ALDH3 activation in SMG stem cell enrichment.

EXPERIMENTAL DESIGN

Adult human and murine SMG stem cells were selected by cell surface markers (CD34 for human and c-Kit for mouse) and characterized for various other stem cell surface markers by flow cytometry and ALDH isozymes expression by quantitative reverse transcriptase PCR. Sphere formation and bromodeoxyuridine (BrdUrd) incorporation assays were used on selected cells to confirm their renewal capacity and three-dimensional (3D) collagen matrix culture was applied to observe differentiation. To determine whether ALDH3 activation would increase stem cell yield, adult mice were infused with a novel ALDH3 activator (Alda-89) or with vehicle followed by quantification of c-Kit(+)/CD90(+) SMG stem cells and BrdUrd(+) salispheres.

RESULTS

More than 99% of CD34(+) huSMG stem cells stained positive for c-Kit, CD90 and 70% colocalized with CD44, Nestin. Similarly, 73.8% c-Kit(+) mSMG stem cells colocalized with Sca-1, whereas 80.7% with CD90. Functionally, these cells formed BrdUrd(+) salispheres, which differentiated into acinar- and ductal-like structures when cultured in 3D collagen. Both adult human and murine SMG stem cells showed higher expression of ALDH3 than in their non-stem cells and 84% of these cells have measurable ALDH1 activity. Alda-89 infusion in adult mice significantly increased c-Kit(+)/CD90(+) SMG population and BrdUrd(+) sphere formation compared with control.

CONCLUSION

This is the first study to characterize expression of different ALDH isozymes in SMG stem cells. In vivo activation of ALDH3 can increase SMG stem cell yield, thus providing a novel means for SMG stem cell enrichment for future stem cell therapy.

Quantitation of human papillomavirus DNA in plasma of oropharyngeal carcinoma patients

PURPOSE

To determine whether human papillomavirus (HPV) DNA can be detected in the plasma of patients with HPV-positive oropharyngeal carcinoma (OPC) and to monitor its temporal change during radiotherapy.

METHODS AND MATERIALS

We used polymerase chain reaction to detect HPV DNA in the culture media of HPV-positive SCC90 and VU147T cells and the plasma of SCC90 and HeLa tumor-bearing mice, non-tumor-bearing controls, and those with HPV-negative tumors. We used real-time quantitative polymerase chain reaction to quantify the plasma HPV DNA in 40 HPV-positive OPC, 24 HPV-negative head-and-neck cancer patients and 10 non-cancer volunteers. The tumor HPV status was confirmed by p16(INK4a) staining and HPV16/18 polymerase chain reaction or HPV in situ hybridization. A total of 14 patients had serial plasma samples for HPV DNA quantification during radiotherapy.

RESULTS

HPV DNA was detectable in the plasma samples of SCC90- and HeLa-bearing mice but not in the controls. It was detected in 65% of the pretreatment plasma samples from HPV-positive OPC patients using E6/7 quantitative polymerase chain reaction. None of the HPV-negative head-and-neck cancer patients or non-cancer controls had detectable HPV DNA. The pretreatment plasma HPV DNA copy number correlated significantly with the nodal metabolic tumor volume (assessed using (18)F-deoxyglucose positron emission tomography). The serial measurements in 14 patients showed a rapid decline in HPV DNA that had become undetectable at radiotherapy completion. In 3 patients, the HPV DNA level had increased to a discernable level at metastasis.

CONCLUSIONS

Xenograft studies indicated that plasma HPV DNA is released from HPV-positive tumors. Circulating HPV DNA was detectable in most HPV-positive OPC patients. Thus, plasma HPV DNA might be a valuable tool for identifying relapse.

Reversal of paraparesis after thoracic aneurysm repair by cerebrospinal fluid drainage

PURPOSE

To describe a case of reversal of delayed paraparesis, after an elective type I thoracoabdominal aortic aneurysm (TAAA) repair, via cerebrospinal fluid (CSF) drainage.

CLINICAL FEATURES

A 75-yr-old woman developed paraparesis 13 hr after type I TAAA repair. The patient had been given combined regional and general anesthesia. There was no cerebrospinal fluid drain inserted at the time of surgery. The patient was hemodynamically stable throughout the procedure and was transported to the intensive care unit with trachea intubated and lungs ventilated. She demonstrated some initial lower limb paraparesis but had good recovery of limb function three hours after cessation of the epidural infusion. However, five hours and forty-five minutes after stopping the epidural, she was again paraparetic. Peripheral nerve injury, prolonged effects of epidural local anesthetic, and epidural hematoma were ruled out as precipitating factors. Cord ischemia was considered possible and a CSF catheter was inserted. Immediate improvement was seen upon catheter insertion and commencement of drainage, beginning with movement in the left toes and foot. Drainage was performed when the CFS pressure became > 15 mmHg. Motor function in the lower limbs continued to improve with each drainage extending to complete recovery after 40 hr. She was discharged home 11 days after surgery with no neurological deficit.

CONCLUSION

Drainage of CSF was useful in treating a case of post-TAAA neurologic deficit.