Challenges in utilizing ALK expression to distinguish primary cutaneous from systemic anaplastic large cell lymphoma

Anaplastic large cell lymphoma (ALCL) is a CD30+ peripheral T-cell lymphoma with a clinical spectrum including cutaneous and systemic presentations. While primary cutaneous ALCL (pcALCL) has a favorable prognosis, systemic ALCL (sALCL) has poorer survival outcomes. Expression of anaplastic lymphoma kinase (ALK) by malignant cells has been suggested to distinguish sALCL from pcALCL. However, there have been documented cases of ALK-positive ALCL confined to the skin. The present study reviewed characteristics of published cutaneous ALK-positive ALCL cases to distinguish between these two entities. In 23 identified adults with ALK-positive pcALCL, 26% developed systemic involvement and 74% had skin-limited disease. In 14 pediatric patients, 36% had both cutaneous and systemic involvement and 64% had cutaneous disease only. This analysis revealed that pcALCL and sALCL could not reliably be distinguished by ALK expression or nuclear vs. cytoplasmic localization. Localized treatment with frequent monitoring may be sufficient in ALK-positive pcALCL until there is evidence of progression. Physicians should be aware of the overall spectrum of ALCL, including cutaneous limited disease, systemic disease, disease with NPM-ALK translocation, disease with ALK positivity and disease with skin recurrence.

Multidisciplinary atopic dermatitis program: A novel approach to managing difficult-to-control atopic dermatitis patients

BACKGROUND/OBJECTIVES

Disease improvement for difficult-to-control pediatric atopic dermatitis may be more challenging to achieve when directed by single specialties due to disjointed and conflicting dialogue with patients.

METHODS

The Multidisciplinary Atopic Dermatitis Program (MADP) was developed through collaborations with the Rady Children's Hospital and UC San Diego Health Divisions of Dermatology, Allergy & Immunology and Clinical Pharmacy, to create team-based evaluation and management of children and adolescents with atopic dermatitis (AD). The MADP allows concurrent, comprehensive evaluations by multiple specialists to develop treatment plans. The program includes extensive patient education to support shared decision making, incorporating patient and family's perspectives along with those of clinical experts into their care. Objective severity measures and patient reported outcome data were collected, along with assessment of patient and family satisfaction with the MADP.

RESULTS

Data showed significant improvement in AD severity as assessed by providers, patients and families by the first follow-up visit. BSA mean percentage decreased by up to 56% by the 7th visit, and pruritus (NRS), CLDQI and POEM mean scores decreased by more than 4 points, 12 points, and over 11 points, respectively. After management was initiated in the MADP, 72.73% of patients achieved an EASI 50 and 47.73% achieved an EASI 75 from a baseline mean of 21.7. Patients who continued in clinic beyond the second visit showed further clinically significant decreases in disease measures.

CONCLUSIONS

The multidisciplinary approach shows success in the treatment of difficult-to-control AD patients with improvements in clinician and patient reported outcome measures.

Immunosequencing applications in cutaneous T-cell lymphoma

Immunosequencing has emerged as a newer clinical test for assessment of T-cell clonality in the blood and skin of cutaneous T-cell lymphoma (CTCL) patients. Utilization of immunosequencing, also known as high-throughput sequencing of the T-cell receptor (HTS-TCR), enables identification and quantification of the precise genetic signature of dominant T-cell clones. Although immunosequencing is more sensitive than commonly used methods such as polymerase chain reaction (PCR) paired with capillary electrophoresis or flow cytometry, it remains underutilized for CTCL management. Nonetheless, incorporation of HTS-TCR in clinical practice offers distinct advantages compared to other molecular analyses that may improve diagnostic evaluation, prognostication, and disease monitoring in CTCL. The objective of this comprehensive review is to provide a thorough explanation of the application of immunosequencing in the context of CTCL. We describe the significance of T-cell clonality and the methods used to detect it, including a detailed comparison between PCR paired with capillary electrophoresis and HTS-TCR. The utilization of immunosequencing in the blood and skin of CTCL patients is discussed in depth, specifically outlining how HTS-TCR can assist in diagnosing CTCL, predicting outcomes, and tracking disease progression. Finally, we address the potential applications of immunosequencing in clinical management and research as well as the novel challenges it presents.

Utility of T-cell immunosequencing in distinguishing mycosis fungoides progression from treatment related cutaneous adverse events

Cutaneous adverse events of both topical and systemic drugs in patients with mycosis fungoides (MF) present a diagnostic challenge as it is often difficult to distinguish drug associated rash from disease progression in the skin. Mogamulizumab and mechlorethamine gel are approved treatments for MF, both of which can cause treatment related cutaneous adverse events. It can often be challenging to distinguish mogamulizumab associated rash (MAR) and mechlorethamine gel associated hypersensitivity dermatitis from MF progression both clinically and histologically. High-throughput sequencing (HTS) of the T-cell receptor (TCR), also known as immunosequencing, can be used to assess T-cell clonality to support a diagnosis of MF. After identification of the malignant TCR clone at baseline, immunosequencing can track the established malignant TCR sequence and its frequency over time with high sensitivity. As a result, immunosequencing clone tracking can aid in distinguishing disease progression from treatment side effects. Here, we present a case series to demonstrate how monitoring of the malignant T-cell frequency by immunosequencing can aid in diagnosis of mogamulizumab and mechlorethamine gel cutaneous adverse events.

Anaplastic Large Cell Transformation of Mycosis Fungoides: Case Report and Review of the Literature

ABSTRACT

We report a 48-year-old man with CD30+ large cell transformation of mycosis fungoides (tMF) with distinctive anaplastic morphology. The patient initially presented with folliculotropic and syringotropic mycosis fungoides (MF) manifested as occipital scalp plaque and trunk and extremities patches. Six years later, he progressed to the tumor stage from his scalp lesion and developed cervical lymphadenopathy. Lymph node and scalp biopsies showed diffuse infiltration of CD30+ anaplastic cells with multinucleated, hallmark-like, Hodgkin-Reed-Sternberg-like, histiocytoid forms, indistinguishable from anaplastic large cell lymphoma (ALCL). T-cell receptor gamma gene (TCRg) rearrangement studies revealed identical clones in the initial MF scalp lesion and nodal anaplastic lesion, confirming the transformation. Ancillary studies showed absence of IRF4/DUSP22 and ALK rearrangements and positive RB1, SMARCA4, SOCS1, and TP53 mutations. The patient achieved partial response with systemic chemotherapy. Our case is an example of tMF presenting as the morphology and phenotype of ALCL. Because clinical behavior and therapeutic options of tMF and primary cutaneous ALCL may be different, it is clinically relevant to differentiate these 2 entities. The proof of clonal relationship may be useful in diagnostically challenging cases with features overlapping between tMF and primary cutaneous ALCL.

Does the visceral fat area impact the histopathology specimen metrics after total mesorectal excision for distal rectal cancer?

BACKGROUND

The aim of this study was to evaluate whether the visceral fat area (VFA) has an impact on the histopathology specimen metrics of male patients undergoing robotic total mesorectal resection (rTME) for distal rectal cancer.

METHODS

Prospectively collected data of patients undergoing rTME for resectable rectal cancer by five surgeons during a period of three years were extracted from the REgistry of Robotic SURgery for RECTal cancer (RESURRECT). VFA was measured in all patients at preoperative computed tomography. Distal rectal cancer was defined as <6cm from the anal verge. The histopathology metrics included circumferential resection margin (CRM) (in mm) and its involvement rate (if <1mm), distal resection margin (DRM), and quality of TME (complete, nearly-complete, incomplete).

RESULTS

Of 839 patients who underwent rTME, 500 with distal rectal cancer were included. One hundred and six (21.2%) males with VFA>100cm² were compared to 394 (78.8%) males or females with VFA≤100cm². The mean CRM of males with VFA>100cm² was not significantly different from its counterpart (6.6 ± 4.8 mm versus 7.1 ± 9.5mm; p=0.752). CRM involvement rates were 7.6% in both groups (p=1.000). The DRM was not significantly different: 1.8±1.9cm versus 1.8±2.6cm; p=0.996. The quality of TME did not significantly differ: complete TME 87.3% vs. 83.7%; nearly complete TME 8.9% vs. 12.8%; incomplete TME 3.8% vs. 3.6%. Complications and clinical outcomes did not significantly differ.

CONCLUSION

This study did not find evidence to support that increased VFA would result in suboptimal histopathology specimen metrics when performing rTME in males with distal rectal cancer.

Recalcitrant Cutaneous Mastocytosis Treated With Genetically Informed Targeted Therapy: A Case Report

Mastocytosis, a clonal proliferation of mast cells commonly involving the skin and bone marrow, has a varied clinical presentation ranging from cutaneous lesions to systemic disease. Cutaneous mastocytosis is managed symptomatically, but systemic mastocytosis is treated with targeted therapy against the mutated receptor tyrosine kinase c-KIT, the pathogenic driver of mastocytosis. However, there are no guidelines for the treatment of cutaneous mastocytosis refractory to symptomatic management. We herein report a method to select genetically informed therapy for symptomatic and recalcitrant cutaneous mastocytosis.

Case presentation

We performed a mutational analysis of dermal mast cells after enrichment by laser capture in a 23-year-old woman with recalcitrant cutaneous mastocytosis. The analysis revealed a aspartic acid to valine substitution at codon 816 (D816V) mutation in the protein c-KIT. Based on these results, we initiated treatment with the multi-kinase/KIT inhibitor midostaurin, a treatment effective against the D816V c-KIT mutation. After 3 months of treatment, the patient exhibited a reduction in the number and size of cutaneous lesions and reported resolution of pruritus and decreased severity of other mast cell-related symptoms.

Discussion

The treatment of mastocytosis relies heavily on whether the disease is limited to the skin or systemic. However, there are no guidelines for cutaneous mastocytosis that does not respond to symptomatic management. In the present report describing a patient with recalcitrant cutaneous mastocytosis, we describe a strategy in which skin mutational analysis is used to guide the selection of targeted therapy.

Conclusion

Performing mast cell mutational analyses in the skin provides a means to select targeted therapy for symptomatic and refractory cutaneous mastocytosis.

The gut-brain axis: effect of antibiotics on canine drug-resistant idiopathic epilepsy

Approximately thirty percent of the dogs with idiopathic epilepsy develop multidrug resistance. Therefore, the search for new non-drug treatment alternatives is important. There is a growing interest in the gut-brain axis and its role in the pathogenesis of epilepsy. The gut microbiota can influence brain function by different neural, endocrine, immune and metabolic pathways, but this process is not yet fully understood. In this study, five client-owned dogs with drug-resistant, idiopathic epilepsy received amoxicillin-clavulanic acid as add-on orally (mean duration 32 days (range 21-64 days)). The mean isolated epileptic seizure frequency of these five dogs was 3.3/ week (range 2.5-6.5) with a mean cluster seizure frequency of 0.9/week (range 0.4-1.5). During the amoxicillin-clavulanic acid treatment, three dogs showed complete seizure freedom, one dog showed an 80% decrease of both isolated epileptic seizure and cluster seizure frequency, and one dog showed an increase in isolated epileptic seizure and cluster seizure frequency of 54% and 38%, respectively. In the two-month follow-up period after cessation of the antibiotic administration, the mean isolated epileptic seizure and cluster seizure frequency increased again to 1.5 seizures/week (range 0.9-2.8) and 0.4 clusters/week (range 0.4-0.6), respectively. The preliminary results in this study highlight the need for future research into the role of the canine gut-brain axis in idiopathic epilepsy.

Recalcitrant Subcutaneous Panniculitis-Like T-Cell Lymphoma Responsive to Histone Deacetylase Inhibitor

Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) is a rare subtype of cutaneous T-cell lymphoma that usually presents with tender subcutaneous nodules on the trunk and extremities. Immunosuppressive therapy is considered first-line treatment for SPTCL, while multiagent chemotherapy is used for SPTCL complicated by hemophagocytic lymphohistiocytosis (HLH). Here, we report a 42-year-old Hispanic man that presented with a 5-year history of recurrent painful subcutaneous lesions in the absence of constitutional symptoms, lymphadenopathy, and hepatosplenomegaly. A punch biopsy revealed an atypical lymphoid infiltrate in between subcutaneous adipose lobules. Lymphocytes expressed CD3, CD8, and Beta F-1 and did not express CD4 and CD56. Based on clinical and histologic findings, the patient was diagnosed with SPTCL. In addition, laboratory findings did not demonstrate any evidence of HLH. He was initially started on both prednisone and hydroxychloroquine with no improvement. A trial of cyclosporine and methotrexate yielded no clinical improvement. As the lesions failed to resolve after treatment with multiple immunosuppressive agents, romidepsin, an intravenous histone deacetylase (HDAC) inhibitor, was initiated. After two cycles of romidepsin, the patient achieved complete clinical response. He continues to be in remission 12 months later with monthly maintenance therapy. This case illustrates that romidepsin can be useful as monotherapy for refractory SPTCL without HLH.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

The role of cardiovascular magnetic resonance imaging with T1 and T2 mapping in sudden cardiac death survivors

Background

Sudden cardiac death (SCD) in the adult population is poorly studied, although determining its etiology is crucial for management and prognosis [1]. Cardiovascular magnetic resonance imaging (CMR) is being increasingly utilized in SCD survivors [1,2]. The role of late gadolinium enhancement (LGE) imaging in patients with recent SCD and no significant coronary artery disease (CAD) is well established, but there is no data on the additive role of T1 and T2 mapping [1–3].

Purpose

This is a retrospective study to assess the role of CMR including T1 and T2 mapping in SCD survivors.

Methods

Between 01/2016 and 12/2019, we retrospectively analyzed patients who underwent CMR on a Siemens Magnetom Avanto 1.5 T scanner within 4 weeks of SCD. CMR protocol included cine imaging, T1 and T2 mapping, and LGE imaging. Native and post-contrast myocardial T1 values were measured within the septum on the mid short axis (SAX) and extracellular volume fraction was calculated using the standard formula. T2 values were measured in six mid segments on the mid SAX map. Additional measurements were performed if long axis T2 maps were available. Clinical data, electrocardiography (ECG), transthoracic echocardiography (TTE), coronary computed tomography angiography (CCTA), and left heart catheterization (LHC) were reviewed from the electronic health record. An ischemic evaluation was performed in 33 (94%) of patients.

Results

A total of 35 patients who underwent CMR for SCD were included for analysis (mean age 46.9±14.1 years; 20 (57%) male). SCD etiology was established based on clinical data, ECG, TTE, CCTA, and LHC in 9 (26%) patients. CMR provided the most probable SCD etiology in an additional 20 (57%) patients with T1 and T2 mapping abnormalities seen in 18 (51%) patients. Diagnoses determined by CMR included myocarditis (35%), hypertrophic cardiomyopathy (CMP) (20%), left ventricular non-compaction CMP (15%), dilated CMP (10%), takotsubo CMP (5%), and myocardial infarction with non-obstructive CAD (15%) (Table, Figure). Elevated native T1 was seen in 15 (43%) (mean T1 1069±60 ms; site specific normal &lt;1080 ms), elevated ECV in 16 (46%) (30±7%; site specific normal &lt;29%), and elevated native T2 in 22 (63%) patients (65±10 ms; site specific normal &lt;60 ms). LGE was present in 31 (89%) patients. The etiology of SCD remained unknown in 6 (17%) patients despite extensive testing including CMR.

Conclusions

CMR has significant diagnostic and prognostic value in assessing SCD etiology compared to non-CMR based evaluation. Myocarditis is a common underdiagnosed cause of SCD in adult patients well seen in a CMR protocol with T1 and T2 mapping. Myocardial inflammation monitoring in SCD survivors with serial CMRs using T1 and T2 mapping could influence clinical decision making by justifying pharmacotherapy modification and timing of ICD implantation. To conclude, CMR with T1 and T2 mapping provides high diagnostic yield in the investigation of SCD etiology.

Funding Acknowledgement

Type of funding sources: None.

Update on pediatric atopic dermatitis

Recent studies have led to new insights into atopic dermatitis (AD) pathogenesis and epidemiology as well as its impact on the quality of life of affected children and adolescents. In addition, there are several novel topical and systemic agents recently approved and in late-stage clinical development programs. Epidemiologic insights include relative prevalence rates in different countries and studies of subsets of pediatric patients with different disease longevity and persistence. Studies on quality of life have shown tremendous impact on sleep, not only in affected individuals but in their parents/guardians. The impact of bathing regimens is discussed. Newer topical therapies are reviewed, including topical crisaborole, with a new indication for infants as young as 3 months of age. Topical Janus kinase (JAK) inhibitors are being developed, with some studies including adolescents and children. Other novel therapies include the topical aryl hydrocarbon receptor agonist tapinarof and oral JAK inhibitors; adolescents are being included in the initial clinical trials for several of these therapies. Dupilumab, the first biologic agent approved for AD, has now been well studied in patients aged 6 years and older, with expanded indication down to 6 years of age.

Rapid cardiovascular magnetic resonance protocol utilizing compressed sensing real-time imaging during the COVID-19 pandemic

Funding Acknowledgements

Type of funding sources: None.

Background

Coronavirus Disease 2019 (COVID-19) poses many workflow challenges for healthcare systems. Elective cardiovascular magnetic resonance (CMR) exams were postponed until safety protocols were instituted. Since reopening, imaging labs are managing COVID-19 safety triaging, exam backlog, and increased referrals, thus innovative solutions for process improvement are needed.

Purpose

An accelerated compressed sensing (CS) real-time (RT) technique offers dynamic cardiac imaging with high spatial and temporal resolution without image degradation. We sought to evaluate the efficiency of a rapid RT CMR protocol with a goal to decrease scan time without compromising study quality and comprehensiveness.

Methods

We retrospectively evaluated 219 CMRs (Siemens Magnetom Sola 1.5T) performed 09/01/2020 - 10/15/2020. After excluding 81 exams due to heterogeneous protocols (Figure 1), we analyzed 138 CMR exams using standard cardiomyopathy or myocarditis protocols. CMR studies utilized either a rapid RT short axis (SAX) cine (spatial resolution of 2.5 mm2 or better and temporal resolution of 55 ms or better) or standard breath-held (BH) SAX cine protocol (Figure 2).  Protocols were chosen by the interpreting physician. Previous internal quality control demonstrated similar volumetric quantification between RT and BH SAX cines. RT cines were reconstructed inline using a CS-based method.  We analyzed the length of time needed to complete each protocol and the number of series performed. Statistical analysis included student t-test with p value &lt;0.05 considered significant.

Results

Of 138 analyzed CMR exams, there were 23 rapid protocols and 115 standard protocols performed. The mean image acquisition time for the rapid protocol was significantly shorter at 26 ± 6 minutes (range 18-44 min) vs 33 ± 6 minutes (range 22-49 min) for the standard protocol, p &lt; 0.001. This represents a mean relative reduction in scan time of 21%. More time was saved in rapid myocarditis (scan time 25 ± 6 min vs 34 ± 6 min, p = 0.01; relative time reduction 26%) vs rapid cardiomyopathy protocols (scan time 27 ± 6 min vs 31 ± 6 min, p = 0.04; relative time reduction 13%). There was no significant difference in the number of series performed (62 ± 14 series in rapid vs 67 ± 11 series in standard protocols, p = 0.09).  T1 and T2 maps constituted the same percentage of acquired images regardless of protocol used (T1 maps 1.8% vs 1.7% for cardiomyopathy, 1.4% vs 1.4% for myocarditis in standard vs rapid protocols respectively; T2 maps 1.8% vs 1.7% for cardiomyopathy, 5.6% vs 5.8% for myocarditis in standard vs rapid protocols respectively).

Conclusions

A rapid CMR protocol utilizing a CS-based RT imaging is significantly shorter as compared to the standard protocol with adequate diagnostic quality. Rapid CMR protocols are an effective tool for process improvement during the COVID-19 pandemic.

Genetic insights in canine degenerative myelopathy

Canine degenerative myelopathy (DM) is a late-onset, progressive, neurodegenerative disorder with a fatal outcome, occurring in a vast number of dog breeds. Most dogs are at least eight years of age when they begin to show clinical signs, starting with general proprioceptive ataxia in the hind limbs and upper motor neuron paraparesis, evolving to lower motor neuron tetraplegia and brain stem signs. A definitive diagnosis can only be made postmortem by the histopathological observation of neuronal degradation and demyelination of the spinal cord. Most DM-affected dogs are homozygous for one of the known superoxide dismutase 1 gene (SOD1) mutations (ENSCAFT00000065394.1:c.82G>A, first described as NM_001003035.1:c.118G>A). A second mutation (NM_001003035.1:c.52A>T) in the same gene has been found but occurs only in Bernese mountain dogs. Not every homozygous dog develops the disease; this indicates that the disease is incompletely penetrant and that modifier loci might be present. In this review, the authors aim to give an overview of the disease progression and the current genetic knowledge of DM, which is of paramount importance for the correct diagnosis and to help reduce the disease incidence.

Sole prednisolone therapy in canine meningoencephalitis of unknown etiology

Meningoencephalitis of unknown etiology (MUE) is a frequently diagnosed and often fatal disease in veterinary neurology. The aim of this retrospective study was to assess the efficacy of three different sole prednisolone treatment schedules in dogs diagnosed with MUE. The dogs were diagnosed clinically with MUE based on previously described inclusion criteria, and treated with a three-, eight- or eighteen-week-tapering prednisolone schedule. Thirty eight dogs were included in the study. Seventeen, fifteen and six dogs received the three-, eight- and eighteen-week tapering schedule, respectively. Overall, 37% of the dogs died or were euthanized because of MUE, and a significant difference in survival time was seen between the three treatment schedules. Surprisingly, the highest number of dogs that died because of MUE was seen in the eightweek treatment schedule (56%), followed by the three-week (26%) and eighteen-week (0%) treatment schedule. Based on the results of this study, no definitive conclusions can be drawn regarding the ideal prednisolone dosing protocol for dogs diagnosed with MUE. However, a more aggressive and immunosuppressive treatment protocol might lead to a better outcome.

Complicaties na marsupialisatie van een arachnoïd diverticulum bij een rottweiler

Een jonge, mannelijke rottweiler werd aangeboden met neurologische symptomen die sinds zijn geboorte aanwezig waren. De hond vertoonde hypermetrie op de voorhand, ataxie op de achterhand en zijn proprioceptie was achteraan duidelijk vertraagd. Computertomografisch onderzoek na myelografie en een MRI-onderzoek toonden een lang dorsaal subarachnoïdaal diverticulum aan, dat zich uitbreidde van craniaal C2 tot craniaal C5. Dit diverticulum veroorzaakte een ruggenmergcompressie, die de neurologische symptomen verklaarde. De hond werd geopereerd via een cervicale dorsale laminectomie, gevolgd door durotomie en marsupialisatie. Postoperatief waren er complicaties, waardoor de hond opnieuw geopereerd moest worden. Hierna was nog een vijftal dagen mechanische ventilatie nodig, waarna de hond weer zelfstandig kon ademen. De neurologische toestand van de hond verbeterde postoperatief geleidelijk. Hij herstelde volledig en deed het elf maanden postoperatief nog altijd goed.

Low-Field Magnetic Resonance Imaging and Multislice Computed Tomography for the Detection of Cervical Syringomyelia in Dogs

BACKGROUND

Syringomyelia (SM) is defined as the presence of fluid-containing cavities within the parenchyma of the spinal cord. Sagittal magnetic resonance (MR) images have been described as the preferred technique for visualizing SM in dogs and humans.

OBJECTIVE

To investigate whether computed tomography (CT) can be used to diagnose SM.

ANIMALS

Thirty-two client-owned dogs referred for investigation of the cervical spine on magnetic resonance imaging (MRI) and CT.

METHODS

Two reviewers retrospectively analyzed sagittal and transverse T1-weighted spin echo (T1WSE) MR images and CT images from each dog for the presence of SM and, if SM was present, the width (mm, syrinx width [SW]) was measured. The results were analyzed statistically.

RESULTS

For the presence of SM there was a moderate interobserver agreement for MR (81%, κ = 0.54) and almost perfect agreement for CT (94%, κ = 0.87). There was a moderate intramodality agreement for both observers (observer 1 81%, κ = 0.59; observer 2 81%, κ = 0.57). For measurement of SW the repeatability was the best on the midsagittal T1WSE images (95% repeatability coefficient <0.52 mm) and the reproducibility was the best on midsagittal images in both modalities (95% limits of agreement -0.55-0.45; P = 0.002).

CONCLUSION AND CLINICAL IMPORTANCE

Both techniques can be used to detect SM. Midsagittal MR and CT images are best used for measuring SW. Computed tomography can be used as a diagnostic tool for SM when MRI is not available, but CT cannot replace MRI as the standard screening technique for the detection of SM in Cavalier King Charles Spaniel for breeding purposes.

Diffuse idiopathic skeletal hyperostosis of the spine in a nine-year-old cat

A nine-year-old intact female domestic shorthair cat was evaluated for paraparesis, ataxia and severe spinal hyperaesthesia. Neurological examination indicated a T3-L3 spinal cord segment lesion. Computed tomography of the thoracolumbar and lumbosacral vertebral column was performed. This showed contiguous smooth new bone formation ventral and lateral to the vertebrae extending from the cranial thoracic area to the lumbosacral junction and appearing similar to canine diffuse idiopathic skeletal hyperostosis. There was also marked dorsolateral stenosis of the vertebral canal at the level of T4-T5 because of degenerative changes of the facet joints. To the authors' knowledge, this is the first published report of feline diffuse idiopathic skeletal hyperostosis.

Low-field MRI and multislice CT for the detection of cerebellar (foramen magnum) herniation in Cavalier King Charles Spaniels

Background

Cavalier King Charles Spaniels (CKCS) have a high prevalence of Chiari‐like malformation (CM). Herniation of the cerebellum into the foramen magnum is a key diagnostic feature for CM. Midsagittal MR images are the preferred technique for visualizing cerebellar herniation (CH).

Objective

To investigate whether CT can be used to diagnose CH.

Animals

Fifteen client‐owned CKCS dogs referred for investigation of the brain and cranial cervical spine on MRI and CT.

Methods

Two reviewers retrospectively analyzed midsagittal T1WSE and T2WSE MR images and midsagittal pre‐ and postcontrast 2D multiplanar reformatted CT images from each dog for the presence of CH. And, if present, the length (mm, CHL) of the herniation was measured. The results were analyzed statistically.

Results

There was no significant difference between the different observers and techniques for the detection of CH and measurement of CHL. Overall, the CHL was longer on the CT images.

Conclusion and Clinical Importance

Both techniques are useful for detecting CH and measuring CHL. Because CHL does not have a known direct impact on the clinical presentation of CM, CT can be used as a diagnostic tool in a routine clinical practice for CM in CKCS when MRI is not available. We emphasize that MRI is the standard screening technique in CKCS for breeding purposes to detect the presence of CM and SM and, at the current time, CT cannot replace MRI.

Wnt and SHH in prostate cancer: trouble mongers occupy the TRAIL towards apoptosis

Prostate cancer is a serious molecular disorder that arises because of reduction in tumour suppressors and overexpression of oncogenes. The malignant cells survive within the context of a three-dimensional microenvironment in which they are exposed to mechanical and physical cues. These signals are, nonetheless, deregulated through perturbations to mechanotransduction, from the nanoscale level to the tissue level. Increasingly sophisticated interpretations have uncovered significant contributions of signal transduction cascades in governing prostate cancer progression. To dismantle the major determinants that lie beneath disruption of spatiotemporal patterns of activity, crosstalk between various signalling cascades and their opposing and promoting effects on TRAIL-mediated activities cannot be ruled out. It is important to focus on that molecular multiplicity of cancer cells, various phenotypes reflecting expression of a variety of target oncogenes, reversible to irreversible, exclusive, overlapping or linked, coexist and compete with each other. Comprehensive investigations into TRAIL-mediated mitochondrial dynamics will remain a worthwhile area for underlining causes of tumourigenesis and for unravelling interference options.

Clinical and electrophysiological characterization of myokymia and neuromyotonia in Jack Russell Terriers

BACKGROUND

Generalized myokymia and neuromyotonia (M/NM) in Jack Russell Terriers (JRTs) is related to peripheral nerve hyperexcitability syndrome in humans, a symptom complex resulting from diverse etiologies.

OBJECTIVE

Clinical and electrodiagnostic evaluation is used to narrow the list of possible etiological diagnoses in JRTs with M/NM.

ANIMALS

Nine healthy JRTs and 8 affected JRTs.

METHODS

A prospective study was conducted comparing clinical and electrophysiological characteristics in 8 JRTs affected by M/NM with 9 healthy JRT controls.

RESULTS

All affected dogs except 1 had clinical signs typical of hereditary ataxia (HA). In 6 dogs, neuromyotonic discharges were recorded during electromyogram. Motor nerve conduction studies showed an axonal neuropathy in only 1 affected dog. Compared with controls, brainstem auditory-evoked potentials (BAEP) showed prolonged latencies (P<.05) accompanied by the disappearance of wave components in 3 dogs. Onset latencies of tibial sensory-evoked potentials (SEP) recorded at the lumbar intervertebral level were delayed in the affected group (P<.001). The BAEP and SEP results of the only neuromyotonic dog without ataxia were normal.

CONCLUSIONS AND CLINICAL IMPORTANCE

The BAEP and spinal SEP abnormalities observed in JRTs with M/NM were associated with the presence of HA. Therefore, these electrophysiological findings presumably arise from the neurodegenerative changes characterizing HA and do not directly elucidate the pathogenesis of M/NM. An underlying neuronal ion channel dysfunction is thought to be the cause of M/NM in JRTs.

Efficacy of Isoniazid Prophylaxis in Renal Allograft Recipients

The efficacy of isoniazid (INH) prophylaxis in renal allograft recipients who are on long-term immunosuppression in a region highly prevalent for tuberculosis (TB) was studied. INH (300 mg/d in patients weighing more than 35 kg and 5 mg/kg/d in patients with <35 kg body weight) together with Pyridoxine 50 mg/d for 1 year was started in randomly assigned renal allograft recipients. Occurrence of clinical tuberculosis during the initial 2 years posttransplantation was observed in the risk group and patients at no risk. Risks were defined as acute rejection episodes and exposure to antirejection therapy, past history of TB completely or incompletely treated, radiological evidence of past tuberculosis, history of tuberculosis in close contacts. Among 480 patients registered in the study, INH prophylaxis was given to 219 randomly assigned renal allograft recipients. Results were compared among patients developing TB during the initial 2 years posttransplantation in both the groups. Risk factors were analyzed for comparison in both groups. No significant difference was observed in terms of past history of TB, TB in close contacts, episodes of acute rejection during the initial 3 months, and comorbidities such as cytomegalovirus infection, hepatitis C virus infection, and posttransplant diabetes. One patient from the INH group and 10 patients from the non-INH group developed TB during the initial 2 years posttransplantation (P < .0001). None of patients required discontinuation of INH. INH was observed to be safe and effective as a chemoprophylactic agent in renal allograft recipients.

Laryngeal paralysis-polyneuropathy complex in young related Pyrenean mountain dogs

OBJECTIVES

To characterise clinical, electrophysiological and histopathological findings. To analyse pedigree information in six young related Pyrenean mountain dogs with laryngeal paralysis-polyneuropathy complex (LP-PNC).

METHODS

A retrospective study of clinical records and pedigrees of six young related Pyrenean mountain dogs with LP-PNC was carried out.

RESULTS

All dogs were presented with laryngeal paralysis and concurrent megaoesophagus. Electrodiagnostic testing was performed in three dogs and showed electrophysiological abnormalities in the distal appendicular muscles. Histopathological findings of peripheral nerve samples were dominated by distal axonal degeneration. Clinical, electrophysiological and histopathological findings were supportive of a diagnosis of degenerative, sensorimotor LP-PNC, similar to that reported in young dalmatians and rottweilers. All dogs died or were euthanased by two years of age. An autosomal recessive mode of inheritance was suspected based on pedigree analysis.

CLINICAL SIGNIFICANCE

Congenital LP-PNC should be suspected in any young dog presenting with laryngeal dysfunction and other concurrent neurological abnormalities. The prognosis is usually poor.

Sensory neuropathy in two Border collie puppies

A peripheral sensory neuropathy was diagnosed in two Border collie puppies. Neurological, electrophysiological and histopathological examinations suggested a purely sensory neuropathy with mainly distal involvement. Urinary incontinence was observed in one of the puppies and histological examination of the vagus nerve revealed degenerative changes. An inherited disorder was suspected.

Calcinosis involving multiple paws in a cat with chronic renal failure and in a cat with hyperthyroidism

Calcinosis of multiple paws is described in two cats. A metastatic pathogenesis was supported by the laboratory findings of hyperphosphataemia and a calcium x phosphorus solubility product > 7 g/L. Hyperparathyroidism could not be confirmed because a valid feline parathyroid hormone assay was not available at the time. One cat was diagnosed with chronic renal failure and presented initially with an irregular nodular calcification on the chin. Dietary and medical management was unsuccessful and ultimately the animal was euthanased. Hyperthyroidism was diagnosed in another cat by laboratory findings and scintigraphic imaging. In addition, the cat had a hyperphosphataemia in the absence of azotaemia. Intravenous administration of radioactive iodine as (131)I was accompanied by reduction and normalization in serum total thyroxine and phosphorus concentrations and resulted in resolution of calcification in the paws.

'Continuous muscle fibre activity' in six dogs with episodic myokymia, stiffness and collapse

Continuous muscle fibre activity was observed in a crossbred dog, a Yorkshire terrier, a border collie and three Jack Russell terriers. The clinical signs consisted of episodes of generalised myokymia which developed into muscle stiffness and delayed muscle relaxation and generally led to the dogs collapsing into lateral recumbency. These episodes were preceded by intense facial rubbing in three of the dogs, and were associated with severe hyperthermia in five of them. All three Jack Russell terriers showed continuous ataxia. The dogs had above normal activities of aspartate aminotransferase, alanine aminotransferase and creatine kinase, but their cerebrospinal fluid was normal. Myokymic discharges were observed by electromyography in two of the dogs. Two of them were treated with membrane-stabilising agents, with variable results.

Atlantoaxial cartilaginous exostosis causing spinal cord compression in a mature Bernese mountain dog

Cartilaginous exostosis developed in the atlantoaxial region of a three-and-a-half-year-old Bernese mountain dog. The dog exhibited ataxia in the hindlimbs and flailing movements in the forelimbs. On survey radiographs of the cervical spine there was a focal calcified mass between the dorsal arch of the atlas and the spinous process of the axis. Lumbar myelography revealed severe dorsal spinal cord compression. The mass was removed surgically and the dog made a complete recovery. Histopathology of the excised mass was consistent with a diagnosis of cartilaginous exostosis.

The effect of bile salts and calcium on isolated rat liver mitochondria

Intact mitochondria were incubated with and without calcium in solutions of chenodeoxycholate, ursodeoxycholate, or their conjugates. Glutamate dehydrogenase, protein and phospholipid release were measured. Alterations in membrane and organelle structure were investigated by electron paramagnetic resonance spectroscopy. Chenodeoxycholate enhanced enzyme liberation, solubilized protein and phospholipid, and increased protein spin label mobility and the polarity of the hydrophobic membrane interior, whereas ursodeoxycholate and its conjugates did not damage mitochondria. Preincubation with ursodeoxycholate or its conjugate tauroursodeoxycholate for 20 min partially prevented damage by chenodeoxycholate. Extended preincubation even with 1 mM ursodeoxycholate could no longer prevent structural damage. Calcium (from 0.01 mM upward) augmented the damaging effect of chenodeoxycholate (0.15-0.5 mM). The combined action of 0.01 mM calcium and 0.15 mM chenodeoxycholate was reversed by ursodeoxycholate only, not by its conjugates tauroursodeoxycholate and glycoursodeoxycholate. In conclusion, ursodeoxycholate partially prevents chenodeoxycholate-induced glutamate dehydrogenase release from liver cell mitochondria by membrane stabilization. This holds for shorter times and at concentrations below 0.5 mM only, indicating that the different constitution of protein-rich mitochondrial membranes does not allow optimal stabilization such as has been seen in phospholipid- and cholesterol-rich hepatocyte cell membranes, investigated previously.

C-terminal isoforms of the myosin heavy chain and smooth muscle function

Two myosin heavy chain isoforms expressed in smooth muscle, SM1 (204 kDa) and SM2 (200 kDa), are derived from alternate splicing that results in different amino acid sequences at their non-helical C-terminal tail regions. These isoforms are developmentally regulated and differentially expressed in various smooth muscle tissues. The functional role of myosin isoforms differing at the C-terminal tail has been investigated both in vitro and in vivo. Removal of the C-terminal tail of SM1 by chymotrypsin activates the ATPase of myosin at low Mg2+ but does not change the maximum activity. Addition of peptides, mimicking C-terminal tail regions specific to the SM1 and SM2 isoforms, to permeabilized taenia coli smooth muscle fibers inhibits maximum shortening velocity (Vm) and decreases Ca2+ sensitivity but has no effect on maximum force. The inhibition of Vm by the SM1-peptide was not reversed on washout, whereas Vm inhibition by the SM2-peptide is reversible. We demonstrated that the SM1 peptide specifically bound to myosin at the subfragment 2-light meromyosin (S2-LMM) junction using crosslinking and immunomicroscopy. Modification at this site could have a direct effect on crossbridge function. The relation between C-terminal myosin isoforms and contractile function in vivo was examined using estrogen administration to ovariectomized rats to increase the relative expression of the SM1 C-terminal isoform in uterine smooth muscle. This increase in SM1 was significantly correlated with an increase in Vm. In contrast, the high ATPase N-terminal isoform was decreased by administration of estrogen to ovariectomized rats. Thus, changes in C-terminal isoform distribution appear to affect contractile function in vivo. We propose a mechanism whereby the interactions between the C-terminal tail of one myosin molecule and the S2-LMM region of another in the thick filament can modulate contractility in an isoform specific manner. Further work is needed to unequivocally identify the function of smooth muscle myosin isoforms. However, our evidence suggests that the C-terminal heavy chain isoforms may be important modulators of smooth muscle contractility.

The care of older persons with diabetes mellitus: families and primary care physicians

OBJECTIVES

To determine the extent to which family members participate in the day-to-day management of diabetes mellitus in older persons, and in older diabetics' medical encounters, and to identify patient and family member characteristics associated with this participation.

DESIGN

A longitudinal observational study, with baseline data being reported herein.

SETTING

Three primary care practice settings in Seattle, Washington, Boston, Massachusetts, and Indianapolis, Indiana.

PARTICIPANTS

Family members of patients 70 years of age or older participating in the Patient Outcomes Research Team (PORT) Study of type II diabetics.

MAIN OUTCOME MEASUREMENTS

The two dependent variables represent, respectively, the extent of family members' assistance with diabetes-related care and participation in older diabetics' medical encounters.

RESULTS

The 357 family members enrolled were older (mean age = 66.3 years), were mostly women (76.2%), and were usually the spouses of diabetic patients (71.3%). Between 22% and 50% of family members reported helping with various aspects of diabetes care; 35.6% of family members participated regularly in their diabetic patients' medical encounters. A multiple linear regression model relating family assistance with diabetes-related care to patient and family member characteristics included four variables: patients' physical function, and the family member's relationship to the patient, assistance with basic activities of daily living (ADLs), and understanding of diabetes management issues (all P < .05). A multiple logistic regression model relating family member participation in the medical encounter to patient and family member characteristics also included four variables: patient age and physical function, and family member assistance with instrumental activities of daily living (IADLs) and with diabetes-related care (all P < .05).

CONCLUSION

The family members studied frequently assisted older diabetics with diabetes-specific care; more than one-third were regular participants in older diabetics' medical encounters. Family member involvement in the day-to-day management of diabetes and in the medical encounter was more likely when patients were functionally disabled. Health care systems and physicians need to educate their older patients, and involved family members when patients are frail, about diabetes-related care issues and support them in their roles in the management of diabetes as well as other chronic diseases.

Acute renal failure due to traumatic rhabdomyolysis

Between 1990 and 1993, we studied 14 cases of acute renal failure due to prolonged muscular exercise (e.g., squat jumping, sit-ups) and blunt trauma inflicted by law enforcement personnel using sticks or leather belts. None of the patients had a prior history of myopathy, neuropathy, or renal disease. All were critically ill and required renal support in the form of dialysis. Although the morbidity was high, 13 of the patients recovered normal renal function. One patient expired due to sepsis.