WHOLE-LUNG torsion following bilateral lung transplant, a rare complication: A case report

Whole lung torsion following bilateral lung transplant is a rare complication. This case report describes the diagnostic difficulties and consequences in a 59 year old patient. This study also includes a brief description of other cases in the literature.

CD40L-stimulated B cells for ex-vivo expansion of polyspecific non-human primate regulatory T cells for translational studies

The therapeutic applications of regulatory T cells (T_regs ) include treating autoimmune diseases, graft-versus-host disease and induction of transplantation tolerance. For ex-vivo expanded T_regs to be used in deceased donor transplantation, they must be able to suppress T cell responses to a broad range of human leukocyte antigen (HLA). Here, we present a novel approach for the expansion of polyspecific T_regs in cynomolgus macaques that was adapted from a good manufacturing practice-compliant protocol. T_regs were isolated by fluorescence-activated cell sorting (FACS) and expanded in the presence of a panel of CD40L-stimulated B cells (CD40L-sBc). Prior to T_reg culture, CD40L-sBc were expanded in vitro from multiple major histocompatibility complex (MHC)-disparate macaques. Expanded T_regs expressed high levels of forkhead box protein 3 (FoxP3) and Helios, a high percentage of T_reg -specific demethylated region (TSDR) demethylation and strong suppression of naïve T cell responses in vitro. In addition, these T_regs produced low levels of inflammatory cytokines and were able to expand post-cryopreservation. Specificity assays confirmed that these T_regs were suppressive upon activation by any antigen-presenting cells (APCs) whose MHC was shared by CD40L-sBc used during expansion, proving that they are polyspecific. We developed an approach for the expansion of highly suppressive cynomolgus macaque polyspecific T_regs through the use of a combination of CD40L-engineered B cells with the potential to be translated to clinical studies. To our knowledge, this is the first report that uses a pool of MHC-mismatched CD40L-sBc to create polyspecific T_regs suitable for use in deceased-donor transplants.

Acute effects of a mavacamten-like myosin-inhibitor (MYK-581 in a feline model of obstructed hypertrophic cardiomyopathy: evidence of improved ventricular filling (beyond obstruction reprieve)

Introduction

Hypertrophic cardiomyopathy (HCM) is a progressive disease characterized by cardiac remodeling, hyperdynamic contraction, and impaired ventricular filling that can lead to dynamic left-ventricular outflow-track (LVOT) obstruction and exertional intolerance. Direct myosin-inhibition with mavacamten can normalize contractility and improve exercise capacity in patients with oHCM, providing sustained symptomatic relief. However, mavacamten can also improve ventricular filling by limiting residual cross-bridges during diastole, and therefore, may offer cardiac benefits beyond obstruction reprieve. This study leveraged a feline model of oHCM, cats with the A31P MYBPC3 variant, to study the acute in vivo effects of MYK-581, a mavacamten surrogate, on cardiac hemodynamics and filling.

Methods

A31P-homozygous cats with HCM (A31P, n=10) and wild-type healthy controls (CTRL, n=9) were anesthetized and instrumented for invasive pressure-volume (PV) measurements as well as trans-thoracic echocardiographic recording. A subset of cats were assigned to receive either vehicle (VEH, n=7) or MYK-581 (MYK, n=8) with a short IV infusion. Cardiac hemodynamics, function, and geometry were assessed at steady state before and during dobutamine challenges (2.5 μg/kg/min IV).

Results

A31P cats had thicker ventricular walls (6.4±0.1 vs. 5.2±0.2 mm, P<0.05) and hyperdynamic contraction (FS: 61±4 vs. 50±3%, P<0.05) relative to controls and presented with dynamic LVOT obstruction in 54% of cases. HCM cats had elevated end-diastolic pressures (17±1.4 vs. 9±1.0 mmHg, P<0.05), with prolonged time constants of relaxation (60±4.1 vs. 36±2.4 ms, P<0.05) and elevated end-diastolic stiffness (Eed: 0.44±0.06 vs. 0.25±0.01 mmHg/mL). Acute treatment with MYK-581 alleviated LVOT obstruction (0% vs. 38%), normalized contractility (FS: −7±2%), and increased systolic/diastolic chamber dimensions (e.g., LVIDd: +13±4%) (all P<0.05), while reducing EDP (15±2 to 13±2 mmHg, P<0.05), suggesting acute improvement in ventricular distensibility. Indeed, MYK-581 treatment reduced end-diastolic stiffness (Eed: 0.48±0.11 vs. 0.36±0. 10 mmHg/mL, P<0.05) and normalized trans-mitral motion patterns during filling.

Conclusions

Bred cats, homozygous for the A31P MYBPC3 variant, presented a cardiac phenotype that models multiple characteristics of the human oHCM phenotype including dynamic LVOT obstruction. Acute treatment with the mavacamten surrogate, MYK-581, not only alleviated hypercontractility and LVOT obstruction, but improved ventricular filling and end-diastolic pressures. Taken together, these pre-clinical observations show potential salutary effects beyond obstruction relief in patients with HCM.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): MyoKardia

Trace metals and persistent organic pollutants fingerprint on the particle flux in the deep subtropical NE Atlantic

Particle flux material collected in 2000 m depth in the Northeast Atlantic at 33°N and 22°W was analyzed for trace metals and persistent organic pollutants. Element enrichment factors relative to lithogenic Al were elevated indicating possible anthropogenic contributions for all trace metals except V. Polycyclic aromatic hydrocarbons, polychlorinated biphenyls and the pesticide DDT exhibited median fluxes of 10.40 μg m^-2d^-1,0.29 μg m^-2 d^-1, and 0.90 μg m^-2 d^-1, respectively. Flux composition reflected long range transport, with low molecular weight and low-chlorinated compounds dominating ∑₁₅PAH and ∑₂₃PCB. PAH isomer ratios identified fossil fuel combustion as the main ∑₁₅PAH source. The composition of ∑₄DDT suggested inputs of the fresh technical pesticide during high dust intensity periods. Pollutant fluxes showed seasonality linked to export production in the region, as well as a dependence on annual and sub-annual dust input events.

Growth of liver allografts over time in pediatric transplant recipients

The liver's capacity to grow in response to metabolic need is well known. However, long-term growth of liver allografts in pediatric recipients has not been characterized. A retrospective review of pediatric recipients at a single institution identified patients who had cross-sectional imaging at 1, 5, and 10 years post-transplant. Using volumetric calculations, liver allograft size was calculated and percent SLV were compared across the different time points; 18 patients ranging from 0.3 to 17.7 years old were identified that had imaging at 2 or more time points. Measured liver volumes increased by 59% after 5 years and 170% after 10 years. The measured liver volumes compared to calculated %SLV for these patients were 123 ± 37%, 97 ± 19%, and 118 ± 27% at 1, 5, and 10 years after transplant, respectively. Our data suggest that liver allografts in pediatric recipients increase along with overall growth, and reach SLVs for height and weight by 5 years post-transplantation. Additionally, as pediatric recipients grow, the livers appear to maintain appropriate SLV.

Treatment of Mongolism with Pituitary Extract

When mongolism was first described, it was considered by some authors to be a form of cretinism (Seguin, 1866), and with the discovery of the effect of thyroid treatment in cretinism, this was tried in mongolism also. The disappointing results diverted attention to other endocrines. Tredgold, in 1929, was recommending a mixture of thyroid, pituitary, thymus, suprarenal and pineal glands, though he did not believe that such treatment was curative.

Anxiety and depression symptoms among sub-fertile women, women pregnant after infertility treatment, and naturally pregnant women

BACKGROUND

Infertility has been associated with psychological distress, but whether these symptoms persist after achieving pregnancy via assisted reproductive technology (ART) remains unclear. We compared the prevalence of anxiety and depressive symptoms between women seeking for infertility treatment and women who conceived after ART or naturally.

METHODS

Four hundred and sixty-eight sub-fertile non-pregnant women, 2972 naturally pregnant women and 143 women pregnant after ART completed a questionnaire in this cross-sectional study. The Anxiety subscale of the Hospital Anxiety and Depression Scale (HADS-A≥8) and Edinburgh Postnatal Depression Scale (EPDS≥12) were used for assessing anxiety and depressive symptoms, respectively. Multivariate Poisson regression models with robust variance were applied to explore associations with anxiety and depressive symptoms.

RESULTS

The prevalence of anxiety and depressive symptoms among sub-fertile, non-pregnant women (57.6% and 15.7%, respectively) were significantly higher compared to women pregnant after ART (21.1% and 8.5%, respectively) and naturally pregnant women (18.8% and 10.3%, respectively). History of psychiatric diagnosis was identified as an independent risk factor for both anxiety and depressive symptoms. The presence of at least one unhealthy lifestyle behavior (daily tobacco smoking, weekly alcohol consumption, BMI≥25, and regular physical exercise<2h/week) was also associated with anxiety (Prevalence Ratio, PR: 1.24; 95%CI: 1.09-1.40) and depressive symptoms (PR: 1.25; 95%CI: 1.04-1.49).

CONCLUSIONS

Women pregnant after ART showed no difference in anxiety and depressive symptoms compared to naturally pregnant women. However, early psychological counseling and management of unhealthy lifestyle behaviors for sub-fertile women may be advisable, particularly for women with a previous history of psychiatric diagnosis.

Standardization of the two-dimensional transcoelomic echocardiographic examination in the central bearded dragon (Pogona vitticeps)

OBJECTIVES

To objectively and subjectively describe the normal spectrum of two-dimensional echocardiographic findings in the central bearded dragon (Pogona vitticeps).

ANIMALS

Sixteen central bearded dragons.

METHODS

Central bearded dragons were prospectively evaluated under manual restraint in right and left lateral recumbency to identify imaging planes for reproducible measurements of cardiac chambers, subjective two-dimensional analysis and color Doppler assessment.

RESULTS

Echocardiography can be performed through windows in the left and right axillae. The window in the left axilla allows for a subjective and objective assessment of cardiac structure and function. The right axillary window allows for evaluation of pulmonary artery flow. Both views provide data for the presence of pericardial effusion or valvular insufficiency. With optimized imaging planes, cardiac chambers and fractional area change along with fractional shortening in the longitudinal and transverse planes can be calculated. Body weight and cardiac chamber dimensions of males were significantly larger than females. Ventricular fractional area change was the most consistent functional assessment. The majority of animals were found to have no evidence of valvular insufficiency, while approximately half had evidence of pericardial fluid. Pulmonary artery flow was assessed in all patients. Left and right aortic velocities cannot be reliably obtained.

CONCLUSIONS

This study is the first to generate reference values for cardiac structure and function in clinically healthy central bearded dragons. Valvular insufficiency is not a normal finding in central bearded dragons, while mild pericardial effusion may be.

Midwives' adoption of the reproductive life plan in contraceptive counselling: a mixed methods study

STUDY QUESTION

How is the reproductive life plan (RLP) adopted in midwifery contraceptive counselling?

SUMMARY ANSWER

A majority of midwives adopted the RLP in their counselling, had predominantly positive experiences and considered it a feasible tool for promoting reproductive health.

WHAT IS KNOWN ALREADY

The RLP is a health-promoting tool recommended by the Centers for Disease Control and Prevention in the USA for improving preconception health. It was recently used in a clinical setting in Sweden and was found to increase women's knowledge about fertility and to influence women's wishes to have their last child earlier in life.

STUDY DESIGN, SIZE, DURATION

An exploratory mixed methods study among 68 midwives who provided contraceptive counselling in primary health care to at least 20 women each during the study period. Midwives received an introduction and materials for using the RLP in contraceptive counselling. Three months later, in the spring of 2014, they were invited to complete a questionnaire and participate in a focus group interview about their adoption of the RLP.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Data collection was through a questionnaire (n = 53 out of 68; participation rate 78%) and five focus group interviews (n = 22). Participants included both younger and older midwives with longer and shorter experiences of contraceptive counselling in public and private health care in one Swedish county. Quantitative data were analysed for differences between users and non-users, and qualitative data were analysed by qualitative content analysis to explore the midwives experiences and opinions of using the RLP.

MAIN RESULTS AND THE ROLE OF CHANCE

Sixty-eight per cent of midwives had used the RLP in their contraceptive counselling. Four categories emerged through the focus group interviews: (i) A predominantly positive experience; (ii) The RLP-a health-promoting tool; (iii) individual and societal factors influence the RLP counselling; and (4) long-term implementation comprises opportunities, risks and needs. The most common reason for not using the RLP was lack of information.

LIMITATIONS, REASONS FOR CAUTION

There was general lack of experience of using the RLP with women from different cultural backgrounds, with non-Swedish speaking women and, when a partner was present. Due to the non-random sample, the limited knowledge about non-responders and a short follow-up period, results apply to short-term implementations and might not fully apply to long-term implementation.

WIDER IMPLICATIONS OF THE FINDINGS

The use of RLP in contraceptive counselling appears a feasible way of promoting reproductive health. Results from the USA and Sweden indicate it is a promising tool for midwives and other health professionals involved in reproductive counselling, which deserves to be explored in other nations.

STUDY FUNDING/COMPETING INTERESTS

Grants were received from the Medical Faculty at Uppsala University and the European Society of Contraception and Reproductive Health. There are no competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Retrospective evaluation of moderate-to-severe pulmonary hypertension in dogs naturally infected with Angiostrongylus vasorum

OBJECTIVES

The outcome in dogs with pulmonary hypertension associated with natural Angiostrongylus vasorum infection is unclear. This study aimed to report long-term outcome of dogs with A. vasorum and pulmonary hypertension, and to evaluate factors associated with pulmonary hypertension development. It was hypothesised that dogs with pulmonary hypertension had a shorter survival time than dogs without pulmonary hypertension.

METHODS

Retrospective review of clinical records of dogs diagnosed with A. vasorum. Dogs were classified as having or not having pulmonary hypertension based on clinical signs and imaging findings. Signalment, signs and outcome were recorded. DNA obtained from banked samples was genotyped for the PDE5a:E90K polymorphism, a possible factor in development of pulmonary hypertension.

RESULTS

The proportion of dogs with moderate-to-severe pulmonary hypertension and A. vasorum infection in the study population was 14 · 6%. No difference in the population characteristics or PDE5a genotype was detected between dogs with and without pulmonary hypertension. Dogs with pulmonary hypertension had a significantly shorter survival time (P = 0 · 006) and a greater risk of death within 6 months of diagnosis (odds ratio 12 · 5, 95% confidence interval 2 · 1 to 74 · 9; P = 0 · 0053).

CLINICAL SIGNIFICANCE

A. vasorum-associated pulmonary hypertension is an important problem in naturally infected dogs and has a negative effect upon survival.

Sacral nerve stimulation: an effective treatment for chronic functional anal pain?

AIM

Chronic idiopathic anal pain is a common condition of unknown aetiology. Patients may have co-existing psychiatric disorders and existing treatments are often ineffective. A small number of published case reports suggest that sacral nerve stimulation (SNS) could treat this condition. This pilot study aimed to investigate the efficacy of SNS for the treatment of chronic anal pain.

METHOD

Ten patients with chronic idiopathic anal pain were recruited. All had failed to respond to conservative treatments. Clinical and psychological evaluation was performed in all patients prior to SNS. Temporary stimulation of the S3 foramina was performed for 3 weeks and outcome assessed by comparison of a pain score diary and visual analogue score obtained during stimulation and at baseline. Primary outcome was defined as a > 50% reduction in pain score.

RESULTS

Of the 10 patients recruited, five were found to have clinical depression. Four patients withdrew from the study prior to testing and six underwent peripheral nerve evaluation (PNE). Three patients had > 50% reduction in pain score and progressed to permanent SNS. Of these, only one had good pain control at latest follow-up of 5 years; the remaining two patients obtained no benefit and had their devices removed or deactivated. These two patients both had depression that was also not improved by SNS.

CONCLUSION

This study would suggest that SNS is not an effective treatment for chronic anal pain in the majority of patients. PNE is not an effective means of identifying which of these patients are likely to respond to permanent SNS.