Nodular regenerative hyperplasia in X-linked agammaglobulinemia: An underestimated and severe complication

BACKGROUND

Late-onset complications in X-linked agammaglobulinemia (XLA) are increasingly recognized. Nodular regenerative hyperplasia (NRH) has been reported in primary immunodeficiency but data in XLA are limited.

OBJECTIVES

This study sought to describe NRH prevalence, associated features, and impact in patients with XLA.

METHODS

Medical records of all patients with XLA referred to the National Institutes of Health between October 1994 and June 2019 were reviewed. Liver biopsies were performed when clinically indicated. Patients were stratified into NRH+ or NRH- groups, according to their NRH biopsy status. Fisher exact test and Mann-Whitney test were used for statistical comparisons.

RESULTS

Records of 21 patients with XLA were reviewed, with a cumulative follow-up of 129 patient-years. Eight patients underwent ≥1 liver biopsy of whom 6 (29% of the National Institutes of Health XLA cohort) were NRH+. The median age at NRH diagnosis was 20 years (range, 17-31). Among patients who had liver biopsies, alkaline phosphatase levels were only increased in patients who were NRH+ (P = .04). Persistently low platelet count (<100,000 per μL for >6 months), mildly to highly elevated hepatic venous pressure gradient and either hepatomegaly and/or splenomegaly were present in all patients who were NRH+. In opposition, persistently low platelet counts were not seen in patients who were NRH-, and hepatosplenomegaly was observed in only 1 patient who was NRH-. Hepatic venous pressure gradient was normal in the only patient tested who was NRH-. All-cause mortality was higher among patients who were NRH+ (5 of 6, 83%) than in the rest of the cohort (1 of 15, 7% among patients who were NRH- and who were classified as unknown; P = .002).

CONCLUSIONS

NRH is an underreported, frequent, and severe complication in XLA, which is associated with increased morbidity and mortality.

Thyroid nodules in xeroderma pigmentosum patients: a feature of premature aging

PURPOSE

Xeroderma pigmentosum (XP) is an autosomal recessive disease with defective DNA repair, a markedly increased risk of skin cancer, and premature aging. Reports from North Africa have described thyroid nodules in XP patients, but thyroid nodule prevalence has never been determined in XP patients enrolled in our natural history study at the National Institutes of Health (NIH).

METHODS

We performed thyroid ultrasound examinations on all 29 XP patients examined from 2011 to 2019 and assessed nodule malignancy using the Thyroid Imaging Reporting and Data System. Thyroid nodule prevalence was also obtained from comparison cohorts. DNA sequencing was performed on thyroid tissue from XP patients who had surgery for thyroid cancer.

RESULTS

Thyroid nodules were identified in 18/29 XP patients (62%). The median age of patients with thyroid nodules in our XP cohort (20 years) was younger than that of three comparison groups: 36 years (California study-208 subjects), 48 years (Korean study-24,757 subjects), and 52 years (NIH-682 research subjects). Multiple (2-4) thyroid nodules were found in 12/18 (67%) of the patients with nodules. Autopsy examination revealed follicular adenomas in 4/8 (50%) additional XP patients. DNA sequencing revealed rare mutations in two other XP patients with papillary thyroid cancer.

CONCLUSIONS

XP patients have an increased incidence of thyroid nodules at an early age in comparison to the general population. These finding confirm another premature aging feature of XP.

POS0802 18F-FLUORODEOXYGLUCOSE POSITRON EMISSION TOMOGRAPHY AS A PREDICTOR OF ANGIOGRAPHIC PROGRESSION OF DISEASE IN LARGE-VESSEL VASCULITIS

Background:

Giant cell arteritis (GCA) and Takayasu’s arteritis (TAK) are the two main forms of large-vessel vasculitis (LVV). Although angiography is essential to detect vascular disease in patients with LVV, there is limited prospective data characterizing change in arterial lesions over time, and factors that predict angiographic change remain unknown.

Objectives:

The objectives of this study were to: 1) describe longitudinal change in angiographic studies in patients with GCA and TAK and 2) determine whether FDG-PET activity predicts angiographic progression of disease.

Methods:

Patients with GCA or TAK were recruited into a prospective, observational cohort. All patients underwent baseline magnetic resonance (MR) or computed tomography (CT) angiography and a follow-up study (same modality) ≥6 months after baseline per a standardized imaging protocol. For patients who had multiple angiograms, the baseline and most recent images were compared. Arterial lesions, defined as stenosis, occlusion, or aneurysm, were evaluated by visual inspection in 4 segments of the aorta and 13 branch arteries by a single reader blinded to clinical status. On follow up angiography, the development of new lesions in these same territories was recorded, and existing lesions were characterized as improved, worsened, or unchanged by visual inspection, with confirmation by an independent reader.

All patients underwent FDG-PET on the same date as angiography. Qualitative assessment of FDG uptake was performed in each corresponding arterial territory evaluated by angiography. Active vasculitis was defined as greater FDG uptake in the arterial wall compared to the liver by visual inspection.

Results:

At the baseline visit, there were 248 arterial lesions (21%) out of 1162 arterial territories evaluated from 70 patients with LVV (TAK=38; GCA=32). Baseline characteristics were as follows: Age [TAK=29.5 years (18.4-39.5), GCA=69.6 years (60.7-75.5)], Female gender [TAK=30 patients (79%), GCA=23 patients (72%)], Disease duration [TAK=2.2 years (0.6-5.5), GCA=0.7 years (0.1-2.6)], Active clinical disease [TAK=17 patients (45%), GCA=20 patients (63%)].

Over 1.6 years (1.0-2.7) of median follow-up, no angiographic change was observed in 1,132 (97%) arterial territories. New lesions developed in 8 arterial territories, exclusively in 5 patients with TAK. Arterial lesions improved in 16 territories (GCA = 7, TAK = 9) and worsened in 6 territories (GCA = 1, TAK = 5). Patients with angiographic improvement were initially imaged earlier in the disease course compared to patients with new/worsening lesions (median 1.1 vs 16.4 months, p=0.09). Patients with angiographic improvement had significantly lower acute phase reactants at follow-up compared to patients with new/worsening arterial lesions [median ESR 3.0 (2.0-15.0) vs. 27.0 (7.3-39) mm/h, p<0.01; median CRP 0.7 (0.3-1.4) vs. 6.1 (3.1-19.6) mg/L, p<0.01]. Seventy-nine percent of patients with new/worsening arterial lesions had received increased treatment over the follow-up interval compared to 100% patients with improved arterial lesions, p=0.09.

FDG-PET activity was evaluated in 1091/1162 (94%) of corresponding arterial territories. PET activity in an arterial territory at baseline was significantly associated with change in that arterial territory (either new/worsening or improvement) on follow-up angiography (p<0.01) (FIGURE 1). PET activity had a sensitivity of 80% and specificity of 74% for predicting change in arterial lesions. Most arterial territories without PET activity at baseline remained unchanged over time by angiography, yielding a negative predictive value of 99%. (FIGURE 1).

Conclusion:

Development of new arterial lesions is infrequent in LVV. Change in arterial lesions is dynamic, and improvement can occur. FDG-PET activity predicts change in angiographic lesions, and lack of PET activity is strongly associated with stable angiographic disease. These data may inform guideline recommendations for imaging monitoring in LVV.

Figure 1.

Disclosure of Interests:

None declared

Deprivation and food access and balance in Saskatoon, Saskatchewan

Introduction

We explored food access and balance in Saskatoon, Saskatchewan, Canada in relation to material and social deprivation.

Methods

We mapped the location of all large supermarkets and fast food retailers in Saskatoon. Supermarket accessibility index scores and food balance scores were compared to material and social deprivation indexes to determine significant associations.

Results

Our results indicate that the poorest access to supermarkets occurred in areas west of the South Saskatchewan River and also in suburban areas around the perimeter of the city. Areas west of the river are some of the most deprived areas in the city. Saskatoon's mean food balance ratio of 2.3 indicates that access favours fast food. However, we did not find a clear pattern or clear socio-economic gradient for most measures.

Conclusion

This study highlights the importance of contextual studies of food access. This study also highlighted a number of other issues that should be explored in the Saskatoon context such as individual-level food consumption patterns, mobility, temporal dimensions of food access and economic access as well as interventions that could improve food access in the city.

Deprivation and food access and balance in Saskatoon, Saskatchewan

INTRODUCTION

We explored food access and balance in Saskatoon, Saskatchewan, Canada in relation to material and social deprivation.

METHODS

We mapped the location of all large supermarkets and fast food retailers in Saskatoon. Supermarket accessibility index scores and food balance scores were compared to material and social deprivation indexes to determine significant associations.

RESULTS

Our results indicate that the poorest access to supermarkets occurred in areas west of the South Saskatchewan River and also in suburban areas around the perimeter of the city. Areas west of the river are some of the most deprived areas in the city. Saskatoon's mean food balance ratio of 2.3 indicates that access favours fast food. However, we did not find a clear pattern or clear socio-economic gradient for most measures.

CONCLUSION

This study highlights the importance of contextual studies of food access. This study also highlighted a number of other issues that should be explored in the Saskatoon context such as individual-level food consumption patterns, mobility, temporal dimensions of food access and economic access as well as interventions that could improve food access in the city.

Unspecified falls among youth: predictors of coding specificity in the emergency department

BACKGROUND

Deficiencies in emergency department (ED) charting is a common international problem. While unintentional falls account for the largest proportion of injury related ED visits by youth, insufficient charting details result in more than one third of these falls being coded as "unspecified". Non-specific coding compromises the utility of injury surveillance data.

OBJECTIVE

To re-examine the ED charts of unspecified youth falls to determine the possibility of assigning more specific codes.

METHODS

400 ED charts for youth (aged 0-19 years) treated at four EDs in an urban Canadian health region between 1997 and 1999 and coded as "Other or unspecified fall" (ICD-9 E888) were randomly selected. A structured chart review was completed and a blinded nosologist recoded the cause of injury using the extracted data. Differences in coding specificity were compared with the original data, and logistic regression was undertaken to examine variables that predicted assignment of a specific E-code.

RESULTS

A more specific code was assigned to 46% of cases initially coded as unspecified. Of these, 73% were recoded as "Slips, trips, and stumbles" (E885), which still lacks the specificity required for injury prevention planning; 2% of charts had no fall documented. Multivariate analysis revealed that dichotomized injury severity (adjusted odds ratio (OR) = 1.75 (95% confidence interval, 1.11 to 2.78)), arrival at the ED by ambulance (adjusted OR = 5.41 (1.07 to 27.0)), and the availability of nurse's notes or triage forms, or both, in the chart (adjusted OR = 3.75 (2.17 to 6.45)) were the strongest predictors of a more specific E-code assignment.

CONCLUSIONS

Deficiencies in both chart documentation and coding specificity contribute to the use of non-specific E-codes. More comprehensive triage coding, improved chart documentation, and alternative methods of data collection in the acute care setting are required to improve ED injury surveillance initiatives.

183W NMR Study of Peroxotungstates Involved in the Disproportionation of Hydrogen Peroxide into Singlet Oxygen ((1)O(2), (1)Delta(g)) Catalyzed by Sodium Tungstate in Neutral and Alkaline Water

The disproportionation of aqueous hydrogen peroxide catalyzed by sodium tungstate has been investigated with regard to the multiplicity of the oxygen molecules released. Trapping experiments and detection of the IR luminescence of (1)O(2) have shown that the yield of (1)O(2) is virtually quantitative. The mono-, di-, and tetraperoxotungstate intermediates W(O(2))(n)()O(4)(-)(n)()(2)(-) (n = 1, 2, 4) have been characterized by UV and (183)W NMR spectroscopies. The diperoxo species is proposed as the precursor of (1)O(2).

Environmental monitoring within the Slovak Republic

In the Slovak Republic (SR) there has not been a complete and coordinated monitoring system for environment until now. The object of environmental monitoring in the SR has been to evaluate certain areas, e.g. components of the environment and the influences affecting it: atmosphere, water, soil, biota (fauna and flora), geological factors, physical fields, forest, wastes, settlement, landuse, contaminants of the food chain and human stress caused by environmental factors. Individual monitoring systems are being built on the basis of these projects.The Monitoring System for the Environment in the SR has been formed by linkage to the Information System on the Environment in the SR which is a basic source of the data on the state of the environment in the SR and the factors affecting it.The guarantor of both these systems is the Ministry of the Environment of the Slovak Republic.

[Photophysical evaluation of photosensitization by various quinolones]

An original physicochemical method is proposed for the evaluation of the photosensitizing activity of drugs in vitro. A Nuclear Magnetic Resonance (NMR) spectrum is recorded during light irradiation of drug solutions. The change in the intensity of the NMR lines under such conditions is termed the Photochemically Induced Dynamic Nuclear Polarization (Photo-CIDNP) effect. It is related to the formation of radical intermediates which may be involved in the in vivo photosensitization reactions (the so-called type-I photoreactions). Nine commercial quinolones were tested by this method: nalidixic, oxolinic, pipemidic and piromidic acids, rosoxacin, flumequine, enoxacin, pefloxacin and norfloxacin. Each quinolone was irradiated in alcoholic solutions in its UV absorption band (300-350 nm) in the absence or in the presence of a biological target chosen as a model: the amino-acid N-acetyltyrosine. The quinolones were classified in two groups in relation to the intensities of the observed CIDNP effects. Nalidixic and oxolinic acids, rosoxacin and flumequine are among the most potent photosensitizers.

What's New in Obstetrics and Gynecology?

This article reviews the current situation in obstetrics and gynecology, with particular reference to prostaglandins and their properties in contraception, abortion and induction of labor; the current status of the Pill, and rubella in pregnancy, with emphasis on selection of patients for vaccination.

Infections of the urinaryin tract in pregnancy

Asymptomatic bacteriuria is common in pregnant women and more easily detected during pregnancy. The risk of pyelonephritis is present, therefore early treatment is necessary. Routine screening of prenatal patients is advisable, since bacteriuria is quite likely to continue after pregnancy. Diagnostic procedures are described and treatment outlined.

The investigation of infertility

Many of the tests for causes of infertility can, and should be carried out by the family physician. This article describes tests such as the Sims test, basal body temperature tests and patency tests. The time factor is stressed, as is the necessity to establish the real need for these tests, since unnecessary testing often does more harm than good.