Autoantibodies against type I IFNs in humans with alternative NF-κB pathway deficiency

Patients with autoimmune polyendocrinopathy syndrome type 1 (APS-1) caused by autosomal recessive AIRE deficiency produce autoantibodies that neutralize type I interferons (IFNs)1,2, conferring a predisposition to life-threatening COVID-19 pneumonia3. Here we report that patients with autosomal recessive NIK or RELB deficiency, or a specific type of autosomal-dominant NF-κB2 deficiency, also have neutralizing autoantibodies against type I IFNs and are at higher risk of getting life-threatening COVID-19 pneumonia. In patients with autosomal-dominant NF-κB2 deficiency, these autoantibodies are found only in individuals who are heterozygous for variants associated with both transcription (p52 activity) loss of function (LOF) due to impaired p100 processing to generate p52, and regulatory (IκBδ activity) gain of function (GOF) due to the accumulation of unprocessed p100, therefore increasing the inhibitory activity of IκBδ (hereafter, p52LOF/IκBδGOF). By contrast, neutralizing autoantibodies against type I IFNs are not found in individuals who are heterozygous for NFKB2 variants causing haploinsufficiency of p100 and p52 (hereafter, p52LOF/IκBδLOF) or gain-of-function of p52 (hereafter, p52GOF/IκBδLOF). In contrast to patients with APS-1, patients with disorders of NIK, RELB or NF-κB2 have very few tissue-specific autoantibodies. However, their thymuses have an abnormal structure, with few AIRE-expressing medullary thymic epithelial cells. Human inborn errors of the alternative NF-κB pathway impair the development of AIRE-expressing medullary thymic epithelial cells, thereby underlying the production of autoantibodies against type I IFNs and predisposition to viral diseases.

Correlation of fine needle aspiration biopsy and dynamic contrast-enhanced 3D magnetic resonance imaging of the breast

OBJECTIVE

To correlate and assess the utility of dynamic contrast-enhanced three-dimensional gadolinium-enhanced magnetic resonance imaging (Gd-3DMRI) and fine needle aspiration biopsy (FNAB) findings in patients with suspected breast disease.

STUDY DESIGN

Beginning in 1993, all patients who underwent percutaneous FNAB of the breast and had concurrent Gd-3DMRI evaluation of the breast were selected for this study. Findings for FNAB and Gd-3DMRI were stratified into two categories, positive and negative. Subsequent clinical management decisions, which included surgical intervention and/or clinical follow-up, were recorded for all patients.

RESULTS

There were 69 FNABs in 59 patients with corresponding Gd-3DMRI evaluation. A positive result by both FNAB and Gd-3DMRI was found in 15 of 18 malignant cases. FNAB missed one case, and Gd-3DMRI missed two, and each of these was thought to be technical. Combining the methods yielded 100% sensitivity. False positive results on Gd-3DMRI (17 cases) were all confirmed to be benign by FNAB and subsequent tissue evaluation. All 32 cases with combined negative results by FNAB and Gd-3DMRI demonstrated a benign process, yielding a specificity of 100% (32/32).

CONCLUSION

Our combined testing modalities showed a high degree of specificity and good sensitivity. FNAB used with dynamic contrast-enhanced Gd-3DMRI can contribute valuable information for physicians treating patients with suspected breast abnormalities.

Ethical issues in instituting and discontinuing enteral feeding

The shift from inpatient care has not lessened the importance of ethical issues in caring for patients. Dilemmas involving withholding and withdrawing enteral nutrition require input from the patient, family, and caregivers. Decisions to forego or discontinue treatment such as home enteral support should never be distinguished from the responsibility of providing support and compassionate care throughout life, even during dying.

Prospective evaluation of a new through-the-scope nasoduodenal enteral feeding tube

BACKGROUND

With present techniques, transpyloric feeding tube placement is unreliable. This study evaluated a new nasoduodenal tube placed through a gastroscope.

METHODS

A therapeutic gastroscope was advanced into the distal duodenum, and through the 3.7-mm channel this feeding tube was advanced under direct vision into the small bowel. The tube/guidewire combination was then advanced with the concomitant equidistant retraction of the scope until the wire could be grasped at the lips and exchanged to the nose using a nasal transfer tube. The guidewire was removed, and a "Y" connector was then attached to the end of the tube.

RESULTS

Successful tube placement in all 21 patients (14M/7F) required an endoscopy time of 31 +/- 3.3 min and the tubes were utilized for 9.24 +/- 0.94 days. Tube tips were confirmed in the distal duodenum (10) or proximal jejunum (11) by radiographic contrast injection.

CONCLUSION

This new through-the-scope tube can be placed in the distal duodenum quickly, safely, and consistently.

Half-Fourier, three-dimensional technique for dynamic contrast-enhanced MR imaging of both breasts and axillae: initial characterization of breast lesions

PURPOSE

To evaluate the ability of asymmetric half-Fourier three-dimensional (3D) magnetic resonance (MR) imaging to characterize signal intensity changes in breasts and axillae after contrast material injection and to compare the spatial resolution and measured signal intensity change of asymmetric and symmetric (keyhole) partial Fourier techniques.

MATERIALS AND METHODS

Imaging was performed in 28 adult patients by collecting a single full-Fourier 3D data set with bolus injection of contrast material during the last 10 seconds followed by collection of six half-Fourier 3D data sets without interimage delays. Postcontrast keyhole and half-Fourier images were formed from the same full-Fourier raw data set.

RESULTS

The asymmetric half-Fourier 3D technique maintained the spatial resolution and lesion signal intensity of the full-Fourier image, whereas the 50% keyhole method degraded the spatial resolution by a factor of two and decreased the lesion signal intensity by 19% for a 2 x 2-pixel region of interest. Histopathologic correlation was attained in 32 lesions in 28 patients. Sensitivity was 100% (five of five) and specificity was 89% (24 of 27).

CONCLUSION

The asymmetric half-Fourier 3D MR imaging technique allows imaging of both breasts and axillae without loss of lesion contrast or temporal resolution and provides the maximum spatial resolution and lesion signal intensity attainable for the views sampled.

Dynamic sequential 3D gadolinium-enhanced MRI of the whole breast

Dynamic contrast-enhanced 2D MR imaging of the breast has shown high sensitivity and specificity for the detection and characterization of breast lesions. We investigated the ability of a dynamic fast 3D MR imaging technique that repeatedly scans the whole breast in 44-s intervals without an interscan delay time to obtain similar sensitivity and specificity as 2D imaging. Fifty-six patients scheduled for breast biopsy were entered into the study, and 83 lesions detected by 3D dynamic scanning were biopsied. Dynamic 3D contrast-enhanced breast imaging with subtraction detected and correctly classified all 23 cancers, and 44 of the 60 benign lesions yielding a sensitivity of 100%, a specificity of 73%, and a 100% predictive negative value. The enhancement profiles of metastatic lymph nodes were similar to those of primary cancer. This technique allowed detection of multifocal and multicentric lesions and did not require a prior knowledge of lesion location. These results indicate that dynamic contrast-enhanced 3D MRI of the whole breast is a useful and economically feasible method for staging breast cancer, providing a comprehensive noninvasive method for total evaluation of the breast and axilla in patients considering breast conservation surgery or lumpectomy.

Gastrointestinal disease in patients receiving salvage chemotherapy or bone marrow transplantation

Thirty-three patients receiving either salvage chemotherapy or bone marrow transplantation with potential surgical illness related to gastrointestinal symptoms were identified. Sixty-nine percent of patients received salvage chemotherapy for either hematological (61%) or visceral malignancies (39%). Twenty-one percent of patients had a previous bone marrow transplant. Twenty-two (66%) had an absolute neutrophil count less than 10(3)/mm3. Ulcerative foregut disease (51%) and perianal disease (21%) were the most common disease entities identified. Esophagogastroduodenoscopy (79%) and anorectal examination under anesthesia (21%) provided the greatest diagnostic yield. The mean hospitalization was 21 days. Surgery was performed in 21% of patients, but was seldom required for abdominal pain or intestinal bleeding. Perianal disease was often chronic and required multiple operative procedures. Overall, a 27% mortality was found. Gastrointestinal disease in patients receiving salvage chemotherapy or bone marrow transplantation is usually manifested by bleeding and localized to the proximal gut, or related to perianal disease.

Hyperbilirubinemia without common bile duct abnormalities and hyperamylasemia without pancreatitis in patients with gallbladder disease

OBJECTIVE

To determine the incidence of jaundice and hyperamylasemia in the absence of common bile duct abnormalities or clinical pancreatitis in patients undergoing cholecystectomy.

DESIGN

A continuous, prospective analysis of a consecutive case series was performed on all patients undergoing cholecystectomy.

SETTING

An urban, tertiary care university hospital.

PATIENTS

Adult patients with gallbladder disease.

INTERVENTION

All patients underwent cholecystectomy.

MAIN OUTCOME MEASURES

The presence or absence of common bile duct abnormalities was evaluated by cholangiography, and pancreatitis was identified by clinical signs, imaging studies, and direct visual inspection during cholecystectomy.

RESULTS

All patients (N = 1746) undergoing cholecystectomy were prospectively categorized as having chronic calculous (n = 1410), acute calculous (n = 217), chronic acalculous (n = 70), or acute acalculous (n = 49) gallbladder disease. It was uncommon for patients with chronic calculous cholecystitis to have an elevated bilirubin level with no choledocholithiasis and a normal common bile duct or to have hyperamylasemia without pancreatitis. Twenty-five percent of the patients with acute calculous cholecystitis had a serum bilirubin level between 34 and 86 mumol/L (2.0 and 5.0 mg/dL) with no common bile duct abnormality and 4% had hyperamylasemia without pancreatitis. Over one third of the patients with acute acalculous cholecystitis had an elevated bilirubin level with a normal common bile duct or an elevated amylase level without pancreatitis.

CONCLUSION

Jaundice and hyperamylasemia can be produced by gallbladder disease alone.

A fast 3D-imaging technique for performing dynamic Gd-enhanced MRI of breast lesions

The characterization of breast lesions by their Gd-enhancement profiles has been proposed as a method for differentiating benign from malignant breast lesions. The limitations of dynamic contrast enhanced 2D imaging of the breast are the low number of slices that can be acquired, and the need to know the location of the lesion a priori to correctly select the noncontiguous 2D slice locations. These problems are exacerbated when multi-focal disease is present but not anticipated. Standard fast 3D gradient-echo imaging has a variable delay between successive acquisitions. We have developed a fast 3D gradient-echo imaging technique for dynamic Gd-DTPA enhanced breast imaging which obtains multiple 3D image sets of 32 contiguous images at 44 s intervals without an interscan delay time. This rapid 3D imaging technique achieves good temporal resolution and reduces patient motion between pre- and postcontrast images while covering a much larger portion of the breast and eliminating the need for a priori knowledge concerning the location of the lesion(s) when performing Gd-enhanced dynamic MR imaging.

Nutrition support in bone marrow transplant recipients

Bone marrow transplantation is a complex therapy designed as curative for a variety of malignant and nonmalignant diseases. It is a highly invasive procedure that uses high-dose chemotherapy and may also include radiation treatment. This results in immunosuppression that is often followed by infection, graft-vs-host disease, pulmonary complications, veno-occlusive disease of the liver, and metabolic and nutritional abnormalities. Parenteral nutrition has been the mainstay of nutrition support in patients undergoing bone marrow transplantation. Parenteral nutrition has not been uniformly successful in improving nutritional status or outcome. Enteral nutrition offers many theoretical advantages but is often not well tolerated. Coordinated efforts of the health care team are needed to optimize the nutrition support of these complicated cases.

Total parenteral nutrition in a premature rhinoceros calf

A female black rhinoceros calf developed significant hypoglycemia (blood glucose, 30 mg/dL) and hypothermia (97 degrees F) within 48 hours of birth and refused to nurse. Normal gestation of the black rhinoceros is 15 months, but elongated hoof slippers and low birth weight (30 kg) suggested prematurity in this calf. Clinical symptoms of neonatal sepsis including lassitude and poor sucking continued in spite of the aggressive use of antibiotics, and the calf required mechanical ventilatory support on day 7. Nutritional support including enteral gavage feedings (Pedialyte/4 ounces of SMA [Wyeth Ayerst] with sucraflox) had been instituted and was supplemented with total parenteral nutrition on day 5. Central venous access was obtained via a jugular cutdown. The total parenteral nutrition included appropriate electrolytes and vitamins for the neonatal calf but did not include trace elements. The use of total parenteral nutrition by our zoos for therapeutic purposes is increasing. Experience with total parenteral nutrition in exotic animals such as the black rhinoceros is limited, yet this may be an important therapeutic modality in these animals, particularly those in danger of extinction.

Failure of APACHE II alone as a predictor of mortality in patients receiving total parenteral nutrition

We followed prospectively over 5 months all medical and surgical ICU patients placed on total parenteral nutrition (TPN) and recorded their Acute Physiology and Chronic Health Evaluation II (APACHE II) scores on the day of admission, on the day TPN was started, length of time in ICU before TPN was started, and the number of days TPN was administered. Sixty-one patients (15 to 82 yr) had an inhospital mortality of 47%. The APACHE II score was significantly higher for nonsurvivors vs. survivors both on the day of admission (24.4 +/- 9.6 vs. 18.4 +/- 6.5; p less than .003) and also on the day TPN was started (21 +/- 8.6 vs. 16.4 +/- 5.6; p less than .002). However, at a 60% risk of dying, specificity was 96.9% and sensitivity 27.6%. The mean number of days before TPN was started was 3.2 and mean number of days on TPN was 9.2 (p = NS). We conclude that calculation of APACHE II score either on ICU admission or on the day TPN is considered does not seem useful in identifying patients who will not benefit from TPN.

Colonization and sepsis from triple-lumen catheters in critically ill patients

Sepsis from central triple-lumen catheters remains a serious and life-threatening problem. Patients requiring triple-lumen catheter placement frequently have multiorgan failure or very serious illness. Every effort should be made to reduce the incidence of catheter-related sepsis. Earlier recognition of catheter sepsis may allow removal of the offending line before sepsis becomes clinically apparent. These data indicate that line colonization occurs early and frequently after triple-lumen catheter placement, and suggests that early, frequent line changes may reduce the incidence of clinical sepsis.

Pancreatitis after biliary tract surgery

Pancreatitis associated with biliary tract operations continues to be an important clinical problem. The results of biliary tract operations performed on 1256 patients were carefully scrutinized for the presence of postoperative hyperamylasemia and pancreatitis persisting after 48 hours. Patients were evaluated in the context of the presence or absence of preoperative pancreatic dysfunction. Similarly, various operative risk factors were evaluated, including cholangiography, choledocholithiasis, common duct exploration, choledochoscopy, choledochoduodenostomy, and sphincteroplasty. Operative cholangiography did not induce postoperative pancreatitis. The incidence of postoperative pancreatitis following cholecystectomy was 0.6%, which was significantly greater than the incidence following common duct exploration (8.4%). Pancreatitis following biliary tract surgery seemed to be not directly related to the performance of choledochoscopy, sphincteroplasty, or choledochoduodenostomy, as it developed with similar frequency in patients undergoing common duct exploration alone. The timing of operative therapy in patients with biliary tract pancreatitis did not significantly alter the frequency with which pancreatitis persisted in the postoperative period. In 970 patients undergoing cholecystectomy, one patient who had preoperative pancreatitis died of postoperative pancreatitis. Of 286 patients undergoing common duct exploration, seven patients died with pancreatitis. In three of these patients there was no active preoperative pancreatitis, and in one of these patients pancreatitis was the cause of death. Four patients with preoperative pancreatitis eventually died of pancreatitis in the postoperative period. Pancreatitis is an important complication of biliary tract disease and operations, and all efforts should be extended to suppress its occurrence and development.

Planned reoperation for generalized intraabdominal infection

Intraabdominal infection remains a common cause of death in surgical patients. Progress in this area with improved survival rates is difficult to demonstrate despite the use of antibiotics, nutritional support, and aggressive maintenance of function of failed organs. This report documents our experience with planned reoperation to cleanse the abdominal cavity in 77 patients with generalized intraabdominal infection. In 34 of the patients, reoperation to cleanse the abdominal cavity was performed every 24 to 48 hours after the first operation until the abdominal cavity was judged to be clean. Forty-three patients underwent a single operation for intraabdominal contamination and were treated expectantly, only undergoing reoperation for signs of recurrent infection. In all patients, the hole in the intestinal tract was controlled primarily by stoma formation at the initial operation to treat intraabdominal infection. Patients with appendiceal disease were excluded. The severity of illness in the two patient groups was compared by a modified acute physiologic score. Planned reoperation was not associated with improvement in survival when compared with patients managed expectantly. Patients managed by planned reoperation had significantly more laparotomies than patients managed expectantly without improving survival. The results of this study disclosed that empiric reoperation to clean the abdominal cavity in patients with generalized intraabdominal infection produced no improvement in survival when compared with observation and reoperation when indicated.

Late effects of jejunoileal bypass operations on hepatic inflammation, fibrosis and lipid content

Patients more than six years following jejunoileal bypass operations for morbid obesity underwent liver biopsy for evaluation of hepatic histology and determination of hepatic lipid content. The amount of hepatic inflammation and fibrosis present was quantitated and compared to that present in liver biopsy specimens obtained at the time of performance of the jejunoileal bypass operation. Hepatic lipid content was compared to that present in the livers of six normal-weight patients with no liver disease, and with liver specimens from twenty morbidly obese patients undergoing gastroplasty operations. Since their jejunoileal bypass operations, hepatic fibrosis has increased in 87% of the patients and hepatic inflammation in 52%. Fibrotic liver disease is currently present in 50% of the patients compared to 10% at the time of performance of the jejunoileal bypass operations. Patients with jejunoileal bypass operations were found to have nine times more hepatic triglyceride than was found in patients with normal livers, and twice as much as identified in obese patients. These results suggest that some patients with jejunoileal bypass operations have severe liver histologic disease associated with increased hepatic triglyceride content. Patients with jejunoileal bypass operations should have periodic histologic evaluation of their liver.

Developing a formulary for enteral nutrition products

A formulary for enteral nutrition products was developed at a university hospital. Advice was solicited from clinical dietetics and the medical staff. Reported important product variables were osmolality, caloric density, protein content and source, fat content and source, freedom from lactose, and, for oral supplements, available flavors. Data were also obtained from manufacturers regarding the composition of their products. Products were categorized as follows: liquid supplemental feedings, high calorie supplemental feedings, isotonic tube feedings, high caloric/high nitrogen tube feedings, high nitrogen tube feedings, and blenderized tube feedings. Bids were solicited in April 1981 (and annually thereafter) from manufacturers of the classified enteral nutrition products, and a contract was signed with the manufacturer in each category submitting the lowest bid. In contrast with previous experience, there was no loss from outdated products during the first year of the formulary. Categorizing enteral nutrition products into therapeutic categories appears to be a workable method to limit the number of products used in a hospital, thereby potentially decreasing inventory, waste, and hospital costs. The descriptive category titles also may encourage rational use of these products without promoting allegiance to a particular company or product.

Repair of aortic coarctation in the first year of life

Twenty-five infants under 1 year of age (mean, 10.3 weeks and 4.0 kg) underwent coarctation repair. Eight had ventricular septal defect (VSD), 3 had transposition of the great arteries with VSD, and 5 had severe tubular hypoplasia. One infant required mitral valve replacement, and 1 required repair of total anomalous pulmonary venous return. Fifteen had repair by primary anastomosis. Seven underwent Dacron or subclavian aortoplasty; the advantages and technique of angioplasty are reviewed. Three patients required bypass grafts. Seventeen patients survived operation. All 5 patients who had severe tubular hypoplasia died postoperatively. The mortality for repair of coarctation with VSD by simultaneous pulmonary artery banding was high; for coarctation with VSD we currently recommend repair without banding, followed by VSD closure if indicated. Three infants have been treated successfully in this manner, with early VSD closure in 1 and regression of the VSD during follow-up in 2. The 17 survivors have been followed for a mean of 41 months with 3 late deaths. Of the 17 survivors, all of whom had a primary anastomosis, 3 have residual gradients. Of the 11 survivors who had preoperative hypertension, 6 are still hypertensive; 3 of these have a gradient between the upper and lower extremities. It is striking that 3 have persistent hypertension despite repair under the age of 1 year.