Nivolumab + Tacrolimus + Prednisone ± Ipilimumab for Kidney Transplant Recipients With Advanced Cutaneous Cancers

PURPOSE

Cancer-related mortality rates among kidney transplant recipients (KTR) are high, but these patients have largely been excluded from trials of immune checkpoint inhibitors because of immunosuppression and risk of treatment-related allograft loss (TRAL). We conducted a prospective clinical trial testing nivolumab (NIVO) + tacrolimus (TACRO) + prednisone (PRED) ± ipilimumab (IPI) in KTR with advanced cutaneous cancers.

METHODS

Adult KTR with advanced melanoma or basal, cutaneous squamous, or Merkel cell carcinomas were eligible. Immunosuppression was standardized to TACRO (serum trough 2-5 ng/mL) + PRED 5 mg once daily. Patients then received NIVO 480 mg IV once every 4 weeks. The primary composite end point was partial or complete (tumor) response (CR) or stable disease per RECIST v1.1 without allograft loss at 16W. Patients with progressive disease (PD) could receive IPI 1 mg/kg IV + NIVO 3 mg/kg once every 3 weeks × 4 followed by NIVO. Donor-derived cell-free DNA (dd-cfDNA) levels were measured approximately once every 2 weeks as a potential predictor of allograft rejection.

RESULTS

Among eight evaluable patients, none met the trial's primary end point. All eight patients experienced PD on NIVO + TACRO + PRED; TRAL occurred in one patient. Six patients then received IPI + NIVO + TACRO + PRED. Best overall responses: two CR (one with TRAL) and four PD (one with TRAL). In total, 7 of 8 pre-NIVO tumor biopsies contained a paucity of infiltrating immune cells. In total, 2 of 5 on-NIVO biopsies demonstrated moderate immune infiltrates; both patients later experienced a CR to IPI + NIVO. In 2 of 3 patients with TRAL, dd-cfDNA elevations occurred 10 and 15 days before increases in serum creatinine.

CONCLUSION

In most KTR with advanced skin cancer, TACRO + PRED provides insufficient allograft protection and compromises immune-mediated tumor regression after administration of NIVO ± IPI. Elevated dd-cfDNA levels can signal treatment-related allograft rejection earlier than rises in serum creatinine.

Postoperative complications of spinal vs general anesthesia in elderly patients undergoing hip hemiarthroplasty

INTRODUCTION

Elderly patients with hip fractures are at high risk for mortality due to postsurgical complications. Hip hemiarthroplasty is a routine procedure done in elderly patients for surgical repair  of femoral neck fractures. Both general and spinal anesthesia can be used in elderly patients undergoing hemiarthroplasty. Rates of postoperative complications among the two anesthetic choices have not been directly compared. In this study, we compare the rates of postoperative complications in elderly patients (age greater than 70) undergoing hip hemiarthroplasty for femoral neck fractures using a national database.

METHODS

Data for the years 2015-2020 from the National Surgical Quality Improvement Program (NSQIP) were used for the study. Patients greater than 70 years of age who received a hip hemiarthroplasty with general anesthesia or spinal anesthesia were identified using CPT procedure codes. Pertinent preoperative variables and rates of postoperative complications were characterized and analyzed.

RESULTS

Our study found that elderly patients who received spinal anesthesia had, on average, longer length of stays but shorter operative times compared to patients who received general anesthesia. Furthermore, we found that patients who received spinal anesthesia had lower rates of systemic sepsis, cardiac arrests, and blood transfusions when compared to patients who received general anesthesia. Finally, we found that overall rates of mortality were significantly lower in the spinal anesthesia cohort compared to the general anesthesia cohort.

CONCLUSION

Our work suggests that patients who underwent spinal anesthesia for hip arthroplasty may have lower rates of postoperative complications. This work further highlights the role of anesthetic choice in preventing complications following hip hemiarthroplasty procedures.

Uncemented Hemiarthroplasty in Displaced Femoral Neck Fractures is associated with Higher Perioperative Surgical Complications but Lower Medical Complications: Analysis from the National Inpatient Database

Objectives

This study aimed to analyze and compare the perioperative outcomes of cemented and uncemented hemiarthroplasty in elderly patients with displaced femoral neck fractures by utilizing the data from the National Inpatient Sample database.

Methods

Data from the National Inpatient Sample Database was analyzed to identify patients who underwent hemiarthroplasty following a displaced femoral neck fracture (cemented and uncemented. Demographic data, comorbidities, length of stay, total charges, and perioperative complications were analyzed.

Results

27390 patients were identified in the cemented group and 29406 in the uncemented group. The patients who underwent uncemented hemiarthroplasty demonstrated a higher incidence of prosthetic dislocation (Odds Ratio (OR) 3.348, p < 0.001), periprosthetic mechanical complications (OR 2.597, p < 0.001), wound dehiscence (OR 2.883, p < 0.001), superficial surgical site infection (OR 2.396, p = 0.043), deep surgical site infection (OR 1.686, p < 0.001), and periprosthetic fractures (OR 2.292, p < 0.001) as compared with patients who underwent cemented hemiarthroplasty. However, patients with uncemented fixation demonstrated a lower incidence of death (OR 0.567, p < 0.001), pulmonary embolism (OR 0.565, p < 0.001), deep vein thrombosis (DVT) (OR 0.746, p < 0.001), myocardial infarction (OR 0.772, p = 0.025) and blood loss anemia (OR 0.869, p < 0.001) as compared with cemented fixation.

Conclusion

Our study on displaced femoral neck fractures utilizing the National Inpatient database found that uncemented hemiarthroplasty was associated with a higher incidence of perioperative surgical complications. Cemented hemiarthroplasty, however, was associated with a statistically significant higher rate of death, pulmonary embolism, deep vein thrombosis, and myocardial infarction.

Patient-Reported Outcome Dashboards Within the Electronic Health Record to Support Shared Decision-making: Protocol for Co-design and Clinical Evaluation With Patients With Advanced Cancer and Chronic Kidney Disease

BACKGROUND

Patient-reported outcomes-symptoms, treatment side effects, and health-related quality of life-are important to consider in chronic illness care. The increasing availability of health IT to collect patient-reported outcomes and integrate results within the electronic health record provides an unprecedented opportunity to support patients' symptom monitoring, shared decision-making, and effective use of the health care system.

OBJECTIVE

The objectives of this study are to co-design a dashboard that displays patient-reported outcomes along with other clinical data (eg, laboratory tests, medications, and appointments) within an electronic health record and conduct a longitudinal demonstration trial to evaluate whether the dashboard is associated with improved shared decision-making and disease management outcomes.

METHODS

Co-design teams comprising study investigators, patients with advanced cancer or chronic kidney disease, their care partners, and their clinicians will collaborate to develop the dashboard. Investigators will work with clinic staff to implement the co-designed dashboard for clinical testing during a demonstration trial. The primary outcome of the demonstration trial is whether the quality of shared decision-making increases from baseline to the 3-month follow-up. Secondary outcomes include longitudinal changes in satisfaction with care, self-efficacy in managing treatments and symptoms, health-related quality of life, and use of costly and potentially avoidable health care services. Implementation outcomes (ie, fidelity, appropriateness, acceptability, feasibility, reach, adoption, and sustainability) during the co-design process and demonstration trial will also be collected and summarized.

RESULTS

The dashboard co-design process was completed in May 2020, and data collection for the demonstration trial is anticipated to be completed by the end of July 2022. The results will be disseminated in at least one manuscript per study objective.

CONCLUSIONS

This protocol combines stakeholder engagement, health care coproduction frameworks, and health IT to develop a clinically feasible model of person-centered care delivery. The results will inform our current understanding of how best to integrate patient-reported outcome measures into clinical workflows to improve outcomes and reduce the burden of chronic disease on patients and health care systems.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/38461.

Shorter versus longer corticosteroid duration and recurrent immune checkpoint inhibitor-associated AKI

BACKGROUND

Corticosteroids are the mainstay of treatment for immune checkpoint inhibitor-associated acute kidney injury (ICPi-AKI), but the optimal duration of therapy has not been established. Prolonged use of corticosteroids can cause numerous adverse effects and may decrease progression-free survival among patients treated with ICPis. We sought to determine whether a shorter duration of corticosteroids was equally efficacious and safe as compared with a longer duration.

METHODS

We used data from an international multicenter cohort study of patients diagnosed with ICPi-AKI from 29 centers across nine countries. We examined whether a shorter duration of corticosteroids (28 days or less) was associated with a higher rate of recurrent ICPi-AKI or death within 30 days following completion of corticosteroid treatment as compared with a longer duration (29-84 days).

RESULTS

Of 165 patients treated with corticosteroids, 56 (34%) received a shorter duration of treatment and 109 (66%) received a longer duration. Patients in the shorter versus longer duration groups were similar with respect to baseline and ICPi-AKI characteristics. Five of 56 patients (8.9%) in the shorter duration group and 12 of 109 (11%) in the longer duration group developed recurrent ICPi-AKI or died (p=0.90). Nadir serum creatinine in the first 14, 28, and 90 days following completion of corticosteroid treatment was similar between groups (p=0.40, p=0.56, and p=0.89, respectively).

CONCLUSION

A shorter duration of corticosteroids (28 days or less) may be safe for patients with ICPi-AKI. However, the findings may be susceptible to unmeasured confounding and further research from randomized clinical trials is needed.

Vessel wall magnetic resonance and arterial spin labelling imaging in the management of presumed inflammatory intracranial arterial vasculopathy

Optimal criteria for diagnosing and monitoring response to treatment for infectious and inflammatory medium–large vessel intracranial vasculitis presenting with stroke are lacking. We integrated intracranial vessel wall MRI with arterial spin labelling into our routine clinical stroke pathway to detect presumed inflammatory intracranial arterial vasculopathy, and monitor disease activity, in patients with clinical stroke syndromes. We used predefined standardized radiological criteria to define vessel wall enhancement, and all imaging findings were rated blinded to clinical details. Between 2017 and 2018, stroke or transient ischaemic attack patients were first screened in our vascular radiology meeting and followed up in a dedicated specialist stroke clinic if a diagnosis of medium–large inflammatory intracranial arterial vasculopathy was radiologically confirmed. Treatment was determined and monitored by a multi-disciplinary team. In this case series, 11 patients were managed in this period from the cohort of young stroke presenters (<55 years). The median age was 36 years (interquartile range: 33,50), of which 8 of 11 (73%) were female. Two of 11 (18%) had herpes virus infection confirmed by viral nucleic acid in the cerebrospinal fluid. We showed improvement in cerebral perfusion at 1 year using an arterial spin labelling sequence in patients taking immunosuppressive therapy for >4 weeks compared with those not receiving therapy [6 (100%) versus 2 (40%) P = 0.026]. Our findings demonstrate the potential utility of vessel wall magnetic resonance with arterial spin labelling imaging in detecting and monitoring medium–large inflammatory intracranial arterial vasculopathy activity for patients presenting with stroke symptoms, limiting the need to progress to brain biopsy. Further systematic studies in unselected populations of stroke patients are needed to confirm our findings and establish the prevalence of medium–large artery wall inflammation.

Nivolumab (NIVO) + tacrolimus (TACRO) + prednisone (PRED) +/- ipilimumab (IPI) for kidney transplant recipients (KTR) with advanced cutaneous cancers

9507

Background: Cancer is a leading cause of death among KTR, but these patients (pts) have been excluded from trials of immune checkpoint inhibitors due to immunosuppression and risk of allograft loss. We report findings from the first prospective clinical trial of NIVO + TACRO + PRED +/- IPI in KTR with selected advanced cutaneous cancers. Methods: The primary composite endpoint was lack of tumor progression per RECIST v1.1 without allograft loss at 16 weeks (W) on NIVO. Adult KTR with advanced melanoma, basal, cutaneous squamous, or Merkel cell carcinoma (MEL, BCC, CSCC, MCC), for whom non-immune therapies were insufficient were eligible. Immunosuppression was standardized to low-dose TACRO (goal trough 2-5 ng/mL) + PRED 5mg daily; pts then received NIVO 480mg IV q4W. Pts with progressive disease (PD) could receive NIVO 3mg/kg + IPI 1mg/kg IV q3W x 4 followed by NIVO 480mg IV q4W. Donor-derived cell-free DNA (dd-cfDNA) levels were measured q2W as a potential predictor of allograft rejection. Results: From 11/2019 - 4/2021, of 12 pts enrolled, 8 pts with CSCC, MCC or MEL were evaluable for response (Table). All pts experienced PD on NIVO; treatment-related allograft loss (TRAL) occurred in 1 pt. 6 pts then received IPI + NIVO. Responses: 2 (33%) with marked tumor regression at 6W and eventual complete response (CR; 1 with TRAL), and 4 (67%) with PD (1 with TRAL). 7/8 pre-NIVO tumor biopsies contained a paucity of infiltrating immune cells. Only 2/5 on-NIVO biopsies demonstrated moderate immune infiltrates; both of these pts later developed a CR to IPI + NIVO. Rejecting allografts contained dense immune responses (plasma cells, CD4+ & CD8+ lymphocytes, PD-1+ lymphocytes, macrophages, PD-L1+ glomerular endothelium, and focal PD-1 & PD-L1 positivity in renal tubules). In 2/3 pts with TRAL, elevations in dd-cfDNA levels occurred 10 and 15 days earlier than increases in weekly serum creatinine levels. TRAL #3 occurred after discontinuation of study therapy (including TACRO) and dd-cfDNA monitoring. Conclusions: In KTR receiving low-dose TACRO + PRED, NIVO augments tumor immune cell infiltration in some pts but is insufficient to mediate tumor regression. Adding IPI can enhance anti-tumor immunity and mediate tumor regression. TACRO + PRED was insufficient to prevent allograft rejection after PD-1 +/- CTLA-4 blockade in 2/8 pts. In pts with TRAL, increased dd-cfDNA levels preceded increased serum creatinine. Based on these findings, we are modifying the trial therapy regimen to augment anti-tumor immunity and preserve allograft function. Clinical trial information: NCT03816332. [Table: see text]

Fetal central nervous system anomalies: When should we offer exome sequencing?

OBJECTIVE

To investigate the detection of pathogenic variants using exome sequencing in an international cohort of fetuses with central nervous system (CNS) anomalies.

METHODS

We reviewed trio exome sequencing (ES) results for two previously reported unselected cohorts (Prenatal Assessment of Genomes and Exomes (PAGE) and CUIMC) to identify fetuses with CNS anomalies with unremarkable karyotypes and chromosomal microarrays. Variants were classified according to ACMG guidelines and association of pathogenic variants with specific types of CNS anomalies explored.

RESULTS

ES was performed in 268 pregnancies with a CNS anomaly identified using prenatal ultrasound . Of those with an isolated, single, CNS anomaly, 7/97 (7.2%) had a likely pathogenic/pathogenic (LP/P) variant. This includes 3/23 (13%) fetuses with isolated mild ventriculomegaly and 3/10 (30%) fetuses with isolated agenesis of the corpus callosum. Where there were multiple anomalies within the CNS, 12/63 (19%) had LP/P variants. Of the 108 cases with CNS and other organ system anomalies, 18 (16.7%) had LP/P findings.

CONCLUSION

ES is an important tool in the prenatal evaluation of fetuses with any CNS anomaly. The rate of LP/P variants tends to be highest in fetuses with multiple CNS anomalies and multisystem anomalies, however, ES may also be of benefit for isolated CNS anomalies.

Erenumab for episodic migraine

In this review, the authors provide an overview of erenumab, a monoclonal antibody used for the preventative treatment of episodic migraine by targeting the CGRP pathway. Randomized controlled trials have shown that erenumab is associated with a statistically significant decrease in monthly migraine days in patients with episodic migraine at monthly doses of 70 or 140 mg when given for a period of 9-12 weeks. Post hoc analyses have also shown long-term maintenance of efficacy. Clinical trials have found erenumab at doses of both 70 and 140 mg to have a favorable safety profile. Erenumab faces significant limitations because of its high financial cost. Additional long-term real-world data are needed to understand the role of erenumab in the treatment of migraine.

TAFRO Syndrome and Elusive Diagnosis of Idiopathic Multicentric Castleman Disease Treated with Empiric Anti-Interleukin-6 Therapy

TAFRO syndrome is defined by the presence of thrombocytopenia (T), anasarca (A), fever (F), reticulin fibrosis/renal dysfunction (R), and organomegaly (O) and can be seen with idiopathic multicentric Castleman disease (iMCD) or as an isolated process without iMCD. Although the diagnosis of iMCD in patients with TAFRO can be challenging to make, iMCD should remain high on the differential diagnosis. Similar to iMCD, the pathophysiology of TAFRO is not well understood but is thought to be related to hypercytokinemia, with interleukin (IL)-6 playing a pivotal role. Anti-IL-6 monoclonal antibody therapy is an effective treatment modality for iMCD, but to date, there is no clear guidance on treatment of TAFRO in the absence of definitive diagnosis of iMCD, leading to suboptimal management and high morbidity. We report a case of TAFRO syndrome and demonstrate benefit with the empiric use of anti-IL-6 antibody therapy in the context of delayed diagnosis of iMCD.

Acute kidney injury in patients treated with immune checkpoint inhibitors

Background

Immune checkpoint inhibitor-associated acute kidney injury (ICPi-AKI) has emerged as an important toxicity among patients with cancer.

Methods

We collected data on 429 patients with ICPi-AKI and 429 control patients who received ICPis contemporaneously but who did not develop ICPi-AKI from 30 sites in 10 countries. Multivariable logistic regression was used to identify predictors of ICPi-AKI and its recovery. A multivariable Cox model was used to estimate the effect of ICPi rechallenge versus no rechallenge on survival following ICPi-AKI.

Results

ICPi-AKI occurred at a median of 16 weeks (IQR 8–32) following ICPi initiation. Lower baseline estimated glomerular filtration rate, proton pump inhibitor (PPI) use, and extrarenal immune-related adverse events (irAEs) were each associated with a higher risk of ICPi-AKI. Acute tubulointerstitial nephritis was the most common lesion on kidney biopsy (125/151 biopsied patients [82.7%]). Renal recovery occurred in 276 patients (64.3%) at a median of 7 weeks (IQR 3–10) following ICPi-AKI. Treatment with corticosteroids within 14 days following ICPi-AKI diagnosis was associated with higher odds of renal recovery (adjusted OR 2.64; 95% CI 1.58 to 4.41). Among patients treated with corticosteroids, early initiation of corticosteroids (within 3 days of ICPi-AKI) was associated with a higher odds of renal recovery compared with later initiation (more than 3 days following ICPi-AKI) (adjusted OR 2.09; 95% CI 1.16 to 3.79). Of 121 patients rechallenged, 20 (16.5%) developed recurrent ICPi-AKI. There was no difference in survival among patients rechallenged versus those not rechallenged following ICPi-AKI.

Conclusions

Patients who developed ICPi-AKI were more likely to have impaired renal function at baseline, use a PPI, and have extrarenal irAEs. Two-thirds of patients had renal recovery following ICPi-AKI. Treatment with corticosteroids was associated with improved renal recovery.

Renal Considerations in COVID-19: Biology, Pathology, and Pathophysiology

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has emerged into a worldwide pandemic of epic proportion. Beyond pulmonary involvement in coronavirus disease 2019 (COVID-19), a significant subset of patients experiences acute kidney injury. Patients who die from severe disease most notably show diffuse acute tubular injury on postmortem examination with a possible contribution of focal macro- and microvascular thrombi. Renal biopsies in patients with proteinuria and hematuria have demonstrated a glomerular dominant pattern of injury, most notably a collapsing glomerulopathy reminiscent of findings seen in human immunodeficiency virus (HIV) in individuals with apolipoprotein L-1 (APOL1) risk allele variants. Although various mechanisms have been proposed for the pathogenesis of acute kidney injury in SARS-CoV-2 infection, direct renal cell infection has not been definitively demonstrated and our understanding of the spectrum of renal involvement remains incomplete. Herein we discuss the biology, pathology, and pathogenesis of SARS-CoV-2 infection and associated renal involvement. We discuss the molecular biology, risk factors, and pathophysiology of renal injury associated with SARS-CoV-2 infection. We highlight the characteristics of specific renal pathologies based on native kidney biopsy and autopsy. Additionally, a brief discussion on ancillary studies and challenges in the diagnosis of SARS-CoV-2 is presented.

Fetal exome sequencing for isolated increased nuchal translucency: should we be doing it?

Objective

To evaluate the utility of prenatal exome sequencing (ES) for isolated increased nuchal translucency (NT) and to investigate factors that increase diagnostic yield.

Design

Retrospective analysis of data from two prospective cohort studies.

Setting

Fetal medicine centres in the UK and USA.

Population

Fetuses with increased NT ≥3.5 mm at 11–14 weeks of gestation recruited to the Prenatal Assessment of Genomes and Exomes (PAGE) and Columbia fetal whole exome sequencing studies (n = 213).

Methods

We grouped cases based on (1) the presence of additional structural abnormalities at presentation in the first trimester or later in pregnancy, and (2) NT measurement at presentation. We compared diagnostic rates between groups using Fisher exact test.

Main outcome measures

Detection of diagnostic genetic variants considered to have caused the observed fetal structural anomaly.

Results

Diagnostic variants were detected in 12 (22.2%) of 54 fetuses presenting with non‐isolated increased NT, 12 (32.4%) of 37 fetuses with isolated increased NT in the first trimester and additional abnormalities later in pregnancy, and 2 (1.8%) of 111 fetuses with isolated increased NT in the first trimester and no other abnormalities on subsequent scans. Diagnostic rate also increased with increasing size of NT.

Conclusions

The diagnostic yield of prenatal ES is low for fetuses with isolated increased NT but significantly higher where there are additional structural anomalies. Prenatal ES may not be appropriate for truly isolated increased NT but timely, careful ultrasound scanning to identify other anomalies emerging later can direct testing to focus where there is a higher likelihood of diagnosis.

Prenatal ES has a low diagnostic rate (<2%) for isolated increased NT but is significantly more likely to yield a diagnosis where there are additional fetal structural anomalies.

Linked article This article is commented on by AN Talati and NL Vora, p. 61–62 in this issue. To view this mini commentary visit https://doi.org/10.1111/1471-0528.16942.

AL Amyloidosis Presenting With Crescentic Glomerulonephritis

Kidney amyloidosis typically presents with nephrotic-range proteinuria. Rare cases of crescentic glomerulonephritis have been reported in patients with kidney amyloidosis but most cases were in the setting of patients with AA amyloidosis from long-standing inflammation and malignancy. We present a case of a previously healthy man in his 70s who was admitted with severe acute kidney injury, nephrotic-range proteinuria, and nephritic urinary sediment. Initial serologic testing for causes of rapidly progressive glomerulonephritis were negative. Kidney biopsy demonstrated the presence of active cellular and fibrocellular crescents with Congo red-positive staining in glomeruli and microvasculature on light microscopy and amyloid fibrils in glomerular basement membrane on electron microscopy. Urinary protein electrophoresis revealed monoclonal λ light chains, leading to a diagnosis of kidney AL amyloidosis, which was confirmed with bone marrow biopsy. Our case illustrates that AL amyloidosis can present with findings suspicious for rapidly progressive glomerulonephritis and crescent formation on kidney biopsy specimens.

Severe jejunitis masquerading as intussusception in a case of Henoch-Schönlein purpura

Intussusception is a well-known complication of Henoch-Schönlein purpura (HSP).1 Diagnosis of intussusception is based on well-defined clinical and radiological features, but certain conditions can mimic intussusception, both clinically and radiologically, so closely as to result in unnecessary invasive procedures. Authors here present a case of HSP complicated by severe acute jejunitis, masquerading as jejuno-jejunal intussusception on ultrasound.

COVID-19-Associated Glomerular Disease

BACKGROUND

Studies have documented AKI with high-grade proteinuria in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In some patients, biopsies have revealed collapsing glomerulopathy, a distinct form of glomerular injury that has been associated with other viruses, including HIV. Previous patient reports have described patients of African ancestry who developed nephrotic-range proteinuria and AKI early in the course of disease.

METHODS

In this patient series, we identified six patients with coronavirus disease 2019 (COVID-19), AKI, and nephrotic-range proteinuria. COVID-19 was diagnosed by a positive nasopharyngeal swab RT-PCR for SARS-CoV-2 infection. We examined biopsy specimens from one transplanted kidney and five native kidneys. Three of the six patients underwent genetic analysis of APOL1, the gene encoding the APOL1 protein, from DNA extracted from peripheral blood. In addition, we purified genomic DNA from paraffin-embedded tissue and performed APOL1 genotype analysis of one of the native biopsies and the donor kidney graft.

RESULTS

All six patients were of recent African ancestry. They developed COVID-19-associated AKI with podocytopathy, collapsing glomerulopathy, or both. Patients exhibited generally mild respiratory symptoms, and no patient required ventilator support. Genetic testing performed in three patients confirmed high-risk APOL1 genotypes. One APOL1 high-risk patient developed collapsing glomerulopathy in the engrafted kidney, which was transplanted from a donor who carried a low-risk APOL1 genotype; this contradicts current models of APOL1-mediated kidney injury, and suggests that intrinsic renal expression of APOL1 may not be the driver of nephrotoxicity and specifically, of podocyte injury.

CONCLUSIONS

Glomerular disease presenting as proteinuria with or without AKI is an important presentation of COVID-19 infection and may be associated with a high-risk APOL1 genotype.

Telehealth for Home Dialysis in COVID-19 and Beyond: A Perspective From the American Society of Nephrology COVID-19 Home Dialysis Subcommittee

The coronavirus disease 2019 (COVID-19) pandemic, technological advancements, regulatory waivers, and user acceptance have converged to boost telehealth activities. Due to the state of emergency, regulatory waivers in the United States have made it possible for providers to deliver and bill for services across state lines for new and established patients through Health Insurance Portability and Accountability Act (HIPAA)- and non–HIPAA-compliant platforms with home as the originating site and without geographic restrictions. Platforms have been developed or purchased to perform videoconferencing, and interdisciplinary dialysis teams have adapted to perform virtual visits. Telehealth experiences and challenges encountered by dialysis providers, clinicians, nurses, and patients have exposed health care disparities in areas such as access to care, bandwidth connectivity, availability of devices to perform telehealth, and socioeconomic and language barriers. Future directions in telehealth use, quality measures, and research in telehealth use need to be explored. Telehealth during the public health emergency has changed the practice of health care, with the post–COVID-19 world unlikely to resemble the prior era. The future impact of telehealth in patient care in the United States remains to be seen, especially in the context of the Advancing American Kidney Health Initiative.

Hemodialysis-induced bradycardia, "a plumbing issue": Resolved with catheter repositioning

Sudden cardiac death (SCD) is reported as leading cause of death in patients on chronic hemodialysis. Arrhythmias are proposed to be a major predisposing factor for SCD. However, triggers for potentially lethal arrhythmias are not well understood. Here we describe a case of 72-year-old man on chronic hemodialysis via permanent Central venous catheter (CVC) who was admitted for evaluation after unwitnessed fall. Within 10 minutes of his first routine dialysis session in the hospital, he had cardiac-arrest. He was successfully resuscitated within 3 minutes. The next day, fifteen minutes into the dialysis session, he had bradycardia with telemetry demonstrating long sinus pause and he lost consciousness. After few minutes of Advanced Cardiac Life Support (ACLS) he regained pulse and consciousness. Further review of the chest X-ray revealed the tip of CVC to be directly touching the distal Superior Vena Cava (SVC) wall. We felt the catheter tip may have migrated after the fall and now is irritating the Sinoatrial node and triggering bradyarrhythmia. Next day, the CVC was exchanged, and the tip was placed higher up in superior vena-cava. After repositioning, we started him on dialysis under intensive monitoring, and he tolerated well without any arrhythmia. Subsequent dialysis was uneventful. We describe a case of recurrent symptomatic intra-dialytic bradycardia due to abnormal positioning of CVC that resolved after the repositioning of the catheter. This case in addition to similar case in nondialysis settlings provides additional insights into mechanisms of fatal arrhythmias in hemodialysis patient having CVC.

Application of Calcium Silicate Materials After Acid Etching May Preserve Resin-Dentin Bonds

INTRODUCTION

The aim of the present study was to evaluate the effect of the application of calcium silicate materials (CSMs), after acid etching, on the longevity of the hybrid layer and marginal adaptation of composite restorations.

METHODS AND MATERIALS

Eighty human permanent molars received an intrapulpal pressure of 15 cm H₂O. Sixty teeth received a mesial proximal slot preparation with the gingival margin extending 1 mm below the cemento-enamel junction. The samples were divided into two groups. Group 1 received restorations using two types of etch-and-rinse adhesives: ethanol based (Single Bond, 3M ESPE, St Paul, MN, USA) and acetone based (Prime & Bond NT, Dentsply, DeTrey GmbH, Germany). In group 2 samples, a commercially available CSM (ProRoot MTA) was allowed to set before grinding and placing into a distilled water solution. This solution was applied on the cavity floor after acid etching. The surface was washed after 30 seconds followed by application of adhesives and restorations as in group 1. The samples were stored in phosphate-buffered saline for six months, maintaining the intrapulpal pressure. An epoxy replica was made, and the marginal adaptation was evaluated using scanning electron microscopy. The percentage of continuous margin (CM) was recorded for each group. Another 20 samples were used for hybrid layer evaluation. The crowns were ground to expose dentin. Intrapulpal pressure was applied. The samples were divided into two groups and restored similar to samples restored for marginal adaptation evaluation. The samples were longitudinally cut in 1-mm slices. The slices were stored under 15 cm of phosphate-buffered saline to simulate the pulpal pressure. After six months, the adhesive interface was evaluated using a scanning electron microscope. Statistical analysis was done with two-way analysis of variance with Holm-Sidak's correction for multiple comparisons.

RESULTS

Application of CSMs improved the marginal adaptation values in both adhesive groups. In group 1, there were areas of incomplete penetration of resins along with evidence of partial degradation of resin tags. Samples receiving CSM application after acid etching demonstrated long and regular resin tags with very few signs of degradation.

CONCLUSIONS

Application of CSMs after acid etching can be a potential avenue in preserving the resin-dentin bonds.

Does the volume of supplemental intraligamentary injections affect the anaesthetic success rate after a failed primary inferior alveolar nerve block? A randomized-double blind clinical trial

AIM

To investigate the efficacy of 0.2 mL vs. 0.6 mL of 2% lidocaine when given as a supplementary intraligamentary injection after a failed inferior alveolar nerve block (IANB).

METHODOLOGY

Ninety-seven adult patients with symptomatic irreversible pulpits received an IANB and root canal treatment was initiated. Pain during treatment was recorded using a visual analogue scale (Heft-Parker VAS). Patients with unsuccessful anaesthesia (n = 78) randomly received intraligamentary injection of either 0.2 mL or 0.6 mL of 2% lidocaine with 1 : 80 000 epinephrine. Root canal treatment was reinitiated. Success after primary injection or supplementary injection was defined as no or mild pain (HP VAS score ≤54 mm) during access preparation and root canal instrumentation. Heart rate was monitored using a finger pulse oximeter. The anaesthetic success rates were analysed with Pearson chi-square test at 5% significance levels. The heart rate changes were analysed using t-tests.

RESULTS

The intraligamentary injections with 0.2 mL solution gave an anaesthetic success rate of 64%, whilst the 0.6 mL was successful in 84% of cases with failed primary IANB. (χ²  = 4.3, P = 0.03). There was no significant effect of the volume of intraligamentary injection on the change in heart rate.

CONCLUSIONS

Increasing the volume of intraligamentary injection improved the success rates after a failed primary anaesthetic injection.

Influence of instrument size and varying electrical resistance of root canal instruments on accuracy of three electronic root canal length measurement devices

AIM

To evaluate the influence of instrument size and the effect of the electrical resistance of endodontic instruments on the accuracy of three electronic root canal length measurement devices (ERCLMDs).

METHODOLOGY

Thirty single-rooted extracted human teeth were divided into three groups (n = 10) on the basis of the ERCLMD used: Root ZX II (J. Morita, Kyoto, Japan); ProPex (Dentsply Maillefer, Ballaigues, Switzerland); and iPex II (NSK, Tochigi, Japan). The electronic working length measurements (EWL) were made with K-files in the sequence sizes 08, 10, 15, 20, 25 and 30. The actual working length (AWL) was calculated by fixing a size 30 K-file in the canal and exposing the apical 5 mm of the root. The minor foramen was identified under an optical microscope, and its distance from the file tip was calculated. The accuracy of the ERCLMDs was evaluated in terms of percentages of accurate measurements (0.0 mm tolerance) and measurements with tolerance limits of ±0.5 mm and ±1.0 mm. The findings were analysed with the McNemar test, Pearson's chi-square tests and two-way analysis of variance. The multiple comparison procedures were carried out using Holm-Sidak method. The maximum electrical resistance tolerated by ERCLMDs was evaluated by connecting commercially available resistors between the file clip and the root canal instrument. The resistance was gradually increased until it started to affect the ERCLMD readings.

RESULTS

The ERCLMDs were able to actually locate the minor foramen in 7% of samples. File size did not affect the accuracy of ERCLMDs (P > 0.05). Overall, the ERCLMDs gave 65% readings within a tolerance limit of ±0.5 mm and 90% within a tolerance of ±1.0 mm. The electrical resistance of endodontic files was less than the maximum electrical resistance tolerated by ERCLMDs (0.6-1 Ω vs. 2500-4000 Ω).

CONCLUSIONS

The size of the root canal instrument did not affect the accuracy of ERCLMDs in this laboratory study.

Amperometric determination of serum total cholesterol with nanoparticles of cholesterol esterase and cholesterol oxidase

We describe the preparation of glutaraldehyde cross-linked and functionalized cholesterol esterase nanoparticles (ChENPs) and cholesterol oxidase nanoparticles (ChOxNPs) aggregates and their co-immobilization onto Au electrode for improved amperometric determination of serum total cholesterol. Transmission electron microscope (TEM) images of ChENPs and ChOxNPs showed their spherical shape and average size of 35.40 and 56.97 nm, respectively. Scanning electron microscope (SEM) studies of Au electrode confirmed the co-immobilization of enzyme nanoparticles (ENPs). The biosensor exhibited optimal response at pH 5.5 and 40°C within 5 s when polarized at +0.25 V versus Ag/AgCl. The working/linear range of the biosensor was 10-700 mg/dl for cholesterol. The sensor showed high sensitivity and measured total cholesterol as low as 0.1 mg/dl. The biosensor was evaluated and employed for total cholesterol determination in sera of apparently healthy and diseased persons. The analytical recovery of added cholesterol was 90%, whereas the within-batch and between-batch coefficients of variation (CVs) were less than 2% and less than 3%. There was a good correlation (r = 0.99) between serum cholesterol values as measured by the standard enzymic colorimetric method and the current method. The initial activity of ENPs/working electrode was reduced by 50% during its regular use (200 times) over a period of 60 days when stored dry at 4°C.

Rational Design of Nanoparticle Platforms for "Cutting-the-Fat": Covalent Immobilization of Lipase, Glycerol Kinase, and Glycerol-3-Phosphate Oxidase on Metal Nanoparticles

The aggregates of nanoparticles (NPs) are considered better supports for the immobilization of enzymes, as these promote enzyme kinetics, due to their unusual but favorable properties such as larger surface area to volume ratio, high catalytic efficiency of certain immobilized enzymes, non-toxicity of some of the nanoparticle matrices, high stability, strong adsorption of the enzyme of interest by a number of different approaches, and faster electron transportability. Co-immobilization of multiple enzymes required for a multistep reaction cascade on a single support is more efficient than separately immobilizing the corresponding enzymes and mixing them physically, since products of one enzyme could serve as reactants for another. These products can diffuse much more easily between enzymes on the same particle than diffusion from one particle to the next, in the reaction medium. Thus, co-immobilization of enzymes onto NP aggregates is expected to produce faster kinetics than their individual immobilizations on separate matrices. Lipase, glycerol kinase, and glycerol-3-phosphate oxidase are required for lipid analysis in a cascade reaction, and we describe the co-immobilization of these three enzymes on nanocomposites of zinc oxide nanoparticles (ZnONPs)-chitosan (CHIT) and gold nanoparticles-polypyrrole-polyindole carboxylic acid (AuPPy-Pin5COOH) which are electrodeposited on Pt and Au electrodes, respectively. The kinetic properties and analytes used for amperometric determination of TG are fully described for others to practice in a trained laboratory. Cyclic voltammetry, scanning electron microscopy, Fourier transform infra-red spectra, and electrochemical impedance spectra confirmed their covalent co-immobilization onto electrode surfaces through glutaraldehyde coupling on CHIT-ZnONPs and amide bonding on AuPPy/Pin5COOH. The combined activities of co-immobilized enzymes was tested amperometrically, and these composite nanobiocatalysts showed optimum activity within 4-5s, at pH 6.5-7.5 and 35°C, when polarized at a potential between 0.1 and 0.4V. Co-immobilized enzymes showed excellent linearity within 50-700mg/dl of the lipid with detection limit of 20mg/dl for triolein. The half life of co-immobilized enzymes was 7 months, when stored dry at 4°C which is very convenient for practical applications. Co-immobilized biocatalysts measured triglycerides in the sera of apparently healthy persons and persons suffering from hypertriglyceridemia, which is recognized as a leading cause for heart disease. The measurement of serum TG by co-immobilized enzymes was unaffected by the presence of a number of serum substances, tested as potential interferences. Thus, co-immobilization of enzymes onto aggregates of NPs resulted in improved performance for TG analysis.

Principal components of hand kinematics and neurophysiological signals in motor cortex during reach to grasp movements

A few kinematic synergies identified by principal component analysis (PCA) account for most of the variance in the coordinated joint rotations of the fingers and wrist used for a wide variety of hand movements. To examine the possibility that motor cortex might control the hand through such synergies, we collected simultaneous kinematic and neurophysiological data from monkeys performing a reach-to-grasp task. We used PCA, jPCA and isomap to extract kinematic synergies from 18 joint angles in the fingers and wrist and analyzed the relationships of both single-unit and multiunit spike recordings, as well as local field potentials (LFPs), to these synergies. For most spike recordings, the maximal absolute cross-correlations of firing rates were somewhat stronger with an individual joint angle than with any principal component (PC), any jPC or any isomap dimension. In decoding analyses, where spikes and LFP power in the 100- to 170-Hz band each provided better decoding than other LFP-based signals, the first PC was decoded as well as the best decoded joint angle. But the remaining PCs and jPCs were predicted with lower accuracy than individual joint angles. Although PCs, jPCs or isomap dimensions might provide a more parsimonious description of kinematics, our findings indicate that the kinematic synergies identified with these techniques are not represented in motor cortex more strongly than the original joint angles. We suggest that the motor cortex might act to sculpt the synergies generated by subcortical centers, superimposing an ability to individuate finger movements and adapt the hand to grasp a wide variety of objects.

Comparison of the anaesthetic efficacy of different volumes of 4% articaine (1.8 and 3.6 mL) as supplemental buccal infiltration after failed inferior alveolar nerve block

AIM

To compare the anaesthetic efficacy of different volumes (1.8 mL vs. 3.6 mL) of 4% articaine with 1 : 100 000 epinephrine injected as buccal infiltrations after a failed inferior alveolar nerve block (IANB) in patients with symptomatic irreversible pulpitis.

METHODOLOGY

Two hundred and thirty-four adult patients, diagnosed with irreversible pulpitis in a mandibular tooth, participated in this multicentre, randomized double-blinded trial. Patients received IANB with 1.8 mL of 4% articaine with 1 : 100 000 epinephrine. Pain during treatment was recorded using the Heft-Parker visual analogue scale (HP VAS). The primary outcome measure, and the definition of 'success', was the ability to undertake pulp chamber access and canal instrumentation with no or mild pain (HP VAS score <55 mm). Patients who experienced 'moderate-to-severe' pain (HP VAS score ≥ 55 mm) were randomly allocated into two groups and received buccal infiltrations with either 1.8 mL or 3.6 mL of 4% articaine with 1 : 100 000 epinephrine. Root canal treatment was re-initiated after 10 min. Success was again defined as no pain or weak/mild pain during endodontic access preparation and instrumentation. Statistical analysis was performed using Mann-Whitney U and chi-square tests.

RESULTS

The initial IANB of 4% articaine gave an overall success rate of 37%. The success rate of supplementary buccal infiltration with 1.8 and 3.6 mL volumes was 62% and 64%, respectively. The difference between the success rates of the two volumes was not statistically significant.

CONCLUSIONS

Increasing the volume of 4% articaine with 1 : 100 000 epinephrine from 1.8 to 3.6 mL, given as supplementary buccal infiltrations after a failed primary IANB with 1.8 mL of 4% articaine with 1 : 100 000, did not improve the anaesthetic success rates in patients with symptomatic irreversible pulpitis.

Comparison of the anaesthetic efficacy of epinephrine concentrations (1 : 80 000 and 1 : 200 000) in 2% lidocaine for inferior alveolar nerve block in patients with symptomatic irreversible pulpitis: a randomized, double-blind clinical trial

AIM

The aim of this randomized controlled, double-blind trial was to comparatively evaluate the anaesthetic efficacy and injection pain of 1.8 mL of 2% lidocaine with different concentrations of epinephrine (1 : 80 000 and 1 : 200 000) in patients with symptomatic irreversible pulpitis.

METHODOLOGY

Sixty-two adult volunteers, actively experiencing pain, were randomly allocated into 2 groups and received 1.8 mL of 2% lidocaine with either 1 : 80 000 or 1 : 200 000 epinephrine concentration. Endodontic access preparation was initiated 15 min after the initial IANB. Pain during treatment was recorded using the Heft-Parker visual analogue scale (HP VAS). The primary outcome measure, and the definition of 'success', was the ability to undertake pulp access and canal instrumentation with no or mild pain (HP VAS score <55 mm). Secondary outcome measure was the pain experienced during LA solution deposition. Statistical analysis was performed using Mann-Whitney U-test and chi-square test.

RESULTS

The anaesthetic success rates of 2% lidocaine solutions containing 1 : 80 000 and 1 : 200 000 epinephrine concentrations were 20% and 28%, respectively. The difference was not statistically significant. There was also no significant difference in the pain experienced during deposition of the solutions.

CONCLUSIONS

Two percent lidocaine solution used for IANB achieved similar success rates when used with 1 : 80 000 or 1 : 200 000 epinephrine concentration.

State-based decoding of hand and finger kinematics using neuronal ensemble and LFP activity during dexterous reach-to-grasp movements

The performance of brain-machine interfaces (BMIs) that continuously control upper limb neuroprostheses may benefit from distinguishing periods of posture and movement so as to prevent inappropriate movement of the prosthesis. Few studies, however, have investigated how decoding behavioral states and detecting the transitions between posture and movement could be used autonomously to trigger a kinematic decoder. We recorded simultaneous neuronal ensemble and local field potential (LFP) activity from microelectrode arrays in primary motor cortex (M1) and dorsal (PMd) and ventral (PMv) premotor areas of two male rhesus monkeys performing a center-out reach-and-grasp task, while upper limb kinematics were tracked with a motion capture system with markers on the dorsal aspect of the forearm, hand, and fingers. A state decoder was trained to distinguish four behavioral states (baseline, reaction, movement, hold), while a kinematic decoder was trained to continuously decode hand end point position and 18 joint angles of the wrist and fingers. LFP amplitude most accurately predicted transition into the reaction (62%) and movement (73%) states, while spikes most accurately decoded arm, hand, and finger kinematics during movement. Using an LFP-based state decoder to trigger a spike-based kinematic decoder [r = 0.72, root mean squared error (RMSE) = 0.15] significantly improved decoding of reach-to-grasp movements from baseline to final hold, compared with either a spike-based state decoder combined with a spike-based kinematic decoder (r = 0.70, RMSE = 0.17) or a spike-based kinematic decoder alone (r = 0.67, RMSE = 0.17). Combining LFP-based state decoding with spike-based kinematic decoding may be a valuable step toward the realization of BMI control of a multifingered neuroprosthesis performing dexterous manipulation.

Neuron Selection by Relative Importance for Neural Decoding of Dexterous Finger Prosthesis Control Application

Future generations of upper limb prosthesis will have dexterous hand with individual fingers and will be controlled directly by neural signals. Neurons from the primary motor (M1) cortex code for finger movements and provide the source for neural control of dexterous prosthesis. Each neuron's activation can be quantified by the change in firing rate before and after finger movement, and the quantified value is then represented by the neural activity over each trial for the intended movement. Since this neural activity varies with the intended movement, we define the relative importance of each neuron independent of specific intended movements. The relative importance of each neuron is determined by the inter-movement variance of the neural activities for respective intended movements. Neurons are ranked by the relative importance and then a subpopulation of rank-ordered neurons is selected for the neural decoding. The use of the proposed neuron selection method in individual finger movements improved decoding accuracy by 21.5% in the case of decoding with only 5 neurons and by 9.2% in the case of decoding with only 10 neurons. With only 15 highly-ranked neurons, a decoding accuracy of 99.5% was achieved. The performance improvement is still maintained when combined movements of two fingers were included though the decoding accuracy fell to 95.7%. Since the proposed neuron selection method can achieve the targeting accuracy of decoding algorithms with less number of input neurons, it can be significant for developing brain-machine interfaces for direct neural control of hand prostheses.

Esophageal Foreign Body in a Neonate: An Unusual Age of Presentation

Ingestion of foreign bodies in neonates is very rare and can be life threatening. We describe a 20 days old neonate presented with vomiting, drooling of saliva and poor feeding tolerance. Chest radiograph showed a metallic foreign body in superior mediastinum. Foreign body was removed by rigid oesophagoscopy. The case describes the unusual age of presentation of foreign body and options available to remove these foreign bodies in neonates. Key words: Esophagus; Foreign body; Neonate DOI: http://dx.doi.org/10.3126/jnps.v32i1.5306   J. Nepal Paediatr. Soc. Vol.32(1) 2012 79-80

Identifying neuron communities during a reach and grasp task using an unsupervised clustering analysis

Recent advances in brain-machine interfaces (BMIs) have allowed for high density recordings using microelectrode arrays. However, these large datasets present a challenge in how to practically identify features of interest and discard non-task-related neurons. Thus, we apply a previously reported unsupervised clustering analysis to neural data acquired from a non-human primate as it performed a center-out reach-and-grasp task. Although neurons were recorded from multiple arrays across motor and premotor areas, neurons were found to cluster into only two groups which differ by their mean firing rate. No spatial distribution of neurons was evident in different groups, either across arrays or at different depths. Using a Kalman filter to decode arm, hand, and finger kinematics, we find that using neurons from only one of the groups resulted in higher decoding accuracy (r=0.73) than using randomly selected neurons (r=0.68). This suggests that the proposed method can be used to prune the input space and identify an optimal population of neurons for BMI tasks.

Noonan syndrome: an anesthesiologist's perspective

Noonan syndrome (NS) is one of the most common non chromosomal syndrome presenting to the cardiac anesthesiologist for the management of various cardiac lesions, predominantly pulmonary stenosis (PS) (80%) and hypertrophic obstructive cardiomyopathy (HOCM) (30%). The presence of HOCM in NS makes these children susceptible to acute congestive heart failure due to hemodynamic fluctuations, thus necessitating optimization of drug and fluid therapy, careful conduct of anesthesia and providing adequate analgesia in the perioperative period. We describe a case of four year old boy with NS who presented to us for the management of PS and HOCM. In our case, transesophageal echocardiography (TEE) played a major role in confirmation of the preoperative findings, detection of any new anomalies missed during the preoperative evaluation, intraoperative monitoring and assessment of the adequacy of repair in the immediate postoperative period. TEE provided invaluable help in taking critical surgical decisions, resulting in a favorable outcome.