Summary The Fontan operation is a widely used palliative procedure in patients with single ventricle anatomy that results in liver injury. As timely identification of liver fibrosis may result in ...management changes to Fontan patients, the aim of our study was to identify clinically meaningful semi-quantitative/quantitative pathologic parameters for biopsy assessment. We performed a retrospective review of 74 liver needle biopsies from Fontan patients. Fibrosis was assessed using quantitative % collagen deposition (%CD) by Sirius red image analysis, METAVIR, congestive hepatic fibrosis score (CHFS), sinusoidal fibrosis (SF) score, and sinusoidal dilation score. Contemporaneous laboratory, hemodynamic, and ultrasound data were collected. Centrilobular and peri-sinusoidal fibrosis was observed in all cases, with 39.2% high grade. Portal fibrosis was observed in 93.2%, with 36.2% high grade (METAVIR F3-F4). Cirrhosis was observed in 5.4%. %CD was increased over control tissue (p<0.001) and correlated with time from Fontan (r=0.3, p=0.009) and prothrombin time (PT) (r=0.25, p=0.034). Mildly elevated PT/INR was the only measure of liver function consistently associated with multiple high-grade fibrosis scores (METAVIR p=0.046, SF p=0.018). Abnormal liver echotexture on ultrasound was associated with high grade CHFS (p=0.03). Pathologic gradings and %CD correlated with each other (r=0.48-0.8, p<0.001). Hepatic fibrosis in Fontan patients in our study is universally present, appears to be time dependent, and correlates with few laboratory measurements of liver function. Careful assessment of needle liver biopsies lends a more meaningful measure of liver fibrosis in the Fontan patient than clinical and laboratory data, allowing for appropriate changes to patient management.
Bt technologies have played a major role in the control of bollworm, Helicoverpa zea (Boddie) (Lepidoptera: Noctuidae), in cotton.Variation in expression levels among varieties and plant parts, along ...with selection pressure on bollworm populations, has led to the development of resistance to some Bt proteins. Trials were conducted to evaluate how cotton varieties expressing different Bt proteins affect bollworm larval behavior and their damage in flowering cotton. Differences in larval recovery were observed among cotton varieties at 3 d with 3-gene Bt cotton having the lowest recovery and non-Bt cotton having the greatest recovery. Loss of bloom tags and abscission of small bolls at the site of infestation affected bollworm larval recovery among varieties. Day after infestation was the main factor that affected bollworm movement across all varieties. Number of total damaged fruiting forms by an individual bollworm larva was different among all varieties. Overall, flower bud (square) and fruit (boll) damage by an individual larva was lower on 3-gene cotton than 2-gene cotton and non-Bt cotton. An individual larva damaged fewer squares on 2-gene cotton than non-Bt cotton, but boll damage from bollworm was similar among 2-gene cotton and non-Bt cotton. The level of square and boll damage in 2-gene cotton has increased compared to previous research further supporting the occurrence of bollworm resistance to Cry proteins. The 3-gene cotton containing the Vip3A gene experienced low levels of damage and survival. These results will be important for improving management recommendations of bollworm in Bt cotton technologies.
Purpose We sought to evaluate the clinical and radiographic outcomes after treatment of symptomatic, recalcitrant scaphoid nonunions using a novel combination of volar scaphoid buttress plating with ...a pedicled vascularized bone graft. Methods We retrospectively followed 9 patients with recalcitrant scaphoid waist nonunions, characterized by failed prior surgery, long duration of nonunion, avascular necrosis of the proximal pole, or considerable bone loss at the nonunion site. We treated these persistent nonunions through a single volar incision with a pedicled vascularized bone graft, based on the volar carpal artery, and a 1.5-mm precontoured, scaphoid-specific, volar buttress plate. Postoperatively, we assessed objective and subjective outcomes as well as radiographs and computed tomography scans. Results The median duration of nonunion was 15 months, ranging from 6 to 96 months. Postoperative follow-up ranged from 11 to 19 months. Computed tomography scans demonstrated union in 8 of 9 cases. Complications included 1 minor hematoma that spontaneously resolved. One scaphoid failed to unite, requiring revision surgery. Three patients experienced problems with the plate. One plate was removed from a patient who noted persistent clicking, and 2 plates have caused symptomatic clicking, likely requiring future removal. Eight of nine patients reported satisfaction with the procedure, with Quick Dash scores averaging 8.2. Conclusions We present a series of recalcitrant scaphoid nonunions treated with a novel technique of volar buttress plating and vascularized bone graft. In this series, we found a high rate of union, with consistent radiographic improvement and symptomatic relief. This procedure can be performed using a single incision and with minimal donor site morbidity. Volar plating of a scaphoid nonunion comes with the risk of articular prominence, but offers a new alternative to headless screw fixation. Our early results from this series are promising and support this protocol as a viable alternative for challenging nonunions. Type of study/level of evidence Therapeutic IV.
Plastic bronchitis is a rare, potentially life-threatening complication after Fontan operation. Hemodynamic alterations (elevated central venous pressure and low cardiac output) likely contribute to ...the formation of tracheobronchial casts composed of inflammatory debris, mucin, and fibrin. Pathologic studies of cast composition support medical treatment with fibrinolytics such as inhaled tissue plasminogen activator (t-PA).
This was a retrospective case series of medical, surgical, and catheter-based treatment of patients with plastic bronchitis after cavopulmonary palliation.
Included were 14 patients (86% male, 93% white). Median age at Fontan operation was 2.7 years (range, 1.2 to 4.1 years), with median interval to plastic bronchitis presentation of 1.5 years (range, 9 days to 15.4 years). Cast composition was available for 11 patients (79%) and included fibrin deposits in 7. All patients were treated with pulmonary vasodilators, and 13 (93%) were treated with inhaled t-PA. Hemodynamically significant lesions in the Fontan pathway were addressed by catheter-based (n=9) and surgical (n=3) interventions. Three patients (21%) underwent heart transplantation. Median follow-up was 2.7 years (range, 0.6 to 8.7 years). Symptoms improved, such that 6 of 13 patients (46%) were weaned off t-PA. Rare or episodic casts are successfully managed with outpatient t-PA in most of the other patients. Of the 3 patients who underwent heart transplant, 2 are asymptomatic and 1 has recurrent casts in the setting of elevated filling pressures and rejection.
A systematic step-wise algorithm that includes optimization of hemodynamics, aggressive pulmonary vasodilation, and inhaled t-PA is an effective treatment strategy for patients with plastic bronchitis after cavopulmonary connection.
Objective We sought to examine the association between maternal serum 25-hydroxyvitamin D (25OHD) concentration in early pregnancy and the subsequent diagnosis of preeclampsia (PE). Study Design This ...was a nested case-control study from 2 prospective Canadian cohorts conducted in Quebec City, Quebec, and Halifax, Nova Scotia, from 2002 through 2010. Participants were pregnant women (n = 169 cases with PE and 1975 controls). Maternal serum was drawn <20 weeks of gestation, and 25(OH)D measurement was performed. Cases were ascertained from medical records. Logistic regression analysis was used to estimate adjusted odds ratios with 95% confidence intervals. Results Women who developed PE had a significantly lower 25(OH)D concentration at a mean gestational age of 14 weeks compared with women in the control group (mean ± SD 25OHD 47.2 ± 17.7 vs 52.3 ± 17.2 nmol/L, P < .0001). Women with 25(OH)D <30 nmol/L compared to those with at least 50 nmol/L had a greater risk of developing PE (adjusted odds ratio, 2.23; 95% confidence interval, 1.29–3.83) after adjustment for prepregnancy body mass index, maternal age, smoking, parity, season and year of blood collection, gestational week at blood collection, and cohort site. Exploratory analysis with cubic splines demonstrated a dose-response relationship between maternal 25(OH)D and risk of PE, up to levels around 50 nmol/L, where the association appeared to plateau. Conclusion Maternal vitamin D deficiency early in pregnancy defined as 25(OH)D <30 nmol/L may be an independent risk factor for PE. The relevance of vitamin D supplementation for women of childbearing age should be explored as a strategy for reducing PE and for promoting a healthier pregnancy.
The tarnished plant bug, Lygus lineolaris (Palisot de Beauvois), is an important pest of cotton in many areas of the southern United States. An experiment was conducted at two locations in ...Mississippi during 2016 and 2017 to evaluate action thresholds for tarnished plant bug on a novel Bacillus thuringiensis cotton that expresses the Cry51Aa2.834_16 toxin. Treatments included the current action threshold, a 2× threshold, and treatments where insecticides were only applied during the early season (preflower) or only during late season (during flowering) based on the current action thresholds. These were compared to an untreated control and a weekly insecticide use regime that received weekly insecticide sprays. All treatments were imposed on both Bt Cry1Aa2.834_16 cotton and a nontraited cotton. The Bt Cry1Aa2.834_16 trait reduced the number of tarnished plant bugs and injury, and improved yields compared to nontraited cotton. For all spray treatments except the weekly insecticide use regime, yields were greater for the Bt Cry51Aa2.834_16 cotton than the nontraited cotton. In terms of thresholds, Bt Cry1Aa2.834_16 cotton sprayed based on current action thresholds resulted in similar yields to the weekly insecticide use regime of both cotton types. In contrast, the 2× threshold resulted in lower yields than the current threshold for both cotton types. Though thresholds intermediate to the currently recommended action threshold and the 2× threshold were not tested, these data suggest that currently recommended action thresholds appear appropriate for Bt Cry51Aa2.834_16 cotton. These results suggest that this trait will be an important component of current IPM programs in cotton where tarnished plant bug is an important pest.
This study assessed pediatric physicians' use of shared decision making (SDM) in 2 chronic conditions. Most physicians indicated that parent and adolescent trust and emotional readiness facilitated ...SDM, physicians' preferred approach to decision making. At the same time, they perceived few barriers, other than insurance limitations, to using SDM.
To assess factors that impact the risk of relapse in patients with noninfectious uveitis (NIU) who undergo adalimumab tapering after achieving remission.
Retrospective study.
In this multicenter ...study, patients with NIU were treated with adalimumab and subsequently tapered. Patient demographics, type of NIU, onset and duration of disease, the period of inactivity before tapering adalimumab, and the tapering schedule were collected. The primary outcome measures were independent predictors of the rate of uveitis recurrence after adalimumab tapering.
Three hundred twenty-eight patients were included (54.6% female) with a mean age of 34.3 years. The mean time between disease onset and initiation of adalimumab therapy was 35.2 ± 70.1 weeks. Adalimumab tapering was commenced after a mean of 100.8 ± 69.7 weeks of inactivity. Recurrence was observed in 39.6% of patients at a mean of 44.7 ± 61.7 weeks. Patients who experienced recurrence were significantly younger than those without recurrence (mean 29.4 years vs 37.5 years, P = .0005), and the rate of recurrence was significantly higher in younger subjects (hazard ratio HR = 0.88 per decade of increasing age, P = .01). The lowest rate of recurrence was among Asian subjects. A faster adalimumab taper was associated with an increased recurrence rate (HR = 1.23 per unit increase in speed, P < .0005). Conversely, a more extended period of remission before tapering was associated with a lower rate of recurrence (HR = 0.97 per 10-weeks longer period of inactivity, P = .04).
When tapering adalimumab, factors that should be considered include patient age, race, and duration of disease remission on adalimumab. A slow tapering schedule is advisable.
The purpose of this study was to determine whether maternal hospitalization for a respiratory-related condition during influenza season results in an increased risk of neonatal morbidity. With the ...use of a 13-year population-based cohort study of all singleton live births in Nova Scotia (1990-2002), neonatal outcomes were compared between women with and without hospital admission for respiratory illness during influenza season at any time in pregnancy. Logistic regression analyses were performed to examine infant outcomes and to estimate relative risks and 95% confidence intervals. Infants who were born to mothers who had been hospitalized for respiratory illness during influenza season at any time during pregnancy were more likely to be small for gestational age (15.3% vs 9.7%; adjusted relative risk, 1.66; 95% confidence interval, 1.11–2.49) and to have lower mean birthweight (3348.5 ± 498.2 g vs 3531.3 ± 504.1 g; β score, –86.67; P < .009) than were infants who were born to women without an influenza-season respiratory hospitalization during pregnancy. Our findings in a cohort of singleton infants who were born in a high-resource setting support the findings that were described in Bangladesh that demonstrated an increased number of small-for-gestational-age infants and a lower mean birthweight among babies who were born to mothers who were not protected by influenza vaccine.
Neonicotinoid insecticides are currently one of two classes of chemicals available as a seed treatment for growers to manage early season insect pests of cotton, Gossypium hirsutum L. (Malvales: ...Malvaceae), and they are used on nearly 100% of cotton hectares in the midsouthern states. An analysis was performed on 100 seed-treatment trials from Arkansas, Louisiana, Mississippi, and Tennessee to determine the value of neonicotinoid seed treatments in cotton production systems. The analysis compared seed treated with neonicotinoid insecticides seed treatments plus a fungicide with seed only treated with fungicide. When analyzed by state, cotton yields were significantly greater when neonicotinoid seed treatments were used compared with fungicide-only treatments. Cotton treated with neonicotinoid seed treatments yielded 123, 142, 95, and 104 kg ha–1, higher than fungicide only treatments for Arkansas, Louisiana, Mississippi, and Tennessee, respectively. Across all states, neonicotinoid seed treatments provided an additional 115 kg lint ha–1 comparedwith fungicide only treated seed. Average net returns from cotton with a neonicotinoid seed treatment were $1,801 per ha–1 compared with $1,660 per ha–1 for cottonseed treated with fungicide only. Economic returns for cotton with neonicotinoid seed treatments were significantly greater than cottonseed treated with fungicide only in 8 out of 15 yr representing every state.These data show that neonicotinoid seed treatments provide significant yield and economic benefits in Mid-South cotton compared with fungicide only treated seed.
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