Faculty Bibliography

OBJECTIVES/OBJECTIVE:We investigated the performance and the clinical impact of histologic examination of infected tissue in patients with suspected invasive fungal infection (IFI) at a tertiary pediatric center. METHODS:Unique episodes of IFI were identified from January 1, 2001, through December 31, 2012. Surgical pathology reports, fungal culture results, and clinical data were abstracted from medical records. RESULTS:Forty-seven patients with IFI were identified. Each patient had one episode of IFI. Risk factors included chemotherapy for an oncologic condition (n = 35), hematopoietic stem cell transplantation (n = 6), solid organ transplantation (n = 4), and primary immunodeficiency (n = 2). Tissue was obtained from deep subcutaneous tissue (n = 21), visceral organs (14 lungs, five livers, and one spleen), or the sinonasal cavity (n = 6). Fungal culture was ordered in 40 of the 47 episodes of IFI. Fungus grew in 27 (68%) of the 40 cultures submitted, and all isolates were concordant with histology. Medical records were available for 36 (77%) of 47 patients. Communication of histology results prompted changes in antifungal therapy 64% of the time. This included initiation of antifungal therapy in 13 patients who were not previously receiving therapy. Fifteen (42%) patients underwent surgical excision within 48 hours of histologic diagnosis. CONCLUSIONS:Histology can provide rapid, accurate, and clinically actionable information to clinicians caring for children with IFI.

HCV infection is the leading cause of liver transplantation in the adult population in the United States. HCV infection occurs in 0.2-0.4% of the pediatric population and progression to HCC is uncommon. Liver transplantation for HCV in children is rare. In this report, we present a case of pediatric patient with HCV and multifocal HCC at the age of 13 who underwent successful liver transplantation. While good graft function was initially observed, at one month after transplant, he experienced significant hepatitis C recurrence. He was treated with low-accelerating dose regimen antiviral therapy of PEG-IFN and RBV, followed by addition of a protease inhibitor, boceprevir, which led to viral clearance. To our knowledge, this is the first case report describing the post-transplant course of a child transplanted for HCV and HCC, and the first pediatric case report on using the triple therapy for management of post-liver transplant recurrence of HCV. This case report demonstrates the need for increased vigilance of surveillance for HCC during childhood.

OBJECTIVES/OBJECTIVE:To estimate rates of cadmium (Cd) uptake from the digestive tract and changes in Cd in biological specimens after intake of Cd mainly in rice. METHODS:Twenty-five young non-smoking Japanese female volunteers (20-23 in age) were recruited and a 20-d experimental study was conducted. With polished rice containing 0.004 ppm and 0.340 ppm of Cd, Meal L and Meal H were prepared. Approximately 12% of total Cd in Meal L and 92% of total Cd in Meal H originated in rice. The volunteers ate Meal L for 11 d to achieve a stable intake-output balance of Cd. Fifteen of the 25 volunteers ate Meal H on the 12(th) day (Group D1), and the remaining 10 ate Meal H on the 12(th), 13(th) and 14(th) day (Group D3). All 25 subjects then resumed the consumption of Meal L to the end of the study (20(th) day). All meals, feces and urine were collected during the study, and Cd intake from the daily meals (Cd-I), Cd in feces (Cd-F) and Cd in urine (Cd-U) were determined. For measurement of Cd in blood (Cd-B), venous blood was collected from all volunteers on the day before the study and again on the 12(th) and 20(th) day; venous blood was also collected from 4-8 volunteers at additional time points. RESULTS:Mean Cd-I was 4.51 microg/d (range: 1.85-6.93) or 48.48 microg/d (range: 27.98-56.27) when they ate Meal L or Meal H. Cd-F and Cd-B exhibited faster responses to the change in Cd-I than did Cd-U. The Cd(uptake) rate, defined as (1-Cd-F(excess) /Cd-I(excess)) (Fig. 1), was 47.2% (range: -9.4-83.3%) in Group D1 and 36.6% (range: -9.2-73.5%) in Group D3, and the Cd(balance) rate, defined as (1-Cd-F(output) /Cd-I(intake)), was 23.9% (range: -4.0-37.7%) in Group D1 and 23.7% (range: -8.2-56.9%) in Group D3. CONCLUSIONS:Cd-F and Cd-B are better biological monitoring parameters for assessing change in Cd-I than Cd-U. The Cd(uptake) and Cd(balance) rates appeared to be higher than those in previous papers when ingested Cd mainly originated in rice.

Japanese national sentiment has been described as paternalistic, which has potentially wide-ranging implications for the manner in which psychiatric patients should participate in medical decision-making. To examine the extent and possible determinants of the desire to participate in medical decision-making among Japanese people, we distributed a packet of questionnaires to 747 (nonmedical) university students and 114 of their parents. The questionnaires included an imaginary case vignette of psychotic depression. The participants were asked whether they would want various types of medical information, i.e., diagnosis, aetiology, treatment, outcomes, medical charts, etc., disclosed to them were they in such a psychiatric condition. Also included was the 1995 Scale for Independent and Interdependent Construal of the Self by Kiuchi. More than half of the participants wanted all the types of medical information disclosed to them. Those participants who wanted to have all types of information disclosed to them (n = 413) as compared to those who did not want to know at least one type of information (n = 445), tended to be male and to have an educational background in psychiatry (9.7% vs 5.4%) as well as an assertive attitude as indicated by a higher score on Independence on the Scale for Independence and Interdependent Construal of the Self. These results suggest that the Japanese in this sample are more likely to want to make an autonomous contribution to the psychiatric decision-making process and that less desire for information can be predicted by some demographic and personality factors.