Jason P. Lott

Towards a Global Human Embryonic Stem Cell Bank

An increasingly unbridgeable gap exists between the supply and demand of transplantable organs. Human embryonic stem cell technology could solve the organ shortage problem by restoring diseased or damaged tissue across a range of common conditions. However, such technology faces several largely ignored immunological challenges in delivering cell lines to large populations. We address some of these challenges and argue in favor of encouraging contribution or intentional creation of embryos from which widely immunocompatible stem cell lines could be derived. Further, we argue that current immunological constraints in tissue transplantation demand the creation of a global stem cell bank, which may hold particular promise for minority populations and other sub-groups currently marginalized from organ procurement and allocation systems. Finally, we conclude by offering a number of practical and ethically oriented recommendations for constructing a human embryonic stem cell bank that we hope will help solve the ongoing organ shortage problem.

Considerations on the use of adjunct red blood cell exchange transfusion in the treatment of severe Plasmodium falciparum malaria

BACKGROUND: Travelers returning to the United States from malaria‐endemic areas are at increased risk of a potentially fatal infection from Plasmodium falciparum, which requires prompt and aggressive treatment.

Iatrogenic hyperpigmentation in chronically infected hepatitis C patients treated with pegylated interferon and ribavirin

To the Editor: A wide range of skin disorders may develop secondary to chronic hepatitis C virus (HCV) infection, and, less commonly, may arise during the course of HCV treatment. We report two cases of iatrogenic hyperpigmentation associated with pegylated interferon (IFN) and ribavirin therapy in patients with chronic HCV infection. A 57-year-old male presented for relapsed chronic HCV infection. A review of systems and physical examination were noncontributory. Laboratory evaluation showed a mild transaminitis and an elevated plasma HCV-RNA viral load. Standard treatment was commenced with pegylated IFN alfa-2a (180 mg subcutaneously once per week) plus ribavirin (1200 mg orally once per day). At 21 weeks of therapy, the patient noted painless ‘‘bruising’’ around the IFN injection sites on his upper arms and thighs. Skin examination revealed hyperpigmented patches within these areas (Fig 1). A skin biopsy taken from the left arm revealed increased epidermal kerotinocytic pigmentation and a perivascular lymphocytic infiltrate in the superficial dermis, with numerous pigmented macrophages. FontanaeMasson staining highlighted both the increase in epidermal pigment and the dermal melanophages (Fig 2). Melanin antigen recognized by T cells (MART-1) staining showed scattered melanocytes along the dermoepidermal junction. One year after treatment, the hyperpigmented regions continue to resolve slowly. A similar case presented in a 60-year-old male with relapsed chronic HCV infection. Standard treatment with pegylated IFN alfa-2a plus ribavirin was initiated. At 24 weeks of therapy, the patient complained of ‘‘dark areas’’ over the IFN injection sites on his arms and thighs. Skin examination confirmed hyperpigmented patches on his back, arms, and abdomen. Skin biopsy with FontanaeMasson and MART-1 staining revealed focal hyperpigmentation of epidermal basal keratinocytes and scattered melanocytes along the dermoepidermal junction. Iron staining did not identify hemosiderin deposition. Six months after the conclusion of treatment, his hyperpigmentation was slowly improving. Up to 5% of the world’s population may be chronically infected with HCV. Transmission occurs through contact with blood products and may lead to hepatic cirrhosis and hepatocellular carcinoma. Cutaneous manifestations include mixed cryoglobulinemia, porphyria cutanea tarda, lichen planus, urticaria, psoriasis, and pruritis. Fig 1. Hyperpigmented patches on the lateral aspect of the arm.

The case for primary placement of tunneled hemodialysis catheters in acute kidney injury.

PURPOSEnNontunneled hemodialysis catheters (NTDCs) are widely used for initial hemodialysis access in new-onset renal failure. The National Kidney Foundation recommends NTDC use for hemodialysis duration of less than 1 week in acute kidney injury because of the increased infection risk compared with tunneled hemodialysis catheters (TDCs) with longer use. The present study was performed to determine whether primary placement of TDCs in this setting is more appropriate, and whether there are predictors of recovery of renal function in less than 1 week.nnnMATERIALS AND METHODSnIn the authors practice, patients referred to the interventional radiology unit in whom no contraindications exist receive a TDC; 76 patients who received a primary TDC for acute kidney injury and who eventually recovered renal function were retrospectively reviewed herein. Causes of renal failure, various renal function parameters, and demographics were collected, as were TDC dwell times, in an effort to determine predictors of recovery and/or extended duration of use.nnnRESULTSnMean TDC dwell time in patients who eventually recovered from acute kidney injury was 34 days; only 15 of 76 (20%) recovered within 1 week. At TDC placement, there were no significant differences between patients who recovered in less than (vs greater than) 1 week.nnnCONCLUSIONSnThe present results support primary placement of TDCs in patients with acute kidney injury who require hemodialysis and in whom no contraindications exist, as no predictors of recovery of renal function in less than 1 week were identified.

Low prevalence of necrolytic acral erythema in patients with chronic hepatitis C virus infection

BACKGROUNDnChronic hepatitis C virus (HCV) infection is associated with necrolytic acral erythema (NAE). However, the prevalence of NAE among patients with HCV is unknown, and the clinical and histologic features have not been well defined.nnnOBJECTIVEnWe sought to determine the prevalence, overall clinical features, and cutaneous histopathological characteristics of patients with NAE.nnnMETHODSnA cross-sectional study was performed among patients with chronic HCV infection cared for at 3 Philadelphia hospitals. Patients completed a questionnaire and underwent a dermatologic examination. All undiagnosed skin lesions with clinical features of NAE as described in the literature underwent skin biopsy.nnnRESULTSnAmong 300 patients with chronic HCV infection (median age 55 years; 73% male; 70% HCV genotype 1), 5 of them (prevalence 1.7%; 95% confidence interval 0.5%-3.8%) had skin lesions consistent with NAE clinically, which were analyzed and confirmed with skin biopsy specimen. All 5 skin biopsy specimens demonstrated variable psoriasiform hyperplasia, mild papillomatosis, parakeratosis, and necrotic keratinocytes in the superficial epidermis. All 5 patients were older than 40 years, were African American men, were infected with HCV genotype 1, and had a high viral load (>200,000 IU/mL).nnnLIMITATIONSnPrevious descriptions of NAE were used to guide the evaluation and need for a biopsy; however, other unknown clinical characteristics of the disease may exist. The senior author was the sole interpreter of the biopsy specimens. Only 300 of the 2500 eligible patients enrolled in the study.nnnCONCLUSIONnThe prevalence of NAE among patients with chronic HCV in this sample was very low. Further research is needed to determine the origin and appropriate therapies of NAE.

Availability of oral isotretinoin and terbinafine on the Internet

2. Gissmann L, Pfister H, Zur Hausen H. Human papilloma viruses (HPV): characterization of four different isolates. Virology 1977;76:569-80. 3. Gibbs S, Harvey I. Topical treatments for cutaneous warts. Cochrane Database Syst Rev 2006;3:CD001781. 4. Lei YJ, Gao C, An R, Shi Q, Chen JM, Yuan YK, et al. Development of a multiplex PCR method for detecting and typing human papillomaviruses in verrucae vulgaris. J Virol Methods 2008;147:72-7. 5. Dolezal JF. A device to prevent cross-contamination when directly applying liquid nitrogen. J Dermatol Surg Oncol 1991;17:827-8. 6. Estes JM, Kirby TO, Huh WK. Autoclave sterilization of instruments used on women with cervical neoplasia is an effective method of eradicating residual human papillomavirus DNA: a polymerase chain reaction-based evaluation. J Low Genit Tract Dis 2007;11:12-7.

Availability of websites offering to sell psilocybin spores and psilocybin.

Abstract This study assesses the availability of websites offering to sell psilocybin spores and psilocybin, a powerful hallucinogen contained in Psilocybe mushrooms. Over a 25-month period beginning in March 2003, eight searches were conducted in Google using the term “psilocybin spores.” In each search the first l00 nonsponsored links obtained were scored by two independent raters according to standardized criteria to determine whether they offered to sell psilocybin or psilocybin spores. No attempts were made to procure the products offered for sale in order to ascertain whether the marketed psilocybin was in fact “genuine” or “counterfeit.” Of the 800 links examined, 58% led to websites offering to sell psilocybin spores. Additionally, evidence that whole Psilocybe mushrooms are offered for sale online was obtained. Psilocybin and psilocybin spores were found to be widely available for sale over the Internet. Online purchase of psilocybin may facilitate illicit use of this potent psychoactive substance. Additional studies are needed to assess whether websites offering to sell psilocybin and psilocybin spores actually deliver their products as advertised.

Cutaneous Mycobacterium haemophilum infection in iatrogenically immunocompromised patients without transplantation.

Cutaneous Mycobacterium haemophilum infections are most often the result of HIV or transplantation-associated immunosuppression. Rarely, M. haemophilum may infect healthy patients or iatrogenically immunosuppressed patients without transplantation. We herein report two cases of cutaneous M. haemophilum infection in HIV-negative patients without transplantation undergoing iatrogenic immunosuppression. Our cases and a literature review highlight the various clinical contexts in which M. haemophilum may arise in this patient population. Accordingly, we emphasize that a high index of suspicion is needed for diagnosis, which ultimately relies on skin biopsy, histopathologic examination, and culture.

A note on normality

To the Editor: In their letter regarding a prior investigation evaluating factors associated with serum interleukin (IL)-33 levels among patients with atopic dermatitis, Lee and Park suggested, among other points, that the linear regression modeling performed in this study was incorrect, in that the latter ‘‘has a premise of a normally distributed dependent variable,’’ and the ‘‘IL-33 serum levels showed a nonnormal distribution.’’ They recommended a log transformation of this dependent variable to resolve this perceived problem. In response, the original study authors stated that the ‘‘issue raised by Lee and Park is appropriate’’ and repeated their analysis accordingly. Because ordinary least squares (OLS) linear regression is a widely used inferential technique in health care research, it is important to understand what normality means in this context. The normality assumption does not apply to the distribution of the dependent variable, but rather demands that the residuals—the differences in predicted and observed values for the dependent variable—are normally distributed. Alternatively stated, with Y outcome

Letter by Bachhuber and Lott Regarding Article, “Characteristics of Children Hospitalized With Infective Endocarditis”

To the Editor:nnA recent study by Day and colleagues1 describes the inpatient prevalence and associated characteristics of pediatric patients hospitalized for infective endocarditis using data extracted from the 2000 and 2003 Kids’ Inpatient Database (KID). As described by the authors, KID is a stratified survey sample …