Abrupt Tapering Research Articles

Gallbladder torsion in an 11-month-old Labrador Retriever.

An intact male Labrador Retriever was presented with signs of an acute abdomen and generalized weakness. Abdominal ultrasonography revealed a distended, horizontally orientated and caudally displaced gallbladder with a thickened wall. Computed tomography (CT) showed an abrupt tapering of the cystic duct in addition to the displacement of the gallbladder.On laparotomy a complete gallbladder torsion was diagnosed. After cholecystectomy the dog made a full recovery. Gallbladder torsion should be considered as a rare, potential differential diagnosis in dogs with an acute abdomen.

S1818 Rare Sequelae of Obstructive Jaundice: Hyperferritinemia and Bile Cast Nephropathy

Introduction: Obstructive jaundice occurs due to a physical blockage in the biliary outflow tract or external compression. While jaundice and scleral icterus are common symptoms initially, long term sequelae include severe systemic manifestations from the buildup of various compounds normally excreted in bile such as bilirubin. Case Description/Methods: A 67-year-old male smoker presented with 3 weeks of pruritus, acholic stools, dark urine, nausea, vomiting, and 20-pound weight loss. Physical exam was notable for jaundice and scleral icterus, LUQ and epigastric tenderness to palpation, but lacked hepatosplenomegaly, ascites or other stigmata of cirrhosis. Liver function tests showed AST 486 IU/L, Alk Phos 1419 IU/L, Alt 600 IU/L, and total bilirubin >30.0 mg/dL with direct bilirubin >10.0 mg/dL. Ferritin was >7500 ng/mL with decreased transferrin of 159 mcg/dL. Hepatitis panel and malignancy/autoimmune markers were negative. CMP showed BUN 74 mg/dL, and creatinine 5.1 mg/dL with 2+bilirubin on urinalysis and microscopic analysis showing pigmented renal tubular cells, bilirubin crystals, and waxy casts suggestive of ATN due to bilirubin damage and possible CKD given waxy casts (Table). CT abdomen reported severe intra and extra hepatic biliary duct dilation with CBD of 17 mm and abrupt tapering with pancreatic head fullness confirmed with MRCP. On day 2, ERCP showed a tight 15mm distal biliary stricture. A small sphincterotomy followed by balloon dilation allowed for placement of a CBD stent with excellent drainage of dark green bile. Following ERCP, patient had a drop of liver function tests and ferritin levels, gradual improvement in BUN and creatinine, and was discharged in stable condition on hospital day 6. On day 16, EUS revealed a hypoechoic area within the periampullary area with atypical cells in brushings collected during repeat ERCP (Figure). Discussion: Iron and iron binding proteins have been shown to be excreted in bile, primarily in iron excess. Our patient showed a large increase in ferritin signifying the potential role of biliary excretion of excess ferritin, with unknown ramifications. Additionally, severe biliary tree obstruction led to markedly elevated bilirubin, overwhelming renal clearance leading to severe tubular damage. With alleviation of obstruction, there was a steady decrease in ferritin and return to normal baseline renal function. Further research is needed to clarify both the consequences of excess ferritin in biliary obstruction and the significance of excess bilirubin in renal injury.Figure 1.: a) Ampulla prior to ERCP on day 2 shows no periampullary abnormality. b) Day 16 - Endoscopic Ultrasound showing narrowing of distal common bile duct with hypoechoic intraductal area. c) Bile casts and bilirubin crystals seen on microscopy. Table 1. - Patient’s Laboratory test results on and post admission Laboratory Values Reference Range Day 1 Day 5 (3 days post-ERCP) Day 21 AST 13 – 39 IU/L 486 187 18 ALT 7 – 52 IU/L 600 315 27 Alkaline Phosphatase 34 – 104 IU/L 1419 886 160 Total Bilirubin 0.3 - 1.2 mg/dL >30.0 13.0 4.4 Albumin 3.5 - 5.2 g/ 3.0 2.9 3.4 BUN 7 – 25 mg/dL 74 64 18 Creatinine 0.5 - 1.2 mg/dL 5.1 2.90 1.01 WBC 4 – 11 K/cmm 13.8 17.7 10.1 Hgb 13.7 - 17.5 g/dL 11.9 9.4 8.5 Ferritin 24 – 336 >7500 4677 976 Transferrin 300 to 360 mcg/dL 159 233 Iron 50 - 182 ug/dL 126 61 Iron Saturation 57% 19% TIBC 250 – 450 ug/dl 233 326 Urine Bilirubin Negative 2+ Negative Urobilinogen 0.0 - 2.0 EU/dL 4.0 < 2.0 PT 9.1 - 13.2 sec 26.6 12.8 PTT 23.3 - 36.6 SEC 42.0 33.0 INR 0.8 - 1.2 2.3 1.1 Alpha-1-Antitrypsin (ATT) 83 – 199 mg/dL 256 Ceruloplasmin 18– 36 mg/dL 51 Carcinoembryonic Antigen (CEA) 0.0 - 3.0 ng/mL 3.9

RADIOGRAPHIC FINDINGS OF CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION

RADIOGRAPHIC FINDINGS OF CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION

Atopic Dermatitis: A Guide to Transitioning to Janus Kinase Inhibitors.

Janus kinase inhibitors (JAKis) are promising medications that the Food and Drug Administration recently approved for treatment of atopic dermatitis in January 2022. These medications offer a novel therapeutic mechanism and may be an additional treatment avenue for patients who are currently reliant on conventional immunosuppressants, such as cyclosporine A, methotrexate, or mycophenolate mofetil, or newer medications, such as dupilumab. However, redundant treatment puts patients at risk for excessive toxicity and polypharmacy, whereas abrupt tapering of a preexisting regimen may cause flares of the disease. Thus, transitioning to JAKis should be implemented strategically to retain the therapeutic benefit and minimize the risk of flares. Herein, we outline gradual transition schemas for patients needing to transition to JAKis from conventional immunosuppressants or dupilumab. There is no evidence-based guideline to instruct this transition to JAKis, and our recommendations are based on expert experience and the review of efficacy data from pivotal trials.

A new species of giant Eunice (Eunicidae, Polychaeta, Annelida) from the east coast of Australia.

A new giant species is described from New South Wales, Australia. Eunicedharastii sp. nov. differs from described Australian species and is most similar to E.aphroditois (Pallas, 1788), E.flavopicta Izuka, 1912, and E.kinbergi Ehlers, 1868. The unique combination of features that characterizes the new species is irregular articulated prostomial appendages; antennae reaching back beyond chaetiger 4; branchiae starting at chaetiger 10, initially button-shaped and distinctly longer than notopodial cirri where best developed; dorsal fleshy knobs on anterior chaetal lobes; notopodial cirri pendulous, abrupt tapering from inflated bases; bidentate compound falcigerous chaetae with both teeth directed laterally, distal tooth much shorter than proximal tooth in median and posterior chaetigers; and dark bidentate subacicular hooks starting at chaetiger 58, tapering to a small head with both teeth directed distally, and proximal tooth much larger than minute and spur-like distal tooth. This new species lives in sandy sediments in coastal waters 1-8 m deep. It is highly mobile and not easy to collect, which may explain why it was not described before.

A Trapped Colon

A Trapped Colon

Dose tapering, increases, and discontinuity among patients on long-term high-dose opioid therapy in the United States, 2017–2019

BackgroundWhile reduced exposure to prescription opioids may decrease risks, including overdose and opioid use disorder, abrupt tapering or discontinuation may pose new risks. ObjectivesTo examine potentially unsafe tapering and discontinuation among dosage changes in opioid prescriptions dispensed to US patients on high-dose long-term opioid therapy. DesignLongitudinal observational study of adults (≥18 years) on stable high-dose (≥50 oral morphine milligram equivalents [MME] daily dosage) long-term opioid therapy during a 180-day baseline and a 360-day follow-up using all-payer pharmaceutical claims data, 2017–2019. MeasuresDosage tapering, increases, and/or stability during follow-up; sustained dosage stability, reductions, or discontinuation at the end of follow-up; and tapering rate. Patients could experience more than one outcome during follow-up. ResultsAmong 595,078 patients receiving high-dose long-term opioid therapy in the sample, 26.7% experienced sustained dosage reductions and 9.3% experienced discontinuation. Among patients experiencing tapering, 62.0% experienced maximum taper rates between > 10–40% reductions per month and 36.1% experienced monthly rates ≥ 40%. Among patients with mean baseline daily dosages ≥ 150 MME, 47.7% experienced a maximum taper rate ≥ 40% per month. Relative to baseline, 19.7% of patients experiencing tapering had long-term dosage reductions ≥ 40% per month at the end of follow-up. ImplicationsDosage changes for patients on high-dose long-term opioid therapy may warrant special attention, particularly over shorter intervals, to understand how potentially sudden tapering and discontinuation can be reduced while emphasizing patient safety and shared decision-making. Rapid discontinuation of opioids can increase risk of adverse outcomes including opioid withdrawal.

Impact of changes in opioid funding and clinical policies on rapid tapering of opioids in Ontario, Canada.

Reports have emerged of abrupt tapering among recipients of long-term prescription opioids to conform new prescribing guidelines. We conducted a population-based, repeated cross-sectional time-series study among very high-dose (≥200 MME) opioid recipients in Ontario, Canada, to examine changes in the monthly prevalence of rapid tapering from 2014 to 2018, defined as recipients experiencing either a ≥50% reduction in daily doses or abrupt discontinuation sustained for 30 days. Interventional autoregressive integrated moving average models were used to test for significant changes following key guidelines and drug policies and programs. A sensitivity analysis examined rapid tapering sustained for 90 days. The monthly prevalence of rapid tapering events was stable from January 2014 to September 2016 (average monthly prevalence: 1.4%) but increased from 1.4% in October 2016 to 1.8% in April 2017 (P = 0.001), coincident with Ontario's Fentanyl Patch-for-Patch Return Program implementation. Transient spikes in the prevalence of rapid tapering also occurred 2 months after Ontario's delisting of publicly funded high-strength opioids and the release of updated Canadian Opioid Prescribing Guideline for Chronic Pain, reaching 2.3% in March 2017 and July 2017, respectively. However, this prevalence decreased to 1.2% in December 2018 (P < 0.0001). Although the prevalence of abrupt opioid discontinuation was lower, similar trends were observed. Our sensitivity analysis examining long-lasting rapid tapering found similar trends but lower prevalence, with no changes in complete discontinuation. These temporary increases in rapid tapering events highlight the need for improved communication and evidence-based resources for prescribers to minimize negative consequences of evolving policies and guidelines.

Corticosteroid‐associated hypothalamic–pituitary–adrenal axis suppression in brain tumours: a focus on dosing and tapering

AbstractBrain tumours are among the most challenging malignancies to treat. The majority of brain tumours are associated with perifocal oedemas and disturbances in the cerebrospinal fluid (CSF) flow. Glucocorticoids (GC) are the mainstay supportive therapy for a variety of disorders associated with brain tumours such as vasogenic oedema, intracranial pressure, headache, and vomiting. In contrast, prolonged exposure to GC has been associated with suppression of the hypothalamic–pituitary–adrenal (HPA) axis. Moreover, abrupt tapering and sudden stopping of GC therapy are the most common causes of HPA axis suppression leading to secondary adrenal insufficiency (SAI). Furthermore, a variety of well‐established dynamic tests have been used to diagnose and assess the integrity of the HPA axis, such as the insulin tolerance test, the metyrapone stimulation test and the adrenocorticotropic hormone stimulation test. Hydrocortisone replacement is the recommended therapy for SAI as it provides the physiological circadian cortisol rhythm. In the context of brain tumours, limited evidence exists to guide clinical practice regarding the optimal dosing of GC with regard to side effects, duration of therapy, withdrawal regimen or quality of life. In this review, we summarise the current status of HPA axis suppression and the SAI associated with GC therapy in brain tumours.

Assessing Variation in State Opioid Tapering Laws: Comparing State Laws with the CDC Guideline.

In 2016, the Center for Disease Control and Prevention released an opioid prescribing guideline for primary care in response to opioid overdose deaths. Despite efforts to encourage safer prescribing practices, experts and federal agencies suspect prescribing guidelines may be misapplied in clinical practice, resulting in abrupt tapering from opioid therapy. Although state laws likely influence prescriber behavior, little is known about state tapering laws. Thus, we examined the scope and variation of state tapering laws compared with federal opioid guidelines. We conducted a comprehensive review of state laws through December 31, 2019, using keyword searches in LexisNexus. Identified laws were coded based on the inclusion of attributes derived from federal opioid guidelines and an expert consensus panel report. We examined whether law attributes were associated with state characteristics, including region, population, governor's political affiliation, opioid prescribing rates, and opioid overdose rates. We found 27 states and one federal district had law(s) mentioning tapering. Most laws were authored by medical boards or workers' compensation groups (65.6%) while some laws included a penalty (32.8%). Approximately half of guideline attributes (54.2%) were included in state laws; however, only two state's laws cautioned against abrupt tapering. States with higher overdose death rates were more likely to enact a tapering law (P < 0.001) and have a penalty (P = 0.007). State tapering laws incorporate some federal guideline attributes but most lack attributes deemed critical by experts. Without clear instruction, patients risk inappropriate tapering and discontinuation of opioid therapy. Given these findings, policymakers should consider addressing this gap.

Diagnostic Accuracy of Magnetic Resonance Cholangiopancreatography to Detect Benign and Malignant Biliary Strictures.

Background:Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive method to detect pancreaticobiliary strictures. In this study, we aimed to evaluate the diagnostic performance of MRCP and detect sensitive and specific radiologic features in distinguishing malignant and benign pathologies.Materials and Methods:In this study, 50 patients with biliary obstruction and a confirmed diagnosis using histopathology were included. The pathologies were evaluated using MRCP which were categorized into malignant and benign strictures. The etiology of strictures was detected using histopathology and endoscopic retrograde cholangiopancreatography. The diagnostic performance of MRCP was calculated using SPSS software. P < 0.05 was considered statistically significant.Results:Of 50 patients, 23 patients (46%) had malignant strictures based on MRCP and histopathology. The sensitivity and specificity of MRCP to detect malignancy were 95.7% and 96.3%, respectively. The most sensitive MRCP features to detect malignancy were upstream biliary duct dilation, abrupt tapering, and the presence of a solid mass with sensitivity 100%, 95.7%, and 78.2%, respectively. The malignancy rate was significantly higher in the strictures with length >11.5 mm or wall thickness >2.75 mm (P < 0.05).Conclusion:MRCP is a sensitive method to differentiate malignant lesions from benign pathologies. A long and thick stricture with the presence of a solid mass, upstream biliary duct dilation, and abrupt tapering is highly suggestive of malignancy.

Interconnecting pancreatic ducts: unique ductogenesis in a patient with Kabuki syndrome and cytochrome C deficiency

A 15-year-old with Kabuki syndrome and cytochrome C deficiency presented with recurrent acute pancreatitis. Laboratory results included alkaline phosphatase 397, alanine aminotransferase 90, aspartate aminotransferase 43, TB 0.7. MRI revealed a dilatated biliary tree with abrupt distal tapering that was concerning for stricture and nonvisualization of the pancreatic duct in the body, with upstream dilatation and irregularity (A). The pancreaticobiliary junction (PBJ) could not be delineated.

Laparoscopic ureteral reconstruction in infant with congenital mid ureteric valve

Congenital mid ureteric valve (MUV) stenosis is a very rare cause of ureteric obstruction and hydronephrosis (HN) in children. We describe how we manage laparoscopically one case of a patient with congenital MUV. We describe a 6-month-old boy born with antenatal left HN, with an anteroposterior diameter (APD) of 1,5cm. Follow-up renal ultrasound at 3 months of age showed an increase in left kidney HN, approximately 2.5cm below the PUJ associated with distal stenosis. Renal scintigraphy with DTPA showed an obstructive pattern. Urography scan showed an abrupt reduction in the caliber of the mid left ureter Based on a preoperative diagnosis of MUV stenosis, we performed a laparoscopic left ureteroplasty. Abrupt tapering of the left ureter at 3cm from the PUJ was identified. Proximal ureter repair was performed before the resection of the narrowing segment. The two edges of the ureter were spatulated and continuous anastomosis was performed without tension. An antegrade JJ stent was inserted after the posterior part of the anastomosis was done. Patient made an uneventful recovery and was discharged on the first postoperative day. Laparoscopic ureteroplasty is a complex but feasible option to treat patients with congenital MUV stenosis.

P885 Pulmonary artery stent implantation in an adult with chronic thromboembolic pulmonary stenosis

Abstract Introduction Pulmonary artery stenosis presenting in adults is rare. Chronic thromboembolic pulmonary hypertension (CTEPH) is by far the most common cause of pulmonary artery stenosis. Stenosis in these patients are not caused by an abnormality of the arterial wall itself, but by intraluminal narrowing as a result of the only partially resolved and organized thromboembolism. In contrast to paediatric patients, in adults with pulmonary artery stenosis, pulmonary stenting is not routinely performed. Case report A 51-year male, smoker, diabetic, hypertensive, and with chronic kidney disease. He was diagnosed two years earlier with bilateral multiple pulmonary emboli and was maintained on oral anticoagulation therapy. Recently, he presented with gradually progressive shortness of breath and signs of right ventricular failure. Diagnostic imaging: 1-Transthoracic and transesophageal echocardiography showed normal global systolic left ventricular function with no regional wall motion abnormalities, dilated right ventricle (RV) with moderately impaired function, severe pulmonic valve incompetence, mild tricuspid incompetence and a severely elevated right ventricular systolic pressure (RVSP) of 82 mmHg. In addition, a small rounded mass (6 x 11 mm) was visualized attached to the posterior wall of the RV outflow tract (RVOT) about 15mm proximal to the pulmonary valve annulus, (figure A). 2- Computed tomography pulmonary angiography showed a right main pulmonary artery (RPA) with circumferential narrowing, which was highly suggestive of chronic thrombosis. There was an abrupt tapering noted in the segmental branches of the right lower lobar pulmonary artery, with non-opacification of the distal arteries. No contrast opacification was noted in the right upper lobe pulmonary arteries. The left main pulmonary artery showed thickening of its bifurcation, again suggestive of chronic thrombosis, with narrowing of its left upper lobar branch, (figures B&amp;C). 3-Cardiac magnetic resonance (CMR) showed a non enhancing RVOT mass protruding through the incompetent pulmonary valve during systole with features suggestive of a thrombus. Management In view of the clinical history, CTEPH was considered to be the most likely aetiology of the pulmonary hypertension. The decision was to perform balloon angioplasty and stent implantation in the RPA. Immediately after the procedure, RVSP was reduced from 80 to 50 mmHg. The clinical course after this procedure was uncomplicated and the patient showed significant clinical improvement. Follow up CMR showed patent stent with improvement of RV function ( fig D) Abstract P885 Figure.

1404 Sclerotic Bone Metastasis From Cholangiocarcinoma: A Case Report

INTRODUCTION: Cholangiocarcinoma (CCA) account for 3% of gastrointestinal malignancies. Commonly it metastasizes to liver, peritoneum and lymph nodes. Rarely it metastasizes to bone with lytic lesions. We are presenting a case of metastatic CCA with sclerotic bone metastasis. CASE DESCRIPTION/METHODS: 59-year-old female with no medical history presented with diffuse abdominal pain for 2 weeks. She denied other complaints, illicit drug use, personal or family of history of malignancy. She was a 40-pack year smoker and social drinker. Vitals and physical exam were unremarkable except minimally diffuse tender abdomen. Labs revealed elevated AST, ALT, ALP and Bilirubin which were 524, 640, 2300 and 1.7 respectively. CT abdomen with IV contrast showed intrahepatic biliary ductal dilatation and prominence of the common hepatic duct with abrupt tapering of the duct proximal to a small, high density mass versus short segment ductal wall thickening, normal Pancreatic duct and widespread sclerotic bone lesions. MRCP showed 3 cm long nonspecific stricture involving the mid CBD regional to the insertion of the cystic duct. No associated mass or abnormal enhancement with moderate intrahepatic biliary duct dilatation in both liver lobes. CA 19-9, CEA, and AFP were elevated to 492, 700, and 7 respectively. Bone scan showed extensive diffuse increased activity over multiple focal areas within the calvarium, sternum, bilateral ribs, scapulae, entire spine, pelvis, diffusely involving most femurs. ERCP with spyglass was done along with brush biopsy and metal stent placement. Biopsy samples were not adequate for tissue diagnosis. Iliac crest biopsy was sent for pathology, immunohistochemistry (IHC), flow cytometry and chromosome analysis which showed metastatic adenocarcinoma, by IHC (pankeratin+ CK7+, CK20+, MOC31+, CK19+, CA19-9+) most compatible with pancreatobilliary primary. Flow cytometry did not show any evidence of myeloproliferative disorder and chromosome analysis could not be done due to nondividing cells. Pt underwent palliative chemotherapy for metastatic CCA with gemcitabine and cisplatin. DISCUSSION: Metastatic CCA to the bone is rare. In the few case reports describing this finding, bony lesions are usually lytic in nature. Sclerotic bone metastasis from CCA has never been reported in literature. Prognosis is extremely poor due to the minimal response to conventional chemotherapy or radiotherapy, symptom control, particularly pain, is the mainstay of treatment for improving the quality of life of the patients.

Differences in early imaging features and pattern of progression on CT between intrahepatic biliary metastasis of colorectal origin and intrahepatic non-mass-forming cholangiocarcinoma in patients with extrabiliary malignancy.

To assess the differences in early imaging features and progression pattern on CT between intrahepatic biliary metastasis (IBM) and non-mass-forming cholangiocarcinoma (NMFC) in patients with extrabiliary malignancy. This retrospective study included 35 patients who were surgically and pathologically confirmed with IBM (n = 14) or NMFC (n = 21) at the time of or after surgery for extrabiliary malignancy. Two observers evaluated the following aspects of biliary lesions on initial or follow-up CT images: location, characteristics of intrahepatic duct (IHD) dilatation, presence of duct wall thickening, and periductal infiltration lesion or periductal expansile mass. All IBMs were associated with colorectal cancer (p = 0.032). As early imaging features on CT, smooth tapered localized IHD dilatation without duct wall thickening and peripheral duct involvement were observed significantly more often in IBM, and IHD dilatation with abrupt tapering or irregularity of transition site and bile duct wall thickening were significantly more common in NMFC (all p < 0.05). Regarding progression pattern, periductal expansile mass was present only in IBM, whereas periductal infiltrative lesion was present only in NMFC (p < 0.001). In the differentiation between IBM and NMFC in patients with extrabiliary malignancy, the differences in early imaging features and progression pattern of the two diseases revealed in this study would be helpful for diagnosis.

84-Year-Old Male With Obstructive Jaundice Due to IGG-4 Related Sclerosing Cholangitis

Patient is 83 y.o. male with history of DM type 2, hypertension, CAD, was hospitalized with 2 weeks of progressive fatigue and jaundice, bilirubin 11.2 mg/dL; ALT 227 U/L and AST 150 U/L, alkaline phosphatase 842 U/L and normal CA 19-9 U/mL. CT abdomen showed intra and extrahepatic biliary ductal dilatation with abrupt tapering of the common bile duct (CBD) at the level of the pancreatic head, prominent pancreas. ERCP revealed normal pancreatic duct and distal CBD stricture; pancreatic and biliary stents were placed, biopsies of the stricture were non diagnostic. Repeat ERCP 1 month later showed resolution of distal biliary stricture and formation of new strictures in the CBD, left hepatic duct and intrahepatic bile ducts. CA 19-9 was mildly elevated at 44 U/mL. Strictures were dilated and additional stricture biopsies were obtained. Pathology showed mild increase in numbers of IgG4 plasma cells up to 28 IgG4 positive plasma cells per 400 per high power field (HPF). Liver biopsy showed a dense peribiliary plasma cell-rich inflammatory infiltrate in a setting of fibrotic background, variable presence of eosinophils within the infiltrate, absence of prominent lymphocytic infiltration of the biliary epithelium, canalicular cholestasis without significant ductular proliferation; mild sinusoidal lymphoplasmacytic infiltrate. An immunohistochemical stain for IgG4 showed numerous peribiliary plasma cells (over 70 IgG4-expressing plasma cells per 400x microscopic field), compatible with IgG4-associated cholangitis. (Figure 1 and 2) IgG4 level was 214.2 mg/dL. Patient was started on 40 mg daily of prednisone which lead to resolution of symptoms and normalization of liver tests. Discussion: IgG4-related disease is an increasingly recognized immune-mediated condition which is comprised of a collection of disorders that share particular pathologic, serologic, and clinical features. It has slight predominance in middle age and older males as we see in our case. IgG4 — related sclerosing cholangitis ((IgG4-SC) may present as a distal or proximal-type disease with or without autoimmune pancreatitis. In some cases diagnosis may be challenging. It can mimic primary sclerosing cholangitis and cholangiocarcinoma due to elevation in CA 19-9 level. High serum immunoglobulin G4 (IgG4 level) is an important feature. Liver biopsy can aid in the prompt diagnosis. High level of suspicion and awareness of this condition can lead to prompt diagnosis and correct treatment.1251_A.tif Figure 1: No Caption available.1251_B.tif Figure 2: No Caption available.

First Description of the Tadpole ofTheloderma gordoni(Anura: Rhacophoridae) from Vietnam

Abstract Here we describe the tadpoles of Theloderma gordoni. These tadpoles can be distinguished from other members of the genus Theloderma by having the combination of the following characters: total length (50.1–54.5 mm, stages 28–33); tail shape (abdominal and dorsal fins with a gradual tapering toward the anterior and posterior portions, without an abrupt tapering in the posterior portion); number of marginal papillae in one row on the oral disc (51–55); degree of pigmentation (body dorsally and ventrally practically black, with a slight bluish tint). We also include a comparative analysis and thorough review of tadpole descriptions of other Theloderma.

Lower Crustal Strength Controls on Melting and Serpentinization at Magma‐Poor Margins: Potential Implications for the South Atlantic

AbstractRifted continental margins may present a predominantly magmatic continent‐ocean transition (COT), or one characterized by large exposures of serpentinized mantle. In this study we use numerical modeling to show the importance of the lower crustal strength in controlling the amount and onset of melting and serpentinization during rifting. We propose that the relative timing between both events controls the nature of the COT. Numerical experiments for half‐extension velocities &lt;=10 mm/yr suggest there is a genetic link between margin tectonic style and COT nature that strongly depends on the lower crustal strength. Our results imply that very slow extension velocities (&lt; 5 mm/yr) and a strong lower crust lead to margins characterized by large oceanward dipping faults, strong syn‐rift subsidence and abrupt crustal tapering beneath the continental shelf. These margins can be either narrow symmetric or asymmetric and present a COT with exhumed serpentinized mantle underlain by some magmatic products. In contrast, a weak lower crust promotes margins with a gentle crustal tapering, small faults dipping both ocean‐ and landward and small syn‐rift subsidence. Their COT is predominantly magmatic at any ultra‐slow extension velocity and perhaps underlain by some serpentinized mantle. These margins can also be either symmetric or asymmetric. Our models predict that magmatic underplating mostly underlies the wide margin at weak asymmetric conjugates, whereas the wide margin is mainly underlain by serpentinized mantle at strong asymmetric margins. Based on this conceptual template, we propose different natures for the COTs in the South Atlantic.

Immune reconstitution inflammatory syndrome in non-HIV immunosuppressed patients.

Immune reconstitution inflammatory syndrome (IRIS) represents a clinical phenomenon of immune-mediated inflammation against various antigens, including pathogenic microorganisms, drugs and unknown autoantigens, during recovery from immunosuppressed conditions. IRIS has become well recognized in HIV-infected populations. However, IRIS has seldom been recognized in HIV-negative immunocompromised patients. In the last 15 years, the immunopathogenesis of drug-induced hypersensitivity syndrome (DIHS) has been largely determined. Laboratory data and clinical observations support the idea that DIHS represents a prototype of non-HIV IRIS. Primary diseases in which non-HIV IRIS is secondary include severe cutaneous adverse drug reactions, such as DIHS, autoimmune diseases, collagen diseases, pregnancy and internal malignancies. Potential triggers of recovery from an immune deterioration state include a discontinuation or abrupt tapering of systemic steroids and/or immunosuppressants, withdrawal or reduced effects of anti-tumor necrosis factor-α antibodies, and the use of immune-checkpoint antagonists for the advanced stages of malignancies. Wide use of IRIS across large populations risks oversimplification but highlights a key unifying principle. Balanced sensitivity and specificity for its diagnostic criteria and classification are necessary for the establishment of clinical practice guidelines for non-HIV IRIS. Additionally, the development of a useful combination of biomarkers is currently an urgent issue.