Martha's Vineyard Hospital

The peripheral blood lymphocyte-to-monocyte ratio (LMR) has been shown to predict outcomes in follicular lymphoma (FL). Among 1018 patients from the RELEVANCE trial (for previously untreated, high tumour burden FL), the median LMR was 2.5 (range, 0.3-93.5) and an LMR cut-off of 2 was mostly associated with survival end-points. Patients with an LMR ≤2 (n = 372; 37%) were older and had higher risk disease. An LMR ≤2 was associated with a shorter progression-free survival (PFS) (hazard ratio [HR] = 1.39, p = 0.002) and overall survival (OS) (HR = 1.44, p = 0.049). The association of the LMR with PFS was significant in the rituximab plus chemotherapy arm (p = 0.01) and inconclusive in the rituximab plus lenalidomide arm (p = 0.08). Within the three Follicular Lymphoma International Prognostic Index risk categories, the LMR retained its association with PFS only in the low-risk group (p = 0.03). An LMR ≤2 was also associated with a higher risk of progression of disease within 24 months of treatment initiation (univariable odds ratio (OR) = 1.84, p < 0.001; multivariable OR = 1.58, p = 0.02). In conclusion, the LMR is an easily accessible parameter informative of outcomes in FL patients in need of treatment, being especially helpful in otherwise low-risk patients. Whether the incorporation of immunomodulators such as lenalidomide will reduce its negative prognostic value needs to be further investigated.

Powassan virus lineage 2 (deer tick virus) is an emergent threat to American public health, causing severe neurologic disease. Its life cycle in nature remains poorly understood. We use a host-specific retrotransposon-targeted real time PCR assay to test the hypothesis that white-footed mice, considered the main eastern U.S. reservoir of the coinfecting agent of Lyme disease, is the reservoir for deer tick virus. Of 20 virus-infected host-seeking nymphal black-legged ticks 65% fed on shrews and none on mice. The proportion of ticks feeding on shrews at a site is positively associated with prevalence of viral infection, but not the Lyme disease agent. Viral RNA is detected in the brain of one shrew. We conclude that shrews are a likely reservoir host for deer tick virus and that host bloodmeal analysis can provide direct evidence to incriminate reservoir hosts, thereby promoting our understanding of the ecology of tick-borne infections.

Gallbladder (GB) carcinoma is a relatively rare malignancy and is associated with poor prognosis. Numerous risk factors have been associated with the development of GB carcinoma. GB carcinomas may present as mass lesions replacing the GB, focal or diffuse thickening of the GB wall, and intraluminal mass in the GB. Various benign conditions can mimic GB carcinoma. This article reviews the epidemiology, pathology, clinical findings, imaging features, and management of GB carcinomas.

Lyme disease (LD) is an increasing public health problem. Current laboratory testing is insensitive in early infection, the stage at which appropriate treatment is most effective in preventing disease sequelae. The Lyme Disease Biobank (LDB) collects samples from individuals with symptoms consistent with early LD presenting with or without erythema migrans (EM) or an annular, expanding skin lesion and uninfected individuals from areas of endemicity. Samples were collected from 550 participants (298 cases and 252 controls) according to institutional review board-approved protocols and shipped to a centralized biorepository. Testing was performed to confirm the presence of tick-borne pathogens by real-time PCR, and a subset of samples was tested for Borrelia burgdorferi by culture. Serology was performed on all samples using the CDC's standard two-tiered testing algorithm (STTTA) for LD. LD diagnosis was supported by laboratory testing in 82 cases, including positive results by use of the STTTA, PCR, or culture or positive results by two enzyme-linked immunosorbent assays for cases presenting with EM lesion sizes of >5 cm. The remaining 216 cases had negative laboratory testing results. For the controls, 43 were positive by at least one of the tiers and 6 were positive by use of the STTTA. The results obtained with this collection highlight and reinforce the known limitations of serologic testing in early LD, with only 29% of individuals presenting with EM lesion sizes of >5 cm yielding a positive result using the STTTA. Aliquots of whole blood, serum, and urine from clinically characterized patients with and without LD are available to investigators in academia and industry for evaluation or development of novel diagnostic assays for LD, to continue to improve upon currently available methods.

This chapter contains sections titled: Introduction Methods Results Discussion Acknowledgments References

Objectives: Telemedicine-enabled acute stroke consultation (TeleStroke) may be useful to determine eligibility for treatment with tissue plasminogen activator (tPA) and provide support to emergency departments without on-site stroke expertise. Methods: Emergency physicians consulted with stroke neurologists via two-way videoconferencing in the evaluation of patients with possible acute stroke. History, neurologic examination, and computed tomography of the head were reviewed to determine eligibility for treatment with tPA. Interpretations of computed tomography were compared for inter-rater reliability between the neurologist and the neuroradiologist using a conventional workstation. Videotape and written records were analyzed to determine time intervals, patient management, and user satisfaction. Results: The authors reviewed data from 24 patients evaluated over 27 months at an island-based hospital. The mean National Institutes of Health Stroke Scale score was 5.7 (range, 0–22). Fifteen patients arrived at the emergency department less than three hours after symptom onset; 12 were presented for TeleStroke consultation within three hours after symptom onset. Eight of these 12 (75%) had acute ischemic stroke, and six of these eight potentially eligible patients (75%) received intravenous tPA. There was very good agreement among all remote readers for detecting the one case of imaging exclusion (subdural hemorrhage). There were no protocol violations, and a mean (± SD) consult-to-needle time of 36 (± 15) minutes and door-to-needle time of 106 (± 22) minutes was achieved. Transfer was avoided in 11 patients. Physicians believed that TeleStroke consultation improved care in >95% of the cases. Conclusions: TeleStroke videoconferencing can support emergency department–based evaluation of acute stroke and may facilitate tPA delivery in neurologically underserved facilities. A prospective, randomized trial is needed to determine if these systems are superior to traditional telephone consultation.