A 2018 Reference Guide to the Banff Classification of Renal Allograft Pathology

The Banff Classification of Allograft Pathology is an international consensus classification for the reporting of biopsies from solid organ transplants. Since its initial conception in 1991 for renal transplants, it has undergone review every 2 years, with attendant updated publications. The rapid expansion of knowledge in the field has led to numerous revisions of the classification. The resultant dispersal of relevant content makes it difficult for novices and experienced pathologists to faithfully apply the classification in routine diagnostic work and in clinical trials. This review shall provide a complete and simple illustrated reference guide of the Banff Classification of Kidney Allograft Pathology based on all publications including the 2017 update. It is intended as a concise desktop reference for pathologists and clinicians, providing definitions, Banff Lesion Scores and Banff Diagnostic Categories. An online website reference guide hosted by the Banff Foundation for Allograft Pathology (www.banfffoundation.org) is being developed, which will be updated with future refinement of the Banff Classification from 2019 onwards. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Received 19 February 2018. Revision received 7 May 2018. Accepted 23 May 2018. Corresponding author: Jan U. Becker, MD, Institute of Pathology, University Hospital of Cologne, Kerpener Str. 62, 50937, Germany, Phone: +4922147898803, Fax: +492214786360, E-mail: janbecker@gmx.com Authors' contribution All authors contributed the discussion of the content, the collation of images and illustrations and to writing of the manuscript. Disclosure: The authors declare no conflicts of interest. Funding Dr. Roufosse's and Dr. Simmond's contribution to this research is supported by the National Institute for Health Research (NIHR) Biomedical Research Centre based at Imperial College Healthcare NHS Trust and Imperial College London. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. Alexandre Loupy is supported by a research grant ATIP AVENIR from the National French Institute of Research. Jan U. Becker is supported by the European Rare Kidney Disease Network (ERKNet); the content of this manuscript is the sole responsibility of the authors. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Transplant-free Survival in Chronic Liver Disease Presenting as Acute Liver Failure in Childhood

Background in adults, the absence of a preexisting chronic liver disease (CLD) is required to diagnose acute liver failure (ALF). The paediatric classification does not considered this aspect, thus previous studies pooled together children with ALF and children with unknown CLD presenting with acute hepatic decompensation (ALF-CLD). We aimed to compare prevalence, features and outcome of children with ALF-CLD to those with a proper ALF. Methods Patients admitted between 1996-2017 because of ALF defined by PALF criteria (raised transaminases, INR ≥2.0, no history of liver disease) were classified as ALF-CLD if diagnosed with autoimmune hepatitis (AIH), Wilson disease (WD), Budd-Chiari syndrome, HBV reactivation, inborn errors of metabolism (IEM). The others were classified as ALF. Results 74 children [median age 4 years, 1.0-8.8, M/F =36/38] with ALF were found ; 18 of

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Assessment of vestibular function in elderly patients

Purpose of review Individuals over the age of 60 are at an increased risk of falls, even if they do not have an isolated dysfunction of the vestibular system. The aim of this article is to review the various vestibular testing currently available and its usefulness in determining the presence of vestibular dysfunction in the elderly population. The primary vestibular tests to be reviewed include: balance function testing, vestibular evoked myogenic potentials (VEMPs), and video head impulse testing (vHIT). Recent findings Balance function testing is important as it evaluates the integration of vestibular information along with sensory and visual information, which may also be impaired. VEMP testing provides a small diagnostic yield as most elderly patients have absent or reduced responses. vHIT gain is reduced in this population, but will still be within the normal range for individuals with normal balance function. Summary The combination of various vestibular tests provides complimentary information instead of redundant information on the patient's balance function. Each test evaluates various aspects of the vestibular system which are all needed to determine stable balance in the elderly population. Correspondence to Rachael Krager, Audiologist, UC Davis Medical Center, 2521 Stockton Blvd., 6th Floor, Sacramento, CA 95817, USA. E-mail: rkrager@ucdavis.edu Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Advances in computer-aided design for bony free-flap reconstruction

Purpose of review The current article reviews the most recent publications of computer-assisted reconstruction using bony free flaps, emphasizing on comparative reports using these novel techniques. Recent findings Computer-aided reconstruction has shown some benefits in comparison with traditional techniques and some of the perceived limitations are currently being addressed in the latest reports. Still, there is a lack of appropriate comparative studies and unblinded measurements to establish solid conclusions. Summary Despite the application of new technologies showed encouraging results, it is premature to state that the traditional technique should be replaced by the modern approaches. Correspondence to Kevin Fung, MD, FRCS(C), FACS, Professor, Chair/Chief, Department of Otolaryngology – Head and Neck Surgery, Schulich School of Medicine and Dentistry, Western University, LHSC – Victoria Hospital, Room B3-427, 800 Commissioners Rd E, London, ON, Canada N6A 4G5. Tel: +1 519 685 8599; fax: +1 519 685 8567; e-mail: kevin.fung@lhsc.on.ca Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Clinical and diagnostic significance of serum immunoglobulin A rheumatoid factor in primary Sjogren’s syndrome

Abstract

Objectives

The aim of this study was to investigate the diagnostic accuracy of rheumatoid factor (RF) isotype for the detection of primary Sjogren's syndrome (pSS) and evaluate the clinical and serological associations of immunoglobulin (Ig) A RF in patients with pSS.

Materials and methods

RF levels were measured in 77 and 37 patients with pSS and idiopathic sicca symptoms, respectively, using ELISA and analysed with respect to clinical and laboratory disease characteristics. Receiver operating characteristic curves were used to determine and compare the diagnostic accuracy of IgA RF with other diagnostic tests.

Results

Serum levels of IgA RF were significantly higher in patients with pSS than in those with idiopathic sicca symptoms. IgA RF showed sensitivity, specificity, positive, and negative predictive values of 83.1, 78.4, 88.9, and 69.0%, respectively, for pSS diagnosis. IgA RF was associated with xerostomia, severe sialoscintigraphic grade, low unstimulated salivary flow rate (USFR), antinuclear antibody, high IgG and IgM/G RF levels, and low C3 levels in patients with pSS. IgA RF titres had positive correlations with sialoscintigraphic grade and IgG and IgG/M RF levels and had negative correlations with USFR and C3 levels.

Conclusion

Our findings confirmed the potential of IgA RF to distinguish pSS from idiopathic sicca symptoms. The presence of IgA RF in patients with pSS was associated with significantly worse exocrine function and active serologic profile. No association between IgA RF and extra-glandular manifestations was noted.

Clinical relevance

IgA RF should be the predictive and diagnostic marker in patients with pSS.

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Mechanisms of acute and chronic pain after surgery: update from findings in experimental animal models

Purpose of review Management of postoperative pain is still a major issue and relevant mechanisms need to be investigated. In preclinical research, substantial progress has been made, for example, by establishing specific rodent models of postoperative pain. By reviewing most recent preclinical studies in animals related to postoperative, incisional pain, we outline the currently available surgical-related pain models, discuss assessment methods for pain-relevant behavior and their shortcomings to reflect the clinical situation, delineate some novel clinical-relevant mechanisms for postoperative pain, and point toward future needs. Recent findings Since the development of the first rodent model of postoperative, incisional pain almost 20 years ago, numerous variations and some procedure-specific models have been emerged including some conceivably relevant for investigating prolonged, chronic pain after surgery. Many mechanisms have been investigated by using these models; most recent studies focussed on endogenous descending inhibition and opioid-induced hyperalgesia. However, surgical models beyond the classical incision model have so far been used only in exceptional cases, and clinical relevant behavioral pain assays are still rarely utilized. Summary Pathophysiological mechanisms of pain after surgery are increasingly discovered, but utilization of pain behavior assays are only sparsely able to reflect clinical-relevant aspects of acute and chronic postoperative pain in patients. Correspondence to Esther Pogatzki-Zahn, Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, A1, 48149 Münster, Germany. Tel: +49 251 8347261; fax: +49 251 88704; e-mail: pogatzki@anit.uni-muenster.de Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Pitfalls in anaphylaxis

Purpose of review Anaphylaxis is an acute medical emergency characterized by sudden presentation of life-threatening respiratory and cardiovascular symptoms. Rapid diagnosis of anaphylaxis is crucial to implement an appropriate treatment and management plan. However, mistakes in the diagnosis of anaphylaxis may occur because of the limited time during which the diagnosis must be made, the stressful environment of the emergency room, the often aspecific or incomplete clinical features of early anaphylaxis and the lack of useful laboratory markers. Recent findings Several disorders may mimick anaphylaxis and cause wrong or delayed diagnosis increasing chances of fatal outcomes. In addition, certain clinical situations, like general anesthesia, may complicate detection of early signs of anaphylaxis. Drugs like beta-blockers, angiotensin converting enzyme-inhibitors, antihistamines or steroids may hide or blunt initial clinical manifestations of anaphylaxis. Summary A careful evaluation of clinical signs in all organs is mandatory to quickly establish and confirm a diagnosis of anaphylaxis. Alternative diagnosis should be considered, particularly in the case of unresponsive patients. Avoiding pitfalls in anaphylaxis diagnosis will help to establish rapidly effective treatments and would further reduce the rate of fatal events. Correspondence to Massimo Triggiani, MD, PhD, Division of Allergy and Clinical Immunology University of Salerno, Via S. Allende Baronissi, Fisciano, Salerno, Italy. Tel: +39 089 965056; fax: +39 089 965056; e-mail: mtriggiani@unisa.it Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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