Donor-transmitted Melanoma Case Study

Donor-transmitted Melanoma Case Study Lakshmi Rangaswamy, D.O., Kim Jordan, MD., FACP, Ronald deAndrade, MD Introduction Organ transplant recipients are at an increased risk of developing malignancy, estimated to occur in 15-20% of graft recipients after 10 years. Most malignancies occur de novo or as recurrence of previously treated disease, related to immunosuppression and oncogenic viruses. Donor-transmitted tumors are rare. From 1994 – 2001, the US Transplant tumor registry reported 18 donor-related cancers in 108,062 recipients. Case Presentation History A 66-year-old female presents with abdominal fullness, fevers, chills and malaise for 1 week’s time. Admitted to transplant service to rule out rejection. Past Medical History End Stage Renal Disease status post cadaveric renal transplant 3 months prior Hypertension Diabetes Mellitus Type 2 -Anemia of chronic disease Social History: No tobacco, alcohol, or drug abuse Medications: (do I really need strength and frequency?) Amlodipine 10 mg daily Aspirin 81 mg daily Bactrim 160 mg daily Carvedilol 25 mg twice daily Clotrimazole 10 mg troche three times daily Insulin Lispro 10 units with meals Lantus 20 units in AM Myofortic 360 mg 2 tablets twice daily Prednisone 10 mg daily Tacrolimus 2mg twice daily Valcyte 450 mg 2 tablets daily Physical exam VITALS: T 100.1, BP 133/60, HR 71, Resp 18, SpO2 99% on RA, nonoliguric Neck: no lymphadenopathy, no carotid bruits Cardiovascular: regular rate and rhythm, no clicks, gallops, rubs, no lower extremity edema Lungs: clear to auscultation bilaterally, no rales or wheezes Abdomen: soft, well healed Gibson incision in RLQ, no graft tenderness, no organomegaly Skin: no rashes or lesions noted on skin Laboratory and Diagnostic Studies (insert images) WBC 3.94 K/mcl; Hgb 9.8 g/dL (patient’s baseline); platelets 104 K/mcl LDH 747 U/L Creatinine 1.72 mg/dL on the day of admission (baseline 1.02 two months prior, after transplant). During the hospital course, her renal failure worsened with creatinine reaching 8.08 mg/dL and patient requiring intermittent hemodialysis CT of the abdomen with contrast and PET scan Findings compatible with metastatic disease to the liver, spleen, bones, and probably lungs. MRI Abdomen/pelvis A few indeterminate T1 and T2 hyperintense lesions in the periphery of the transplant kidney, suspicious for neoplasm. Innumerable bone marrow and splenic lesions, suspicious for hemorrhagic metastasis MRI of brain Diffuse bony metastases, no signs of intraparenchymal metastasis PET: Positive for multiple lesions in the transplant kidney, bone, and spleen. CT guided Bone marrow biopsy: Metastatic malignant neoplasm, quite consistent with metastatic malignant melanoma **Within days of patient’s admission, it was discovered that the recipient of the liver from the same donor developed melanoma within the transplanted liver and the recipient of the mate kidney had developed melanoma in the renal allograft. **The transplant center reported no known history of donor melanoma and normal visual inspection of donor organs at time of transplant. Clinical Course Patient elected to undergo allograft nephrectomy. Surgical pathology of removed donor kidney confirmed malignant melanoma that was BRAF-V600E mutation positive (insert histo slide of melanoma in kidney) Patient was taken off of all immunosuppressive therapy and was started on chemotherapy with zelboraf and immunotherapy with ipilimumab (completed 4 months of zelboraf and 4 cycles of ipilimumab) Patient currently off of chemotherapy, and undergoes repeat imaging every month. At 6 months, CT body from 6 months â€Å"demonstrates basically stable disease.† This patient is now undergoing hemodialysis for her end stage renal disease The two other recipients died from metastatic melanoma found in the transplanted liver and renal allograft; this patient is the sole survivor of the transplanted melanoma. Transmission of melanoma by organ transplantation (VIPER) Not only is melanoma the most common fatal form of skin cancer, it is the most common tumor responsible for donor-derived malignancy. The late disease recurrence of melanoma is related to the dormancy of melanoma. Major theories for the dormancy of melanoma include cell-cycle arrest and blocked angiogenesis. Per Lancet article entitled â€Å"Transmission of donor melanoma by organ transplantation,† late recurrence of dormant melanoma can occur because of micrometastases or solitary dormant cells. Dormant micrometastasis occurs because of the inability for angiogenesis; therefore there is an equilibrium between cell proliferation and apoptosis and thus an inability of malignant cell growth. In dormant solitary cells, there is an absence of proliferation or apoptosis, in essence a pause in cell growth. Because of these theories, it is possible that these dormant cells stay latent in immunocompetent individuals for decades and even forever, but the immunosuppression of the organ recipient can reactivate the melanoma cells. Transplantation for end-stage organ disease has become routine care with resultant increased demand for donor organs. With increased public awareness and donor pool expansion, many transplant programs are easing criteria for selection by accepting older donors and those with remote history of low-grade skin cancers and/or remote â€Å"cured cancers.† A recent study reported 23 cases of donor-transmitted melanoma from 12 separate donors between 1972 and 2006. Only 2 donors had known history of melanoma and one case of fatal melanoma occurred from a donor who had surgically removed melanoma sixteen years prior to donation. History of melanoma remains a contraindication to organ donation given melanoma high transmission rate of 74% and mortality of 58%. Treatment of donor-related melanoma involves withdrawing immunosuppression and allowing the body to reject the transplanted organ, followed by explantation of the allograft carrying the melanoma cells. Summary Melanoma incidence in the general population is increasing, but whether this will translate into increased incidence of donor-transmitted melanoma and resultant increased mortality remains to be determined. Physicians must not only discuss risks of malignancy with transplant candidates, but also carefully question all donors and their family about recent and remote malignancy, particularly melanoma, given its high transmission rate and mortality. Patients with any history of melanoma, whether it be in the early stages or cured, showed not be considered as organ donors. References Geller, A.,et al (2013). Melanoma Epidemic: An Analysis of Six Decades of Data From the Connecticut Tumor Registry.Journal of Clinical Oncology,31, 4172-4178. Geller, A.,et al (2014). Screening and early detection of melanoma. Retrieved January 1,  2014, from http://www.uptodate.com/ Morris-Stiff, G.,et al (2004). Transmission of Donor Melanoma to Multiple Organ  Transplant Recipients.American Journal of Transplantation,10, 444-446. Strauss, D. (2010). Transmission of donor melanoma by organ transplantation. Lancet  Oncology, 11, 790-796. Retrieved from www.thelancet.com/oncology

Mang Inasal Sample Paper Essay

Numbers of employees of mang inasal – 21 employees including manager including the managers. Number of hours of operation a day – working hours, 8. Staff operation 8:00 am to 10:00 pm, on customers, 9:00 am to 8:00 am. Reasons for choosing the branch location – Since people love to spend most of their time in the mall, Problems encountered during the business operation – the manager laughs that she always encounters some problems to her subordinates, like being late at duties, some members that are hard headed, and reaction of customers that gets the wrong order and slow serving. How they see their business 5 to 10 years from now? – the manager say’s she can picture Mang Inasal being as more popular as before, growing bigger and better. Like jolibee, she sees Mang Inasal having many branches that extends internationally. Notable Experience in running the business – Reasons for having that kind of business – according to the manager, Miss Kristine Loayon, they were informed during their job seminars and orientations, the owner of mang inasal, Edgar â€Å"Injap† Sia , had a target to have a business that people will love and can be successful without a doubt. Since Filipinos love to eat, specially barbeques and Filipino dishes, then why not make food-chain business which features barbeques and pinoy foods Types of products, services offered? – Philippine cuisine Fast food, deliveries and reservations of tables only at the second floor of mang inasal ormoc branch. ECOTAXA – Introduction MANG INASAL – Philippine’s fastest growing barbeque fast food chain, serving chicken, pork barbeque and other Filipino favorites, was first established on December12,2003 in Iloilo City. Currently, there are 445 branches nationwide and with over 10,000 employees system wide. MANG INASAL is doing its share in alleviating the unemployment burden of the country. The presence of every MANG INASAL in a certain area provides not only employment but also opportunities to community members including suppliers of kalamansi, charcoal, banana leaves, vegetables, bamboo sticks, and other ingredients. It also indirectly gives income – generating activities to many. MANG INASAL is operating at the following areas: Bacolod, Iloilo, Roxas, Laguna, Bicutan, Metro Manila, Davao, Cagayan De Oro, Koronadal, Ozamiz, Iligan, Surigao, General Santos, Pagadian, Batangas, Lucena, Naga City, Davao del Norte, Davao del Sur, Tagaytay, Palawan, Tacloban, Ilocos Sur and Tarlac. MANG INASAL is targeting to open 500 stores by 2012. Apart from the usual food presentations of multinational food company copycats, Mang Inasal endeavors to adhere to elements that bear a distinctively Pinoy stamp-grilling with charcoal, rice wrapped in banana leaves, a marinade concocted out of local spices and herbs, bamboo sticks for skewers, and the ambiance that encourages kinamot (the ilonggo term in eating with the hands) whenever chicken inasal is served. All these evoke a rush of nostalgia for tradition, culture, and most of all, Home. Mang Inasal is proud to do its share in alleviating the unemployment burden of the country. It is effectively stimulating economic activities in communities where branches are situated. Local suppliers of calamansi, charcoal, banana leaves, sorbeteros, vegetables, fish, bamboo sticks, and other ingredients, as well as LGU’s, trisikad (pedicab) drivers, and a host of other enterprises are benefited by the presence of Mang Inasal in their area. Mang Inasal has steadily grown since it offered franchising. Mang Inasal has branches in Bacolod, Iloilo, Roxas, Metro Manila, Cebu, Davao, Kalibo, Tarlac, Boracay, Antique, Mindoro, Batangas, Pampanga, General Santos, Tuguegarao, Iligan, Bulacan, Cavite, Baguio, Laguna, Panabo, Cagayan De Oro, Lucena Surigao, Palawan, Agusan Del Sur, Malabon, Zamboanga Pagadian, Koronadal, Rizal, Pangasinan, Dipolog, La Union, Ozamiz, Kabankalan As of today, Mang Inasal has 423 branches nationwide and counting. In Mang Inasal, â€Å"Pinagsikapan naming laging mabilis, laging masarap, at laging abot-kaya† so that the Pinoy can truly say, â€Å"Kumbinsing!†

When Terror Struck - 2279 Words

When Terror Struck Imagine living in country where people who do not even know you already despise you. Imagine people not seeing you as a human being, but as a creature. Imagine being treated or thought of as dirt, and always having people tell you are worthless. During World War II the Jewish community was isolated from the rest of the world, because Hitler had represented the Jews as a threat to the collective health of the German nation. Even though the German army targeted other groups, such as the disabled, gypsies, and slaves, they placed Jews in a special category. Jews were considered a disease, and an alien, and therefore they had to be separated from the rest of the German†¦show more content†¦They took all the Jews and placed 15479 (3) them in concentration camps. When this policy was put in action many Jews tried to get out of Germany, but many countries started restricting the entry of Jewish immigrants. World War II erupted with the German invasion of Poland. Gottfried stated â€Å"The German invasion of Poland brought a new dimension to the history of warfare (Gottfried31).† The Euthanasia started with outbreak of war, Hitler authorized doctors and medical aids to participate in the murder of their ill patients. The doctors gassed their patients in rooms camouflaged as shower chambers. Large number of people that were participates in this manner were SS. The doctors doing this had no shame they simply believed that they were cleansing the Fatherland. The Program stopped when relatives of the victims protested the deaths of their love ones. The program was effectively disguised and continued until the end of the war (Feldman). Following the German invasion of the Soviet Union, the Nazis decide to annihilate the Jewish people. The Jews were forced into ghettos. The ghettos were meant to serve temporary areas of Jewish settlement, until the establishment of a camp in the east or in Madagascar was done, but the plans failed. 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Sentirse Conjugation in Spanish, Translation, and Examples

The verb sentirse is a reflexive verb that means to feel. It is used to talk about how someone feels psychologically or physically. For example, Me siento feliz (I feel happy) or Nos sentimos cansados (We feel tired). This verb can also be used as a non-reflexive verb, sentir, in which case it can have several different meanings. It can mean to feel or sense something, and sometimes it can even mean to taste or hear something. For example, Siento el viento en mi cara (I feel the wind on my face) or Siento sabor a chocolate en la bebida (I taste chocolate flavor in the beverage). Sentir can also mean to be sorry, as in the common expression lo siento (Im sorry) or Siento que hayamos llegado tarde (Im sorry that we arrived late). Sentirse Conjugation Since sentirse is most often used in its reflexive form, this article includes sentirse conjugations including the reflexive pronouns in the indicative mood (present, past, conditional, and future), the subjunctive mood (present and past), the imperative mood, and other verb forms. Notice that sentirse is a stem-changing verb. This means that in some conjugations, when the vowel of the stem is in a stressed syllable, the e changes to ie and sometimes i. For example, the present tense first person singular conjugation is me siento, and the preterite third person conjugation singular conjugation is se sintià ³. When conjugating sentirse, make sure to avoid confusion with the verb sentarse (to sit down), which has a very similar conjugation. Present Indicative When conjugating a reflexive verb, you must always include the reflexive pronoun before each conjugated verb. In the present tense, the stem change e to ie occurs in all the conjugations except nosotros and vosotros. Yo me siento Yo me siento feliz con mi familia. I feel happy with my family. Tà º te sientes Tà º te sientes cansada al final del dà ­a. You feel tired at the end of the day. Usted/à ©l/ella se siente Ella se siente triste por la mala noticia. She feels sad because of the bad news. Nosotros nos sentimos Nosotros nos sentimos emocionados por el triunfo del equipo. We feel excited about the team's victory. Vosotros os sentà ­s Vosotros os sentà ­s enfermos despuà ©s de comer mucho. You feel sick after eating too much. Ustedes/ellos/ellas se sienten Ellos se sienten relajados en la playa. They feel relaxed at the beach. Preterite Indicative You can use the preterite tense to describe completed actions in the past. In the preterite, there is a stem change e to i only for the third person singular and plural conjugations. Yo me sentà ­ Yo me sentà ­ feliz con mi familia. I felt happy with my family. Tà º te sentiste Tà º te sentiste cansada al final del dà ­a. You felt tired at the end of the day. Usted/à ©l/ella se sintià ³ Ella se sintià ³ triste por la mala noticia. She felt sad because of the bad news. Nosotros nos sentimos Nosotros nos sentimos emocionados por el triunfo del equipo. We felt excited about the team's victory. Vosotros os sentisteis Vosotros os sentisteis enfermos despuà ©s de comer mucho. You felt sick after eating too much. Ustedes/ellos/ellas se sintieron Ellos se sintieron relajados en la playa. They felt relaxed at the beach. Imperfect Indicative You can use the imperfect tense to describe actions in the past that were ongoing or repeated. It can be translated as was feeling or used to feel. There are no stem changes in the imperfect. Yo me sentà ­a Yo me sentà ­a feliz con mi familia. I used to feel happy with my family. Tà º te sentà ­as Tà º te sentà ­as cansada al final del dà ­a. You used to feel tired at the end of the day. Usted/à ©l/ella se sentà ­a Ella se sentà ­a triste por la mala noticia. She used to feel sad because of the bad news. Nosotros nos sentà ­amos Nosotros nos sentà ­amos emocionados por el triunfo del equipo. We used to feel excited about the team's victory. Vosotros os sentà ­ais Vosotros os sentà ­ais enfermos despuà ©s de comer mucho. You used to feel sick after eating too much. Ustedes/ellos/ellas se sentà ­an Ellos se sentà ­an relajados en la playa. They used to feel relaxed at the beach. Future Indicative The future tense is conjugated with the infinitive form and the future tense endings (à ©, à ¡s, à ¡, emos, à ©is, à ¡n). There are no stem changes in the future tense, since the base for this conjugation is the complete infinitive, sentir. Yo me sentirà © Yo me sentirà © feliz con mi familia. I will feel happy with my family. Tà º te sentirà ¡s Tà º te sentirà ¡s cansada al final del dà ­a. You will feel tired at the end of the day. Usted/à ©l/ella se sentirà ¡ Ella se sentirà ¡triste por la mala noticia. She will feel sad because of the bad news. Nosotros nos sentiremos Nosotros nos sentiremos emocionados por el triunfo del equipo. We will feel excited about the team's victory. Vosotros os sentirà ©is Vosotros os sentirà ©is enfermos despuà ©s de comer mucho. You will feel sick after eating too much. Ustedes/ellos/ellas se sentirà ¡n Ellos se sentirà ¡n relajados en la playa. They will feel relaxed at the beach. Periphrastic  Future Indicative   The periphrastic future tense consists of three components, the verb ir (to go), the preposition a, and the infinitive sentir. The reflexive pronoun should be placed before the conjugated verb ir (to go). Yo me voy a sentir Yo me voy a sentir feliz con mi familia. I am going to feel happy with my family. Tà º te vas a sentir Tà º te vasa sentir cansada al final del dà ­a. You aregoing to feel tired at the end of the day. Usted/à ©l/ella se va a sentir Ella se vaa sentir triste por la mala noticia. She isgoing to feel sad because of the bad news. Nosotros nos vamos a sentir Nosotros nos vamosa sentir emocionados por el triunfo del equipo. We aregoing to feel excited about the team's victory. Vosotros os vais a sentir Vosotros os vaisa sentir enfermos despuà ©s de comer mucho. You aregoing to feel sick after eating too much. Ustedes/ellos/ellas se van a sentir Ellos se vana sentir relajados en la playa. They aregoing to feel relaxed at the beach. Present Progressive/Gerund Form The gerund or present participle can be used as an adverb or to form progressive tenses like the present progressive. For reflexive verbs in progressive tenses there are two options for placing the reflexive pronoun: before the conjugated auxiliary verb estar, or attached to the end of the present participle. Notice that the gerund for sentir has the stem change e to i. Present Progressive ofSentirse se està ¡ sintiendo / està ¡ sintià ©ndose Ella se està ¡ sintiendo triste por la mala noticia. She is feeling sad because of the bad news. Past Participle The past participle can be used in perfect tenses like the present perfect. Note that the reflexive pronoun has to go before the conjugated auxiliary verb haber. Present Perfect of Sentirse se ha sentido Ella se ha sentido triste por la mala noticia. She has felt sad because of the bad news. Conditional Indicative The conditional tense is usually translated as would verb. Yo me sentirà ­a Yo me sentirà ­a feliz con mi familia si nos llevà ¡ramos bien. I would feel happy with my family if we got along. Tà º te sentirà ­as Tà º te sentirà ­as cansada al final del dà ­a si hicieras ejercicio. You would feel tired at the end of the day if you worked out. Usted/à ©l/ella se sentirà ­a Ella se sentirà ­atriste por la mala noticia, pero no tiene sentimientos. She would feel sad because of the bad news, but she has no feelings. Nosotros nos sentirà ­amos Nosotros nos sentirà ­amos emocionados por el triunfo del equipo si ganà ¡ramos. We would feel excited about the team's victory if we won. Vosotros os sentirà ­ais Vosotros os sentirà ­ais enfermos despuà ©s de comer mucho, pero comisteis comida liviana. You would feel sick after eating too much, but you ate light food. Ustedes/ellos/ellas se sentirà ­an Ellos se sentirà ­an relajados en la playa si pudieran descansar. They would feel relaxed at the beach if they could rest. Present Subjunctive Notice that in the present subjunctive all the conjugations have a stem change. However, the nosotros and vosotros conjugations only change from e to i, while the rest change from e to ie. Que yo me sienta Mi padre espera que yo me sienta feliz con mi familia. My father hopes that I feel happy with my family. Que tà º te sientas El jefe espera que que tà º no te sientas cansada al final del dà ­a. The boss hopes that you do not feel tired at the end of the day. Que usted/à ©l/ella sesienta Eric espera que ella no se sienta triste por la mala noticia. Eric hopes that she doesn't feel sad because of the bad news. Que nosotros nos sintamos El entrenador sugiere que nosotros nos sintamos emocionados por el triunfo del equipo. The coach suggests that we feel excited about the team's victory. Que vosotros os sintà ¡is Laura espera que vosotros no os sintà ¡is enfermos despuà ©s de comer mucho. Laura hopes that you don't feel sick after eating too much. Que ustedes/ellos/ellas sesientan David recomienda que ellas se sientan relajadas en la playa. David recommends that they feel relaxed at the beach. Imperfect Subjunctive You can conjugate the imperfect subjunctive in two different ways; both forms require the stem change e to i. Option 1 Que yo me sintiera Mi padre esperaba que yo me sintiera feliz con mi familia. My father hoped that I would feel happy with my family. Que tà º te sintieras El jefe esperaba que tà º no te sintieras cansada al final del dà ­a. The boss hoped that you did not feel tired at the end of the day. Que usted/à ©l/ella sesintiera Eric esperaba que ella no se sintiera triste por la mala noticia. Eric hoped that she didn't feel sad because of the bad news. Que nosotros nos sintià ©ramos El entrenador sugerà ­a que nosotros nos sintià ©ramos emocionados por el triunfo del equipo. The coach suggested that we feel excited about the team's victory. Que vosotros os sintierais Laura esperaba que vosotros no os sintierais enfermos despuà ©s de comer mucho. Laura hoped that you didn't feel sick after eating too much. Que ustedes/ellos/ellas sesintieran David recomendaba que ellas se sintieran relajadas en la playa. David recommended that they feel relaxed at the beach. Option 2ï » ¿ Que yo me sintiese Mi padre esperaba que yo me sintiese feliz con mi familia. My father hoped that I would feel happy with my family. Que tà º te sintieses El jefe esperaba que que tà º no te sintieses cansada al final del dà ­a. The boss hoped that you did not feel tired at the end of the day. Que usted/à ©l/ella sesintiese Eric esperaba que ella no se sintiese triste por la mala noticia. Eric hoped that she didn't feel sad because of the bad news. Que nosotros nos sintià ©semos El entrenador sugerà ­a que nosotros nos sintià ©semos emocionados por el triunfo del equipo. The coach suggested that we feel excited about the team's victory. Que vosotros os sintieseis Laura esperaba que vosotros no os sintieseis enfermos despuà ©s de comer mucho. Laura hoped that you didn't feel sick after eating too much. Que ustedes/ellos/ellas sesintiesen David recomendaba que ellas se sintiesen relajadas en la playa. David recommended that they feel relaxed at the beach. Sentirse Imperative To give direct orders or commands you can use the imperative mood. For reflexive verbs you must be careful where the pronoun is placed: in positive commands, it goes after the verb, while in negative commands, it goes before the verb. Positive Commands Tà º sià ©ntete  ¡Sià ©ntete cansado al final del dà ­a! Feel tired at the end of the day! Usted sià ©ntase  ¡Sià ©ntase triste por la mala noticia! Feel sad because of the bad news! Nosotros sintà ¡monos  ¡Sintà ¡monos emocionados por el triunfo del equipo! Let's feel excited about the team's victory! Vosotros sentidos  ¡Sentidos enfermos despuà ©s de comer mucho! Feel sick after eating too much! Ustedes sià ©ntanse  ¡Sià ©ntanse relajados en la playa! Feel relaxed at the beach! Negative Commands Tà º no te sientas  ¡No te sientas cansado al final del dà ­a! Don't feel tired at the end of the day! Usted no se sienta  ¡No se sienta triste por la mala noticia! Don't feel sad because of the bad news! Nosotros no nos sintamos  ¡No nos sintamos emocionados por el triunfo del equipo! Let's not feel excited about the team's victory! Vosotros no os sintà ¡is  ¡No os sintà ¡is enfermos despuà ©s de comer mucho! Don't feel sick after eating too much! Ustedes no se sientan  ¡No se sientan relajados en la playa! Don't feel relaxed at the beach!