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Given two eigenforms, it is a natural question to ask if the product of the eigenforms is again an eigenform. In the case of elliptic modular forms, this was answered in the full level case by Duke and Ghate and in the general level case by Johnson. In this paper, we consider the case of genus two Siegel modular forms with general congruence level.

To demonstrate the obstetric profile of teenage pregnancy and maternity parity in the metropolitan region of Curitiba, in southern Brazil, from 2009 to 2014, in order to provide information for interventions in preventing non-planned pregnancy in this population.Data regarding maternal age, gestational age, newborn weight, obstetric complications and type of delivery were collected in 4668 patients aged between 15 and 19 years, and those aged 20 to 24, with previous teenage pregnancy. An Excel table was created to store the information, later analysed. Most patients were primigravid (71%), with 22% in the second pregnancy. Multiparity was present in 29% of pregnant women. The mean age at first pregnancy was 17.3 years (standard deviation of 1.30). The main route of delivery was vaginal, in 80%. Episiotomy was performed in 70% of these deliveries. Cesarean deliveries occurred mainly due to induction failure (19.8%), cephalopelvic disproportion (14.4%) and fetal distress (11.1%). Mean gestational age was 39.1 weeks (standard deviation 1.5). Low birth weight occurred in 7% of newborns, and 4% were preterm. Most of the patients analysed were primiparous aged 17.3 years. Multiparity in adolescence proved to be a frequent phenomenon in the region studied, with a prevalence of 30%, occurring at an average age of 18.6 years old. A quarter of 20-year-old patients’ population had more than two pregnancies. The presence of episiotomy was high, performed in 70% of vaginal deliveries, a value above the recommended by WHO.]

Ewing sarcoma (ES) is a malignant neoplasm that affects bones and soft tissues, usually in young patients. Currently, ES is grouped with other tumors that share the same histological and genotypic characteristics, forming the Ewing Sarcoma Family of Tumors (ESFT), which includes ES of bone, extraosseous ES (peripheral neuroepithelioma), Askin tumor, and peripheral primitive neuroectodermal tumor (PNET). Its origin in peripheral nerves is extremely rare, making its diagnosis and treatment very challenging. We describe a case of a 27-year-old male with extraosseous ES originating in the sciatic nerve, which was surgically removed, and discuss the difficulties encountered in the management of this patient.

Background Recombinant adeno-associated virus (rAAV) is widely used in the neuroscience field to manipulate gene expression in the nervous system. However, a limitation to the use of rAAV vectors is the time and expense needed to produce them. To overcome this limitation, we evaluated whether unpurified rAAV vectors secreted into the media following scalable PEI transfection of HEK293T cells can be used in lieu of purified rAAV. Methods We packaged rAAV2-EGFP vectors in 30 different wild-type and mutant capsids and subsequently collected the media containing secreted rAAV. Genomic titers of each rAAV vector were assessed and the ability of each unpurified virus to transduce primary mixed neuroglial cultures (PNGCs), organotypic brain slice cultures (BSCs) and the mouse brain was evaluated. Results There was ~ 40-fold wide variance in the average genomic titers of the rAAV2-EGFP vector packaged in the 30 different capsids, ranging from a low ~ 4.7 × 1010 vector genomes (vg)/mL for rAAV2/5-EGFP to a high of ~ 2.0 × 1012 vg/mL for a capsid mutant of rAAV2/8-EGFP. In PNGC studies, we observed a wide range of transduction efficiency among the 30 capsids evaluated, with the rAAV2/6-EGFP vector demonstrating the highest overall transduction efficiency. In BSC studies, we observed robust transduction by wild-type capsid vectors rAAV2/6, 2/8 and 2/9, and by capsid mutants of rAAV2/1, 2/6, and 2/8. In the in vivo somatic brain transgenesis (SBT) studies, we found that intra-cerebroventricular injection of media containing unpurified rAAV2-EGFP vectors packaged with select mutant capsids resulted in abundant EGFP positive neurons and astrocytes in the hippocampus and forebrain of non-transgenic mice. We demonstrate that unpurified rAAV can express transgenes at equivalent levels to lysate-purified rAAV both in vitro and in vivo. We also show that unpurified rAAV is sufficient to drive tau pathology in BSC and neuroinflammation in vivo, recapitulating previous studies using purified rAAV. Conclusions Unpurified rAAV vectors secreted into the media can efficiently transduce brain cells in vitro and in vivo, providing a cost-effective way to manipulate gene expression. The use of unpurified virus will greatly reduce costs of exploratory studies and further increase the utility of rAAV vectors for standard laboratory use.

Clinicians have a tendency to dismiss patients with psychiatric illness like skin picking disorder without assessing completely for organic disease. Patients with psychocutaneous disease have the potential to develop true dermatopathology and should always be examined thoroughly. We describe a case of skin picking disorder with underlying pilomatricoma. The patient met criteria for skin picking disorder and had been prescribed numerous topical treatments without efficacy by countless physicians over 18 years. In addition, a pilomatricoma was discovered within a self-inflicted ulcer. Pilomatricomas can rarely result from trauma and develop ossification, both of which were true of this lesion. The prevalence of skin picking disorder proves more pervasive than previously realized and it has only recently been recognized by the DSM-5 as an independent diagnosis. Therefore, it is necessary to clarify the diagnosis as well as remind clinicians not to discount underlying dermatologic disease. In addition to the risk of bleeding and infection, these patients are at risk for masking neoplasms, which should be removed. Our case emphasizes the need for thorough examination of patients with psychocutaneous disease and further work-up when necessary to prevent permanent disfigurement.

233 Background: Advance directives (ADs) are legal tools that direct treatment or decision making and appoint a surrogate decision-maker (health care proxy). The presence of ADs is associated with decreased rates of hospitalization, use of life-sustaining treatment, and deaths in a hospital setting. Additionally, completed ADs lead to increased use of hospice or palliative care, more positive family outcomes, improved quality of life for patients, and reduced costs for healthcare. Despite the benefits of advance care planning, only 18-36% of adults have completed advance care plans. The aims of our pilot study were to 1) implement a synchronized system for advance care planning across the UT Health San Antonio health system and 2) improve advance care planning rates in a primary care clinic and palliative oncology clinic. Methods: During a 10-month prospective period, system processes for advance care planning were reviewed with identification of three primary drivers for advance care plan completion: a) electronic/EMR processes, b) clinical workflows and training, and c) patient resources and education. As a result of this quality improvement initiative, standardized forms, resources, and processes for obtaining advance care plans were implemented in the selected clinics. Results: At baseline, the primary care clinic had 84/644 (13%) patients and the palliative oncology clinic had 25/336(7%) with completed advance care plans. With the implementation of a standardized process, 108 patients (23% increase in rate of completion) in the primary clinic and 56 patients (71% increase in rate of completion) in the palliative oncology setting completed advance care planning (ACP). Additionally, there was a 5-fold increase in billing of ACP CPT codes within the clinics during the first 6 months compared to the prior full year. Conclusions: While this quality improvement pilot initiative was limited to two clinics, the synchronized modifications suggest that the system changes could be expanded to other clinics in our UT health system to promote ACP discussions, completion of plans, and ultimately improved patient care.

The authors present an historical review of aspects of the life of Professor Manuel R. Gómez, a Spanish neuropediatrician, who graduated in Havana and is known internationally for his work while he was in charge of Pediatric Neurology at the Mayo Clinic in Rochester, USA. His main contribution was related to the tuberous sclerosis complex, demystifying the Vogt triad previously used as a diagnostic criterion, and he was considered the “father of the tuberous sclerosis complex “ in the USA. RESUMO Os autores apresentam uma revisão histórica sobre aspectos da vida do professor Manuel R. Gómez, neuropediatra espanhol, formado em Havana e conhecido internacionalmente pelo seu trabalho à frente do serviço de Neurologia Pediátrica da clínica Mayo em Rochester, EUA. Sua principal contribuição esteve relacionada com o complexo esclerose tuberosa desmitificando a tríade de Vogt até então usada como critério diagnóstico da doença, pelo que foi considerado o ‘pai do complexo esclerose tuberosa’ nos EUA.

Langerhans cell histocytosis (LCH) and Erdheim-Chester disease are two rare histiocytic disorders. Their occurrence in the same patient is more infrequent, but has been described. We report a case of a 38-year-old woman who presented with a diagnosis of single system cutaneous LCH. Subsequently, she developed multiple papules on her extremities consistent with a non-LCH xanthogranuloma type lesion. BRAF(V600E) mutation immunostain, VE1 was positive in the skin lesion, which was confirmed by molecular polymerase chain reaction (PCR) studies, initiating a complete systemic workup for Erdheim-Chester disease. Systemic involvement was confirmed with bilateral sclerotic bone lesions and retroperitoneal and pelvic fibrosing disease. She was also found to have a BRAF(V600E) mutation positive papillary thyroid carcinoma. New suspicious cutaneous lesions presenting in patients with a history of LCH need to be biopsied. A BRAF(V600E) mutation in a non-LCH histiocytic lesion with a xanthogranuloma phenotype (CD163/CD68/CD14/fascin/Factor 13a) should prompt an Erdheim-Chester disease workup. This is a unique case of a woman with BRAF(V600E) mutation positive Erdheim-Chester disease and cutaneous LCH, while also being, to our knowledge, the first reported case in the English literature of it occurring in a patient with a BRAF(V600E) mutation positive papillary thyroid carcinoma.

Langerhans cell histiocytosis and xanthogranuloma are both conditions characterized by increased histiocytic proliferation and are both more commonly seen in children. Nevertheless, the two are completely separate entities and have distinct differences in clinical presentation, histopathological appearance, prognosis, and therapy. Although adult forms of either disorder are rare, concurrent presentation of both is even more unusual. We report a 61-year-old man who presented with disseminated yellow-red papules coalescing into nodules, on a background of erythema and alopecia. Histopathology exhibited a dense dermal infiltrate of foamy histiocytes and lymphocytes in addition to follicular mucinosis with atypical folliculotropic cells. Appropriate staining revealed that the foamy histiocytes throughout the dermis represented a xanthogranulomatous process, while the folliculotropic proliferation represented Langerhans cell histiocytosis. Further work-up of this multiple adult xanthogranulomas with follicular mucinosis-associated Langerhans cell histiocytosis exposed underlying chronic myelogenous leukemia per bone marrow biopsy, which was likely either solely or partially an initiating factor in the eruption of multiple histiocytic process in this patient.