21 No heritability data are available for the combined dex/CRH test. However, In the Munich Vulnerability Study,22,23 the combined dex/CRH test was conducted In healthy selleck first-degree relatives of patients with a major depressive disorder, who are assumed to carry a genetic vulnerability for affective disorders. These so-called high-risk probands (HRPs) are

characterized by a moderately elevated hormonal response to the combined dex/CRH test, which was significantly higher compared with controls without a personal or familial history of psychiatric disorders, Inhibitors,research,lifescience,medical but less pronounced compared with the response in acutely depressed patients. Modell and coworkers24 replicated these findings In Inhibitors,research,lifescience,medical still unaffected HRPs who were re-examined in a follow-up Investigation about 4 years later (Figure 3), suggesting that this trait-like impaired regulation of the HPA system could reflect the genetic vulnerability for affective disorders in these

subjects. Figure 3. Cortisol response to the combined dex/CRH test is moderately elevated in high risk probands for affective disorders Inhibitors,research,lifescience,medical (AUC, P<.05), which was stable over time at the group level (AUC, P=.758) as well as at the individual level (Pearson correlation, ... Despite the statistical evidence for a considerable heritability of the stress response, the number of significant genetic findings Is small, and the conclusiveness Inhibitors,research,lifescience,medical rather limited. The findings are summarized in Table I. Due to the Importance of the HPA system for the stress response, which is primarily regulated by GR, the GR gene has been proposed as the primary candidate Inhibitors,research,lifescience,medical for the genetic association studies. Significant associations between GR and psychosocial stress response were reported, but only when a haplotype approach is applied25

or when male subjects are separately analyzed (Kumsta and Wust, 2006; personal communication). Further genetic associations, not yet replicated, are reported for the γ-aminobutyric acid (GABA) A 6 receptor subunit gene26 and for an nonsynonymous exon single-nucleotide polymorphism (SNP) of the micro-opiold receptor 1 (MOR) gene.27 Table I. Genetic associations and with stress response in human paradigms. GABA, γ-aminobutyric acid; ACTH, adrenocorticotropic hormone; CRH, corticotropin-releasing hormone; HPA, hypothalamic-pituitary-adrenal Additional evidence for an Involvement of the GR gene in the genetics of the stress response has been provided by two other studies (Table I) employing a low-dose dex suppression test In elderly subjects.

Conflict of Interest: None declared.
Background: Activation of the ubiquitin-proteasome pathway in various malignancies, including FTY720 clinical trial colorectal cancer, is established. This pathway mediates the degradation of damaged

proteins and regulates growth and stress response. The novel human gene, UBE2Q2, with a putative ubiquitin-conjugating enzyme activity, is reported to be overexpressed in some malignancies. We sought to investigate the expression levels of the UBE2Q2 gene in colorectal cell lines as well as in cancerous and normal tissues from patients with colorectal cancer. Inhibitors,research,lifescience,medical Methods: Levels of UBE2Q2 mRNA in cell lines were assessed by Real-Time PCR. Western blotting was employed to investigate Inhibitors,research,lifescience,medical the levels of the UBE2Q2 protein in 8 colorectal cell lines and 43 colorectal tumor samples. Results: Expression of UBE2Q2 was observed at the level of both mRNA and protein in colorectal cell lines, HT29/219, LS180, SW742, Caco2, HTC116, SW48, SW480, and SW1116. Increased levels of UBE2Q2 immunoreactivity was observed in the 65.11% (28 out of 43) of the colorectal carcinoma tissues when compared with their corresponding normal tissues. Difference between the mean intensities of UBE2Q2 bands from cancerous and normal tissues was statistically significant at P<0.001 (paired t test). Conclusion: We showed the expression pattern of the novel human gene, UBE2Q2, in 8 colorectal Inhibitors,research,lifescience,medical cell lines. Overexpression

of UBE2Q2 in the majority of the colorectal carcinoma samples denotes that it may have implications for the pathogenesis of colorectal cancer. Keywords: UBE2Q2, Colorectal Cancer, Inhibitors,research,lifescience,medical Cell Line, Gene Expression Introduction Colorectal cancer (CRC) is the third most common type of non-skin cancer worldwide and the third Inhibitors,research,lifescience,medical cause of cancer-related death in the Western world.1,2 The molecular defects in CRC can be due to changes that result in increased activity of oncogenes or to changes that lead to loss of function of the tumor-suppressor genes.3 A large

number of colorectal tumors show mutations in the KRAS oncogene as well as in the APC, p53, and SMAD4/DPC4 tumor-suppressor genes. An increasing number of mutated genes have been identified in CRC.3,4 These genes encode proteins with essential roles in CRC carcinogenesis.4 These proteins are shown to be regulated by the ubiquitin-proteasome system (UPS). This system regulates various cellular Parvulin processes by targeting proteins for activation, degradation, or localization at specific intracellular sites.4,5 Ubiquitin-mediated degradation of proteins is comprised of steps mediated by ubiquitin-activating enzymes (E1s), ubiquitin-conjugating enzymes (E2s), and ubiquitin ligases (E3s). The E1 enzyme activates ubiquitin and then transfers it to E2s. Subsequent conjugation of ubiquitin with the specific protein substrate is catalyzed by E2s alone or by E2s together with E3s.

Human studies Pregnancy is associated with an increased risk for mood and anxiety episodes. The fraction of pregnant women that present the diagnostic criteria for major depression ranges from 7% to 26%62,63 and about 40% of patients with a history of major depression relapse during pregnancy.64 Given the deleterious effects of maternal depression on fetal Inhibitors,research,lifescience,medical development, an increasing fraction of woman (up to 13% of pregnant women in some studies) are treated with antidepressants during pregnancy.62,65 Unfortunately, SSRIs cross the placenta49,66 and have been shown to impact the

developing fetus.63,67 Ultrasonographic observations of fetuses throughout gestation revealed that exposure to SSRIs altered the emergence of quiet nonrapid eye movement sleep during the last trimester and decreased the inhibitory motor control during this sleep phase.68 Furthermore, exposure to SSRIs reduced fetal middle cerebral artery blood flow as well as fetal heart rate variability.69 Exposure to SSRIs during pregnancy Inhibitors,research,lifescience,medical is associated with lower APGAR scores, with poor neonatal adjustment, increased

risk for neonatal respiratory distress, jaundice, feeding problems,62,70-74 delayed head growth,75 pulmonary hypertension, and preterm birth.70,75,76 Newborns exposed to SSRIs during Inhibitors,research,lifescience,medical late gestation more frequently display symptoms such as myoclonus, restlessness, tremor, hyperreflexia, Inhibitors,research,lifescience,medical shivering, and rigidity.73 Neonatal symptoms were usually mild and disappeared within 2 weeks of age.77 Adverse neonatal outcomes were generally attributed to a withdrawal or a toxicity effect from SSRI exposure. However, a recent study indicates that infants exposed to

SSRIs during gestation, but for whom the drug was stopped 14 days before delivery, still displayed an increased Inhibitors,research,lifescience,medical risk for adverse neonatal outcomes, suggesting that exposure to SSRIs during late gestation resulted in more enduring effects.78 At later developmental time points, gestational SSRI exposure was associated with blunted pain reactivity,79 a slight delay in motor development,71,74 and increased internalizing behaviors.80 More worrisome IWP-2 datasheet findings come from two recent studies showing that antidepressant exposure may increase the risk for autism spectrum disorder81,82; however, it should be noted that in retrospective studies that examined the long-term effects of SSRI exposure it is often difficult oxyclozanide to control for the severity of maternal depression and associated psychiatric comorbidities. Thus, some of the developmental consequences attributed to SSRI exposure could be due to the effects of increased maternal stress in the context of complex psychiatric psychopathology. Serotonin and stressor controllability Stress acts across different developmental time periods and can have a profound impact on the functional maturation of different sets of neural circuits.

Abbreviations used in this article BDI, Beck Depression Inventory; BPAD, EPZ5676 bipolar affective

disorder; ECT, electroconvulsive therapy; HAMD, Hamilton Rating Scale for Depression; HDRS, Hamilton Depression Rating Scale; IV, intravenous administration; MADRS-SI, Montgomery–Asberg Depression Rating Scale—Suicidality Item; MDD, major depressive disorder; MDE, major depressive episode; QIDS-SR, Quick Inventory of Depressive Symptomatology—Self-Report; Inhibitors,research,lifescience,medical SSF, Suicide Status Form; SSI, Scale for Suicide Ideation; TR, treatment resistant. Footnotes Funding: This research received no specific Inhibitors,research,lifescience,medical grant from any funding agency in the public, commercial, or not-for-profit sectors Conflict of interest statement: Derek Tracy has received honoraria for educational talks from Lilly UK and Roche UK. Sukhwinder Shergill has received grant support from clinical trials from GlaxoSmithKline, Roche, Abbvie and Envivo, and Inhibitors,research,lifescience,medical has served as consultant, scientific advisor and had speaking engagements for Sunovion, Roche and Dainippon Sumitomo Pharma. Contributor Information Caroline Caddy, Cognition Schizophrenia and Imaging Laboratory, Department of Psychosis Studies, the Institute of Psychiatry, King’s College London, UK. Giovanni Giaroli,

Inhibitors,research,lifescience,medical Cognition Schizophrenia and Imaging Laboratory, Department of Psychosis Studies, the Institute of Psychiatry, King’s College London, UK and North East London NHS Foundation Trust, London, UK. Thomas P. White, Cognition Schizophrenia and Imaging Laboratory, Department Inhibitors,research,lifescience,medical of Psychosis Studies,

the Institute of Psychiatry, King’s College London, UK. Sukhwinder S. Shergill, Cognition Schizophrenia and Imaging Laboratory, Department of Psychosis Studies, the Institute of Psychiatry, King’s College London, UK and South London and Maudsley NHS Foundation Trust, London, UK. Derek K. Tracy, Consultant Psychiatrist, Oxleas NHS Foundation Trust, Princess Royal University Hospital, Orpington, BR6 8NY, UK and Cognition Schizophrenia and Imaging Laboratory, Department of Psychosis Studies, the Institute of Psychiatry, King’s College London, UK.

Sir, Unoprostone Intranasal corticosteroid sprays are a mainstay treatment for allergic rhinitis and other conditions. The usual drug prescription textbooks, such as the Physicians’ Desk Reference, do not mention mania as a possible adverse event. Confronted with a bipolar patient who developed a hypomanic episode after taking mometasone furoate, we briefly reviewed the literature on the topic of mania and nonsystemic corticosteroid therapy.

Current understanding of antidepressant action primarily revolves around pharmacological effects regulating the Cediranib order activity of serotonin neurotransmission, although a variety of other mechanisms, mostly not inconsistent

with serotoninergic regulation, have been proposed. Certainly the antipsychotic drugs used in bipolar disorder have effects on serotonin receptors. As well as all having a high affinity at the 5-HT2A receptor, Inhibitors,research,lifescience,medical asenapine, olanzapine and clozapine have very high relative 5-HT2C receptor affinities. The 5-HT2C receptors have strong evidence supporting their potential as targets for antidepressant action [Jensen et al. 2010]. Most atypicals, namely Inhibitors,research,lifescience,medical asenapine, ziprasidone, quetiapine and aripiprazole, have a partial agonist activity at 5-HT1A receptors which may be functional at clinical doses. Further potentially valuable effects of asenapine, some of which are shared with other atypicals, include antagonism of the presynaptic 5-HT1B receptor that may lead to an increase

in serotonin release, antagonism of inhibitory alpha2 adrenoceptors found on serotonin neurons resulting in their increased activity, and actions at 5-HT6 and 5-HT7 receptors. The latter two receptors have attracted much recent research interest; both agonists and antagonists at the 5-HT6 receptor have been reported to have potential Inhibitors,research,lifescience,medical antidepressant and anxiolytic effects [Wesolowska, 2010]; this receptor is also a target for procognitive drugs. The 5-HT7 receptor too is considered a valuable target for antidepressant drugs [Hedlund, Inhibitors,research,lifescience,medical 2009]. Notably both these reviews highlight the particular potential of 5-HT6 or 5-HT7 antagonists in augmenting the effects of established antidepressant drugs, indicating the possibility of an enhanced antidepressant action Inhibitors,research,lifescience,medical associated with their antagonism in conjunction with other pharmacological mechanisms increasing synaptic serotonin by e.g. alpha2 adrenergic or 5-HT1B receptor antagonism as may occur with asenapine. However this synergism may also be true of other established antidepressant targets including the

5-HT2A [Blier and Szabo, 2005] and 5-HT2C receptors. Adverse effects Extrapyramidal side effects A consequence of dopamine D2 receptor antagonism, the main anti-manic mechanism others of the antipsychotic drugs, is an inhibition of dopaminergic function in the basal ganglia, regions of the brain controlling automatic motor function. This results in the acute extrapyramidal side effects (EPS), which include the relatively immediate effects of akathisia, dystonia and parkinsonism, as well as tardive dyskinesia (TD), a severe and occasionally irreversible problem associated with chronic antipsychotic drug treatment. The avoidance of these acute and chronic EPS has driven the development of the second generation of antipsychotic drugs.

2009). The CRS-R motor subscore was significantly and inversely correlated with a general absence/presence of brain activation in the pain network and with the number of activated regions. At first sight, this result is surprising, as one might have expected a positive correlation between brain activation in the pain matrix and the clinical reaction to noxious stimuli. However, absent motor reaction to

pain stimulation does not necessarily mean the absence Inhibitors,research,lifescience,medical of pain perception. Perception of pain, more precisely the sensory afference, and the visible motor reaction, thus the motor efference, are two different and independent pathways and can be impaired separately from each other. In fact, our findings emphasize that the clinical examination of UWS patients is difficult and might miss some patients who are actually more conscious than they seem (Childs et al. 1993; Andrews et al. 1996; Schnakers et al. 2009). This fact stresses the necessity Inhibitors,research,lifescience,medical for new methods, like functional imaging, to examine patients with disorders of consciousness objectively. Of course, diagnosis of consciousness remains a philosophical problem, not just a neurological one. An increase of brain activity in some brain areas Inhibitors,research,lifescience,medical cannot strongly prove the presence of subjective experience. However, given pain-related changes in such brain structures as anterior check details insula and ACC, which are related to emotional awareness and autonomic

regulation of pain (Vogt 2005), we find it risky to still argue that the respective patients are unable to feel pain. Note that among these were also chronic patients (several years after the incident) Inhibitors,research,lifescience,medical with a very severe hypoxic brain injury. Limitations By definition, subjective threshold of pain perception and pain tolerance cannot be obtained in UWS patients. Therefore, and primarily for ethical reasons, rather moderate noxious stimuli were applied in the present experiment. Inhibitors,research,lifescience,medical We cannot rule out that they were weaker than in the comparable PET studies, which would partially explain the differences in results. Moreover, to avoid long, uncomfortable, and exhausting transportation, the patients were examined at

two different imaging centers with different scanners. Although the results obtained with the 1.5 T and the 3 T scanners are not substantially different, a replication study in which all patients are measured with the same scanner is desirable. Furthermore, Boyle et al. (2006) either demonstrated that MRI scanner noise significantly reduces unpleasantness ratings of pain stimulation. Although healthy individuals evaluated the presented stimuli as highly arousing and rather unpleasant, it should be taken into account that the evaluations were done immediately outside MRI scan (i.e., without noise). The difference in the physical environment should, therefore, also be considered when discussing neuroimaging studies on human pain perception.

Resources to manage and act on the transmitted information from these patients are vital to the success of home monitoring. Studies have shown that the amount of information in a controlled, limited-time trial setting already seems overwhelming.

The legal implications of timely follow-up of continuously monitored information and the scope of false positives with health care utilizations is a daunting aspect for handling the information. Moreover, the cost of phone monitoring with no reimbursements might make this modality Inhibitors,research,lifescience,medical less lucrative as opposed to using already available ICD/CRT-D technology. Also, the presence of multiple vendors and proprietary Inhibitors,research,lifescience,medical algorithms of each device company poses a challenge in creating a universally simplified approach to implement a structured algorithm. For those who do not need an implantable device, buy GW9662 advancements in wearable monitors and Bluetooth transmission of information seems promising, yet with no strong evidence. Patient compliance issues with these technologies might be overcome by emerging piezo crystal sensors. Recently, Benett et al.30 reported the feasibility of

using the EarlySense’s EverOn® (EarlySense, Waltham, MA) under-the-mattress Inhibitors,research,lifescience,medical sensor system to track physiological information such as respiratory rate, heart rate, and movement rate during sleep in three patients. Also, advancements in implantable Inhibitors,research,lifescience,medical wireless technology seen with the pulmonary capillary pressure monitoring device CardioMEMS® (CardioMEMS, Inc., Atlanta, GA) and the left atrial pressure monitor HeartPOD™ System (St. Jude Medical, Inc., St. Paul, MN) or Promote® LAP System (St. Jude Medical, Inc., St. Paul, MN) bring us closer to finding the holy grail of home monitoring systems. Attempts at shifting the burden of self management to patients have not been very effective due to the complexity of the therapies and the advancing age of HF patients in the United Inhibitors,research,lifescience,medical States. Between 27–44%

of Medicare enrollees have marginal or inadequate health literacy,31 making this task more challenging. Powell et al.32 in the HART study found that the addition of self-management counseling to an educational intervention did not make a difference in death Dichloromethane dehalogenase or HF hospitalization in patients with mild to moderate HF. Earlier smaller studies also have not shown any convincing evidence for self-management.33-36 Therefore, a strategy that minimizes patient responsibility in monitoring and care might be more pragmatic. All strategies should still aim at having a patient-centered care plan along with stressing patient education.37 Moreover, there is overwhelming evidence that a multidisciplinary approach to HF care reduces hospital readmissions and improves outcomes in these patients.38 Hence, it is recommended in both U.S. and European guidelines.

89,90 There are usually no associated brain anomalies or other congenital malformations, although occasionally the SBH can merge anteriorly with pachygyric cortex which has been described as a “pachy-band.”79 Microscopic examination of SBH shows the band to consist of a superficial zone of disorganized neurons, an intermediate

zone of small neurons with some columnar organization and a deeper zone where the heterotopia may break into nodules. Trie overlying cortex has a normal histological appearance.65 All forms of SBH are thought to be a defect of neuroblast migration with neurons that fail to migrate completely SGC-CBP30 ic50 forming the heterotopic band.91 Patients Inhibitors,research,lifescience,medical with SBH will usually have mild-to-moderate intellectual disability and a mixed seizure disorder with onset at any age, but occasionally delayed until the second or third decade.87,92,93 The spectrum of epilepsy and intellectual Inhibitors,research,lifescience,medical disability is wide with severity roughly correlating with the thickness of the heterotopic

band.92 Typical SBH shows a striking skewing of sex ratio to females,87,91 although the malformation has rarely been reported in males as well.94,97 Occasional patients with mild partial forms of SBH may appear asymptomatic.90 Patients with SBH usually have no dysmorphic features or other congenital anomalies. SBH is rarely recognized using CT Inhibitors,research,lifescience,medical scanning and when seen may be mistaken for lissencephaly, and partial forms may be difficult

to appreciate, even using MRI. MRI will show a four-layered cerebral parenchyma composed of (from ventricle to cortex); (i) normal periventricular white matter; (ii) layer of heterotopic gray matter; (iii) thin layer of subcortical white matter; and (iv) normal Inhibitors,research,lifescience,medical cortical gray matter,92 as shown in Figure 6. Figure 6. Imaging features of subcortical band heterotopia. Sagittal (left) and coronal (right) T1-weighted MRIs showing typical features of subcortical band heterotopia with bilateral, symmetric band of tissue with identical signal to cortical Inhibitors,research,lifescience,medical gray matter interspersed … Mutations in two genes have been identified as causing SBH; the DCX gene and the LIS1 gene. The vast, majority of both sporadic SB-3CT and familial cases of the most common form of SBH (bilateral, symmetric, and with a frontal predominance) are due to mutations of DCX. 89,98 As DCX is carried on the X chromosome males with mutations in DCX will usually have classical lissencephaly whereas females will have SBH. It is assumed that females with SBH secondary to DCX mutations have two populations of neurons; those with the mutant gene inactive that migrate normally and form the cortex, and those with the normal gene inactivated that migrate abnormally and form the heterotopic band. Carriers of mild DCX mutations may show no evidence of SBH on MRI, but may have intellectual disability or epilepsy.

The idea is that of a selective marker because in the elderly particular nootropic drugs are able to significantly restore P300.28 Figure 5. Age-related modifications in P300. Top left: Average curves for elderly (aged >55 years; blue lines) and young volunteers (gray lines) for several scalp positions. Top right: Statistical comparison between elderly and young subjects.

Bottom left: … Due to the lack of clinical efficacy of AchE inhibitors,29 more and more alternative mechanisms of action on central receptors or enzymes are being explored. Inhibitors,research,lifescience,medical An example of the effect of a noncholinergic drug is given in Figure 5 (bottom).30 Indeed, a clear-cut indication of recovery can be observed, even though the increase in absolute terms is modest. The concept of a pharmacological model in young Inhibitors,research,lifescience,medical volunteers The established approach in behavioral neuropsychopharmacology is the use of a pharmacological challenge to reversibly provoke symptoms. As an example, we refer to the model that makes use of the comparison of performance in a battery of psychometric tests (eg, digit vigilance speed) and recording of continuous electrical cerebral activity.31 Inhibitors,research,lifescience,medical Both types of examination undergo changes with scopolamine and some of these effects have been shown to be reversed by AchE inhibitors. Hence P300 responses constitute

a useful tool in neuropsychopharmacology in exactly the same way as continuous electrical Inhibitors,research,lifescience,medical cerebral activity, for the reasons shown in Figure 4. Interestingly, manipulation with benzodiazepines in order to provoke – like scopolamine – symptoms of cognitive impairment at the clinical level in, for example, free word recall,32 induces similar collapses in P300 in auditory33-36 (eg, lorazepam, Figure 6) and visually37 evoked cognitive responses. Inhibitors,research,lifescience,medical Figure 6. Superimposed average P300 responses for baseline conditions (light-blue lines) and after a drug challenge (dark-blue lines). The

effect of an acetylcholinesterase (AchE) inhibitor (gray lines) restores the deteriorated signal in the direction of baseline … In our experience, the effects on neurophysiological parameters are often much more sensitive than the effects seen in performance Cediranib (AZD2171) changes. Schematically, the procedure can be summarized as follows: Drug 1 induces a simulation of the acute state of “nontreated” patient (symptom provocation). Drug 2 is used to verify its potency to (partially) reverse the deterioration (validation for find more pharmacotherapy). An example of the reversal of the challenge-induced deterioration (drug 1) with an AchE inhibitor (drug 2) is shown in Figure 6 (for study design see reference 38). The interesting aspect of such a model is the possibility of preventing the induction of symptoms by compounds with out, direct, cholinergic effects39 and using a neurophysiological readout, as surrogate marker at the same time.

The only factor determining long term survival is the stage of the malignancy. As seen in our series, the majority of our patients had very advanced disease on diagnosis and fared badly subsequently with almost all the patients developing disease recurrences. Though several of our patients developed peritoneal disease

subsequently, it could be related to the advanced staging and progression of the primary malignancy rather than contributed by the perforation. Unfortunately, large series is not available in the literature to shed more light into this. The role of surgery in gastric lymphoma has been addressed by numerous reports and should only be performed as a primary radical #Fulvestrant supplier keyword# treatment, palliative procedure or when emergency complications such as massive bleeding or perforation are encountered (25)-(28). The implications of the gastric perforation in Inhibitors,research,lifescience,medical the long term survival of these patients appear minimal with no reports of associated recurrence reported. The most important factor determining the long term survival is again the stage of the lymphoma. None of our patients had any systemic or peritoneal recurrence and both are currently well upon completion of their chemotherapy. Conclusions Surgery in perforated gastric malignancy is fraught with numerous

challenges. Short-term outcome is dismal and is dependent on the various Inhibitors,research,lifescience,medical patient and disease factors. Long-term survival in these patients is dependent on the underlying Inhibitors,research,lifescience,medical stage of the malignancy.

Footnotes No potential conflict of interest.
Anal cancer is a highly curable disease. Chemoradiotherapy has superseded surgery since it results in an equivalent survival with the benefit of a better functional outcome, as there is no need for colostomy. However, the long-term complications of definitive chemoradiotherapy for anal cancer have not been systematically described. In this report, we present the case of a woman who presented with therapy-induced myelodysplasia within a year after treatment for anal cancer. A 58-year-old woman with no significant past medical history was diagnosed Inhibitors,research,lifescience,medical with squamous-cell carcinoma of the anal canal, during a work-up for hematochezia. She regularly drank moderate amounts of vodka in the evening, and was a heavy smoker. The anal these cancer was treated in standard fashion with chemoradiation, the chemotherapy consisting of 5-fluorouracil and mitomycin C. Follow-up physical examination and imaging studies revealed a complete response, as well as a normal complete blood count (CBC) during the following months. One year after the end of treatment, a CBC performed 2 days prior to a scheduled visit revealed a platelet count of 15 x 109/L. The patient was immediately called to the clinic for an evaluation. She denied any complaint. One to two weeks before the visit, she had been scratched by a pet cat. This was followed by fever, and swelling of the right hand.