Transesophageal Echocardiography Assisting in the Identification of Intraabdominal Bleeding During Cardiac Surgery

We present a case in which intraoperative transesophageal echocardiography (TEE) helped detect intraabdominal bleeding, a rare complication in cardiac surgery. A patient undergoing ascending aortic aneurysm and aortic valve repair had increasing vasopressor and transfusion requirement during sternal closure with TEE imaging revealing a nonspecific, hypoechoic fluid-like collection anterior to the stomach. Discussion between the anesthesiology and surgical teams prompted further investigation including a diagnostic laparoscopy which confirmed the presence of intraabdominal bleeding. Hemostasis was later achieved after identifying the source of bleeding from a pre-peritoneal vein and associated peritoneal defect adjacent to a mediastinal chest tube placed earlier in the operation.

Prevalence of diagnostically-discrepant Clostridioides difficile clinical specimens: insights from longitudinal surveillance

Background

Clostridioides difficile Infection (CDI) is a healthcare-associated diarrheal disease prevalent worldwide. A common diagnostic algorithm relies on a two-step protocol that employs stool enzyme immunoassays (EIAs) to detect the pathogen, and its toxins, respectively. Active CDI is deemed less likely when the Toxin EIA result is negative, even if the pathogen-specific EIA is positive for C. difficile. We recently reported, however, that low-toxin-producing C. difficile strains recovered from Toxin-negative ('discrepant') clinical stool specimens can be fully pathogenic, and cause lethality in a rodent CDI model. To document frequency of discrepant CDI specimens, and evaluate C. difficile strain diversity, we performed longitudinal surveillance at a Southern Arizona tertiary-care hospital.

Methods

Diarrheic stool specimens from patients with clinical suspicion of CDI were obtained over an eight-year period (2015-2022) from all inpatient and outpatient Units of a > 600-bed Medical Center in Southern Arizona. Clinical laboratory EIA testing identified C. difficile-containing specimens, and classified them as Toxin-positive or Toxin-negative. C. difficile isolates recovered from the stool specimens were DNA fingerprinted using an international phylogenetic lineage assignment system ("ribotyping"). For select isolates, toxin abundance in stationary phase supernatants of pure cultures was quantified via EIA.

Results

Of 8,910 diarrheic specimens that underwent diagnostic testing, 1733 (19.4%) harbored C. difficile. Our major findings were that: (1) C. difficile prevalence and phylogenetic diversity was stable over the 8-year period; (2) toxigenic C. difficile was recovered from 69% of clinically Tox-neg ('discrepant') specimens; (3) the six most prevalent USA ribotypes were recovered in significant proportions (>60%) from Tox-neg specimens; and (4) toxin-producing C. difficile recovered from discrepant specimens produced less toxin than strains of the same ribotype isolated from non-discrepant specimens.

Conclusion

Our study highlights the dominance of Toxin EIA-negative CDI specimens in a clinical setting and the high frequency of known virulent ribotypes in these specimens. Therefore, a careful reevaluation of the clinical relevance of diagnostically-discrepant specimens particularly in the context of missed CDI diagnoses and C. difficile persistence, is warranted.

Ectopic pregnancy management by V-NOTES technique

Ectopic pregnancy is a frequent and life-threatening risk of childbearing. Its management represents a mainstay of emergency gynecological surgery, and laparoscopy is the surgical gold standard technique. The technique of transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) for the management of ectopic pregnancy is presented herein. The procedure is illustrated by an instructive video article that standardizes the essential steps to make the technique ergonomic and easy to perform (step-by-step explanations). This surgical technique allows to consider vaginal salpingectomy using a combined cœlio-vaginal approach. After a posterior colpotomy, an Alexis retractor was inserted in the pouch of Douglas followed by the placement of a dedicated platform on which three trocars were fixed. Pneumoperitoneum was then achieved. Once the diagnosis of ruptured tubal ectopic pregnancy was established, a salpingectomy was performed. As a minimally invasive approach, this procedure has high patient acceptance and seems to improve favorable clinical outcomes.

Phylogenomic analysis of Clostridioides difficile ribotype 106 strains reveals novel genetic islands and emergent phenotypes

Clostridioides difficile infection (CDI) is a major healthcare-associated diarrheal disease. Consistent with trends across the United States, C. difficile RT106 was the second-most prevalent molecular type in our surveillance in Arizona from 2015 to 2018. A representative RT106 strain displayed robust virulence and 100% lethality in the hamster model of acute CDI. We identified a unique 46 KB genomic island (GI1) in all RT106 strains sequenced to date, including those in public databases. GI1 was not found in its entirety in any other C. difficile clade, or indeed, in any other microbial genome; however, smaller segments were detected in Enterococcus faecium strains. Molecular clock analyses suggested that GI1 was horizontally acquired and sequentially assembled over time. GI1 encodes homologs of VanZ and a SrtB-anchored collagen-binding adhesin, and correspondingly, all tested RT106 strains had increased teicoplanin resistance, and a majority displayed collagen-dependent biofilm formation. Two additional genomic islands (GI2 and GI3) were also present in a subset of RT106 strains. All three islands are predicted to encode mobile genetic elements as well as virulence factors. Emergent phenotypes associated with these genetic islands may have contributed to the relatively rapid expansion of RT106 in US healthcare and community settings.

Easy way to perform salpingectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) (with video)

The transvaginal natural orifice transluminal endoscopic surgery (vNOTES) is a new minimally invasive and emerging technique. Feasibility and safety profiles of peritoneal access via transvaginal routes have been demonstrated especially for the adnexal surgery. In order to be reproducible and replicable with a standardized procedure, we propose the step-by-step video description of the vNOTES salpingectomy. The advantages of the vNOTES (low postoperative pain, faster postoperative recovery, scarless surgery) could lead to a promising alternative to conventional laparoscopic salpingectomy/adnexectomy.

[Cystocele repair by a light tension-free vaginal mesh: results after 6 years of follow-up]

INTRODUCTION

The objective of this study was to evaluate the long-term anatomical and functional efficacy, but also the safety of tension-free vaginal mesh in cystocele repair.

METHODS

This retrospective and monocentric study included 90 women who underwent a prolapse repair between June 2006 and November 2008. A light-weight polypropylene vaginal mesh (22g/m2, Novasilk COLOPLAST®) was used without any fixation. Females were followed at 1 month, 1 year, 3 years and 6 years. Only long-term results are presented in this study. The anatomical result was assessed by the POP-Q classification and the functional results by standardized symptoms (PFDI-20), sexuality (PISQ-12) and quality of life (PFIQ-7) questionnaires.

RESULTS

6 years after surgery, the follow-up rate was 74%. Anatomically, the prolapse recurrence rate (Ba≥0) was 17% (n=8). Functionally, the overall patient satisfaction rate was 89%. Quality of life and symptoms scores (4,11±8.45 vs. 17.5±14.4 and 35.8±15.9 vs 94±23.4 respectively) were significantly improved (p<0.001). Concerning the prevalence of the complication, the retraction and exposition rate was 1.7% (n=1) and a re-intervention rate was 6.7% (n=4). The rate of de novo dyspareunia was 1.7% (n=1).

CONCLUSION

In this short retrospective series of vaginal mesh interposition for cystocele repair, the prevalence of medium-term patient satisfaction was high.

Characterisation of immunogenotypes of diffuse large B-cell lymphoma

INTRODUCTION

Diffuse large B-cell lymphoma (DLBCL) is the most common aggressive type of non-Hodgkin lymphoma with variable clinical outcomes. The immunogenotypic features of this heterogeneous disease in Malaysia were not well characterized.

MATERIALS & METHODS

In total 141 local series of DLBCL cases from UKM Medical Centre were retrospectively studied.

RESULTS

Of these cases, we classified our patients into two subtypes: 32.7% (37/113) GCB and non-GCB 67.3% (76/113) by Hans algorithm and the results showed strong agreement with the results by Choi algorithm (κ = 0.828, P<0.001). Survival analysis indicated significant difference in between GCB and non-GCB subtypes (P=0.01), elevated serum LDH (P=0.016), age more than 60-year-old (P=0.021) and the presence of B symptoms (P=0.04). We observed 12% DLBCL cases were CD5 positive and 81.8% of them died of the disease (P=0.076). Analysis on the dual expression of MYC/BCL2 revealed that there is no significant difference in DE and non-DE groups (P=0.916). FISH study reported there were 9.22% (13/141) rearranged cases observed in our population at which highest frequency of BCL6 gene rearrangement (76.9%), followed by MYC (15.4%) and BCL2 (7.7%); no BCL10 and MALT-1 gene rearrangement found regardless of using TMAs or whole tissue samples. More cases of MYC protein overexpression observed compared to MYC translocation.

CONCLUSION

Relatively lower frequency of GCB tumours and low gene rearrangement rates were observed in Malaysian population. A national study is therefore warranted to know better the immunogenotypic characteristics of DLBCL in Malaysia and their implications on the survival.

An Engineered Synthetic Biologic Protects Against Clostridium difficile Infection

Morbidity and mortality attributed to Clostridium difficile infection (CDI) have increased over the past 20 years. Currently, antibiotics are the only US FDA-approved treatment for primary C. difficile infection, and these are, ironically, associated with disease relapse and the threat of burgeoning drug resistance. We previously showed that non-toxin virulence factors play key roles in CDI, and that colonization factors are critical for disease. Specifically, a C. difficile adhesin, Surface Layer Protein A (SlpA) is a major contributor to host cell attachment. In this work, we engineered Syn-LAB 2.0 and Syn-LAB 2.1, two synthetic biologic agents derived from lactic acid bacteria, to stably and constitutively express a host-cell binding fragment of the C. difficile adhesin SlpA on their cell-surface. Both agents harbor conditional suicide plasmids expressing a codon-optimized chimera of the lactic acid bacterium's cell-wall anchoring surface-protein domain, fused to the conserved, highly adherent, host-cell-binding domain of C. difficile SlpA. Both agents also incorporate engineered biocontrol, obviating the need for any antibiotic selection. Syn-LAB 2.0 and Syn-LAB 2.1 possess positive biophysical and in vivo properties compared with their parental antecedents in that they robustly and constitutively display the SlpA chimera on their cell surface, potentiate human intestinal epithelial barrier function in vitro, are safe, tolerable and palatable to Golden Syrian hamsters and neonatal piglets at high daily doses, and are detectable in animal feces within 24 h of dosing, confirming robust colonization. In combination, the engineered strains also delay (in fixed doses) or prevent (when continuously administered) death of infected hamsters upon challenge with high doses of virulent C. difficile. Finally, fixed-dose Syn-LAB ameliorates diarrhea in a non-lethal model of neonatal piglet enteritis. Taken together, our findings suggest that the two synthetic biologics may be effectively employed as non-antibiotic interventions for CDI.

Enteropathogenic Escherichia coli EspH-Mediated Rho GTPase Inhibition Results in Desmosomal Perturbations

BACKGROUND & AIMS

The diarrheagenic pathogen, enteropathogenic Escherichia coli (EPEC), uses a type III secretion system to deliver effector molecules into intestinal epithelial cells (IECs). While exploring the basis for the lateral membrane separation of EPEC-infected IECs, we observed infection-induced loss of the desmosomal cadherin desmoglein-2 (DSG2). We sought to identify the molecule(s) involved in, and delineate the mechanisms and consequences of, EPEC-induced DSG2 loss.

METHODS

DSG2 abundance and localization was monitored via immunoblotting and immunofluorescence, respectively. Junctional perturbations were visualized by electron microscopy, and cell-cell adhesion was assessed using dispase assays. EspH alanine-scan mutants as well as pharmacologic agents were used to evaluate impacts on desmosomal alterations. EPEC-mediated DSG2 loss, and its impact on bacterial colonization in vivo, was assessed using a murine model.

RESULTS

The secreted virulence protein EspH mediates EPEC-induced DSG2 degradation, and contributes to desmosomal perturbation, loss of cell junction integrity, and barrier disruption in infected IECs. EspH sequesters Rho guanine nucleotide exchange factors and inhibits Rho guanosine triphosphatase signaling; EspH mutants impaired for Rho guanine nucleotide exchange factor interaction failed to inhibit RhoA or deplete DSG2. Cytotoxic necrotizing factor 1, which locks Rho guanosine triphosphatase in the active state, jasplakinolide, a molecule that promotes actin polymerization, and the lysosomal inhibitor bafilomycin A, respectively, rescued infected cells from EPEC-induced DSG2 loss. Wild-type EPEC, but not an espH-deficient strain, colonizes mouse intestines robustly, widens paracellular junctions, and induces DSG2 re-localization in vivo.

CONCLUSIONS

Our studies define the mechanism and consequences of EPEC-induced desmosomal alterations in IECs. These perturbations contribute to the colonization and virulence of EPEC, and likely related pathogens.

Development of an ovine model for training in vaginal surgery for pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

This aim of this study was to evaluate the feasibility and usefulness of an ovine model for training in vaginal surgery.

METHODS

Four senior urogynaecological surgeons and five residents attended five sessions of vaginal surgery for pelvic organ prolapse (POP) in five old multiparous female sheep. Urogynaecological examinations were performed and measurements similar to the POP-Q classification in humans were obtained. Standard POP surgical procedures with and without mesh were performed. A pelvic CT scan was done on one animal and the structures were compared with the pelvic structures in a woman. After the feasibility of vaginal surgery had been established in three cadavers, surgery was performed in two living animals under general anaesthesia and was followed by laparoscopy to explore the internal pelvic anatomy.

RESULTS

We found anatomic similarities in the vaginal and pelvic structures between sheep and women. After caudal traction on the cervix, all five sheep had significant POP of stage 3 or 4. We proved the feasibility of all types of vaginal surgery in this animal model: traditional anterior and posterior repair, apex fixation and anterior wall repair with mesh. The video shows the internal pelvic anatomy and different vaginal procedures.

CONCLUSION

This study showed that training in vaginal surgery for POP is feasible and useful in an animal model, the ewe, that has vaginal and pelvic structures very similar to those in women.

Abstract P3-14-12: Oncologic outcomes of immediate breast reconstruction after neoadjuvant chemotherapy in breast cancer patients: A matched case control study

Introduction: Although the indication for total mastectomy (TM) with immediate breast reconstruction (IBR) has been expanded, IBR after neoadjuvant chemotherapy (NACT) is still controversy. We assumed that TM with IBR after NACT is feasible surgical treatment in breast cancer patients. Methods: A retrospective review of breast cancer patients who underwent TM with IBR after NACT between 2008 and 2015 at a single center was conducted. These cases were matched by 1:5 to patients who underwent mastectomy alone after NACT. Matching variables included age, clinical T and N staging before NACT, response to NACT, and pathologic staging after NACT. Pathological stage was followed by seventh American Joint Committee on Cancer (AJCC) classification. Results: Overall, 31 patients were identified in the TM with IBR group (Study group) and 85 patients (Control group) were matched. In the study group, 13 (41.9%) patients underwent nipple-sparing mastectomy (NSM) and 18 (58.1%) underwent skin-sparing mastectomy (SSM). Median follow-up duration was 29.2 (7-31) and 38.8 (11-85) months for the study and control group, respectively. Median age was 37.0 (26-57) and 40.0 (24-56) years for the study and control group, respectively. The clinicopathologic characteristics of both groups are summarized in Table1. Disease-free survival (p=0.520), local recurrence-free survival (p=0.610), distant metastasis-free survival (p=0.795), and over survival (p=0.971) did not differ significantly between two groups. Conclusion: TM with IBR after NACT is feasible surgical treatment option in breast cancer patients.

Clinicopathologic characteristicsVariablesControl group (n=85)Study group (n=31)p-valueAge, years (matching variables)  0.890≤3515 (17.7)9 (29.0) 36-5061 (71.8)21 (67.7) 51≥9 (10.6)1 (3.2) BMI, m2/kg  0.13025≤62 (72.9)28 (90.3) 26-3018 (21.2)2 (6.5) 30&gt;5 (5.9)1 (3.2) Histology  0.326Ductal carcinoma in situ2 (2.4)3 (9.7) Invasive ductal carcinoma74 (87.1)28 (90.3) Invasive lobular carcinoma2 (2.4)0 (0) Others7 (8.2)0 (0) Multiplicity  0.063yes19 (22.6)12 (40.0) no65 (77.4)18 (60.0) Lymphovascular invasion  0.161yes33 (39.3)17 (54.8) no51 (60.7)14 (45.2) Nuclear grade  0.317Low10 (11.9)1 (3.3) Intermediate27 (32.1)14 (46.7) High47 (56.0)15 (24.2) Pathologic T stage (matching variable)  0.154T17 (8.2)6 (19.4) T229 (34.1)15 (48.4) T331 (36.5)4 (12.9) T418 (21.2)6 (19.4) Pathologic N stage (matching variable)  0.494N036 (42.4)13 (41.9) N123 (27.1)13 (41.9) N216 (18.8)4 (12.9) N310 (11.8)1 (3.2) Estrogen receptor  0.608positive49 (57.7)15 (48.4) negative36 (42.4)16 (51.6) Progesterone receptor  0.291positive40 (47.1)10 (32.3) negative45 (52.9)21 (67.7) HER2 status  0.345amplification29 (34.1)10 (32.3) not amplification56 (65.9)21 (67.7) Clinical T-stage (matching variable)  0.897cT12 (2.4)1 (3.2) cT231 (36.5)12 (38.7) cT346 (54.1)16 (51.6) cT46 (7.1)2 (6.5) Clinical N stage (matching variable)  0.947cN03 (3.5)1 (3.2) cN120 (23.5)10 (32.3) cN236 (42.4)10 (32.3) cN326 (30.6)10 (32.3) Response (matching variable)  1.000Partial response64 (75.3)27 (29.7) Stable disease21 (24.7)4 (12.9) 

Citation Format: Ryu JM, Lee JE, Kim SW, Yu J, Rayzah M, Lee SK, Mansoor A, Bae SY, Park S, Paik H-J, Kim I, Bang SI, Jeon BJ, Mun G-H, Pyon J-K. Oncologic outcomes of immediate breast reconstruction after neoadjuvant chemotherapy in breast cancer patients: A matched case control study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-14-12.

Genotype CC of rs12979860 is providing protection against infection rather than assisting in treatment response for HCV genotype 3a infection

Recent discovery of single-nucleotide polymorphisms located in the upstream region of interleukin-28B (IL28B) has shown association with interferon (IFN) treatment response especially in hepatitis C virus (HCV) genotype 1-infected patients. Pakistan, being the country with second highest prevalence of HCV with predominantly 3a genotype infection, bears a significant disease burden. The present study was conducted to evaluate the effect of rs12979860 genotypes on treatment response in HCV-3a-infected patients. This study shows that the CC genotype is providing protection against infection to HCV. But once infected, the CC genotype patients show viral persistence following IFN therapy. The TT genotype is assisting the 3a patients in viral clearance after IFN treatment. To our knowledge, this is the first study showing rs12979860 genotype association with IFN response in Pakistani HCV-3a-infected patients.

Reovirus as a successful ex vivo purging modality for multiple myeloma

Autologous stem cell rescue (ASCT) following high-dose myeloablative chemotherapy is considered to be a therapeutic option for many multiple myeloma (MM) patients; however relapse post ASCT presents a major challenge. The oncolytic potential of reovirus has been previously demonstrated and is currently undergoing phase I monotherapy clinical trials for MM and phase II/III clinical trials for solid tumors. Here we tested the hypothesis that reovirus can successfully purge MM in a murine model that partially recapitulates human MM. RPMI 8226, MM1S, H929 and U266 human myeloma cell lines were exposed to reovirus and oncolysis was assessed. Apheresis product admixed with MM cells was purged with live reovirus (LV) or dead virus (DV) and purging efficacy was monitored via flow cytometry, reverse transcribed-PCR (RT-PCR) and disease relapse in non obese diabetic/severe combined immune deficient (NOD/SCID) mice. Significant LV purging was seen with MM1S, H929 and U266 and the complete ex vivo purging achieved with RPMI 8226 was confirmed by flow cytometry, RT-PCR and absence of disease relapse in vivo. Mice that received LV-purged autografts exhibited 100% survival in comparison to mice that received DV-purged controls. Reovirus's unique ability to kill MM while sparing hematopoietic stem cells places it as an attractive purging agent for MM during ASCT.

[Prospective evaluation of an intravaginal electrical stimulation in the treatment of women with pure genuine stress urinary incontinence]

OBJECTIVES

To study the objective and subjective effectiveness of transvaginal electrical stimulation for treatment of female pure genuine stress incontinence.

PATIENTS AND METHODS

This was a multicenter prospective trial including 207 patients with genuine stress incontinence who used the stimulator for 10 weeks. Similar pre-treatment and post-treatment assessments included both validated symptom severity index and health-related quality of life.

RESULTS

Objective evaluation showed a significant improvement in 65.7% of subjects with stress incontinence. All domains of quality of life improved significantly after treatment (P=0.0001) and rate of satisfactory was 84.7%. There were no statistical differences between the two stimulators.

DISCUSSION AND CONCLUSION

Pelvic floor electrical stimulation seems to be effective in treating female genuine stress incontinence and could be considered first-line therapy.

[Health-related quality of life in women operated on by surgical anti-incontinence procedures: comparison of three techniques]

OBJECTIVES

To assess the health-related quality of life (Contilife) after three surgical anti-incontinence procedures (Tension-Free Vaginal Tape [TVT], Transobturator Vaginal Tape [TOT], and Transobturator Vaginal Tape [TVT-O]).

PATIENTS AND METHODS

We performed a prospective analysis of 90 women (30 TVT, 30 TOT, 30 TVT-0) with genuine stress incontinence pre- and postoperatively at 18 months. The objective cure rate was determined by clinical and urodynamic examination and the subjective cure rate by the Contilife questionnaire.

RESULTS

Prior to surgery, patients complained more of effort activities, followed by global well-being. Postoperatively, all domains improved significantly without statistical difference between the three groups and 90% of the patients would advise the intervention to one of their friends.

DISCUSSION AND CONCLUSION

Surgical outcomes vary greatly depending on the methodology of the study. Health-related quality of life seems paramount to decide time of surgery and to evaluate postoperatory results. We have chosen the Contilife questionnaire because of its scientific and clinical validity, reliability, responsiveness and linguistic validation. These results confirm that TVT/TOT/TVT-O procedures are a safe and effective surgical method and that they significantly improved health-related quality of life.

[Unusual perineal pain in postpartum period: contribution of perineal ultrasound]

We report two cases of persistent [correction of persistant] perineal pain in postpartum period due to transfixation of the anus with a suture and the contribution of perineal ultrasound in the diagnosis of unusual perineal pain.

High affinity IL-2 receptor (CD25) expression among Chronic Lymphocytic leukemia (CLL) patients is independent of mutational status and ZAP-70 positivitys

Background: Recent studies have suggested promising roles for immunotherapy through CD40 ligand /IL-2 signaling pathway in CLL patients. Differential expression of the IL-2 receptor (IL-2 R) has been reported in CLL and other B-cell malignancies. Because CLL is divided into two distinct prognostic groups (based on the level of somatic hypermutation or alternatively on the presence or absence of ZAP-70), it is important to determine the correlation of IL-2 R expression with mutational status and/or ZAP-70 positivity in CLL for better patient group stratification in clinical trials. Methods: In this study, 132 pts (82 M/50F; M: F 1.6) with an age range of 33-91 yrs (median 66 yrs) were included. Of these, 67/132 (51%) were found to be CD25+, 44/132 (33%) CD25- and 16% were CD25 dim (not further analyzed). In terms of ZAP positivity, 19/132 (14%) pts were ZAP-70+ and 113 (86%) were ZAP-70-. Results: Mutational data (n=93) revealed 60/93 (65%) patients with SHM and 33/ 93 (35%) without. Correlation between ZAP-70+ and absence of SHM was highly significant (p< 0.0001), however, no statistically significant correlation was noted between CD25 expression and SHM (p= 0.331) or ZAP positivity (p= 0.785). Conclusions: This data suggests that IL-2 R expression, although noted among a significant proportion of patients with B-CLL, is independent of somatic hypermutation or ZAP-70 expression. This observation will be important in evaluation of clinical efficacy of immunotherapy among CLL patients, and points to the existence of another mechanism for the presence of IL-2 R in these patients. Abbreviations: B-CLL (B-cell Chronic Lymphocytic Leukemia), SHM (Somatic Hypermutation)

Corona mortis: An anatomical study with clinical implications in approaches to the pelvis and acetabulum

The "corona mortis" is an anatomical variant, an anastomosis between the obturator and the external iliac or inferior epigastric arteries or veins. It is located behind the superior pubic ramus at a variable distance from the symphysis pubis (range 40-96 mm). The name "corona mortis" or crown of death testifies to the importance of this feature, as significant hemorrhage may occur if accidentally cut and it is difficult to achieve subsequent hemostasis. It constitutes a hazard for orthopedic surgeons especially in the anterior approach to the acetabulum. We carried out forty cadaver dissections (80 hemi-pelvises) through the ilioinguinal approach. A vascular anastomosis was found in 83% of specimens. Of these, 60% had a large diameter (>3 mm) channel along the posterior aspect of the superior pubic ramus. In clinical practice, however, 492 anterior approaches (to the best of our knowledge the largest series described) have been carried out over the last 15 years by the senior author (MB) and only five of these problematic vessels were discovered, and in only two cases was there troublesome bleeding. This study confirms a paradox: in anatomical dissections a large vessel was identified behind the superior pubic ramus, whereas in clinical practice this vessel does not seem to be as great a threat as initially perceived. Orthopedic surgeons planning an anterior approach to the acetabulum, such as the ilioinguinal or the intrapelvic approach (modified Stoppa), have to be cautious when dissecting near the superior pubic ramus. Despite the high prevalence of these large retropubic vessels in the dissecting room, surgeons should exercise caution but not alter their surgical approach for fear of excessive hemorrhage.

Early post-transplant smooth muscle neoplasia of the colon presenting as diminutive polyps: a case complicating post-transplant lymphoproliferative disorder

A 44-year-old woman, 3 years post-transplant for pulmonary sarcoidosis, developed abdominal pain and diarrhea 13 months subsequent to an eradicated diffuse large B-cell-type, post-transplant lymphoproliferative disorder (PTLD) of the cecal region. Endoscopic examination identified multiple pale tan 5-to-9 mm rubbery nodules of the transverse and right colon in an otherwise unremarkable mucosa. Histology was characterized by bland smooth muscle proliferations, focally pushing into the mucosa. Immunohistochemistry (IHC), in situ hybridization (ISH), and polymerase chain reaction (PCR) of the sampled nodules confirmed Epstein-Barr virus (EBV) infection of neoplastic cells. To our knowledge, this is the first reported case of EBV-related post-transplant lymphoproliferative and smooth muscle neoplasms (PTSN) having distinct tropism for the colon. Endoscopic features of early PTSN, which in this case presented as diminutive polypoid lesions, have not been described previously.

Les trajets anatomiques des bandelettes sous-urétrales, rétropubiennes TVT et transobturatrices TOT, sont-ils différents ? Apport de l'échographie introïtale

OBJECTIVE

Using perineal ultrasound in two groups of patients having either TVT or TOT procedure to know if TOT is sufficiently oblique and if the large dissection in TOT procedure might be responsible for migration of the tape.

PATIENTS AND METHODS

Thirty-two patients, 16 TVT and 16 TOT, had a sonography. The tape is visualised in the sagittal and frontal planes at rest, maximum holding and valsalva straining. The angle between the two limbs of the tape is measured as well as the distance tape-bladder neck and the width of the tape.

RESULTS

The aspect of the tape at rest is like a V, in both groups. During straining, the urethra is flattened on the tape which becomes round. During maximum retaining, the V closes by traction on the limbs. The mean angle under the urethra at rest is 109.9 degrees. In the TVT group it is 101.6 degrees versus 118.1 degrees in the TOT group. This difference is statistically significant (P=0.001). The width of the tape is 6.7 mm (2.4-10.3). The distance tape-bladder neck is 14.8 mm (8.2-25.7), 14.6 mm for the TVT group and 15.6 mm for the TOT group, the mean urethral length being 33.1 mm.

DISCUSSION AND CONCLUSION

The angle of TOT is more open. It remains sufficiently oblique and allows the tape to be put with light tension if needed in low-pressure urethra. In spite of larger urethrovaginal dissection in TOT, the tape does not migrate close to the bladder neck and remains at mid-urethra.

Management of difficult intubation in a patient with ankylosing spondylitis--a case report

We describe a case of difficult intubation in a patient suffering from ankylosing spondylitis undergoing total hip replacement surgery. The anesthetic management of 42 year old patient with difficult airway is discussed. Failure of epidural anesthesia procedure necessitated general anesthesia. The problems of performing awake fibreoptic intubation and other alternative techniques to secure the airway are described. Cervical spine involvement in ankylosing spondylitis is of great concern for the anesthetist. Longstanding progressive course of this disease leads to fibrosis, ossification and ankylosis of entire spine and sacroiliac joints. Cervical spine mobility is decreased and in severe cases total fixity occurs in a flexed position. Patient may also have atlanto-occipital and temporo-mandibular joint involvement as well. Cricoarytenoid cartilages involvement may result in upper airway compromise. Furthermore cervical spine vertebrae are prone to fractures, especially on hyperextension and may lead to spinal cord transection and quadriplegia. In this case report we describe the airway management of such patient with fixed rigidity of cervical spine and thoracolumbar kyphosis.

Distribution of HLA-A alleles in eight ethnic groups from Pakistan

The extreme polymorphism found at some loci of the HLA system has made it an invaluable tool for population genetic analyses. In this study eight diverse ethnic groups from Pakistan were analyzed at the HLA-A locus using sequence specific primers for polymerase chain reaction (PCR-SSP) and then further typed to the allele level using a two-stage sequence specific oligonucleotide probe (SSOP) strategy. Four of these ethnic groups (Burusho, Hazara, Kalash, Pathan) were from the north and four (Baloch, Brahui, Sindhi and Parsi) were from the south of Pakistan. Nine alleles were identified as unique to a particular ethnic group within Pakistan. Maximum variation was seen in the HLA-A*02 allele family for which 11 alleles were detected in the eight Pakistani ethnic groups. The alleles that showed significant variation between the Pakistani ethnic groups include A*0101, A*0206, A*0209, A*0207, A*0217, A*1101, A*2402/09 N/11 N, A*2902, A*3301 and A*3001. A phylogenetic tree based on DA distances for HLA-A allele frequencies separated the Pakistani populations from other world populations and also separated the only Dravidian speaking population of Pakistan, the Brahui, from the remaining Indo-European speaking ethnic groups of Pakistan.

Frequency of CCR5 Gene 32-bp deletion in Pakistani ethnic groups

CCR5 is a G-protein-coupled chemokine receptor that is used as a co-factor by macrophage-tropic (M-tropic) isolates of human immunodeficiency virus-1 (HIV-1) to gain entry into host cells. A 32-bp deletion in the CCR5 gene (CCR5-Delta32) leads to the production of an altered gene product that prevents HIV-1 from entering the host cell. This study was carried out to determine prevalence of CCR5-Delta32 allele frequency in a large Pakistani population sample (n = 821) representing 10 ethnic groups. No individual was homozygous for the mutant allele and the frequency of the CCR5-Delta32 allele ranged from 0.62% to 3.57%. The CCR5-Delta32 allele frequency was generally lower in populations from southern Pakistan. The overall frequency of the CCR5-Delta32 allele in Pakistan was 2.31%, which is much lower than that found in European populations and similar to that in the Middle East. This is consistent with the historical records and genetic data that indicate a close genetic affinity among these populations. This study demonstrates that the Pakistani population is highly susceptible to M-tropic isolates of HIV-1 and public health measures need to be enforced with urgency if Pakistan is to avoid an HIV epidemic.

HLA polymorphism in six ethnic groups from Pakistan

The extreme polymorphism found at some of the loci of the HLA system has made it an invaluable tool for population genetic analyses. In this study the genetic polymorphism of six Pakistani ethnic groups was investigated at the HLA-A, -B, -C, -DRB and DQB1 loci using polymerase chain reaction with sequence specific primers. The groups included in this study are the Baloch, Brahui and Sindhi from the south and the Burusho, Kalash and Pathan from the north of Pakistan. The allele frequencies, three-locus haplotype frequencies for HLA-A, -C, -B and HLA-A, -B, -DRB1 are given. Variation in the allele and haplotype distribution between the six Pakistani ethnic groups was observed. A phylogenetic tree and correspondence analysis based on HLA-A, -B, -C, -DRB1 and -DQB1 allele frequencies revealed the Kalash population to be distinct from the remaining Pakistani populations. The Baloch and Brahui were closely related to one another. The Sindhi were closer to the Pathan and Burusho populations than to the neighboring Baloch and Brahui populations, indicating admixture between the northern and southern populations of Pakistan. A phylogenetic tree and correspondence analysis comparing the Pakistani populations with various other world populations showed that the Pakistani ethnic groups lie within the cluster of Asian Indian populations. The three-locus haplotypes found in the Pakistani populations suggest an influence from Caucasian and Oriental populations.

Cytogenetic findings in lymphoplasmacytic lymphoma/Waldenström macroglobulinemia. Chromosomal abnormalities are associated with the polymorphous subtype and an aggressive clinical course

We correlated bone marrow cytogenetic findings with morphologic and immunophenotypic data in 37 patients with lymphoplasmacytic lymphoma (LPL)/Waldenström macroglobulinemia (WM). Each LPL/WM case was classified as lymphoplasmacytoid (n = 18), lymphoplasmacytic (n = 10), or polymorphous (n = 9) using the Kiel criteria. Of 12 cases with chromosomal abnormalities, a single numeric abnormality was present in 4 and a complex karyotype in 8. The most common numeric abnormalities were and -8 in 3 cases each; the most common structural abnormality was del(6q) in 6 cases. Cytogenetic abnormalities were significantly less common in the lymphoplasmacytic and lymphoplasmacytoid groups (5/28 [18%]) compared with the polymorphous group (7/9 [78%]). Clinical follow-up was available for 28 patients for a median of 36 months. Six (67%) of 9 patients with aneuploid tumors, including 4 with polymorphous subtype, subsequently had clinical progression or developed high-grade lymphoma. In contrast, 4 (21%) of 19 patients with diploid tumors, including 1 of polymorphous type, developed clinical progression or high-grade lymphoma. We conclude that abnormal cytogenetic findings in LPL/WM correlate with the polymorphous subtype and poor prognosis.

Lymphoplasmacytic lymphoma/Waldenström macroglobulinemia associated with Hodgkin disease. A report of two cases

Although the clinical course of lymphoplasmacytic lymphoma (LPL)/Waldenström macroglobulinemia (WM) is usually indolent, high-grade non-Hodgkin lymphoma may develop in a small subset of patients. We have not found any patients with LPL/WM associated with Hodgkin disease (HD) described in the literature, prompting us to report 2 cases. In case 1, the patient had LPL/WM involving bone marrow diagnosed 1 week before left supraclavicular lymph node biopsy revealed LPL/WM and classical HD. In case 2, the patient had a 15-year history of LPL/WM before classical HD developed involving bone marrow, liver, and lymph node. Both cases were positive for IgM, monotypic immunoglobulin light chain, and B-cell antigens and were CD3-. The neoplastic Hodgkin cells were CD15+, CD20+ (case 1), CD30+, CD3-, and CD45- and were negative for Epstein-Barr virus RNA. Both patients were treated with chemotherapy for HD. In case 1, clinical response was excellent with no histologic evidence of HD in subsequent biopsy specimens. In case 2, HD was progressive at last follow-up, despite therapy. Patients with LPL/WM, similar to patients with other types of low-grade B-cell lymphoma, can develop HD that may respond to chemotherapy.

Tissue inhibitor of metalloproteinases 1 regulation of interleukin-10 in B-cell differentiation and lymphomagenesis

Tissue inhibitors of metalloproteinases (TIMPs), first described as specific inhibitors of matrix metalloproteinases, have recently been shown to exert growth factor activities. It was previously demonstrated that TIMP-1 inhibits apoptosis in germinal center B cells and induces further differentiation. Interleukin-10 (IL-10) is reported as a vital factor for the differentiation and survival of germinal center B cells and is also a negative prognostic factor in non-Hodgkin lymphoma (NHL). However, the mechanism of IL-10 activity in B cells and the regulation of its expression are not well understood. IL-10 has been shown to up-regulate TIMP-1 in tissue macrophages, monocytes, and prostate cancer cell lines, but IL-10 modulation of TIMP-1 in B cells and the effect of TIMP-1 on IL-10 expression has not been previously studied. It was found that TIMP-1 expression regulates IL-10 levels in B cells and that TIMP-1 mediates specific B-cell differentiation steps. TIMP-1 inhibition of apoptosis is not IL-10 dependent. TIMP-1 expression in B-cell NHL correlates closely with IL-10 expression and with high histologic grade. Thus, TIMP-1 regulates IL-10 expression in B-cell NHL and, through the inhibition of apoptosis, appears responsible for the negative prognosis associated with IL-10 expression in these tumors.

Waldenstrom macroglobulinemia presenting as a pleural effusion

We describe a patient with Waldenstrom macroglobulinemia who presented with a lymphocytic pleural effusion. Pleural involvement in Waldenstrom macroglobulinemia is very rare. In addition, to our knowledge, there are no reports in the literature in which a primary diagnosis was made on the basis of pleural fluid analysis. The presence of small lymphocytes in serous cavity fluid can pose great difficulty in the differentiation between a low-grade lymphoproliferative disorder and reactive lymphocytosis. The diagnosis of malignancy in this case was established on the basis of morphologic testing, flow cytometry, and the detection of B-cell immunoglobulin gene rearrangement.

The seismocardiogram as magnetic-field-compatible alternative to the electrocardiogram for cardiac stress monitoring

Seismocardiography (SCG) is a methodology derived from the field of seismology to measure non-invasively compression waves generated by myocardial motion. The use of SCG is proposed here as method to monitor cardiac function during stress testing and magnetic resonance imaging (MRI). It is shown that recording of the seismocardiogram in subjects undergoing an MRI study is not compromised by flow-induced electrical voltages that can severely distort the electrocardiogram. Electromagnetic compatibility of the seismocardiograph device with the MRI scanner hardware was tested. Experiments in an animal model proved that changes in the SCG waveform during different levels of LAD stenosis correlate with the changes seen in LV function with cine MRI. The changes in the SCG waveform characteristic for the onset of ischemia were observed almost immediately after the creation of a flow-limiting stenosis. This novel application of SCG to monitor changes in peak acceleration from cardiac blood flow and wall motion may represent a solution to the long-standing and important problem of monitoring patients for signs of myocardial ischemia during MRI.

African and Levantine origins of Pakistani YAP+ Y chromosomes

We surveyed 9 Pakistani subpopulations for variation on the nonrecombining portion of the Y chromosome. The polymorphic systems examined were the Y-chromosome Alu insertion polymorphism (YAP) at DYS287, 5 single nucleotide polymorphisms, and the tetranucleotide microsatellite DYS19. Y chromosomes carrying the YAP element (YAP+) were found in populations from southwestern Pakistan at frequencies ranging from 2% to 8%, whereas northeastern populations appeared to lack YAP+ chromosomes. In contrast to other South Asian populations, several Pakistani subpopulations had a high frequency of the DYS19*B allele, the most frequent allele in West Asian, North African, and European populations. The combination of alleles at all polymorphic sites gave rise to 9 YAP-DYS19 combination haplotypes in Pakistani populations, including YAP+ haplotypes 4-A, 4-B, 5-C, and 5-E. We hypothesize that the geographic distributions of YAP+ haplotypes 4 and 5 trace separate migratory routes to Pakistan: YAP+ haplotype 5 may have entered Pakistan from the Arabian Peninsula by means of migrations across the Gulf of Oman, whereas males possessing YAP+ haplotype 4 may have traveled over land from the Middle East. These inferences are consistent with ethnohistorical data suggesting that Pakistan's ethnic groups have been influenced by migrations from both African and Levantine source populations.

In vitro suppression of programmed cell death of B cells by tissue inhibitor of metalloproteinases-1

Cellular pathways for induction of programmed cell death (PCD) have been identified, but little is known about specific extracellular matrix processes that may affect apoptosis along those pathways. In this study, a series of Burkitt's lymphoma (BL) cell lines were assayed for their expression of tissue inhibitor of metalloproteinases (TIMP)-1. Results indicate that TIMP-1-positive BL lines show resistance to cold-shock-induced apoptosis. Furthermore, recombinant TIMP-1, but not TIMP-2 or a synthetic metalloproteinase inhibitor (BB-94), confers resistance to apoptosis induced by both CD95-dependent and -independent (cold shock, serum deprivation, and gamma-radiation) pathways in TIMP-1-negative BL lines. TIMP-1 suppression of PCD is not due to metalloproteinase inhibition, as reduction and alkylation of the TIMP-1 did not abolish this activity. Retroviral induction of TIMP-1 not only resulted in cell survival but also in continued DNA synthesis for up to 5 d in the absence of serum, while controls underwent apoptosis. This resistance to apoptosis is reversed by anti-TIMP-1 antibodies, demonstrating that secreted TIMP-1 is active in blocking apoptosis. Furthermore, TIMP-1 upregulation induced expression of Bcl-XL but not Bcl-2 as well as decreased NF-kappaB activity as compared with controls. These results demonstrate that TIMP-1 suppresses apoptosis in B cells and suggests a novel activity for TIMP-1 in tissue homeostasis.

Differential structuring of human populations for homologous X and Y microsatellite loci

The global pattern of variation at the homologous microsatellite loci DYS413 (Yq11) and DXS8174 and DXS8175 (Xp22) was analyzed by examination of 30 world populations from four continents, accounting for more than 1,100 chromosomes per locus. The data showed discordant patterns of among- and within-population gene diversity for the Y-linked and the X-linked microsatellites. For the Y-linked polymorphism, all groups of populations displayed high FST values (the correlation between random haplotypes within subpopulations, relative to haplotypes of the total population) and showed a general trend for the haplotypes to cluster in a population-specific way. This was especially true for sub-Saharan African populations. The data also indicated that a large fraction of the variation among populations was due to the accumulation of new variants associated with the radiation process. Europeans exhibited the highest level of within-population haplotype diversity, whereas sub-Saharan Africans showed the lowest. In contrast, data for the two X-linked polymorphisms were concordant in showing lower FST values, as compared with those for DYS413, but higher within-population variances, for African versus non-African populations. Whereas the results for the X-linked loci agreed with a model of greater antiquity for the African populations, those for DYS413 showed a confounding pattern that is apparently at odds with such a model. Possible factors involved in this differential structuring for homologous X and Y microsatellite polymorphisms are discussed.

Prevalence of Epstein-Barr viral sequences and EBV LMP1 oncogene deletions in Burkitt's lymphoma from Pakistan: epidemiological correlations

To investigate the potential relationship of socioeconomic status with the prevalence of Epstein-Barr virus (EBV) and to understand the significance of del-LMP-1 within EBV+ cases of Burkitt's lymphoma (BL), we studied 10 cases of BL, 30 cases of diffuse large cell lymphoma (DLCL) arising in nonimmunocompromised patients, and 30 reactive tonsillar biopsy specimens from Pakistan. Each lymphoma was analyzed for EBV by EBER1 RNA in situ hybridization (EBV-RISH). Cases showing hybridization signal within neoplastic cells and all reactive tonsillar tissues were analyzed for EBV strain type by EBNA-2 polymerase chain reaction (PCR) and for the presence of a del-LMP-1 by PCR. Eight of 10 (80%) of BL were EBV+, each containing EBV strain A and a wild-type LMP-1 gene. In contrast, only 4 of 30 DLCL (13%) cases were EBV positive (three strain A, one strain B), each containing a wild-type LMP-1 gene. Fifteen of 30 tonsillar biopsy specimens contained EBV, all of which were strain A and wild-type for LMP1. The prevalence of EBV in BL from Pakistan is slightly lower than in BL in endemic regions, but significantly higher than in BL in North America. EBV positivity probably reflects the socioeconomic status of the patient population and age at seroconversion. The absence of del-LMP-1 within all EBV+ BL cases is consistent with the view that del-LMP-1 is not involved in the pathogenesis of BL, and the presence of del-LMP-1 in EBV+ cases of BL reported in other studies may likely reflect the prevalence of a viral strain containing the 30-bp deletion within the respective population studied.

Expression of matrix metalloproteinases and tissue inhibitors of metalloproteinases in reactive and neoplastic lymphoid cells

We have studied the expression of gelatinase A, gelatinase B, interstitial collagenase, tissue inhibitor of metalloproteinase (TIMP)-1 and TIMP-2 in reactive lymphoid cells, as well as in a series of cell lines derived from neoplasms of B- and T-cell lineage. Using both Northern blot analysis and zymography, gelatinase B activity was detected by zymography in two Burkitt cell lines and in a tonsillar cell suspension, while gelatinase A and interstitial collagenase activities were not detected by either method. TIMP-1 expression was demonstrated by Northern blot analysis in the multipotential neoplastic K-562 cell line, the high grade Burkitt's B-cell lymphoma lines, isolated tonsillar B cells and at low levels in peripheral blood T cells, but was not expressed in any of the neoplastic T-cell lines or isolated peripheral blood B cells. In contrast, TIMP-2 expression was restricted to tissues containing cells of T-cell lineage with high levels being observed in the neoplastic T-cell lines and lower levels in normal peripheral blood T cells and hyperplastic tonsil. Expression of TIMP-1 and TIMP-2 was confirmed at the protein level by reverse zymography and immunofluorescence assays using antihuman TIMP polyclonal antibodies. Expression of gelatinase B by the high grade B-cell Burkitt's lymphoma cell lines is consistent with previous findings in large cell immunoblastic lymphomas and indicates that this enzyme may play an important role in high grade non-Hodgkin's lymphomas. TIMP expression correlated with cell lineage in that TIMP-1 was primarily observed in B cells and TIMP-2 was restricted to T cells.