Spontaneous Rupture of the Uterine Artery in an Otherwise Normal Pregnancy.

Spontaneous rupture of a uterine artery in pregnancy is associated with a high rate of mortality. Although uterine artery rupture has been associated with postpartum hemorrhage, it is rarely found during pregnancy. Unfortunately, clinical signs and symptoms are usually vague and nonspecific. We report a case of a 36-year-old woman at 20 weeks gestation presenting with abdominal pain who was found to have a spontaneous uterine artery rupture. To our knowledge, this is the first case report demonstrating imaging findings in a patient with this condition. Our patient underwent successful ligation of the uterine vessel with preservation of both mother and fetus. We will discuss possible etiologies of uterine artery rupture during pregnancy, associated imaging findings, and management options.

Aspergillus thyroiditis: a complication of respiratory tract infection in an immunocompromised patient.

A 59-year-old male with past medical history significant for non-Hodgkin's lymphoma status after chemotherapy presented with acute onset of neck pain, odynophagia, and dysphagia associated with subjective fever, chills, and dyspnea. Physical findings included a temperature of 38.4°C, hypertension, and tachycardia. Patient was found to have anterior neck tenderness. Laboratory evaluation revealed neutropenia. The patient was started on empiric antibacterial and antiviral therapy and continued on home prophylactic antifungal treatment. Thyroid function tests revealed overt hyperthyroidism. A thyroid ultrasound showed heterogeneous echotexture without discrete nodules. Subacute thyroiditis was treated with methylprednisolone, metoprolol, and opiate analgesics. Patient's antibacterial, antifungal, and antiviral treatments were broadened. A fine needle aspiration was not conducted. The patient's condition deteriorated rapidly over his brief hospital course and he expired. Autopsy showed fungal thyroiditis secondary to disseminated invasive Aspergillus. This report describes the presentation of fungal thyroiditis secondary to disseminated invasive Aspergillus originating from the respiratory tract. The authors review the diagnostic challenges, pathophysiology, and treatment of this condition.

Reduced immune response to Borrelia burgdorferi in the absence of γδ T cells.

Little is known regarding the function of γδ T cells, although they accumulate at sites of inflammation in infections and autoimmune disorders. We previously observed that γδ T cells in vitro are activated by Borrelia burgdorferi in a TLR2-dependent manner. We now observe that the activated γδ T cells can in turn stimulate dendritic cells in vitro to produce cytokines and chemokines that are important for the adaptive immune response. This suggested that in vivo γδ T cells may assist in activating the adaptive immune response. We examined this possibility in vivo and observed that γδ T cells are activated and expand in number during Borrelia infection, and this was reduced in the absence of TLR2. Furthermore, in the absence of γδ T cells, there was a significantly blunted response of adaptive immunity, as reflected in reduced expansion of T and B cells and reduced serum levels of anti-Borrelia antibodies, cytokines, and chemokines. This paralleled a greater Borrelia burden in γδ-deficient mice as well as more cardiac inflammation. These findings are consistent with a model of γδ T cells functioning to promote the adaptive immune response during infection.

A novel model of blunt thoracic aortic injury: a mechanism confirmed?

BACKGROUND: There is no consensus on the mechanism of traumatic injury to the thoracic aorta and no reproducible animal model. Advances in injury scene analysis suggest that lateral and oblique force vectors cause aortic injury. We hypothesized that the spectrum of aortic injury could be reproduced in an animal model by application of an obliquely directed load to the pressurized aorta. METHODS: Graded air impulses of 80, 100, 110, and 120 pounds per square inch (PSI) were delivered to the descending thoracic aorta of 19 swine with a novel pneumatic device. Aortic isthmus strain was recorded with microminiature probes. Gross and microscopic injury was recorded with digital photography. RESULTS: The spectrum of human aortic injury was reproduced in this model. Deep injuries to the aortic media were common. The majority of injuries occurred within the region of the isthmus. Impulse pressure of 120 PSI caused transections, whereas lower impulse pressure resulted in less severe injuries. Aortic isthmus strain was greater in the animals exposed to 120 PSI than those receiving lower PSI (19.6 +/- 4.9% vs. 8.7 +/- 2.5%, p = 0.067). CONCLUSIONS: Direct loading of the pressurized descending thoracic aorta causes isthmus injury secondary to aortic wall strain. Deep medial lesions are common and could propagate soon after injury to form pseudoaneurysms. A critical load is required to cause complete uncontained transection with exsanguination, which may have relevance to injury scene death.

Eyelid mucous membrane grafts: a histologic study of hard palate, nasal turbinate, and buccal mucosal grafts.

PURPOSE: To histologically evaluate the outcome of mucous membrane grafts to the eyelid. METHODS: Case series of 31 eyes from 24 patients who underwent transplantation of hard palate (25 eyes), buccal (1 eye), or nasal turbinate (5 eyes) mucosa to the posterior eyelid surface. These grafts were biopsied at 0.5 months to 84 months (mean, 20 months) postoperatively. They were examined with light microscopy and compared with either the donor mucosa from the same patient (2 patients) or the typical donor site histology (22 patients). RESULTS: Graft biopsies revealed general epithelial morphology that was quite similar to the respective donor sites in virtually all cases. Six (25%) of 24 hard palate graft biopsies, which were obtained at 8 months to 49 months (mean, 22 months) postoperatively, displayed orthokeratosis alternating with parakeratosis, while 12 (50%) demonstrated parakeratosis alone, and another 6 (25%) showed adjacent regions of parakeratotic and nonkeratinized epithelium. No hard palate grafts showed complete absence of keratinization after transplantation. Other significant findings included loss of goblet cells in nasal turbinate grafts and few submucosal glands remaining in any specimen. CONCLUSIONS: Full-thickness mucosal grafts typically maintain their native epithelial morphology following transplantation to the ocular surface. Submucosal glands usually do not survive transplantation, which could be the result of intentional thinning of the graft at the time of transplantation. Contrary to the opinion that hard palate graft epithelium usually undergoes metaplasia from keratinized to nonkeratinized within 6 months following transplantation to the eye, all hard palate grafts in this study remained orthokeratotic and/or parakeratotic.

Can Ki-67 predict recurrence of NO squamous cell carcinoma of the tongue?

OBJECTIVES: Ki-67 is a molecular marker of cellular proliferation that predicts prognosis of some head and neck tumors. Studies of Ki-67 in oropharyngeal cancer have yielded conflicting findings. This study was designed to test Ki-67 as a marker for poor prognosis in N0 tongue squamous cell carcinoma. METHODS: We examined 29 cases in a retrospective cohort to test the hypothesis that a high rate of tumor cell proliferation (high levels of Ki-67 staining) at the invasive edge of N0 squamous cell carcinoma of the tongue correlates with increased risk of recurrence. RESULTS: There were 14 cases of recurrence. The average age of the patients with recurrence was 58 years. The average time to recurrence was 13.1 months. A 0% to 33% uptake of Ki-67 at the tumor's leading edge was associated with a 6-times-greater risk of recurrence. The mean length of survival for the group with 0% to 33% uptake was 21 months; for the group with > 33% uptake, it was 33 months. Overall uptake of Ki-67 and histologic grade did not correlate with risk of recurrence. CONCLUSIONS: In this sample, low rates of Ki-67 staining at the invasive edge of the tumor predicted a risk of recurrence. These results need to be confirmed before Ki-67 can be used for predicting recurrence of tongue squamous cell carcinoma.

Fas ligand deficiency impairs host inflammatory response against infection with the spirochete Borrelia burgdorferi.

Lyme disease represents a complex response to Borrelia burgdorferi that involves both bacterial factors as well as host responses. This results in an inflammatory reaction at several sites, including the synovial lining of joints. Synovial tissues of inflamed joints contain cells expressing high levels of Fas and Fas ligand (FasL). Although Fas stimulation is typically associated with cell death, it can also transmit stimulatory signals to certain cell types. Among these are dendritic cells and macrophages, which are abundant in inflamed synovium. To better assess the role of FasL in the pathogenesis of Lyme arthritis, we evaluated the response to B. burgdorferi infection in C3H/HeJgld mice that bear a nonfunctional mutation in FasL. Compared to wild-type C3H+/+ mice, C3Hgld mice had a similar bacterial burden and antibody response 2 weeks and 4 weeks following infection, but they manifested a significantly reduced Borrelia-specific cytokine response. In addition, C3Hgld mice developed a greatly reduced incidence and severity of arthritis. The findings document a contribution of FasL to the host inflammatory response to B. burgdorferi.

Pulmonary vein encircling ablation alters the atrial electrophysiologic response to autonomic stimulation.

OBJECTIVE: Pulmonary vein encircling ablation is often effective in the treatment of atrial fibrillation (AF). The success of the procedure does not depend upon creation of continuous lines of block. Thus mechanisms by which pulmonary vein encircling can cure AF remain unclear. Stimulation of cardiac autonomic ganglia alters atrial refractoriness and potentiates AF. We hypothesized that pulmonary vein encircling alters atrial autonomic function and that these alterations account in part for prevention of AF recurrences following ablation. METHODS: Atrial effective refractory periods (ERP) and AF inducibility were quantified in ten dogs before and during central autonomic nerve stimulation. Pulmonary vein encircling ablation was then performed and electrophysiologic testing repeated. In two dogs subjected to sham procedures measurements were repeated without performance of ablation. Hearts were examined histologically. RESULTS: Autonomic nerve stimulation led to decreased atrial refractoriness and increased AF inducibility and duration. Each of these effects were attenuated following pulmonary vein encircling (e.g., mean ERP decreased before (-23.7 +/- 1.8, p < 0.001) but not after ablation (-2.3 +/- 1.9, p = 0.25); AF inducibility increased by 26% before vs. 5% after ablation). No attenuation was seen in the sham operated animals. Histologic analysis following pulmonary vein encircling demonstrated destruction of some but not all autonomic ganglia. CONCLUSION: Autonomic stimulation shortens atrial refractory periods and potentiates AF. Pulmonary vein encircling ablation partially destroys atrial autonomic inputs, attenuates the refractory period shortening effect of autonomic stimulation and decreases AF inducibility. Destruction of autonomic ganglia may contribute to the anti-fibrillatory effects of pulmonary vein encircling and warrants further investigation.

Death certification errors at an academic institution.

CONTEXT: The correctly completed death certificate provides invaluable personal, epidemiologic, and legal information and should be thorough and accurate. Death certification errors are common and range from minor to severe. OBJECTIVE: To determine the frequency and type of errors by nonpathologist physicians at a university-affiliated medical center. DESIGN: Fifty random patients were identified who died at this academic medical center between January 2002 and December 2003 and did not undergo an autopsy. From medical chart review, clinical summaries were produced. Two pathologists used these summaries to create mock death certificates. The original and mock death certificates were then compared to identify errors in the original certificate. Errors were graded on a I to IV scale, with grade IV being the most severe. RESULTS: Of the 50 death certificates reviewed, grade I, II, and III errors were noted in 72%, 32%, and 30%, respectively. Seventeen certificates (34%) had grade IV errors (wrong cause or manner of death). Multiple errors were identified in 82% of the death certificates reviewed. CONCLUSIONS: The rate of major (grade IV) death certification errors at this academic setting is high and is consistent with major error rates reported by other academic institutions. We attribute errors to house staff inexperience, fatigue, time constraints, unfamiliarity with the deceased, and perceived lack of importance of the death certificate. To counter these factors, we recommend a multifaceted approach, including an annual course in death certification and discussion of the death certificate for each deceased patient during physician rounds. These measures should result in increased accuracy of this important document.

Safety and efficacy of epicardial cryoablation in a canine model.

OBJECTIVES: The purpose of this study was to evaluate the safety and efficacy of cryoablation in a closed chest canine epicardial ablation model. BACKGROUND: Limitations of radiofrequency energy in the epicardial space warrants investigation of alternative energy sources. METHODS: A linear-tip catheter with a 3-cm freezing element and a 6-mm-tip catheter were used to create epicardial atrial and ventricular cryolesions. Epicardial coronary arteries were targeted to evaluate the effects of cryoablation on epicardial vessels. Cryoablation was performed at -90 degrees C for 4 minutes per lesion. Pathologic examination of the hearts was performed. Lesions were stained with tetrazolium chloride, analyzed grossly, and examined histologically. RESULTS: Ten of 11 linear catheter atrial lesions were transmural (average depth 1.5 +/- 1.3 mm). Only three of 13 6-mm-tip atrial lesions were transmural (average depth 1.1 +/- 1.2 mm). Ventricular lesions were continuous and not transmural (average depth of lesion for the linear and 6-mm-tip catheters: 2.7 +/- 1.3 mm and 1.6 +/- 0.7 mm, respectively). Angiographic stenosis (20-100%) during freezing was detected in 9 of 28 lesions, with TIMI III flow present in all vessels 5 minutes following thaw. Neointimal proliferation was present in 13 vessels, with no evidence of damage in vessels with internal diameters greater than 0.7 mm. Occlusive injury was identified in one small branch vessel. CONCLUSIONS: Creation of transmural lesions was possible in the atria but not in the ventricles. Cryothermal ablation can cause neointimal proliferation, with the probability that damage will be directly proportional to lesion depth and inversely proportional to vessel diameter.

Beta-2 microglobulin amyloidosis presenting as bilateral ovarian masses: a case report and review of the literature.

We report a case of systemic beta-2 microglobulin amyloidosis (B2M) in which the initial clinical presentation was that of bilateral ovarian masses. A 56-year-old woman who had been on renal dialysis for 12 years because of familial glomerulonephritis underwent a total hysterectomy and bilateral salpingo-oophorectomy for suspected ovarian malignancy. Pathologic findings included extensive amyloid infiltration of both ovaries, fallopian tubes, and focal perivascular deposition in the myometrium. The diagnosis of amyloidosis was confirmed with Congo red stain, B2M immunohistochemistry, and electron microscopy. Systemic amyloidosis in renal dialysis patients commonly presents as bone and/or joint disease, although visceral involvement has been reported. This is the first report in the English language literature to describe amyloidosis presenting as bilateral ovarian masses.