Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial.

Importance: The tracheal tube introducer, known as the bougie, is typically used to aid tracheal intubation in poor laryngoscopic views or after intubation attempts fail. The effect of routine bougie use on first-attempt intubation success is unclear. Objective: To compare first attempt intubation success facilitated by the bougie vs the endotracheal tube + stylet. Design, Setting, and Patients: The Bougie Use in Emergency Airway Management (BEAM) trial was a randomized clinical trial conducted from September 2016 through August 2017 in the emergency department at Hennepin County Medical Center, an urban, academic department in Minneapolis, Minnesota, where emergency physicians perform all endotracheal intubations. Included patients were 18 years and older who were consecutively admitted to the emergency department and underwent emergency orotracheal intubation with a Macintosh laryngoscope blade for respiratory arrest, difficulty breathing, or airway protection. Interventions: Patients were randomly assigned to undergo the initial intubation attempt facilitated by bougie (n = 381) or endotracheal tube + stylet (n = 376). Main Outcomes and Measures: The primary outcome was first-attempt intubation success in patients with at least 1 difficult airway characteristic (body fluids obscuring the laryngeal view, airway obstruction or edema, obesity, short neck, small mandible, large tongue, facial trauma, or the need for cervical spine immobilization). Secondary outcomes were first-attempt success in all patients, first-attempt intubation success without hypoxemia, first-attempt duration, esophageal intubation, and hypoxemia. Results: Among 757 patients who were randomized (mean age, 46 years; women, 230 [30%]), 757 patients (100%) completed the trial. Among the 380 patients with at least 1 difficult airway characteristic, first-attempt intubation success was higher in the bougie group (96%) than in the endotracheal tube + stylet group (82%) (absolute between-group difference, 14% [95% CI, 8% to 20%]). Among all patients, first-attempt intubation success in the bougie group (98%) was higher than the endotracheal tube + stylet group (87%) (absolute difference, 11% [95% CI, 7% to 14%]). The median duration of the first intubation attempt (38 seconds vs 36 seconds) and the incidence of hypoxemia (13% vs 14%) did not differ significantly between the bougie and endotracheal tube + stylet groups. Conclusions and Relevance: In this emergency department, use of a bougie compared with an endotracheal tube + stylet resulted in significantly higher first-attempt intubation success among patients undergoing emergency endotracheal intubation. However, these findings should be considered provisional until the generalizability is assessed in other institutions and settings. Trial Registration: clinicaltrials.gov Identifier: NCT02902146.

Reduction in Opioid Prescribing Using a Postoperative Pain Management Protocol following Scrotal and Subinguinal Surgery.

INTRODUCTION: Excess prescribing of opioid pain medication increases medical costs and the potential for abuse by patients and others. We sought to improve our understanding of postoperative pain and opioid use after scrotal and subinguinal urological surgery to develop a protocol for pain management. METHODS: We retrospectively analyzed opioid prescribing and usage in 20 patients undergoing scrotal or subinguinal surgery. Collected data were used to develop a standardized postoperative protocol. This protocol included enhanced pain management education and limiting outpatient opioid prescriptions. Outcomes analysis was then performed for 60 consecutive patients via questionnaire. Statistical analysis was performed using the Wilcoxon rank sum test and ANOVA. Linear regression was performed comparing age and narcotic use. RESULTS: Comparison of preprotocol and postprotocol implementation opioid prescriptions and consumption showed a statistically significant decrease in the number of tablets prescribed but no difference in opioid usage. Preprotocol and postprotocol opioid prescription usage was 20 and 10 tablets, respectively, while median usage was 3.5 and 3 tablets, respectively. CONCLUSIONS: Evaluation of postoperative pain management revealed excessive prescribing of opioid medications compared to actual usage. Our protocol resulted in a significant decrease in opioid prescribing without compromising management of postoperative pain. Adjunct treatments for pain, including scrotal support, ice packs, elevation and nonsteroidal anti-inflammatory drugs, may improve postoperative pain control without increasing opioid usage. The combination of enhanced patient education and reduced opioid prescribing may result in decreased opioid use, opioid abuse and medication costs.

The Bougie and First-Pass Success in the Emergency Department.

STUDY OBJECTIVE: The bougie may improve first-pass intubation success in operating room patients. We seek to determine whether bougie use is associated with emergency department (ED) first-pass intubation success. METHODS: We studied consecutive adult ED intubations at an urban, academic medical center during 2013. Intubation events were identified by motion-activated video recording. We determined the association between bougie use and first-pass intubation success, adjusting for neuromuscular blockade, video laryngoscopy, abnormal airway anatomy, and whether the patient was placed in the sniffing position or the head was lifted off the bed during intubation. RESULTS: Intubation with a Macintosh blade was attempted in 543 cases; a bougie was used on the majority of initial attempts (80%; n=435). First-pass success was greater with than without bougie use (95% versus 86%; absolute difference 9% [95% confidence interval {CI} 2% to 16%]). The median first-attempt duration was higher with than without bougie (40 versus 27 seconds; difference 14 seconds [95% CI 11 to 16 seconds]). Bougie use was independently associated with greater first-pass success (adjusted odds ratio 2.83 [95% CI 1.35 to 5.92]). CONCLUSION: Bougie was associated with increased first-pass intubation success. Bougie use may be helpful in ED intubation.

Emergency Department Airway Management of Severe Angioedema: A Video Review of 45 Intubations.

STUDY OBJECTIVE: Angioedema is an uncommon but important cause of airway obstruction. Emergency airway management of angioedema is difficult. We seek to describe the course and outcomes of emergency airway management for severe angioedema in our institution. METHODS: We performed a retrospective, observational study of all intubations for angioedema performed in an urban academic emergency department (ED) between November 2007 and June 2015. We performed a structured review of video recordings of each intubation. We identified the methods of airway management, the success of each method, and the outcomes and complications of the effort. RESULTS: We identified 52 patients with angioedema who were intubated in the ED; 7 were excluded because of missing videos, leaving 45 patients in the analysis. Median time from arrival to the ED to the first intubation attempt was 33 minutes (interquartile range 17 to 79 minutes). Nasotracheal intubation was the most common first method (33/45; 73%), followed by video laryngoscopy (7/45; 16%). Two patients required attempts at more invasive airway procedures (retrograde intubation and cricothyrotomy). The intubating laryngeal mask airway was used as a rescue method 5 times after failure of multiple methods, with successful oxygenation, ventilation, and intubation through the laryngeal mask airway in all 5 patients. All patients were successfully intubated. CONCLUSION: In this series of ED patients who were intubated because of angioedema, emergency physicians used a range of methods to successfully manage the airway. These observations provide key lessons for the emergency airway management of these critical patients.

Multiplatform molecular profiling identifies potentially targetable biomarkers in malignant phyllodes tumors of the breast.

Malignant phyllodes tumor is a rare breast malignancy with sarcomatous overgrowth and with limited effective treatment options for recurrent and metastatic cases. Recent clinical trials indicated a potential for anti-angiogenic, anti-EGFR and immunotherapeutic approaches for patients with sarcomas, which led us to investigate these and other targetable pathways in malignant phyllodes tumor of the breast. Thirty-six malignant phyllodes tumors (including 8 metastatic tumors with two cases having matched primary and metastatic tumors) were profiled using gene sequencing, gene copy number analysis, whole genome expression, and protein expression. Whole genome expression analysis demonstrated consistent over-expression of genes involved in angiogenesis including VEGFA, Angiopoietin-2, VCAM1, PDGFRA, and PTTG1. EGFR protein overexpression was observed in 26/27 (96%) of cases with amplification of the EGFR gene in 8/24 (33%) cases. Two EGFR mutations were identified including EGFRvIII and a presumed pathogenic V774M mutation, respectively. The most common pathogenic mutations included TP53 (50%) and PIK3CA (15%). Cases with matched primary and metastatic tumors harbored identical mutations in both sites (PIK3CA/KRAS and RB1 gene mutations, respectively). Tumor expression of PD-L1 immunoregulatory protein was observed in 3/22 (14%) of cases. Overexpression of molecular biomarkers of increased angiogenesis, EGFR and immune checkpoints provides novel targeted therapy options in malignant phyllodes tumors of the breast.

Prostatitis and male infertility.

The prostate gland plays an important role in male reproduction. Inflammation of the prostate gland (prostatitis) is a common health problem affecting many young and middle aged men. Prostatitis is considered a correctable cause of male infertility, but the pathophysiology and appropriate treatment options of prostatitis in male infertility remain unclear. This literature review will focus on current data regarding prostatitis and its impact on male infertility.

Male-to-female sex ratios of abnormalities detected by fluorescence in situ hybridization in a population of chronic lymphocytic leukemia patients.

Distorted sex ratios occur in hematologic disorders. For example, chronic lymphocytic leukemia (CLL) displays disproportionate sex ratios with a large male excess. However, the underlying genetics for these disparities are poorly understood, and gender differences for specific cytogenetic abnormalities have not been carefully investigated. We sought to provide an initial characterization of gender representation in genetic abnormalities in CLL by using fluorescence in situ hybridization (FISH). We confirm the well known skewed male-tofemale (M/F sex ratio) of ~1.5 in our CLL study population, but also determine the genotypic M/F sex ratio values corresponding to specific FISH DNA probes. Genetic changes in CLL detectable by four FISH probes were statistically compared with respect to gender. Initial FISH evaluations of 4698 CLL patients were retrospectively examined and new findings of the genotypic M/F sex ratios for these probes are reported. This study represents the largest CLL survey conducted in the United States using FISH probes. The CLL database demonstrated that FISH abnormalities (trisomy 12, 13q14.3 deletion and 17p13.1 deletion) probes had skewed M/F ratios of ~1.5. Also, by statistical analysis it was shown that ATM gene loss (11q22.3q23.1 deletion) solely or with other abnormalities was considerably higher in males with an M/F ratio of 2.5 and significantly different from M/F ratios of 1.0 or 1.5. We hypothesize that interactions involving these autosomal abnormalities (trisomy 12, and deletions of 11q22.3, 13q14.3, and 17p13.1), and the sex chromosomes may provide the genetic basis for the altered phenotypic M/F ratio in CLL.

Pregnancy after varicocelectomy: impact of postoperative motility and DFI.

OBJECTIVE: To examine clinical and laboratory variables to determine which, if any, predict improved semen parameters and pregnancy after varicocelectomy. METHODS: Surgical logs were reviewed for men who underwent varicocele ligation for a fertility concern. Clinical, demographic, and laboratory data was obtained through medical chart review and paired with postoperative reproductive outcomes obtained through chart review and survey. RESULTS: Eighty-three subjects met inclusion criteria of which 63 and 24 completed both preoperative and postoperative basic and advanced semen testing, respectively. There was a statistically significant improvement in semen concentration, total motile count, sperm DNA fragmentation index (DFI), and total normal sperm count (TNSC) after varicocelectomy. Motility improved significantly in patients with preoperative asthenospermia. Concentration and motility demonstrated mean increases of 5.2 M/mL and 18%, respectively. DFI decreased from a preoperative mean of 40.8% to a postoperative mean of 24.5%. Fifty-one percent of couples were able to conceive using natural conception, intrauterine insemination, or in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI). Pregnancy, regardless of the method used to conceive, was associated with a higher postoperative motility. The mean postoperative DFI in couples who reported a spontaneous pregnancy was 34%, which was statistically higher than the mean DFI of 17.5% in couples who reported a pregnancy with IVF/ICSI (P = .04). CONCLUSION: Varicocele ligation improves multiple semen parameters. An increase in motility was the only variable associated with postoperative pregnancy irrespective of the method by which pregnancy was obtained. Mean DFI in couples able to achieve spontaneous pregnancy was above 30% and statistically higher than couples who reported pregnancy via IVF/ICSI.

Durability of flexible cystoscopes in the outpatient setting.

OBJECTIVE: To ascertain cystoscope durability in relation to usage and cost in the outpatient setting. METHODS: Six flexible cystoscopes were provided to our outpatient clinic by 2 vendors. Five Wolf 7305.006S02 cystoscopes (Richard Wolf Medical Instruments Corporation, Vernon Hills, IL) and 1 Olympus CYF-5 (Olympus America, Center Valley, PA) were used 2477 times over a 14-month study period. Prospective data were accumulated on each cystoscope including type of procedure, number of uses until mechanical failure, physician usage, and maintenance costs. All staff was trained in proper handling and maintenance of cystoscopes utilizing an Occupational Safety and Health Administration (OSHA) approved protocol. Retrospective comparison was performed of 1346 cystoscopic procedures during the previous 8 months before implementation of the processing protocol, with data including type and quantity of mechanical failures along with maintenance costs. RESULTS: Five total study period failures occurred in 4 cystoscopes, with a mean of 495.4 procedures/failure. In 3 separate cystoscopes, failure occurred after 70 (perforation of working channel), 194 (leak in bending rubber), and 236 uses (hole in bending rubber). One cystoscope had 2 failures after 168 (cut in bending rubber) and 255 uses (failed leak test). During the retrospective period, there were 10 failures, with a mean of 134.6 procedures/failure. Four failures were secondary to crushed insertion tubes. Comparison of retrospective and study period costs revealed a 43.9% decrease from $9.64 per procedure to $5.41 per procedure. CONCLUSION: Outpatient flexible cystoscope durability seems directly related to optimization of handling and storage of cystoscopes. Costs related to mechanical failure were reduced with a rigorous reprocessing protocol.

Androgen deficiency in older men: indications, advantages, and pitfalls of testosterone replacement therapy.

The decline in testosterone with age has been associated with specific physical changes that affect quality of life and life expectancy, although a cause-and-effect relationship is yet to be established. While female menopause is rapid and well described, "male menopause" or androgen decline in older men is gradual and marked by nonspecific symptoms. This makes diagnosis of true testosterone deficiency and prediction of response to testosterone replacement therapy (TRT) challenging. This article reviews androgen decline in men, focusing on those over age 40, and covers symptoms, indications, contraindications,diagnosis, treatments, and the risks and benefits of treatment [corrected].

Flow cytometry rapidly identifies all acute promyelocytic leukemias with high specificity independent of underlying cytogenetic abnormalities.

Acute promyelocytic leukemia (APL) is a highly aggressive disease requiring prompt diagnosis and specific early intervention. Immunophenotyping by flow cytometry (FCM) facilitates a rapid diagnosis, but commonly used criteria are neither sufficiently sensitive nor specific. With an antibody panel for diagnostic screening in routine practice, we found all 149 APL cases in this study exhibited a unique immunophenotypic profile, ie, a characteristic CD11b- myeloid population and absent CD11c expression in all myeloid populations; 96.6% of cases also lacked HLA-DR expression. These distinctive features allowed recognition of all unusual cases phenotypically resembling the regular myeloblasts (CD34+/HLA-DR+) or granulocytes (CD117-/CD34-/HLA-DR-). FCM effectively identified all 19 APL cases with variant translocations, including cases with a normal karyotype due to a cryptic submicroscopic t(15;17)(q22;q21), t(11;17)(q23;q21) that escaped the detection by fluorescence in situ hybridization for t(15;17) and der(15)ider(17)(q10) that lacked a simple reciprocal t(15;17). When APL-associated profiles were validated against 107 AML cases of non-APL subtypes, including 51 HLA-DR- cases, the diagnostic specificity and positive predictive value were 98%. FCM effectively provides independent detection of APL during diagnostic workup and harmonizes with the subsequent molecular cytogenetic diagnosis.

Physiological responses and air consumption during simulated firefighting tasks in a subway system.

Professional firefighters (33 men, 3 women), ranging in age from 30 to 53 years, participated in a simulation of a subway system search and rescue while breathing from their self-contained breathing apparatus (SCBA). We tested the hypothesis that during this task, established by expert firefighters to be of moderate intensity, the rate of air consumption would exceed the capacity of a nominal 30-min cylinder. Oxygen uptake, carbon dioxide output, and air consumption were measured with a portable breath-by-breath gas exchange analysis system, which was fully integrated with the expired port of the SCBA. The task involved descending a flight of stairs, walking, performing a search and rescue, retreat walking, then ascending a single flight of stairs to a safe exit. This scenario required between 9:56 and 13:24 min:s (mean, 12:10 ± 1:10 min:s) to complete, with an average oxygen uptake of 24.3 ± 4.5 mL kg(-1) min(-1) (47 ± 10 % peak oxygen uptake) and heart rate of 76% ± 7% of maximum. The highest energy requirement was during the final single-flight stair climb (30.4 ± 5.4 mL kg(-1) min(-1)). The average respiratory exchange ratio (carbon dioxide output/oxygen uptake) throughout the scenario was 0.95 ± 0.08, indicating a high carbon dioxide output for a relatively moderate average energy requirement. Air consumption from the nominal "30-min" cylinder averaged 51% (range, 26%-68%); however, extrapolation of these rates of consumption suggested that the low-air alarm, signalling that only 25% of the air remains, would have occurred as early as 11 min for an individual with the highest rate of air consumption, and at 16 min for the group average. These data suggest that even the moderate physical demands of walking combined with search and rescue while wearing full protective gear and breathing through the SCBA impose considerable physiological strain on professional firefighters. As well, the rate of air consumption in these tasks classed as moderate, compared with high-rise firefighting, would have depleted the air supply well before the nominal time used to describe the cylinders.

Randomized clinical trial of propofol versus ketamine for procedural sedation in the emergency department.

OBJECTIVES: The objective was to compare the occurrence of respiratory depression, adverse events, and recovery duration of propofol versus ketamine for use in procedural sedation in the emergency department (ED). METHODS: This was a randomized nonblinded prospective clinical trial of adult patients undergoing procedural sedation for painful procedures in the ED. Patients with pain before the procedure were treated with intravenous (IV) morphine sulfate until their pain was adequately treated at least 20 minutes before starting the procedure. Patients were randomized to receive either propofol 1 mg/kg IV followed by 0.5 mg/kg every 3 minutes as needed or ketamine 1.0 mg/kg IV followed by 0.5 mg/kg every 3 minutes as needed. Doses, vital signs, nasal end-tidal CO(2) (ETCO(2)), and pulse oximetry were recorded. Subclinical respiratory depression was defined as a change in ETCO(2) of >10 mm Hg, an oxygen saturation of <92% at any time, or an absent ETCO(2) waveform at any time. Clinical interventions related to respiratory depression were noted during the procedure, including the addition of or increase in the flow rate of supplemental oxygen, the use of a bag-valve mask apparatus, airway repositioning, or stimulation to induce breathing. After the procedure, patients were asked if they experienced pain during the procedure and had recall of the procedure. Physicians were asked to describe any adverse events or the occurrence of recovery agitation. RESULTS: One-hundred patients were enrolled; 97 underwent sedation and were included in the analysis. Fifty patients received propofol and 47 received ketamine. Subclinical respiratory depression was seen in 20 of 50 patients in the propofol group and 30 of 47 patients in the ketamine group (p = 0.019, effect size 22.8%; 95% CI = 4.0% to 43.6%). Clinical interventions related to respiratory depression were used in 26 of 50 propofol patients and 19 of 47 ketamine patients (p = 0.253, effect size = -13.7%; 95% CI = -33.8% to 6.4%). The median times of the procedures were 11 minutes (range = 4 to 33 minutes) for the ketamine group versus 10 minutes (range = 5 to 33 minutes) for the propofol group (p = 0.256). The median time to return to baseline mental status after the procedure was completed was 14 minutes (range = 2 to 47 minutes) for the ketamine group and 5 minutes (range = 1 to 32 minutes) for the propofol group (p < 0.001). Pain during the procedure was reported by 3 of 50 patients in the propofol group and 1 of 47 patients in the ketamine group (effect size = -3.9%, 95% confidence interval [CI] = -11.9 to 4.1). Recall of some part of the procedure was reported by 4 of 50 patients in the propofol group and 6 of 47 patients in the ketamine group (effect size = 4.8%, 95% CI = -7.6% to 17.1%). Forty-eight of 50 procedures were successful in the propofol group and 43 of 47 in the ketamine group (p = 0.357, effect size = 0.3%; 95% CI = -7.8% to 8.4%). Recovery agitation was reported in 4 of 50 in the propofol group and 17 of 47 in the ketamine group (effect size = 28.2%, 95% CI = 12.4% to 43.9%). CONCLUSIONS: This study detected a higher rate of subclinical respiratory depression in patients in the ketamine group than the propofol group. There was no difference in the rate of clinical interventions related to respiratory depression, pain, or recall of the procedure between the groups. Recovery agitation was seen more frequently in patients receiving ketamine than in those receiving propofol. The time to regain baseline mental status was longer in the ketamine group than the propofol group. This study suggests that the use of either ketamine or propofol is safe and effective for procedural sedation in the ED.

Air management and physiological responses during simulated firefighting tasks in a high-rise structure.

Air consumption, oxygen uptake (VO(2)), carbon dioxide output (VCO(2)) and respiratory exchange ratio (RER=VCO(2)/VO(2)) were measured directly from the self-contained breathing apparatus (SCBA) as 36 professional firefighters (three women) completed scenarios of high-rise stair climbing and fifth floor search and rescue. During stair climbing VO(2) was 75+/-8% VO(2max) (mean+/-SD), RER=1.10+/-0.10, and heart rate=91+/-3% maximum (based on maximum treadmill data). Firefighters stopped climbing on consuming 55% of the air cylinder then descended. In the fifth floor search and rescue VO(2) was slightly lower than stair climbing but RER remained elevated (1.13+/-0.12) reflecting high anaerobic metabolism. The first low air alarm sounded, indicating 25% of the air remaining in a "30-min cylinder", during the stair climb at 8 min with 19 of 36 sounding before 12 min. Aggressive air management strategies are required for safety in high-rise firefighting.

The flavonoid apigenin potentiates the growth inhibitory effects of gemcitabine and abrogates gemcitabine resistance in human pancreatic cancer cells.

OBJECTIVES: The aim of the study was to evaluate the effect of combination therapy of apigenin and gemcitabine on cell proliferation, the cell cycle, and gemcitabine resistance in human pancreatic cancer cells. METHODS: Cell counting was used to assess the effect of single-agent and combination treatment on the proliferation of CD18 and AsPC-1 pancreatic cancer cells. Flow cytometry was performed to assess the effect of combination treatment on cell cycle progression and induction of apoptosis. Western blot analysis was used to evaluate phosporylated AKT (pAkt) and cell cycle proteins. The effect of apigenin on gemcitabine-resistant AsPC-1 cells was assessed via thymidine incorporation. RESULTS: Apigenin in combination with gemcitabine inhibited pancreatic cancer cell proliferation more than either agent alone. Combination treatment induced both S and G2/M phase arrest and increased apoptosis. Apigenin down-regulated pAkt expression and abrogated gemcitabine-mediated pAkt induction. In gemcitabine-resistant AsPC-1 cells, apigenin significantly inhibited cell proliferation in a dose-dependent manner. CONCLUSION: Combination treatment with apigenin and gemcitabine inhibited pancreatic cancer cell growth via cell cycle arrest, down-regulation of the prosurvival factor pAkt, and induction of apoptosis. Combination therapy may prove useful for the treatment of pancreatic cancer.

Identification of parental chromosomes involved in translocations BCR-ABL, t(9;22) and PML-RARA, t(15;17).

Cells of blood and bone marrow often exhibit a genome- or ploidywise organization of the two haploid sets, representing apparently maternal and paternal chromosomes in interphase nuclei and in metaphase spreads. This provides the opportunity to perform "genomic karyotyping." Such application of karyotyping may indicate whether two chromosomes involved in a translocation are both maternal, both paternal, or intermingled, i.e., one maternal and the other paternal (we refer to this as mixed). The parental origin for these translocations likely has profound differences and implications in disease expression and response to treatments, making such information very important to personalized medicine. In this mini-review, we present our observations from specimens with translocations BCR-ABL, t(9;22) and PML-RARA, t(15;17). About 20% metaphases of these specimens indicated ploidywise organization and were amenable to genomic karyotyping analysis. Fluorescence in situ hybridization (FISH) probes for BCR-ABL translocation suggest a close approximation of the HSA 9 and 22, as control values for false-positive signals run from approximately 5-10%. Given a ploidywise distribution of the maternal and paternal sets of chromosomes, it would be expected that the chromosomes involved in the translocation t(9;22) would more often belong to one of the two genomes, either maternal or paternal. Contrastingly, HSA 15 and 17 are not considered as spatially close to each other and therefore an intragenomic involvement would be rarer for translocation t(15;17). In 14 out of the 21 (66.6%) specimens with informative metaphases, the chromosomes involved in the translocation BCR-ABL were restricted to one of the two genomes--either maternal or paternal. In cases of translocation PML-RARA only 4 out of 21 (19.1%) specimens indicated an intragenomic involvement. These simple yet informative analyses of cancer-related translocations show profound underlying genomic origins and lend support to genomic karyotyping.