Horner's Syndrome as Initial Manifestation of Possible Brachial Plexopathy Neurolymphomatosis.

Introduction: Horner's syndrome is an established clinical finding unique to neoplastic brachial plexopathy. Background: We present the case of a patient who developed Horner's syndrome as the first manifestation of neurolymphomatosis (NL) of the brachial plexus that did not have the usually associated bulky adenopathy/Pancoast syndrome phenotype. Discussion: We discuss the clinical utility of Horner's syndrome with regards to brachial plexopathy of indeterminate etiology, as well as the utility of other diagnostic modalities in NL. Concluding Remarks: NL, particularly of the brachial plexus, is particularly challenging to diagnose. MRI and CSF studies are often inconclusive. FDG-PET imaging can be difficult to get insurance to approve. The presence of Horner's syndrome in brachial plexopathy of indeterminate etiology, even in the absence of bulky adenopathy, should raise clinical suspicion of NL, possibly prompting such interventions as fascicular nerve biopsy.

Lack of added predictive value of portable chest radiography in diagnosing ventilator-associated pulmonary infection.

INTRODUCTION: The accurate diagnosis of ventilator-associated pulmonary infection (VAPI) poses an ongoing challenge. At our institution, patients in whom VAPI is strongly suspected on the basis of the Clinical Pulmonary Infection Score (CPIS) undergo diagnostic mini-bronchoalveolar lavage (mBAL) with quantitative cultures, followed by empiric antibiotic therapy in our surgical intensive care unit (sICU). We sought to determine the role of portable chest X-radiography (pCXR) in the diagnosis of VAPI. METHODS: We conducted a retrospective analysis of mechanically ventilated adult (>18 y of age) patients with suspected VAPI undergoing concomitant pCXR and diagnostic mBAL in a combined tertiary-care unit for trauma and surgical intensive care. Portable chest X-radiographs were evaluated in a blinded manner by surgical intensivists, critical care fellows, general surgical residents, and radiologists, and were rated as: (0) Not suspicious for pneumonia, (1) possible pneumonia, or (2) likely pneumonia. These results were compared with the microbiologic results of mBAL culture. Demographic and clinical characteristics including age, gender, white blood cell count (WBC), temperature, purulence of secretions, blood and urine culture results, and length of hospitalization were correlated with the results of mBAL. RESULTS: Regardless of interpreter specialty or level of training, pCXR had no predictive value for VAPI. The overall sensitivity and specificity of pCXR were 77% and 74%, respectively, and its positive predictive value, negative predictive value, and receiver-operating characteristic (ROC) curve areas all had values below 50%. The inter-rater agreement (ρ) was 0.965, showing little discrepancy between raters. The degree of purulence on mBAL, concurrent blood stream infection, and increase in the number of days of hospitalization before diagnostic testing were correlated with an increased frequency of VAPI. The three CPIS criteria of febrile response, leukocytosis/leukopenia, and arterial oxygenation correlated poorly with the results of mBAL culture. CONCLUSION: Portable chest X-radiography has no added predictive value in identifying patients who should be evaluated further for VAPI. This supports the elimination of findings on chest X-radiography as defining characteristics of VAP, which accords with the U.S. Centers for Disease Control and Prevention's recent definition of VAP as but one of a number of types of ventilator-associated pulmonary infection (VAPI).

An epidermotropic canine papillomavirus with malignant potential contains an E5 gene and establishes a unique genus.

A novel canine papillomavirus, CfPV-2, was cloned from a footpad lesion of a golden retriever. Unlike the known canine oral papillomavirus (COPV), which has a double-stranded DNA genome size of 8607 bps, the genome of CfPV-2 is 8101 bps. Some of this size difference is due to an abbreviated early-late region (ELR), which is 1200 bps shorter than that of COPV. However, CfPV-2 has other differences from COPV, including the presence of an E5 ORF between the E2 gene and the ELR and an enlarged E4 ORF (one of the largest PV E4 open reading frames). The genome of CfPV-2 shares low homology with all the other papillomaviruses and, even in the most highly conserved ORF of L1, the nucleotide sequence shares only 57% homology with COPV. Due to this highly divergent DNA sequence, CfPV-2 establishes a new PV genus, with its closest phylogenetic relatives being amongst the Xi and Gamma genuses. CfPV-2 also has unique biological features; it induces papillomas on footpads and interdigital regions which, if infection is persistent, can progress to highly metastatic squamous cell carcinoma. CfPV-2 does not induce oral papillomas in immunocompetent animals and antibodies generated against COPV and CfPV-2 are type-specific. The availability of a new canine papillomavirus with differing genetic and biological properties now makes it possible to study type-specific host immune responses, tissue tropism and the comparative analysis of viral gene functions in the dog.

The scientific basis for evaluation and management of thrombotic disorders.

The hemostatic mechanisms at work in the body involve a complex series of interactions between platelets, the endothelium, and the coagulation cascade. Much has been learned regarding the molecular mechanisms governing these intricate processes. The hypercoagulable state involves a disruption of the normal homeostatic equilibrium. This state may be either inherent or acquired. The prevention of associated thromboembolic complications requires therapeutic anticoagulation. A broader understanding of the factors contributing to these prothrombotic tendencies and the subtleties involved in their management provides the surgeon with another weapon in the armamentarium to promote better and safer patient outcomes.

Characterization of HPV16 L1 loop domains in the formation of a type-specific, conformational epitope.

BACKGROUND: Virus-like particles (VLPs) formed by the human papillomavirus (HPV) L1 capsid protein are currently being tested in clinical trials as prophylactic vaccines against genital warts and cervical cancer. The efficacy of these vaccines is critically dependent upon L1 type-specific conformational epitopes. To investigate the molecular determinants of the HPV16 L1 conformational epitope recognized by monoclonal antibody 16A, we utilized a domain-swapping approach to generate a series of L1 proteins composed of a canine oral papillomavirus (COPV) L1 backbone containing different regions of HPV16 L1. RESULTS: Gross domain swaps, which did not alter the ability of L1 to assemble into VLPs, demonstrated that the L1 N-terminus encodes at least a component of the 16A antigenic determinant. Finer epitope mapping, using GST-L1 fusion proteins, mapped the 16A epitope to the L1 variable regions I and possibly II within the N-terminus. CONCLUSIONS: These results suggest that non-contiguous loop regions of L1 display critical components of a type-specific, conformational epitope.