Uterine transplantation: what else needs to be done before it can become a reality?

Uterine transplantation may be a possible treatment option in the future for absolute uterine infertility. We describe three important areas of research that we feel are important in order to move closer to a successful and, crucially, safe transplant in the human setting. With closer collaboration among the various international teams working on this project, the first human uterine transplant should be possible in the next few years.

medpie: an information extraction package for medical message board posts.

SUMMARY: We have developed medpie, a software package for preparing medical message board corpora and extracting patient mentions and statistics for drugs, herbs and adverse effects experienced from them. The package is divided into web-crawling, HTML-cleaning, de-identification and information extraction modules. It also includes a sample controlled vocabulary of drugs, herbs and adverse effect terms. AVAILABILITY: http://www.cis.upenn.edu/~ungar/medpie.zip. DEPENDENCIES: Python 2.6 or 2.7.

Abdominal radical trachelectomy in West London.

OBJECTIVE: Traditionally, the surgical management of invasive cervical carcinoma that has progressed beyond microinvasion has been a radical abdominal hysterectomy. However, this results in the loss of fertility, with significant consequences for the young patient. This report describes abdominal radical trachelectomy (ART) as a potential replacement for radical hysterectomy in patients with stage IA2-IIA cervical cancer who desire a fertility-sparing procedure without decreasing the curative rates. DESIGN: Observational, retrospective study. SETTING: Teaching hospital and regional cancer centre in London, UK. POPULATION: Patients undergoing ART. METHODS: Patients presenting during the period 2000-2009 with cervical cancer stage IA2-IIA were offered a trachelectomy, if they expressed a desire to preserve fertility. The type of trachelectomy (vaginal/abdominal) was chosen based on patient anatomy and neoplastic and magnetic resonance imaging characteristics. Each patient was counselled as to the experimental nature of the procedure. MAIN OUTCOME MEASURES: Survival, recurrence and fertility issues among ART patients. RESULTS: A total of 30 patients underwent ART (open and laparoscopic) between 2001 and 2009. Three patients presented with a recurrence, two of which have died (median follow-up: 24 months). Only three patients required further surgical re-intervention because of operative complications. Ten patients attempted to conceive, resulting in three conceptions (30%) and two live children. CONCLUSIONS: Abdominal radical trachelectomy provides a feasible, cost-effective and safe treatment option for young women who have been diagnosed with early-stage cervical cancer and wish to preserve their fertility.

Femoral artery embolism in patients undergoing a laterally extended parametrectomy (LEP) procedure.

INTRODUCTION: Since 1993 an operative technique without adjuvant therapy (laterally extended parametrectomy, the LEP procedure) has been in use at our institution for the treatment of Stage IIB cervical cancer and for patients with pelvic lymph node metastases in Stages IA-IIA. Iliac/femoral artery embolic occlusion in the cohort of LEP operated patients was studied in an 11 years long period. METHODS: The LEP-Wertheim procedure was used in 320 patients between 1994 and 2005. Embolic occlusion of the iliac and/or femoral arteries was detected in four out of 255 (1.6%) cases. Thrombectomy was done on one blood vessel in three cases, on both the deep and superficial femoral arteries in one case were executed to restore the vessel patency. RESULTS: Three out of four patients following external iliac/femoral artery emboli removal healed up without any arterial occlusion-related symptoms. In one case preventive fasciotomy was needed to treat tumescence of the legs. This patient developed transient peroneal palsy, which necessitated the use of plantar support for one month and physiotherapy for one year for gait rehabilitation. CONCLUSIONS: Embolus occlusion of the iliac/femoral artery during the LEP-Wertheim procedure was observed in 1.6% of cases. This complication has not been reported in the literature before in relation to radical surgery in cervical cancer. Operating teams using LEP operations should be aware of that risk, and should be prepared for treatment.

Preservation of fertility in reproductive-age women with the diagnosis of cancer.

Over the past few decades the number of young, reproductive age cancer survivors has increased as a result of improved and less destructive cancer treatments. Certain types of cancers are predominantly diagnosed among reproductive age women and a small proportion of cancers originating in the reproductive tract are also detected in this age group. Treatment in the past used to be definitive and in most cases led to sterility. In recent years, improved medical treatments and more conservative surgical approaches have been introduced increasing the number of young survivors of cancer treatment. These less invasive treatments seem to be associated with similar survival rates and fertility can be preserved in most cases. This has led to studies evaluating the reproductive options of these women. Conservative surgical techniques, the use of chemotherapeutic agents with a reduced gonadotoxic side-effect profile, and the application of more focused radiation therapy are associated with maintenance of fertility. In addition, assisted reproductive technology (ART) has undergone tremendous improvements and now offers several alternatives to those who wish to maintain fertility before or even after cancer therapy. This review summarizes the fertility sparing medical and surgical as well as ART options that reproductive age women desiring to maintain fertility may utilize if they face cancer therapy.

Identification of potential CSF biomarkers in ALS.

BACKGROUND: The clinical diagnosis of ALS is based entirely on clinical features. Identification of biomarkers for ALS would be important for diagnosis and might also provide clues to pathogenesis. OBJECTIVE: To determine if there is a specific protein profile in the CSF that distinguishes patients with ALS from those with purely motor peripheral neuropathy (PN) and healthy control subjects. METHODS: CSF obtained from patients with ALS, disease controls (patients with other neurologic disorders), and normal controls were analyzed using the surface-enhanced laser desorption/ionization time-of-flight mass spectrometry proteomics technique. Biomarker sensitivity and specificity was calculated with receiver operating characteristic curve methodology. ALS biomarkers were purified and sequence identified by mass spectrometry-directed peptide sequencing. RESULTS: In initial proteomic discovery studies, three protein species (4.8-, 6.7-, and 13.4-kDa) that were significantly lower in concentration in the CSF from patients with ALS (n = 36) than in normal controls (n = 21) were identified. A combination of three protein species (the "three-protein" model) correctly identified patients with ALS with 95% accuracy, 91% sensitivity, and 97% specificity from the controls. Independent validation studies using separate cohorts of ALS (n = 13), healthy control (n = 25), and PN (n = 7) subjects confirmed the ability of the three CSF protein species to separate patients with ALS from other diseases. Protein sequence analysis identified the 13.4-kDa protein species as cystatin C and the 4.8-kDa protein species as a peptic fragment of the neurosecretory protein VGF. CONCLUSION: Additional application of a "three-protein" biomarker model to current diagnostic criteria may provide an objective biomarker pattern to help identify patients with ALS.

Pelvic exenteration without external urinary or fecal diversion in gynecological cancer patients.

In 1993, the authors introduced an orthotopic bladder replacement technique in the treatment of gynecological cancer patients. In this series, they report their long-term experience with orthotopic urinary reconstruction in case of primary- and radiotherapy-treated recurrent gynecological malignancies. Between 1993 and 2003, in 29 patients orthotopic ileocecal ascending colon reservoirs (Budapest pouch) were created. Twenty-one of the 29 patients received radiotherapy prior to their operation. In 12 out of these 29 cases, the fecal stream was reconstructed with the use of low rectal anastomosis. Two patients (6.9%) died in the perioperative period. Orthotopic reconstruction of the lower urinary system was successful in 77% of the cases. Success rate was 68% in the irradiated cohort of patients. All orthotopic bladder replacement patients voided voluntarily at the time of their follow-up, without the need of self-catheterization, and 23.5% of them complained of some degree of daytime incontinence and 47% of nighttime incontinence. Low rectal anastomosis reconstruction of the fecal stream was successful in all but one case. Our present experience demonstrated that anterior and total supralevator pelvic exenteration in patients with gynecological malignancies is feasible with orthotopic reconstruction of the lower urinary tract.

Radical hysterectomy for cervical carcinoma in pregnant women--a case of decidua mimicking metastatic carcinoma in pelvic lymph nodes.

Intraoperative histology is commonly used to guide the treatment of women with carcinoma of the cervix. We present a case where frozen section of the pelvic lymph nodes from a pregnant woman was suggestive of metastatic cervical carcinoma but final histology showed only decidual change.

Selective vessel ligation in the pelvis: an invaluable tool in certain surgical procedures.

While developing the technique of abdominal radical trachelectomy for conservative cervical cancer management, the vascular supply of the uterus was thoroughly examined. The question of how many vessels the uterus requires to ensure its viability arose. Following an abdominal radical trachelectomy for stage IB cervical carcinoma, blood supply of the body of the uterus is successfully maintained by only the two infundibulopelvic vessels (n= 34). Pregnancy has resulted following this technique (n= 2). Selective ligation of the pelvic vasculature has been utilized in the abdominal radical trachelectomy procedure. The objectives of this study were to investigate the vasculature of the infundibulopelvic and broad ligaments, to assess the contribution of the ovarian and uterine vessels to overall uterine perfusion, and to consider the clinical applications of selective pelvic vessel ligation. Ten fresh dissections of the infundibulopelvic vessels, broad ligaments of benign total abdominal hysterectomy, and bilateral salpingo-oophorectomy specimens were performed. Perfusion index (PI) and oxygen saturation (O(2)Sat) measurements using a modified probe were taken at specified intervals at the uterine cornu during ten routine benign abdominal hysterectomies to assess the contribution of the ovarian and uterine vessels to overall uterine perfusion and the concepts studied were utilized in certain gynecological procedures. The ovarian/infundibulopelvic vessels course medially through the broad ligament toward the uterine cornu and consistently give off a branch to the ovary on its lateral border. In addition, further vessels were noted to run laterally from the uterine cornu along the ovarian ligament to the medial aspect of the ovary. PI and O(2)Sat measurements imply that the uterine and ovarian vessels contribute almost equally to uterine perfusion. Clinical application by selective ligation of the pelvic vasculature has been utilized in certain gynecological procedures often prone to torrential life-threatening uterine hemorrhage. Selective temporary ligation of the uterine and ovarian vessels has proven useful in the surgical management of chemoresistant gestational trophoblastic disease, in the Strassman procedure, fertility-sparing surgery in ruptured cornual ectopic pregnancies, and unrelenting postpartum hemorrhage. Of the six supplying vessels (ovarian, uterine, and vaginal) to the uterus only two (ovarian or uterine or a combination thereof) are required for uterine viability.

Laparoscopic abdominal radical trachelectomy.

BACKGROUND: Radical trachelectomy is a fertility preserving alternative for young women with early stages of cervical cancer. Currently, a technique of abdominal radical approach is used in a few centres. With growing availability of laparoscopy, a novel technique of laparoscopic radical trachelectomy might be an alternative. CASE: Presented is one case of laparoscopic pelvic lymphadenectomy with radical trachelectomy in young woman with IB cervical cancer. No intraoperative or postoperative complications occurred. Operation time reached 250 min, estimated blood loss was 250 ml. Limited follow-up of 9 months was uneventful and patient indicates normal menstrual pattern and satisfactory sexual intercourse. CONCLUSION: Laparoscopic abdominal radical trachelectomy with pelvic lymphadenectomy might be an alternative technique in the treatment of early stages cervical cancer in patients who desire future pregnancy. The procedure is in principle identical to the standard abdominal radical hysterectomy. Centres practising laparoscopic radical hysterectomy can adopt the technique without any special surgical training.

[Abdominal radical trachelectomy--technique and experience]. / Abdominailni radikailni trachelektomie--technika a zkusenosti.

OBJECTIVE: Discussion of current experiences with abdominal radical trachelectomy in the treatment of early stages of cervical cancer in fertile women. DESIGN: Case-reports. SETTING: Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Medical Faculty, Charles University, Prague. METHODS: Presentation of 4 cases of abdominal radical trachelectomy and pelvic lymphadenectomy. Discussion with published data. RESULTS: Three cases of open abdominal and one case of laparoscopic abdominal radical trachelectomies together with pelvic lymphadenectomies are presented. All procedures were indicated for cervical cancer stages IA2-IB1. Frozen section of pelvic nodes and a slice of upper margin of cervix revealed no metastasis or infiltration. In total 22-43 pelvic nodes were removed, being negative in all cases. Operative time ranged between 148 and 270 min. in laparotomy and 250 min. in laparoscopy. Blood loss reached 350-3500 ml. There were no intraoperative complications, postoperatively one case of bladder atony was treated by suprapubic drainage for 30 days, one case of ileus was managed pharmacologically. Vaginal suture healed properly in all cases. No complications occurred within limited follow-up of 1-5 months. CONCLUSION: Abdominal radical trachelectomy with pelvic lymphadenectomy is a rational alternative in the treatment of stages IA2-IIA cervical cancer in women of fertile age. Standard radicality in parametria resection and easy incorporation into armamentarium of oncogynecological centers are main advantages of such approach. Laparotomy can be avoided using laparoscopy.

[Initial experience in exenteration interventions in the pelvis]. / První zkusenosti s exenteracními výkony v pánvi.

OBJECTIVE: Discussion of experiences with pelvic exenterations. DESIGN: Case-report. SETTING: Department of Obstetrics and Gynecology, Department of Urology, Department of Surgery, Department of Pathology, Department of Clinical Oncology, General Teaching Hospital and Ist Medical Faculty of the Charles University, Prague, Czech Republic. METHODS: Presentation of 4 cases of pelvic exenterations. Discussion with published data. RESULTS: Altogether four cases of pelvic exenterations are presented, one case of supralevator total exenteration for recurrent cervical cancer, one case of infralevator total exenteration for recurrent vaginal cancer, one case of supralevator anterior exenteration in the treatment of locally advanced cancer of urinary bladder, and one case of supralevator posterior exenteration for recurrent vaginal cancer.

Surgical treatment of lymph node metastases in stage IB cervical cancer: the laterally extended parametrectomy (LEP) procedure.

A surgical method has been introduced for the treatment of early stage cervical cancer patients with pelvic lymph node metastases. The procedure was used without any adjuvant treatment in 31 stage IB cervical cancer patients, where pelvic lymph node metastases were proven by intraoperative histology. Two patients were lost for follow-up. Twenty-nine patients were followed up for 24-105 months (mean 60 months). Twenty-five of 29 patients were alive and disease-free at the end of the study period. Kaplan-Meier 5 years cumulative proportion survival was 85% (SE 7%). Complications in four cases (16%) necessitated a second operation. One patient developed treatment-refractory grade II incontinence. All but the one incontinent patient are alive without significant treatment related symptoms. The results suggest that pelvic lymph node metastases can be cured by surgery alone. The LEP procedure seems to be a treatment alternative to chemoradiotherapy for early stage cervical cancer patients with pelvic lymph node metastases.

Chloroplast transit peptide prediction: a peek inside the black box.

Previous work in predicting protein localization to the chloroplast organelle in plants led to the development of an artificial neural network-based approach capable of remarkable accuracy in its prediction (ChloroP). A common criticism against such neural network models is that it is difficult to interpret the criteria that are used in making predictions. We address this concern with several new prediction methods that base predictions explicitly on the abundance of different amino acid types in the N-terminal region of the protein. Our successful prediction accuracy suggests that ChloroP uses little positional information in its decision-making; an unexpected result given the elaborate ChloroP input scheme. By removing positional information, our simpler methods allow us to identify those amino acids that are useful for successful prediction. The identification of important sequence features, such as amino acid content, is advantageous if one of the goals of localization predictors is to gain an understanding of the biological process of chloroplast localization. Our most accurate predictor combines principal component analysis and logistic regression. Web-based prediction using this method is available online at http://apicoplast.cis.upenn.edu/pclr/.

[A structured course for primary care physicians on breaking bad news].

Physicians are frequently required to break bad news to their patients. Previous research has shown that inconvenience, incompetence, and difficulty in dealing with patients' feelings are the main complaints expressed by physicians after such an encounter. Current educational programs dealing with breaking bad news are usually short, given in lecture format, and are inadequate in addressing essential issues such as knowledge, personal beliefs and attitudes, and previous personal experiences of physicians in such situations. In the past 8 years our Dept. of Family Medicine has implemented a course in breaking bad news that addresses these issues. A senior family practitioner and a medical social worker conduct 14 sessions of discussions and role-playing for small groups of residents and primary care physicians. The program is based on: theory dealing with methods of managing stress and crisis intervention, clarifying personal attitudes, discussions of previous personal encounters of the participants, various modalities of communication, methods of addressing patients' feelings and emotions, and coping with the emotions of the one breaking the bad news. On a 1-5 Likert scale questionnaire the course received an overall score of 4.47 (SD 0.51). Participants noted that they gained relevant communication skills for future patient encounters. A reliable examination of practitioners' competence in breaking bad news is mandatory in order to assess the efficiency of such courses.

[Successful outcome of an intrauterine twin pregnancy combined with ectopic pregnancy]. / Méhen kívüli terhességgel szövödött, sikeresen kiviselt méhen belüli ikerterhesség esete.

Authors present a case of twin intrauterine pregnancy combined with ectopic pregnancy. The simultaneous pregnancies occurred after the use of clomiphene citrate. In this case viable intrauterine twin gestation was observed by vaginal ultrasound examination, the simultaneous ectopic pregnancy was observed by laparotomy. Right salpingectomy was performed. The intrauterine twin pregnancy continued normally to the 35th week of pregnancy, finished with normal vaginal delivery. The healthy twin boys weighed 2650 g and 2070 g left the hospital in a good general condition on the 5th past delivery day. Authors discuss the etiology, the mode of diagnosis and the therapy of this rare condition.

Treating morbid obesity with laparoscopically placed, adjustable gastric band.

The authors present their first experiences on the laparoscopically placed, adjustable gastric band treatment of morbid obesity. Treating of the morbid obesity in a surgical way, this particular method is widely accepted as the less invasive and most modern procedure, with the benefit of adjustability of the gastric band. During the spring of 1999, 4 patients were treated with the method described above, 3 male and 1 female, the average BMI was 47.5 kg/m2. The mean operating time was 150 minutes (90-270), the patients left hospital the third day after the operations. We noticed no early complications, except for 1 band being displaced, it was replaced immediately by laparoscopic technique. The method, widely used all over the world is opening new aspects on treating morbid obese patients in our country, if properly indicated and operated, giving long lasting effective results.