Implications of Clostridium septicum in Vascular Surgery: A Case Report and Outcomes Literature Review.

Clostridium septicum is a rare organism, accounting for approximately 1.3% of clostridial infections and is associated with synchronous colonic malignancy. This case report describes a patient successfully treated for a mycotic aortic aneurysm secondary to C. septicum bacteremia. Subsequent evaluation confirmed a colonic malignancy, prompting early intervention. A systematic literature review revealing a rate of gastrointestinal malignancy in this patient population is 71%, and hematologic malignancy is 3.9%, with the remaining cohort of patients having an unknown source. Infectious involvement of the aorta and associated vascular structures portends a poor prognosis with a 57% mortality rate. Our case and updated review demonstrates the implications of C. septicum vascular seeding and subsequent treatment outcomes.

Performance and Practice Guideline for the Use of Neoadjuvant Systemic Therapy in the Management of Breast Cancer.

PURPOSE: The American Society of Breast Surgeons (ASBrS) sought to provide an evidence-based guideline on the use of neoadjuvant systemic therapy (NST) in the management of clinical stage II and III invasive breast cancer. METHODS: A comprehensive nonsystematic review was performed of selected peer-reviewed literature published since 2000. The Education Committee of the ASBrS convened to develop guideline recommendations. RESULTS: A performance and practice guideline was prepared to outline the baseline assessment and perioperative management of patients with clinical stage II-III breast cancer under consideration for NST. RECOMMENDATIONS: Preoperative or NST is emerging as an important initial strategy for the management of invasive breast cancer. From the surgeon's perspective, the primary goal of NST is to increase the resectability of locally advanced breast cancer, increase the feasibility of breast-conserving surgery and sentinel node biopsy, and decrease surgical morbidity. To ensure optimal patient selection and efficient patient care, the guideline recommends: (1) baseline breast and axillary imaging; (2) minimally invasive biopsies of breast and axillary lesions; (3) determination of tumor biomarkers; (4) systemic staging; (5) care coordination, including referrals to medical oncology, radiation oncology, plastic surgery, social work, and genetic counseling, if indicated; (6) initiation of NST; (7) post-NST breast and axillary imaging; and (8) decision for surgery based on extent of disease at presentation, patient choice, clinical response to NST, and genetic testing results, if performed.

Genomic V exons from whole genome shotgun data in reptiles.

Reptiles and mammals diverged over 300 million years ago, creating two parallel evolutionary lineages amongst terrestrial vertebrates. In reptiles, two main evolutionary lines emerged: one gave rise to Squamata, while the other gave rise to Testudines, Crocodylia, and Aves. In this study, we determined the genomic variable (V) exons from whole genome shotgun sequencing (WGS) data in reptiles corresponding to the three main immunoglobulin (IG) loci and the four main T cell receptor (TR) loci. We show that Squamata lack the TRG and TRD genes, and snakes lack the IGKV genes. In representative species of Testudines and Crocodylia, the seven major IG and TR loci are maintained. As in mammals, genes of the IG loci can be grouped into well-defined IMGT clans through a multi-species phylogenetic analysis. We show that the reptilian IGHV and IGLV genes are distributed amongst the established mammalian clans, while their IGKV genes are found within a single clan, nearly exclusive from the mammalian sequences. The reptilian and mammalian TRAV genes cluster into six common evolutionary clades (since IMGT clans have not been defined for TR). In contrast, the reptilian TRBV genes cluster into three clades, which have few mammalian members. In this locus, the V exon sequences from mammals appear to have undergone different evolutionary diversification processes that occurred outside these shared reptilian clans. These sequences can be obtained in a freely available public repository (http://vgenerepertoire.org).

MammaPrint Feasibility in a Large Tertiary Urban Medical Center: An Initial Experience.

Background. The MammaPrint (MP) diagnostic assay stratifies breast cancer patients into high- and low-risk groups using mRNA analysis of a 70-gene profile. The assay is validated for assessment of patients with estrogen receptor positive or negative tumors less than 5 cm with 3 or fewer malignant lymph nodes. TargetPrint (TP) is an assay for assessing estrogen, progesterone, and HER2-neu receptor status based on mRNA expression. A potential limitation of these assays is that they require an evaluation of fresh tissue samples. There is limited published experience describing MP or TP implementation. Methods. Over 10 months, 4 breast surgeons obtained samples from 54 patients for MP/TP analysis. The samples were analyzed by Agendia Labs. The tumors were independently evaluated for receptor status using immunohistochemistry (IHC). Retrospectively, we identified patients who were assessed by MP/TP during this period. Patients who underwent OncotypeDx evaluation were also identified. Results. Of the 54 patients receiving MP, 4 were found ineligible for MP risk assessment because >3 lymph nodes were found to be malignant. Out of all eligible patients, 14/50 (28%) had samples whose quantity of tumor was not sufficient for analysis (QNS). Out of eligible patients with tumors <1 cm, 7/8 (88%) had QNS samples. 7/42 with tumors ≥1 cm (17%) had QNS samples. Nine patients had discordant receptor results when evaluated by IHC versus. TP. Of patients who also underwent OncotypeDx testing, 6/14 (43%) had discordant results with MP. Conclusions. This study indicates that using MP/TP assay is feasible in a tertiary care center but there may be utility in limiting MP testing to patients with tumors between 1 and 5 cm due to high likelihood of uninformative results in subcentimeter tumors. Further study is needed to explore the discordance between oncotype and MP results.

The immunoglobulin heavy chain locus in the platypus (Ornithorhynchus anatinus).

Immunoglobulins loci in mammals are well known to be organized within a translocon, however their origin remains unresolved. Four of the five classes of immunoglobulins described in humans and rodents (immunoglobulins M, G, E and A-IgM, IgG, IgE and IgA) were found in marsupials and monotremes (immunoglobulin D-IgD was not found) thus showing that the genomic structure of antibodies in mammals has remained constant since its origin. We have recently described the genomic organization of the immunoglobulin heavy chain locus in reptiles (IGHM, IGHD and IGHY). These data and the characterization of the IGH locus in platypus (Ornithorhynchus anatinus), allow us to elucidate the changes that took place in this genomic region during evolution from reptile to mammal. Thus, by using available genome data, we were able to detect that platypus IGH locus contains reptilian and mammalian genes. Besides having an IGHD that is very similar to the one in reptiles and an IGHY, they also present the mammal specific antibody genes IGHG and IGHE, in addition to IGHA. We also detected a pseudogene that originated by recombination between the IGHD and the IGHM (similar to the IGHD2 found in Eublepharis macularius). The analysis of the IGH locus in platypus shows that IGHY was duplicated, firstly by evolving into IGHE and then into IGHG. The IGHA of the platypus has a complex origin, and probably arose by a process of recombination between the IGHM and the IGHY. We detected about 44 VH genes (25 were already described), most of which comprise a single group. When we compared these VH genes with those described in Anolis carolinensis, we find that there is an evolutionary relationship between the VH genes of platypus and the reptilian Group III genes. These results suggest that a fast VH turnover took place in platypus and this gave rise to a family with a high VH gene number and the disappearance of the earlier VH families.

Percutaneous balloon occlusion of the inferior vena cava as an adjunct for treating ruptured type IV thoracoabdominal aneurysm and aortocaval fistula.

Spontaneous aortocaval fistulas are rare and thoracoabdominal aneurysms eroding into the inferior vena cava are rarer still. We describe a patient who presented to our hospital with a fistula between a Type IV thoracoabdominal aneurysm and the inferior vena cava. Expanding endovascular capabilities of vascular surgeons enabled us to insert proximal and distal occluding balloon catheters into the vena cava which greatly minimized blood loss.

Bloqueo intradural (raquianestesia) con morfínicos al término del trabajo del parto / Intradural block (spinal) with morphoids in the second stage of labour

Los autores aportan una raquianestesia con 10 µg de sufentanilo, efectuada al término del trabajo de parto para el expulsivo de un niño en presentación de nalgas y de dos gemelos, en parturientas cuyo estado de agitación hacía sospechar un expulsivo por vía baja hipotético o difícil. El efecto antiálgico se instaló en 5 min y fue posible el parto por vía vaginal. La utilidad de la técnica es discutida en casos de situaciones difíciles al término del trabajo de parto, en el caso de que una analgesia peridural no se hubiera instaurado (AU)

Un caso de meningitis por Staphylococcus aureus después de anestesia epidural obstétrica / A case of meningitis caused by Staphylococcus aureus following obstetric epidural anaesthetic

Las complicaciones infecciosas secundarias a una anestesia epidural obstétrica, absceso epidural, meningitis y espondilitis son raras y excepcionales. Estas enfermedades sobrevienen esencialmente sobre un campo frágil y como consecuencia de una contaminación directa en el lugar de la punción, o bien son debidas a una contaminación indirecta a partir de un foco infeccioso vecino, o de una contaminación indirecta por vía hematógena. Aportamos un caso de meningitis iatrógena por Staphylococcus aureus que sobrevino después de una anestesia epidural, tras una probable brecha o traumatismo en la duramadre (AU)

Miastenia y gestación / Myasthaenia and pregnancy

Presentando un caso personal reciente de miastenia en el curso de la gestación, los autores, después de un recuerdo de la enfermedad, intentan precisar las actitudes preconizadas para una puesta al día de esta patología en el curso del embarazo, ayudados por un repaso exhaustivo de la bibliografía. La gestación de nuestra paciente se ha desarrollado en buenas condiciones, sin agravamiento de su miastenia. De acuerdo con los datos de la bibliografía, la influencia de la gestación sobre la enfermedad es muy variable: un tercio se estabiliza, un tercio mejora y otro se agrava. El período expulsivo es de alto riesgo para la descompensación de la enfermedad, y los esfuerzos durante el mismo deben ser limitados sin, necesariamente, recurrir a la cesárea, salvo indicaciones estrictamente obstétricas. Se aconseja la anestesia epidural, pues disminuye la fatiga y facilita la realización de una extracción instrumental. La lactancia materna está autorizada salvo en caso de afectación grave con una tasa de anticuerpos muy elevada. Solamente se han descrito 5 casos de preeclampsia en pacientes miasténicas. Esta situación es de alto riesgo materno y fetal, precisando vigilancia en una unidad especializada. La afectación fetal puede presentarse de dos formas: una afectación neuromuscular de mal pronóstico, pero rara, o una miastenia neonatal en el 10-20 por ciento de los casos. La miastenia es un proceso autoinmune que afecta principalmente a la mujer joven. El obstetra no está libre, pues, de enfrentarse al problema de un embarazo que sobreviene en una mujer miasténica. El seguimiento de esta asociación rara necesita un buen conocimiento de la enfermedad y una estrecha colaboración entre los diferentes especialistas (AU)