To correlate the persistence of new or worsening induced wall motion abnormalities in dobutamine stress magnetic resonance imaging (DSMR) and the extent of coronary artery disease (CAD) in invasive coronary angiography.DSMR is a highly sensitive and specific non-invasive method for detecting induced wall motion abnormalities (IWMAs) in patients with significant CAD. Yet little is known about the duration of IWMA during the recovery period. We hypothesize that the persistence of IWMAs during recovery may be associated with the extent of CAD.DSMR was performed in twenty-eight consecutive patients with suspected or known CAD scheduled for clinically indicated invasive coronary angiography. Each patient underwent routine DSMR including cine imaging at rest and during dobutamine infusion. Additionally, three standard short axis and longitudinal axis views were obtained after five, ten and fifteen minutes during the recovery period in order to detect persisting wall motion abnormalities in ischemic myocardial territories, which were assigned to coronary arteries based on the 17 segment model. Intermediate and severe coronary stenosis were defined as 50-75% and >75% luminal narrowing using invasive coronary angiography, respectively  and at five  and ten minutes  during recovery phase.Patients with intermediate and those with severe stenoses demonstrated no significant difference in the rate pressure product at maximum stress level , during recovery after five minutes (p=0.38) and ten minutes (p=0.16).We demonstrated that normalization of left ventricular IWMAs is related to the extent of CAD. Cine imaging during the recovery phase may be helpful for additional risk stratification.


We describe our experience in detecting and containing the first documented CRKP outbreak in Saudi Arabia (SA).A prospective investigation of all cases identified with carbapenem resistance during the outbreak peroid and six months prior.During March 2010, a cluster of 6 patients with CRKP was detected. Patients with CRKP were placed under strict contact isolation. Admission and periodic active surveillance cultures showed a downward trend of CRKP clinical cases over the following months to zeros in July and August. All patients had prolonged hospital stay before CRKP detection and the majority had recent history of carbapenem use (75%), colonization/infection with other MDROs (75%), surgical procedures (80%), indwelling devices (83%), and mechanical ventilation (75%). About 33% of patients with CRKP had clinical infection and 58% died during the current hospitalization. PFGE results identified a dominant clone during the outbreak, Figure 1.Infection control practices are not enough to eliminate the emergence of resistant pathogens. More active interventional methods including an antimicrobial stewardship program would be essential to combat the emergence of multidrug resistant organisms.None declared.


The HIV vaccine regimen showing partial efficacy in the RV 144 study included a canarypox-vectored vaccine (ALVAC). The ongoing HIV vaccine efficacy trial, HVTN 505, involves two gene-based vaccines developed by VRC/NIAID/NIH: plasmid DNA and adenoviral-vectored vaccines. The “NIH Guidelines for Research Involving Recombinant DNA Molecules,” established in 1976, have evolved over time. Current NIH policy is that every clinical trial of rDNA vaccines must have IBC reviews. The primary role of the IBC is to assess risk to public health and the environment.The NIAID Barriers to Clinical Research project identified repetitive IBC review of gene-based vaccines as a barrier. For example, in the last 10 years >100 local IBC reviews have been conducted for the VRC HIV vaccines. IBC reviews for ALVAC vaccines remain a requirement for NIH funding despite completion of a Phase III clinical trial, >20 years of human experience with ALVAC vaccines and widespread community-based use of USDA-approved canarypox-vectored veterinary vaccines, which have not indicated a risk to public health or the environment.The NIAID policy change proposal has been considered by a Recombinant DNA Advisory Committee (RAC) working group. Policy change options were discussed at the September 2011, December 2011 and March 2012 RAC meetings. The RAC proposal will be published in the Federal Register for public comments.Repetitive IBC reviews of rDNA vaccine clinical trials divert time and attention of IBC expertise from truly novel agents and incur a cost to NIH with no added safety benefit. NIAID proposes that IBC review is no longer needed for clinical trials of non-transmissible rDNA vaccines because there are no unique biosafety concerns for this class of vaccines based on their recombinant DNA nature. The IBC specific roles are not applicable for rDNA vaccine protocols and are fulfilled through other regulatory oversight including the FDA.


Aspergillus nidulans. Fluorescence analysis of haploid and diploid strains expressing KapB::GFP and/or KapA::mRFP showed patches of both karyopherins concurrently translocating long distances in apically-growing cells. Anterograde and retrograde movements allowed those patches to reach cell tips and distal regions with an average speed in the range of μm/s. This bidirectional traffic required microtubules as well as kinesin and dynein motors, since it is blocked by benomyl and also by the inactivation of the dynein/dynactin complex through nudA1 or nudK317 mutations. Deletion of Kinesin-3 motor UncA, required for the transport through detyrosinated microtubules, strongly inhibited KapA and KapB movement along hyphae. Overall, this is the first report describing the bidirectional dynamics of the main nuclear import system in coenocytic fungi. A functional link is proposed between two key cellular machines of the filamentous fungal cell: nuclear transport and the tip-growth apparatus.Karyopherins are transporters involved in the bidirectional, selective and active transport of macromolecules through nuclear pores. Importin-β1 is the paradigm of karyopherins and, together with its cargo-adapter importin-α, mediates the general nuclear import pathway. Here we show the existence of different cellular pools of both importin-α and -β1 homologues, KapA and KapB, in the coenocytic ascomycete  Cells develop polarity to orient their activities in a variety of different ways . For exaNeurospora crassa and Aspergillus nidulans 82]. Video S1KapB::GFP movement through the cytoplasm of vegetative hyphae . Videos were constructed using MetaMorph® and/or ImageJ software . Time scale is indicated in sec. Note the movement of KapB::GFP patches through the cytoplasm to the tip and distal regions. Patches crossed SPBs and cytoplasmic MTOCs.(AVI)Click here for additional data file.Video S2KapA::mRFP movement through the cytoplasm of vegetative hyphae . Video displays 7 fs and time scale is in sec. KapA::mRFP moves to the tip and distal regions in patches.(AVI)Click here for additional data file.Video S3Movement of KapB::GFP and KapA::mRFP patches through the cytoplasm of diploid vegetative hyphae . Both fusions move simultaneously. KapB::GFP and KapA::mRFP analysis was done using a dual-channel acquisition device . The video combines three streams: green/GFP (up) and red/mRFP (middle) channels with a third merged video in magenta (bottom). Video displays 5 fs and time is indicated in sec.(AVI)Click here for additional data file.Video S4Comparison of KapB::GFP with RabA(Rab5)::mRFP labeled early endosomes . Video displays 7 fs and time is indicated in sec. The upper video shows the green channel (KapB::GFP) and the middle video the red channel (RabA::mCh). The lower is the merged video in magenta.(AVI)Click here for additional data file.Video S5uncA hyphae Click here for additional data file.Video S6uncA hyphae Click here for additional data file.


Free-floating left atrial ball thrombus is a rare condition. We report a giant left atrial ball thrombus which was removed under surgery uneventfully, in a 48-year-old male patient with the presence of sinus rhythm and no valvular disease with previous off-pump coronary artery bypass surgery. A left atrial free floating ball thrombus is a relatively rare event, especially without a mitral valve disease [2]. Although rare, it is important because of its potentially fatal effects. The thrombus can produce sudden circulatory arrest by obstructing the mitral orifice or can cause severe cerebral or peripheral embolic events [3]. The following report describes the very unusual case of a patient who underwent an off-pump coronary artery bypass (OPCAB) surgery with a large free-floating left-atrial thrombus. Free-floating left atrial ball thrombus is an extremely rare and serious disorder that usually occurs in the setting of a large, dilated left atrium with stagnant flow, commonly the result of severe rheumatic mitral stenosis and accompanying atrial fibrillation . As LV dysfunction is usually associated with an abnormal mitral flow pattern and reduced filling in the left atrial appendix (LAA), the patient is at risk of stasis of blood in the LAA [11]. Our patient had moderate LV dysfunction which might have predisposed LA thrombus formation.  Significant LV systolic and/or diastolic dysfunction predispose to LA thrombus formation via their secondary effect on LA hemodynamic [ In conclusion, we report a giant left atrial ball thrombus which was removed under surgery, uneventfully, in a patient with the presence of sinus rhythm and no valvular disease with previous CABG.


From December 2009 to July 2010 there were 47 cases of anthrax amongst injecting drug users in Scotland with 13 fatalities. The majority presented as severe soft tissue infection following i.v. injection or muscle popping as described by Ringertz and colleagues [Patients admitted to the ICU with NF or injectional anthrax from 1 January 2008 to 30 June 2011 were identified. The white blood count (WBC) and C-reactive protein (CRP) at presentation were recorded. Demographic data  were retrieved. All data were collected prospectively for routine ICU management.There were six patients with injectional anthrax and 16 with NF. The results are presented in Table Anthrax releases three factors: lethal factor (LF), edema factor (EF) and protective antigen (PA). PA and LF form lethal toxin which kills macrophages and inhibits B-cell and T-cell function so minimising the immune response to anthrax. This is reflected in the inappropriately low CRP levels at presentation. Severe soft tissue infection in an injecting drug user associated with subjectively poor inflammatory response should raise the possibility of anthrax infection.


Adjuvant imatinib improves recurrence-free survival of patients following resection of primary KIT-positive gastrointestinal stromal tumors. However, it is unknown whether patients who previously received adjuvant imatinib therapy will respond to imatinib rechallenge as treatment for recurrent disease. Here we present the first report documenting the benefits of imatinib rechallenge in a patient previously exposed to imatinib during adjuvant treatment.A 51-year-old Asian woman with a wedge-resected primary gastric gastrointestinal stromal tumor at high risk of relapse underwent two years of adjuvant treatment with imatinib. Only 10 months after the completion of adjuvant imatinib treatment, a computed tomography scan revealed gastrointestinal stromal tumor recurrence in this patient, with multiple peritoneal nodules in the upper abdomen being detected. Our patient was rechallenged with imatinib 400 mg/day and had a partial response after one month of treatment. Imatinib rechallenge was well tolerated by our patient; the only adverse events she experienced were grade 1 edema, anemia and fatigue. Our patient maintained a partial response two years and six months after the imatinib rechallenge. However, computed tomography scans three months later showed that our patient had disease progression.This case report demonstrates that a patient with a gastrointestinal stromal tumor who had previously received adjuvant imatinib therapy responded to imatinib rechallenge as treatment for her recurrent disease. These results indicate that imatinib sensitivity can be maintained in a patient with previous exposure to adjuvant imatinib therapy. Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract. These tumors are characterized by activating mutations of either receptor tyrosine kinase KIT or, less commonly, platelet-derived growth factor receptor α (PDGFRα) . ImatiniKIT exon 11 mutations who are at high risk of relapse following surgical resection of the primary GIST [A recent Korean, single-arm, Phase II study evaluated the efficacy of two years of adjuvant imatinib treatment in GIST patients with ary GIST . The stuary GIST . These rary GIST , it remaKIT exon 11 deletions, a genotype shown to be associated with adverse outcomes after surgery [KIT exon 11-mutant GIST at high risk of relapse [A 51-year-old Asian woman diagnosed with a primary gastric GIST underwent wedge resection, achieving complete removal of the entire tumor with microscopic examination of the margins showing no tumor cells (R0 margins). She was considered at high risk for recurrence based on the tumor size (8 cm × 7 cm × 3 cm) and high mitotic rate (>50 mitoses per 50 high powered fields (HPF)) of the excised GIST ,10. In a relapse . Our patTen months after stopping adjuvant imatinib treatment, recurrence was detected in this patient, as computed tomography (CT) scans revealed three gross peritoneal nodules in her upper abdomen Figure  and 1B. The results of this case report demonstrate that a GIST patient who has undergone adjuvant imatinib therapy responded when rechallenged with imatinib as a treatment for her recurrent disease. These results suggest that sensitivity to imatinib was not compromised by prior exposure to adjuvant imatinib.KIT exon 11 mutations at high risk of recurrence  [KIT mutations, along with a high mitotic rate and larger tumor size, was an independent risk factor for poor prognosis in patients with localized GIST [KIT exon 11 mutations appeared to be more sensitive to imatinib treatment than GIST of other genotypes in the metastatic setting [KIT exon 11 mutations at high risk of recurrence would be most likely to benefit from adjuvant treatment with imatinib. The fact that some patients, including our patient described in this case report, developed disease recurrence after stopping adjuvant therapy suggests that two years of adjuvant imatinib treatment may not be sufficient for eradicating residual GIST tumor cells and preventing relapse in these high-risk patients. Our patient's residual tumor cells remained sensitive to imatinib therapy, as evidenced by her good response to subsequent imatinib rechallenge. However, it appears that the sensitive residual tumor cells need to be continuously suppressed with adjuvant imatinib therapy to prevent or further delay disease recurrence. The question of how long patients should be treated with adjuvant imatinib remains. The Phase III study conducted by the Scandinavian Sarcoma Group (SSG) and the Sarcoma Group of the Arbeitsgemeinschaft Internistische Onkologie  recently demonstrated that three years of adjuvant imatinib treatment, compared with one year of imatinib treatment, significantly improves RFS and OS in GIST patients who have a high estimated risk of recurrence after surgery [The Korean adjuvant Phase II study referred to in this case report enrolled patients with resected primary GIST possessing  ≥10 cm) ,10. Our  setting , patient surgery . This su surgery .Our patient in this case report remained progression-free for two years and nine months, which is shorter than the median progression-free survival (PFS) of approximately four years achieved in a Korean Phase II study of patients with advanced GIST , but lonRechallenge with imatinib may provide substantial clinical benefit to patients with recurrent GIST after cessation of adjuvant imatinib therapy.Written informed consent was obtained from our patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.YKK is a consultant for Novartis, and has received research funding and honoraria from Novartis for lectures.


Radio-frequency catheter ablation (RFCA) in children is difficult because the size of heart chamber change with age and the catheter made for adults is not appropriate for a child. Three-dimensional (3D) images for electroanatomic mapping (EAM) have been used to create from images of multi-detector computed tomography (MDCT) which need to perform entailed by contrast medium injection and radiation exposure. This study sought to evaluate the usability of 3D Cardiac Magnetic Resonance Image (CMR) in pediatrics cases.Between June 2009 and May 2012, 164 young patients  underwent RFCA. 84 patients underwent CMR prior to RFCA without beta blocker and nitroglycerin. CMR was performed by using 1.5-T magnet MR systems  with 5-element cardiac coils. EAM was created by the Carto XP system. CMR results were visually inspected by at least two experienced angiographers whether the image quality of 3D CMR is sufficient for EAM. We also make a comparison of radiation exposure time between with and without 3D CMR images.In spite of dull images because of sinus tachycardia, all CMR images were sufficient for EAM. Radiation exposure time with EAM from CMR was significant shorter than without CMR .CMR image integration into EAM system was successfully performed in pediatrics patients undergoing RFCA. Procedure of CMR didn't require any medication, contrast medium or radiation exposure. In pediatrics cases, almost all cases are considered an indication for CMR imaging for EAM.None.


Evaluate Internal Flow Fraction (IFF) in Tetralogy of Fallot (TOF) patients before Pulmonary Valve Replacement (PVR) to examine the progression of left ventricular dyssynchrony.Standard of care for TOF patients is a complete surgical repair in infancy but this results in free pulmonary regurgitation as no suitable long-term substitute for the obstructive valve is available. Although chronic pulmonary regurgitation can be well tolerated for decades, many patients (>20%) eventually develop right ventricular dysfunction and often require PVR. Determining the optimal timing of PVR is difficult, and there is no clear consensus within the medical community.In TOF patients before PVR, clinical studies have demonstrated a correlation between QRS duration and RV size with negative electromechanical interaction and dyssynchrony that progresses with RV enlargement. IFF is a quantitative measure of the energy loss throughout the cardiac cycle due to dyssynchronous contraction. We have developed a means of quantifying IFF non-invasively from cardiac magnetic resonance (CMR) images. In this study, we hypothesized that IFF within the left ventricle would increase in serial CMR exams prior to PVR.We retrospectively analyzed two serial CMR studies in 24 pediatric patients with TOF and complete surgical repair before PVR. The average age at the first CMR was 10.8 +/- 5 years and the average age at the second CMR was 14.1 +/- 5.4 years. Images were obtained with 1.5T MRI systems; cine SSFP sequences were acquired in short axis with no gap and covered the entire left ventricle. Global left ventricular IFF was evaluated using an in-house developed MATLAB program.Global left ventricular IFF was significantly increased between the two CMR exams , Figure Left ventricular IFF increased over time in pediatric TOF patients with complete surgical repair. The increased IFF indicated more dyssynchronous contraction developed over time before PVR. The IFF could be a new marker for PVR timing in TOF patients and warrants further investigation.


Percutaneous transthoracic left ventricular (LV) access and closure would be an enabling technology for a wide range of structural heart, electrophysiologic and proximal aorta procedures. We propose a real-time MRI guided approach to access and close the LV using novel active devices.Sixteen Yorkshire swine underwent percutaneous transthoracic LV access and followed up to three months (n=8).All procedures were guided by real-time bSSFP MRI  using two slices along the needle trajectory and a short-axis slice for cardiac monitoring.Transthoracic ventricular puncture was performed using a customized 18G active needle with integrated loop coil. Puncture trajectory was planned using real-time MRI to identify optimal LV puncture target and trajectory with respect to intraventricular and valvular structures Figure . After nVentricular puncture hole was closed using a modified Amplatzer muscular VSD occluder with a titanium screw to improve MR appearance. A custom active delivery cable incorporating a loopless antenna was used to enhance the visibility of the device deployment.Occluder device was deployed by opening the distal disk at the endocardial surface Figure , separatReal time MRI guidance enabled access to the LV without injuring intraventricular structures in 15/16 animals. In one animal the sheath injured the inter-ventricular septum.Real-time MRI guided LV closure was achieved using the occluder device. Three types of failure modes of VSD occluder device mediated closure were observed during follow up. (1) Device was pulled out of the LV wall and resulted in fatality . (2) Pericardial entrapment by the proximal disc of the device resulted in continuous bleed and mortality . (3) In one animal the puncture was apical and despite appropriate delivery, the device could not effectively occlude the puncture hole.During follow-up (n=9), small pericardial effusion was aspirated on days 3-6 (196±127 ml). LV function was preserved and histology analysis indicated complete healing process around the device with no distant myocardial effects.Percutaneous transthoracic LV access and closure is a feasible approach using real time MRI and active devices. Transient “permissive pericardial tamponade” is important for effective deployment of the closure device.


Populus spp.) is considered a model tree species for genomics research and also a good system in forest pathology [Melampsora poplar rust. We pursued various approaches to identify poplar genes involved in the interaction with the biotrophic Melampsora rust pathogen.With their long life cycle, trees must have accurate mechanisms to perceive microbial invasion and elaborate signalling networks in order to activate the appropriate defense response through transcriptional reprogramming. Transcriptional activators and repressors participate in the tight regulation of the stress response, which is key to minimise the fitness costs associated with an activated response. With the availability of its whole genome sequence, ease of growth and clonal propagation, and routine transformation, poplar  are associated with poplar disease resistance against Melampsora rust [PtiZFP1, which belongs to the C2H2 ZFP family of transcriptional EAR repressors.The JAZ family of transcriptional repressors were recently identified as key negative regulators of jasmonate (JA) responses.Transcript analyses show that some ZFP and JAZ members exhibit hormone-related expression profiles and up-regulation by rust infection. This up-regulation of JAZ and ZFP transcripts after rust infection strongly suggests that a hormonal response including JA is a key component of the poplar defence response against Melampsora. Late and sustained kinetics of PtiZFP1 and specificJAZ up-regulation suggest that the corresponding proteins may be required for late regulation of defense mechanisms.Recent transcriptome analyses from our lab have shown that the expression of genes encoding several transcription factors are up-regulated during infection by ora rust . New datPtiZFP1 through the 26S proteasome.Our work suggests that PtiZFP1 and JAZs are part of Melampsora specific hormone-related responses, and by correlation as putative transcriptional repressors, participate in the regulation of the transcriptional responses downstream of these stress hormones.We hypothesize that the observed gene induction play a negative feedback loop needed to replace PtiZFP1 and JAZ proteins that were degraded following through the 26S proteasome. Newly synthesized repressor proteins could contribute to defense attenuation and therefore prevent a runaway response.Several recent data have shownthat proteolytic cleavage of transcriptional repressors is a general mechanism used by plants to activate gene induction. This mechanism is now well documented for jasmonate signaling, which depends on proteasome-mediated degradation of the JAZ repressors ,4. In thMelampsora. The activation of poplar MAPKs would lead toPtiZFP1 degradation and as a result to transcriptional activation of defense-related genes. In parallel we also observed that several genes involved in the JA response (including JAZ) are induced following Melampsora infection. This model highlights the importance of the 26S proteasome in regulating protein pools of transcriptional repressor. For future studies we intend to uncover which cis elements and target genes are recognized by PtiZFP1 and perform functional approaches to uncover JAZ interacting proteins in poplar.Based on our data, we propose a model Figure  where twPtiZFP1 inhibit the expression of stress-related genes. Following stress perception, a MAPK signaling cascade is activated leading to phosphorylation of PtiZFP1. Phosphorylation targets PtiZFP1 for degradation via the 26S proteasome (P26S), thus relieving repression of defense genes. Defense signaling in turn activates PtiZFP1 gene transcription in order to replenish normal PtiZFP1 protein levels and complete a regulatory cycle necessary to attenuate the defense response. A similar regulatory cycle exists for jasmonic acid (JA) signaling. JA biosynthesis is induced by stress which then promotes proteasome-mediated degradation of JAZ proteins. These indirect transcriptional repressors sequester the bHLH MYC2, thus inhibiting expression of defense genes under non-stressed conditions. Upon release, MYC2 ensures both positive and negative feedback loops by activating LOX3 and JAZ genes respectively. Confirmed and hypothetical pathways are presented in bold and dashed lines respectively.During normal conditions, direct transcriptional repressors such as


Antiviral treatment is associated with reduced mortality, length of stay and improved clinical outcomes among patients hospitalized with influenza.We wished to assess trends in use of antiviral treatment of adults hospitalized with influenza before , during and after the 2009 influenza pandemicCNISP has carried out prospective surveillance for laboratory confirmed influenza in hospitalized adults since 2006. These data were reviewed to assess antiviral use.>65 years. A decrease in antiviral use among inpatients >65 years was not observed until the 2011-2012 season. A median of 3 days between symptom onset and antiviral treatment was reported for all three influenza seasons. Among high-risk groups, adults with underlying medical conditions were significantly more likely to receive antiviral treatment during the pandemic than during the post-pandemic seasons . A higher proportion of adults admitted to the ICU during the 2009 pandemic (94.2%) received antiviral treatment compared with the 2010-11 and 2011-12 seasons . There was no difference in antiviral treatment among inpatients who died within 30 days of admission during the pandemic (84.3%) than during the post-pandemic seasons .A higher proportion of adults hospitalized with laboratory-confirmed influenza received antiviral treatment during the 2009 influenza pandemic  compared with the 2010-2011  and 2011-12  influenza seasons. The decrease in antiviral us . e between the 2009 pandemic season and the 2010-11 season was statistically significant in all age groups except for inpatients Antiviral treatment of adults hospitalized with laboratory-confirmed influenza significantly fell in the two seasons following the 2009 influenza pandemic. In order to guide strategies aimed at minimizing the impact of influenza among hospitalized adults, reasons for the decline in antiviral treatment need to be further explored.None declared


Epigenetic mechanisms including DNA methylation are supposed to play a key role in fetal development. Here we have investigated fetal DNA-methylation levels of 27,578 CpG loci in 47 chorionic villi (CVS) and 16 amniotic cell (AC) samples. Methylation levels differed significantly between karyotypically normal AC and CVS for 2,014 genes. AC showed more extreme DNA-methylation levels of these genes than CVS and the differentially methylated genes are significantly enriched for processes characteristic for the different cell types sampled. Furthermore, we identified 404 genes differentially methylated in CVS with trisomy 21. These genes were significantly enriched for high CG dinucleotid (CpG) content and developmental processes associated with Down syndrome. Our study points to major tissue-specific differences of fetal DNA-methylation and gives rise to the hypothesis that part of the Down syndrome phenotype is epigenetically programmed in the first trimester of pregnancy. The epigenetic composition of the fetus has gained much attention in the recent past. In particular, the patterns of DNA methylation and their changes during normal and pathologic fetal development are subject of studies in various fields of research. These include reproduction failure, effects of assisted reproduction, disturbances of the maternal-fetal interface, disorders of development, syndromes caused by errors in imprinting, fetal programming of behavior or disease or the impact of maternal factors on fetal development Compared to its sequence the methylation of DNA shows a much higher plasticity both intra- and interindividually. DNA methylation patterns differ between tissues and epigenetic modifications are supposed to be major determinants of the cell type-specific gene expression program and, thus, to imprint the cellular protein expression, function and destiny This figure - besides through the effect of modifier genes - could well be explained by a secondary epigenetic mark influencing cardiac development established or erased directly or indirectly through the effect of a gene on chromosome 21.DNA methylation patterns can also be of relevance for diagnostics. In this regard, a series of locus-specific and genome-wide DNA methylation profiling studies has been performed in the recent past in order to detect methylation patterns differentiating fetuses with chromosomal aberrations from those with normal karyotypes. This led to the development of novel approaches for noninvasive prenatal diagnosis of e.g. trisomy 21 by analysis of fetal-specific DNA methylation in maternal blood It is remarkable, that description of fetal trisomic and non-trisomic fetal DNA methylation patterns, respectively, has so far been almost exclusively based on the analysis of a limited number of placental DNA both from first and third trimester pregnancies In order to characterize and compare DNA methylation patterns between amniotic and chorionic tissue samples we performed an array-based methylation profiling study in an extensive series of 63 fetal tissues derived from routine prenatal AC and CVS sampling. Through analysis of CVS samples from fetuses with trisomy 21 we unravel potential novel markers for non-invasive prenatal testing. Finally, by describing the molecular features shared by the genes differentially methylated between the different tissues as well as the CVS samples with and without trisomy 21 we provide initial insights into the biological processes underlying epigenetic patterns in normal fetal differentiation and development as well as potentially in the manifestation of the typical phenotype of Down syndrome.The study was performed on 63 samples from 61 different women left over from routine prenatal cytogenetic testing. This included 47 chorionic villi samples (CVS) and 16 samples derived from amniocentesis (AC). CVS and AC sampling was performed with written informed consent of the patients according to standard methods. The main indications for invasive prenatal testing were advanced maternal age as well as abnormal ultrasound findings such as elevated nuchal translucency (NT) or abnormal first trimester screening. Clinical details on the pregnancies as well as pregnancy outcome are summarized in DNA was extracted from native CVS tissue left over after setting up direct preparations and long-term cultures for cytogenetic analyses as well as from long-term cultured AC cells. Samples were cryopreserved until DNA extraction. DNA extraction was performed centrally by a single person to widely exclude batch effects applying the High Pure PCR Template Preparation Kit .DNA methylation analysis using the HumanMethylation27k BeadChip  was performed using a custom service provided by AROS Applied Biotechnology AS . The HumanMethylation27 BeadChip was developed to assay 27,578 CpG sites selected from more than 14,000 genes in parallel simple scaling normalization) were done using the lumi package for R Raw hybridisation signals were processed using GenomeStudio software  applying the default settings. Further analyses were performed using the R-package http://igc.otago.ac.nz/home.html26 and http://www.geneimprint.com/site/genes-by-species27) and a previously published review To analyze whether promoter regions of differentially methylated genes showed different CpG compositions, we used a previously described classification into promoters with high (HCP), intermediate (ICP) and low (LCP) CpG content KIAA0575, ECEL1, SOX11 and STG4 has been analyzed in this study.Bisulfite conversion of genomic DNA was performed using the EpiTect Bisulfite Conversion Kit  according to the manufacture’s protocol. Bisulfite Pyrosequencing was performed according to previously published protocols AMEL gene locus using primers yielding different sized PCR fragments from the X-chromosomal  and Y-chromosomal  copy of the gene. PCR fragments were analyzed using an ABI 3100 . DNAs from peripheral blood of normal males (n = 6), normal females (n = 5) as well as mixtures of normal male and female DNA  acted as control. The ratios of the peak area of X- and Y-chromosomal specific peaks were calculated. Using the controls as standard values in a regression analysis, the content of fetal tissue in CVS samples has been determined in CVS samples from male fetuses.To determine the content of fetal tissue in CVS samples obtained from male fetuses we performed a PCR based GeneScan analysis on the Applying the “Infinium HumanMethylation27 BeadChip” we investigated 27,578 CpG sites selected from more than 14,000 genes in a series of 63 fetal tissues left over from routine prenatal genetic testing. In particular, we investigated 47 chorionic villi samples (CVS) and 16 samples derived from amniocentesis (AC). Besides samples from fetuses with normal male or female karyotype these included six cases with trisomy 18  and three cases with trisomy 21 . One CVS sample was derived from a fetus with a gonosomal chromosome pattern typical for Turner Syndrome. Two samples  were obtained from pregnancies induced by intracytoplasmatic sperm injection (ICSI). None of the chromosomal aberrations was mosaic. Clinical details are summarized in The reproducibility and validity of the applied array platform for determination of DNA-methylation levels has been extensively demonstrated by us in previous studies using different types of samples and comparison to alternative techniques like methylation specific PCR, bisulfite pyrosequencing or bisulfite sequencing −15, t-test) differentially methylated between AC and CVS  of the complete data set from the remaining 50 samples clearly separated AC from CVS samples . This in and CVS . Like in and CVS . We concInterestingly, inspection of the heatmap  suggesteAMELX/AMELY locus in CVS samples derived from male fetuses revealing a detectable maternal contamination of between 0% and 29% (median 17%).The more intermediate methylation levels of the genes differentially methylated between amniotic and chorionic samples could be due to the fact that tissue sampled by CVS is a mixture of various embryonic and also maternal cell compartments. In contrast, cells derived from AC usually lack maternal contamination if the sample is not contaminated by blood. The potential differences in the contribution of maternal cells between AC and CVS prompted us to investigate the correlation of the DNA-methylation patterns with fetal sex. Unsupervised analysis of the 50 samples already suggested that fetal sex was less visible in the methylation pattern of CVS than in AC. To corroborate this observation we focused on the X-chromosomal genes as many  of those are being methylated in 50% of the X-chromosomes of females due to X-inactivation not present in normal males. In an unsupervised approach both AC and CVS samples separated according to fetal sex based on the methylation levels of the X-chromosomal genes. Nevertheless, three CVS samples from male fetuses clustered separately from the other CVS samples of male fetuses , arrow. Next we wondered whether the 2014 genes differentially methylated between amniotic and chorionic samples share certain biological features. Several studies demonstrated that genes with promoters either containing a high CpG content (HCP) or a low CpG content (LCP) show different DNA methylation properties We further investigated whether genes differentially methylated between AC and CVS were enriched for certain biological functions by performing a gene ontology analysis. This approach revealed that the 2014 genes differentially methylated between AC and CVS were significantly enriched for genes involved in various regulatory and developmental processes including e.g. regulation of adenylate cyclase activity which might point e.g. to hormonal or neuronal signaling . In addiOne single locus  was differentially methylated between CVS with trisomy 18 and both normal CVS and peripheral blood samples from normal females (hypermethylated in trisomy 18 samples).Finally, we wondered whether maternal factors could be associated with methylation differences in CVS and AC samples with normal karyotype. Due to the tissue differences shown above we treated both sample sources differently. By PCA we failed to detect any significant effect of maternal age, BMI or smoking status on the methylation pattern in AC and CVS, respectively (data not shown). Probably, the number of samples under investigation was too low to get a conclusive significant result.Having determined the methylation patterns in AC and CVS samples with normal karyotypes we aimed in the second part of the analyses at investigating whether fetal trisomies were associated with an altered DNA-methylation pattern. We limited the bioinformatic analyses to the CVS samples as the number of fetuses with a trisomy in the AC population was too low. In the three CVS samples with a fetal trisomy 21 (including one conceived by ICSI) a total of 464 loci ; q<0.01 In contrast to the samples with trisomy 21, an analysis comparing the five CVS samples with trisomy 18 to the normal controls identified only 15 significantly differentially methylated loci, corresponding to 14 genes . No signFinally, we wondered whether the single sample of AC with trisomy 18, the CVS sample with a gonosomal chromosome pattern typical for Turner Syndrome and the AC samples derived from a pregnancy after ICSI showed peculiar patterns of methylation. Obviously, bioinformatic analysis of single samples is meaningless. Nevertheless, displaying the methylation pattern of the X-chromosomal genes in the Turner sample as compared to the mean values of the normal male and female CVS samples showed lack of both, the typical female X-inactivation pattern and of the male methylation pattern . FinallyIn the present study we performed array-based methylation profiling on an extensive series of fetal samples with normal and aberrant karyotypes obtained by routine prenatal CVS and AC sampling. Obviously, relying on left-over samples from routine prenatal testing implements a certain selection bias as with few exceptions only fetuses at risk for chromosomal aberrations and/or with abnormal ultrasound findings or maternal serum screenings will be sampled due to ethical considerations. Thus, the present series was enriched for pregnancies with normal karyotype but abnormal ultrasound (n = 12), aberrant first trimester screen (n = 23) or advanced maternal age (n = 41) (multiple answers were permitted). Moreover, samples with known chromosomal aberrations were included on purpose. Thus, the analyses provided here reflect the findings of an “at-risk” cohort rather than of the normal distribution of pregnancies.http://www.molcell.rwth-aachen.de/dms. Based on the DNA methylation values of seven CpG loci present on the HumanMethylation27k Bead Chip Koch et al. developed an algorithm to investigate these parameters from in vitro cultured cells Moreover, it needs to be taken into account that whereas native (cryopreserved) CVS samples were investigated without prior culturing the AC cells had to be cultured to obtain sufficient amounts of DNA for the analyses. In this regard it needs to be considered that amplification of unmodified DNA prepared from uncultured AC cells would not have been suitable for the methylation arrays applied as by the amplification process the DNA methylation marks get lost. In turn, amplification of bisulfite treated DNA might have introduced experimental biases due to selective amplification of methylated or unmethylated DNA. The minute DNA amounts left over after routine diagnostics from uncultured amniotic cells might also be the reason why hitherto genome-wide methylation profiling studies focused on CVS or placental samples. Obviously, culturing cells harbors the risk of changing the DNA methylation pattern. Nevertheless, based on our own and others reports on lymphoblastoid cell lines as compared to normal lymphocytes we think that the culture-induced methylation changes are minor as compared to the tissue-specific differences which were in the focus of the present study Even taking into account potential sampling and culturing artifacts the differences in the methylation patterns between CVS and AC samples with normal karyotype were striking. Investigating nearly 800 selected genes using the Illumina GoldenGate DNA Methylation Cancer Panel I array, Yuen et al. A striking feature of loci differentially methylated between CVS and AC were the preferentially intermediate methylation levels of these loci in CVS in contrast to the extreme DNA-methylation levels in AC samples . DNA metAnother feature which explains intra-sample heterogeneity might be contamination with maternal cells. By analysis of X-chromosomal methylation patterns we show (here) that such contamination might be variable and can even affect detection of the fetal sex via methylation-based X-inactivation patterns. In contrast to the CVS samples cultured cells derived from AC usually lack maternal contamination.F2RL3 locus recently shown to be differentially methylated in peripheral blood with regard to the smoking status We failed to identify any association of maternal factors like maternal age, BMI or smoking status on the methylation pattern in AC and CVS likely due to the small size of the cohort for such analyses. In line with this, targeted analysis of the Analyses of the association of karyotypic aberrations with DNA methylation levels had to be restricted to CVS samples due to the low number of AC samples with such changes. The intra-sample variability of CVS samples described above might be the cause that we only detected 15 loci, corresponding to 14 genes  significCOL6A2, H2BFS, RUNX1) and 1/17 hypomethylated (MCM3AP) genes are located on chromosome 21. Thus, the trisomy 21 is associated with a genome-wide perturbance of DNA methylation not restricted to chromosome 21 that predominately leads to hypermethylation. This is in line with the pattern of differentially methylated genes observed by Kerkel et al. Remarkably, in trisomy 21 fetuses studied herein more than 95% (387/404) of the differentially methylated genes were hypermethylated as compared to normal CVS samples. Only 3/387 hypermethylated Click here for additional data file.Figure S2Verification of results obtained from BeadArray analysis by bisulfite pyrosequencing (BPS). 6 CpG loci have been analyzed both by BPS  and by BeadChip technology  in the same samples. The color code indicates methylation value . (B) Scatter plots of results obtained in (A). Pearson’s product-moment correlation r2 = 0.69(TIF)Click here for additional data file.Figure S3The majority of CpG loci present on the array are comparably methylated in CVS and AC samples. Histograms showing the frequency of the DNA methylation values in CVS (A) and AC (B). Scatter plot comparing DNA methylation values of CVS and AC samples (C). Histograms and scatter plots show DNA methylation values of CpG loci not differentially methylated between AC and CVS . Pearson’s product-moment correlation r2 = 0.94.(TIF)Click here for additional data file.Figure S4Hierarchic cluster analysis of DNA methylation values of 767 X-chromosomal CpG loci present on the array. The upper panel on top of the heatmap indicates the sample type  while the second panel indicates the fetuses’ sex . The third panel indicates normal karyotype (yellow) versus Turner syndrome (black). Three CVS samples from male fetuses show a DNA methylation pattern similar to female samples (arrow). A blue bar at the right site indicates genes methylated specifically in male fetuses, an orange bar genes methylated in female samples and a black bar genes with tissue- specific DNA methylation.(TIF)Click here for additional data file.Figure S5The AC sample derived from a pregnancy after ICSI showed a peculiar pattern of methylation. PCA (A) and hierarchic cluster analysis of DNA methylation values of 2418 CpG loci differentially methylated between AC (green sphere (A) or green square (B)) and CVS (red sphere (A) or red square (B)) . One AC sample from ICSI is indicated by a blue sphere (A) or a blue square (B), respectively.(TIF)Click here for additional data file.Table S1Clinical characteristics of the samples included in the study.(XLS)Click here for additional data file.Table S2Gene ontology terms (GO) significantly enriched in the group of genes differentially methylated between CVS and AC samples as compared to the entirety of loci present on the array .(XLS)Click here for additional data file.Table S3Gene ontology terms (GO) significantly enriched in the group of genes differentially methylated between CVS samples without chromosomal imbalances and samples with known trisomy 21 as compared to the entirety of loci present on the array .(XLS)Click here for additional data file.Table S4DNA methylation values  of loci differentially aberrantly methylated in trisomy 21 (sheet 1) and trisomy 18 (sheet 2). Data from CVS (trisomy and CVS) as well as from peripheral blood samples from normal female and male donors are included.(XLS)Click here for additional data file.


Most vaccines are delivered into the muscle although it contains very few potent antigen presenting cells, such as dendritic cells (DCs) that are critical for driving adaptive immune responses. Understanding the early mechanisms that dictate vaccine responses and why some adjuvants like the oil-in-water emulsion MF59 are shown to be more potent than alum is important for the design of new vaccines. Here, we investigated the recruitment of immune cells to the vaccine injection site and uptake of a clinically relevant HIV-1 envelope glycoprotein (Env) and MF59 in a non-human primate (NHP) model.Rhesus macaques received intramuscular injections of either fluorescently-labeled Env gp120 alone or together with MF59 in the deltoid and quadriceps muscles. Donor-matched injections of PBS and MF59 alone served as controls. At 24-72 hrs, blood, muscle and lymph nodes were sampled for flow cytometry and confocal microscopy.There was a robust infiltration into the muscle of multiple immune cells by MF59+/-Env. CD66abce+ neutrophils were most frequent followed by CD14+ monocytes and CD11c+ myeloid DCs. CD123+ plasmacytoid DCs which do not normally reside in muscle, were also recruited by MF59. Internalization of Env and MF59 was readily detectable in all DC subsets both in the muscle and in the draining lymph nodes. Although injection of Env alone did not lead to cell infiltration, the few resident DCs showed efficient Env uptake. Groups receiving Env together with distinctly different adjuvants  are underway.MF59 as an adjuvant leads to significant influx of cells that efficiently engulf vaccine protein antigen. Antigen/adjuvant carrying DC subsets appear early in the lymph nodes draining the injection site. As NHP DC subsets are similar to humans, this offers a powerful model that can yield data to be translated into optimizing future vaccine formulations and delivery strategies.


Asthma is a chronic inflammatory disorder of the lung airways that is associated with airway remodeling and hyperresponsiveness. Its is well documented that the smooth muscle mass in asthmatic airways is increased due to hypertrophy and hyperplasia of the ASM cells. Moreover, eosinophils have been proposed in different studies to play a major role in airway remodeling. Here, we hypothesized that eosinophils modulate the airways through enhancing ASM cell proliferation. The aim of this study is to examine the effect of eosinophils on ASM cell proliferation using eosinophils isolated from asthmatic and normal.Eosinophils were isolated from peripheral blood of 6 mild asthmatics and 6 normal control subjects. ASM cells were incubated with eosinophils or eosinophil membranes and ASM proliferation was estimated using thymidine incorporation. The mRNA expression of extracellular matrix (ECM) in ASM cells was measured using quantitative real-time PCR. The effect of eosinophil-derived proliferative cytokines on ASM cells was determined using neutralizing antibodies. The role of eosinophil derived Cysteinyl Leukotrienes in enhancing ASM was also investigated.Co-culture with eosinophils significantly increased ASM cell proliferation. However, there was no significant difference in ASM proliferation following incubation with eosinophils from asthmatic versus normal control subjects. Co-culture with eosinophil membranes had no effect on ASM proliferation. Moreover, there was no significant change in the mRNA expression of ECM proteins in ASM cells following co-culture with eosinophils when compared with medium alone. Interestingly, blocking the activity of cysteinyl Leukotries using antagonists inhibited eosinophil-derived ASM proliferation.Eosinophils enhances the proliferation of ASM cells. This role of eosinophil does not seem to depend on ASM derived ECM proteins nor on Eosinophil derived TGF-β or TNF-α. Eosinophil seems to induce ASM proliferation via the secretion of Cysteinyl Leukotrienes.


Midbrain dopamine neurons fire in a pacemaker-like fashion in vitro where they are deprived of most afferent input. In vivo, these neurons can emit a burst of action potentials with fast (~50 Hz) frequencies . However


Predicting the likelihood of a clinical outcome using biomarkers during the course of a cancer immunotherapy can be a powerful tool for time-sensitive decision making on personalized treatment options. In a clinical trial with the survivin-targeting vaccine DPX-Survivac, we showed using established methods (ELISpot/tetramer/flow cytometry) that a high-dose of DPX-Survivac vaccine in combination with low dose metronomic oral cyclophosphamide (mCPA) induced much stronger immune responses in ovarian cancer patients  compared to vaccine alone  or low dose vaccine with mCPA . Immune responses were detected ex vivo in patients’ PBMCs particularly in cohort C, a reflection of the magnitude of the immune responses generated by the vaccine. We further analyzed the kinetics of various T cell phenotypes of the CD4 and CD8 lineages, including effector/ central memory T cells and late differentiated CD8 T cells. We established a model for the sequential appearance of polyfunctional T cells of the various phenotypes and for the persistence of these cell types following repeated immunizations with DPX-Survivac. In addition, we explored a unique PCR-based ‘real-time’ method developed by Hitachi Chemical Research Center for analyzing mRNA expression signatures that could be associated with vaccine induced immune responses. For this, small quantities of fresh blood from immunized patients were directly incubated with vaccine antigens and analyzed by qPCR at pre- and one month post-immunization time points. Among 9 immune response-related biomarkers tested, mRNA for molecules such as IFN-γ, GM-CSF, TNF-α and CXCL10 were detected de novo in the blood of four out of four subjects tested among six patients from cohort C at one month following the third vaccination. These results are in keeping with the establishment of stronger immune responses and the kinetics of vaccine-induced memory/effector T cells observed at this time point in patients receiving the combination of DPX-Survivac and cyclophosphamide. Taken together, these findings provide a framework for identifying a potential immune response signature soon after initiation of the vaccine therapy. We will determine whether this immune response signature is predictive of clinical activity in a planned randomized phase 2 trial.


A variety of complications related to endovascular procedures are being reported. We present an annoying complication implying complete migration of stent-graft of subclavian artery into the aortic lumen.A 61 years old man with abdominal endovascular aortic stent-graft inserted previously, had a saccular aneursym of descending aorta distal to left subclavian artery and a small dissection flap with saccular aneursym originating from left subclavian artery. Since the patient refused to have any surgical procedure for left subclavian artery revascularisation, thoracic aortic-stenting for descending aorta just below the subclavian origin and a second stent-graft for left subclavian artery just above the orifice was planned. Coverage of left subclavian artery was not preferred aiming to avoid possible cerebrovascular events. During intervention, stent-graft to be inserted inside subclavian artery migrated totally into aortic arch in a perpendicular fashion.Bilateral femoral and left brachial artery accesses were done. A 16x41mm stent-graft was inserted inside left subclavian artery. While insertion with balloon dilatation, stent-graft migrated distally with the balloon forming a partial prolapse into aortic arch. We tried several endovascular maneuvers including inserting a second graft into subclavian artery to stabilize the first one or trying to press this graft with the one inserted into descending aorta, but unfortunately the stent totally migrated into aorta. We catheterized migrated stent with balloon catheter and were able to move the graft with inflated balloon fixing it. Stent-graft and inflated balloon were pulled slowly back together to proximal part of left arm of the previously inserted abdominal aortic stent-graft and stabilized it carefully. Control DSA showed settled graft without any stenosis.We present a bothering complication and an endovascular solution we performed without complication.


Current assessment techniques for regional contractility require cardiac magnetic resonance-tagged or strain encoded imaging sequences and their analysis is complex. A new steady-state free precession cine sequence (SSFP) based technique called feature tracking can readily be performed on standard SSFP sequences. To test the feasibility of feature tracking in patients with coarctation of the aorta (CoA) and to quantify regional contractility patterns pre and post percutaneous dilation and stent implantation in the region of CoA.6 consecutive male patients  with CoA underwent cardiac MRI pre and 1 to 2 years post stent implantation in a 1,5 Tesla Achieva MR system  using a 5 element cardiac coil. 3 conventional SSFP cine short axis slices  were analyzed for peak myocardial radial strain, peak myocardial circumferential strain and fractional area change dA/dt (FAC) pre and post catheter intervention using Feature Tracking software . Comparison between groups were calculated using a general linear model for repeated measurements .Patients showed a post-procedural significant increase of myocardial radial strain (p=0.05) with the highest extent within the apical myocardial segments Fig.. CircumfFeature tracking is a new and promising technique for the assessment of regional contractility using robust, standard SSFP images and can therefore be performed without the need of additional imaging sequences or even retrospectively. Measurements in our study group showed as significant increase of radial myocardial contractility after stent implantation. To verify the results of this pilot study an adjacent trial including more patients as well as a healthy control group is required.None.


Drug desensitization is the induction of temporary clinical unresponsiveness todrug antigens to which patients have presented severe hypersensitivity reactions (HSR). Rapid desensitization in patients suffering immediate hypersensitivity reactions with chemotherapeutic agents and monoclonal antibodies have been widely described and have shown to be successful. Non-immediate hypersensitivity reactions with other drugs have usually required desensitization with several days’ protocols to achieve total doses.Thirty-eight desensitization procedures were performed in 5 patients with a 12-13 step, 6-hour protocol. All patients had developed a delayed maculopapular rash with the use of chemotherapeutic and/or biological agents. Three patients were pretreated with corticosteroids, paracetamol and antihistamines before each desensitization procedure.All the 38 desensitizations undertaken were successfully completed . We observed HSR during 8 (21%) of desensitizations, including 5 inmediate exantema and 3 delayed local macular exantema. Two patients were treated with corticosteroids and anti-histamines after the desensitization protocol to avoid more delayed HSR.Rapid desensitization protocols are safe and effective in getting over delayed HSR to chemotherapeutic and monoclonal antibodies and allow patients with severe diseases to continue their treatment.


Nasopharyngeal carcinoma (NPC) occurs more frequently in patients with south-east Asian racial backgrounds. This disease may spreads superiorly to the skull base and intracranium followed by skull base destruction. We report a 56 year-old man presented with headache and diplopia. Magnetic resonance imaging (MRI) revealed extension of destructive mass from ethmoid sinus to the parenchyma. Intraoperative touch cytology showed loose syncytial sheets of pleomorphic abnormal epithelial cells, dyskeratotic cells with abnormal chromatin clumping and irregular nuclear outlines, in a necrotic background. These findings were infavor of keratizing squamous cell carcinoma which was confirmed by histopathology. During interpretation of intraoperative imprint cytology of central nervous system tumors, the possibility of local invasive tumors like NPC should be considered. NPC is a rare tumor in many parts of the world, but is prevalent among Southeast Asian. It usually arises from eustachian tube opening in the Rosenmuller fossa. Initial complaints are often due to middle ear obstruction (otitis media or hearing loss) or local invasion . There are few reports of NPC with diffuse skull base destruction, resulting in obstructive hydrocephalus, cerebellopontine involvement or even cavernous sinus metastasis 2]3]4][3][4]2][[4][3][4][3][4]2].We report a 56 year-old man presented with headache, dizziness and diplopia for one-month duration. On physical examination third and sixth cranial nerve palsy were detected. Past medical history was not significant. MRI showed a soft tissue mass originates from ethmoid sinus with upward extension to brain parenchyma  [6]. TheNPC is endemic in Southern China and is associated with Epstein–Barr virus (EBV) as strong aetiological factor. The titre levels of antibodies to EBV immunoglobulin A viral capsid antigen (IgA VCA) and early antigen (IgA EA) have been widely used as screening and diagnostic markers for NPC. Quantitation of EBV DNA viral load using a real-time PCR technique is highly sensitive and specific method for NPC and correlates well with tumor burden. EBV DNA can be used clinically to monitor disease response and recurrence 9]. NPC . NPC 9].In our experience, imprint cytology test is a rapid and inexpensive diagnostic test that tissue integrity is well preserved. In interpretation of imprint cytology of central nervous system tumors, the possibility of local invasive tumors such as NPC should be considered. In these cases, careful examination of the nasopharynx is essential for the exclusion of nasopharyngeal undifferentiated carcinoma because of the obvious differences in treatment and prognosis.


Renilla Luciferase to determine binary protein:protein interactions (PPIs) of the PKA network. We compared time- and dose-dependent influences of cAMP-elevation on mutually exclusive PPIs of PKAc with the phosphotransferase inhibiting RIIb and RIa subunits and the protein kinase inhibitor peptide (PKI). We analyzed PKA dynamics following integration of patient mutations into PKAc and RIa. We observed that oncogenic modifications of PKAc(L206R) and RIa(Δ184-236) as well as rare disease mutations in RIa(R368X) affect complex formation of PKA and its responsiveness to cAMP elevation. With the cell-based PKA PPI reporter platform we precisely quantified the mechanistic details how inhibitory PKA interactions and defined patient mutations contribute to PKA functions.The second messenger molecule cAMP links extracellular signals to intracellular responses. The main cellular cAMP effector is the compartmentalized protein kinase A (PKA). Upon receptor initiated cAMP-mobilization, PKA regulatory subunits (R) bind cAMP thereby triggering dissociation and activation of bound PKA catalytic subunits (PKAc). Mutations in PKAc or RIa subunits manipulate PKA dynamics and activities which contribute to specific disease patterns. Mutations activating cAMP/PKA signaling contribute to carcinogenesis or hormone excess, while inactivating mutations cause hormone deficiency or resistance. Here we extended the application spectrum of a Protein-fragment Complementation Assay based on the  As a consequence PKAc phosphorylates compartmentalized substrates which affects enzyme activities, PPI, localization, or protein abundance  and activating PRKACA gene (PKAc) mutations/fusions provoke deregulated PKAc activities. As examples, mutations in RIa and PKAc account for the generation of endocrine tumors, cortisol-producing adenomas, and chimeric fusions with PKAc have been linked to the manifestation of hepatocellular carcinoma  mutations impair cAMP-dependent PKA activation and cause hormone resistance as observed in the rare disease Acrodysostosis    and signal propagation Clapham, . The secHEK293 and U2OS cells were grown in DMEM supplemented with 10% FBS. Transient transfections were performed with Transfectin reagent (Biorad). Cells were treated with Forskolin (Biaffin) or Isoproterenol (Sigma) with indicated concentrations and for the indicated time frames. As primary antibody we used mouse anti-PKAc .Rluc PCA based hybrid proteins RIIb-F[1] and PKAc-F[2] have been designed as previously described  gene (protein accession number: NP_002725.1) and PKI alpha gene  2 and the Rluc PCA fragments (pcDNA3.1 backbone vector). Site directed mutagenesis have been performed to generate the PKAc amino acid (aa) mutations G187V and L206R in the PRKACA gene and the RIa aa mutations R368X  in the PRKAR1A gene. In addition we deleted the corresponding nucleotide sequence from the aa 184–236 in the PRKAR1A gene.The Rluc PCA based reporter constructs in 24 or 12 well-plate formats. In case of the HEK293 cells we exchanged growth medium and resuspended cells in PBS 24 or 48 h post-transfection. Cell suspensions were transferred to 96-well plates and subjected to luminescence analysis using the LMax™-II-384 luminometer (Molecular Devices). Rluc luminescence signals were integrated for 10 s.HEK293 cells were grown in DMEM supplemented with 10% FBS. We transiently overexpressed indicated versions of the Rluc PCA based reporter constructs. 24 or 48 h post-transfection we exchanged growth medium with PBS. We performed luminescence analyses of attached U2OS cells at room temperature using the LMax™-II-384 luminometer (Molecular Devices). Time dependent changes of the Rluc luminescence signals were integrated in 3-s intervals following addition of the Rluc substrate benzyl-coelenterazine  with or without Isoproterenol  .We seeded U2OS cells into white-walled 96 well-plates with transparent bottom. We transiently overexpressed indicated versions of the Rluc PCA) to quantify mutually exclusive PKA interactions directly in living cells. It is the simplicity and sensitivity of the genetically encoded Rluc PCA which enables different kinds of perturbation studies to unveil mechanistic details of PKA dynamics. The Rluc PCA facilitates the precise quantification of cellular PPI in an appropriate in vivo setting  and PKAc which is indicated through alterations of bioluminescence signals. For the cloning of the PPI reporter constructs we fused the carboxy terminus of the PKA subunits  and PKI to complementary fragments of the Rluc PCA (either -F[1] or -F[2]). In all cases the bait/prey proteins and the Rluc PCA fragments are separated by an interjacent 10 amino acid (aa) linker with the sequence (GGGGS)2. It is a standard linker we previously showed to function using the dynamic RIIb:PKAc Rluc PCA reporter , respectively. In this context it needs to be considered that distinct mechanism have been described how β2AR switch their G protein coupling from stimulatory G proteins to inhibitory ones  triggered R:PKAc complex dissociation. We observed no major changes of PPI between PKI:PKAc and RIIb homodimers following 15 min of cAMP elevation  and full length Rluc we observed that Isoproterenol immediately induced the dissociation of heterodimeric type I and type II PKA complexes with similar kinetics. Again, β2AR activation for 4 min has no major effect on the RIIb dimer and on PKAc:PKI interactions  which is caused through a resistance to several hormones  application of the PKA Rluc PCA reporter to detect even modest changes of PPIs in response to second messenger elevations. Overall we underline with this study that the Rluc PCA is a versatile reporter system to map transient and small molecule controlled PPI. Besides linking membrane receptor pathways to alterations of molecular interactions, the consequence of patient mutations on PPI can be tested with a simple protocol and in parallel fashion. The implementation of this PPI reporter platform will unveil consequences of distinct patient mutations on binary PKA network dynamics. We envision that the mutation approach will disclose hot spots in these critically regulated kinase complexes which become pharmaceutical targets to target both PPI and/or cAMP sensing. This will help to gain novel insights into mechanism of PKA activation which will be relevant for the diagnosis and for identifying treatments of kinase involved diseases.We also tested two patient mutations of RIa which are related to two different diseases showing opposite effects on PKA activity. We demonstrated that the Carney complex relevant R1a-Δ184-236 mutation had a major impact on PKA complex formation when compared to the wild type PKA holoenzyme type I. Our data showed that R1a-Δ184-236 has less affinity for PKAc. We assume that the reduced affinity for PKAc contributes to disease relevant elevations of PKAc phosphotranferase activities. The second mutation RIa-R368X (= 14aa truncation) caused a defect in PKA activation. The mutation introduces a stop codon and shortens the cAMP binding domain B. The resulting deletion of 14 aa at the C terminus reduced the cooperative binding of cAMP first to binding domain B and then to binding domain A, which is a prerequisite for PKAc dissociation and activation (Kim et al., RR, JM, VB, and ES performed the experiments. RR, JM, VB, and ES analyzed the results. ES wrote the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


A 64-year-old female with history of previous aortoiliac occlusion and aortoiliac bypass operation four months ago presented with dyspnea, ascites and leg edema. She has been suffering from bloody diarrhea since two weeks earlier. Laboratory data showed important eosinophilia and stool examination was positive for Strongyloides stercoralis. Patient had clinical signs of heart failure. A cardiac MRI revealed hypersignal subendocardium in favor of endomyocardial fibrosis. Hypereosinophilic syndrome is defined by persistent hypereosinophilia for more than 6 months. The association with different etiologies is known but the report of cardiac involvement due to S. stercoralis infection is not very common. Cardiac manifestation is characterized by a restrictive cardiomyopathy due to toxic damage produced by activated eosinophils. Figure 2). Thrombus is characterization by no evidence of early or late enhancement and of myocardial fibrosis by late gadoilnium enhancement (LGE). The delayed hyperenhancement explained by myocardial scarring which increases gadolinium concentration. The diagnosis of Endomyocardial fibrosis (EMF) was made on the basis of this typical MRI finding. Cardiac catheterization and biopsy was scheduled but unfortunately was not performed due to patient’s preference. Patient received Ivermectin for S. stercoralis treatment and medication for heart failure. On 6 month follow up she still has dyspnea with minimal exertion. She did not accept the risk of surgery.A 64-year-old female with history of previous aortoiliac occlusion and aortoiliac bypass operation four months ago presented with dyspnea, ascites and leg edema. She has been suffering from bloody diarrhea since two weeks earlier. Laboratory data showed important eosinophilia in count of 2100 cells/µL and stool examination was positive for S. stercoralis. Patient had clinical signs of heart failure and standard treatment of heart failure started. Chest radiography revealed an enlarged cardiac shadow with a congestive vascular pattern The ECG showed sinus tachycardia with normal QRS morphology and duration. The transthoracic echocardiogram revealed left ventricular ejection fraction of 35%, severe diastolic dysfunction, moderate pulmonary hypertension and severe mitral and tricuspid regurgitation with apical filling of the both ventricles. A cardiac MRI revealed normal wall thickening in pre- and postgadolinium diethylenetriamine pentaacetic acid (Gd-DTPA) infusion dynamic sequences (S. stercoralis infection is not that common (Hypereosinophilic syndrome is defined by persistent hypereosinophilia for more than 6 months. The association with different etiologies is known but cardiac involvement due to t common . Cardiact common . It provt common . Cardiact common . The LGE


Dear SirA 26-year-old primigravida with breech presentation came to the emergency in 2nd stage of labor with meconium stained per vaginal leak. Patient was initially taken to a primary health centre were artificial rupture of membrane was done to augment labor but later referred here since labor did not progress. After an emergency cesarean section, a female baby was delivered who on examination had a hematoma over right buttock, anal laceration, perianal edema, and severe rectal bleeding . Anal injury during artificial rupture of membrane was suspected. Patient was managed conservatively by anal pack for 24 hours and later local dressings and antibiotics. The edema and hematoma resolved in 1 week . The child has normal continence. Intrauterine anogenital injury can occur due to repeated maternal vaginal examination in which the examiners fingers traverses the cervical os into the neonatal rectum or vagina. It can also occur during cesarean delivery due to blunt dissection of endometrium or bimanual traction while delivering the breech from maternal pelvis. There are very few case reports regarding anal injuries in breech delivery, [1-4] but this is probably the first such incidence where it occurred due to artificial rupture of membranes. This injury stimulated baby to pass meconium in-utero which could be life threatening. Mal-presentation is a contraindication for labor augmentation or induction procedures like artificial rupture of membrane. Management of such injuries depends on the grade of injury.[5] Mild degree laceration can be managed conservatively like in our case. The more severe degree laceration of sphincter or those extending into rectum or genitalia are managed by a diverting stoma and primary repair. [1-4] Source of Support: NilConflict of Interest: None


Several studies suggest that an increased oxidative stress is a key event in migraine, especially in the form with aura. One of the most efficient first line antioxidant defense system of cells exposed to oxygen is Superoxide Dismutase (SOD) system. The SOD1 gene presents a polymorphism (A/C substitution - rs2234694) resulting in lower serum activitiy in subjects carrying CC genotype. SOD2 gene presents a polymorphism  which leads to an instable mRNA and reduced transport of the enzyme in TT genotype carriers.To investigate whether these variants are associated to migraine without aura (MO), migraine with aura (MA), or chronic migraine (CM) in a cohort of Caucasian patients from the Interinstitutional Multidisciplinary BioBank (BioBIM).From 2009 to 2013, 490 Caucasian unrelated migraineurs and 246 healthy control subjects were consecutively recruited at the our Headache and Pain Unit. Demographic and clinical migraine features were carefully detailed and gathered with face-to face interviews.The polymorphisms were determined by direct sequencing analysis.Genotypes and the allele frequencies of polymorphisms in migraineurs and controls did not significantly differ from those predicted by the Hardy–Weinberg equilibrium. When considering unilateral cranial autonomic symptoms (UAs), we observed a significant increase of SOD2 rs4880 TT  genotype in MA (P=0.042).SOD2 TT genotype correlates with MA with UAs. We hypothesize that in SOD2 TT carriers with MA, a defective control of oxidative phenomena characterizing cortical spreading depression leads to a more intense antidromic stimulation of trigeminal endings, thus triggering the trigemino-autonomic reflex.No conflict of interest.


Early recognition and prevention of deterioration of ward patients can improve patient outcomes and reduce critical care admissions . In low To design a clinically relevant short course for ward nurses in a LMIC to be delivered by local nursing tutors and facilitators.To assess whether such a clinically focused programme would increase ward nurses' knowledge and skills in identifying and managing deteriorating patients.A multi-modal 2 day acute care course for ward nurses was co-designed and delivered by specialist overseas trainers in partnership with national tutors. The courses were sponsored by the Ministry of Health, Sri Lanka. Based upon the NICST model of collaborative course design, local faculty were up skilled in delivery and content through a pre course Train the Trainer programme .Candidates were invited to undertake on-line pre course e-learning. Core clinical guidelines were delivered using mini lectures. Facilitator-led skills stations and structured scenarios were used to develop clinical skills.Short term knowledge acquisition was tested by a pre and post course Multi-Choice Questionnaire (MCQ). Newly acquired skills and their application was assessed through a post course Objective Clinical Skills Assessment (OSCA) station.122 ward nurses were trained over 6 courses in 2 locations. Post MCQ scores were significantly higher for each course compared to pre MCQ (Wilcoxon sign rank test P < 0.0001).Over 71% passed the OSCA (pass mark of 60). Feedback reveals high candidate satisfaction.Our short course results demonstrate an increase in relevant knowledge and clinical skills of the participants. Our NICST model demonstrates the feasibility of a local nursing faculty in a LMIC co-designing and effectively delivering a setting adapted acute care training programme integrated into the local nurse training system.


E.coli ST131 is a globally disseminated clone of multi-drug resistant E. coli responsible for that vast majority of global extra-intestinal E. coli infections. Recent global genomic epidemiological studies have highlighted the highly clonal nature of this group of bacteria, however there appears to be inconsistency in some phenotypes associated with the clone, in particular capsule types as determined by K-antigen testing both biochemically and by PCR.We performed improved quality assemblies on ten ST131 genomes previously sequenced by our group and compared them to a new reference genome sequence JJ1886 to identify the capsule loci across the drug-resistant clone H30Rx. Our data shows considerable genetic diversity within the capsule locus of H30Rx clone strains which is mirrored by classical K antigen testing. The varying capsule locus types appear to be randomly distributed across the H30Rx phylogeny suggesting multiple recombination events at this locus, but that this capsule heterogeneity has little to no effect on virulence associated phenotypes in vitro.E. coli ST131 and further beyond to ExPEC strains, and highlights how capsular mosaicism may be an important strategy in becoming a successful globally disseminated human pathogen.Our data provides a framework for determining the capsular genetics of The online version of this article (doi:10.1186/1471-2164-15-830) contains supplementary material, which is available to authorized users. Escherichia coli (ExPEC) infections are one of the leading causes of morbidity in the developed world and are particularly associated with infections of the urinary tract (UTI) and with bacteraemia. In recent years one particular clone of ExPEC has emerged to become a globally dominant cause of human infection, E. coli ST131 Additional file 1:


Coronary subclavian steal syndrome is a rare ischemic cause in patients after myocardial revascularization surgery. Subclavian artery stenosis or compression proximal to the internal mammary artery graft is the underlying cause. The authors present a clinical case of a patient with previous history of non-ST elevation myocardial infarction, triple coronary bypass, and effort angina since the surgery, with a positive ischemic test. Coronary angiography revealed a significant stenosis of the left subclavian artery, proximal to the internal mammary graft. The coronary subclavian steal syndrome (CSSS) was first described in 1974 and is caused by retrograde or insufficient blood flow through the internal mammary artery graft, with subsequent myocardial ischemia. Proximal atherosclerotic stenosis of the ipsilateral subclavian artery is the most frequent cause . The traThe authors present the case report of a 69-year-old male patient with several cardiovascular risk factors  and history of coronary artery bypass grafting (CABG) 6 years before when the left internal mammary artery (LIMA) was grafted to the left anterior descending artery (LAD), saphenous vein conduit was grafted to posterior descendent artery and left radial artery grafted to the intermediary branch. No medical imaging of the aortic arch and its branches was performed before cardiac surgery.He had recurrence of angina following the surgery (CCS class II) mainly when exerting the upper limbs. His therapy was adjusted and remained only mildly symptomatic until 2011 when he was referred to for coronary angiography because of gradually worsening exertional angina with no response to medical therapy. There were no neurological or claudication complaints. Physical examination only showed an II/VI systolic murmur. Basal EKG and blood analysis were unremarkable. On the transthoracic echocardiogram, there was only mild aortic sclerosis and good global and segmental systolic left ventricle function. He had a positive exercise electrocardiographic stress test, showing a 1.5 mm ST segment depression on anterior and inferior leads accompanied by chest pain on 2nd stage Bruce treadmill protocol. The coronary angiography showed no new lesions in native-vessel circulation or the bypass grafts, except for the occlusion of the saphenous venous conduit grafted to the posterior descendent artery and partial retrograde filling through the LIMA graft from the LAD . Subclavian angiography showed a proximal severe stenosis (83%: quantitative coronary angiography) with slow distal flow; there were no significant stenosis in the carotid arteries .It was performed an ad hoc, left main percutaneous angioplasty, using a drug-eluting stent 4,0/12 mm (Promus Element) without trifurcation involvement, with final angiographic success . In a seNowadays LIMA is the most used graft conduit due to excellent long-term patency, and although CSSS has a low described incidence 0.5–6.8%), perhaps this incidence could be underestimated. Ischemic symptoms can present immediately following CABG surgery or up to 7-8 years later , 4. Some–6.8%, peControversy remains that to whether or not a routine subclavian artery angiography should be performed before CABG surgery . Some auThe most appropriate management of concomitant brachiocephalic coronary artery disease also remains a matter of debate, but both endovascular stenting and extrathoracic surgical bypass are safe and effective treatments for CSSS in the short and medium term; extrathoracic surgical bypasses are more durable in the long term . Some auOur case demonstrates the need for evaluating the supra-aortic branches in patients previously submitted to CABG surgery and persistent/recurrent angina symptoms, particularly in those without other causes of ischemia. The percutaneous treatment for subclavian stenosis is effective and safe.


Hybrid nanocomposites were constructed based on colloidal nanofibrillar hydrogels with interpenetrating supramolecular hydrogels, displaying enhanced rheological yield strain and a synergistic improvement in storage modulus. The supramolecular hydrogel consists of naphthyl-functionalized hydroxyethyl cellulose and a cationic polystyrene derivative decorated with methylviologen moieties, physically cross-linked with cucurbit[8]uril macrocyclic hosts. Fast exchange kinetics within the supramolecular system are enabled by reversible cross-linking through the binding of the naphthyl and viologen guests. The colloidal hydrogel consists of nanofibrillated cellulose that combines a mechanically strong nanofiber skeleton with a lateral fibrillar diameter of a few nanometers. The two networks interact through hydroxyethyl cellulose adsorption to the nanofibrillated cellulose surfaces. This work shows methods to bridge the length scales of molecular and colloidal hybrid hydrogels, resulting in synergy between reinforcement and dynamics. Recently, natural structural materials have inspired synthetic solvent-based and solid nanocomposite architectures.–6 NaturaOne of the main strategies used by nature is the combination of colloidal-length-scale reinforcement with supramolecular bonds on a molecular level, thus allowing rapid dissociation and reformation. Thus preThe present study focuses on the combination of colloidal and molecular length scales in hydrogels to engineer a dynamic supramolecular sacrificial network that promotes stiffness and connectivity in nanofibrillated cellulose (NFC) colloidal hydrogels. Pure NFC forms hydrogels, in which the skeleton is formed by native cellulose nanofibers with lateral diameters of nanometers and lengths up to several micrometers. NFC has Supramolecular interactions embedded within hydrogels have allowed for stimuli responsivity, controlled unzipping, and supramolecular cross-link reformations without immediate failure of the entire network.,27 SpeciIn more detail, the architecture comprised of a colloidal NFC network enhanced by association with a dynamic supramolecular network Figure . A CB[8]By combining a variable amount of NFC (0–1.5 wt. %) with fixed amounts of STMV (0.15 wt. %) and CB[8] (0.1 wt. %), no apparent increase in the storage modulus was observed. Good compatibility was inferred as no apparent aggregation or phase separation occurred. Next, a fixed amount of HEC-Np (0.5 wt. %) was added to form the heteroternary complex and to attach the ensuing supramolecular hydrogel to the NFC hydrogel through adsorbing the HEC to the NFC surface. This resulted in synergistic enhancement of the low-strain elastic modulus as the two networks were bound together Figure . The stoG′, the addition of the CB[8] network to the NFC network resulted in increased yield strain ; however, the yield strain was reduced with repeated gel-to-sol transitions  images support the schematic description of the network Figure , as the In conclusion, a supramolecular hydrogel bridges the colloidal nanofibrillar NFC hydrogel domains, leading to significantly enhanced storage modulus values and improved maximum elastic yield values. This was promoted by the fast dissociation/association dynamics of the supramolecular CB[8]-based supramolecular cross-links in combination with the adsorption of hydroxyethyl cellulose component of the supramolecular hydrogel to the NFC nanofibers. The work shows biomimetic routes to combine components of different length scales and physical interactions to tune rheological properties.


Complete removal of breast cancer during a single breast-conserving lumpectomy procedure is often challenging due to the lack of adequate intraoperative tools to accurately determine the margin status. About one-third of lumpectomy patients are found to have positive margins upon final histologic analysis, which usually is reported within a week after surgery. These patients are then required to undergo additional surgeries, which increases the patient morbidity, cosmetic challenges, and healthcare cost. Spectrally encoded confocal microscopy (SECM) is a high-speed confocal microscopy technique  that canμm). After SECM imaging, each specimen was processed and cut as hematoxylin and eosin (H&E) stained slides. SECM images were analyzed in comparison with the corresponding H&E slides to identify features in the SECM images that distinguished benign from malignant breast tissues.We imaged 44 fresh breast tissue samples with SECM and compared the SECM images with corresponding histologic slides. The specimens were obtained from mastectomy and lumpectomy operations conducted at MGH and according to an IRB-approved protocol. Each specimen was immersed in 5% acetic acid to increase the nuclear contrast in SECM. Large-area SECM images (4 mm by 2 mm to 10 mm by 4.8 mm) were obtained at 5 imaging levels (imaging depth: 0 to 200 SECM images enabled the visualization of architectural and cellular features of normal and diseased breast tissues that were structurally similar to those seen by histopathology. SECM images of normal breast tissues showed morphologic features of adipose cells and benign glands. Low-grade invasive ductal carcinoma showed small glands invading the stroma in a disorganized fashion . High-grResults from this preliminary imaging study showed that SECM can be used to visualize key histomorphologic features associated with breast cancers. We are currently conducting a validation study of testing sensitivity and specificity of SECM for diagnosing breast cancers. When utilized during lumpectomy, SECM may have the potential to rapidly provide margin status and help the surgeon achieve more thorough removal of the tumor in a single surgery.


Pancreatic metastases are rare, accounting for 2.8% of cases in RCC, occurring as a result of haematogenous spread to the pancreas. High affinity of some renal cancer cells for the pancreatic parenchyma present solely as isolated pancreatic metastases.Literature reviews have highlighted that aggressive surgery for isolated pancreatic metastasis has been shown to increase 5 year survival rates unto 60%; particularly nephrectomy & metastasectomy with adjuvant therapy.The objective of this case study was to identify the benefits of pancreas-preserving enucleation in treatment of isolated pancreatic RCC metastases over traditional pancreatic resections.Patient X was identified as a candidate for this case report.Mr X. is a 77 year old fit and healthy male, presented with 2 day history of frank haematuria & weight loss of 3kg over 6 months with no associated fever, flank pain or dysuria. CT KUB revealed lobulated soft tissue density in the right kidney, suspicious for a tumour. Further staging investigations of CT TAP demonstrated a small enhancing nodule in pancreatic body confirmed as pancreatic metastasis with EUA FNA. The patient subsequently underwent Open Right Radical Nephrectomy with Enucleation of Pancreatic Metastasis.Comparisons drawn between Pancreatic-sparing Enucleations and standard resection (Complete Pancreatectomy) explore variations in surgical challenges & post-operative complications. While there has been no difference in morbidity and recurrence noted compared to complete pancreatectomy; there has been significant reduction in post-operative diabetes mellitus.Pancreatic resections are associated with high rates of morbidity and mortality. A reduction in operative risk following pancreatic surgery have been demonstrated, in recent times. As such, Pancreas-sparing Enucleation & Enucleo-resection has been considered a worthy option. Preservation of pancreatic tissue allows for better quality of life without diabetes mellitus.The patient had signed a written consent for publication of this abstract on Pancreatic Metastases.


Spasm of the radial artery is the most important cause of failure to perform coronary angiography via the transradial approach. Spasmolytic cocktail may prevent radial artery spasm but is relatively contraindicated in patients with aortic stenosis or diminished left ventricular function. In this case report we describe a recently published technique to overcome severe radial spasm during transradial coronary angiography in a patient with moderate aortic valve stenosis. After a two-decade evolution, the transradial approach (TRA) in coronary angiography and percutaneous coronary intervention (PCI) has become a viable and attractive alternative for the femoral approach –4. The iOne of the most encountered problems is radial artery spasm. In a multicenter registry containing over 1900 transradial procedures, the incidence of radial spasm was 2.7%, with multiple puncture attempts and use of larger introducer sheaths (7F) being independent predictors of radial spasm . AnotherRadial artery spasm can be prevented by administration of intraarterial spasmolytic cocktails . HoweverIn this case report, we describe a recently published technique  to overcA 70-year-old male patient was referred for coronary angiography because of chest pain on exertion. In preceding years, he visited our outpatient department for echocardiographic follow-up of a moderate aortic valve stenosis. During the last visit he expressed typical anginal complaints while echocardiographic evaluation of the aortic valve displayed a stable function.Patient underwent coronary angiography via right radial access. After uneventful puncture and cannulation of a 5F introducer sheath  5000 IU of heparin was administered. Initially, no spasmolytic cocktail was used because of patient's moderate aortic stenosis. A 5F JL catheter  over a 0.035′′ standard guide wire could uneventfully cannulate the left main ostium. After visualization of the left coronary artery, over the wire exchange for a 5F JR catheter resulted in severe patient discomfort of the forearm, resulting from spasm. Half-dose spasmolytic cocktail  did not permit the JR catheter to pass and resulted in a significant fall of intra-arterial blood pressure. Visualization of the radial revealed severe and refractory spasm .In order to cross the spastic segment, a 5F Kimny guide (Boston Scientific) was loaded with a 2.0 × 15 mm Mini Trek PTCA catheter (Abbott Vascular) over a 0.014′′ Sion coronary guide wire (Asahi). The balloon catheter, which was kept partially outside the distal end of the guiding catheter, was inflated at 4 bars to ensure fixation of the guiding catheter onto the coronary wire . As suchThe patient underwent PCI of the ostial lesion of the RCA 1 week later. Radial artery angiography revealed a smooth and undamaged vessel .The evolution of the TRA in the preceding two decades brought along new procedural difficulties that should be overcome by evolving techniques and equipment. As in above-described case, spasm of the radial artery are a major obstacle to a successful TRA and may result in catheter-induced perforation or conversion to a transfemoral approach.The tunica media of the muscular radial artery is comprised of concentric layers of smooth muscle cells. Both circulating catecholamines and mechanical stimuli  may cause smooth muscle cell contraction and hereby spasm of the radial artery. Forced cannulation of a spastic radial artery may cause the catheter tip to brush the endothelium, which may aggravate spasm and cause vascular damage. BAT of the guiding catheter was recently described by Patel and colleagues  to overcIn conclusion, BAT was successful in this patient with radial artery spasm refractory to low dose spasmolytics.


Respiratory syncytial virus (RSV) infections are associated with thrombocytopenia. The underlying mechanism of thrombocytopenia in this setting is unknown. Herein, we report a case of RSV-related thrombocytopenia associated with transient cytogenetic abnormalities that occurred following umbilical cord blood transplantation. Respiratory syncytial virus (RSV) infections are associated with extra pulmonary manifestations including thrombocytopenia . The undWe report here a case of a 28-year-old male patient who underwent a double umbilical cord blood transplant for acute lymphoblastic leukemia (ALL) in second remission in 2008. Original cytogenetic analysis revealed normal karyotype. Nineteen months after transplant, he presented to clinic with upper respiratory infection symptoms. RSV was detected by molecular tests performed on a nasal wash sample and a CT scan of the chest showed right upper lobe cavitary lesion containing a nodular density concerning pneumonia for which he was treated with aerosolized ribavirin. At the same time, the patient was found to be thrombocytopenic . BecauseWe report a case of RSV-related thrombocytopenia associated with transient cytogenetic abnormalities that occurred following umbilical cord blood transplantation. Development of thrombocytopenia following transplantation is a sign of possible disease relapse. In our case, the patient had no morphologic changes of leukemia. Donor cells leukemia (DCL), on the other hand, is a rare complication following allogeneic hematopoietic stem cell transplant –4. Wang The most probable explanation for our findings is RSV infection, though no viral etiology was described in the cases reported by Otero et al. The transient cytogenetic changes in our case occurred at the time of thrombocytopenia and accordingly might provide an explanation for RSV-related thrombocytopenia. Recent data suggest that RSV might infect bone marrow stromal cells  which mi


A 59-year-old male patient was referred to our hospital for treatment of paroxysmal atrial fibrillation since 8 years, with frequent presentations to the emergency department for cardioversion. Previously, post-cardioversion sinus bradycardia was observed. After extensive discussion of the treatment options, the patient opted for a minimally invasive surgical pulmonary vein isolation. The ECG shown was recorded during ablation of the left-sided pulmonary veins Fig. .Fig 1ECGQuestionWhat is the mechanism of this trigeminy rhythm?You will find the answer elsewhere in this issue.


Ventricular assist devices have been routinely used in patients with end stage heart failure as a bridge to transplantation. We present a case of using a Bi-Ventricular Assist Device (BiVAD) in a patient with fulminant heart failure as a bridge to recovery.A 36 year old lady with a history of Grave's Disease and three months post-partum presented with fulminant myocarditis.She presented to her local hospital on 2nd January with episodes of ventricular tachycardia (VT) and syncope. She was transferred to a tertiary level cardiology centre as she failed to cardiovert. Echocardiography demonstrated significant left ventricular (LV) thickening and LV stasis. She continued to have VT storms and was referred to our advanced heart failure service.On arrival she rapidly deteriorated with recurrent VT and ventricular fibrillation (VF) episodes causing severe haemodynamic compromise. A decision was made to institute mechanical circulatory support with veno-arterial Extra-Corporeal Membrane Oxygenation (VA- ECMO). During cardiopulmonary resuscitation she was placed onto VA-ECMO and stabilised. That same evening she underwent conversion to BiVAD support for offloading of both ventricles.She was extubated on the first post-operative day. Myocardial biopsy performed during BiVAD implantation confirmed florid myocarditis.Over the ensuing days, she was mobilised and rehabilitated on the ITU and there was a gradual recovery of myocardial function. On the 25th post-operative day her BIVAD circuit was explanted following a successful wean.After further rehabilitation she was discharged home, 39 days after admission. MRI prior to discharge demonstrated satisfactory biventricular function with a small right atrial thrombus.Ventricular assist device therapy can be utilised as an effective primary treatment modality for patients in fulminant heart failure within the spectrum of post-partum cardiomyopathy. We suggest early discussions with regional advanced heart failure centres to facilitate prompt intervention leading to full recovery.