The 5-HT1F receptor as the target of ditans in migraine - from bench to bedside

Migraine is a leading cause of disability in more than one billion people worldwide, yet it remains universally underappreciated, even by individuals with the condition. Among other shortcomings, current treatments (often repurposed agents) have limited efficacy and potential adverse effects, leading to low treatment adherence. After the introduction of agents that target the calcitonin gene-related peptide pathway, another new drug class, the ditans - a group of selective serotonin 5-HT_1F receptor agonists - has just reached the international market. Here, we review preclinical studies from the late 1990s and more recent clinical research that contributed to the development of the ditans and led to their approval for acute migraine treatment by the US Food and Drug Administration and the European Medicines Agency.

Excellent Response to OnabotulinumtoxinA: Different Definitions, Different Predictors

The identification of patients who can benefit the most from the available preventive treatments is important in chronic migraine. We explored the rate of excellent responders to onabotulinumtoxinA in a multicenter European study and explored the predictors of such response, according to different definitions. A pooled analysis on chronic migraineurs treated with onabotulinumtoxinA and followed-up for, at least, 9 months was performed. Excellent responders were defined either as patients with a ≥75% decrease in monthly headache days (percent-based excellent responders) or as patients with <4 monthly headache days (frequency-based excellent responders). The characteristics of excellent responders at the baseline were compared with the ones of patients with a <30% decrease in monthly headache days. Percent-based excellent responders represented about 10% of the sample, whilst frequency-based excellent responders were about 5% of the sample. Compared with non-responders, percent-based excellent responders had a higher prevalence of medication overuse and a higher excellent response rate even after the 1st and the 2nd injection. Females were less like to be frequency-based excellent responders. Chronic migraine sufferers without medication overuse and of female sex may find fewer benefits with onabotulinumtoxinA. Additionally, the excellent response status is identifiable after the first cycle.

AB0004 THE ASSOCIATION OF THE RARE RS35667974 IFIH1 GENE POLYMORPHISM WITH SIX AUTOIMMUNE DISEASES: STRUCTURAL BIOLOGICAL INSIGHTS

Background:

Genome wide association studies (GWAS) have successfully identified novel autoimmune disease-associated loci, with many of them shared by multiple disease-associated pathways but much of the genetics and pathophysiological mechanisms remain still obscure. Considering that most of the potential causal variants are still unknown, many studies showed that the missense variant rs35667974 at interferon induced with helicase C domain 1 (IFIH1) gene is protective for type 1 diabetes (T1D), psoriasis (PS) and psoriatic arthritis (PsA), while it was found to be also associated with ankylosing spondylitis (AS), Crohn’s disease (CD) and ulcerative colitis (UC). IFIH1 gene encodes a cytoplasmic RNA helicase that recognizes viral RNA and is involved in innate immunity through recognition of viral RNA [1].

Objectives:

To investigate the role of the rare rs35667974 variant of IFIH1 gene, which resides in exon 14 and changes a conserved isoleucine at position #923 to valine in T1D, PS, PsA, AS, CD and UC [2-4] as well as the mechanism that may affect the function in the protein structure.

Methods:

Evolutionary analysis revealed heavily conserved sequence elements among species, indicating structural/functional importance of the mutation at position #923. In silico mutagenesis and three-dimensional (3D) homology modeling was used to localize the polymorphism under study on the IFIH1 protein. The mutant was constructed using molecular modeling with the program Maestro (Schrodinger, LLC) [5]. Molecular mechanics/dynamics studies were applied to validate structural/functional changes caused by the Ile923V substitution. All figures depicting 3D models were generated using the PyMOL molecular-graphics system V.2.2 [6].

Results:

Evolutionary and structural analysis revealed that the position of residue Ile923 is located on a protein loop (921-927) directly interacting with mRNA both to the phosphoribose chain and the base pairs. Mutation of Ile to Val at position #923 will directly affect the said interaction with mRNA [7] (Figure 1). Moreover, it has been reported that pre-mRNA or mRNA levels did not correlate with Ile923Val, suggesting that, Ile923Val did not alter the expression of IFIH1 in a major way [7].

Figure 1.

Structural representation of the interferon-induced helicase C domain-containing protein 1 [Homo sapiens] structure (4GL2 from Protein Data Bank) (in green) bound to the double stranded RNA (in orange-yellow). The location of the mutation (I923V) is highlighted in pink. The proximity of the aminoacid 923 to the nucleotide is apparent.

Conclusion:

This study represents a comprehensive evaluation of the role of the shared rs35667974 variant of autoimmune locus IFIH1, reported to lead to a loss of function phenotype and, as a consequence, reduced levels of IFIH1 protein and activity that protect against autoimmunity. Structural analysis of rare shared genetic susceptibility or protection loci may provide insight to our understanding of the pathophysiology of autoimmune diseases and the research findings may affect the better management of the diseases under study.

References:

[1]Nejentsev S et al. (2009). Science 324:387–389.

[2]Smyth DJ et al. (2006). Nat Genet. 38: 617–619.

[3]Li Y et al. (2010). J Invest Dermatol 130:2768–2772.

[4]Ellinghaus D et al. (2016). Nat Genet 48:510–518.

[5]Schrödinger Release 2017-1: Maestro, Schrödinger, LLC, New York, NY, 2017.

[6]Schrödinger LLC: The PyMOL Molecular Graphics System 2016 version 2.2.

[7]Wu B et al. (2013). Cell 152:276-289[8] Downes K et al. (2010). PLoS One 5:e12646.

Disclosure of Interests:

None declared

Comparison of long-term survivals following hepatectomy for hepatocellular carcinoma according to the time-point of recurrence and treatment modalities for recurrent disease

Objective

Disease recurrence following curatively intended hepatectomy for hepatocellular carcinoma (HCC) limits oncologic outcome. Based on the extent, location and time-point of tumor recurrence, different therapeutic modalities are available to treat recurrent HCC. Therefore, our aim was to investigate the role of these treatments and the time-point of recurrence on long-term survival.

Methods

Clinicopathological data of patients, who underwent hepatectomy for HCC at a major hepatobiliary center in Switzerland between 2012 and 2019, were assessed. Patients suffering tumor recurrence were stratified according to the treatment modalities for recurrent HCC including surgical treatment (repeat hepatectomy or liver transplantation), interventional treatment, and conservative treatment (chemotherapy or best supportive care). Groups were compared regarding to overall survival (OS). Additionally, long-term outcomes were compared between patients with early (≤ 12 months) and late (&gt; 12 months) tumor recurrence.

Results

During the study period, 159 patients underwent hepatectomy for HCC. Median follow-up time was 53 months. After a median time of seven (1-64) months, 74 patients were diagnosed with tumor recurrence (47 %). The majority of patients developed early recurrence (n = 49) and 58 patients had intrahepatic recurrence only. Treatment options were re-resection, liver transplantation, interventional methods, and palliative therapy in 5, 15, 23, and 31 patients, respectively. Surgical treatment was significantly associated with improved OS compared to interventional and conservative treatment (5-year OS: 84% vs. 39% vs. 30%, p &lt; 0.0001). OS was significantly better among patients with late recurrence compared to patients with early recurrence, irrespective of the treatment modality used for the recurrent disease (5-year OS: 70% vs. 38%, p = 0.008).

Conclusion

Repeat hepatectomy or liver transplantation for recurrent HCC following hepatectomy is associated with better long-term survival compared to interventional or conservative therapies, especially for patients with late tumor recurrence. Patients with intrahepatic HCC recurrence should be evaluated according to the extent of tumor burden, liver function, and functional status to identify the best candidates for a surgical treatment.

Parenchymal-sparing hepatectomy for colorectal liver metastases reduces postoperative morbidity while maintaining equivalent oncologic outcomes compared to non-parenchymal-sparing resection

Objective

Modern chemotherapy and repeat hepatectomy allow to tailor the surgical strategies for the treatment of colorectal liver metastases (CRLM). This study addresses the hypothesis that parenchymal-sparing hepatectomy reduces postoperative complications while ensuring similar oncologic outcomes compared to the standardized non-parenchymal-sparing procedures.

Methods

Clinicopathological data of patients who underwent liver resection for CRLM between 2012 and 2019 at a major hepatobiliary center in Switzerland were assessed. Patients were stratified according to the tumor burden score [TBS2 = (maximum tumor diameter in cm)2 + (number of lesions)2)] and were dichotomized in a lower and a higher tumor burden cohort according to the median TBS. Postoperative outcomes, overall survival (OS) and disease-free survival (DFS) of patients following parenchymal-sparing resection (PSR) for CRLM were compared with those of patients undergoing non-PSR.

Results

During the study period, 153 patients underwent liver resection for CRLM with curative intent. PSR was performed in 79 patients with TBS &lt; 4.5, and in 42 patients with TBS ≥ 4.5. In patients with lower tumor burden (TBS &lt; 4.5), PSR was associated with lower complication rate (15.2% vs. 46.2%, p = 0.009), and shorter length of hospital stay (5 vs. 9 days, p = 0.006) in comparison to non-PSR. For TBS &lt; 4.5, PSR resulted in equivalent 5-year OS (48% vs. 39%, p = 0.479) and equivalent 5-year DFS rates (DFS, 44% vs. 29%, p = 0.184) compared to non-PSR. For TBS ≥ 4.5, PSR resulted in lower postoperative complication rate (33.3% vs. 63.2%, p = 0.031), lower length of hospital stay (6 vs. 9 days, p = 0.005), equivalent 5-year OS (29% vs. 22%, p = 0.314), and equivalent 5-year DFS rates (29% vs. 22%, p = 0.896) compared to non-PSR. Among all patients treated with PSR, patients undergoing minimal-invasive hepatectomy had equivalent 5-year OS (42% vs. 37%, p = 0.261) and equivalent 5-year DFS (34% vs. 34%, p = 0.613) rates compared to patients undergoing open hepatectomy.

Conclusion

PSR for CRLM is associated with lower postoperative morbidity, shorter length of hospital stay, and equivalent oncologic outcomes compared to non-PSR independently from tumor burden. Our findings suggest that minimal-invasive PSR should be considered as the preferred method for the treatment of curatively resectable CRLM if allowed by tumor size and location.

Major postoperative complications increase tumor recurrence rate and diminish long-term survival following resection for pancreatic ductal adenocarcinoma

Objective

Major complications have been associated with worse oncologic outcomes following resection for several gastrointestinal malignancies. However, the impact of major postoperative morbidity on the survival of patients undergoing resection for pancreatic ductal adenocarcinoma (PDAC) remains unclear.

Methods

Clinicopathological data of patients who underwent resection for PDAC between 2014 and 2019 in a major swiss hepatopancreatobiliary center were assessed. We evaluated the disease-free (DFS) and overall survival (OS) of patients suffering a major postoperative complication (grade-3 or higher within 90 days according to Clavien-Dindo classification) in comparison to those of patients without any major postoperative adverse events.

Results

During the study period, 186 patients underwent resection for PDAC with curative intent. Pancreatoduodenectomy, distal pancreatectomy, and total pancreatectomy were performed in 66%, 12%, and 22% of patients, respectively. Major 90-day postoperative morbidity and mortality rate were 21.5% and 4.3%, respectively. After excluding patients who died within 90 days, major postoperative morbidity significantly increased the length of hospital stay [median 22 (8-66) days vs. 13 (5-26) days, p &lt; 0.0001] resulting in a delay of returning to intended oncologic treatment and reducing the likelihood of receiving adjuvant chemotherapy (56% vs. 83%, p = 0.001). Postoperative major complications were associated with significantly worse DFS (median DFS 10 vs. 16 months, hazard ratio 1.9, 95% confidence interval 1.91-2.96, p = 0.004) and worse OS (median OS 14 vs. 37 months, hazard ratio 1.7, 95% confidence interval 1.02-2.75, p = 0.04) in multivariate analysis.

Conclusion

Major postoperative complications promote tumor recurrence following resection for PDAC, thus limiting long-term survival. Careful patient selection and optimized complication management may reduce postoperative morbidity, thereby lowering its negative impact on oncologic prognosis.

Endoscopic ultrasound-guided hepaticogastrostomy vs. ERCP for preoperative biliary drainage in patients undergoing pancreatic resection

Objective

Preoperative bile drainage in patients with obstructive jaundice due to pancreatic head malignancy is needed, if pancreatic head resection cannot be performed in a timely fashion. The safety and efficacy of ultrasound-guided hepaticogastrostomy (HGS) as an alternative to the established endoscopic retrograde cholangio-pancreatography (ERCP) with stent placement needs further investigation.

Methods

Clinicopathological data of patients who underwent partial or total pancreaticoduodenectomy between January 2017 and December 2019 in a major swiss hepatopancreatobiliary center were assessed. We compared the HGS with ERCP/stent regarding the kinetics of bilirubin decrease, the procedure-related morbidity, and the postoperative surgical outcomes.

Results

During the study period, 102 patients underwent pancreaticoduodenectomy or total pancreatectomy for pancreatic malignancy. Preoperative bile drainage was performed in 65 patients (20 HGS, 45 ERCP). HGS was associated with a faster (6 vs. 10 days, P = 0.042) and more effective (133 µmol/L vs. 101 µmol/L, P = 0.037) reduction of the serum bilirubin levels. HGS was safe and did not differ from ERCP with stent placement concerning post-interventional complications (P = 0.565), postoperative mortality (P = 0.996) and postoperative morbidity (P = 0.896), including infectious complications (wound infection, P = 0.662/ intra-abdominal abscess, P = 0.587), severe pancreatic fistula (P = 0.587), bile leak (P = 0.131), and postoperative hemorrhage (P = 0.886).

Conclusion

HGS performed in a specialized multidisciplinary hepatopancreatobiliary center is feasible and safe and may result in more accelerated and effective bile drainage compared to the established ERCP. In patients with obstructive jaundice related to pancreatic malignancy unable to undergo adequate bile drainage by ERCP, HGS may be an effective alternative method enabling surgery in a timely manner.

Radiological assessment of response and adverse events associated with novel systemic oncological therapies

The last decade has seen a paradigm shift in medical oncology treatment with the rise of novel systemic agents, principally molecular targeted therapy and immunotherapy. These new groups of anti-cancer treatment have revolutionised the prognostic landscape for certain patient cohorts with advanced disease, and it is hoped that through ongoing extensive clinical research, significant survival benefits may be demonstrated in the majority of tumour types. However, radiological response assessment of these new agents has become more nuanced for radiologists, as the behaviour of both responding and progressing tumour burden can be more diverse than with conventional chemotherapy. Additionally, radiologists need to be aware of adverse events associated with these treatments as some side effects carry a high morbidity/mortality and may manifest radiologically before they become clinically apparent. This review discusses radiological response assessment and adverse events associated with these novel agents, which have become fundamental aspects of systemic oncological therapy.

[Laparoscopic versus open gastrectomy for advanced gastric cancer : Operative and postoperative results]

BACKGROUND

Minimally invasive gastrectomy is increasingly becoming established worldwide as an alternative to open gastrectomy (OG); however, the majority of available articles in the literature refer to Asian populations and early stages of gastric cancer. This makes an international comparison difficult due to a discrepancy in patient populations and tumor biology as well as Asian and western treatment approaches. Little is known, therefore, whether laparoscopic gastrectomy (LG) can be performed in advanced cancer, in particular with respect to laparoscopic D2 lymphadenectomy, with sufficient radicality and safety in this country.

MATERIAL AND METHODS

All gastrectomies performed for the treatment of advanced gastric cancer with clinical UICC stages 2 and 3 between 2005 and 2017 were analyzed. A case match by age, gender and UICC stage was performed to compare the operative and early postoperative results of LG and OG.

RESULTS

A total of 243 patients with advanced gastric cancer were analyzed. Of these 81 patients (33.3%) underwent LG. The operative time for LG was around 74 min longer (279.2 min vs. 353.4 min, OG vs. LG; p < 0.001), the hospital stay after LG was around 4 days shorter (22.9 days vs. 18.4 days, OG vs. LG; p < 0.001). Significantly more lymph nodes were resected by LG (24.1 lymph nodes vs. 28.8 lymph nodes, OG vs. LG; p < 0.001). In terms of morbidity and mortality there were no differences between the groups.

CONCLUSION

The present study showed that minimally invasive gastrectomy can be performed safely and with comparable histopathological results to open surgery, even in advanced gastric cancer in western populations; however, larger case series and evidence from high-quality studies are urgently needed especially to compare short-term and long-term survival.

THU0027 THE ASSOCIATION OF THE RS35677470 DNASE1L3 GENE POLYMORPHISM WITH SLE, RA AND SSC: STRUCTURAL/BIOLOGICAL INSIGHTS

Background:

Genome-wide association studies (GWAS) have identified hundreds of autoimmune diseases-associated loci so far but much of the heritability of these diseases remains unknown. In an attempt to identify potential causal variants, various studies revealed that the missense variant rs35677470 atDNASE1L3is associated with the development of systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and systemic sclerosis (SSc), thus exhibiting a pleiotropic effect. Deoxyribonuclease I-like 3 (DNase1L3) is a member of human DNase I family, representing a nuclease that cleaves double-stranded DNA during apoptosis and is involved in the development of autoimmune diseases [1].

Objectives:

To investigate the role of the rs35677470 polymorphism atDNASE1L3gene leading to the R206C mutation in SLE, RA and SSc [2-3] and the mechanism that may affect the loss of function in the protein structure.

Methods:

TheDNASE1L3evolution was investigated to define conservation elements in the protein sequence using, BLASTP extended searches [4], TCOFFEE [5] multiple sequence alignments, and MEGAX [6] for phylogenetics analysis. Three-dimensional (3D) homology modeling was used to localize the polymorphism under study. The mutant was constructed by molecular modeling using the structures of homologous DNAses (PDB entries 1atn, 4awn, 3d3w; [7-9]). Molecular mechanics/dynamics studies were applied to validate structural/functional changes caused by the R206C substitution. All figures depicting 3D models were generated using the PyMOL molecular-graphics system V.2.2 (Schrodinger, LLC).

Results:

The evolutionary analysis shows heavily conserved sequence elements among species indicating structural/functional importance. Structural analysis revealed that the rs35677470 SNP codes for a nonconservative amino acid variation, R206C, disrupts the conserved electrostatic network holding protein secondary structure elements to place. Specifically, the R206 to E170 interaction, part of a salt bridge network stabilizing two a-helices, is being interrupted, thereby affecting the molecular architecture (Fig. 1). Indeed, previous studies on the effect of this SNP in Caucasian populations resulting in a lower level of DNAse1L3 activity are consistent with this observation [10].

Figure 1.

Ribbon representation of the DNAse1L3 homology model showing the position of the stabilizing salt bridge network (E170- R206, R208- D219). Insert figure shows the R206C mutation. Positively charged R (in blue), negatively charged D,E (in red) and C (in yellow) are shown. Distances are in Angstroms.

Conclusion:

This study represents a comprehensive evaluation of the shared autoimmune loci ofDNASE1L3(rs35677470), reported to produce an inactive form of DNaseIL3 [10]. The structural analysis, explains the potential role of the produced mutation by modifying the placement of structural elements and consequently introducing disorder in the protein folding and affecting biological function. Altogether, this study contributes to the delineation of the genetic architecture of SLE, RA and SSc.

References:

[1]Sisirak V et al (2016). Cell 166:88–101

[2]Westra HJ et al (2018). Nat Genet. 50:1366-74

[3]Acosta-Herrera M et al. (2018). Ann Rheum Dis. 78:311-19

[4]Altschul SF et al (1997) Nucleic Acids Res. 25:3389-402.

[5]Notredame et al (2000) JMB, 302:205-17

[6]Kumar S et al (2018) Mol. Biol. Evol. 35:1547-9

[7]Kabsch W et al (1990) Nature 347: 37-44

[8]Parciegla et al (2012) Biochemistry 51: 10250

[9]Sasaki K et al (1993) Acta Cryst., A 49: 111-2

[10]Ueki et al (2009) Clinica Chim. Acta 407:20–4

Disclosure of Interests:

None declared

De-novo Upper Gastrointestinal Tract Cancer after Liver Transplantation: A Demographic Report

BACKGROUND

Immunosuppression is essential after liver transplantation (LT). It, however, increases the risk for cancer.

OBJECTIVE

To evaluate the prevalence and outcome of upper gastrointestinal (GI) tract cancer in LT patients and assess the perioperative risk of surgery for the upper GI malignancies post-LT.

METHODS

2855 patients underwent LT at our clinic from 1988 to 2018. 20 patients developed upper GI cancer. Data were retrospectively extracted from our database. Analysis included patients' specific data, tumor histopathology and stage, the treatment given and survival.

RESULTS

23 patients developed upper GI malignancies (2 gastric and 18 esophageal cancers; 3 excluded), translating to a incidence of 26.4 per 100,000 population per year. All patients were male. 80% showed alcohol-induced cirrhosis before LT. Most of the tumors were diagnosed at a stage ≥III. 70% underwent surgery and 78.6% developed postoperative complications. One-year-survival was 50%. Total survival rate was 28.6% with a median follow-up of 10 months (range: 0-184).

CONCLUSION

Upper GI malignancies are more common after LT compared to the general population. Men after LT, due to alcohol-induced liver cirrhosis, are at a higher risk. Upper GI surgery after LT can be safe, but the severe risk for complications and a poor survival require strict indications.

A multicentre assessment of prostate MRI quality and compliance with UK and international standards

AIM

To assess prostate magnetic resonance imaging (MRI) image quality and compliance with technical standards between centres in the South West region of the UK.

MATERIALS AND METHODS

Fifteen imaging sites in the region submitted seven consecutive anonymised MRI studies. These were assessed by two experienced radiologists in consensus. Overall, subjective image quality for T2-weighted imaging (T2W), diffusion weighted imaging (DWI), and dynamic contrast enhancement (DCE) was scored on a five-point Likert scale. Five additional quality parameters were also assessed visually, including image noise, motion, artefact, and distortion. The degree of compliance by each site with 21 published technical standards was also assessed.

RESULTS

Ninety-four MRI examinations were reviewed from across all sites (mean 6.3 scans per site, range 5-7). Mean compliance with technical standards was 63% (range 38-86%). Forty-seven percent of sites did not perform DCE. One site used a 3 T scanner. The percentage of patients with overall quality scores of ≥3 (diagnostically acceptable) were 68% for T2W, 81% for DWI, and 60% for both T2W and DWI. Ninety-three percent of the 45 patients who underwent DCE had diagnostically acceptable studies. By scanner age, the percentage of patients with diagnostically acceptable T2W scores was 53% for scanners ≥7 years and 80% when <7 years (p=0.006). Comparing individual sites, the mean overall quality scores were 2.9 (range 2.2-4.2) for T2W, 3.2 (1.8-4.7) for DWI, and 3.4 (2.5-4.7) for DCE.

CONCLUSION

There is wide variation in compliance with recognised technical standards and image quality across sites. If MRI is to replace biopsy in selected low-risk patients, improvements in image quality may be required.

Primary headaches during lifespan

Primary headaches are one of the most prevalent neurological disorders and can occur during a wide range of lifespan. Primary headaches, especially migraine, are cyclic disorders with a complex sequence of symptoms within every headache attack. There is no systematic review of whether these symptoms changes during lifespan. Indeed, the clinical presentation of migraine shows an age-dependent change with a significantly shorter duration of the attacks and occurrence of different paroxysmal symptoms, such as vomiting, abdominal pain or vertigo, in childhood and, in contrast, largely an absence of autonomic signs and a more often bilateral headache in the elderly. The age-dependent differences in the clinical presentation are less distinct in cluster headache and, especially, in tension-type headache. The differences in the clinical presentation are in agreement with the idea that the connectivity of hypothalamic areas with different brainstem areas, especially the central parasympathetic areas, is important for the clinical manifestation of migraine, as well as, the change during lifespan.

Organic synthesis in a modular robotic system driven by a chemical programming language

The synthesis of complex organic compounds is largely a manual process that is often incompletely documented. To address these shortcomings, we developed an abstraction that maps commonly reported methodological instructions into discrete steps amenable to automation. These unit operations were implemented in a modular robotic platform by using a chemical programming language that formalizes and controls the assembly of the molecules. We validated the concept by directing the automated system to synthesize three pharmaceutical compounds, diphenhydramine hydrochloride, rufinamide, and sildenafil, without any human intervention. Yields and purities of products and intermediates were comparable to or better than those achieved manually. The syntheses are captured as digital code that can be published, versioned, and transferred flexibly between platforms with no modification, thereby greatly enhancing reproducibility and reliable access to complex molecules.

Hepatotoxicity following systemic therapy for colorectal liver metastases and the impact of chemotherapy-associated liver injury on outcomes after curative liver resection

Patients with colorectal liver metastases (CLM) have remarkably benefited from the advances in medical multimodal treatment and surgical techniques over the last two decades leading to significant improvements in long-term survival. More patients are currently undergoing liver resection following neoadjuvant chemotherapy, which has been increasingly established within the framework of curative-indented treatment strategies. However, the use of several cytotoxic agents has been linked to specific liver injuries that not only impair the ability of liver tissue to regenerate but also decrease long-term survival. One of the most common agents included in modern chemotherapy regimens is oxaliplatin, which is considered to induce a parenchymal damage of the liver primarily involving the sinusoids defined as sinusoidal obstruction syndrome (SOS). Administration of bevacizumab, an inhibitor of vascular endothelial growth factor (VEGF), has been reported to improve response of CLM to chemotherapy in clinical studies, concomitantly protecting the liver from the development of SOS. In this review, we aim to summarize current data on multimodal treatment concepts for CLM, give an in-depth overview of liver damage caused by cytostatic agents focusing on oxaliplatin-induced SOS, and evaluate the role of bevacizumab to improve clinical outcomes of patients with CLM and to protect the liver from the development of SOS.

[The Impact of Tumor Cell Proliferation on Occult Micrometastases, Tumor Recurrence and Patient Outcome Following Resection for Liver Malignancies]

Liver resection is currently considered to be essential part of the curative treatment of primary and secondary liver malignancies. However, long-term survival in these patients is limited by the high incidence of tumor recurrence. Recent clinical and experimental studies have indicated that cellular and molecular mechanisms associated with liver regeneration after partial hepatectomy may have a proliferative effect on occult micrometastases and circulating tumor cells and are thus responsible for recurrent disease. Growth factors and cytokines involved in liver regeneration have also been shown to influence tumour growth and metastasis. However, the underlying mechanisms explaining the interactions between regenerating liver tissue and tumour cell proliferation remain unclear. The development of modern agents specifically targeting these processes may improve disease-free and overall survival rates after oncological hepatectomy.

Divergence from the classical hydroboration reactivity; boron containing materials through a hydroboration cascade of small cyclic dienes

Quantitative dihydroboration of cyclic dienes leading to new, tunable boron-containing hydrocarbon polymeric materials.

The hydroboration 1,3- and 1,4-cyclic dienes has been systematically investigated. The behavior of such dienes towards mono and dihydroboration was monitored directly by ¹¹B NMR to identify the actual boron species formed, as opposed to the most common analysis of the resultant oxidation products. Quantitative dihydroboration was achieved for the full range of cyclic dienes investigated including dienes, which were previously reported to be resistant to dihydroboration, leading to the formation of new boron-containing polymeric materials. The conditions favoring dihydroboration are reported as well as full characterisation of the materials. Furthermore, a hydroboration cascade mechanism is proposed for the formation of such boron-containing polymers, supported by both experimental and theoretical data.

Twenty-year longitudinal follow-up after orthotopic liver transplantation: a single-center experience of 313 consecutive cases

With excellent short-term survival in liver transplantation (LT), we now focus on long-term outcome and report the first European single-center 20-year survival data. Three hundred thirty-seven LT were performed in 313 patients (09/88-12/92). Impact on long-term outcome was studied and a comparison to life expectancy of matched normal population was performed. A detailed analysis of 20-years follow-up concerning overweight (HBMI), hypertension (HTN), diabetes (HGL), hyperlipidemia (HLIP) and moderately or severely impaired renal function (MIRF, SIRF) is presented. Patient and graft survival at 1, 10, 20 years were 88.4%, 72.7%, 52.5% and 83.7%, 64.7% and 46.6%, respectively. Excluding 1-year mortality, survival in the elderly LT recipients was similar to normal population. Primary indication (p < 0.001), age (p < 0.001), gender (p = 0.017), impaired renal function at 6 months (p < 0.001) and retransplantation (p = 0.034) had significant impact on patient survival. Recurrent disease (21.3%), infection (20.6%) and de novo malignancy (19.9%) were the most common causes of death. Prevalence of HTN (57.3-85.2%, p < 0.001), MIRF (41.8-55.2%, p = 0.01) and HBMI (33.2-45%, p = 0.014) increased throughout follow-up, while prevalence of HLIP (78.0-47.6%, p < 0.001) declined. LT has conquered many barriers to achieve these outstanding long-term results. However, much work is needed to combat recurrent disease and side effects of immunosuppression (IS).

Measurement reproducibility of perfusion fraction and pseudodiffusion coefficient derived by intravoxel incoherent motion diffusion-weighted MR imaging in normal liver and metastases

OBJECTIVE

To determine the measurement reproducibility of perfusion fraction f, pseudodiffusion coefficient D and diffusion coefficient D in colorectal liver metastases and normal liver.

METHODS

Fourteen patients with known colorectal liver metastases were examined twice using respiratory-triggered echo-planar DW-MRI with eight b values (0 to 900 s/mm(2)) 1 h apart. Regions of interests were drawn around target metastasis and normal liver in each patient to derive ADC (all b values), ADC(high) (b values ≥ 100 s/mm(2)) and intravoxel incoherent motion (IVIM) parameters f, D and D by least squares data fitting. Short-term measurement reproducibility of median ADC, ADC(high), f, D and D values were derived from Bland-Altman analysis.

RESULTS

The measurement reproducibility for ADC, ADC(high) and D was worst in colorectal liver metastases (-21 % to +25 %) compared with liver parenchyma (-6 % to +8 %). Poor measurement reproducibility was observed for the perfusion-sensitive parameters of f (-75 % to +241 %) and D (-89 % to +2,120 %) in metastases, and to a lesser extent the f (-24 % to +25 %) and D (-31 % to +59 %) of liver.

CONCLUSIONS

Estimates of f and D derived from the widely used least squares IVIM fitting showed poor measurement reproducibility. Efforts should be made to improve the measurement reproducibility of perfusion-sensitive IVIM parameters.

Endovascular treatment of ruptured dissecting posterior inferior cerebellar artery aneurysms

Dissecting aneurysms of the posterior inferior cerebellar artery (PICA) distal to its origin from vertebral artery (VA) are very rare. Although rare, they associated with a high risk of rebleeding and they present a therapeutic challenge. This study reviewed the clinical presentations, angiographic characteristics of dissecting aneurysms of the PICA and to assess the clinical and angiographic outcomes of patients who underwent endovascular treatment. Ten patients with ten dissecting aneurysms who underwent endovascular treatment were identified in the clinical records of a single medical center from January 2000 to December 2010. The mean follow-up duration was 2.8 years. All patients presented with subarachnoid hemorrhage (SAH). They all underwent endovascular treatment, which included occlusion of the dissected segment and the parent artery after detailed angiographic evaluation of the vascular anatomy, and test occlusion of the PICA. In all patients the endovascular treatment was successfully completed without procedure related complications. Long-term follow-up studies in seven out of ten patients showed complete occlusion of the aneurysm with no new neurologic deficits. The clinical outcome was good in eight cases, whereas two patients with poor clinical condition at admission died during their initial hospital stay. Endovascular occlusion of the parent vessel and the dissected segment is relatively safe treatment option for dissecting aneurysms of the PICA distal to its origin.

Reversible cerebral vasoconstriction syndrome: treatment with multiple sessions of intra-arterial nimodipine and angioplasty

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by acute severe headache with or without additional neurological symptoms and reversible cerebral vasoconstriction. Unruptured aneurysms have been reported in some cases with RCVS. We describe a severe case of a 50-year-old woman with RCVS presenting as cortical subarachnoid hemorrhage. Cerebral angiogram demonstrated the typical angiographic findings of RCVS and two very small unruptured aneurysms of the left internal carotid artery. The patient was treated with calcium channel blockers and the two aneurysms were successfully treated endovascularly. On day 16 the patient developed new focal neurological symptoms (severe paraparesis) and was successfully treated with intraarterial nimodipine and angioplasty in multiple sessions.

New strategies in the treatment of coronary bifurcations

Despite major improvements in stent technology (i.e., drug-eluting stents, DES), treatment of coronary bifurcations is an ever occurring problem of the interventional cardiology. While stenting the main branch with provisional side branch stenting seems to be the prevailing approach, in the era of DES various two-stent techniques emerged (crush) or were re-introduced (V or simultaneous kissing stents, crush, T, culottes, etc.) to allow stenting in the side branch when needed. New techniques in imaging like optical coherence tomography help in better understanding bifurcation anatomy and, thus, have the potential to help us better treat this challenging subset of lesions. In addition, new dedicated bifurcation stents have been proposed in an attempt to overcome limitations associated with current approaches, and they showed promising results in early studies; however, the safety and the efficacy of these devices remain to be seen in the ongoing and upcoming trials. This review focuses on the current approaches and the development of new techniques employed for the treatment of bifurcation disease.

Association of the PTPN22 R620W polymorphism with increased risk for SLE in the genetically homogeneous population of Crete

Autoimmune diseases affect approximately 5% of the population, but much work remains to define the genetic risk factors and pathogenic mechanisms underlying these conditions. There is accumulating evidence that common genetic factors might predispose to multiple autoimmune disorders. Systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) are complex autoimmune disorders with multiple susceptibility genes. The functional R620W (C1858T) polymorphism of the protein tyrosine phosphatase non-receptor type 22 (PTPN22) gene, a member of the PTPs that negatively regulate T-cell activation, has been recently associated with susceptibility to various autoimmune diseases. The aim of this study was to assess whether the C1858T polymorphism of PTPN22 also confers increased risk for SLE and RA in the genetically homogeneous population of Crete. It was found that the minor T allele of the PTPN22 C1858T SNP was more common in SLE patients than in control individuals (odds ratio [OR] = 1.91, 95% confidence interval [CI] = 1.11 to 3.9, p = 0.017). No significant difference was observed in the frequency of this allele when RA patients were compared with controls (OR = 1.14, 95% CI = 0.65 to 1.9, p = 0.64). Although the PTPN22 1858 T allele is found at decreased frequency in Southern Europe, including Crete, an association was found between this allele and SLE in the population studied.

Diffusion-weighted magnetic resonance imaging for tumour response assessment: why, when and how?

Diffusion-weighted magnetic resonance imaging (DWI) is increasingly being used to assess tumour response to a variety of anticancer treatments. The technique is quick to perform without the need for administration of exogenous contrast medium, and enables the apparent diffusion coefficient (ADC) of tissues to be quantified. Studies have shown that ADC increases in response to a variety of treatments including chemotherapy, radiotherapy, minimally invasive therapies and novel therapeutics. In this article, we review the rationale of applying DWI for tumour assessment, the evidence for ADC measurements in relation to specific treatments and some of the practical considerations for using ADC to evaluate treatment response.

[Second-look operation in pancreatic carcinoma previously assessed as unresectable]

BACKGROUND

The only curative therapy for patients with pancreatic carcinoma consists of -complete surgical tumour removal. Preoperative diagnostic investigations may help, however, the definite decision on tumour resectability can only be made intraoperatively during explorative laparotomy.

PATIENTS AND METHODS

We report herein on 17 patients who were judged during exploratory laparotomy elsewhere to suffer from non-resectable pancreatic cancer and who underwent a second-look operation after referral to our hospital.

RESULTS

During the second-look operation 13 patients (76.5 %) underwent tumour resection, where-as in 4 patients (23.5 %) the tumour remained non-resectable. An R0 resection was achieved in 9 of 13 (69 %) and an R1 resection in 4 of 13 (31 %) patients, respectively. The classic Kausch-Whipple operation was performed in 4, pylorus-preserving pancreaticoduodenectomy in 5, and left pancreatic -resection in another 4 patients. Mean survival in patients after tumour resection was increased, reach-ing 17.6 months compared to 6.5 months in patients with non-resectable pancreatic cancer.

CONCLUSIONS

Our results suggest that the prediction of resectability depends highly on the experience of the surgical team. Although considered as non-resectable during prior laparotomy else-where, the majority of patients (76.5 %) suffered from a resectable tumour disease. Moreover, most of them (69 %) underwent complete (R0) -tumour removal. Thus, complex visceral operations like pancreatic carcinoma resection should preferably be performed in high-volume centres exclusively.

Successful embolization of a giant perimedullary arteriovenous fistula of the cervical spine in a 6-year-old child

CASE

We report a case of a 6-year-old boy with a giant perimedullary arteriovenous fistula of the cervical spine who presented with progressive tetraparesis.

METHOD

Transarterial glue embolization was performed and complete occlusion of the fistula was achieved.

RESULT

The patient's symptoms resolved completely during the next year.

Assessing the effects of three dental impression materials on the isolated sciatic nerve of rat and frog

The effects on nerve tissue of three dental impression pastes were compared in this study. Two of the impression pastes, Examix and Express 3M, contained vinyl polysiloxane while the other, Xanthopren, did not. An in vitro model based on the isolated sciatic nerve of the frog and rat was used. As an indication of the proper functioning of the fibres in the nerve, the amplitude of evoked compound action potential (CAP) was monitored continuously. The results clearly showed that the number of active nerve fibres in the isolated sciatic nerves of either rat or frog exposed directly to impression pastes containing vinyl polysiloxane, decreased much faster than those of the nerves in contact to impression material without vinyl polysiloxane. When the nerve of the frog was exposed to Xanthopren there was a decrease in the CAP to 50% of the control values within 56.87+/-2.42 h (n=6). This value was called inhibition time to 50%, IT(50) and for Examix it was found to be 9.97+/-1.53 h. When the nerve of the rat was exposed to Xanthopren, the IT(50) was 15.34+/-2.97 h (n=6) for the Xanthopren and only 2.86+/-1.20 h for Examix and 2.76+/-0.48 h for Express 3M (n=6). There was no significant difference between the action of the last two compounds (P=0.85). This fast nerve fibre inactivation could be caused either by the chemical used for the synthesis of the two impression pastes, Examix and Express 3M, or by the unusual constriction of the nerve when it is embedded in the materials with vinyl polysiloxane. There is strong evidence to support the first case, since the incubation of the nerve in the presence of Examix, Express 3M and Xantopren in a way so the nerve was not in contact with the impression pastes, shows a much faster decrease of the CAP in the presence of the first two pastes. The decrease is caused by the death of nerve fibres, since there is no recovery in the CAP after the removal of Examix from the incubating saline.

Endovascular treatment of peripheral intracranial aneurysms

BACKGROUND AND PURPOSE

Distally located cerebral aneurysms are difficult to treat with preservation of the parent vessel. We report the angiographic results and clinical outcome for 27 patients with peripheral cerebral aneurysms.

METHODS

From January 2000 to June 2005, 27 patients, 13 female and 14 male, presented to our institution with peripheral intracranial aneurysms and were treated endovascularly. None of these aneurysms were mycotic in origin. The age of our patients ranged from 23 to 76 years with a mean age of 53. Twenty of the 27 patients had subarachnoid and/or intracerebral hemorrhage upon presentation. In 5 patients, the aneurysm was an incidental finding. One patient with a fusiform P2 aneurysm presented with cranial nerve III palsy, and another patient with P4 aneurysm had visual disturbances. Locations of the aneurysms were as follows: posterior cerebral artery in 9 patients, superior cerebellar artery in 5 patients, anterior inferior cerebellar artery in 1 patient, posterior inferior cerebellar artery in 5 patients, middle cerebral artery (MCA) in 5 patients, and anterior cerebral artery in 2 patients.

RESULTS

Seven patients were treated with selective embolization with Guglielmi detachable coils (GDCs). Nineteen patients with fusiform aneurysms underwent parent artery occlusion (PAO). Fifteen PAOs were performed with coils and 4 with glue. One patient with a MCA aneurysm was found at the time of planned embolization to have spontaneously thrombosed the aneurysm and the distal branch of the MCA, 1 day after the initial diagnostic angiogram. Five patients (5/18 or 27.7%) who underwent PAO developed neurologic deficits. Two patients (2/18 or 11.1%) had permanent neurologic deficits (a visual field defect).

CONCLUSION

Our results support that distally located aneurysms can be treated with endovascular PAO in the cases in which selective occlusion of the aneurysmal sac with GDC or surgical clipping cannot be achieved.

Molecular profiling of bladder tumors based on the detection of FGFR3 and TP53 mutations

PURPOSE

On a routine basis we performed systematic molecular screening for FGFR3 and TP53 mutations in 121 bladder tumors. We then specifically analyzed the predictive value of the recurrence of FGFR3 and TP53 genotypes in superficial lesions.

MATERIALS AND METHODS

The FGFR3 gene was analyzed by direct sequencing of exons 7, 10 and 15, whereas TP53 status was determined using the p53 functional assay in yeast.

RESULTS

We identified a missense FGFR3 mutation in 66% of pTa, 26% of pT1 and 12% of pT2 tumors. Of activating FGFR3 mutations 54% and 85% were found in low G1 and intermediate G2 grade tumors, respectively, but in only 20% of high grade G3 tumors. We detected inactivating TP53 mutations in 10% of pTa, 42% of pT1 and 58% of pT2 tumors. Moreover, TP53 mutations were found only in 23% of grade G1 and 3% of grade G2 tumors but in 44% of high grade G3 tumors. When the 2 genotypes were combined, we observed that 58% of pTa tumors had the (mutant FGFR3, WT TP53) genotype, whereas 58% of invasive lesions harbored the inverse genotype (WT FGFR3, mutant TP53). The (mutant FGFR3, WT TP53) genotype and the (WT FGFR3, mutant TP53) genotype were detected in 23% and 38% of pT1G3 tumors, respectively. In the subgroup of 92 patients with superficial pTa-T1 bladder tumors we did not find that the TP53 or FGFR3 genotype alone or combined had a predictive value for tumor recurrence.

CONCLUSIONS

Our data again represent solid proof for the pivotal role of FGFR3 and TP53 mutations in superficial and invasive bladder tumors, respectively. However, other molecular markers should be identified for borderline pT1G3 bladder tumors, which are probably at the crossroads of these 2 distinct molecular pathways.

Multi-purpose HealthCare Telemedicine Systems with mobile communication link support

The provision of effective emergency telemedicine and home monitoring solutions are the major fields of interest discussed in this study. Ambulances, Rural Health Centers (RHC) or other remote health location such as Ships navigating in wide seas are common examples of possible emergency sites, while critical care telemetry and telemedicine home follow-ups are important issues of telemonitoring. In order to support the above different growing application fields we created a combined real-time and store and forward facility that consists of a base unit and a telemedicine (mobile) unit. This integrated system: can be used when handling emergency cases in ambulances, RHC or ships by using a mobile telemedicine unit at the emergency site and a base unit at the hospital-expert's site, enhances intensive health care provision by giving a mobile base unit to the ICU doctor while the telemedicine unit remains at the ICU patient site and enables home telemonitoring, by installing the telemedicine unit at the patient's home while the base unit remains at the physician's office or hospital. The system allows the transmission of vital biosignals (3-12 lead ECG, SPO2, NIBP, IBP, Temp) and still images of the patient. The transmission is performed through GSM mobile telecommunication network, through satellite links (where GSM is not available) or through Plain Old Telephony Systems (POTS) where available. Using this device a specialist doctor can telematically "move" to the patient's site and instruct unspecialized personnel when handling an emergency or telemonitoring case. Due to the need of storing and archiving of all data interchanged during the telemedicine sessions, we have equipped the consultation site with a multimedia database able to store and manage the data collected by the system. The performance of the system has been technically tested over several telecommunication means; in addition the system has been clinically validated in three different countries using a standardized medical protocol.

Xeroderma pigmentosum group G with severe neurological involvement and features of Cockayne syndrome in infancy

We describe a premature, small for gestational age infant girl with micropthalmia, bilateral congenital cataracts, hearing impairment, progressive somatic and neurodevelopmental arrest, and infantile spasms. She presented a massive photosensitive reaction with erythema and blistering after minimal sun exposure, which slowly gave place to small skin cancers. Her skin fibroblasts were 10-fold more sensitive than normal to UV exposure due to a severe deficiency in nucleotide excision repair. By complementation analysis, the patient XPCS4RO was assigned to the very rare xeroderma pigmentosum (XP) group G (XP-G). One allele of her XPG gene contained a 526C-->T transition that changed Gln-176 to a premature UAG stop codon. Only a minor fraction of XPG mRNA was encoded by this allele. The second, more significantly expressed XPG allele contained a 215C-->A transversion. This changed the highly conserved Pro-72 to a histidine, a substitution that would be expected to seriously impair the 3' endonuclease function of XPG in nucleotide excision repair. In cases suspected of having XP and/or early-onset Cockayne syndrome, extensive DNA repair studies should be performed to reach a correct diagnosis, thereby allowing reliable genetic counseling and prenatal diagnosis.

One-sided high-frequency oscillatory ventilation in the management of an acquired neonatal lobar emphysema: a case report and review

We describe a premature infant (gestational age 28 weeks and birth weight 1280 g) with a left-sided acquired lobar emphysema (ALPE). Left lateral decubitus positioning, right-sided conventional ventilation (CV), tracheal high-frequency oscillatory ventilation (HFOV), and dexamethasone administration were subsequently used in the treatment without success. The emphysema was resolved and the patient was extubated after selective intubation and HFOV of the right unaffected lung. We also review the reported cases of ALPE in neonates that were treated by one-sided high-frequency ventilation (HFV).

Utility of brainstem auditory evoked potentials in children with spastic cerebral palsy

In a retrospective study of 75 children with spastic cerebral palsy (CP), brainstem auditory evoked potentials (BAEP) were recorded and subsequently correlated with birthweight, gestational age, aetiology and type of CP, neuroradiological findings, additional impairments and disabilities (including the inability to walk independently). Seventeen patients (22.7%) had abnormal BAEP recordings. Thirteen of these 17 patients (76.5%) had spastic tetraplegia, 16 patients (94.1%) were full-term infants, 12 patients (70.6%) had myoskeletal problems, 9 (52.9%) had epilepsy, 16 (94.1%) had visual impairment, 13 patients (76.5%) were unable to walk independently, while all 17 patients (100%) had speech impairment and mental retardation. The aetiology of CP was prenatal in 2 of these 17 patients (11.8%) and perinatal in 15 patients (88.2%). Thirteen patients (76.5%) had cortical atrophy determined by either computed tomography or magnetic resonance imaging, two patients (11.8%) had an infarct picture and two patients (11.8%) had maldevelopment of the central nervous system. There was a definite statistically significant association between abnormal BAEP recordings and full-term delivery, perinatal aetiology of CP, spastic tetraplegia, speech, visual and myoskeletal impairments, epilepsy, mental retardation, inability to walk independently and cortical atrophy on neuroimaging (p < 0.001). We conclude that abnormal BAEP recordings in children with spastic CP are indicative of poor prognosis and associated with a "multihandicap state". BAEP testing should be incorporated into the diagnostic plan of all children with spastic CP newly referred to neurodevelopmental centres.

Biomechanical stability of five stand-alone anterior lumbar interbody fusion constructs

Anterior lumbar interbody fusion (ALIF) cages are expected to reduce segmental mobility. Current ALIF cages have different designs, suggesting differences in initial stability. The objective of this study was to compare the effect of different stand-alone ALIF cage constructs and cage-related features on initial segmental stability. Human multisegmental specimens were tested intact and with an instrumented L3/4 disc level. Five different ALIF cages (I/F, BAK, TIS, SynCage, and ScrewCage) were tested non-destructively in axial rotation, flexion/extension and lateral bending. A cage 'pull-out' concluded testing. Changes in neutral zone (NZ) and range of motion (ROM) were analyzed. Cage-related measurements normalized to vertebral dimensions were used to predict NZ and ROM. No cage construct managed to reduce NZ. The BAK and TIS cages had the largest NZ increase in flexion/extension and lateral bending, respectively. Cages did reduce ROM in all loading directions. The TIS cage was the least effective in reducing the ROM in lateral bending. Cages with sharp teeth had higher 'pull-out' forces. Antero-posterior and mediolateral cage dimensions, cage height and wedge angle were found to influence initial stability. The performance of stand-alone ALIF cage constructs generally increased the NZ in any loading direction, suggesting potential directions of initial segmental instability that may lead to permanent deformity. Differences between cages in flexion/extension and lateral bending NZ are attributed to the severity of geometrical cage-endplate surface mismatch. Stand-alone cage constructs reduced ROM effectively, but the residual ROM present indicates the presence of micromotion at the cage-endplate interface.

Ilio-psoas abscess in a neonate

A full-term, small-for-gestational-age, neonate was born 4 days after rupture of the membranes. On the 5th day of life, she developed sepsis due to Klebsiella pneumoniae. On the 18th day of life, the right hip was noted swollen with limited range of motion, but it was painless on passive movements. Ultrasonography revealed abscess of the right ilio-psoas muscle with normal appearance of the right hip joint. Surgical incision and drainage and antibiotic administration resulted in a gradual full recovery. Ultrasonography can confirm the diagnosis of this exceptional clinical entity in neonates, which is difficult to differentiate from septic arthritis of the hip.

Primary cutaneous aspergillosis in neonates: case report and review

A premature neonate (gestational age, 26 weeks) with multiple prematurity-related problems developed primary cutaneous aspergillosis due to Aspergillus fumigatus on the 30th day of life. The infection developed in an area that had been macerated by adhesive tape. During the infection, renovation of the hospital was in progress near the neonatal intensive care unit. The infection was cured with a short course of therapy with amphotericin B. Five cases of primary cutaneous aspergillosis in neonates have been previously reported in the English-language literature. We review these cases and discuss the risk factors and favorable outcome of the disease when treatment with amphotericin B is instituted.

Fetal varicella syndrome with manifestations limited to the eye

The manifestations of fetal varicella syndrome usually involve several organ systems, including skin, ocular, neurologic, gastrointestinal, and genitourinary. Although ocular anomalies have been reported to be as high as 68%, manifestations limited to the eyes is extremely rare. Herein we report the case of fetal varicella syndrome with no clinical signs other than esotropia and a chorioretinal scar.