Paraspinous Muscle Flaps in Complex Pediatric Spine Surgeries: A 12-Year Single Institution Experience

PURPOSE

The benefits of paraspinous flaps in adult complex spine surgery patients are established in the literature; however, their use in pediatric patients has not been well described. This study compares clinical outcomes with and without paraspinous muscle flap closure in pediatric patients who have undergone spine surgery.

METHODS

We conducted a retrospective review of all pediatric spine surgeries at the University of California, San Francisco from 2011 to 2022. Patients were divided into 2 cohorts based on whether the plastic surgery service closed or did not close the wound with paraspinous muscle flaps. We matched patients by age, American Society of Anesthesiology classification, prior spinal surgical history, and diagnosis. Surgical outcomes were compared between the 2 cohorts.

RESULTS

We identified 226 pediatric patients who underwent at least one spinal surgery, 14 of whom received paraspinous flap closure by plastic surgery. They were matched in a 1:4 ratio with controls (n = 56) that did not have plastic surgery closure. The most common indication for plastic surgery involvement was perceived complexity of disease by the spine surgeon with concern for inadequate healthy tissue coverage (78.6%), followed by infection (21.4%). Postoperative complications were similar between the two groups. The plastic surgery cohort had a higher rate of patients who were underweight (57.1% vs 14.3%, P < 0.01) and had positive preoperative wound cultures (28.6% vs 8.9%, P = 0.05), as well as a higher rate of postoperative antibiotic usage (78.6 vs 17.9%, P < 0.01). There was no difference in recorded postoperative outcomes.

CONCLUSIONS

Spine surgeons requested paraspinous flap closure for patients with more complex disease, preoperative infections, history of chemotherapy, or if they were underweight. Patients with paraspinous flap coverage did not have increased postoperative complications despite their elevated risk profile. Our findings suggest that paraspinous muscle flaps should be considered in high-risk pediatric patients who undergo spine surgery.

Gender Is a Spectrum: Evaluating Current and Novel Ways to Inquire About Gender Identity in the Health Care Setting

PURPOSE

The use of visuals to inquire about gender in the clinical setting has been rare. We developed a survey that included a visual spectrum to assess perceptions about the most and least inclusive ways of inquiring about gender in patients with gender dysphoria.

METHODS

The survey included a multiple-choice question (MCQ), free-response question, and a visual spectrum on which respondents were asked to select one box that best depicts their gender. The survey was administered to all patients diagnosed with gender dysphoria at our institution between April and June 2022.

RESULTS

A total of 223 of 856 patients responded. Those with more masculine gender identities selected boxes near the visual spectrum corner of "man," whereas responses were more variable for more feminine genders. The free-response question was identified by 59% of respondents as the most inclusive. The MCQ was identified as least inclusive by 70.4%. The visual spectrum was considered the most inclusive method by the majority of patients who self-identified as woman and demiwoman/demifemale. Being asked about pronouns was extremely or very important in the health care setting for 52% of respondents, but 68.6% indicated that they are rarely or sometimes asked about their pronouns in this setting.

CONCLUSIONS

The traditional MCQ format for self-identifying gender may be lacking in inclusivity and fails to represent the nuances of gender identity. Free response was considered the most inclusive way to inquire about gender among our respondents. These findings highlight the importance of formatting gender identity questionnaires to foster inclusivity for transgender patients.

The Effect of Pectoral Nerve Blocks on Opioid Use and Postoperative Pain in Masculinizing Mastectomy: A Randomized Controlled Trial

BACKGROUND

Bilateral masculinizing mastectomy is the most common gender-affirmation operation performed. Currently, there is lack of data regarding intraoperative and postoperative pain control for this population. It is the authors' aim to study the effects of the pectoral nerve (Pecs) I and II regional nerve blocks in patients undergoing masculinizing mastectomy.

METHODS

A randomized, double-blind, placebo-controlled trial was performed. Patients undergoing bilateral gender-affirmation mastectomy were randomized to receive either a Pecs block with ropivacaine or placebo injection. The patient, surgeon, and anesthesia team were blinded to the allocation. Intraoperative and postoperative opioid requirements were collected and recorded as morphine milligram equivalents (MME). Participants recorded postoperative pain scores at specific time points on the day of surgery through postoperative day 7.

RESULTS

Fifty patients were enrolled between July of 2020 and February of 2022. Twenty-seven were randomized to the intervention group and 23 to the control group, with 43 patients undergoing analysis. There was no significant difference in intraoperative MME between the Pecs block group and the control group (9.8 versus 11.1; P = 0.29). In addition, there was no difference in postoperative MME between the groups (37.5 versus 40.0; P = 0.72). Postoperative pain scores were also similar between the groups at each specified time point.

CONCLUSIONS

There was no significant reduction in opioid consumption or postoperative pain scores in patients undergoing bilateral gender-affirmation mastectomy who received a regional anesthetic when compared with placebo. In addition, a postoperative opioid-sparing approach may be appropriate for patients undergoing bilateral masculinizing mastectomy.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, I.

Developing Gender-Affirming Surgery Curricula for Plastic Surgery Residency and Fellowship via Delphi Consensus

BACKGROUND

Gender-affirming surgery (GAS) is a rapidly growing field within plastic surgery, and residents and fellows must receive appropriate training. However, there are no standardized surgical training curricula. The objective of this study was to identify core curricula within the field of GAS.

METHODS

Four GAS surgeons from different academic institutions identified initial curricular statements within six categories: (1) comprehensive GAS care, (2) gender-affirming facial surgery, (3) masculinizing chest surgery, (4) feminizing breast augmentation, (5) masculinizing genital GAS, and (6) feminizing genital GAS. Expert panelists consisting of plastic surgery residency program directors and GAS surgeons were recruited for three rounds of the Delphi-consensus process. The panelists decided whether each curriculum statement was appropriate for residency, fellowship, or neither. A statement was included in the final curriculum when Cronbach α value was greater than or equal to 0.8, meaning that 80% or more of the panel agreed on inclusion.

RESULTS

A total of 34 panelists (14 plastic surgery residency program directors and 20 GAS surgeons representing 28 US institutions) participated. The response rate was 85% for the first round, 94% for the second, and 100% for the third. Out of 124 initial curriculum statements, 84 reached consensus for the final GAS curricula, 51 for residency, and 31 for fellowship.

CONCLUSIONS

A national consensus on core GAS curriculum for plastic surgery residency and GAS fellowship was achieved by a modified Delphi method. Implementation of this curriculum will ensure that trainees in plastic surgery are adequately prepared in the field of GAS.

Microfluidics-free single-cell genomics with templated emulsification

Current single-cell RNA-sequencing approaches have limitations that stem from the microfluidic devices or fluid handling steps required for sample processing. We develop a method that does not require specialized microfluidic devices, expertise or hardware. Our approach is based on particle-templated emulsification, which allows single-cell encapsulation and barcoding of cDNA in uniform droplet emulsions with only a vortexer. Particle-templated instant partition sequencing (PIP-seq) accommodates a wide range of emulsification formats, including microwell plates and large-volume conical tubes, enabling thousands of samples or millions of cells to be processed in minutes. We demonstrate that PIP-seq produces high-purity transcriptomes in mouse-human mixing studies, is compatible with multiomics measurements and can accurately characterize cell types in human breast tissue compared to a commercial microfluidic platform. Single-cell transcriptional profiling of mixed phenotype acute leukemia using PIP-seq reveals the emergence of heterogeneity within chemotherapy-resistant cell subsets that were hidden by standard immunophenotyping. PIP-seq is a simple, flexible and scalable next-generation workflow that extends single-cell sequencing to new applications.

Perceptions of a virtual education platform: how plastic surgery education has progressed during the COVID-19 pandemic at one academic institution

BACKGROUND

To continue education during the COVID-19 pandemic, we implemented a Virtual Education Platform (VEP) and Virtual Visiting Professorship (VVP) in March 2020 into our plastic surgery residency curriculum. This study investigated resident and guest speaker perceptions of the VEP since the start of the pandemic.

METHODS

The VEP consists of weekly VVP lectures and usual conferences held over Zoom. In May 2020, residents and speakers completed surveys that assessed the perceptions of the VEP using a 5-point Likert scale and open-ended responses. In August 2021, residents also completed follow-up surveys.

RESULTS

A total of 19 (100%) residents and 10 (100%) speakers responded to the 2020 surveys and 15 (88.2%) residents responded to the 2021 follow-up survey. Speakers represented nine academic institutions, one international. 74% of residents responded that they learned a lot or a great deal from the VVP. In 2021, 100% of residents agreed that virtual conferences should remain a core component in PRS residency education, even after social distancing requirements subside. The VVP lectures were mentioned as the most helpful lectures in both years. Easy accessibility without travel time was the most mentioned advantage of the VEP in both years, with significantly more residents citing this benefit in 2021 (p = 0.0076). The most reported disadvantage for residents was the lack of social interaction and community in both years, with significantly more residents in 2021 citing this as a disadvantage (p = 0.0307). Residents' attitudes also shifted such that significantly more residents liked and were satisfied with the VVP lectures from 2020 to 2021 (p = 0.04).

CONCLUSION

Over a year into the COVID-19 pandemic, resident perceptions of a virtual education platform and virtual visiting professorship were very positive. The quick development, implementation, and high efficacy of these educational experiences underscore that learning is possible in alternative forms in unprecedented times.

Double-incision mastectomy after reduction mammaplasty for persistent gender dysphoria: a case report

Most patients undergo just one type of gender-affirming top surgery, but some will have a double-incision mastectomy after reduction mammaplasty. We describe a 46-year-old transgender man who requested a flatter chest after undergoing reduction mammoplasty the previous year. We also provide three considerations to guide surgical decision-making in this situation.

Evaluating the Quality and Reliability of Gender-affirming Surgery Videos on YouTube and TikTok

Background:

Social media platforms have changed the way medical information is disseminated. Transgender patients may utilize social media to learn about gender-affirming surgery (GAS). Although videos on social media are readily accessible, their content is not verified or peer-reviewed. Therefore, this study aimed to evaluate the quality and reliability of YouTube and TikTok videos related to GAS.

Methods:

YouTube and TikTok were queried for gender-affirming top surgery, metoidioplasty, phalloplasty, breast augmentation, and vaginoplasty. Quality of video content was analyzed by the DISCERN scale. Quality scores were compared among the type of GAS, account user, and content category.

Results:

There were 275 YouTube videos and 55 TikTok videos. Most videos focused on masculinizing top surgery (P < 0.001). Overall, videos on masculinizing GAS had higher quality and reliability than videos on feminizing GAS (P < 0.001). Chest surgery videos were of higher quality than those on genital surgery (P ≤ 0.001). Videos on masculinizing top surgery had the highest quality, whereas vaginoplasty had the lowest quality and reliability (P < 0.001). Videos produced by health care professionals and academic institutions had the greatest quality and reliability, respectively (P < 0.0001), whereas videos produced by patients were the least reliable (P < 0.0001).

Conclusions:

Videos on GAS ranged from poor to good quality and reliability. Health care professionals, especially plastic surgeons, should create high-quality videos on social media to educate transgender patients. There should also be greater efforts in disseminating existing high-quality videos on social media. Resources posted on social media platforms can reach a wide audience through accessible means.

The Incidence of Breast Cancer After Gender-Affirming Mastectomy in Transmen

BACKGROUND

The incidence of breast cancer in transmale patients and their continued risk after gender-affirming mastectomy (GAM) has not been well established. Plastic surgeons who offer GAM are often one of the few medical professionals sought out by this population, placing them in a unique position to not only deliver surgical care but also improve access to preventative cancer care.

METHODS

We reviewed the senior author's experience with GAMs over the past 5 years for any incidence of breast cancer noted after or at time of surgery. We subsequently performed a thorough review of the literature for cases of breast cancer in transmen, to provide a comprehensive overview of screening, therapy, and postoperative surveillance practices.

RESULTS

We identified 2 cases of breast cancer (ages 49 and 54 years) found on routine examination of pathology specimens after GAM at our institution. Both patients had been taking hormone therapy for the past 1 year. Pathology specimen revealed low-grade estrogen receptor-/progesterone receptor-positive ductal carcinoma in situ in 1 patient, and estrogen receptor-/progesterone receptor-positive invasive ductal carcinoma in the other. Both patients were referred to oncology for appropriate treatment, and both elected to continue their exogenous hormone therapy for personal reasons.Review of the literature demonstrated 36 other cases of documented breast cancer in transmen. Sixty-seven percent (24) were found after GAM, and of those, 50% were incidentally found on pathology specimen. At least 50% were found to be either estrogen-, progesterone-, or androgen receptor-positive cancers. At least 17% of cases documented continued use of masculinizing hormone therapy after cancer diagnosis.

CONCLUSIONS

Most documented cases of breast cancer in transmen were diagnosed after gender-affirming surgery, which would suggest residual breast tissue does pose some risk for breast cancer. In addition, those diagnosed with cancer may elect to continue exogenous testosterone therapy despite potential added risks with hormone-receptor positivity. These cases highlight the need for agreement in current screening practices, surgical recommendations, and continuation of masculinizing hormone therapy.Plastic surgeons have the unique opportunity to educate these patients on appropriate breast cancer-related surveillance both before and after chest surgery.

A Dual-Surgeon Approach to Breast Cancer Surgery in a Transmale

ABSTRACT

With increasing numbers of gender-affirming chest surgery, new questions regarding breast cancer management and surgical practice arise. Guided by our case report, we present a comprehensive review of breast cancer surgery in a transman to educate both plastic and breast surgeons on various factors to consider when caring for these patients.Our case involves a 31-year-old transmale patient who presented for plastic surgery consultation for gender-affirming mastectomy but was subsequently found to have a right breast mass. This is the first case in the literature of a transmale on hormone therapy with breast cancer interested in gender-affirming surgery, thus requiring a dual-surgeon approach for oncologic and gender-affirming mastectomy. With a multidisciplinary patient-centered approach involving breast surgery, plastic surgery, medical oncology, and radiology, we devised a surgical plan to safely remove his breast tissue with consideration for his gender-affirming goals. He underwent a right skin-sparing mastectomy with sentinel node biopsy and left prophylactic skin-sparing mastectomy through skin markings by the plastic surgeon, with bilateral free nipple grafts. Final pathology confirmed estrogen and progesterone receptor-positive and androgen receptor-positive invasive ductal carcinoma with clear margins and negative sentinel node. The patient did not require adjuvant chemotherapy or radiation but was started on adjuvant hormone therapy targeting his hormone receptor positive cancer. He elected to stay on low-dose masculinizing hormone therapy with continued surveillance examinations.We follow our case with a review of the current literature involving breast cancer in transmales to explore current screening practices, surgical recommendations, adjuvant therapies, continuation of masculinizing hormone therapy, and postoperative surveillance guidelines in the hopes of informing plastic surgeons in having these discussions with their transmale patients and thus improving informed cancer care for this population.

The Breast Response to Estrogenic Stimulation in Transwomen Classification: Evaluation of Breast Response to Estrogenic Stimulation in Transwomen

BACKGROUND

Hormone therapy with exogenous estrogen and/or spironolactone is commonly used in transfemales to induce breast development. However, inherent differences in adult male and female anatomy create persistent deformities and inadequate gender congruency despite glandular breast development. This includes nipple characteristics, position of inframammary fold, and the distribution of breast tissue. Accordingly, the Tanner stages do not accurately reflect these persistent deformities because they relate to breast development in transwomen. Herein, we describe a classification system for breast development in transwomen treated with hormone therapy.

METHODS

Ninety-nine transfemale patients who underwent breast augmentation from 2014 to 2018 were retrospectively reviewed and categorized using a novel scheme, the Breast Response to Estrogenic Stimulation in Transwomen (BREST) scale. Preoperative demographics, anatomic measurements, surgical technique, and postoperative results were also compared among BREST types.

RESULTS

Most patients were rated as BREST type II (25%) or type IV (37%). The BREST scale exhibited moderate interrater reliability (κ = 0.58) between 3 plastic surgeons. Objective breast measurements such as sternal notch-to-nipple distance and nipple-to-inframammary fold distance correlated with the BREST scale. Multivariate logistical regression identified the nipple-to-inframammary fold distance and different between the bust and chest circumference as the strongest predictors of BREST type (odds ratio, 2.57 and 1.96, respectively). Body mass index was not a predictor of BREST type after controlling for confound variables on multivariate analysis.

CONCLUSIONS

The BREST scale uniquely captures the differences in breast phenotypes in transgender women according to hormone therapy response. Although some subjectivity exists with moderate interrater reliability, the BREST scale correlates with objective breast measurements. The BREST scale provides a transwoman-specific metric allowing for a common language in assessment of transgender breast development and optimal communication among providers, different specialties, and insurance companies.

Prophylactic Muscle Flaps in Primary Vascular Procedures of the Groin

BACKGROUND

Complications following vascular procedures involving the groin can lead to significant morbidity. Achieving stable soft tissue coverage over sites of revascularization can help mitigate complications. Prior evidence supports the use of muscle flaps in reoperative groins and in high risk patient populations to reduce postoperative complications. Data regarding the use of prophylactic muscle flap coverage of the groin is lacking. Therefore, the purpose of this study is to evaluate the effect of immediate prophylactic muscle flap coverage of vascular wounds involving the groin.

METHODS

A retrospective cohort study was performed on all patients undergoing primary open vascular procedures involving the groin for occlusive, aneurysmal, or oncologic disease between 2014 and 2020 at a single institution where plastic surgery was involved in closure. Patient demographics, comorbidities, surgical details, and postoperative complications were compared between patients who had sartorius muscle flap coverage of the vascular repair versus layered closure alone.

RESULTS

A total of 133 consecutive groins were included in our analysis. A sartorius flap was used in 115 groins (86.5%) and a layered closure was used in 18 (13.5%). Wound breakdown was similar between groups (25.2% sartorius vs. 38.9% layered closure, P = 0.26). However, the rate of reoperation was significantly higher in the layered closure group (50.0% vs. 12.2%, P < 0.01). Among patients who experienced wound breakdown (N = 36), a larger proportion of layered closure patients required operative intervention (71.4% vs. 20.7%, P = 0.02). Other rates of complications were not statistically different between groups.

CONCLUSIONS

In patients undergoing primary open vascular procedures involving the groin, patients who underwent prophylactic sartorius muscle flap closure had lower rates of reoperation. Although incisional breakdown was similar between the groups overall, the presence of a vascularized muscle flap overlying the vascular repair was associated with reduced need for reoperation and allowed more wounds to be managed with local wound care alone. Consideration should be given to this low morbidity local muscle flap in patients undergoing vascular procedures involving the groin.

Rotational Thromboelastometry Derivative Fibrinogen-Platelet Ratio Predicts Thrombosis in Microsurgery

BACKGROUND

 Early detection of thrombotic events is of paramount importance for microsurgical procedures. Here, we present findings that underscore the value of rotational thromboelastometry (ROTEM) to aid in decision-making for pre- and postoperative anticoagulation, as well for patients with suspected hypercoagulability.

METHODS

 We prospectively collected pre- and postoperative ROTEM values on all free flap cases at the University of California, San Francisco, from 2015 to 2016. Patient age, body mass index, comorbidities, operative reports, risk factors, thrombotic complications, and outcomes were collected from electronic medical records. Two-sample t-tests were used to compare ROTEM values between cohorts. Modeling for sensitivity, specificity, and accuracy was done for threshold fibrinogen-to-platelet ratio (FPR).

RESULTS

 Of 52 patients who underwent free-tissue transfer, 15 had a thrombotic event either intraoperatively or postoperatively that required revision of the vascular anastomosis. Eight patients were clinically hypercoagulable preoperatively, seven of which had a thrombotic event. Several pre- and postoperative ROTEM values differed significantly between thrombotic and nonthrombotic cases. Preoperative (p = 0.027) and postoperative (p = 0.013) FPR were statistically significant when comparing the thrombotic to the nonthrombotic cohort. Threshold FPR ≥ 30 was the most sensitive and FPR ≥ 40 was the most specific.

CONCLUSION

 Our study affirms other studies that established ROTEM as an effective predictive tool for thrombotic events during free-tissue transfer. However, a lower threshold for FPR improves catchment of thrombotic events and flap failure with acceptable sensitivity. Our results support the routine use of ROTEM for detecting hypercoagulability in patients who would potentially benefit from intervention to prevent thrombotic complications.

A Systematic Review of the Utility of Indocyanine Angiography in Autologous Breast Reconstruction

BACKGROUND

In the last decade, a number of studies have demonstrated the utility of indocyanine green (ICG) angiography in predicting mastectomy skin flap necrosis for immediate breast reconstruction. However, data are limited to investigate this technique for autologous breast reconstruction. Although it may have the potential to improve free flap outcomes, there has not been a large multicenter study to date that specifically addresses this application.

METHODS

A thorough literature review based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines was conducted. All studies that examined the use of intraoperative ICG angiography or SPY to assess perfusion of abdominally based free flaps for breast reconstruction from January 1, 2000, to January 1, 2020, were included. Free flap postoperative complications including total flap loss, partial flap loss, and fat necrosis were extracted from selected studies.

RESULTS

Nine relevant articles were identified, which included 355 patients and 824 free flaps. A total of 472 free flaps underwent clinical assessment of perfusion intraoperatively, whereas 352 free flaps were assessed with ICG angiography. Follow-up was from 3 months to 1 year. The use of ICG angiography was associated with a statistically significant decrease in flap fat necrosis in the follow-up period (odds ratio = 0.31, P = 0.02). There was no statistically significant difference for total or partial flap loss.

CONCLUSIONS

From this systematic review, it can be concluded that ICG angiography may be an effective and efficient way to reduce fat necrosis in free flap breast reconstruction and may be a more sensitive predictor of flap perfusion than clinical assessment alone. Future prospective studies are required to further determine whether ICG angiography may be superior to clinical assessment in predicting free flap outcomes.

Systematic review of fertility preservation options in transgender patients: a guide for plastic surgeons

Transgender patients often desire to have biological children. However, their reproductive potential is often negatively impacted by gender affirming surgery (GAS) such as gender confirmation surgery (bottom surgery) and medical hormone therapy. Therefore, counselling patients on fertility preservation options before initiating gender-affirming treatments is prudent to avoid reducing their reproductive potential. A systematic review of English, Spanish, Chinese, French and Turkish languages from 2000 to December 23rd, 2019, using the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) guidelines, was conducted. The search strategy was designed and conducted by an experienced librarian with input from the study's principle investigator. Fifteen articles that report outcomes of fertility preservation options in transgenders were included. Eight articles described options for transgender women, six reported options for transgender men and one included both transgender women and transgender men. Semen cryopreservation and oocyte cryopreservation are the most common and available methods for fertility preservation in transgenders. Physician awareness of fertility preservation options in transgender patients is crucial to ensure informed discussions regarding reproductive options in the early phase of transition.

Nipple-areola complex reconstruction in transgender patients undergoing mastectomy with free nipple grafts: a systematic review of techniques and outcomes

Nipple-areola complex (NAC) reconstruction in transgender and gender non-binary (TGNB) individuals undergoing chest wall masculinization surgery is critical for adequate satisfaction and aesthetic results. Here, we conducted a systematic review to find the various techniques and outcomes of NAC reconstruction in double-incision mastectomy and free nipple grafts (DIM-FNG). A comprehensive search of several databases was conducted based on PRISMA guidelines. We included studies that described the NAC reconstruction technique after DIM-FNG, and evaluated the surgical outcomes, or satisfaction, or aesthetic results after a minimum duration of follow-up of 6 months. Studies were assessed for risk of bias. A qualitative synthesis was performed. A total of 19 studies, comprising 1,587 patients (3,174 breasts), were included. There was a total of 14 studies using the conventional FNG technique, 4 describing new approaches for NAC reconstruction in FNG and 1 study comparing the conventional FNG technique to another alternative technique. A total of 1,347 patients underwent DIM-FNG with conventional FNG and 240 underwent alternative techniques for NAC reconstruction after DIM-FNG. Postoperative complications were low, and satisfaction was high for conventional and alternative techniques. Newer techniques aim to reshape the new NACs in an oval shape, reduce nipple size and place the NACs using the pectoralis major lateral and inferior borders as reference. In addition, a horizontal oval incision at the recipient site may avoid an undesired vertical NAC.

Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence

BACKGROUND

There is an unknown percentage of transgender and gender non-confirming individuals who undergo gender-affirmation surgeries (GAS) that experiences regret. Regret could lead to physical and mental morbidity and questions the appropriateness of these procedures in selected patients. The aim of this study was to evaluate the prevalence of regret in transgender individuals who underwent GAS and evaluate associated factors.

METHODS

A systematic review of several databases was conducted. Random-effects meta-analysis, meta-regression, and subgroup and sensitivity analyses were performed.

RESULTS

A total of 27 studies, pooling 7928 transgender patients who underwent any type of GAS, were included. The pooled prevalence of regret after GAS was 1% (95% CI <1%-2%). Overall, 33% underwent transmasculine procedures and 67% transfemenine procedures. The prevalence of regret among patients undergoing transmasculine and transfemenine surgeries was <1% (IC <1%-<1%) and 1% (CI <1%-2%), respectively. A total of 77 patients regretted having had GAS. Twenty-eight had minor and 34 had major regret based on Pfäfflin's regret classification. The majority had clear regret based on Kuiper and Cohen-Kettenis classification.

CONCLUSIONS

Based on this review, there is an extremely low prevalence of regret in transgender patients after GAS. We believe this study corroborates the improvements made in regard to selection criteria for GAS. However, there is high subjectivity in the assessment of regret and lack of standardized questionnaires, which highlight the importance of developing validated questionnaires in this population.

Prognostic Molecular and Biological Characteristics of Phyllodes Tumors of the Breast

Prognosis for some histological variants of a rare breast disease, phyllodes tumors, is evaluated. The prognostic potential of some molecular biological factors significantly correlating with breast cancer prognosis is evaluated on a unique clinical material (244 cases with benign, intermediate, and malignant phyllodes tumors). The development of benign phyllodes tumor relapse directly correlated with the number of G0/1-phase cells and inversely correlated with the number of cells in the G2+M and S phases. The level of steroid hormone receptors in phyllodes tumors cannot serve as a prognostic marker predicting the disease course. The presence of somatic mutations of TP53 gene and loss of heterozygosity of specific intragenic loci in the tumor correlate with the development of disease relapse (p<0.05).

Regulatory T cells use arginase 2 to enhance their metabolic fitness in tissues

Distinct subsets of Tregs reside in nonlymphoid tissues where they mediate unique functions. To interrogate the biology of tissue Tregs in human health and disease, we phenotypically and functionally compared healthy skin Tregs with those in peripheral blood, inflamed psoriatic skin, and metastatic melanoma. The mitochondrial enzyme, arginase 2 (ARG2), was preferentially expressed in Tregs in healthy skin, increased in Tregs in metastatic melanoma, and reduced in Tregs from psoriatic skin. ARG2 enhanced Treg suppressive capacity in vitro and conferred a selective advantage for accumulation in inflamed tissues in vivo. CRISPR-mediated deletion of this gene in primary human Tregs was sufficient to skew away from a tissue Treg transcriptional signature. Notably, the inhibition of ARG2 increased mTOR signaling, whereas the overexpression of this enzyme suppressed it. Taken together, our results suggest that Tregs express ARG2 in human tissues to both regulate inflammation and enhance their metabolic fitness.

Transcriptional Programming of Normal and Inflamed Human Epidermis at Single-Cell Resolution

Perturbations in the transcriptional programs specifying epidermal differentiation cause diverse skin pathologies ranging from impaired barrier function to inflammatory skin disease. However, the global scope and organization of this complex cellular program remain undefined. Here we report single-cell RNA sequencing profiles of 92,889 human epidermal cells from 9 normal and 3 inflamed skin samples. Transcriptomics-derived keratinocyte subpopulations reflect classic epidermal strata but also sharply compartmentalize epithelial functions such as cell-cell communication, inflammation, and WNT pathway modulation. In keratinocytes, ~12% of assessed transcript expression varies in coordinate patterns, revealing undescribed gene expression programs governing epidermal homeostasis. We also identify molecular fingerprints of inflammatory skin states, including S100 activation in the interfollicular epidermis of normal scalp, enrichment of a CD1C⁺CD301A⁺ myeloid dendritic cell population in psoriatic epidermis, and IL1β^hiCCL3^hiCD14⁺ monocyte-derived macrophages enriched in foreskin. This compendium of RNA profiles provides a critical step toward elucidating epidermal diseases of development, differentiation, and inflammation.

Cheng et al. report single-cell RNA sequencing of normal and inflamed human epidermis, revealing a discrete set of specialized keratinocytes that exhibit a distinct composition at different anatomic sites. Myeloid dendritic cells and macrophages also vary sharply with epidermal anatomic site and inflammation, indicating dynamic programming of antigen-presenting cells.

A20 and ABIN1 Suppression of a Keratinocyte Inflammatory Program with a Shared Single-Cell Expression Signature in Diverse Human Rashes

Genetic variation in the NF-κB inhibitors, ABIN1 and A20, increase risk for psoriasis. While critical for hematopoietic immune cell function, these genes are believed to additionally inhibit psoriasis by dampening inflammatory signaling in keratinocytes. We dissected ABIN1 and A20's regulatory role in human keratinocyte inflammation using an RNA sequencing-based comparative genomic approach. Here we show subsets of the IL-17 and tumor necrosis factor-α signaling pathways are robustly restricted by A20 overexpression. In contrast, ABIN1 overexpression inhibits these genes more modestly for IL-17, and weakly for tumor necrosis factor-α. Our genome-scale analysis also indicates that inflammatory program suppression appears to be the major transcriptional influence of A20/ABIN1 overexpression, without obvious influence on keratinocyte viability genes. Our findings thus enable dissection of the differing anti-inflammatory mechanisms of two distinct psoriasis modifiers, which may be directly exploited for therapeutic purposes. Importantly, we report that IL-17-induced targets of A20 show similar aberrant epidermal layer-specific transcriptional upregulation in keratinocytes from diseases as diverse as psoriasis, atopic dermatitis, and erythrokeratodermia variabilis, suggesting a contributory role for epidermal inflammation in a broad spectrum of rashes.

High-Yield Purification, Preservation, and Serial Transplantation of Human Satellite Cells

Investigation of human muscle regeneration requires robust methods to purify and transplant muscle stem and progenitor cells that collectively constitute the human satellite cell (HuSC) pool. Existing approaches have yet to make HuSCs widely accessible for researchers, and as a result human muscle stem cell research has advanced slowly. Here, we describe a robust and predictable HuSC purification process that is effective for each human skeletal muscle tested and the development of storage protocols and transplantation models in dystrophin-deficient and wild-type recipients. Enzymatic digestion, magnetic column depletion, and 6-marker flow-cytometric purification enable separation of 10⁴ highly enriched HuSCs per gram of muscle. Cryostorage of HuSCs preserves viability, phenotype, and transplantation potential. Development of enhanced and species-specific transplantation protocols enabled serial HuSC xenotransplantation and recovery. These protocols and models provide an accessible system for basic and translational investigation and clinical development of HuSCs.

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High-efficiency purification permits serial transplantation of human satellite stem cells

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Cryopreservation preserves satellite cell function and phenotype

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1 gram of adult skeletal muscle yields 10⁴ highly purified satellite cells

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Purified uncultured endogenous human satellite cells can be stored and shared

Brain MRI measurements at a term-equivalent age and their relationship to neurodevelopmental outcomes

BACKGROUND AND PURPOSE

An increased prevalence of disabilities is being observed as more preterm infants survive. This study was conducted to evaluate correlations between brain MR imaging measurements taken at a term-equivalent age and neurodevelopmental outcome at 2 years' corrected age among very low-birth-weight infants.

MATERIALS AND METHODS

Of the various brain MR imaging measurements obtained at term-equivalent ages, reproducible measurements of the transcerebellar diameter and anteroposterior length of the corpus callosum on sagittal images were compared with neurodevelopmental outcomes evaluated by the Bayley Scales of Infant Development (II) at 2 years' corrected age (mean ± standard deviation, 16.1 ± 6.4 months of age).

RESULTS

Ninety infants were enrolled. The mean gestational age at birth was 27 weeks and the mean birth weight was 805.5 g. A short corpus callosal length was associated with a Mental Developmental Index <70 (P = .047) and high-risk or diagnosed cerebral palsy (P = .049). A small transcerebellar diameter was associated with a Psychomotor Developmental Index <70 (P = .003), Mental Developmental Index <70 (P = .004), and major neurologic disability (P = .006).

CONCLUSIONS

A small transcerebellar diameter and short corpus callosal length on brain MR imaging at a term-equivalent age are related to adverse neurodevelopmental outcomes at a corrected age of 2 years and could be a useful adjunctive tool for counseling parents about future developmental outcomes.

[Minimally invasive methods for the treatment of the recurrent varicosis]

The experience of 193 cases of recurrent variceal disease (RVD) was summarized. Major reasons of recurrences after surgery were analyzed. Traditional and miniinvasive RVD treatment approaches are listed and its efficacy was thoroughly analyzed. Thus, endovasal laser coagulation and phleboscleroobliteration of insufficient communicant veins were effective in 85% and 65% of RVD, respectively. Possibilities of cryophleboextraction as well as apparate phlebectomy with transillumination were described.

[Outcomes of surgical management of patients with thromboses of the superficial and deep venous system]

Presented herein are the outcomes of examination, surgical management and conservative treatment of 211patients presenting with phlebothromboses of the superficial and deep venous system of the lower limbs. Of these, 119 were treated conservatively and 92 underwent various types of surgical intervention, however those treated conservatively were not included into the final analysis. The diagnosis was verified using ultrasonographic duplex scanning (USDS) of the venous system of the inferior vena cava basin, allowing of assessing the condition of the superficial and deep venous system of the both lower extremities, followed by determining the length of the thrombotic lesion. Based on the findings of USDS, 68 (74%) patients were found to have thrombosis of the superficial veins and 24 (26%) subjects were diagnosed with deep-vein thrombosis. All the patients in order to prevent thromboembolic complications were subjected to active surgical policy. Also studied were methods of surgical management in patients with various-localization thromboses. Based on the obtained findings, it was determined that surgical treatment of patients with thromboses of the superficial and deep venous system of the lower limbs is a justified method to prevent the development of pulmonary thromboembolism.

[Minimally invasive interventions in surgical management of varicose diseases and its relapses]

Over the past several decades, many surgical methods of treatment for varicose disease have been implemented into clinical practice. Nonetheless, an intrinsically too traumatic nature thereof unsatisfactory cosmetic outcomes obtained, long-term postoperative rehabilitation required, and high recurrence rates reported send us in search of minimally invasive but at the same time highly efficient methods of treatment for varicose disease. The present article deals with the experience gained by Russian and foreign authors in and suggesting efficiency of novel minimally invasive technologies used for treatment of both newly diagnosed varicose disease and its relapsing forms. This is followed by analysing different variants of the procedural techniques involved.

[Combined therapy of lower limb variceal disease]

Complex surgical and medical therapy was used for 386 patients with lower limb variceal disease 2nd and 3rd form (segmental and disseminated varices with reflux through the superficial and perforant veins) and chronic venous insufficiency stage I (according to the Russian classification). Five main types of surgical interventions were fulfilled: combined phlebectomy, trunk scleroobliteration, short stripping with insufficient perforants ligation, short stripping with excision or damage of variceal influx, and short stripping with trunk scleroobliteration. Besides, vast majority of patients received venotonic drug Phlebodia 600 pre and postoperatively. Miniinvasive and atraumatic interventions were characterized by the decrease of postoperative subcutaneous hematomas, no incidence of n. saphenus damage and lymphorrhea, good cosmetic outcomes due to the absence of additional incisions. The duration of postoperative recovery correlated with intraoperative trauma and Phlebodia 600 administration. In conclusion, combination of complex surgical procedures and venotonic drugs can be widely used for the management of lower limb variceal disease, especially for its uncomplicated forms. While preserving the radicality, these interventions yield favorite esthetical results, reduce the time of postoperative recovery and disability, thus, appear to be cost effective.

[Influence of neoadjuvant therapy on VEGFR-2 levels in tumor and blood serum from breast cancer patients]

Degree and trends of changes taking place in the angiogenic factors VEGF and VEGFR-2 were studied in cytosols and blood serum sampled from breast cancer patients in the course of neoadjuvant therapy. Such evidence was evaluated vis-alpha-vis basic indices for clinic-morphological features of the disease. The study included 30 cases of locally-advanced tumors. Our results pointed to an influence produced by preoperative therapy on the levels of angiogenic factors both in tumor and serum. However, trends of development of such parameters are different and independent of therapeutic modality. Correlation was established between VEGF and VEGFR-2 levels in residual tumor, on the one hand, and degree of therapeutic pathomorphosis, on the other.

Sonographic windsock sign of a duodenal web

We report a neonate with a duodenal web demonstrating the windsock appearance on US. In neonates, duodenal web is rare and its windsock appearance is also rarely seen. The windsock sign of duodenal web has been a well-known finding on upper gastrointestinal series. The corresponding windsock appearance may be demonstrated on US. Duodenal web can, therefore, be accurately diagnosed by identifying the sonographic windsock sign even in neonates.

Quantification of ground-glass opacity on high-resolution CT of small peripheral adenocarcinoma of the lung: pathologic and prognostic implications

OBJECTIVE

The purpose of our study was to correlate the high-resolution CT findings of small peripheral adenocarcinoma of the lung with underlying histopathology and to evaluate the prognostic implications of the CT findings.

MATERIALS AND METHODS

The high-resolution CT findings of small peripheral adenocarcinoma of the lung in 224 patients were analyzed by two independent observers for location, size, marginal characteristics, and extent of ground-glass opacity and necrosis. The pathologic specimens were reviewed by an experienced lung pathologist.

RESULTS

One hundred and thirty-two patients had bronchioloalveolar carcinoma and 92 had adenocarcinoma. The extent of ground-glass opacity was greater in bronchioloalveolar carcinomas (mean +/- SD, 29% +/- 31.6%) than in other adenocarcinomas (8% +/- 13.3%) (p < 0.001). The extent of ground-glass opacity was significantly greater in patients without recurrence (p = 0.020) and those without nodal (p = 0.017) or distant (p = 0.007) metastases than in patients with nodal or distant metastases or in whom the carcinoma had recurred.

CONCLUSION

The extent of ground-glass opacity in a nodule is greater in bronchioloalveolar carcinomas than in other adenocarcinomas. Greater extent of ground-glass opacity also correlates with improved prognosis.

High-resolution CT of alveolar filling disorders

Airspace filling process is characterized on CT by the presence of one or more fairly homogeneous areas of consolidation with little or no volume loss. The consolidation may be segmental, subsegmental, lobular, or acinar (10 mm or less in diameter). Poorly defined centrilobular nodules may be associated. The margin of the consolidation usually is poorly defined except in the areas in which the consolidation abuts the pleura. Air-containing bronchi or bronchioles (CT air bronchograms or air bronchiolograms) are seen frequently. Many diseases can present with alveolar filling disorders. Because the HRCT findings overlap among various alveolar filling disorders, it may be impossible to make a definite diagnosis with HRCT findings alone. Integration of HRCT findings including disease pattern and distribution and time factors including evolution and resolution of the disease, however, may enable to narrow differential diagnosis of alveolar filling diseases. Furthermore, clinical and laboratory findings also may provide helpful clues to reach a reasonable diagnosis. The role of HRCT in alveolar filling disorders is not limited to diagnosis. HRCT also plays a useful role in determining the extent of disease and in identifying accompanying abnormalities, and complications of the primary disease.

Focal organizing pneumonia: CT and pathologic findings

The purpose of this study was to describe the CT findings of focal organizing pneumonia and to compare the findings with pathology. CT findings of histologically proven focal organizing pneumonias in 26 consecutive patients were analyzed. In 17 patients who had undergone surgical resections, the findings were correlated with pathology. Focal organizing pneumonias appeared as a nodule (n= 13) or a mass (n=13), ranging from 9 mm to 66 mm in diameter. Ground-glass opacity was seen in 6/13 (46%) nodules and 6.5/13 (50%) masses (k=.48) with an extent ranging from 5% to 75% (mean, 16%). In 4/26 (15%) patients, the extent was more than 50% of the lesion. They showed smooth (n=4), lobulated (n=8), spiculated (n=1), or lobulated and spiculated margin (n=13). On correlative analysis, nodule or mass on CT consisted histologically of intraalveolar exudate or microabscess, chronic inflammatory cell infiltration, fibrotic nodules, and polypoid granulation tissue in the alveolar or bronchiolar spaces. Ground-glass opacity consisted of interstitial fibrosis and chronic inflammatory cell infiltration and intraalveolar polypoid granulation tissue. Focal organizing pneumonia may simulate a lung cancer with variable appearances on CT and the findings reflect underlying histopathology of the disease.

Interstitial pneumonia in progressive systemic sclerosis: serial high-resolution CT findings with functional correlation

PURPOSE

The aim of our study was to assess the serial high-resolution CT findings and their correlation with the results of pulmonary function tests in patients with progressive systemic sclerosis (PSS) and interstitial pneumonia.

METHOD

The study included 40 patients with symptoms or signs of PSS and interstitial pneumonia, who underwent serial high-resolution CT scans (mean follow-up period 39 months). Seventeen patients simultaneously had serial pulmonary function tests (mean follow-up period 40 months). On high-resolution CT, the pattern and extent of parenchymal abnormalities were retrospectively analyzed. Serial changes on high-resolution CT were correlated with the changes of pulmonary function tests.

RESULTS

On initial CT, areas of ground-glass opacity (mean +/- SD extent 17.7 +/- 12.3% in all patients), irregular linear opacity (4.4 +/- 4.4% in 36 patients), small nodules (3.9 +/- 12.5% in 28), consolidation (1.9 +/- 4.2% in 13), and honeycombing (1.9 +/- 3.8% in 12) were seen. The total disease extent (p = 0.042) and extents of ground-glass opacity (18.9 +/- 15.5%; p = 0.04) and honeycombing (5.0 +/- 7.2%; p = 0.002) increased significantly on follow-up CT. Both forced vital capacity (from 2.4 +/- 0.4 to 2.0 +/- 0.4 L; p = 0.002) and forced expiratory volume in 1 s (from 2.0 +/- 0.4 to 1.6 +/- 0.3 L; p = 0.013) decreased significantly on follow-up examination. The increase in the extent of honeycombing on CT correlated significantly with the decrease in diffusing capacity for carbon monoxide (r = -0.411, p = 0.049).

CONCLUSION

In patients with PSS and interstitial pneumonia, the overall extent of disease and extents of honeycombing and ground-glass opacity increase significantly on follow-up CT. Increase of honeycombing correlates well with decrease of diffusing capacity for carbon monoxide.

Using edge enhancement to identify subtle findings on soft-copy neonatal chest radiographs

OBJECTIVE

The purpose of this study was to evaluate whether edge enhancement could improve the visibility of subtle findings on soft copies of neonatal chest radiographs.

MATERIALS AND METHODS

Two radiologists reviewed 82 soft-copy neonatal chest radiographs before and after the application of edge enhancement on our picture archiving and communication system (PACS). The visibility of a pneumothorax (n = 22), central venous catheter (n = 32), umbilical arterial catheter (n = 36), endotracheal tube (n = 40), and normal anatomic structures (the minor fissure, anterior segmental bronchus of the right upper lobe, and aortic arch, n = 57) was evaluated. Six of 22 soft-copy images depicting a pneumothorax were excluded from the evaluation of image quality either because of the large size of the pneumothorax itself (n = 7) or because of the lack of confirmatory evidence that would have been provided by an additional lateral decubitus (n = 6) or cross-table lateral radiograph (n = 3). Image quality was evaluated by visual grading analysis.

RESULTS

The visibility of a pneumothorax (p < 0.01), vascular catheters (p < 0.001), the minor fissure (p < 0.001), and the anterior segmental bronchus of the right upper lobe (p < 0.001) improved significantly after applying edge enhancement to soft copies of neonatal chest radiographs, whereas the visibility of the aortic arch did not improve. Evaluations of the improvements in the visibility of the endotracheal tube were inconsistent.

CONCLUSION

Application of edge enhancement to soft copies of neonatal chest radiographs helps radiologists to identify small pneumothoraces, vascular catheters, and delicate normal structures, thereby improving the detection of subtle chest findings in the neonatal intensive care unit.

Acid secretion from a heterotopic gastric mucosa in the upper esophagus demonstrated by dual probe 24-hour ambulatory pH monitoring

Heterotopic gastric mucosa in the upper esophagus is frequently found during endoscopic examination. Although most patients with heterotopic gastric mucosa of the upper esophagus, referred as inlet patch, are asymptomatic, symptomatic patients with complications resulting from this ectopic mucosa have also been reported. Acid secretion by the inlet patch has been suggested in some reports. We report a case of heterotopic gastric mucosa in the upper esophagus, with secretion of acid, demonstrated by continuous ambulatory pH monitoring, and the improvement of pharyngeal symptoms after the use of a proton pump inhibitor.

Malignant thymic epithelial tumors: CT-pathologic correlation

OBJECTIVE

The purpose of our study was to describe and compare the CT and pathologic findings of atypical thymoma and thymic carcinoma.

MATERIALS AND METHODS

Twenty-seven consecutive patients (14 men, 13 women ranging in age from 22 to 77 years [mean age, 52 years]) with pathologically proven atypical thymoma (n = 9) and thymic carcinoma (n = 18) constituted the study population. The chest CT findings in each of the 27 patients were reviewed retrospectively in consensus by two chest radiologists. These findings were correlated with pathologic findings.

RESULTS

The tumors were located in the anterior mediastinum, and most tumors had a lobulated margin (24/27, 89%). Atypical thymomas were significantly smaller (mean, 4.7 cm) than thymic carcinomas (mean, 7.2 cm) (p = 0.041) on CT. The findings of invasion of the great vessels, lymph node enlargement, extrathymic metastases, and phrenic nerve palsy were seen only in patients with thymic carcinoma. The frequencies of necrosis, intratumoral calcification, pleural effusion, pleural implants, pericardial effusion, and obliteration of the mediastinal fat plane were not significantly different between atypical thymomas and thymic carcinomas (p > 0.05). Various histologic subtypes were included in thymic carcinoma. The tumor necrosis and calcification seen on CT were confirmed at pathologic examination.

CONCLUSION

When a large thymic tumor appears with invasion of the great vessels, lymph node enlargement, phrenic nerve palsy, or extrathymic metastases on CT, thymic carcinoma rather than atypical thymoma should be considered.

Nitric oxide mediates platelet activating factor-induced microvascular leakage in rat airways

Platelet activating factor (PAF), a highly potent chemical mediator in inflammation and allergic reactions, induces microvascular leakage in several tissues. In rat airways, PAF-induced microvascular leakage is probably mediated by an endothelial cell receptor in the microvessels. Nitric oxide (NO), first identified as endothelium-derived relaxing factor, has been suggested to be a mediator of airway microvascular leakage. However, the role of NO in PAF-induced microvascular leakage in the airways has not yet been established. The aim of this study was to investigate the role of NO in PAF-induced microvascular leakage in rat nasal mucosa and trachea. We injected PAF (1 microg/kg) intravenously, and the amount of PAF-induced microvascular leakage was measured with extravasation of Evans blue dye (30 mg/kg, injected intravenously 5 minutes before the injection of PAF) by means of spectrophotometry and fluorescence microscopy. Five Sprague-Dawley rats were pretreated with NG-nitro-L-arginine methyl ester (L-NAME; 10 mg/kg, intravenously injected 1 hour before the injection of PAF) to inhibit NO synthase, and control rats (n = 4) were pretreated with normal saline solution. The average amount of extravasated Evans blue dye was significantly lower in the L-NAME-pretreated rats than in the control rats (t-test, p < .01). Tissue sections of the L-NAME-pretreated rats clearly showed a decreased extravasation of Evans blue dye on fluorescence microscopy. In conclusion, pretreatment with L-NAME clearly inhibited PAF-induced microvascular leakage in the nasal mucosa and trachea of rats. This finding implies that PAF may activate the constitutive endothelial NO synthase in the microvessels, and that activated endogenous NO may mediate PAF-induced microvascular leakage in rat airways.

Biological monitoring of occupational exposure to N,N-dimethylformamide--the effects of co-exposure to toluene or dermal exposure

OBJECTIVES

The objective of this study is to assess the exposure and intake dose of N,N-dimethylformamide (DMF) and the correlation between them, according to the type of exposure for the workers in the DMF industry.

METHODS

We monitored 345 workers occupationally exposed to DMF, from 15 workshops in the synthetic fiber, fiber coating, synthetic leather and paint manufacturing industries. Ambient monitoring was carried out with personal samplers to monitor the external exposure. Biological monitoring was done to determine the internal dose by analyzing N-methylformamide (NMF) in end-shift urine. Work procedure and exposure type of each DMF workshop was carefully surveyed, to classify workers by exposure type according to work details. Workers were classified into three groups (Group A: continuous and direct exposure through inhalation and skin; Group B: intermittent and short-term exposure through inhalation and skin; Group C: continuous and indirect exposure mostly through inhalation).

RESULTS

Geometric mean of DMF concentration in air was 2.62 (GSD 5.30) ppm and that of NMF in urine was 14.50 (GSD 3.89) mg/l. In the case of continuous absorption through inhalation and dermal exposure (Group A), the value of NMF in urine corresponding to 10 ppm of DMF was 45.3 mg/l (r = 0.524, n = 178), 39.1 mg/g creatinine (r = 0.424), while it was 37.7 mg/l (r = 0.788, n = 37), 24.2 mg/g creatinine (r = 0.743) in the case of absorption mostly through inhalation (Group C). Creatinine correction reduced the correlation between two parameters.

CONCLUSION

The NMF in urine corresponding to 10 ppm DMF, of the dermal and inhalation exposure group was 39.1 mg/g creatinine (r = 0.424, n = 178), while that of the inhalation exposure-only group was 24.2 mg/g creatinine (r = 0.743, n = 37). Co-exposure with toluene reduced the NMF excretion in urine.

Cytomegalovirus pneumonia: high-resolution CT findings in ten non-AIDS immunocompromised patients

OBJECTIVE

To describe the HRCT findings of cytomegalovirus (CMV) pneumonia in non-AIDS immunocompromised patients

MATERIALS AND METHODS

This retrospective study involved the ten all non-AIDS immunocompromised patients with biopsy-proven CMV pneumonia and without other pulmonary infection encountered at our Medical Center between January 1997 and May 1999. HRCT scans were retrospectively analysed by two chest radiologists and decisions regarding the findings were reached by consensus.

RESULTS

The most frequent CT pattern was ground-glass opacity, seen in all patients, with bilateral patchy (n = 8) and diffuse (n = 2) distribution. Other findings included poorly-defined small nodules (n = 9) and consolidation (n = 7). There was no zonal predominance. The small nodules, bilateral in eight cases and unilateral in one, were all located in the centrilobular region. Consolidation (n = 7), with patchy distribution, was bilateral in five of seven patients (71%). Pleural effusion and bilateral areas of thickened interlobular septa were seen in six patients (60%).

CONCLUSION

CMV pneumonia in non-AIDS immunocompromised patients appears on HRCT scans as bilateral mixed areas of ground-glass opacity, poorly defined centrilobular small nodules, and consolidation. Interlobular septal thickening and pleural effusion are frequently associated.

Fetus-in-fetu in the scrotal sac of a newborn infant: imaging, surgical and pathological findings

We report a case of fetus-in-fetu located in the scrotal sac of a newborn male infant. Plain radiography (including specimen radiography), ultrasonography and MRI clearly demonstrated vertebral column, ribs, skull, pelvic bones, femurs and a portion of tibiae and humeri. The diagnosis was confirmed by pathological examination.

Hypoxia-induced paracrine regulation of vascular endothelial growth factor receptor expression

Vascular endothelial growth factor (VEGF)/vascular permeability factor (VPF), an endothelial cell (EC)-specific mitogen, stimulates angiogenesis in vivo, particularly in ischemic regions. VEGF/VPF expression by cells of hypoxic tissues coincides with expression of its two receptors, KDR and flt-1, by ECs in the same tissues. We investigated whether hypoxia or hypoxia-dependent conditions operate in coordinating this phenomenon. Human umbilical vein and microvascular ECs were exposed to direct hypoxia or to medium conditioned (CM) by myoblasts maintained in hypoxia for 4 d. Control ECs were maintained in normoxia or normoxia-CM. Binding of 125I-VEGF to ECs was then evaluated. Hypoxic treatment of ECs had no effect on 125I-VEGF binding. However, treatment of ECs with hypoxia-CM produced a threefold increase in 125I-VEGF binding, with peak at 24 h (P < 0.001, ANOVA). Scatchard analysis disclosed that increased binding was due to a 13-fold increase in KDR receptors/cell, with no change in KDR affinity (Kd = 260 +/- 51 pM, normoxia-CM versus Kd = 281 +/- 94 pM, hypoxia-CM) and no change in EC number (35.6 +/- 5.9 x 10(3) ECs/cm2, normoxia-CM versus 33.5 +/- 5.5 x 10(3) ECs/cm2, hypoxia-CM). Similar results were obtained using CM from hypoxic smooth muscle cells. KDR upregulation was not prevented by addition to the hypoxia-CM of neutralizing antibodies against VEGF, tumor necrosis factor-alpha, transforming growth factor beta 1 or basic fibroblast growth factor. Similarly, addition of VEGF or lactic acid to the normoxia-CM had no effect on VEGF binding. We conclude that mechanism(s) initiated by hypoxia can induce KDR receptor upregulation in ECs. Hypoxic cells, normal or neoplastic, not only can produce VEGF/VPF, but can also modulate its effects via paracrine induction of VEGF/VPF receptors in ECs.

Hypoxia induces vascular endothelial growth factor in cultured human endothelial cells

Smooth muscle cells, macrophages, glial cells, keratinocytes, and transformed cells have been established as synthesis sites for vascular endothelial growth factor (VEGF). The modulating effects of VEGF are essentially limited to endothelial cells (ECs), the only cell type consistently shown to express VEGF receptors. VEGF has thus been considered to act exclusively via a paracrine pathway. We sought to determine whether the role of human ECs might, under selected conditions, extend beyond that of a target to involve contingency synthesis of VEGF. In both unstimulated human umbilical vein ECs (HUVECs) and human derma-derived microvascular ECs (HMECs), Northern analysis detected no VEGF transcripts. Phorbol-12-myristate 13-acetate (10(-7) M) treatment, however, induced VEGF mRNA expression in both HUVECs and HMECs, peaking at 3 and 6 h, respectively, and returning to undetectable levels by 12 h. In vitro exposure of HUVECs to a hypoxic environment (pO2 = 35 mm of mercury) for 12, 24, and 48 h and exposure of HMECs for 6, 12, 24, and 48 h induced VEGF mRNA in a time-dependent fashion. Re-exposure to normoxia (pO2 = 150 mm of mercury) for 24 h after 24 h of hypoxia returned VEGF mRNA transcripts to undetectable levels in HUVECs. Cobalt chloride and nickel chloride treatment each induced VEGF mRNA in ECs. Cycloheximide treatment further augmented expression of VEGF mRNA induced by cobalt chloride, nickel chloride, and hypoxia in HUVECs. VEGF protein production in hypoxia HUVECs was demonstrated immunohistochemically. Conditioned media from hypoxic HUVECs caused a 2-fold increase in the incorporation of tritiated thymidine. Finally, immune precipitates of anti-KDR probed with anti-Tyr(P) antibodies demonstrated evidence of receptor autophosphorylation in hypoxic but not normoxic HUVECs. These findings thus establish the potential for an autocrine pathway that may augment and/or amplify the paracrine effects of VEGF in stimulating angiogenesis.

Variable expression of the estrogen receptor in normal and atherosclerotic coronary arteries of premenopausal women

BACKGROUND

The relative absence of coronary atherosclerosis in premenopausal women has been established. Estrogen is presumed to play a role in the protection of coronary arteries from atherosclerosis, and part of this protective effect appears to be mediated by amelioration of serum lipid profiles. However, all of the atheroprotective effect of estrogen is not explained by alteration of serum lipids. In this study, we attempt to identify evidence of estrogen receptors in coronary artery specimens of female patients and in human vascular smooth muscle cells.

METHODS AND RESULTS

Postmortem coronary artery specimens were obtained from premenopausal (n = 18) and postmenopausal (n = 22) women who died with significant coronary artery disease (n = 19) and from noncardiac causes with normal coronary arteries (n = 21). Sections were examined for evidence of estrogen receptor expression using a monoclonal antibody stain. Radioligand binding assays for estrogen receptors were performed on human vascular smooth muscle cells in culture, and gel retardation assays were performed to confirm the presence of functional estrogen receptors. Estrogen receptor expression was identified by immunostaining in a total of 21 coronary arteries, with the majority of normal arteries (15 positive of 21 total, P = .0117) demonstrating evidence of estrogen receptor expression. Conversely, a minority (6 of 19, P = NS) of atherosclerotic arteries were positive for estrogen receptor expression. Furthermore, the relation between estrogen receptor expression and absence of coronary atherosclerosis was most evident in premenopausal subjects, with 10 of 12 normal arteries in this group demonstrating evidence of estrogen receptors, whereas only 1 of 6 atherosclerotic coronary arteries was positive (P = .0062). Radioligand binding assays confirmed the presence of estrogen receptors at significant concentrations in intact human vascular smooth muscle cells. Gel retardation assays also documented the presence of functional estrogen receptors in extracts from human vascular smooth muscle cells.

CONCLUSIONS

This investigation provides evidence of estrogen receptors in smooth muscle cells from human coronary arteries. The demonstrated relation between the presence of the receptors and the absence of atherosclerosis in premenopausal women suggests that these receptors may play a functional role in coronary atheroprotection.

[Na,K-ATPase activity in the myocardial sarcolemma in ischemia]

The total time-controlled ischemia (up to 45 min) was studied for its effect on the Na,K-ATPase activity, content of nonesterified fatty acids (NEFA) and intensity of lipid peroxidation (LP) in sarcolemmal (SL) preparations and soluble fractions (SF) from the rat and guinea-pig left ventricles. A strong correlation between Na, K-ATPase inhibition and NEFA accumulation was revealed in the SF. On the contrary, changes in the NEFA content and LP level both in SL and SF did not correlate with a decrease in the enzymic activity. Pretreatment with albumin (0.5 mg/ml) induced equally small increase both in the control and in the ischemic SL preparations. It is suggested that the Na,K-ATPase activity during a short period of myocardial ischemia (up to 45 min) may be due to the NEFA accumulation in the cytosolic and/or extracellular space, but not in SL.

[The mechanism of formation of spectrum of nonesterified fatty acids in biological fluids of rabbits with alimentary hypercholesterolemia]

Increase in activity of fatty tissue lipoprotein lipase and blood plasma post-heparin lipoprotein lipase, decrease in activity of myocardial lipoprotein lipase as well as in the rate of intracellular lipolysis of triacylglycerols in fatty tissue, unaltered activity of liver tissue endothelial lipase were observed in rabbits with moderate alimentary hypercholesterolemia (9.63 +/- 3.48 mumole of cholesterol per ml of blood plasma as compared with 1.51 +/- 0.16 mumole/ml under conditions of normal state). The ratio of stearate was increased in composition of unesterified fatty acids from blood plasma, mesenteric lymph and myocardial sarcolemma as well as in triacylglycerols of chylomicrons total fraction, in very low density lipoproteins and their remnants. Ratios free stearate/total content of other acids correlated in blood plasma and myocardial sarcolemma (r = 0.65). Any shifts in the spectra of fatty acid residues of phospholipids were not found in myocardial membranes. In rabbits with alimentary hypercholesterolemia importance of intestine-derived triacylglycerols for production of circulating unesterified fatty acids was increased, as a result of which the ratio of various acyls, metabolized in myocardium, was altered.

[Changes in the activity and regulatory properties of Na, K-ATPase from the myocardial sarcolemma in total graded ischemia]

Na, K-ATPase activity of the rat and guinea-pig myocardial sarcolemma and its sensitivity to digoxin (DG) and carbamylcholine (CCh) were investigated during experimental ischemia. Ischemia was induced by the incubation of hearts in the air at 37 degrees C. This 15-, 30- and 45-min treatment led to a decrease in enzymatic activity which was similar in both animal species. Dose-related dependence of DG effect (10(-8)-10(-2) M) on sarcolemmal Na, K-ATPase activity of guinea-pig ischemic hearts did not differ from the control, whereas the rat enzyme sensitivity to glycosides rose with the progress of ischemia. CCh (10(-7)-10(-3) M) produced an inhibition of Na, K-ATPase activity which had reached 40% both in the rat and guinea-pig myocardial preparations. This effect was blocked by atropine (10(-6) M). The magnitude of enzyme responses to CCh declined depending on the duration of ischemia, with it being greater in guinea-pig sarcolemma than in rat membrane. The increased sensitivity of the rat Na, K-ATPase to CCh was also observed.