Is posterior compartment prolapse associated with anal incontinence?

OBJECTIVE: It has been claimed that manifestations of posterior compartment prolapse, such as rectocele, enterocele and intussusception, are associated with anal incontinence (AI), but this has not been studied while controlling for anal sphincter trauma. We aimed to investigate this association in women with intact anal sphincter presenting with pelvic floor dysfunction. METHODS: This retrospective study analyzed 1133 women with intact anal sphincter presenting to a tertiary urogynecological center for pelvic floor dysfunction between 2014 and 2016. All women underwent a standardized interview, including assessment of symptoms of AI, clinical examination and three-/four-dimensional transperineal ultrasound. Descent of the rectal ampulla, true rectocele, enterocele, intussusception and anal sphincter trauma were diagnosed offline. RESULTS: Mean age was 54.1 (range, 17.6-89.7) years and mean body mass index was 29.4 (range, 14.7-67.8) kg/m2 . AI was reported by 149 (13%) patients, with a median St Mark's anal incontinence score of 12 (interquartile range, 1-23). Significant posterior compartment prolapse was seen in 693 (61%) women on clinical examination. Overall, 638 (56%) women had posterior compartment prolapse on imaging: 527 (47%) had a true rectocele, 89 (7.9%) had an enterocele and 26 (2.3%) had an intussusception. Women with ultrasound-diagnosed enterocele had a significantly higher rate of AI (23.6% vs 12.3%; odds ratio (OR), 2.21 (95% CI, 1.31-3.72); P = 0.002), but when adjusted for potential confounders, this association was no longer significant (OR, 1.56 (95% CI, 0.82-2.77); P = 0.134). CONCLUSION: In women without anal sphincter trauma, posterior compartment prolapse, whether diagnosed clinically or by imaging, was not shown to be associated with AI. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Haemophagocytic Lymphohistiocytosis with Leptospirosis: A Rare but Devastating Complication.

INTRODUCTION: Secondary haemophagocytic lymphohistiocytosis (sHLH), often associated with an array of infections, malignancies, and autoimmune diseases, is rarely seen with leptospirosis, which carries a relatively poor prognosis even with modern state-of-the-art medical care. We describe a patient with leptospirosis complicated by sHLH who succumbed to illness following multiorgan dysfunction. Case Description. A 74-year-old farmer presented with high-grade, unsettling fever for a week. Muddy water exposure and suggestive symptoms prompted investigation and management in the line of leptospirosis (IV ceftriaxone was instituted, and later, MAT (microscopic agglutination test) became positive). Subsequently, he developed severe acute hypoxemia requiring mechanical ventilation and acute renal failure requiring renal replacement therapy. Bone marrow biopsy and markedly elevated serum ferritin and triglyceride levels done on day 10 (with unresolving fever, hepatosplenomegaly, and pancytopaenia) confirmed the diagnosis of HLH. The routine cultures, retroviral studies, CMV, dengue, hanta and mycoplasma antibodies, tuberculosis and COVID-19 PCR, and malaria screening were all normal. There was no improvement of hypoxemia following intravenous methylprednisolone. He died on day 15 despite escalating organ support. CONCLUSION: Leptospirosis is a common zoonotic disease in the tropics with significant morbidity and mortality. In the case of severe leptospirosis, overlapping clinical features with sHLH make the diagnosis of the latter challenging. No assessment tools are available to date to predict the risk of developing sHLH in a patient having leptospirosis. Outcome following sHLH due to leptospirosis still remains majorly ominous. A high index of suspicion and low threshold for specific investigations could possibly alter the outcome following such an occurrence.

The impact of radical parotidectomy with immediate facial nerve reconstruction: a quality-of-life measure.

OBJECTIVE: Immediate facial nerve reconstruction is the standard of care following radical parotidectomy; however, quality of life comparisons with those undergoing limited superficial parotidectomy without facial nerve sacrifice is lacking. METHOD: Patients who underwent parotidectomy were contacted to determine quality of life using the University of Washington Quality of Life and Parotidectomy Specific Quality of Life questionnaires. A total of 29 patients (15 in the radical parotidectomy and 14 in the limited superficial parotidectomy groups) completed and returned questionnaires. RESULTS: Using the University of Washington Quality of Life Questionnaire, similar quality of life was noted in both groups, with the radical parotidectomy group having significantly worse speech and taste scores. Using the Parotidectomy Specific Quality of Life Questionnaire, the radical parotidectomy group reported significantly worse speech, eye symptoms and eating issues. CONCLUSION: Those undergoing radical parotidectomy with reconstruction had comparable overall quality of life with the limited superficial parotidectomy group. The Parotidectomy Specific Quality of Life Questionnaire better identified subtle quality of life complaints. Eye and oral symptoms remain problematic, necessitating better rehabilitation and more focused reconstructive efforts.

Location of obstetric anal sphincter injury scars on translabial tomographic ultrasound.

OBJECTIVE: Obstetric anal sphincter injury (OASI) is a common preventable cause of anal incontinence. Both diagnosis and primary repair of OASI are often suboptimal, partly owing to the absence of effective clinical audit. The aim of this study was to evaluate the location of scars or defects of the external anal sphincter (EAS), diagnosed by translabial ultrasound (TLUS), following primary OASI repair. METHODS: This was a retrospective analysis of 309 women who were seen at a tertiary obstetric unit after primary repair of OASI between June 2012 and May 2019. All women underwent a standardized interview, including St Mark's incontinence score, followed by clinical examination and TLUS assessment within 2-9 months after OASI repair. Postprocessing of TLUS volume datasets was performed by an investigator who was blinded to all other information. Tomographic ultrasound imaging was used to evaluate the presence of a scar or defect in the proximal and distal parts of the EAS. Women were classified into four groups according to the imaging findings: (1) no visible defect or distortion (likely false positive); (2) only proximal OASI; (3) only distal OASI; and (4) both proximal and distal OASI. RESULTS: Of the 309 women seen during the study period, 34 were excluded because they were referred for reasons other than recent (< 1 year) OASI, 16 owing to missing data and four owing to poor image quality, leaving 255 patients for analysis. Women were seen on average 0.25 ± 0.1 years after the index birth, and their mean age at delivery was 29.1 ± 4.6 years. Anal incontinence was reported by 97 (38.0%) women. A scar or defect was seen only in the proximal part of the EAS in 64 (25.1%) women and only in the distal part in 19 (7.5%) (P < 0.001). In 165 (64.7%) women, the damage affected both the proximal and distal EAS. CONCLUSIONS: EAS scars after primary OASI repair commonly affect the entire length of the EAS; however, partial tears seem to be more likely to occur proximally. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Ultrasound to the Rescue: Axillary Clearance under Complete Regional Blockade.

No single regional anaesthetic technique is capable of complete anaesthesia of the axillary region. Regional or interfascial nerve blockade could be an effective alternative where administering general anaesthesia is not feasible, with superior analgesia, favourable haemodynamics, and reduced opiate related adverse effects. Ultrasound guidance improves effectiveness and safety profile. We report a case of a successful axillary clearance conducted under combined regional blocks for an axillary nodal recurrence following mastectomy for a breast carcinoma, in a patient who was not fit for general anaesthesia due to a persistent lobar pneumonia and recurrent asthma exacerbations. Our experience and current evidence supersede the initial conceptions of difficult ultrasonic intercostobrachial nerve (ICBN) visualization.

Does the presence of a true radiological rectocele increase the likelihood of symptoms of prolapse?

INTRODUCTION AND HYPOTHESIS: Posterior compartment prolapse is commonly due to a 'true' rectocele, i.e., a diverticulum of the rectal ampulla. This condition is associated with symptoms of obstructed defecation and may contribute to prolapse symptoms. We tested the hypothesis: 'A true rectocele is an independent predictor of symptoms of prolapse.' METHODS: This was a retrospective cohort study of patients presenting to a urogynecology unit for symptoms of pelvic floor dysfunction between September 2011 and June 2016. Assessment included a structured interview, POP-Q examination and 4D TLUS. Ultrasound volume data were acquired on Valsalva. Offline measurements were performed by analysis of stored volume data sets at a later date, blinded to all clinical data. RESULTS: One hundred six patients were excluded because of incomplete data. Of the remainder, Bp was the most distal point on POP-Q in 348. Statistical analysis was performed on this cohort. Mean age was 60 (33-86) years and mean BMI 31 (18-55) kg/m². One hundred fifty-three patients (44%) presented with symptoms of prolapse; 272 were diagnosed with a true rectocele on TLUS. Bp on POP-Q and true rectocele on TLUS were both significantly associated with prolapse symptoms; however, on multivariate analysis the latter became nonsignificant (p = 0.059). Receiver-operating characteristic (ROC) analysis confirmed that the presence of a true rectocele on TLUS did not contribute significantly to symptoms of prolapse (AUC 0.66 for model with rectocele, AUC 0.65 without). CONCLUSIONS: The presence of a true rectocele on TLUS does not seem to contribute substantially to the manifestation of clinical symptoms of prolapse.

Levator avulsion and vaginal parity: do subsequent vaginal births matter?

INTRODUCTION AND HYPOTHESIS: Tears of the levator ani muscle are common after vaginal birth and associated with pelvic organ prolapse (POP). Although such trauma is usually attributed to the first vaginal birth, epidemiological evidence suggests an additional effect of subsequent vaginal deliveries. Our hypothesis was: "The prevalence of avulsion increases with the number of vaginal births". METHODS: We conducted a retrospective cohort study in patients who presented to a tertiary urogynaecology clinic. Assessment included a physician-directed interview, POP-Q and 4D translabial ultrasound (TLUS), supine, after voiding, at rest, on maximum pelvic floor muscle contraction (PFMC) and Valsalva. Offline analysis of levator integrity was undertaken by tomographic imaging (TUI) at a later date, blinded against all other data. RESULTS: A total of 1,124 patients had been seen between 1 January 2014 and 30 June 2016, on average 33 (0.32-69.7) years after their first birth. Mean age was 56 (19-90) years. 1,012 (90%) were vaginally parous with a median vaginal parity of 2 (1-8). On TUI, avulsion was diagnosed in 257 (23%) women, all of whom were vaginally parous. On univariate analysis, there was no significant difference in the prevalence of avulsion on comparing vaginally primiparous and multiparous women (P = 0.6), nor was there any difference between vaginal parity groups (one, two, three, and ≥4 births; p = 0.7). This remained true after controlling for potential confounding factors using multivariate regression (p = 0.6). CONCLUSIONS: There was no significant difference in the prevalence of avulsion between vaginally primiparous and multiparous women. Vaginal deliveries after a first vaginal birth are unlikely to cause avulsion.

Efficacy of small-volume gastrografin videofluoroscopic screening for detecting pharyngeal leaks following total laryngectomy.

OBJECTIVES: Pharyngocutaneous fistulae are dreaded complications following total laryngectomy. This paper presents our experience using 3-5 ml gastrografin to detect pharyngeal leaks following total laryngectomy, and compares post-operative videofluoroscopy with clinical follow-up findings in the detection of pharyngocutaneous fistulae. METHODS: A retrospective case-control study was conducted of total laryngectomy patients. The control group (n = 85) was assessed clinically for development of pharyngocutaneous fistulae, while the study group (n = 52) underwent small-volume (3-5 ml) post-operative gastrografin videofluoroscopy. RESULTS: In the control group, 24 of 85 patients (28 per cent) developed pharyngocutaneous fistulae, with 6 requiring surgical correction. In the study group, 24 of 52 patients (46 per cent) had videofluoroscopy-detected pharyngeal leaks; 4 patients (8 per cent) developed pharyngocutaneous fistulae, but all cases resolved following non-surgical management. Patients who underwent videofluoroscopy had a significantly lower risk of developing pharyngocutaneous fistulae; sensitivity and specificity in the detection of pharyngocutaneous fistulae were 58 per cent and 100 per cent respectively. CONCLUSION: Small-volume gastrografin videofluoroscopy reliably identified small pharyngeal leaks. Routine use in total laryngectomy combined with withholding feeds in cases of early leaks may prevent the development of pharyngocutaneous fistulae.

What is a significant defect of the anal sphincter on translabial ultrasound?

OBJECTIVE: The anal sphincter is commonly evaluated with endoanal ultrasound. Recently, translabial ultrasound imaging has been proposed for sphincter imaging, with moderate to good correlation between the methods. An endosonographic defect is defined as one with a radial extension of > 30° in at least two-thirds of the length of the anal sphincter. This is equivalent to defining significant anal sphincter trauma on translabial tomographic ultrasound imaging (TUI) as a defect in at least four of six slices, a definition which has been validated. This study was designed to validate a residual defect angle of > 30° for the definition of significant anal sphincter trauma on translabial ultrasound. METHODS: This was a retrospective study involving 399 women attending a tertiary urogynecology unit in 2014. All underwent a standardized interview, including determination of St Mark's fecal incontinence score (SMIS), clinical examination and 3D/4D translabial ultrasound examination with the woman at rest and on pelvic floor muscle contraction (PFMC). External (EAS) and internal (IAS) anal sphincter defect angles were measured in individual TUI slices and associations with anal incontinence symptoms, bother score and SMIS were analyzed. RESULTS: There were weak but significant correlations of anal incontinence symptoms, bother score and SMIS with EAS and IAS defect angle, measured on images acquired with the woman at rest and on PFMC. The predictive value of single-slice defect angle on TUI was low, and areas under the receiver-operating-characteristics curves were too low to determine a distinct cut-off value for defect angle. CONCLUSIONS: Anal sphincter residual defects on single translabial TUI slices are weakly associated with measures of anal incontinence. Single-slice defect angle is too poor a predictor to allow validation of the 30° defect angle cut-off used in endoanal ultrasound. Larger studies in populations with a higher prevalence of anal incontinence are needed before we can disregard anal sphincter defects smaller than 30° on translabial ultrasound. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Does estrogen deprivation affect pelvic floor muscle contractility?

INTRODUCTION AND HYPOTHESIS: Pelvic floor muscle (PFM) function plays a role in pelvic organ support, and estrogen deprivation is commonly seen as a risk factor for pelvic floor dysfunction. This study investigated the association between estrogen deprivation and PFM contractility. METHODS: This was a retrospective study on women attending a tertiary urogynecological unit. The assessment included an interview, POPQ assessment, Modified Oxford Scale (MOS) score, and 4D translabial ultrasound (US) on PFM contraction (PMFC). Hormonal status and details on hormone replacement therapy (HRT) were recorded. Corrected menopausal age was defined as the duration of systemic estrogen deprivation. Offline analysis of stored US volumes was performed to measure the reduction in anteroposterior hiatal diameter and bladder neck elevation on PFMC at a later date. RESULTS: Seven hundred thirty-nine women were seen during the study period. Fifty-three were excluded for missing data, leaving 686. Mean age was 56 (17-89, SD 13.3) years; average BMI was 29 (16-66, SD 6.6) kg/m²; 60.6% (n = 416) were menopausal at a mean duration of 16 (1-56, SD 10.2) years. Forty-nine (7.1%) were currently on systemic HRT, while 104 (15.2%) had used it previously. Mean corrected menopausal age (menopausal age - systemic HRT duration) was 7.4 (0-56, SD 10.0) years. Current local estrogen use ≥ 3 months was reported by 31 (4.5%). Mean PFM contractility measured by MOS was 2 (0-5, SD 1.1,). On multivariate analysis there was no association between menopausal age and PFM contractility. CONCLUSIONS: Estrogen deprivation may not be an independent predictor of pelvic floor muscle contractility.

Does exclusion of subcutaneous external anal sphincter on exoanal imaging matter?

OBJECTIVE: There is some speculation that an intact distal anal sphincter complex is of decisive importance for continence, although the external anal sphincter (EAS) is considered to be a single functional and anatomical entity. On tomographic translabial ultrasound (TLUS), the caudal slice at the level of the subcutaneous EAS is currently omitted from the diagnostic algorithm due to the prevalence of artifact at that level. The aim of this study was to determine the predictive value of assessment of the subcutaneous EAS on tomographic TLUS for anal incontinence (AI). METHODS: This was a retrospective study of 463 women seen at our urogynecological service in 2015. All underwent a standardized questionnaire, including determination of St Mark's incontinence score (SMIS), clinical examination and three-/four-dimensional TLUS. On tomographic TLUS, EAS defect angles in slices one to seven were measured on maximum pelvic floor muscle contraction. A slice was defined as positive for a defect if the defect angle was ≥ 30°. The association between significant subcutaneous EAS trauma (i.e. defect angle of ≥ 30° in slice seven) and symptoms of AI, symptom bother score and SMIS was assessed. The performances of the standard six-slice model and the seven-slice model, including the subcutaneous EAS, in the prediction of AI were compared. RESULTS: While there was a highly significant association between all measures of AI and significant EAS trauma in slice seven, addition of the seventh slice to the existing six-slice model did not improve the predictive value for AI. CONCLUSION: As inclusion of the subcutaneous slice of the EAS on tomographic TLUS does not seem to improve the predictive value for AI, the current methodology for assessment of EAS trauma on tomographic TLUS can remain unchanged. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Impact of postoperative radiotherapy on survival and loco-regional control in node-negative oral cavity tumours classified as T3 using the AJCC Cancer Staging Manual eighth edition.

According to the eighth edition of the AJCC Cancer Staging Manual (AJCC8), a depth of invasion (DOI) >10mm is classified as pT3, representing a locally advanced tumour requiring postoperative radiotherapy (PORT). When node-negative, however, evidence regarding whether PORT improves loco-regional control or survival is unclear. To clarify this, two cohorts of patients were studied: (1) patients classified as pT3N0 by the seventh edition of the AJCC manual (AJCC7), with DOI >10mm and a tumour diameter >4cm (17 patients who received PORT), and (2) patients classified as pT1N0 and pT2N0 by AJCC7, with DOI >10mm and a tumour diameter <4cm (55 patients who did not receive PORT). Loco-regional control and survival were analysed. PORT was found not to impact overall survival or disease-free survival. It was also found not to impact local, regional, or distant recurrence. Although the two subsets of patients considered here (DOI >10mm with tumour diameter below or above 4cm) were previously distinct, they are both considered pT3 in AJCC8. Data from this study indicate that the routine administration of PORT to patients with a DOI >10mm may not be warranted in the absence of other risk features such as nodal disease or close margins.

How repeatable is assessment of external anal sphincter trauma by exoanal 4D ultrasound?

OBJECTIVE: Three-/four-dimensional translabial ultrasound (TLUS) is gaining popularity for the assessment of anal sphincter trauma, although repeatability data are lacking. This study aimed to determine the repeatability of tomographic ultrasound imaging (TUI) on TLUS for the diagnosis of external anal sphincter (EAS) trauma and compare the performance of a novice with that of an experienced investigator. METHODS: This was a retrospective study of archived ultrasound datasets of patients who presented with symptoms of pelvic floor dysfunction and were examined twice between 2012 and 2016 at an average interval of 260 (range, 1-1100) days. All volumes were obtained using a GE Medical Systems Voluson 730 Expert or E8 ultrasound system. Post-processing of volumes was performed independently by two investigators, one with over 1 year's experience and another with no prior experience in using TUI, who were blinded to clinical data, each other's results and the results obtained at the first timepoint. Significant trauma on EAS was diagnosed if four of the six TUI slices showed a defect of ≥ 30°. Intra- and interobserver agreement were determined using Cohen's kappa (κ) and intraclass correlation coefficients. RESULTS: During the study period, 105 women underwent two TLUS assessments of the anal sphincter. Of these, 103 patients with ultrasound volumes available for both timepoints were included in the analysis. The novice investigator demonstrated average repeatability for assessment of significant EAS trauma and single-slice defect (κ, 0.30 and 0.22, respectively) despite relatively high agreement between measurements obtained at the two timepoints (84.5% and 79.3%, respectively). The experienced investigator demonstrated good to very good repeatability for significant EAS trauma and single-slice defect (κ, 0.91 and 0.78, respectively) between the two assessments, which equates to 98.1% and 94.7% agreement, respectively. CONCLUSION: The repeatability of TLUS measurements for diagnosis of EAS trauma seems to be very good when imaging is undertaken with state-of-the-art equipment and the analysis is performed by an experienced observer; however, the performance of a novice investigator is much poorer. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Determinants of level Ib involvement in oral squamous cell carcinoma and implications for submandibular gland-sparing neck dissection.

Traditional neck dissection for oral squamous cell carcinoma (OSCC) involves removal of the submandibular salivary gland. Several studies have cited the low incidence of direct gland invasion by tumours and have recommended gland-sparing neck dissection. In this study, a detailed audit of level Ib involvement in OSCC was performed in order to assess the feasibility of submandibular gland-sparing in neck dissection; the rate of direct involvement by the primary tumours, the involvement of periglandular level Ib nodes, and their determinants were investigated. A total of 586 neck dissection specimens obtained between 2005 and 2014 from patients operated on at the study institution for floor of mouth, tongue, and buccal primaries, were evaluated for direct invasion of the gland and periglandular lymphadenopathy. Of 226 node-positive patients, 21 (9.3%) had direct gland invasion by tumour. Risk factors were tumour diameter >4cm (P=0.002) and depth of invasion >10mm (P=0.003). Determinants of periglandular lymphadenopathy were depth of invasion >10mm (P<0.001), perineural invasion (P=0.02), lymphovascular invasion (P=0.014), and moderate/poor differentiation (P<0.0001). Gland-sparing neck dissection is safe in early tumours (pT1pN0-1), with a good chance of minimizing xerostomia without radiotherapy. Larger tumours without clear evidence of submandibular gland invasion or suspicious level Ib lymphadenopathy may be considered for gland preservation, however the oncological safety is unclear.

Peri-operative outcomes following major surgery for head and neck cancer in the elderly: institutional audit and case-control study.

OBJECTIVE: Elderly patients have been consistently shown to receive suboptimal therapy for cancers of the head and neck. This study was performed to determine the peri-operative outcomes of these patients and compare them with those of younger patients. METHODS: In this retrospective analysis, 115 patients aged 70 years or more undergoing major surgery for head and neck cancers were matched with 115 patients aged 50-60 years, and univariate analysis was performed. RESULTS: Elderly patients had a reduced performance status (p < 0.001) and more co-morbid illnesses (p = 0.007), but a comparable intra-operative course. They had a longer median hospital stay (p = 0.016), longer intensive care unit stay (p = 0.04), longer median tracheostomy dependence (p = 0.04) and were more often discharged with feeding tubes (p < 0.001). They also had a higher incidence of post-operative non-fatal cardiac events (p = 0.045). CONCLUSION: Elderly patients with good performance status should receive curative-intent surgery. Although hospital stay and tube dependence are longer, morbidity and mortality are comparable with younger patients.

Emergence of breath testing as a new non-invasive diagnostic modality for neurodegenerative diseases.

Neurodegenerative diseases (NDDs) are incapacitating disorders that result in progressive motor and cognitive impairment. These diseases include Alzheimer's disease, the most common cause of dementia, frontotemporal dementia, amyotrophic lateral sclerosis, dementia with Lewy bodies, Parkinson's, Huntington's, Friedreich's ataxia, and prion disease. Dementia causing NDDs impose a high social and economic burden on communities around the world. Rapid growth in knowledge regarding the pathogenic mechanisms and disease-associated biomarkers of these diseases in the past few decades have accelerated the development of new diagnostic methods and therapeutic opportunities. Continuous effort is being applied to the development of more advanced, easy-to-apply and reliable methods of diagnosis, that are able to identify disease manifestation at its earliest stages and before clinical symptoms become apparent. Development of these diagnostic tools are essential in aiding effective disease management through accurate monitoring of disease progression, timely application of therapeutics and evaluation of treatment efficacy. Recently, several studies have identified novel biomarkers based on compounds in exhaled breath associated with specific NDDs. The use of breath testing, as a means of monitoring neurodegenerative disease onset and progression, has the potential to have a significant impact on augmenting the diagnosis of NDDs as the approach is non-invasive, relatively cost effective and straight forward to implement. This review highlights key features of current diagnostic methods utilised to identify NDDs, and describes the potential application and limitations associated with the use of breath analysis for disease diagnosis and progression monitoring.

Is pulmonary metastasectomy beneficial in head and neck squamous cell carcinoma? A review of literature.

Metastatic head and neck squamous cell carcinoma (HNSCC) has traditionally carried a dismal prognosis; however with advances in care, it has been shown that pulmonary metastasectomy is a viable therapeutic option in selected patients, palliating symptoms and improving survival. With the increasing incidence of human papilloma virus-related HNSCC and better availability of minimal access surgery, there is a need to better understand the role of pulmonary metastasectomy in the treatment of HNSCC. This article summarizes the literature on indications, results, surgical options and approaches, clinical dilemmas, and controversies associated with pulmonary metastasectomy in HNSCC, to identify suitable candidates and optimize outcomes.

Formation and magnetic properties of InFeP:Ag nanorods fabricated with noble metal Ag using an ion milling method.

The formation, including the density and height of the InFeP:Ag nanorods doped with noble metal Ag using an ion milling method, was preponderantly determined from transmission electron microscopy and x-ray diffraction analyses. We investigate, in particular, the enhanced ferromagnetism of the well-aligned InFeP:Ag nanorods. Auger electron spectroscopy and x-ray photoelectron spectroscopy measurements were carried out in order to investigate the incorporation of Ag and to verify the local chemical bonding of the InFeP:Ag nanorods. The variation of FWHM for the double-crystal x-ray rocking curve and triple-axis diffraction peaks demonstrates that noble metal Ag is incorporated into the InFeP:Ag nanorods. The noticeable ferromagnetic signature (M-H curve) of the InFeP:Ag nanorods is observed and T c persists up to almost 350 K (3.9 × 10-4 emu g-1), as determined by temperature-dependence magnetization (M-T curve) measurements. This study suggests that the InFeP:Ag nanorods should be a potential candidate for the application of spintronic devices.

A comprehensive mapping of the structure and gene organisation in the sheep MHC class I region.

BACKGROUND: The major histocompatibility complex (MHC) is a chromosomal region that regulates immune responsiveness in vertebrates. This region is one of the most important for disease resistance because it has been associated with resistance or susceptibility to a wide variety of diseases and because the MHC often accounts for more of the variance than other loci. Selective breeding for disease resistance is becoming increasingly common in livestock industries, and it is important to determine how this will influence MHC polymorphism and resistance to diseases that are not targeted for selection. However, in sheep the order and sequence of the protein coding genes is controversial. Yet this information is needed to determine precisely how the MHC influences resistance and susceptibility to disease. METHODS: CHORI bacterial artificial chromosomes (BACs) known to contain sequences from the sheep MHC class I region were sub-cloned, and the clones partially sequenced. The resulting sequences were analysed and re-assembled to identify gene content and organisation within each BAC. The low resolution MHC class I physical map was then compared to the cattle reference genome, the Chinese Merino sheep MHC map published by Gao, et al. (2010) and the recently available sheep reference genome. RESULTS: Immune related class I genes are clustered into 3 blocks; beta, kappa and a novel block not previously identified in other organisms. The revised map is more similar to Bovidae maps than the previous sheep maps and also includes several genes previously not annotated in the Chinese Merino BAC assembly and others not currently annotated in the sheep reference chromosome 20. In particular, the organisation of nonclassical MHC class I genes is similar to that present in the cattle MHC. Sequence analysis and prediction of amino acid sequences of MHC class I classical and nonclassical genes was performed and it was observed that the map contained one classical and eight nonclassical genes together with three possible pseudogenes. CONCLUSIONS: The comprehensive physical map of the sheep MHC class I region enhances our understanding of the genetic architecture of the class I MHC region in sheep and will facilitate future studies of MHC function.

Conserved haplotype blocks within the sheep MHC and low SNP heterozygosity in the Class IIa subregion.

This report describes single-nucleotide polymorphisms (SNPs) in the sheep major histocompatibility complex (MHC) class II and class III regions and provides insights into the internal structure of this important genomic complex. MHC haplotypes were deduced from sheep family trios based on genotypes from 20 novel SNPs representative of the class II region and 10 previously described SNPs spanning the class III region. All 30 SNPs exhibited Hardy-Weinberg proportions in the sheep population studied. Recombination within an extended sire haplotype was observed within the class II region for 4 of 20 sheep chromosomes, thereby supporting the presence of separated IIa and IIb subregions similar to those present in cattle. SNP heterozygosity varied across the class II and III regions. One segment of the class IIa subregion manifested very low heterozygosity for several SNPs spanning approximately 120 Kbp. This feature corresponds to a subregion within the human MHC class II region previously described as a 'SNP desert' because of its paucity of SNPs. Linkage disequilibrium (LD) was reduced at the junction separating the putative class IIb and IIa subregions and also between the class IIa and the class III subregions. The latter observation is consistent with either an unmapped physical separation at this location or more likely a boundary characterized by more frequent recombination between two conserved subregions, each manifesting high within-block LD. These results identify internal blocks of loci in the sheep MHC, within which recombination is relatively rare.