Complex Reconstruction with Flaps After Abdominoperineal Resection and Groin Dissection for Anal Squamous Cell Carcinoma: A Difficult Case Involving Many Specialities.

BACKGROUND Anal squamous cell carcinoma accounts for about 2-4% of all lower gastrointestinal malignancies, with a distant disease reported in less than 5%. Although surgical treatment is rarely necessary, this often involve large dissections and difficult reconstructive procedures. CASE REPORT We present a complex but successful case of double-flap reconstruction after abdominoperineal resection and groin dissection for anal squamous cell carcinoma (cT3N3M0) with metastatic right inguinal lymph nodes and ipsilateral threatening of femoral vessels. A multi-specialty team was involved in the operation. A vascular and plastic surgeon performed the inguinal dissection with en bloc excision of the saphenous magna and a cuff of the femoral vein, while colorectal surgeons carried out the abdominoperineal excision. The 2 large tissue gaps at the groin and perineum were covered with an oblique rectus abdominis myocutaneous flap and a gluteal lotus flap, respectively. A partially absorbable mesh was placed at the level of the anterior sheath in order to reinforce the abdominal wall, whereas an absorbable mesh was used as a bridge for the dissected pelvic floor muscles. The post-operative period was uneventful and the follow-up at 5 months showed good results. CONCLUSIONS An early diagnosis along with new techniques of radiochemotherapy allow patients to preserve their sphincter function. However, a persistent or recurrent disease needs major operations, which often involve a complex reconstruction. Good team-work and experience in specialized fields give the opportunity to make the best choices to perform critical steps during the management of complex cases.

Elicitation of Protective Antibodies against a Broad Panel of H1N1 Viruses in Ferrets Preimmune to Historical H1N1 Influenza Viruses.

Most preclinical animal studies test influenza vaccines in immunologically naive animal models, even though the results of vaccination may not accurately reflect the effectiveness of vaccine candidates in humans that have preexisting immunity to influenza. In this study, novel, broadly reactive influenza vaccine candidates were assessed in preimmune ferrets. These animals were infected with different H1N1 isolates before being vaccinated or infected with another influenza virus. Previously, our group has described the design and characterization of computationally optimized broadly reactive hemagglutinin (HA) antigens (COBRA) for H1N1 isolates. Vaccinating ferrets with virus-like particle (VLP) vaccines expressing COBRA HA proteins elicited antibodies with hemagglutination inhibition (HAI) activity against more H1N1 viruses in the panel than VLP vaccines expressing wild-type HA proteins. Specifically, ferrets infected with the 1986 virus and vaccinated with a single dose of the COBRA HA VLP vaccines elicited antibodies with HAI activity against 11 to 14 of the 15 H1N1 viruses isolated between 1934 and 2013. A subset of ferrets was infected with influenza viruses expressing the COBRA HA antigens. These COBRA preimmune ferrets had superior breadth of HAI activity after vaccination with COBRA HA VLP vaccines than COBRA preimmune ferrets vaccinated with VLP vaccines expressing wild-type HA proteins. Overall, priming naive ferrets with COBRA HA based viruses or using COBRA HA based vaccines to boost preexisting antibodies induced by wild-type H1N1 viruses, COBRA HA antigens elicited sera with the broadest HAI reactivity against multiple antigenic H1N1 viral variants. This is the first report demonstrating the effectiveness of a broadly reactive or universal influenza vaccine in a preimmune ferret model.IMPORTANCE Currently, many groups are testing influenza vaccine candidates to meet the challenge of developing a vaccine that elicits broadly reactive and long-lasting protective immune responses. The goal of these vaccines is to stimulate immune responses that react against most, if not all, circulating influenza strains, over a long period of time in all populations of people. Commonly, these experimental vaccines are tested in naive animal models that do not have anti-influenza immune responses; however, humans have preexisting immunity to influenza viral antigens, particularly antibodies to the HA and NA glycoproteins. Therefore, this study investigated how preexisting antibodies to historical influenza viruses influenced HAI-specific antibodies and protective efficacy using a broadly protective vaccine candidate.

Quantification of carotid plaque lipid content with magnetic resonance T2 mapping in patients undergoing carotid endarterectomy.

BACKGROUND AND PURPOSE: Techniques to stratify subgroups of patients with asymptomatic carotid artery disease are urgently needed to guide decisions on optimal treatment. Reliance on estimates of % luminal stenosis has not been effective, perhaps because that approach entirely disregards potentially important information on the pathological process in the wall of the artery. METHODS: Since plaque lipid is a key determinant of plaque behaviour we used a newly validated, high-sensitivity T2-mapping MR technique for a systematic survey of the quantity and distribution of plaque lipid in patients undergoing endarterectomy. Lipid percentage was quantified in 50 carotid endarterectomy patients. Lipid distribution was tested, using two imaging indices (contribution of the largest lipid deposit towards total lipid (LLD %) and a newly-developed LAI 'lipid aggregation index'). RESULTS: The bifurcation contained maximal lipid volume. Lipid percentage was higher in symptomatic vs. asymptomatic patients with degree of stenosis (DS ≥ 50%) and in the total cohort (P = 0.013 and P = 0.005, respectively). Both LLD % and LAI was higher in symptomatic patients (P = 0.028 and P = 0.018, respectively), suggesting that for a given plaque lipid volume, coalesced deposits were more likely to be associated with symptomatic events. There was no correlation between plaque volume or lipid content and degree of luminal stenosis measured on ultrasound duplex (r = -0.09, P = 0.53 and r = -0.05, P = 0.75), respectively. However, there was a strong correlation in lipid between left and right carotid arteries (r = 0.5, P <0.0001, respectively). CONCLUSIONS: Plaque lipid content and distribution is associated with symptomatic status of the carotid plaque. Importantly, plaque lipid content was not related to the degree of luminal stenosis assessed by ultrasound. Determination of plaque lipid content may prove useful for stratification of asymptomatic patients, including selection of optimal invasive treatments.

Design and Characterization of a Computationally Optimized Broadly Reactive Hemagglutinin Vaccine for H1N1 Influenza Viruses.

UNLABELLED: One of the challenges of developing influenza A vaccines is the diversity of antigenically distinct isolates. Previously, a novel hemagglutinin (HA) for H5N1 influenza was derived from a methodology termed computationally optimized broadly reactive antigen (COBRA). This COBRA HA elicited a broad antibody response against H5N1 isolates from different clades. We now report the development and characterization of a COBRA-based vaccine for both seasonal and pandemic H1N1 influenza virus isolates. Nine prototype H1N1 COBRA HA proteins were developed and tested in mice using a virus-like particle (VLP) format for the elicitation of broadly reactive, functional antibody responses and protection against viral challenge. These candidates were designed to recognize H1N1 viruses isolated within the last 30 years. In addition, several COBRA candidates were designed based on sequences of H1N1 viruses spanning the past 100 years, including modern pandemic H1N1 isolates. Four of the 9 H1N1 COBRA HA proteins (X1, X3, X6, and P1) had the broadest hemagglutination inhibition (HAI) activity against a panel of 17 H1N1 viruses. These vaccines were used in cocktails or prime-boost combinations. The most effective regimens that both elicited the broadest HAI response and protected mice against a pandemic H1N1 challenge were vaccines that contained the P1 COBRA VLP and either the X3 or X6 COBRA VLP vaccine. These mice had little or no detectable viral replication, comparable to that observed with a matched licensed vaccine. This is the first report describing a COBRA-based HA vaccine strategy that elicits a universal, broadly reactive, protective response against seasonal and pandemic H1N1 isolates. IMPORTANCE: Universal influenza vaccine approaches have the potential to be paradigm shifting for the influenza vaccine field, with the goal of replacing the current standard of care with broadly cross-protective vaccines. We have used COBRA technology to develop an HA head-based strategy that elicits antibodies against many H1 strains that have undergone genetic drift and has potential as a "subtype universal" vaccine. Nine HA COBRA candidates were developed, and these vaccines were used alone, in cocktails or in prime-boost combinations. The most effective regimens elicited the broadest hemagglutination inhibition (HAI) response against a panel of H1N1 viruses isolated over the past 100 years. This is the first report describing a COBRA-based HA vaccine strategy that elicits a broadly reactive response against seasonal and pandemic H1N1 isolates.

Efficacy and Safety of Augmenting the Preclose Technique with a Collagen-Based Closure Device for Percutaneous Endovascular Aneurysm Repair.

PURPOSE: To report our experience of selectively augmenting the preclose technique for percutaneous endovascular aneurysm repair (p-EVAR) with an Angio-Seal device as a haemostatic adjunct in cases of significant bleeding after tensioning the sutures of the suture-mediated closure devices. MATERIALS AND METHODS: Prospectively collected data for p-EVAR patients at our institute were analysed. Outcomes included technical success and access site complications. A logistic regression model was used to analyse the effects of sheath size, CFA features and stent graft type on primary failure of the preclose technique necessitating augmentation and also on the development of complications. RESULTS: p-EVAR was attempted via 122 CFA access sites with a median sheath size of 18-French (range 12- to 28-French). Primary success of the preclose technique was 75.4% (92/122). Angio-Seal augmentation was utilised as an adjunct to the preclose technique in 20.5% (25/122). The overall p-EVAR success rate was 95.1% (116/122). There was a statistically significant relationship (p = 0.0093) between depth of CFA and primary failure of preclose technique. CFA diameter, calcification, type of stent graft and sheath size did not have significant effects on primary preclose technique failure. Overall 4.9% (6/122) required surgical conversion but otherwise there were no major complications. CONCLUSION: Augmentation with an Angio-Seal device is a safe and effective adjunct to increase the success rate of the preclose technique in p-EVAR.

Results of a seven-year, single-centre experience of the long-term outcomes of bovine ureter grafts used as novel conduits for haemodialysis fistulas.

PURPOSE: To report the long-term outcomes of bovine ureter grafts as novel conduits for haemodialysis fistulas. MATERIALS AND METHODS: Thirty-five patients underwent placement of a total of 40 SynerGraft 100 (SG100; CryoLife Europa(®), Guildford, UK) bovine ureter grafts between April 2002 and February 2009. Prospective data were collected on all patients, including active surveillance with blood flow studies and 6-monthly duplex ultrasound studies. Main outcome measures were primary and secondary patency rates. RESULTS: Mean follow-up time was 97 weeks (range 4-270). Thirteen patients died from unrelated causes during the study period; 12 of these patients had a functioning graft at the time of death. Five patients underwent transplantation, and all had a functioning graft at transplantation. Twelve patients had a functioning graft at the end of the study period. One hundred and ten stenoses were detected, and 97 venoplasty procedures were performed. Of the stenoses, 41.8% were located at the venous anastomosis, 12.7% within the graft, 17.3% in the outflow veins, and 28.1% in central veins. No arterial stenoses were detected. Primary patency rates were 53% at 6 months and 14% at 1 year. Secondary patency rates were 81% at 6 months, 75% at 1 year, and 56% at 2 years. CONCLUSIONS: Active surveillance and intervention was able to achieve satisfactory long-term secondary patency for these novel conduits compared with those made of PTFE seen in other studies [1].

Management of a ruptured mycotic pseudo-aneurysm following pancreas-kidney transplantation.

BACKGROUND: Simultaneous pancreas kidney transplantation (SPK) is accepted as a therapy for patients with type 1 diabetes and coexisting renal failure. Mycotic pseudoaneurysm formation is a life-threatening complication of transplantation, despite this however, little has been published with regards to its occurrence following SPK transplantation. CASE REPORT: We describe the case of a 35 year old patient who 18 days after receiving a SPK transplant developed an iliac-enteric fistula, following mycotic pseudoaneurysm formation. An emergency laparotomy was required to manage a life threatening gastrointestinal hemorrhage, which necessitated graft pancreatectomy. Resection of the diseased segment of recipient iliac artery onto which the allograft was anastomosed was also required. The patient went on to develop a vascular leak, managed initially by endovascular stenting. With the development of subsequent sepsis and a further leak, operative management was required to remove the infected stent and achieve hemostasis. Immunosupression was withdrawn in an attempt to tackle the ensuing life-threatening sepsis. The patient showed signs of improvement over the following weeks, but unfortunately, developed signs of recurrent sepsis and increasing, unremitting discomfort over the kidney allograft. On re-exploration the allograft was found to be heavily infected, with the concurrent progressive renal failure, the decision was made to remove the allograft. CONCLUSIONS: This case highlights important considerations when managing mycotic pseudoaneurysms in transplant recipients. Stent placement to manage such complications may not be a long lasting solution and where stent deployment is used close follow-up of patients is mandatory.

Characterization of microRNAs involved in embryonic stem cell states.

Studies of embryonic stem cells (ESCs) reveal that these cell lines can be derived from differing stages of embryonic development. We analyzed common changes in the expression of microRNAs (miRNAs) and mRNAs in 9 different human ESC (hESC) lines during early commitment and further examined the expression of key ESCenriched miRNAs in earlier developmental states in several species. We show that several previously defined hESC-enriched miRNA groups (the miR-302, -17, and -515 families, and the miR-371-373 cluster) and several other hESC-enriched miRNAs are down-regulated rapidly in response to differentiation. We further found that mRNAs up-regulated upon differentiation are enriched in potential target sites for these hESC-enriched miRNAs. Interestingly, we also observed that the expression of ESC-enriched miRNAs bearing identical seed sequences changed dynamically while the cells transitioned through early embryonic states. In human and monkey ESCs, as well as human-induced pluripotent stem cells (iPSCs), the miR-371-373 cluster was consistently up-regulated, while the miR-302 family was mildly down-regulated when the cells were chemically treated to regress to an earlier developmental state. Similarly, miR-302b, but not mmu-miR-295, was expressed at higher levels in murine epiblast stem cells (mEpiSC) as compared with an earlier developmental state, mouse ESCs. These results raise the possibility that the relative expression of related miRNAs might serve as diagnostic indicators in defining the developmental state of embryonic cells and other stem cell lines, such as iPSCs. These data also raise the possibility that miRNAs bearing identical seed sequences could have specific functions during separable stages of early embryonic development.

The pathology of depopulated bovine ureter xenografts utilized for vascular access in haemodialysis patients.

AIMS: Vascular access for long-term haemodialysis is obtained through the surgical fashioning of arteriovenous fistulae, utilizing the patients' native blood vessels, or by insertion of synthetic grafts or non-synthetic gluteraldehyde cross-linked biological xenografts. These non-native grafts have high complication rates and a depopulated bovine ureter xenograft has recently been developed as an alternative. The aim was to undertake the first systematic review of the histopathology of bovine ureter xenografts (n = 25) utilized for haemodialysis vascular access in humans. METHODS AND RESULTS: Pre-insertion specimens (n = 7) showed preservation of some cellular architecture and histological antigenicity. Uncomplicated segments of post-insertion specimens (n = 18) showed myofibroblastic in-growth but no luminal endothelialization and no vascularization of the wall, other than at sites of needle puncture. Post-insertion, 50% showed a severe adventitial host inflammatory response with a dominant granulomatous and eosinophil-rich infiltrate. Inflammation was present in grafts with various complications (stenosis, thrombosis, aneurysm), but there was no clear pathogenic link. CONCLUSIONS: We conclude that repopulation of bovine ureter xenografts by host cells is limited and that, in specimens removed for complications, an inflammatory reaction to the xenograft is common. This could reflect retention of some antigenicity following pre-insertion 'depopulation' of the grafts.

Impact of pulsatile perfusion on postoperative outcome of kidneys from controlled donors after cardiac death.

Pulsatile perfusion (PP) might be a cost-effective cold preservation technique to reduce the incidence of delayed graft function (DGF) in kidneys from deceased donors. With the aim to address whether PP can reduce the incidence of DGF in kidneys from controlled donors after cardiac death (cDCD), we compared the clinical outcome of 30 recipients of kidneys from cDCD preserved by static cold storage (cDCD-SCS) with 30 recipients of cDCD kidneys preserved by PP (cDCD-PP). The end-points were the incidence of primary nonfunction (PNF), DGF and acute rejection (AR), the length of hospitalization, 1, 3, 6 and 12-months graft function, graft survival and patient survival. Donor, recipient and preimplantation data were well matched. DGF was significantly lower (53.3% vs. 86.6% P<0.001) and the length of hospitalization shorter (10 vs. 14 days P<0.033) in the cDCD-PP group. Similarly, postoperative and short-term graft function (7 and 30 days and 6 and 12 months, respectively) was statistically better in the cDCD-PP than in the cDCD-SCS. In summary, in this cohort, clinical introduction of PP was associated with a significant reduction of DGF, shorter hospitalization and better graft function than SCS.

Diagnostic imaging of and radiologic intervention for bovine ureter grafts used as a novel conduit for hemodialysis fistulas.

OBJECTIVE: The objectives of our study were to review the appearances on diagnostic imaging and amenability to imaging-guided intervention of a novel bovine ureter graft (Syner-Graft 100 [SG 100]) for use as a conduit for hemodialysis fistulas. CONCLUSION: The SG 100 shows initial promise as a conduit for hemodialysis fistulas in patients with difficult vascular access. The SG 100 has characteristic appearances on diagnostic imaging and is prone to similar pathologic processes that affect autogenous venous and synthetic grafts. These grafts are readily amenable to imaging-guided percutaneous intervention, which plays a major role in prolonging graft function.

Major effects of delayed graft function and cold ischaemia time on renal allograft survival.

BACKGROUND: There is mounting evidence from experimental and clinical studies that the quality of organs from cadaver donors may be influenced by events occurring around the time of brain death, and that these may affect transplant outcome. The aim of this study is to investigate the influence of donor factors on renal allograft outcome in a homogeneous cohort of 518 patients transplanted in a single centre over a 9 year period. METHODS: Endpoints of the study were delayed graft function (DGF), acute rejection (AR), 1 year graft survival and long-term survival of those grafts that reached 1 year. Multivariate analysis was performed to determine factors that may have influenced the graft outcome indicators. RESULTS: DGF was the major predictor of graft failure overall with cold ischaemia time (CIT) as an important independent factor. The level of histocompatibility did not influence graft survival. DGF was the major factor affecting 1 year graft survival (P<0.0005) with effects persisting beyond 1 year. DGF was significantly influenced by CIT, donor age, female kidney into male recipient and donor creatinine (P<0.05). Other donor factors and factors associated with donor management were not risk factors for DGF, rejection episodes or graft survival. The risk factors for a number of AR episodes were HLA-DR mismatch and DGF (P<0.005). When grafts surviving for 1 year were considered, only CIT, recipient age and creatinine at 1 year (P<0.05) were found to affect graft survival significantly. CONCLUSIONS: The results of this analysis of well-matched transplant recipients show that CIT and DGF are the most important predictors of poor short and long-term graft survival. Therefore, in order to improve the long-term survival of renal allografts efforts should focus on limiting CIT and the damage that occurs during this period and on improving our understanding of DGF.

The myth of secure computing.

Few senior executives pay a whole lot of attention to computer security. They either hand off responsibility to their technical people or bring in consultants. But given the stakes involved, an arm's-length approach is extremely unwise. According to industry estimates, security breaches affect 90% of all businesses every year and cost some $17 billion. Fortunately, the authors say, senior executives don't need to learn about the more arcane aspects of their company's IT systems in order to take a hands-on approach. Instead, they should focus on the familiar task of managing risk. Their role should be to assess the business value of their information assets, determine the likelihood that those assets will be compromised, and then tailor a set of risk abatement processes to their company's particular vulnerabilities. This approach, which views computer security as an operational rather than a technical challenge, is akin to a classic quality assurance program in that it attempts to avoid problems rather than fix them and involves all employees, not just IT staffers. The goal is not to make computer systems completely secure--that's impossible--but to reduce the business risk to an acceptable level. This article looks at the types of threats a company is apt to face. It also examines the processes a general manager should spearhead to lessen the likelihood of a successful attack. The authors recommend eight processes in all, ranging from deciding how much protection each digital asset deserves to insisting on secure software to rehearsing a response to a security breach. The important thing to realize, they emphasize, is that decisions about digital security are not much different from other cost-benefit decisions. The tools general managers bring to bear on other areas of the business are good models for what they need to do in this technical space.

Low-dose valaciclovir prophylaxis against cytomegalovirus disease in renal transplant recipients.

High-dose valaciclovir at up to 8 g/day has been shown to be effective in prophylaxis against cytomegalovirus (CMV) disease in renal transplant recipients. We report our experience with low-dose valaciclovir prophylaxis of up to 3 g/day, adjusted to creatinine clearance. A group of patients at high risk of developing CMV disease who received prophylaxis were selected as the study group. This included all CMV-positive patients who received antilymphocyte therapy (R+, n=20) and all CMV-negative recipients of CMV-positive organs (D+R-, n=15). D+R- patients receiving antilymphocyte therapy were excluded, as most of the patients in the control group had received ganciclovir prophylaxis. A historical control group was used, which consisted of patients who did not receive prophylaxis. Low-dose valaciclovir prophylaxis resulted in a statistically significant decrease (8.5 vs 37%, P=0.004) in CMV disease in the study group at 6 months. On subgroup analysis the decrease was statistically significant only in the R+ group (5 vs 45%, P=0.003), not in the D+R- group (13.3 vs 26.6%, P=0.651). Low-dose valaciclovir prophylaxis seems to be adequate for R+ patients receiving antilymphocyte therapy. The role of low-dose valaciclovir prophylaxis needs to be assessed further in a prospective trial.