The Tricky Trachea: Tracheitis and Mediastinitis Treated With Infliximab and Steroids in a Patient With Ulcerative Colitis.

Pulmonary extra-intestinal manifestations of inflammatory bowel disease are rare, comprising 0.21% to 0.4% of the inflammatory bowel disease population. Common symptoms include cough, chest pain, and dyspnea. Abnormal pulmonary function tests are common in these patients, with restrictive, obstructive, and diffusion capacity defects. CT scanning remains the most sensitive imaging technique to detect abnormalities. Pulmonary manifestations are diverse and include airway, parenchymal, and pleural disease. Large airway disease predominates, particularly bronchiectasis. Upper airway disease is rare but concerning for the development of acute airway compromise. To our knowledge, there are no reports of concurrent mediastinitis with tracheitis in the setting of inflammatory bowel disease. We present a case of a patient with ulcerative proctitis who experienced the development of inflammatory tracheitis and mediastinitis. Her disease responded to systemic steroids and biologic therapy. In addition to our case, we reviewed the literature and provide an approach to pulmonary complications as extra-intestinal manifestation of inflammatory bowel disease.

Invasion, isolation and evolution shape population genetic structure in Campanula rotundifolia.

The distribution and genetic structure of most plant species in Britain and Ireland bear the imprint of the last ice age. These patterns were largely shaped by random processes during recolonization but, in angiosperms, whole-genome duplication may also have been important. We investigate the distribution of cytotypes of Campanula rotundifolia, considering DNA variation, postglacial colonization, environmental partitioning and reproductive barriers. Cytotypes and genome size variation from across the species' range were determined by flow cytometry and genetic variation was assessed using cpDNA markers. A common garden study examined growth and flowering phenology of tetraploid, pentaploid and hexaploid cytotypes and simulated a contact zone for investigation of reproductive barriers. Irish populations were entirely hexaploid. In Britain, hexaploids occurred mostly in western coastal populations which were allopatric with tetraploids, and in occasional sympatric inland populations. Chloroplast markers resolved distinct genetic groups, related to cytotype and geographically segregated; allopatric hexaploids were distinct from tetraploids, whereas sympatric hexaploids were not. Genome downsizing occurred between cytotypes. Progeny of open-pollinated clones from the contact zone showed that maternal tetraploids rarely produced progeny of other cytotypes, whereas the progeny of maternal hexaploids varied, with frequent pentaploids and aneuploids. The presence of distinctive hexaploid chloroplast types in Ireland, Scottish islands and western mainland Britain indicates that its establishment preceded separation of these land masses by sea-level rise c. 16 000 years BP. This group did not originate from British tetraploids and probably diverged before postglacial invasion from mainland Europe. The combination of cytotype, molecular, contact zone and common garden data shows an overall pattern reflecting postglacial colonization events, now maintained by geographic separation, together with more recent occasional local in situ polyploidisation. Reproductive barriers favour the persistence of the tetraploid to the detriment of the hexaploid.

Splenic Angiosarcoma with Bone Marrow Involvement Initially Diagnosed as Systemic Mastocytosis: A Case Report.

We describe the case of a 67-year-old female patient presenting with constitutional symptoms and rapid decline. Two bone marrow core biopsies were performed, with spindled cells identified and thought to represent marrow involvement by systemic mastocytosis on the first biopsy. A diagnosis of metastatic vascular malignancy with sarcomatoid features was favored on the second core biopsy. The patient rapidly deteriorated and passed away. The post-mortem examination revealed a splenic angiosarcoma with metastasis to the liver and bone marrow. Splenic angiosarcoma is a rare, aggressive entity, with bone marrow metastasis even more uncommon. This report perceives this as a diagnostic consideration on bone marrow biopsies with spindled cells and explores the diagnostic dilemma and overlapping features of systemic mastocytosis and angiosarcoma.

Synchronous bilateral lipoma arborescens of bicipitoradial bursa-a rare entity.

Lipoma arborescens is a rare non-neoplastic condition that affects the synovial lining of joints and bursae accounting for less than 1% of all lipomatous lesions. Characterized by villous proliferation of the synovium, it is an uncommon cause of intra/periarticular mass presenting as a painless, slowly progressive longstanding swelling, and is sometimes accompanied by intermittent monoarticular effusions. We describe a rare case of bilateral lipoma arborescens in the bicipitoradial bursae in a young male referred for MRI evaluation of spontaneous bilateral elbow swelling. We chose to bring this case to light because of the rare simultaneous involvement of the bicipitoradial bursae bilaterally and the role of MR in providing a definite diagnosis, hence obviating the need for biopsy and avoiding consideration of other complex intra/periarticular masses.

A Case of Localized Pulmonary Calcification Presenting as a Persistent Mass Lesion in an Immunosuppressed Patient Following Treatment of a Pseudomonas Pneumonia.

We report a case of a persistent right upper lobe opacity following treatment for a Pseudomonas infection in an immunosuppressed patient with a recent renal transplantation. The patient underwent a surgical lung biopsy for definitive diagnosis of the mass. The lesion was composed of extensive calcifications deposited throughout the lung with associated fibrosis. The patient had a history of a remote parathyroidectomy for hyperparathyroidism; however, the parathyroid hormone (PTH) and the calcium levels were still mildly elevated. No other calcified lung lesions had developed in a follow-up after the initial resection. Pulmonary calcification has been classically associated with varicella pneumonia; no viral cytopathic changes were identified for varicella or other viruses in this case. The calcification appears to be secondary to the recent Pseudomonas pneumonia. To our knowledge, this is the first report of a Pseudomonas pneumonia resulting in extensive localized pulmonary calcification. This is an important diagnostic consideration as this benign entity should be considered in patients with persistent opacities following treatment for pneumonia.

Current trends in minilaparoscopy.

PURPOSE OF REVIEW: The purpose of this review is to understand the current use of minilaparoscopy in the field and how minilaparoscopy compares with traditional laparoscopy in terms of operative times, complications, pain, and cosmesis. RECENT FINDINGS: Although there are few randomized controlled trials comparing minilaparoscopy with traditional laparoscopy in gynecologic procedures, the results suggest that minilaparoscopy can be performed safely with improved cosmetic outcomes and similar complication rates and operating times. Postoperative pain may be decreased with minimizing incisions sizes. Recently, case reports and case series have been published demonstrating the use of minilaparoscopy across many subtypes of gynecologic surgery. SUMMARY: Traditional laparoscopic surgery has become common practice in gynecology as it has been found to be a well tolerated procedure with improved outcomes and decreased morbidity when compared with laparotomy. Although minilaparoscopy has been used for over 2 decades, its role in gynecology is continuing to evolve. Minilaparoscopy is a growing surgical option in gynecology as we try to minimize the impact of surgery. Results of minilaparoscopy in gynecology mirror those found in urology and general surgery. Although research is limited, minilaparoscopy has proven to be a well tolerated alternative for gynecology.

Amyloid deposition in extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue: A clinicopathologic study of 5 cases.

Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) is the most common subtype of marginal zone lymphoma (MZL), with stomach being the most frequent primary site, followed by salivary gland, lung and ocular adnexa. Although clinically indolent, MALT lymphoma has the potential of local recurrence and systemic spread. Amyloid deposition is a very unusual complication of MALT lymphoma. In this study, we report clinicopathologic features of 5 cases of MALT lymphomas with associated amyloid deposits. One case showed amyloid deposits in the primary lesion; the other four cases showed amyloid deposits only in recurrences. Previous studies suggest that the amyloid deposits do not implicate worse prognosis. In our study, although amyloid deposits were focal and organ confined, one patient had extensive deposits of amyloid in the large bowel wall leading to bowel perforation and another patient developed significant peripheral neuropathy due to amyloid deposits in the brachial plexus. In conclusion, amyloid deposits in MALT lymphomas are rare and organ/tumour confined. However, complications can be critical and cause considerable morbidity. Therefore, pathologists should be aware of the association between MALT lymphoma and amyloid deposition, and clinical follow up is warranted.

Alterations in platelet-derived growth factor expression in the pathophysiology of necrotizing enterocolitis.

BACKGROUND: Necrotizing enterocolitis (NEC) involves impaired ileal blood flow due to alterations in vascular tone control and intestinal angiogenesis. Platelet-derived growth factor (PDGF) is a mediator of normal angiogenesis in intestinal epithelium. We hypothesized that gene dysregulation during experimental NEC results in altered PDGF expression. METHODS: Sprague-Dawley rats were randomized to groups by litter. Controls were delivered vaginally and dam-fed. NEC groups were delivered prematurely by cesarean section and subjected to an established NEC protocol. Ileum was obtained at 0, 12, 24, 48, 72, and 96 h of life from all animals (N = 108 animals). Western blot analysis was carried out for every time point, and samples were evaluated by immunohistochemistry. Antibodies against PDGF-A, PDGF-B, and their receptors, PDGFR-α and PDGFR-ß, were used. Statistical analysis was performed using two-way analysis of variance with a priori P < 0.05. RESULTS: Ileal PDGF-A concentration was higher in controls versus NEC from 24-96 h of life. Its receptor, PDGFR-α, was low in concentration in both groups at all time points. PDGF-B concentration was increased in controls at 24 and 72 h of life but decreased at the 48-h mark. Its receptor, PDGFR-ß, was also low in both groups at 12 and 24 h but increased in controls at 48 and 72 h. CONCLUSIONS: These data support our hypothesis that PDGF and PDGF receptor expression are altered in experimental NEC. Dysregulation of PDGF during intestinal maturation could contribute to the development of NEC. Further investigation into this pathway could yield new therapeutic targets for this devastating disease.

Three-dimensional modeling of the human fallopian tube fimbriae.

OBJECTIVE: Ovarian cancer is the most lethal gynecological malignancy that affects women. Recent data suggests that the disease may originate in the fallopian fimbriae; however, the anatomical origin of ovarian carcinogenesis remains unclear. This is largely driven by our lack of knowledge regarding the structure and function of normal fimbriae and the relative paucity of models that accurately recapitulate the in vivo fallopian tube. Therefore, a human three-dimensional (3D) culture system was developed to examine the role of the fallopian fimbriae in serous tumorigenesis. METHODS: Alginate matrix was utilized to support human fallopian fimbriae ex vivo. Fimbriae were cultured with factors hypothesized to contribute to carcinogenesis, namely; H2O2 (1mM) a mimetic of oxidative stress, insulin (5µg/ml) to stimulate glycolysis, and estradiol (E2, 10nM) which peaks before ovulation. Cultures were evaluated for changes in proliferation and p53 expression, criteria utilized to identify potential precursor lesions. Further, secretory factors were assessed after treatment with E2 to identify if steroid signaling induces a pro-tumorigenic microenvironment. RESULTS: 3D fimbriae cultures maintained normal tissue architecture up to 7days, retaining both epithelial subtypes. Treatment of cultures with H2O2 or insulin significantly induced proliferation. However, p53 stabilization was unaffected by any particular treatment, although it was induced by ex vivo culturing. Moreover, E2-alone treatment significantly induced its canonical target PR and expression of IL8, a factor linked to poor outcome. CONCLUSIONS: 3D alginate cultures of human fallopian fimbriae provide an important microphysiological model, which can be further utilized to investigate serous tumorigenesis originating from the fallopian tube.

Carcinoma of the larynx, metastatic to illeum, presents as ruptured appendicitis: case report and literature review.

OBJECTIVES: Metastasis of laryngeal squamous cell carcinoma (SCC) to the intra-abdominal gastrointestinal tract is exceedingly rare. The objectives of this case report are to describe a case involving a perforated metastasis of a laryngeal SCC to the ileum and to review the literature pertaining to other similar cases. METHODS: A review of patient's chart and a review of the English literature involving malignant SCC of the larynx with metastasis to the small bowel. RESULTS: We describe the case of a 58-year-old man who had failed induction chemotherapy and underwent a laryngopharyngectomy with bilateral neck dissection and pectoralis major flap for a T4N2c laryngeal SCC. Subsequently, the patient was treated with postoperative radiation and cituximab.The patient went on to present with symptoms consistent with a ruptured appendix, supported by ultrasound imaging. The patient was taken to the operating room where a right hemicolectomy was performed. Pathological gross examination confirmed a 4 cm transmural perforation in the terminal ileum. Microscopy demonstrated deposits of metastatic squamous cell carcinoma in the surrounding smooth muscle. Metastatic carcinoma was also found in a separate nodule from the abdominal wall. The patient had an uncomplicated post-operative period, and survived several months thereafter. CONCLUSIONS: Metastasis of laryngeal SCC to the small bowel with perforation is exceedingly rare, but possible. These patients may be successfully managed with resection.

Stepwise approach to laparoscopic hysterectomy: evaluation of technique and cost benefit.

This article examines factors associated with performing a laparoscopic hysterectomy in a stepwise fashion and addresses the technique and cost effectiveness of this procedure compared with abdominal hysterectomy. We review techniques of the laparoscopic hysterectomy as well difficulties that may be encountered throughout the procedure. The hysterectomy is profiled in a method that provides a reproducible system that allows surgeons to increase their surgical numbers and comfort level. When assessing cost-benefit analysis, the cost of hysterectomy is primarily influenced by the operative time, length of hospital stay, equipment, and complications. Robotic and laparoscopic hysterectomy had the highest mean hospital charges. The laparoscopic approach to hysterectomy provides better rates of recovery, length of stay, and hospital cost. The use of the stepwise approach to hysterectomy may allow surgeons to readily perform the procedure and also identify areas and techniques that need improvement. Regardless of age, body mass index (BMI), comorbities, and other nonclinical factors, the laparoscopic hysterectomy compared with abdominal hysterectomy and vaginal hysterectomy has been shown to be better for the patient's recovery and quality of life.

An endonasal approach to the resection of a papillary seromucinous adenocarcinoma of the eustacian tube.

OBJECTIVES: Papillary seromucinous adenocarcinoma of the sinonasal tract is exceedingly rare. The objectives of this case report are to describe a case of papillary seromucinous adenocarcinoma presenting in the nasopharynx and to review the literature pertaining to other similar cases. METHODS: A review of the patient's chart and a review of the English literature were conducted. RESULTS: We describe the case of a 64 year-old woman who presented with a 3-year history of epistaxis and right-sided otitis media with effusion. The patient had been followed for a known nasopharyngeal mass that had twice been biopsied and in both cases was considered a benign mass pathologically. A third biopsy was diagnosed as a low-grade papillary seromucinous adenocarcinoma. The patient was otherwise asymptomatic. The patient was referred to a multidisciplinary cancer clinic at which endoscopic resection was determined to be the preferred treatment modality. A literature review and approach to patients with nasopharyngeal masses will be presented. CONCLUSIONS: Papillary seromucinous adenocarcinoma is a rare tumor that can present in the nasopharynx. We describe the endoscopic surgical management of one such patient that presented to our care.

Direct peritoneal resuscitation augments ileal blood flow in necrotizing enterocolitis via a novel mechanism.

PURPOSE: Endothelin-1, prostaglandins (PGs), and nitric oxide (NO) have been implicated in the intestinal microvascular dysfunction of necrotizing enterocolitis (NEC). We hypothesized that direct peritoneal resuscitation (DPR) dilates the intestinal microvasculature and improves blood flow independent of these mechanisms. METHODS: Rat pups were assigned by litter to experimental NEC or CONTROL groups. Laser Doppler flowmetry evaluation of intestinal microvascular blood flow was studied at baseline, with mediator blockade (endothelin-A receptor, endothelin-B receptor, PG synthesis, or NO synthase) and with DPR. Repeated-measures analysis of variance test was applied with Tukey-Kramer honestly significant difference test (P < .05). RESULTS: At baseline, NEC animals demonstrated significantly decreased ileal blood flow as compared with CONTROLs (P < .05). Endothelin-A receptor and PG inhibition increased flow in the intestinal microvasculature, but this was significantly augmented by the addition of DPR (P < .05). Blockade of NO synthase decreased intestinal blood flow, which was overcome with addition of DPR (P < .05). CONCLUSION: Ileal blood flow was significantly reduced in NEC animals as compared with CONTROLs. The addition of DPR to the peritoneum increased ileal blood flow significantly in all groups in spite of blockade of these known vasoactive mechanisms. Direct peritoneal resuscitation may be a novel strategy to improve intestinal blood flow in NEC.

Global endometrial ablation.

Abnormal uterine bleeding (AUB) is a significant health problem for many women. Surgical treatment of AUB often follows failed attempts with first-line medical therapy. Hysterectomy, while being a definitive treatment, is a major surgical procedure with potential for significant complications and economic costs. Endometrial ablation was developed as an alternative to hysterectomy. The first-generation endometrial ablation devices required extensive training and experience to be performed effectively and safely. As a result, newer ablative devices were developed addressing the need for less technical knowledge and improved safety. Since 1997, the United States FDA has approved 5 global endometrial ablation devices for treatment of AUB attributable to benign causes. This review will focus on the technical aspects of these second- generation devices and their applications for treatment of AUB.