Multilocular infection caused by hypervirulent Klebsiella pneumoniae.

Hypervirulent strains of Klebsiella pneumoniae (hvKP) can cause atypical multilocular infections in otherwise healthy patients. Diagnosis of infection caused by hvKP is based mainly on clinical findings and laboratory results, including detection of virulence genes. It typically manifests as hepatic abscess with metastatic spread. Treatment is based on surgical intervention in combination with targeted antimicrobial therapy. The occurrence of hvKP infection is relatively common in Asia, and while still rare in Europe, incidence is increasing. The article aims to provide a short overview of the issue and increase awareness of the possible occurrence of hvKP infections.

[Toxoplasmosis after immunosuppressive therapy--our experience]. / Toxoplazmová infekcia u pacientov po transplantácii krvotvorných buniek--skúsenosti jedného pracoviska

Toxoplasmosis is a parasitic disease associated with high mortality in immunocompromised patients. It may lead to life-threatening conditions, usually neuroinfections, pneumonia or disseminated disease. It may be potentially dangerous, especially for patients with prolonged lymphopenia or those treated with immunosuppressive drugs. In our centre, we have observed 3 cases of toxoplasmosis in patients after allogeneic haematopoietic stem cell transplantation (HSCT) (2.6% of 116 allo-HSCT patients since 2000) and one case after autologous HSCT (0.3% of 395 auto-HSCT patients since 1997). Toxoplasmosis is manifested by neurological symptoms including hemiparesis and paraparesis, cerebral salt-wasting syndrome (hyponatraemia and hypoosmolality), psychoorganic syndrome and signs of respiratory infection. The diagnosis was made by combining clinical signs and results of PCR and CT examinations. The patients were treated with high-dose pyrimethamine, clindamycin, co-trimoxazole and folic acid. Three of the four patients have survived with no signs of the disease. One patient died prior to treatment. The increasing use of highly immunosuppressive chemotherapy and conditioning regimens (including rituximab, fludarabine and anti-thymocyte globulin) is associated with a significant risk of toxoplasmosis. Variable manifestations, non-specific results of MRI or CT examinations and possibility of PCR negativity are the main obstacles to successful diagnosis.

First Report of Anthracnose Caused by Colletotrichum acutatum on Strawberry in the Czech Republic.

Colletotrichum acutatum J. H. Simmond is the causal agent of anthracnose rot and strawberry blackspot. This pathogen is listed by the EPPO as a regulated (formerly quarantined) organism for all European countries and is widely distributed throughout Europe (e.g., the United Kingdom, France, and Germany) (2). In the autumn of 2005, typical symptoms of anthracnose caused by C. acutatum (circular, dark, and sunken spots on fruit, dark, sunken lesions on petioles, and withering of the leaf, buds, and flowers) were repeatedly observed on field-grown strawberry plants in the Melník Region of central Bohemia and Breclav Region in southern Moravia, Czech Republic. Strawberry fruits and petioles showing typical symptoms were surface sterilized (30 s in 70% ethanol, 1 min in 10% NaOCl, and 15 s in 70% ethanol), rinsed in sterile water, dissected under aseptic conditions, and plated on 2% malt extract agar or placed in wet chambers and incubated at room temperature (18 to 20°C) for 10 days. All isolated strains were independently identified by morphological characteristics, plate-trapped antigen enzyme-linked immunosorbent assay (PTA-ELISA) (1), and PCR with the C. acutatum-specific primers ITS4 and CaInt2 (3). Morphological studies of C. acutatum were carried out on potato dextrose agar (4). The colonies were white, cream, grayish, or rose-orange before sporulation and the colony reverse was cream to orange with brown spots. The mycelial growth rate was 7.5 mm per day at 25°C. The conidia were one-celled, hyaline, cylindrical, 11.3 to 19.7 × 3.6 to 5.5 µm, and the majority of conidia were pointed at either or both ends. The appresoria were brown, globose to ellipsoidal, 5.0 to 7.5 × 5.0 to 6.2 µm, and the sclerotia were absent. Ten strawberry plants with green fruits of each cultivar Elsanta and Kama were sprayed with 500 ml of suspension of C. acutatum conidia (104 conidia per ml). This test was carried out in the glasshouse under quarantine conditions at 20 to 25°C. C. acutatum caused withering of the flowers or dark brown spots on green fruits on five plants of cv. Elsanta and on four plants of cv. Kama after a 6-week incubation period. Isolation and identification of the pathogen from the diseased tissues were done as described above. C. acutatum was reisolated from three fruits, four leaf blades, and four petioles from five plants of cv. Elsanta and four fruits, four leaf blades, and two petioles from four plants of cv. Kama. The fungus was not reisolated from the control strawberry plants. In three cases, the pathogen was detected in the crown of plants of cv. Elsanta by PCR and ELISA. References: (1) Anonymous. OEPP/EPPO Bull. 34:155, 2004. (2) I. M. Smith and L. M. F. Charles, eds. Distribution Maps of Quarantine Pests for the European Union and for the European and Mediterranean Plant Protection Organization. CABI Publishing, Wallingford, UK, 1998. (3) S. Sreenivasaprasad et al. Plant Pathol. 45:650, 1996. (4) P. Talhinhas et al. Phytopathology 92:986, 2002.

Hypoxia and vascular endothelial growth factor expression in human squamous cell carcinomas using pimonidazole as a hypoxia marker.

Hypoxia in human tumors is associated with poor prognosis, but the molecular mechanisms underlying this association are poorly understood. One possibility is that hypoxia is linked to malignant progression through vascular endothelial growth factor (VEGF) induction and the associated angiogenesis and metastasis. The present clinical study measures hypoxia and VEGF expression on a cell-by-cell basis in human squamous cell carcinomas to test the hypothesis that hypoxia and VEGF protein expression are coupled in human tumors. Eighteen patients with invasive squamous cell carcinoma of the uterine cervix and head and neck have been investigated by a quantitative image analysis of immunostained sections from their tumors. The hypoxia marker pimonidazole was used to measure tumor hypoxia, and a commercially available antibody was used to measure VEGF protein expression. A quantitative immunohistochemical comparison of hypoxia and VEGF protein expression revealed no correlation between the two factors.

Immunohistochemical analyses of estrogen receptor in endometrial adenocarcinoma using a monoclonal antibody.

Immunohistochemical localization of estrogen receptor (ER) using specific monoclonal anti-human estrogen receptor antibody, H222, with an immunoperoxidase technique was performed on fresh frozen tissue derived from 100 endometrial adenocarcinomas. Immunohistochemical evaluation incorporated both intensity and distribution of staining. In all cases, H222 localized in the nucleus of target cells. A significant quantitative relationship was shown between histological score (H-Score) and the biochemical analysis of ER content in tissue homogenates (r = 0.65, P = 0.00001). Excellent sensitivity (92%) and specificity (93%) were observed for the comparison of H-Score to the biochemical assay. Significant ER localization was present in stromal and myometrial elements, component H-Score of which correlated weakly with component H-Scores of malignant epithelial elements. Divergent receptor localization in stromal and myometrial versus malignant epithelial elements suggests that biochemical assays of endometrial carcinoma specimens may not reflect cancer-relevant receptor content. The data presented here suggest that the immunoassay of ER using H222 monoclonal antibody provides additional histochemical information to complement conventional analyses of endometrial adenocarcinomas.

HER-2/neu amplification in benign breast disease and the risk of subsequent breast cancer.

PURPOSE: The purpose of this study was to determine whether the presence of HER-2/neu gene amplification and/or overexpression in benign breast disease was associated with an increased risk of subsequent breast cancer. PATIENTS AND METHODS: We conducted a nested case-control study of a cohort of women who were diagnosed with benign breast disease at the Mayo Clinic and who were subsequently observed for the development of breast cancer. Patients who developed breast cancer formed the case group, and a matched sample from the remaining cohort served as controls. Benign tissue samples from 137 cases and 156 controls and malignant tissues from 99 cases provided DNA or tissue for evaluation of HER-2/neu amplification and protein overexpression. RESULTS: Among the controls, seven benign tissues (4.5%) demonstrated low-level HER-2/neu amplification, whereas 13 benign (9.5%) and 18 malignant (18%) tissue specimens from cases exhibited amplification. HER-2/neu amplification in benign breast biopsies was associated with an increased risk of breast cancer (odds ratio ¿OR = 2.2; 95% confidence interval ¿CI, 0.9 to 5.8); this association approached statistical significance. The risks for breast cancer associated with benign breast histopathologic diagnoses were OR = 1.1 (95% CI, 0.6 to 1.9) for lesions exhibiting proliferation without atypia and OR = 1.5 (95% CI, 0.4 to 5.6) for the diagnosis of atypical ductal hyperplasia. For women having both HER-2/neu amplification and a proliferative histopathologic diagnosis (either typical or atypical), the risk of breast cancer was more than seven-fold (OR = 7.2; 95% CI, 0.9 to 60.8). Overexpression of the HER-2/neu protein product, defined as membrane staining in 10% or more of epithelial cells, was found in 30% of the breast tumors but was not detected in any of the benign breast tissues. Case patients who had HER-2/neu gene amplification in their malignant tumor were more likely to have had HER-2/neu amplification in their prior benign biopsy (P =.06, Fisher's exact test). CONCLUSION: Women with benign breast biopsies demonstrating both HER-2/neu amplification and a proliferative histopathologic diagnosis may be at substantially increased risk for subsequent breast cancer.

A clinical study of hypoxia and metallothionein protein expression in squamous cell carcinomas.

The objective was to discover whether the oxygen-regulated protein, metallothionein, is expressed in the hypoxic cells of squamous cell carcinomas. Twenty patients with squamous cell carcinoma of the uterine cervix or head and neck were infused with a solution of the hypoxia marker, pimonidazole hydrochloride, at a dose of 0.5 g/m2. The following day, biopsies were collected, formalin fixed, paraffin embedded, and sectioned at 4 microm. Sections from each biopsy were immunostained for pimonidazole binding, metallothioneins I and II, involucrin, and proliferating cell nuclear antigen. A total of 84 biopsies were analyzed. Sixty-four of 84 biopsy sections contained hypoxia. Of the hypoxia-containing sections, 43 of 64 or 67% showed no microregional overlap between hypoxia and metallothionein; 7 of 64 showed overlap; and 14 of 64 showed a combination of overlap and no overlap. On a tumor-by-tumor basis, 5 of 7 head and neck and 7 of 13 cervix tumors showed no overlap between metallothionein and hypoxia at the microregional level. Ranges for the percentage of the area of hypoxia in head and neck (<0.9 to 17%) and cervix (<0.1 to 14%) tumors were similar. In the hypoxia-containing sections, immunostaining for involucrin, a molecular marker for differentiation, overlapped with that for hypoxia in 82% of the cases. The majority of hypoxic cells in squamous cell carcinomas do not express metallothionein protein, although metallothionein is induced by hypoxia in human tumor cells in vitro. Hypoxic cells in human tumors tend to be in regions immunostaining for involucrin, and it seems possible that differentiation of hypoxic cells in squamous cell carcinomas might affect metallothionein I and II expression.

Hypertriglyceridemic waist - a simple clinical tool to detect cardiometabolic risk: comparison with harmonized definition of metabolic syndrome.

With the increasing prevalence of obesity and especially abdominal obesity, a simple clinical tool is needed that identifies the cardiometabolic risk for cardiovascular disease and type 2 diabetes. The aim of our study was to evaluate a broad spectrum of metabolic variables and IMT in subjects with and without hypertriglyceridemic waist (HTGW) and compare it with the harmonized definition of metabolic syndrome (MS) with both a higher (MS-I) and lower waist circumference (MS-II) for Europids. We enrolled 607 asymptomatic dyslipidemic subjects (295 men and 312 women) into our cross-sectional study. The subjects with HTGW had an atherogenic lipid profile (significantly higher triglycerides, AIP, non-HDL-C, lower HDL-C and ApoA-1, and the women also higher TC and ApoB), increased markers of insulin resistance (insulin, HOMA, C-peptide, proinsulin), inflammation (hsCRP), thrombosis (fibrinogen, PAI-1), SBP and DBP, and lower adiponectin (p<0.05-0.001 for all). These risk factors were entirely similar in HTGW, MS-I and MS-II. Age-adjusted IMT was significantly higher only in the women with HTGW but this significance disappeared after further adjustment for TC, SBP, and smoking. Our results support the routine use of HTGW as a simple and inexpensive screening tool to detect subjects at increased cardiometabolic risk in clinical practice.

Proliferation and hypoxia in human squamous cell carcinoma of the cervix: first report of combined immunohistochemical assays.

PURPOSE: To characterize the distribution of hypoxia and proliferation in human squamous cell carcinoma of the cervix via an immunohistochemical approach prior to initiation of therapy. METHODS AND MATERIALS: Patients with primary squamous cell carcinoma of the cervix uteri received a single infusion of the 2-nitroimidazole, pimonidazole (0.5 g/m2 i.v.), and 24 h later punch biopsies of the primary tumor were taken. Tissue was formalin fixed, paraffin embedded, and sectioned for immunohistochemistry. Hypoxia was detected by monoclonal antibody binding to adducts of reductively activated pimonidazole in malignant cells. Staining for endogenous MIB-1 and PCNA was detected in tumor cells via commercially available monoclonal antibodies. Point counting was used to quantitate the fraction of tumor cells immunostained for MIB-1, PCNA, and hypoxia marker binding. RESULTS: Immunostaining for pimonidazole binding was distant from blood vessels. There was no staining in necrotic regions, and only minimal nonspecific staining, mostly in keratin. In general, cells immunostaining for MIB-1 and PCNA did not immunostain for pimonidazole binding. Cells immunostaining for MIB-1 and PCNA showed no obvious geographic predilection such as proximity to vasculature. Quantitative comparison showed an inverse relationship between hypoxia marker binding and proliferation. CONCLUSIONS: Immunohistochemical staining for pimonidazole binding is consistent with the presence of hypoxic cells in human tumors and may be useful for estimating tumor hypoxia prior to radiation therapy. Immunostaining for pimonidazole binding is an ideal complement to immunohistochemical assays for endogenous proliferation markers allowing for comparisons of tumor hypoxia with other physiological parameters. These parameters might be used to select patients for radiation protocols specifically designed to offset the negative impact of hypoxia and/or proliferation on therapy. The inverse relationship between pimonidazole binding and proliferation markers is a preliminary result requiring verification.

Human alveolar macrophage-56 and carcinoembryonic antigen monoclonal antibodies in the differential diagnosis between primary ovarian and metastatic gastrointestinal carcinomas.

The immunohistochemical expression and localization of monoclonal antibodies to carcinoembryonic antigen (CEA) and human alveolar macrophage (HAM-56) were evaluated in primary ovarian and metastatic gastrointestinal (GI) carcinomas. Immunohistochemistry was performed using an avidin-biotin-peroxidase complex method with capillary gap technology on formalin-fixed, paraffin-embedded tissues from 41 primary ovarian epithelial neoplasms, 17 metastatic gastrointestinal malignancies, and 10 tumors of uncertain primary origin. Overall, immunostaining for HAM-56 was positive in 35 (85%) ovarian epithelial neoplasms compared with only two (12%) gastrointestinal cancers. Carcinoembryonic antigen was positive in 16 (39%) ovarian versus 13 (76%) GI tumors. Of the primary ovarian neoplasms, 22 were positive for HAM-56 only, 13 were positive for both HAM-56 and CEA, three were positive for CEA only (all mucinous neoplasms), and three were negative for both. Of the primary GI neoplasms, 12 were positive for CEA only (including all eight colon cancers), one was positive for both HAM-56 and CEA, one was positive for HAM-56 only, and three were negative for both. Of the 10 neoplasms of unknown origin at initial presentation, six were positive for HAM-56 only, three were positive for CEA only, none was positive for both HAM-56 and CEA, and one was negative for both. Only three of these 10 neoplasms remained of indeterminate origin after pathological review and clinical follow-up. When positive, CEA was usually strong and generalized in GI cancers but weak and focal in ovarian neoplasms. The HAM-56 positivity in ovarian neoplasms was typically focal and largely limited to areas with glandular or papillary differentiation with apical linear accentuation. We conclude that an immunohistochemical panel using both HAM-56 (Enzo Diagnostics, Syosset, NY) and CEA monoclonal antibodies is helpful in differentiating primary ovarian neoplasms from metastatic gastrointestinal malignancies, and in evaluating metastatic adenocarcinoma of unknown primary site.

Recurrent alveolar proteinosis following double lung transplantation.

We present a case of recurrent alveolar proteinosis following double lung transplantation.

Acute and chronic lung allograft rejection during pregnancy.

Young women who undergo lung transplantation may regain normal fertility and become pregnant. Currently, little is known about the outcome of pregnancy after lung transplantation. We present a case of pregnancy after bilateral lung transplantation complicated by acute and chronic allograft rejection, resulting in irreversible loss of lung function.

MRI of Askin's tumor. Case report at 1.5 T.

This represents the first case of an Askin's tumor demonstrated on MRI. It showed a large pleural-based mass which trapped pleural fluid in large pseudotumors. The disease was unilateral and involved the mediastinum as well. Magnetic resonance imaging was helpful in demonstrating extrathoracic disease in the area of the right brachial plexus.

Distinguishing tubal metaplasia from endocervical dysplasia on cervical Papanicolaou smears.

Tubal metaplasia is a benign endocervical lesion. There may be confusion, however, in distinguishing tubal metaplasia from endocervical gland dysplasia on Papanicolaou smear. We present a case in which a cervical smear diagnosis initially reported as endocervical atypia was corrected to a diagnosis of tubal metaplasia upon cytologic review, thus altering patient management. The presence of terminal bars and cilia are the most helpful features in the cytologic recognition of tubal metaplasia. The evaluation of endocervical gland dysplasia suggested by Papanicolaou smear may include diagnostic conization; therefore, to prevent unnecessary intervention, it is important to distinguish endocervical gland dysplasia from tubal metaplasia.

Primary adenocarcinoma of the gallbladder presenting as primary gynecologic malignancy: a report of two cases.

BACKGROUND: Carcinoma metastatic to the uterus from extragenital sites is rare. Such metastatic disease is typically diagnosed at autopsy or in patients with known primary malignancies. This report discusses two cases of primary carcinoma of the gallbladder presenting as abnormalities in gynecologic screening procedures. CASES: A 71-year-old woman presented with postmenopausal bleeding. Uterine curettage revealed poorly differentiated adenocarcinoma of presumed endometrial origin. Intraoperative frozen-section analysis of the uterus showed carcinoma involving the lymphatics, but no primary tumor. Further exploration revealed primary adenocarcinoma of the gallbladder, with widespread metastases. The second case was a 67-year-old asymptomatic woman. Routine cervical cytology showed adenocarcinoma, but tissue studies were negative. She developed jaundice 1 month later. Computed tomography of the upper abdomen revealed a mass in the gallbladder fossa, and needle biopsy of the lesion showed adenocarcinoma. CONCLUSIONS: Metastatic carcinoma of non-genital tract origin may present as primary gynecologic malignancy. The physician should be aware of the implications of both the common and unusual interpretations of screening and diagnostic procedures. When the clinicopathologic presentation is atypical, a thorough knowledge of the differential diagnoses of abnormal test results allows appropriate and expeditious patient management.

Pelvic granulomata mimicking endometriosis following the administration of oil-based contrast media for hysterosalpingography.

BACKGROUND: Hysterosalpingography is used commonly in the evaluation of infertility and in the diagnosis of anomalies of the uterus and fallopian tubes. There is continued debate over the safety and diagnostic or therapeutic efficacy of water-soluble versus oil-based contrast media. CASE: A 29-year-old woman with secondary infertility underwent hysterosalpingography with both water-soluble and oil-based contrast. The fallopian tubes appeared normal. Six months later, a plain abdominal radiograph obtained at the occasion of a minor motor vehicle accident revealed evidence of retained loculated pelvic contrast material. Subsequent laparoscopy identified adhesions and cul-de-sac implants strongly suspicious for endometriosis. Biopsy and pathologic study documented lipogranuloma. CONCLUSION: Oil-based contrast media instilled into the pelvis at hysterosalpingography can persist for prolonged periods and create granulomatous lesions mimicking endometriosis. In view of the controversy whether oil-based contrast materials are superior to water-soluble media, the routine use of oil-based contrast media should be considered carefully.

Endometrial cancer: histologic correlates of immunohistochemical localization of progesterone receptor and estrogen receptor.

Progesterone and estrogen receptor localization, using monoclonal anti-receptor antibodies JZB39 and H222, was studied in 105 endometrial adenocarcinomas. Immunohistochemical evaluation incorporated both intensity and distribution of staining. Both anti-progesterone receptor and anti-estrogen receptor localized in the nucleus of target cells. Significant levels of progesterone receptor and estrogen receptor were seen localized in stromal and myometrial elements that diverged from the malignant epithelial component. Analyses of endometrial adenocarcinomas with anti-progesterone receptor and anti-estrogen receptor antibodies correlated with histologic differentiation. The ability to define divergent receptor populations in stromal and myometrial elements versus malignant epithelial elements indicates that immunohistochemical assay of progesterone and estrogen receptor provides information complementary to that from conventional quantitative ligand binding assays.

Effect of exogenous gonadotropins on endometrial maturation in oocyte donors.

OBJECTIVE: To determine the effects of controlled ovarian hyperstimulation (COH) on endometrial maturation. DESIGN: Prospective, before and after evaluation of midluteal endometrial biopsies in oocyte donor's spontaneous and subsequent COH cycles. SETTING: Tertiary academic medical center assisted reproductive technologies clinic. PATIENT(S): Nineteen oocyte donors. INTERVENTION(S): Exogenous gonadotropins, endometrial biopsies. MAIN OUTCOME MEASURE(S): Endometrial histology and an immunohistochemical marker of uterine receptivity, the alphavbeta3 vitronectin. RESULT(S): Glandular and stromal dyssynchrony was more common after COH in 16 (80%) of 20 cycles than 6 (30%) of 20 spontaneous cycles (P <.05). Glandular lag was more frequent in COH cycles and unaffected by progesterone administration. The beta3 subunit of the alphavbeta3 vitronectin receptor was present in 9 (45%) of 20 spontaneous and 2 (10%) of 20 COH cycles (P <.05). CONCLUSION(S): Exogenous gonadotropin use in healthy reproductive age women did not result in endometrial evidence of a luteal phase defect. A greater incidence of glandular-stromal dyssynchrony resulted from the use of exogenous gonadotropins. The presence of alphavbeta3 was noted in most endometrial specimens demonstrating in phase glandular maturation. We conclude that endometrial dyssynchrony that results from delayed glandular development most likely represents a normal histologic variant.

Complementary insulin therapy improves blood glucose and serum lipid parameters in type 2 (non-insulin-dependent) diabetic patients. II. Effects on serum lipids, lipoproteins and apoproteins.

The aim of the present study was to evaluate the effects of complementary insulin therapy, consisting of a single dose of 1 to 8 units of shortacting insulin before each meal (4-6x daily) and sometimes at 02.30 h, on concentrations of serum lipids, lipoproteins and apoproteins in type 2 (non-insulin-dependent) diabetic patients, unsatisfactorily controlled either by oral hypoglycemic agents (OHA) or by longacting insulin 1-2x daily (INS 1-2). Compared means +/- SD. Patients on INS 1-2 (n = 82) had better baseline glycemic control than patients on OHA (n = 68) (HbAlc: 9.33 +/- 1.76% vs. 10.59 +/- 1.83%, p < 0.001 and fructosamine: 3.34 +/- 0.74 mmol/l vs. 3.85 +/- 0.84 mmol/l, p < 0.001) and serum triglyceride concentrations (3.03 +/- 2.05 mmol/l vs. 4.95 +/- 4.48 mmol/l, p < 0.001), in spite of longer duration of diabetes (13.35 +/- 8.07 years vs. 10.1 +/- 6.9 years, p < 0.001). After 8-10 weeks of complementary insulin therapy, OHA patients (n = 33) improved both the glycemic control (HbA1c: 10.5 +/- 1.78% vs. 9.0 +/- 1.75%, p < 0.001) and fructosamine: 4.0 +/- 0.85 mmol/l vs. 3.5 +/- 0.76 mmol/l, p < 0.001) and most of the lipid parameters (decreased serum triglyceride: 5.8 +/- 5.64 mmol/l vs. 3.6 +/- 4.69 mmol/l, p < 0.001, total cholesterol/HDL-cholesterol: 6.8 +/- 3.13 vs. 5.6 +/- 2.23, p < 0.01 and increased HDL-cholesterol: 1.0 +/- 0.30 mmol/l vs. 1.2 +/- 0.30 mmol/l, p < 0.001, apo AI: 1.6 +/- 0.26 g/l vs. 1.8 +/- 0.28 g/l, p < 0.001, LpAI particles: 0.6 +/- 0.1 g/l vs. 0.7 +/- 0.12 g/l, p < 0.001 and LDL-cholesterol/apo B: 2.1 +/- 0.67 vs. 2.7 +/- 0.67, p < 0.001). In patients previously on INS 1-2x (n = 34), complementary insulin therapy with reduced dose of insulin per day (49.6 +/- 22.5 U/d vs. 36.6 +/- 13.3 U/d, p < 0.001) did not further improve glycemic control but improved the number of proatherogenic and antiatherogenic lipoprotein particles (decreased apo B: 1.7 +/- 0.52 g/l vs. 1.5 +/- 0.94 g/l, p < 0.01, apo AI/Lp AI: 2.9 +/- 1.01 vs. 2.3 +/- 0.98, p < 0.01 and increased Lp AI particles: 0.6 +/- 0.10 g/l vs. 0.7 +/- 0.12 g/l, p < 0.0001); BMI also decreased (29.4 +/- 4.28 kg/m2 vs. 28.9 +/- 4.24 kg/m2, p < 0.05). These results demonstrate that complementary insulin therapy probably induces antiatherogenic lipoprotein changes in NIDDM patients previously treated by either OHA or INS 1-2x. Thus, this type of therapy should be used more often and start earlier, and should be preferred to longacting insulins.

Desmoid tumor of the vulva associated with pregnancy.

Extra-abdominal desmoid tumor is a locally aggressive neoplasm that occurs most commonly in the pelvic or shoulder region in the third or fourth decade. We have identified one previously reported case of primary desmoid tumor of the vulva. Herein, we describe another case and, to our knowledge, the first reported case of vulvar desmoid tumor associated with pregnancy.