AHCC® Supplementation to Support Immune Function to Clear Persistent Human Papillomavirus Infections.

Objective: To determine the efficacy, safety, and durability of the use of AHCC supplementation for 6 months to support the host immune system to clear high-risk human papillomavirus (HPV) infections. The AHCC supplement is a proprietary, standardized extract of cultured lentinula edodes mycelia (AHCC®, Amino Up, Ltd., Sapporo, Japan) that has been shown to have unique immune modulatory benefits. Study Design: This was a randomized, double-blind, placebo-controlled study (CTN: NCT02405533) in 50 women over 30 years of age with confirmed persistent high-risk HPV infections for greater than 2 years. Patients were randomized to placebo once daily for 12 months (N = 25) or AHCC 3-g supplementation by mouth once daily on empty stomach for 6 months followed by 6 months of placebo (N = 25). Every 3 months, patients were evaluated with HPV DNA and HPV RNA testing as well as a blood sample collected to evaluate a panel of immune markers including interferon-alpha, interferon-beta (IFN-ß), interferon-gamma (IFN-γ), IgG1, T lymphocytes, and natural killer (NK) cell levels. At the completion of the 12-month study period, patients on the placebo arm were given the option to continue on the study to receive AHCC supplementation unblinded for 6 months with the same follow-up appointments and testing as the intervention arm. Results: Fifty women with high-risk HPV were enrolled, and 41 completed the study. Fourteen (63.6%) of the 22 patients in the AHCC supplementation arm were HPV RNA/HPV DNA negative after 6 months, with 64.3% (9/14) achieving a durable response defined as being HPV RNA/HPV DNA negative 6 months off supplementation. On the placebo arm, two (10.5%) of 19 patients were HPV negative at 12 months. In the twelve placebo arm patients who elected to continue on the unblinded study, 50% (n = 6) were HPV RNA/HPV DNA negative after 6 months of AHCC supplementation. At the time of completion of the study, there were a total of 34 patients (22 blinded and 12 unblinded) who had received AHCC supplementation with an overall response rate of 58.8% that cleared HPV persistent infections. At the time of enrollment, the mean IFN-ß level was 60.5 ± 37.6 pg/ml in women with confirmed persistent HPV infections. Suppression of IFN-ß to less than 20 pg/ml correlated with an increase in T lymphocytes and IFN-γ and durable clearance of HPV infections in women who received AHCC supplementation. Conclusion: Results from this phase II study demonstrated that AHCC 3 g once daily was effective to support the host immune system to eliminate persistent HPV infections and was well tolerated with no significant adverse side effects reported. The duration of AHCC supplementation required beyond the first negative result needs more evaluation to optimize success for durable outcomes. The suppression of the IFN-ß level to less than 20 pg/ml correlated with clearance of HPV infections and merits further evaluation as a clinical tool for monitoring patients with HPV infections. Clinical Trial Registration: clinicaltrials.gov/ct2/, identifier NCT02405533.

Monochorionic Diamniotic Vasa Previa Pregnancy: A Medical Student Perspective.

Monochorionic diamniotic twins and vasa previa are uncommon. We present a case that was followed from ultrasound diagnosis to delivery.

From Bench to Bedside: Evaluation of AHCC Supplementation to Modulate the Host Immunity to Clear High-Risk Human Papillomavirus Infections.

Objective: There is currently no effective medicine or supplement for clearance of high risk- human papillomavirus (HR-HPV) infections. We have taken a systematic approach evaluating the potential use of AHCC supplementation to support clearance of HR-HPV infections. The primary objective of this research was to evaluate AHCC supplementation to modulation of the host immune system to clear HR-HPV infections from bench to bedside. Methods: Cervical cancer cells, CaSki (HPV16+), HeLa(HPV18+), SiHa(HPV16/18+), and C-33A(HPV-), were treated in vitro with AHCC 0.42 mg/mL daily x7 days then observed x7 days with daily sample collection. A confirmatory study in cervical cancer mouse models, SiHa(HPV16/18+) and C-33A(HPV-), was conducted: mice were divided into three groups per cell line then dosed with AHCC 50 mg/kg/d (N = 10), or vehicle alone (N = 10), or no supplementation (N = 10) for a total of 90 days followed by 30 days of observation. Tumors were measured 3x/week and blood samples collected bi-weekly to evaluate interferon (IFN) alpha(α), beta(ß), and gamma(γ) and immunoglobulin G(IgG) by immunoassays. Tumors were evaluated for HR-HPV expression by PCR. Two pilot studies of 10 patients each were conducted in women with confirmed persistent HR-HPV+ infections. The 1st study evaluated AHCC 3g from 5 weeks up to 6 months and 2nd study evaluated AHCC 1g < 8 months. HR-HPV DNA status and the immune panel were monitored at each visit. Results: HR-HPV clearance was observed in vitro and confirmed in the animal studies as a durable response. Four of six (66.7%) patients had confirmed HR-HPV clearance after 3-6 months of AHCC 3g. Similarly, 4 of 9 (44%) patients had confirmed HR-HPV clearance after 7 months of AHCC 1g. Suppression of IFNß <25 pg/mL was observed in those clearing the HR-HPV infection. Conclusion: Pre-clinical in vitro and in vivo studies demonstrated durable clearance of HR-HPV infections. The preliminary data from the two pilot studies suggested that AHCC supplementation supports the host immune system for successful clearance of HR-HPV infections. A confirmatory phase II randomized, double-blinded, placebo-controlled study is ongoing.

Pfannenstiel versus Vertical Skin Incision for Cesarean Delivery in Women with Class III Obesity: A Randomized Trial.

OBJECTIVE: To compare Pfannenstiel versus vertical skin incision for the prevention of cesarean wound complications in morbidly obese women. STUDY DESIGN: Women with body mass index ≥ 40 kg/m2 undergoing cesarean delivery (CD) were randomly allocated to Pfannenstiel or vertical skin incision. The primary outcome was a wound complication within 6 weeks. Due to a low consent rate, we limited enrollment to a defined time period for feasibility. We conducted a traditional frequentist analysis with log-binomial regression to obtain relative risks (RRs), and a Bayesian analysis to estimate the probability of treatment benefit. A priori, we decided that a ≥60% probability of treatment benefit for either incision type would be convincing evidence to pursue a larger trial. RESULTS: A total of 648 women were approached, 228 were consented, and 91 were randomized. The primary outcome rate was 19% in the Pfannenstiel group and 21% in the vertical group (RR: 1.18; 95% confidence interval: 0.49-2.85). Bayesian analysis revealed a 59% probability that Pfannenstiel had a lower primary outcome rate. CONCLUSION: In the first published randomized trial to compare skin incision types for obese women undergoing CD, we were unable to demonstrate differences in clinical outcomes. Our trial suggests that a larger study would have a low probability for different findings. TRIAL REGISTRATION: NCT 01897376 (www.clinicaltrials.gov).

Intra-amniotic inflammation induces preterm birth by activating the NLRP3 inflammasome†.

Intra-amniotic inflammation is strongly associated with spontaneous preterm labor and birth, the leading cause of perinatal mortality and morbidity worldwide. Previous studies have suggested a role for the NLRP3 (NLR family pyrin domain-containing protein 3) inflammasome in the mechanisms that lead to preterm labor and birth. However, a causal link between the NLRP3 inflammasome and preterm labor/birth induced by intra-amniotic inflammation has not been established. Herein, using an animal model of lipopolysaccharide-induced intra-amniotic inflammation (IAI), we demonstrated that there was priming of the NLRP3 inflammasome (1) at the transcriptional level, indicated by enhanced mRNA expression of inflammasome-related genes (Nlrp3, Casp1, Il1b); and (2) at the protein level, indicated by greater protein concentrations of NLRP3, in both the fetal membranes and decidua basalis prior to preterm birth. Additionally, we showed that there was canonical activation of the NLRP3 inflammasome in the fetal membranes, but not in the decidua basalis, prior to IAI-induced preterm birth as evidenced by increased protein levels of active caspase-1. Protein concentrations of released IL1ß were also increased in both the fetal membranes and decidua basalis, as well as in the amniotic fluid, prior to IAI-induced preterm birth. Finally, using the specific NLRP3 inhibitor, MCC950, we showed that in vivo inhibition of the NLRP3 inflammasome reduced IAI-induced preterm birth and neonatal mortality. Collectively, these results provide a causal link between NLRP3 inflammasome activation and spontaneous preterm labor and birth in the context of intra-amniotic inflammation. We also showed that, by targeting the NLRP3 inflammasome, adverse pregnancy and neonatal outcomes can be significantly reduced.

Inflammasome activation during spontaneous preterm labor with intra-amniotic infection or sterile intra-amniotic inflammation.

PROBLEM: The inflammasome is implicated in the mechanisms that lead to spontaneous preterm labor (PTL). However, whether there is inflammasome activation in the amniotic cavity of women with PTL and intra-amniotic infection (IAI) or sterile intra-amniotic inflammation (SIAI) is unknown. METHOD OF STUDY: Amniotic fluid samples were collected from women with PTL who delivered at term (n = 31) or preterm without IAI or SIAI (n = 35), with SIAI (n = 27), or with IAI (n = 17). As a readout of inflammasome activation, extracellular ASC (apoptosis-associated speck-like protein containing a CARD) was measured in amniotic fluid by ELISA and the expression of ASC, caspase-1, and interleukin (IL)-1ß was detected in the chorioamniotic membranes by multiplex immunofluorescence. Acute inflammatory responses in amniotic fluid and the placenta were also evaluated. RESULTS: (a) Amniotic fluid concentrations of ASC and IL-6 were higher in women with PTL and IAI or SIAI than in those who delivered preterm or at term without intra-amniotic inflammation; (b) amniotic fluid concentrations of ASC and IL-6 were lower in women with PTL and SIAI than in those with IAI; (c) there was a significant nonlinear correlation between ASC and IL-6 amniotic fluid concentrations; (d) the expression of inflammasome-related proteins (ASC, caspase-1, and IL-1ß) in the chorioamniotic membranes was increased in women with PTL and IAI or SIAI than in those who delivered preterm or at term without intra-amniotic inflammation; (e) inflammasome activation in the chorioamniotic membranes was weaker in women with PTL and SIAI than in those with IAI; (f) women with PTL and IAI had elevated amniotic fluid white blood cell counts compared to those without this clinical condition; and (g) severe acute placental inflammatory lesions were observed in women with PTL and IAI and in a subset of women with PTL and SIAI. CONCLUSION: Inflammasome activation occurs in the settings of intra-amniotic infection and sterile intra-amniotic inflammation during spontaneous preterm labor.

Human ß-defensin-1: A natural antimicrobial peptide present in amniotic fluid that is increased in spontaneous preterm labor with intra-amniotic infection.

PROBLEM: Human ß-defensins (HBDs) are antimicrobial peptides that participate in the soluble innate immune mechanisms against infection. Herein, we determined whether HBD-1 was present in amniotic fluid during normal pregnancy and whether its concentrations change with intra-amniotic inflammation and/or infection. METHOD OF STUDY: Amniotic fluid was collected from 219 women in the following groups: (a) midtrimester who delivered at term (n = 35); (b) term with (n = 33) or without (n = 17) labor; (c) preterm labor with intact membranes who delivered at term (n = 29) or who delivered preterm with (n = 19) and without (n = 29) intra-amniotic inflammation and infection or with intra-amniotic inflammation but without infection (n = 21); and (d) preterm prelabor rupture of membranes (pPROM) with (n = 19) and without (n = 17) intra-amniotic inflammation/infection. Amniotic fluid HBD-1 concentrations were determined using a sensitive and specific ELISA kit. RESULTS: (a) HBD-1 was detectable in all amniotic fluid samples; (b) amniotic fluid concentrations of HBD-1 were changed with gestational age (midtrimester vs term no labor), being higher in midtrimester; (c) amniotic fluid concentrations of HBD-1 were similar between women with and without spontaneous labor at term; (d) among patients with spontaneous preterm labor, amniotic fluid concentrations of HBD-1 in women with intra-amniotic inflammation/infection and in those with intra-amniotic inflammation without infection were greater than in women without intra-amniotic inflammation or infection who delivered preterm or at term; and (e) the presence of intra-amniotic inflammation and infection in patients with pPROM did not change amniotic fluid concentrations of HBD-1. CONCLUSION: HBD-1 is a physiological constituent of amniotic fluid that is increased in midtrimester during normal pregnancy and in the presence of culturable microorganisms in the amniotic cavity. These findings provide insight into the soluble host defense mechanisms against intra-amniotic infection.

The immunophenotype of amniotic fluid leukocytes in normal and complicated pregnancies.

PROBLEM: The immune cellular composition of amniotic fluid is poorly understood. Herein, we determined: 1) the immunophenotype of amniotic fluid immune cells during the second and third trimester in the absence of intra-amniotic infection/inflammation; 2) whether amniotic fluid T cells and ILCs display different phenotypical characteristics to that of peripheral cells; and 3) whether the amniotic fluid immune cells are altered in women with intra-amniotic infection/inflammation. METHOD OF STUDY: Amniotic fluid samples (n = 57) were collected from 15 to 40 weeks of gestation in women without intra-amniotic infection/inflammation. Samples from women with intra-amniotic infection/inflammation were also included (n = 9). Peripheral blood mononuclear cells from healthy adults were used as controls (n = 3). Immunophenotyping was performed using flow cytometry. RESULTS: In the absence of intra-amniotic infection/inflammation, the amniotic fluid contained several immune cell populations between 15 and 40 weeks. Among these immune cells: (i) T cells and ILCs were greater than B cells and natural killer (NK) cells between 15 and 30 weeks; (ii) T cells were most abundant between 15 and 30 weeks; (iii) ILCs were most abundant between 15 and 20 weeks; (iv) B cells were scarce between 15 and 20 weeks; yet, they increased and were constant after 20 weeks; (v) NK cells were greater between 15 and 30 weeks than at term; (vi) ILCs expressed high levels of RORγt, CD161, and CD103 (ie, group 3 ILCs); (vii) T cells expressed high levels of RORγt; (viii) neutrophils increased as gestation progressed; and (ix) monocytes/macrophages emerged after 20 weeks and remained constant until term. All of the amniotic fluid immune cells, except ILCs, were increased in the presence of intra-amniotic infection/inflammation. CONCLUSION: The amniotic fluid harbors a diverse immune cellular composition during normal and complicated pregnancies.

Are amniotic fluid neutrophils in women with intraamniotic infection and/or inflammation of fetal or maternal origin?

BACKGROUND: Neutrophils are the most abundant white blood cells found in the amniotic cavity of women with intraamniotic infection and/or inflammation. The current belief is that these neutrophils are of fetal origin. However, abundant neutrophils have been found in the amniotic fluid of women with a severe acute maternal inflammatory response but without a severe fetal inflammatory response in the placenta, suggesting that these innate immune cells can also be of maternal origin or a mixture of both fetal and maternal neutrophils. OBJECTIVE: We sought to investigate the origin of amniotic fluid neutrophils from women with intraamniotic infection and/or inflammation and to correlate these findings with acute histologic maternal and fetal inflammatory responses in the placenta. STUDY DESIGN: Amniotic fluid was collected from 15 women with suspected intraamniotic infection and/or inflammation (positive microbiological cultures and/or interleukin-6 concentrations ≥2.6 ng/mL). Amniotic fluid neutrophils were purified by fluorescence-activated cell sorting, DNA was extracted, and DNA fingerprinting was performed. DNA fingerprinting was also performed in the umbilical cord and maternal blood DNA. Fluorescence in situ hybridization was assayed in women with male neonates. Blinded placental histopathological evaluations were conducted. RESULTS: First, DNA fingerprinting revealed that 43% (6/14) of women who underwent a single amniocentesis had mostly fetal neutrophils in the amniotic fluid. Second, DNA fingerprinting showed that 36% (5/14) of the women who underwent a single amniocentesis had predominantly maternal neutrophils in the amniotic fluid. Third, DNA fingerprinting indicated that 21% (3/14) of the women who underwent a single amniocentesis had an evident mixture of fetal and maternal neutrophils in the amniotic fluid. Fourth, DNA fingerprinting revealed that a woman who underwent 2 amniocenteses (patient 15) had fetal neutrophils first, and as infection progressed, abundant maternal neutrophils invaded the amniotic cavity. Fifth, fluorescence in situ hybridization confirmed DNA fingerprinting results by showing that both fetal and maternal neutrophils were present in the amniotic fluid. Sixth, most of the women who had predominantly amniotic fluid neutrophils of fetal origin at the time of collection delivered extremely preterm neonates (71% [5/7]). Seventh, all of the women who had predominantly amniotic fluid neutrophils of maternal origin at the time of collection delivered term or late preterm neonates (100% [6/6]). Eighth, 2 of the women who had an evident mixture of fetal and maternal neutrophils in the amniotic fluid at the time of collection delivered extremely preterm neonates (67% [2/3]), and the third woman delivered a term neonate (33% [1/3]). Finally, most of the women included in this study presented acute maternal and fetal inflammatory responses in the placenta (87% [13/15]). CONCLUSION: Amniotic fluid neutrophils can be either predominantly of fetal or maternal origin, or a mixture of both fetal and maternal origin, in women with intraamniotic infection and/or inflammation. The findings herein provide evidence that both fetal and maternal neutrophils can invade the amniotic cavity, suggesting that both the fetus and the mother participate in the host defense mechanisms against intraamniotic infection.

Development of a Novel Test for Simultaneous Bacterial Identification and Antibiotic Susceptibility.

Background. Elucidation of a pathogen's antimicrobial susceptibility requires subculture after the organism is first isolated. This takes several days, requiring patients to be treated with broad-spectrum antibiotics. This approach contributes to the development of bacterial resistance. Methods. Microtiter wells were coated with a polyclonal antibody targeting the pathogen of interest. Bacterial suspensions were added in the presence/absence of selected antibiotics. After washing, captured bacteria were detected. Findings. Group B streptococcus (GBS), Enterococcus faecalis, and Neisseria gonorrhoeae were each detected at 105 bacteria/mL following a 20-minute incubation period. Susceptibility to select antibiotics was discernable following a 6-hour incubation period (GBS and Enterococcus). Sensitivity was increased to 10-2 bacteria/mL for GBS, 10-1 bacteria/mL for E. faecalis, and 101 bacteria/mL for N. gonorrhoeae following 18-24-hour culture. Conclusion. This novel assay allows for the highly sensitive and specific identification of a pathogen and simultaneous determination of its antimicrobial susceptibility in a reduced time.

Repair of a recurrent rectovaginal fistula with a biological graft.

This case involves a patient with the congenital absence of the lower third of the vagina. While undergoing surgical restoration of the vagina, she sustained a laceration, which ultimately led to the development of a rectovaginal fistula. After two unsuccessful attempts at repair, the recommendation was for a diverting colostomy with another attempted repair, and she presented to our clinic to discuss other possible surgical options. The patient underwent repair of the fistula using a porcine-derived small intestinal submucosal extracellular matrix graft, which resulted in the repair of the rectovaginal fistula without recurrence at 18 months' follow-up.

Unidirectional barbed suture versus interrupted vicryl suture in vaginal cuff healing during robotic-assisted laparoscopic hysterectomy.

This study examined the performance of unidirectional barbed suture versus polyglactin 910 with respect to vaginal cuff healing in robotic-assisted total laparoscopic hysterectomy (RATLH). This was a retrospective cohort study of 93 patients who underwent RATLH in a teaching hospital from July 2008 to June 2012. In the first 44 patients, the vaginal cuff was closed by interrupted polyglactin (Vicryl) 2-0 suture. In the following 49 patients, unidirectional barbed suture (V-loc) in a running fashion was used for cuff closure. Patients were seen 2 and 6 weeks postoperatively to evaluate cuff healing. Age, tobacco use, hemoglobin, deliveries, uterine weight, menopause, steroid use, underlying health problems, and concomitant procedures were found not to be significantly different between the two groups. There was one cuff dehiscence in the unidirectional barbed suture group and none in the interrupted polyglactin group (P > 0.05). The mean cuff healing time (8.5 vs. 7.7 weeks), incidence of cuff cellulitis (4.6 vs. 4.1 %), and postoperative bleeding (22.7 vs. 14.3 %) were not statistically significantly different between polyglactin and barbed suture closures, respectively (P > 0.05). However, polyglactin suture was associated with greater presence of granulation tissue than barbed suture (27.3 vs. 8.2 %, odds ratio = 3.34, P < 0.05). Unidirectional barbed suture cases were associated with shorter total operative times (220.2 vs. 272.8 min) and less estimated blood loss (164.8 vs. 274.9 ml); however, cuff closure times were not specifically measured. In our study, unidirectional barbed suture was identified as possibly superior to polyglactin cuff closure because of less observed granulation tissue, shorter operative duration, and lower estimated blood loss. However, there was no statistical difference in cuff healing time, cuff dehiscence, cellulitis, or postoperative bleeding between the two groups. A prospective randomized trial would be necessary to confirm these findings.

Accuracy of an accelerated, culture-based assay for detection of group B streptococcus.

OBJECTIVE: To determine the validity of a novel Group B Streptococcus (GBS) diagnostic assay for the detection of GBS in antepartum patients. STUDY DESIGN: Women were screened for GBS colonization at 35 to 37 weeks of gestation. Three vaginal-rectal swabs were collected per patient; two were processed by traditional culture (commercial laboratory versus in-house culture), and the third was processed by an immunoblot-based test, in which a sample is placed over an antibody-coated nitrocellulose membrane, and after a six-hour culture, bound GBS is detected with a secondary antibody. RESULTS: 356 patients were evaluated. Commercial processing revealed a GBS prevalence rate of 85/356 (23.6%). In-house culture provided a prevalence rate of 105/356 (29.5%). When the accelerated GBS test result was compared to the in-house GBS culture, it demonstrated a sensitivity of 97.1% and a specificity of 88.4%. Interobserver reliability for the novel GBS test was 88.2%. CONCLUSIONS: The accelerated GBS test provides a high level of validity for the detection of GBS colonization in antepartum patients within 6.5 hours and demonstrates a substantial agreement between observers.

Necrotizing soft-tissue infections in obstetric and gynecologic patients.

For the clinician, necrotizing soft-tissue infections have remained a daunting opponent since the first writings on the subject over 2000 years ago. Early disease may be incorrectly diagnosed as cellulitis, and this delay in correctly diagnosing and expeditiously proceeding to radical surgical debridement may lead to a high degree of mortality. Although several inciting events and risk factors have been described that allow for the development and progression of this disease, the diagnosis is still made clinically. Only aggressive surgical management in combination with broad-spectrum antibiotics will offer a chance at improving patient outcomes.

Optimization of a rapid diagnostic test for detection of group B streptococcus from antepartum patients.

We analyzed the performance of a new rapid diagnostic test for use in determining group B streptococcus colonization in pregnancy. Vaginal-rectal specimens were compared by the rapid test, a commercial laboratory culture result, and an in-house culture. Of 150 patient samples, 72 were positive by the rapid test, giving a prevalence of 48.0% versus 24.7% by traditional culture. Characterization of these results showed cross-reactivity with Enterococcus. The addition of bacitracin reduced this interference, and when reanalyzed, a colonization rate of 31.3% was found (P = 0.3961, chi-square), as well as a sensitivity of 100% (95% confidence interval [CI] 89.1-100) and a specificity of 93.6% (95% CI 86.9-97.2). The addition of bacitracin greatly improves the reliability of this diagnostic test and demonstrates a novel approach to reduce interference. An accurate determination of the test's sensitivity and specificity, however, awaits enrollment of the remaining subjects.

Rapid diagnostic test for identifying group B streptococcus.

Neonatal infection with Streptococcus agalactiae (group B streptococcus [GBS]) causes significant morbidity and mortality. A truly rapid diagnostic test for identifying GBS would allow for more timely initiation of antibiotic prophylaxis and also reduce the administration of antibiotics for the prevention of early onset neonatal GBS infection. A stock culture was formed from a laboratory reference strain of GBS and was diluted from 10 (7) to 10 (1) bacteria/mL. Specific concentrations were used to inoculate nitrocellulose membranes (NCMs) that had been coated previously with polyclonal rabbit antibody against GBS. After specific times, the NCMs were removed from the sheep blood agar medium, and horseradish-peroxidase conjugate polyclonal antibody against GBS was added. Bound antibody was detected with diaminobenzidine. After 6 hours of incubation, GBS was detected at concentrations from 10 (7) through 10 (4) bacterial/mL. After 4 hours of incubation, GBS was detected at concentrations from 10 (7) through 10 (5) bacteria/mL. GBS was not detected at 2 hours of incubation. Rapid growth and detection of GBS can be performed, and the results can be reliably attained as early as 4 hours. This is in marked contrast to the 48 to 72 hours required by current methods.

Premature termination of nursing secondary to Serratia marcescens breast pump contamination.

BACKGROUND: Serratia marcescens, a known pathogen associated with postpartum mastitis, may be identified by its characteristic pigmentation. CASE: A 36-year-old P0102 woman presented postpartum and said that her breast pump tubing had turned bright pink. S marcescens was isolated, indicating colonization. She was started on antibiotics. After viewing an Internet report in which a patient nearly died from a Serratia infection, she immediately stopped breastfeeding. CONCLUSION: Serratia colonization may be noted before the development of overt infection. Because this pathogen can be associated with mastitis, physicians should be ready to treat and should encourage patients to continue nursing after clearance of the organism. Exposure to sensational Internet reports may make treatment recommendations difficult.

Small bowel perforation 17 months after robotic surgery for endometrial cancer: A case report.

► Robotic surgery offers several advantages in the management of endometrial cancer. ► No long-term data exist regarding recurrence in patients undergoing robotic surgery. ► Metastasis or recurrence may result in bowel obstruction post surgery.