Localization of the greater occipital nerve through palpation of bony landmarks: A cadaveric study.

OBJECTIVE: to provide anatomic confirmation that standard methods which practitioners skilled in palpation use, can reliably identify the most likely site of emergence of the greater occipital nerve in most patients. The location and frequency of subcutaneous emergence of the greater occipital nerve and occipital artery with respect to the external occipital protuberance-mastoid line are reported. METHODS: The external occipital protuberance and the mastoid processes were identified by palpation bilaterally on 57 body donors and the medial trisection point of a line connecting these bony landmarks was identified. A 4 cm circular dissection guide divided into 4 quadrants was centered on the trisection point and used to guide the removal of a circle of skin. The in-situ location of the nerve and artery were exposed by deep dissection within the circle. The frequency of the emergence and occurrence of the nerve and artery by quadrant were analyzed. RESULTS: In 114 total dissections the greater occipital nerve was found to emerge within the circle 96 times (84%) and the occipital artery 100 times (88%). The nerve (90%) and artery (81%) emerged from the two inferior quadrants most of the time with no difference noted between male and female donors. The greater occipital nerve and occipital artery were found to emerge together most commonly in inferior lateral quadrant. Branches of the nerve and artery traveled together most frequently through the two lateral quadrants. CONCLUSION: This study confirmed that the medial trisection point of the external occipital protuberance-mastoid line can be located via palpation and reliably used to pinpoint the subcutaneous emergence of the greater occipital nerve and occipital artery in most individuals. When relying on palpation alone to identify the trisection point in the clinic, infusion of nerve block inferior and lateral to this point is most likely to bathe the greater occipital nerve in anesthetic.

ABO blood types, but not Secretor or Lewis blood types, influence strength of antibody response to Hepatitis B vaccine in Black South African children.

Subunit vaccines for the Hepatitis B virus (HBV) have greatly reduced the prevalence of infection and morbidity through HBV-related liver cirrhosis and cancer. However, strength of immune response to vaccination varies considerably. While it is known that ABO blood types may influence HBV infection risk, the role of ABO and related blood types in strength of immune response to HBV vaccine has not been investigated. We examined 16 polymorphisms in the ABO, FUT2, and FUT3 genes and their related phenotypes for associations with strength of antibody response to HBV vaccine in Black South African infants. Anti-HBc and anti-HBs antibody levels were measured by CMIA assay 1-3 months after the last dose of HBV vaccine. Prior infection occurred in 8/207 individuals (3.86%) who were removed from further study. Of the remaining 199 individuals, 83.4% individuals were strong responders (anti-HBs ≥ 100 mIU/ml, median 973 mIU/ml), another 15.6% were weak responders (anti-HBs < 100 mIU/ml, median 50 mIU/ml) and 1% were non-responders (anti-HBs < 10 mIU/ml). The frequency of weak responders to HBV vaccine was not significantly affected by sex, birthweight, use of an additional booster dose of vaccine or cohort of origin. We characterised patterns of genetic variation present at the ABO, FUT2 and FUT3 loci by use of MassArray genotyping and used these data to predict ABO, Secretor and Lewis phenotypes. We observed significant association of ABO blood type with strength of antibody response to HBV vaccine in a Black South African cohort (p = 0.002). In particular, presence of rs8176747G and expression of B antigen (whether in B blood type or AB blood type) was associated with decreased antibody response to HBV vaccine. Secretor and Lewis blood types were not associated with antibody response to HBV vaccine. This work increases our understanding of the impact that host genetic variation may have on vaccine immunogenicity.

Hermansky-Pudlak syndrome: Report of two patients with updated genetic classification and management recommendations.

Hermansky-Pudlak syndrome (HPS) is a rare autosomal recessive disorder caused by mutations in one of nine genes involved in the packaging and formation of specialized lysosomes, including melanosomes and platelet-dense granules. The cardinal features are pigmentary dilution, bleeding diathesis, and accumulation of ceroid-like material in reticuloendothelial cells. Pulmonary fibrosis induced by tissue damage is seen in the most severe forms, and one subtype is characterized by immunodeficiency. We describe two patients with HPS type 1 and review the updated gene-based classification, clinical features, and recommendations for evaluation and follow-up.

Assessment of an Alternative to the Uterine Vein for Venous Drainage in Human Uterine Transplantation: A Case Series Following Laparoscopic Hysterectomy.

BACKGROUND/AIMS: To determine an alternative to the uterine vein, considering the utero-ovarian vein (UOV) for venous drainage in human uterine transplantation. METHODS: A case series of 10 total laparoscopic hysterectomies was conducted for benign indications and a vascular study was performed ex vivo on the surgical specimen, demonstrating ipsilateral and contralateral flow between the uterine artery (UA) and UOV visualizing anastomoses between these vessels. The flow pattern was documented using heparinized saline and illustrated through fluoroscopy using Isovue-300 dye. RESULTS: Successful cannulation of UA was accomplished in all 10 cases. Ipsilateral flow between the UA and UOV was demonstrated in all except one case, and contralateral flow was observed. Due to the long interval between the time of specimen retrieval and vascular study, the time to cannulation limited the ability to demonstrate ipsilateral and contralateral flow in 2 cases. CONCLUSION: Uterine transplantation has become a viable option for women with absolute uterine factor infertility. However, this surgery requires extensive surgical dissection, and the surgical retrieval of the uterine vein proposes a challenge. We present a potential option for venous drainage in uterine transplant surgery, considering the UOV for venous drainage as an alternative to the uterine vein and a possibility for minimally invasive approach.

Early pediatric atopic dermatitis shows only a cutaneous lymphocyte antigen (CLA)(+) TH2/TH1 cell imbalance, whereas adults acquire CLA(+) TH22/TC22 cell subsets.

BACKGROUND: Identifying differences and similarities between cutaneous lymphocyte antigen (CLA)(+) polarized T-cell subsets in children versus adults with atopic dermatitis (AD) is critical for directing new treatments toward children. OBJECTIVE: We sought to compare activation markers and frequencies of skin-homing (CLA(+)) versus systemic (CLA(-)) "polar" CD4 and CD8 T-cell subsets in patients with early pediatric AD, adults with AD, and control subjects. METHODS: Flow cytometry was used to measure CD69/inducible costimulator/HLA-DR frequency in memory cell subsets, as well as IFN-γ, IL-13, IL-9, IL-17, and IL-22 cytokines, defining TH1/cytotoxic T (TC) 1, TH2/TC2, TH9/TC9, TH17/TC17, and TH22/TC22 populations in CD4 and CD8 cells, respectively. We compared peripheral blood from 19 children less than 5 years old and 42 adults with well-characterized moderate-to-severe AD, as well as age-matched control subjects (17 children and 25 adults). RESULTS: Selective inducible costimulator activation (P < .001) was seen in children. CLA(+) TH2 T cells were markedly expanded in both children and adults with AD compared with those in control subjects, but decreases in CLA(+) TH1 T-cell numbers were greater in children with AD (17% vs 7.4%, P = .007). Unlike in adults, no imbalances were detected in CLA(-) T cells from pediatric patients with AD nor were there altered frequencies of TH22 T cells within the CLA(+) or CLA(-) compartments. Adults with AD had increased frequencies of IL-22-producing CD4 and CD8 T cells within the skin-homing population, compared with controls (9.5% vs 4.5% and 8.6% vs 2.4%, respectively; P < .001), as well as increased HLA-DR activation (P < .01). CONCLUSIONS: These data suggest that TH2 activation within skin-homing T cells might drive AD in children and that reduced counterregulation by TH1 T cells might contribute to excess TH2 activation. TH22 "spreading" of AD is not seen in young children and might be influenced by immune development, disease chronicity, or recurrent skin infections.

A 21-day-old boy with an annular eruption. Tinea faciei / Tinea capitis.

A healthy 21-day-old black male was referred to pediatric dermatology for evaluation of a facial and scalp eruption that had been present for less than 1 week. The child's parents had applied a topical corticosteroid cream for several days without any improvement noted. The child was otherwise well and thriving. Review of systems was negative. Family history was unremarkable for autoimmune or infectious skin diseases. On physical examination the patient was alert, active, and vigorous. He had multiple 1 to 2.5-cm erythematous annular, scaly plaques with pustules on the periphery on his upper cheeks, forehead, and anterior scalp (Figures 1-2). No alopecia was noted. Occipital and neck lymph nodes were not palpable. A potassium hydroxide skin preparation was negative for fungal elements and a fungal culture was performed. Serum laboratory testing was also performed.

Patterning of superhydrophobic paper to control the mobility of micro-liter drops for two-dimensional lab-on-paper applications.

Superhydrophobic paper substrates were patterned with high surface energy black ink using commercially available desktop printing technology. The shape and size of the ink islands were designed to control the adhesion forces on water drops in two directions, parallel ('drag-adhesion') and perpendicular ('extensional-adhesion') to the substrate. Experimental data on the adhesion forces shows good agreement with classical models for 'drag' (Furmidge equation) and 'extensional' adhesion (modified Dupré equation). The tunability of the two adhesion forces was used to implement four basic unit operations for the manipulation of liquid drops on the paper substrates: storage, transfer, mixing and sampling. By combining these basic functionalities it is possible to design simple two-dimensional lab-on-paper (LOP) devices. In our 2D LOP prototype, liquid droplets adhere to the porous substrate, rather than absorbing into the paper; as a result, liquid droplets remain accessible for further quantitative testing and analysis, after performing simple qualitative on-chip testing. In addition, the use of commercially available desktop printers and word processing software to generate ink patterns enable end users to design LOP devices for specific applications.

The human promyelocytic leukemia protein is a tumor suppressor for murine skin carcinogenesis.

Expression of the PMLRARalpha fusion dominant-negative oncogene in the epidermis of transgenic mice resulted in spontaneous skin tumors attributed to changes in both the PML and RAR pathways [Hansen et al., Cancer Res 2003; 63:5257-5265]. To determine the contribution of PML to skin tumor susceptibility, transgenic mice were generated on an FVB/N background, that overexpressed the human PML protein in epidermis and hair follicles under the control of the bovine keratin 5 promoter. PML was highly expressed in the epidermis and hair follicles of these mice and was also increased in cultured keratinocytes where it was confined to nuclear bodies. While an overt skin phenotype was not detected in young transgenic mice, expression of keratin 10 (K10) was increased in epidermis and hair follicles and cultured keratinocytes. As mice aged, they exhibited extensive alopecia that was accentuated on the C57BL/6J background. Following skin tumor induction with 7, 12-dimethylbenz[a]anthracene (DMBA) as initiator and 12-O-tetradecanoylphorbol-13-acetate (TPA) as promoter, papilloma multiplicity and size were decreased in the transgenic mice by 35%, and the conversion of papillomas to carcinomas was delayed. Cultured transgenic keratinocytes underwent premature senescence and upregulated transcripts for p16 and Rb but not p19 and p53. Together, these changes suggest that PML participates in regulating the growth and differentiation of keratinocytes that likely influence its activity as a suppressor for tumor development.

VEGF contributes to mammary tumor growth in transgenic mice through paracrine and autocrine mechanisms.

Vascular endothelial growth factor (VEGF) has been identified as a vascular permeability factor, angiogenic cytokine, and a survival factor. To address its role in mammary carcinogenesis, we used transgenic mice with human VEGF(165) targeted to mammary epithelial cells under the control of the mouse mammary tumor virus (MMTV) promoter. Metastatic mammary carcinomas were induced by mating the MMTV-VEGF mice with MMTV-polyoma virus middle T-antigen (MT) mice to generate VEGF/MT mice. Tumor latency was decreased in the VEGF/MT mice, which developed mammary carcinomas with increased vasodilatation at 4 weeks of age. There was increased incidence, multiplicity, and weight of the mammary tumors in 6- and 8-week-old VEGF/MT mice, compared to their MT-only littermates. Macro- and microscopic lung metastases were detected in the VEGF/MT mice but not the MT mice at 6 and 8 weeks of age. Enhanced tumor growth was attributed to increased microvascular density (MVD), as well as increased tumor cell proliferation and survival. Angiogenesis array analysis showed that 24 of 25 differentially expressed genes were upregulated in the VEGF/MT tumors. In vitro studies revealed increased proliferative activity and upregulation of Flk-1 in the VEGF/MT tumor cells, compared with the MT-only tumor cells. Moreover, there was decreased proliferative activity with downregulation of Flk-1 in tumor cells isolated from conditional knockout (VEGF(-/-)) MT-induced mammary carcinomas. The slow growing VEGF(-/-) tumor cells were accumulated in the G(1)/G(0) phase of the cell cycle and this was associated with stimulation of p16(ink4a) and p21(WAF1). Similarly, p16(ink4a) was stimulated in VEGF(lox/lox)/MT mammary tumor cells following Adeno-cre-mediated VEGF gene inactivation. Collectively, the data from these transgenic models indicate that VEGF contributes to mammary tumor growth through increased neovascularization, as well as autocrine stimulation of growth and inhibition of apoptosis.