Placenta Previa Percreta: A Case Report of Successful Management via Conservative Surgery.

Placenta percreta is one of the most serious complications of placenta previa and is frequently associated with severe obstetric hemorrhage usually necessitating hysterectomy. We present a case of placenta previa percreta diagnosed by ultrasound and magnetic resonance imaging techniques, in which we accomplished conservative management of postpartum hemorrhage. The management we propose includes the following steps: preventive catheterization of the descending aorta via transhumeral access; Stark cesarean delivery; uterotonics drugs; Affronti endouterine square hemostatic sutures; intrauterine application of Bakri balloon and partial filling with 100 mL of normal saline; B Lynch suture, hysterorrhaphy, and filling a Bakri balloon with up to 500 mL of normal saline; reversible radiological embolization; and/or surgical ligation of the uterine arteries. The bleeding stopped following placement of Affronti sutures combined with external (B-Lynch suture) and internal (Bakri balloon) uterine compression. Our experience indicates that this conservative method can be considered an option in the management of selected cases of pregnancy at high risk for intrapartum hemorrhage.

Gliomatosis cerebri type II: two case reports.

INTRODUCTION: TWO TYPES OF GLIOMATOSIS CEREBRI EXIST: Type I and Type II. We report the results of a histological and genetic study of two cases of gliomatosis cerebri Type II, correlating these results with therapy and prognosis. CASE PRESENTATION: Two patients, a 52-year-old man (Patient 1) and a 76-year-old man (Patient 2) with gliomatosis cerebri II were admitted to our institution; they underwent surgical treatment and received radiotherapy and chemotherapy. At the 24-month follow-up, Patient 1 was still alive, while Patient 2 had died. The poor prognosis of Patient 2 was underlined by molecular analysis which showed that the angiogenesis related genes VCAM1 and VEGF were overexpressed, reflecting the high degree of neovascularization. CONCLUSION: Genes involved in drug resistance and metallothioneins were highly expressed in Patient 2 and this, associated with unmethylated O6-methylguanine methyltransferase, can explain the lack of response to chemotherapy.

Ovarian torsion in in vitro fertilization-induced twin pregnancy: combination of Doppler ultrasound and laparoscopy in diagnosis and treatment can quickly solve the case.

OBJECTIVE: To diagnose and treat adnexal torsion in pregnancy. DESIGN: Case report. SETTING: Obstetrics and Gynecology Department of Perugia Hospital. PATIENT(S): A 38-year-old woman, gravida 2, para 1 with bichorial twin pregnancy in the 10th week of gestation who was admitted for abdominal pain. She conceived after an IVF attempt. Even if symptoms compared 2 days before the admission, they aggravated just 2 hours before. INTERVENTION(S): An ovarian torsion was suspected, and Doppler ultrasound showed a complete absence of vascular flow. The dimension of the right ovary and the absence of ovarian blood flow were strong arguments in favor of the diagnosis of adnexal torsion, and laparoscopic ovarian adnexectomy was performed. MAIN OUTCOME MEASURE(S): The ovarian torsion was confirmed, and right adnexectomy was necessary. RESULT(S): The patient had a quick convalescence and was discharged on the third postoperative day. She had no more pain. She underwent a cesarean section for placenta previa. She and her children have remained well. CONCLUSION(S): Considering the increased number of IVF pregnancies, an ovarian torsion should be less uncommon than in the past. Doppler ultrasound should be considered as a first-line exam. The complete absence of vascular flow in the ovary may be an indication for adnexectomy. An ovarian torsion in pregnancy should be treated laparoscopically.

Correlative analysis of gene expression profile and prognosis in patients with gliomatosis cerebri.

BACKGROUND: In modern clinical neuro-oncology, the pathologic diagnoses are very challenging, creating significant clinical confusion and affecting therapeutic decisions and prognosis. METHODS: TP53 and PTEN gene sequences were analyzed, and microarray expression profiling was also performed. The authors investigated whether gene expression profiling, coupled with class prediction methodology, could be used to determine the prognosis of gliomatosis cerebri in a more consistent manner than standard pathology. RESULTS: The authors reported the results of a molecular study in 59 cases of gliomatosis cerebri, correlating these results with prognosis. The well-known prognostic factors of gliomas (ie, age, Karnofsky performance status, histology [grade 2 vs 3], and contrast enhancement) were found to be predictive of response or outcome in only a percentage of patients but not in all patients. The authors identified a 23-gene signature that was able to predict patient prognosis with microarray gene expression profiling. With the aim of producing a prognosis tool that is useful in clinical investigation, the authors studied the expression of this 23-gene signature by real-time quantitative polymerase chain reaction. Real-time expression values relative to these 23 gene features were used to build a prediction method able to distinguish patients with a good prognosis (those more likely to be responsive to therapy) from patients with a poor prognosis (those less likely to be responsive to therapy). CONCLUSIONS: The results of the current study demonstrated not only a strong association between gene expression patterns and patient survival, but also a robust replicability of these gene expression-based predictors.

Division protein interaction web: identification of a phylogenetically conserved common interactome between Streptococcus pneumoniae and Escherichia coli.

The ability of each of the 11 Streptococcus pneumoniae division proteins to interact with itself and with each of the remaining proteins was studied in 66 combinations of protein pairs, using a bacterial two-hybrid system. Interactions (homo- or hetero-dimerizations) were detected between 37 protein pairs, whereas 29 protein pairs did not interact. In some cases, positive interactions of the S. pneumoniae proteins were confirmed by co-immunoprecipitation experiments in Escherichia coli. Comparison between the S. pneumoniae division protein interaction web and that of E. coli, the only micro-organisms for which the whole division interactome has been described systematically, was also performed. At least nine division proteins, ZapA, FtsZ, FtsA, FtsK, FtsQ/DivIB, FtsB/DivIC, FtsL, FtsI and FtsW, are believed to have a conserved function between these bacteria and thus we may say that a significant part of the interactions are conserved. Out of 45 protein pairs tested in both bacteria, 30 showed the same behaviour: 23 interacted while seven did not. In agreement with these results, cross-interactions between S. pneumoniae proteins and the corresponding E. coli orthologues were observed. Taken together, these results suggest a phylogenetically conserved minimal common interactome of the division proteins.

The Escherichia coli FtsK functional domains involved in its interaction with its divisome protein partners.

FtsK is a multifunctional protein involved in both cell division and chromosome segregation. As far as its role in cell division is concerned, FtsK is among the first divisome proteins that localizes at mid-cell, after FtsZ, FtsA and ZipA, and is required for the recruitment of the other divisome components. The ability of FtsK to interact with several cell division proteins, namely FtsZ, FtsQ, FtsL and FtsI, by the two-hybrid assay was already shown by our group. In this work, we describe the identification of the protein domain(s) involved in the interaction with the cell division partner proteins. The biological role of some interactions is also discussed.

Mesenteric chylous cysts simulating a pelvic disease: a case report.

Mesenteric chylous cysts, also known as retroperitoneal chylomatous cysts, mesenteric lymphangiomas or chyloma of the mesentery, are extremely rare and their aspecific clinical presentation can mimic other diseases. In addition, imaging techniques, which are rarely helpful in the correct diagnosis, can demonstrate aspecific features. The Authors report the case of a 62-year-old woman admitted to the hospital for two incidental abdominal masses diagnosed during a yearly monitoring examination and considered to be large adnexal masses. The abdominal masses were removed at laparotomy. Both frozen section and final histopathological examination showed mesenteric chylous cysts. Mesenteric chylous cysts are usually a benign abdominal pathology. As illustrated by this case, even if they are extremely rare, they should be not underrated. The Authors review the literature, confirming the rarity of the disease and defining its characteristics.

Altered clonogenic capability and stromal cell function characterize bone marrow of HIV-infected subjects with low CD4+ T cell counts despite viral suppression during HAART.

BACKGROUND: Inflammatory cytokines in bone marrow may impair hematolymphopoiesis in human immunodeficiency virus (HIV)-infected subjects who do not experience reconstitution of CD4(+) T cells despite suppression of virus replication while receiving highly active antiretroviral therapy (HAART) (immunological nonresponders). METHODS: Bone marrow samples from 12 immunological nonresponders receiving HAART were studied and compared with samples from 11 immunological responders. The mean CD4(+) T cell count (+/- standard deviation) was 174 +/- 68 cells/mm(3) and plasma HIV RNA levels had been <50 copies/mL for at least 1 year for individuals enrolled in the study. The clonogenic capability of bone marrow samples was evaluated using the colony forming cell assay and the long-term culture-initiating cell assay. CD34(+) cells from the colony forming cell assay were pooled for real-time polymerase chain reaction analysis of Fas and Fas ligand. Bone marrow cytokine production (interleukin-2 and tumor necrosis factor-alpha) and stromal interleukin-7 levels were analyzed by enzyme-linked immunosorbent assay in both groups. Flow cytometric analysis of CD4(+) and CD8(+) T cell subsets was performed. RESULTS: A reduced clonogenic capability and a decrease in the level of more primitive progenitor cells were observed in parallel with lower production of interleukin-2 and increased tumor necrosis factor-alpha levels. A significant upregulation of Fas and Fas ligand on CD34(+) cells and a higher stromal interleukin-7 production were observed. Impairment of the naive T cell compartment and persistent T cell activation were observed in peripheral blood. CONCLUSIONS: Samples from immunological nonresponders show reduced growth of in vitro colonies and an altered cytokine production in bone marrow. The cytokine pattern observed and the altered Fas and Fas ligand pathway may determine stem cell apoptosis and low CD4(+) cell recovery. These features, which are similar to those observed in HIV-infected subjects before starting therapy, persist despite treatment.

Plasmacytoid dendritic cells count in antiretroviral-treated patients is predictive of HIV load control independent of CD4+ T-cell count.

The depletion in circulating dendritic cells (DCs) and inverse correlation with viral load have been described in human immunodeficiency virus (HIV)-infected patients. The aim of this study was to investigate whether the DC blood count in antiretroviral-treated patients might be predictive of viral load control independent of CD4+ T cell count. Plasmacytoid DCs (pDCs) and myeloid DCs (mDCs) were enumerated using a newly developed flow cytometric assay based on TruCOUNT. A significant reduction of circulating pDCs and mDCs was detected both in untreated and -treated subjects. The probability of experiencing viral load increase according to pDC, and CD4 count at baseline was evaluated in 39 treated patients. Individuals with lower baseline pDCs were more likely to have an increase of HIV-RNA during the 30 month follow-up in comparison with patients with high pDCs (p <0.001). In particular, the pDC measurement may be useful in the context of a high CD4 count, to distinguish the patients who have virological failure despite high CD4 counts. These findings suggest that in treated patients the enumeration of circulating DCs, especially pDC count, can augment the predictive value of CD4 measurement in predicting virologic failure.

Successful treatment with intravenous immunoglobulins in a patient affected by dermatomyositis/systemic lupus erythematosus overlap syndrome and tuberculosis.

The case of a 56-year-old woman, with a previous history of systemic lupus erythematosus (SLE), later diagnosed as also affected by active dermatomyositis (DM) associated with tuberculosis (TB) is reported. Since TB is a contra-indication to receive immunosuppressive therapy for DM/SLE, intravenous immunoglobulins (IVIG) with low-dose steroids and anti-TB therapy were administered with excellent clinical results. This report underlines the crucial role of IVIG in the treatment of critical patients suffering from connective tissue disorders associated with severe infections.

Thiamine deficiency and beriberi features in a patient with hyperemesis gravidarum.

Wernicke's encephalopathy has been sporadically reported in patients with severe hyperemesis gravidarum. We report a new case of Wernicke's encephalopathy in a patient who had hyperemesis gravidarum associated with signs and symptoms of dry and wet beriberi. The case was managed with very large doses of thiamine. The conclusion was that, in long-lasting hyperemesis gravidarum, recognizing signs of beriberi may help prevent the onset of Wernicke's encephalopathy, thanks to timely therapy with thiamine supplements. A thiamine therapy similar to the one reported in this article could prove useful in long-lasting hyperemesis gravidarum complicated by Wernicke's encephalopathy.

Bone marrow clonogenic capability, cytokine production, and thymic output in patients with common variable immunodeficiency.

In patients with primary Ab deficiencies, hematological and immunological abnormalities are frequently observed. A regenerative failure of hemopoietic stem/progenitor cells has been hypothesized. We evaluated in the bone marrow (BM) of 11 patients with common variable immunodeficiency, the phenotype of BM progenitors and their in vitro growth by colony-forming cell (CFC) and long-term culture (LTC) assays. A significant decrease in erythroid and mixed CFC and, to a greater extent, in primitive LTC-CFC progenitors was observed in patients compared with healthy controls. The frequency of BM pre-B and pro-B cells correlated directly with the absolute number of CD19+ lymphocytes. BM cells cultured in vitro produced spontaneously lower amounts of IL-2 and elevated levels of TNF-alpha compared with controls, indicating a skewing toward a proapoptotic cytokine pattern. In addition, stromal cells generated after BM LTC secreted less IL-7 and displayed by immunohistochemistry an altered phenotype. These findings were associated with a significant decrease in naive Th cells coexpressing CD31 in the peripheral blood. These results indicate an impaired growth and differentiation capacity of progenitor cells in patients with common variable immunodeficiency.

The combined maternal administration of magnesium sulfate and aminophylline reduces intraventricular hemorrhage in very preterm neonates.

OBJECTIVE: To determine whether the adjunctive administration of aminophylline and magnesium sulfate to mothers at risk for preterm birth can reduce the rate of intraventricular hemorrhage in neonates born at less than 30 weeks of gestation. STUDY DESIGN: A prospective study was conducted to determine whether the rate of intraventricular hemorrhage was different in patients at risk for preterm delivery treated with ritodrine, magnesium sulfate, aminophylline, and corticosteroids (group A) versus patients treated with ritodrine and corticosteroids (group B). During the study period (January 1996 to December 2001), 125 patients enrolled in the study. Treatment was assigned by alternative allocation, and the study was designed to compare the rate of intraventricular hemorrhage in neonates born before the 30th week of gestation (primary outcome), 78 newborns in group A and 68 in group B. The proportion of neonates with intraventricular hemorrhage was calculated, and data were analyzed with Student t test, chi 2 , and logistic regression analysis. RESULTS: The frequency of severe respiratory distress syndrome needing surfactant replacement and high-pressure positive ventilation, patent ductus arteriosus, and retinopathy of prematurity was not different between the 2 groups. However, the rate of intraventricular hemorrhage was lower in neonates born before 30 weeks whose mothers received adjunctive aminophylline and magnesium sulphate (group A) than in the group that did not receive these 2 agents (group B). The overall frequency of intraventricular hemorrhage was 5.1% (4/78) versus 20.6% (14/68) ( P < .001), and the frequency of intraventricular hemorrhage grade 3-4 was 1.3% (1/78) versus 10.3 % (7/68; P < .001), respectively. CONCLUSION: Adjunctive maternal administration of aminophylline and magnesium sulfate was associated with a significant reduction in the rate of intraventricular hemorrhage in neonates born before 30 completed weeks.

Duodenal pathology and clinical-immunological implications in common variable immunodeficiency patients.

OBJECTIVES: Common variable immunodeficiency (CVID) is an immunological disorder characterized by defective antibody production. An increased prevalence of celiac disease has been suggested in patients with this disorder. This study aimed to assess duodenal pathology and its clinical implications in these patients. METHODS: A total of 32 consecutive CVID patients with anemia or GI symptoms were enrolled. Patients underwent upper endoscopy, and biopsy specimens were taken in the descending duodenum for histological assessment. A blood sample was obtained to determine immunoglobulin and Hb levels and to evaluate the CD4+ T-lymphocyte count. Body mass index was calculated for all patients. RESULTS: Histological assessment of duodenal specimens revealed the presence of villous atrophy in 10 (31.2%) patients, a feature of nodular lymphoid hyperplasia in five (15.6%), and mild duodenitis in two (6.3%), whereas normal histology was observed in the remaining 15 (46.9%) patients. Patients with villous atrophy had anemia more frequently than those without, whereas the frequency of persistent diarrhea did not differ between these two groups. Moreover, both CD4 levels and body mass index were significantly lower in patients with atrophy than in controls. CONCLUSIONS: Duodenal villous atrophy is very frequent in symptomatic CVID patients, with relevant clinical and immunological implications. Specifically, this histological alteration is significantly associated with anemia, malnutrition, and low blood CD4+ lymphocyte levels.