Emerging Infectious Diseases Are Virulent Viruses-Are We Prepared? An Overview.

The recent pandemic caused by SARS-CoV-2 affected the global population, resulting in a significant loss of lives and global economic deterioration. COVID-19 highlighted the importance of public awareness and science-based decision making, and exposed global vulnerabilities in preparedness and response systems. Emerging and re-emerging viral outbreaks are becoming more frequent due to increased international travel and global warming. These viral outbreaks impose serious public health threats and have transformed national strategies for pandemic preparedness with global economic consequences. At the molecular level, viral mutations and variations are constantly thwarting vaccine efficacy, as well as diagnostic, therapeutic, and prevention strategies. Here, we discuss viral infectious diseases that were epidemic and pandemic, currently available treatments, and surveillance measures, along with their limitations.

A Customized Human Mitochondrial DNA Database (hMITO DB v1.0) for Rapid Sequence Analysis, Haplotyping and Geo-Mapping.

The field of mitochondrial genomics has advanced rapidly and has revolutionized disciplines such as molecular anthropology, population genetics, and medical genetics/oncogenetics. However, mtDNA next-generation sequencing (NGS) analysis for matrilineal haplotyping and phylogeographic inference remains hindered by the lack of a consolidated mitogenome database and an efficient bioinformatics pipeline. To address this, we developed a customized human mitogenome database (hMITO DB) embedded in a CLC Genomics workflow for read mapping, variant analysis, haplotyping, and geo-mapping. The database was constructed from 4286 mitogenomes. The macro-haplogroup (A to Z) distribution and representative phylogenetic tree were found to be consistent with published literature. The hMITO DB automated workflow was tested using mtDNA-NGS sequences derived from Pap smears and cervical cancer cell lines. The auto-generated read mapping, variants track, and table of haplotypes and geo-origins were completed in 15 min for 47 samples. The mtDNA workflow proved to be a rapid, efficient, and accurate means of sequence analysis for translational mitogenomics.

HPV Integration Site Mapping: A Rapid Method of Viral Integration Site (VIS) Analysis and Visualization Using Automated Workflows in CLC Microbial Genomics.

Human papillomavirus (HPV) integration within the host genome may contribute to carcinogenesis through various disruptive mechanisms. With next-generation sequencing (NGS), identification of viral and host genomic breakpoints and chimeric sequences are now possible. However, a simple, streamlined bioinformatics workflow has been non-existent until recently. Here, we tested two new, automated workflows in CLC Microbial Genomics, i.e., Viral Hybrid Capture (VHC) Data Analysis and Viral Integration Site (VIS) Identification for software performance and efficiency. The workflows embedded with HPV and human reference genomes were used to analyze a publicly available NGS dataset derived from pre- and cancerous HPV+ cervical cytology of 21 Gabonese women. The VHC and VIS workflow median runtimes were 19 and 7 min per sample, respectively. The VIS dynamic graphical outputs included read mappings, virus-host genomic breakpoints, and virus-host integration circular plots. Key findings, including disrupted and nearby genes, were summarized in an auto-generated report. Overall, the VHC and VIS workflows proved to be a rapid and accurate means of localizing viral-host integration site(s) and identifying disrupted and neighboring human genes. Applying HPV VIS-mapping to pre- or invasive tumors will advance our understanding of viral oncogenesis and facilitate the discovery of prognostic biomarkers and therapeutic targets.

A Customized Monkeypox Virus Genomic Database (MPXV DB v1.0) for Rapid Sequence Analysis and Phylogenomic Discoveries in CLC Microbial Genomics.

Monkeypox has been a neglected, zoonotic tropical disease for over 50 years. Since the 2022 global outbreak, hundreds of human clinical samples have been subjected to next-generation sequencing (NGS) worldwide with raw data deposited in public repositories. However, sequence analysis for in-depth investigation of viral evolution remains hindered by the lack of a curated, whole genome Monkeypox virus (MPXV) database (DB) and efficient bioinformatics pipelines. To address this, we developed a customized MPXV DB for integration with "ready-to-use" workflows in the CLC Microbial Genomics Module for whole genomic and metagenomic analysis. After database construction (218 MPXV genomes), whole genome alignment, pairwise comparison, and evolutionary analysis of all genomes were analyzed to autogenerate tabular outputs and visual displays (collective runtime: 16 min). The clinical utility of the MPXV DB was demonstrated by using a Chimpanzee fecal, hybrid-capture NGS dataset (publicly available) for metagenomic, phylogenomic, and viral/host integration analysis. The clinically relevant MPXV DB embedded in CLC workflows proved to be a rapid method of sequence analysis useful for phylogenomic exploration and a wide range of applications in translational science.

HPV DeepSeq: An Ultra-Fast Method of NGS Data Analysis and Visualization Using Automated Workflows and a Customized Papillomavirus Database in CLC Genomics Workbench.

Next-generation sequencing (NGS) has actualized the human papillomavirus (HPV) virome profiling for in-depth investigation of viral evolution and pathogenesis. However, viral computational analysis remains a bottleneck due to semantic discrepancies between computational tools and curated reference genomes. To address this, we developed and tested automated workflows for HPV taxonomic profiling and visualization using a customized papillomavirus database in the CLC Microbial Genomics Module. HPV genomes from Papilloma Virus Episteme were customized and incorporated into CLC "ready-to-use" workflows for stepwise data processing to include: (1) Taxonomic Analysis, (2) Estimate Alpha/Beta Diversities, and (3) Map Reads to Reference. Low-grade (n = 95) and high-grade (n = 60) Pap smears were tested with ensuing collective runtimes: Taxonomic Analysis (36 min); Alpha/Beta Diversities (5 s); Map Reads (45 min). Tabular output conversion to visualizations entailed 1-2 keystrokes. Biodiversity analysis between low- (LSIL) and high-grade squamous intraepithelial lesions (HSIL) revealed loss of species richness and gain of dominance by HPV-16 in HSIL. Integrating clinically relevant, taxonomized HPV reference genomes within automated workflows proved to be an ultra-fast method of virome profiling. The entire process named "HPV DeepSeq" provides a simple, accurate and practical means of NGS data analysis for a broad range of applications in viral research.

Molecular Pap Smear: Validation of HPV Genotype and Host Methylation Profiles of ADCY8, CDH8, and ZNF582 as a Predictor of Cervical Cytopathology.

Primary high-risk Human Papillomavirus (hrHPV) screening has recently become an accepted standalone or co-test with conventional cytology. Unfortunately, hrHPV singularly lacks specificity for cytopathological grade. However, mechanisms and markers of evolving virus-host interactions at the epigenome level may be harnessed as a better predictor of carcinogenesis. This study aimed to validate and expand the clinical performance of a multiparametric biomarker panel, referred to as the "Molecular Pap smear" based, on HPV genotype and ADCY8, CDH8 and ZNF582 CpG-methylation as a predictive classifier of cervical cytology. This prospective, cross-sectional study used an independent cohort of residual liquid-based cytology for HPV genotyping and epigenetic analysis. Extracted DNA underwent parallel PCR using 3 primer sets for HPV DNA amplification. HPV-infected samples were genotyped by Sanger sequencing. Promoter methylation levels of 3 tumor suppressor genes were quantified by bisulfite-pyrosequencing of genomic DNA on the newest high-resolution PyroMark Q48 platform. Logistic model performance was compared, and model parameters were used to predict and classify binary cytological outcomes. A total of 883 samples were analyzed. HPV DNA positivity correlated with worsening grade: 125/237 (53%) NILM; 136/235 (58%) ASCUS; 222/229 (97%) LSIL; and 157/182 (86%) HSIL samples. The proportion of carcinogenic HPV-types in PCR-positive sequenceable samples correlated with worsening grade: NILM 34/98 (35%); ASCUS 50/113 (44%); LSIL 92/214 (43%); HSIL 129/152 (85%). Additionally, ADCY8, CDH8, and ZNF582 methylation levels increased in direct correlation with worsening grade. Overall, the multi-marker modeling parameters predicted binarized cytological outcomes better than HPV-type alone with significantly higher area under the receiver operator curve (AUC)s, respectively: NILM vs. > NILM (AUC 0.728 vs. 0.709); NILM/ASCUS vs. LSIL/HSIL (AUC 0.805 vs. 0.776); and

Abundance of HPV L1 Intra-Genotype Variants With Capsid Epitopic Modifications Found Within Low- and High-Grade Pap Smears With Potential Implications for Vaccinology.

Background: The aim of this study was to explore the Human Papillomavirus (HPV) genotype composition and intra-genotype variants within individual samples of low- and high-grade cervical cytology by deep sequencing. Clinical, cytological, sequencing, and functional/structural data were forged into an integrated variant profiling pipeline for the detection of potentially vaccine-resistant genotypes or variants. Methods: Low- and high-grade intraepithelial lesion (LSIL and HSIL) cytology samples with +HPV were subjected to amplicon (L1 gene fragment) sequencing by dideoxy (Sanger) and deep methods. Taxonomic, abundance, diversity, and phylogenetic analyses were conducted to determine HPV genotypes/sub-lineages, relative abundance, species diversity and phylogenetic distances within and between samples. Variant detection and functional analysis of translated L1 amino acid sequences determined structural variations of interest. Results: Pure and mixed HPV infections were common among LSIL (n = 6) and HSIL (n = 6) samples. Taxonomic profiling revealed loss of species richness and gain of dominance by carcinogenic genotypes in HSIL samples. Phylogenetic analysis showed excellent correlation between HPV-type specific genetic distances and carcinogenic potential. For combined LSIL/HSIL samples (n = 12), 11 HPV genotypes and 417 mutations were detected: 375 single-nucleotide variants (SNV), 29 insertion/deletion (indel), 12 multi-nucleotide variants (MNV), and 1 replacement variant. The proportion of nonsynonymous mutations was lower for HSIL (0.38) than for LSIL samples (0.51) (p < 0.05). HPV variant analysis pinpointed nucleotide-level mutations and amino acid-level structural modifications. Conclusion: HPV L1 intra-host and intra-genotype variants are abundant in LSIL and HSIL samples with potential functional/structural consequences. An integrated multi-omics approach to variant analysis may provide a sensitive and practical means of detecting changes in HPV evolution and dynamics within individuals or populations.

Deep sequencing of HPV E6/E7 genes reveals loss of genotypic diversity and gain of clonal dominance in high-grade intraepithelial lesions of the cervix.

BACKGROUND: Human papillomavirus (HPV) is the carcinogen of almost all invasive cervical cancer and a major cause of oral and other anogenital malignancies. HPV genotyping by dideoxy (Sanger) sequencing is currently the reference method of choice for clinical diagnostics. However, for samples with multiple HPV infections, genotype identification is singular and occasionally imprecise or indeterminable due to overlapping chromatograms. Our aim was to explore and compare HPV metagenomes in abnormal cervical cytology by deep sequencing for correlation with disease states. RESULTS: Low- and high-grade intraepithelial lesion (LSIL and HSIL) cytology samples were DNA extracted for PCR-amplification of the HPV E6/E7 genes. HPV+ samples were sequenced by dideoxy and deep methods. Deep sequencing revealed ~60% of all samples (n = 72) were multi-HPV infected. Among LSIL samples (n = 43), 27 different genotypes were found. The 3 dominant (most abundant) genotypes were: HPV-39, 11/43 (26%); -16, 9/43 (21%); and -35, 4/43 (9%). Among HSIL (n = 29), 17 HPV genotypes were identified; the 3 dominant genotypes were: HPV-16, 21/29 (72%); -35, 4/29 (14%); and -39, 3/29 (10%). Phylogenetically, type-specific E6/E7 genetic distances correlated with carcinogenic potential. Species diversity analysis between LSIL and HSIL revealed loss of HPV diversity and domination by HPV-16 in HSIL samples. CONCLUSIONS: Deep sequencing resolves HPV genotype composition within multi-infected cervical cytology. Biodiversity analysis reveals loss of diversity and gain of dominance by carcinogenic genotypes in high-grade cytology. Metagenomic profiles may therefore serve as a biomarker of disease severity and a population surveillance tool for emerging genotypes.

Molecular Pap smear: HPV genotype and DNA methylation of ADCY8, CDH8, and ZNF582 as an integrated biomarker for high-grade cervical cytology.

BACKGROUND: The Pap smear has remained the foundation for cervical cancer screening for over 70 years. With advancements in molecular diagnostics, primary high-risk human papillomavirus (hrHPV) screening has recently become an accepted stand-alone or co-test with conventional cytology. However, both diagnostic tests have distinct limitations. The aim of this study was to determine the association between HPV genotypes and cellular epigenetic modifications in three grades of cervical cytology for screening biomarker discovery. METHODS: This prospective, cross-sectional study used residual liquid-based cytology samples for HPV genotyping and epigenetic analysis. Extracted DNA was subjected to parallel polymerase chain reactions using three primer sets (MY09/11, FAP59/64, E6-E7 F/B) for HPV DNA amplification. HPV+ samples were genotyped by DNA sequencing. Promoter methylation of four candidate tumor suppressor genes (adenylate cyclase 8 (ADCY8), cadherin 8, type 2 (CDH8), MGMT, and zinc finger protein 582 (ZNF582)) out of 48 genes screened was quantified by bisulfite-pyrosequencing of genomic DNA. Independent validation of methylation profiles was performed by analyzing data from cervical cancer cell lines and clinical samples from The Cancer Genome Atlas (TCGA). RESULTS: Two hundred seventy-seven quality cytology samples were analyzed. HPV was detected in 31/100 (31 %) negative for intraepithelial lesion or malignancy (NILM), 95/100 (95 %) low-grade squamous intraepithelial lesion (LSIL), and 71/77 (92 %) high-grade squamous intraepithelial lesion (HSIL) samples. The proportion of IARC-defined carcinogenic HPV types in sequenced samples correlated with worsening grade: NILM 7/29 (24 %), LSIL 53/92 (58 %), and HSIL 65/70 (93 %). Promoter methylation of ADCY8, CDH8, and ZNF582 was measured in 170 samples: NILM (N = 33), LSIL (N = 70), and HSIL (N = 67) also correlated with worsening grade. Similar hypermethylation patterns were found in cancer cell lines and TCGA samples. The combination of four biomarkers, i.e., HPV genotype and three-gene promoter methylation, predicted HSIL (AUC 0.89) better than HPV alone (AUC 0.74) by logistic regression and probabilistic modeling. CONCLUSIONS: HPV genotype and DNA methylation of ADCY8, CDH8, and ZNF582 are correlated with cytological grade. Collectively, these biomarkers may serve as a molecular classifier of Pap smears.

Recombinant Xeno-Free Vitronectin Supports Self-Renewal and Pluripotency in Protein-Induced Pluripotent Stem Cells.

Patient safety is a major concern in the application of induced pluripotent stem cells (iPSCs) in cell-based therapy. Efforts are being made to reprogram, maintain, and differentiate iPSCs in defined conditions to provide a safe source of stem cells for regenerative medicine. Recently, human fibroblasts were successfully reprogrammed into pluripotent stem cells using four recombinant proteins (OCT4, c-Myc, KLF4, and SOX2) fused with a cell-penetrating peptide (9R). These protein-induced pluripotent stem cells (piPSCs) are maintained and propagated on a feeder layer of mouse embryonic fibroblasts. Use of animal-derived products in maintenance and differentiation of iPSCs poses risks of zoonotic disease transmission and immune rejection when transplanted into humans. To avoid potential incorporation of xenogenic products, we cultured piPSCs on recombinant human matrix proteins. We then tested whether recombinant human matrix proteins can support self-renewal and pluripotency of piPSCs. After long-term culture on recombinant human vitronectin in xeno-free conditions, piPSCs retained the expression of pluripotent markers. The pluripotency of these cells was further evaluated by differentiating toward ectoderm, mesoderm, and endoderm lineages in vitro. In conclusion, recombinant human vitronectin can support the long-term culture and maintain the stemness of piPSCs in defined nonxenogenic conditions.

All Military Adolescents Are Not the Same: Sexuality and Substance Use among Adolescents in the U.S. Military Healthcare System.

Data examining sexuality and substance use among active duty and military-dependent youth is limited; however, these psychosocial factors have military implications. Adolescents and young adults aged 12-23 were recruited from an active-duty trainee clinic (n = 225) and a military pediatric clinic (n = 223). Active duty participants were more likely to be older, male, White, previous tobacco users, and report a history of sexual activity and less contraception use at their most recent intercourse, compared to the dependent group. Over 10% of all participants indicated attraction to members of the same gender or both genders. In logistic regression analysis, non-White participants were less likely to use contraception compared to White participants. Adolescents and young adults seen in military clinics frequently engage in high-risk behavior. Clinicians who care for military youth should assess their patient's psychosocial history. Further study of this population is warranted to identify factors that may influence risk and resilience.

Profiling the microRNA Expression in Human iPS and iPS-derived Retinal Pigment Epithelium.

The purpose of this study is to characterize the microRNA (miRNA) expression profiles of induced pluripotent stem (iPS) cells and retinal pigment epithelium (RPE) derived from induced pluripotent stem cells (iPS-RPE). MiRNAs have been demonstrated to play critical roles in both maintaining pluripotency and facilitating differentiation. Gene expression networks accountable for maintenance and induction of pluripotency are linked and share components with those networks implicated in oncogenesis. Therefore, we hypothesize that miRNA expression profiling will distinguish iPS cells from their iPS-RPE progeny. To identify and analyze differentially expressed miRNAs, RPE was derived from iPS using a spontaneous differentiation method. MiRNA microarray analysis identified 155 probes that were statistically differentially expressed between iPS and iPS-RPE cells. Up-regulated miRNAs including miR-181c and miR-129-5p may play a role in promoting differentiation, while down-regulated miRNAs such as miR-367, miR-18b, and miR-20b are implicated in cell proliferation. Subsequent miRNA-target and network analysis revealed that these miRNAs are involved in cellular development, cell cycle progression, cell death, and survival. A systematic interrogation of temporal and spatial expression of iPS-RPE miRNAs and their associated target mRNAs will provide new insights into the molecular mechanisms of carcinogenesis, eye differentiation and development.

Genotyping human papillomaviruses: development and evaluation of a comprehensive DNA microarray.

GOALS: To define the analytical and clinical performance of a human papillomavirus (HPV) custom-designed microarray targeting the HPV L1 gene for viral genotyping. METHODS: Microarray probes were designed by cataloging the genome sequence of all 120 known HPV types to generate tiling probes using eArray® software against the unique L1 capsid gene segments targeted by MY09/11 and FAP59/64 primers. The microarray (1 slide×8 arrays×60K features) synthesized in situ by inkjet printing was tested using synthetic type-specific HPV DNA and existing HPV DNA from cervical cytology. The synthetic HPV L1 segments (genotypes 6, 11, 16, 18, 31, 33, 35, 45, 53, 58, 66, 73, 83) were manufactured from sequences stored in the NCBI taxonomy database. Using the hybridization patterns of the synthetic HPV DNA as the Support Vector Machine classifier, HPV DNA from patient samples were genotyped and compared to antecedent DNA sequencing/BLAST® results for concordance. RESULTS: 16 cytology-derived HPV DNA samples and 13 synthetic type-specific HPV DNA samples were tested singly, in duplicate, or in combination on 40 arrays. The synthetic HPV DNA hybridization patterns were found to be uniquely distinctive to serve well as a classifier of unknown HPV-containing specimens. For the 16HPV DNA+ samples classified, 15 were concordant with DNA sequencing results. In 6/16 (38%) samples, the microarray hybridization pattern revealed ≥2 concurrent HPV infections. CONCLUSION: The novel "HPV Array" was sensitive and specific for detecting single and multiple infections. This proof-of-principle project demonstrated the accuracy and advantages of microarray technology for HPV genotyping.

HPV molecular assays: defining analytical and clinical performance characteristics for cervical cytology specimens.

OBJECTIVE: To compare the analytical and clinical performance characteristics of 3 different primer sets targeting the human papillomavirus (HPV) L1 gene for detection and genotyping of HPV. METHODS: Liquid-based cytology was obtained prospectively from 90 colposcopy clinic patients. After automated extraction, cellular DNA was subjected to SYBR Green quantitative polymerase chain reaction (qPCR) using GP5+/6+ primers and conventional PCR with MY09/11 and FAP59/64 primers. The resulting SYBR Green counts and melting temperatures (T(m)) were used for quantification of HPV genomes and discrimination between presence and absence of amplicons. qPCR and PCR products were resolved by gel electrophoresis. HPV+amplicons were sequenced directly and BLAST® aligned for genotype identification. RESULTS: Of the 90 samples, 57 (63%) were qPCR+with a range of HPV viral load detected from 191 to 3.4 million genomes (~5 Log(10)). Only HPV-positives exhibited characteristic T(m) (75-80°C). The dynamic range of detection was similar for MY and FAP. Clinical net sensitivity was highest with simultaneous testing using all primer sets (93%) instead of individual primer pairs (GP (67%), MY (62%), FAP (49%)). Of the 27 HPV genotypes identified among 64 sequenced samples, the 3 most prevalent were HPV-16 (20%), -53 (9%), -31 (6%). The 4th rank included HPV-6, -33, -58, -66 (4.7% each). CONCLUSION: The performance characteristics of 3 leading PCR-based HPV assays revealed qPCR to be sensitive and specific for HPV detection and quantification. Parallel PCR testing using the 3 primers and direct sequencing offered the greatest clinical sensitivity and breadth of detection for known HPV types.

Gardasil™ HPV vaccination: surveillance of vaccine usage and adherence in a military population.

OBJECTIVES: To investigate the usage patterns and adherence rates with the quadrivalent HPV (qHPV) vaccine at Naval Medical Center San Diego. METHODS: This retrospective, cross-sectional study was conducted by using AHLTA (Electronic Health Record of DoD) to identify all qHPV recipients between 2006 and 2009. Charts were reviewed to extract demographic variables and immunization schedules for association analysis. Subjects were assigned intention-to-treat (ITT) if they initiated the series and reached the 1-year anniversary after dose-1 or in-progress (IP) if the series was incomplete and within 1-year. ITT subjects were designated non-adherent or adherent based on 1-2 or 3 doses received. RESULTS: 6792 females and 46 males with respective mean ages (years) of 19 (95% CI: 10-29) and 27 (95% CI: 9-46) initiated the qHPV series. The evaluable ITT population consisted of 5088 females and 31 males. The adherence rate for females was 32% (1656/5088) versus 3% (1/31) for males. For females, adherence declined from 45%, 24%, to 14% with respect to increasing age: 8-17, 18-26, 27-50years. Adherence declined accordingly by beneficiary status: dependent daughters (43%), spouses (21%) and active duty (16%); and by clinic of vaccine initiation: Pediatrics/Adolescent (45%), Primary Care (38%), Immunization (21%), and OB/GYN (9%). Males were predominantly active duty 84%, vaccinated through immunization clinics 84%, and poorly adherent 3%. CONCLUSIONS: Optimal HPV immunization efficacy is derived from vaccine adherence and HPV naivety. This study of qHPV adherence has provided insight into real-world suboptimal use post-marketing. Usage patterns and adherence rates were significantly associated with demographic characteristics.

Operation Enduring Freedom: trends in combat casualty care by forward surgical teams deployed to Afghanistan.

This study examined the clinical experience of a U.S. Army Forward Surgical Team (FST) deployed to Afghanistan in 2005 and compared the findings with those of 3 previously deployed FSTs. Medical records of all patients evaluated by the FST were abstracted for analysis. Demographically, the cohort (n = 614) was predominantly male (94%), with a median age of 24, and distributed according to the following: disease (8.6%), nonbattle injury (42%), and battle injury (49%). Combat casualties were mostly Afghan National Army or Police (56%) and U.S. military (21%). Predominant wounding instruments were small arms (34%), improvised explosive devices (33%), and rocket-propelled grenades (15%). Anatomical sites of battle injury were extremities (38%), external soft tissue (35%), and head/neck/torso (28%). Operative procedures for combat injury (n = 227) were primarily orthopedic (45%) or thoracic/abdominal (36%). Combat casualty statistics provide insight to trauma epidemiology, patterns, and trends vital for surgical management. Workload statistics guides the structuring, training, and employment of FSTs.

Nerve-sparing radical hysterectomy using modern bipolar electrosurgical instruments based on the ForceTriad energy platform.

OBJECTIVE: To describe and evaluate a novel technique of nerve-sparing radical abdominal hysterectomy with pelvic lymphadenectomy (NSRH/PLND) using the bipolar Ligasure Atlas sealer/divider and Bissenger bipolar shears. METHODS: Retrospective study of 4 consecutive patients who underwent NSRH/PLND for stage IB1-IIB cervical carcinoma was conducted. Resection of the cardinal and uterosacral ligaments was performed with the Ligasure Atlas. Pelvic autonomic nerve dissection and lymphadenectomy were completed with the bipolar shears. Outcomes were collectively analyzed. RESULTS: Mean operative time was 251 minutes (range, 230-265). Blood loss averaged 625 mL (range, 400-900). Average LOS was 5 days (range, 4-5). Average duration until normal postvoid residual volume was 17 days (range, 10-24). No perioperative complications were encountered. CONCLUSION: Bipolar surgical instrumentation offers many advantages. The Ligasure Atlas provides efficient sealing and division of vascular pedicles, while the bipolar shears allow precise and fine dissection. Our results demonstrate the "bipolar sealer and shears technique" a preferable method of NSRH/PLND.

ON-Q anesthetic pump in gynecologic oncology: feasibility study of a novel placement technique at an army hospital.

OBJECTIVES: The goals were (1) to describe a novel placement technique for the ON-Q anesthetic system based on somatic neural anatomy and (2) to determine its feasibility, efficacy, and associated morbidity among surgical patients on a gynecologic oncology service. METHODS: A retrospective observational study of 100 consecutive patients who underwent a vertical laparotomy and received an ON-Q system was performed. The ON-Q system was composed of a soaker catheter (threaded longitudinally within the rectus sheaths) and an elastomer pump that infused 0.5% bupivacaine at 2 mL/hour for up to 5 days. RESULTS: The average duration of ON-Q system use was 4.4 days (range, 2-5 days). The median numeric pain scores (range, 0-10) were 3, 2, 1, 0, and 0 on postoperative days 1, 2, 3, 4, and 5, respectively. Complications encountered included suturing of the catheter to the fascia (n = 1), wound hematomas (n = 2), and device failure (n = 1). CONCLUSIONS: Intrafascial placement of the ON-Q soaker catheter for bupivacaine infusion appears effective for incisional analgesia, with negligible wound morbidity and device failure rates.

Outpatient implantation of a central venous access system in gynecologic oncology patients.

OBJECTIVE: To determine the feasibility, accuracy, complications and cost of implantation of the PORT-A-CATH II Fluoro-Free venous access system (SIMS Deltec Inc., St. Paul, Minnesota) in the procedure room setting. STUDY DESIGN: A prospective study of 49 consecutive gynecologic oncology patients who underwent 53 PORT-A-CATH II System implantations was conducted. Local anesthesia and conscious sedation were used for the procedure. To localize and position the catheter tip, the CATH-FINDER (SIMS Deltec) electronic catheter sensing device was utilized. Demographic characteristics, operative data, complication rates, failure rates and itemized costs were collected and analyzed. RESULTS: For the 53 ports implanted, the mean operative time was 54 minutes (range, 39-74) and mean estimated blood loss was 17 mL (range, 7-50). Immediate complications included failure to thread the catheter or guidewire past the left subclavian vein (4 patients), pneumothorax (1) and electronic wire fracture (1). All catheter tips were positioned accurately, as confirmed by chest radiography. The procedural charge ranged from $1,946 to $2,042. The CATH-FINDER obviated the need for, and expenses of, fluoroscopy, operating room and anesthesia services, resulting in savings of approximately $2,000 per procedure. CONCLUSION: Implantation of the PORT-A-CATH II System was performed safely, accurately and cost effectively in the procedure room setting. The advantages of functional longevity, low complication rates and reduced cost of this port system offer an excellent option for long-term central venous access.

Ascites as a predictor of ovarian malignancy.

OBJECTIVE: To determine the utility of ascites as a predictor of ovarian malignancy and define its relationship with the histologic type of ovarian tumor (benign, borderline, or malignant) and stage of disease. METHODS: This retrospective cohort study analyzed the clinical and pathological finding of 125 patients from two institutions treated for a pelvic mass. Preoperative data to include: physical examination, imaging studies (USD, CT, or MRI), and operative reports were reviewed for evidence of ascites. This was correlated with final pathologic findings and stage of disease. Collected data were summarized with descriptive statistics. Further statistical analysis was performed using Pearson's chi(2), cross tabulation, and the Median Test. Data were analyzed with SPSS 6.1 for Windows. RESULTS: One-hundred twenty-five patients were evaluable for this study. The ovarian pathologic findings were as follows: 57 benign (45%), 12 borderline (10%), and 56 malignant (45%). Fifty-three patients (42%) had frank ascites at laparotomy. Seventy-two patients (58%) had no ascites. All patients with ascites diagnosed preoperatively (n = 41) on physical examination or imaging studies were confirmed intraoperatively. Absence of ascites was correctly diagnosed preoperatively in 72/84 patients (86%). Of the 57 benign tumors, only 5 patients (9%) had small amounts of peritoneal effusion. Of the 12 borderline tumors, 7 patients (58%) had ascites. Of the 56 malignant tumors, 41 (73%) had ascites. Using presence or absence of ascites on clinical assessment as the predictor variable and benign or malignant (borderline and invasive histopathology) tumors as the outcome variable, the positive predictive value (PPV) of ascites to detect ovarian malignancy was 95% and the negative predictive value (NPV) was 64%. When borderline tumors were excluded, the PPV and NPV of ascites to detect malignant invasive tumors were 95 and 73%, respectively. Furthermore, a progressive relationship between stage of ovarian malignancy and percentage of cases with ascites was identified. Ovarian malignancies in the early stages (I and II) produced ascites only in 17% of the cases. In advanced stages (III and IV), 89% produced ascites. In addition, for stage I and II disease, all patients possessed <0.5 liters of ascites at surgery, whereas the majority of patients (66%) with stage III and IV disease had >0.5 liters. CONCLUSIONS: Our findings indicate the presence of ascites on preoperative physical examination or imaging study is highly predictive of ovarian malignancy in women with a pelvic mass. The absence of ascites may not always predict benign disease since nearly half of borderline tumors and 83% of early stage malignant ovarian tumors do not produce ascites. A progressive relationship between stage of malignancy and incidence as well as volume of ascites was also observed.