IMPORTANCE: Giant cell arteritis (GCA) is the most common systemic vasculitis in elderly individuals. Diagnosis is confirmed by temporal artery (TA) biopsy, although biopsy results are often ...negative. Despite the use of corticosteroids, disease may progress. Identification of causal agents will improve outcomes. Biopsy-positive GCA is associated with TA infection by varicella-zoster virus (VZV). OBJECTIVE: To analyze VZV infection in TAs of patients with clinically suspected GCA whose TAs were histopathologically negative and in normal TAs removed post mortem from age-matched individuals. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional study for VZV antigen was performed from January 2013 to March 2015 using archived, deidentified, formalin-fixed, paraffin-embedded GCA-negative, GCA-positive, and normal TAs (50 sections/TA) collected during the past 30 years. Regions adjacent to those containing VZV were examined by hematoxylin-eosin staining. Immunohistochemistry identified inflammatory cells and cell types around nerve bundles containing VZV. A combination of 17 tertiary referral centers and private practices worldwide contributed archived TAs from individuals older than 50 years. MAIN OUTCOMES AND MEASURES: Presence and distribution of VZV antigen in TAs and histopathological changes in sections adjacent to those containing VZV were confirmed by 2 independent readers. RESULTS: Varicella-zoster virus antigen was found in 45 of 70 GCA-negative TAs (64%), compared with 11 of 49 normal TAs (22%) (relative risk RR = 2.86; 95% CI, 1.75-5.31; P < .001). Extension of our earlier study revealed VZV antigen in 68 of 93 GCA-positive TAs (73%), compared with 11 of 49 normal TAs (22%) (RR = 3.26; 95% CI, 2.03-5.98; P < .001). Compared with normal TAs, VZV antigen was more likely to be present in the adventitia of both GCA-negative TAs (RR = 2.43; 95% CI, 1.82-3.41; P < .001) and GCA-positive TAs (RR = 2.03; 95% CI, 1.52-2.86; P < .001). Varicella-zoster virus antigen was frequently found in perineurial cells expressing claudin-1 around nerve bundles. Of 45 GCA-negative participants whose TAs contained VZV antigen, 1 had histopathological features characteristic of GCA, and 16 (36%) showed adventitial inflammation adjacent to viral antigen; no inflammation was seen in normal TAs. CONCLUSIONS AND RELEVANCE: In patients with clinically suspected GCA, prevalence of VZV in their TAs is similar independent of whether biopsy results are negative or positive pathologically. Antiviral treatment may confer additional benefit to patients with biopsy-negative GCA treated with corticosteroids, although the optimal antiviral regimen remains to be determined.
Objective To present four cases of twin tubal pregnancies and discuss possible etiologies. Twin tubal pregnancies are a rare event, with incidence rates estimated as 1 out of 725–1,580 of tubal ...pregnancies. Design Case series. Setting Department of obstetrics and gynecology at a tertiary health care facility. Patient(s) All women with twin tubal pregnancy diagnosed and treated in the department during the years 2007–2009, according to electronic files and histologic reports. Intervention(s) None. Main Outcome Measure(s) Artificial reproductive technique preceding twin tubal pregnancies Result(s) We diagnosed four twin pregnancies of 163 tubal pregnancies, an incidence of 2.4%. Of the four cases, two conceived after gonadotropin stimulation and intrauterine insemination. The third conceived following in vitro fertilization and intracytoplasmic sperm injection. The fourth was a spontaneous conception diagnosed as monochorial monoamniotic twin tubal pregnancy. Conclusion(s) Twin tubal pregnancies may not be as rare as previously thought. Three of the four cases indentified during a 2-year period followed artificial reproductive technique. We hope that this report will promote the study of the epidemiology of this event, improve diagnosis, and encourage the development of treatment modalities.
Objective To supplement existing cases of cesarean scar pregnancy presenting as acute conditions. All of the study women had been treated by a conservative surgical approach. Design Retrospective ...study. Setting Department of obstetrics/gynecology of a tertiary referral center. Patient(s) We identified six pregnant women at 7-15 weeks' gestation who underwent emergency laparotomy and uterine-preserving surgery. Four of them were initially treated by uterine curettage because of misdiagnosed intrauterine pregnancies. The other two experienced failed methotrexate treatment. Intervention(s) All patients underwent a similar surgical technique while actively bleeding. This included laparotomy and ligation of bilateral uterine arteries, followed by wedge resection of the entire pregnancy in scar. The uterus was sutured in two layers. Main Outcome Measure(s) All the reported women in our series had been cured and their uteruses have been preserved. Result(s) There was an inadvertent injury to the bladder in one case, which was immediately repaired, and blood transfusion was required in two other cases. The postoperative course was uneventful for all the patients. One of the patients has already spontaneously conceived and she had an ongoing normal pregnancy at the time of writing. Conclusion(s) This small case series emphasizes that uterine-preserving surgery is an optional management for cesarean scar pregnancies presenting as acute conditions, cases resistant to medical treatment, or for women at advanced gestation.
BACKGROUNDRare incidence cases are part of the routine work of pediatric surgeons. Cecal anomalies in children are an example of such cases. Objectives: To describe the presentation, workup, ...management and outcome of rare cecal anomalies in children and to analyze the skills needed for their successful treatment. METHODSA retrospective chart review was conducted of all cases of cecal anomalies managed by the pediatric surgical service at a tertiary hospital from June 2017 to January 2020. Data regarding demographics, clinical presentation, radiological studies, surgical treatment, pathology, complications, and outcome were collected. RESULTSFive cases of cecal anomalies were encountered over a period of 32 months, including a cecal volvulus, cecal duplication, cecal intussusception, and two cecal masses (one ulcerated lipoma and one polyp). All patients, except the patient with cecal duplication, presented acutely and were managed surgically. Long-term follow-up of 17-24 months was unremarkable in all cases. CONCLUSIONSA wide knowledge base, careful judgment, and creativity enable pediatric surgeons to successfully treat rare conditions such as rare cecal anomalies. These skills should be part of the education of pediatric surgery trainees.
Our aim was to characterize excised breast masses in children and adolescent and to identify factors associated with a more aggressive pathology.
Retrospective review of all female patients <19 who ...underwent excision of breast masses at our institution between 1999 and 2018. Demographic, clinical, imaging, pathological and management data were collected. We assessed possible association of any of the variables with a more aggressive pathology (phyllodes tumor and malignancy). Correlation between core needle biopsy results and final pathology results was also calculated.
70 patients were included. Median age was 17 years (range: 11–19). Resected mass size was 4 cm (range: 2–16). Final pathology results were: fibroadenoma (49), juvenile fibroadenoma (7), hamartoma (5), benign phyllodes (7), malignant phyllodes (1) and sarcoma (1). Pathology was benign in 61 (87%) patients and more aggressive (phyllodes and sarcoma) in 9 (13%). None of the tested variables was associated with a more aggressive pathology. Presurgical core biopsy results matched final pathology in only 63.6%.
Excised breast masses in children and adolescents are sometimes of a more aggressive pathology, which cannot be predicted by presurgical factors, including a core needle biopsy.
Prognosis study
III.
OBJECTIVE:Varicella-zoster virus (VZV) infection may trigger the inflammatory cascade that characterizes giant cell arteritis (GCA).
METHODS:Formalin-fixed, paraffin-embedded GCA-positive temporal ...artery (TA) biopsies (50 sections/TA) including adjacent skeletal muscle and normal TAs obtained postmortem from subjects >50 years of age were examined by immunohistochemistry for presence and distribution of VZV antigen and by ultrastructural examination for virions. Adjacent regions were examined by hematoxylin & eosin staining. VZV antigen–positive slides were analyzed by PCR for VZV DNA.
RESULTS:VZV antigen was found in 61/82 (74%) GCA-positive TAs compared with 1/13 (8%) normal TAs (p < 0.0001, relative risk 9.67, 95% confidence interval 1.46, 63.69). Most GCA-positive TAs contained viral antigen in skip areas. VZV antigen was present mostly in adventitia, followed by media and intima. VZV antigen was found in 12/32 (38%) skeletal muscles adjacent to VZV antigen–positive TAs. Despite formalin fixation, VZV DNA was detected in 18/45 (40%) GCA-positive VZV antigen–positive TAs, in 6/10 (60%) VZV antigen–positive skeletal muscles, and in one VZV antigen–positive normal TA. Varicella-zoster virions were found in a GCA-positive TA. In sections adjacent to those containing VZV, GCA pathology was seen in 89% of GCA-positive TAs but in none of 18 adjacent sections from normal TAs.
CONCLUSIONS:Most GCA-positive TAs contained VZV in skip areas that correlated with adjacent GCA pathology, supporting the hypothesis that VZV triggers GCA immunopathology. Antiviral treatment may confer additional benefit to patients with GCA treated with corticosteroids, although the optimal antiviral regimen remains to be determined.
The association of Helicobacter pylori-negative gastritis with lymphoid follicles (LFs) in children is still unclear. Therefore, we aimed to investigate the natural history and significance of H. ...pylori-negative gastritis with LFs in children.
We identified children with histologically proven H. pylori-negative gastritis with LFs between June 2014 and January 2017. The children were invited for a follow-up examination. The clinical, endoscopic, and histological findings of the index esophagogastroduodenoscopy (EGD) were revised and compared to the follow-up findings.
A total of 754 children underwent EGD. Among the 48 children diagnosed with H. pylori-negative gastritis, 17 (35.41%) had gastric LFs. Eight agreed to participate in the study. The mean follow-up was 25.58 ± 4.52 (range, 20.53-35.73) months. Three children still had histologic findings of chronic gastritis with LFs. Four children had resolution of the gastritis but still had LFs, and 1 patient had resolution of both the gastritis and LFs.
LFs were still present in children with H. pylori-negative gastritis after a mean follow-up of 2 years, and in some children, despite resolution of the gastritis. Therefore, this histological finding might be a non-pathological feature in children and does not need any contribution or follow-up.
Objectives
The purpose of this study was to assess fertility performance and obstetric outcomes after treatment of cesarean scar pregnancy.
Methods
We conducted a retrospective study in a large ...tertiary hospital in Israel. The study included 18 women with a diagnosis of cesarean scar pregnancy between 2000 and 2009.
Results
The incidence of cesarean scar pregnancy among our parturient patients was 1 per 3000 for the general obstetric population and 1 per 531 among those with at least 1 cesarean delivery. Sixteen were treated primarily with methotrexate. Two were treated primarily by surgery, and 2 more were treated by surgery after failed methotrexate treatment. After cesarean scar pregnancy treatment, 7 women conceived spontaneously, and 1 conceived by in vitro fertilization–intracytoplasmic sperm injection. The remaining 10 (55%) did not wish to conceive again. Two of the women who became pregnant (25%) had recurrent cesarean scar pregnancy.
Conclusions
This study shows encouraging results for fertility performance and obstetric outcomes after treatment of cesarean scar pregnancy. Nevertheless, the risk of recurrent cesarean scar pregnancy is not negligible.
Objectives To define the rate of positive surgical margins (PSMs) and analyze the outcome of patients with PSMs. The outcome and proper management of patients with positive PSMs during nephron ...sparing surgery (NSS) are questionable. In this study we define the clinical outcomes of PSMs at NSS and suggest management. Methods Clinical records of 114 renal units who underwent open NSS for a renal mass between May 1995 and September 2005 were reviewed. Results PSMs were suspected on frozen section in 17 of 114 renal units (15%). Tumors with suspected PSMs at frozen section were smaller (2.9 ± 1.6) in comparison to those with negative surgical margins (3.4 ± 1.8 cm) ( P = .001). Nine of 17 (53%) cases underwent total nephrectomy (5 immediately, 4 delayed). In 4 (24%), immediate re-excision of the renal crater was performed. A total of 4 (24%) that were followed up clinically were with no evidence of disease. Therefore, in 13 of 17 (77%) cases, the presence of tumor cells at the remaining side of the kidney could be evaluated histologically. In 2 cases from the immediate response group, tumor cells were found in the side opposite to the resection. There was no residual tumor in any case subjected to delayed nephrectomy. At median follow-up of 71 months, 15 of 17 patients are alive and with no evidence of disease. Two patients died because of unrelated causes. The overall 5-year survival rate is 98.2% and there is no cancer-specific mortality. Conclusions The true PSM rate is in the range of 1.75%-5.26%. No disease progression or deaths attributable to renal cell carcinoma were associated with PSMs. Total nephrectomy should be avoided as a response to PSMs.
PDF
