Sonia Mendlovic

Prevalence and distribution of VZV in temporal arteries of patients with giant cell arteritis

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.

Analysis of Varicella-Zoster Virus in Temporal Arteries Biopsy Positive and Negative for Giant Cell Arteritis

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.

Positive surgical margins with renal cell carcinoma have a limited influence on long-term oncological outcomes of nephron sparing surgery.

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.

Clinical, sonographic, and epidemiologic features of second‐ and early third‐trimester spontaneous antepartum uterine rupture: a cohort study

To present prenatal findings and maternal and neonatal outcomes following second‐ and early third‐trimester spontaneous antepartum uterine rupture events in our institute.

Fertility Performance and Obstetric Outcomes Among Women With Previous Cesarean Scar Pregnancy

The purpose of this study was to assess fertility performance and obstetric outcomes after treatment of cesarean scar pregnancy.

Fetal abnormalities leading to third trimester abortion: nine‐year experience from a single medical center

To assess fetal abnormalities and events leading to third‐trimester abortion.

Prediction of morbidly adherent placenta using a scoring system

To evaluate the accuracy of an ultrasound‐based scoring system for diagnosing morbidly adherent placenta (MAP).

Predicting of morbidly adherent placenta using a scoring system: A prospective study

To evaluate the accuracy of an ultrasound‐based scoring system for diagnosing morbidly adherent placenta (MAP).

Twin tubal pregnancy: a rising complication?

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 identified 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.

Pelvic splenosis – a gynaecological challenge

Pelvic splenosis is a post-traumatic spleen autotransplantation, which can mimic various gynaecological diseases. A case of a 39-year-old woman, who underwent partial splenectomy because of a road accident in her childhood, currently presenting with abdominal pain and suspected corpus luteus torsion. Diagnostic laparoscopy was conducted which ruled out twisted ovary. This confirmed disseminated pelvic splenosis as a coincidental finding. Following this procedure, the abdominal pain ceased. The current report aims to raise the awareness of splenosis so that it may be appropriately recognized and differentiated from other pelvic findings.