Nutcracker phenomenon presenting as left varicocele.

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Successful endovascular infrarenal aneurysm repair in a patient with situs inversus totalis

Situs inversus totalis is a rare autosomal recessive developmental anomaly. There are very few reports in the published literature of abdominal aortic aneurysm in patient with situs inversus totalis, all of whom underwent open aneurysm repair. This is the first case in the world's literature to describe a patient with situs inversus totalis who had a successful endovascular infrarenal aneurysm repair. Although endovascular infrarenal aneurysm repair should not be more challenging, the endovascular approach may decrease risk of potential errors because of unfamiliar anatomy. Technical considerations in performing endovascular procedures in patients with situs inversus totalis are discussed in this article. © Annals of Vascular Surgery Inc.postprin

Diagnosing deep vein thrombosis in the lower extremity: correlation of clinical and duplex scan findings.

OBJECTIVE: To identify factors that predict a positive duplex scan examination result in patients with suspected deep vein thrombosis of the lower extremity. DESIGN: Retrospective study. SETTING: Vascular laboratory in a university teaching hospital. PATIENTS AND METHODS: The results of 345 lower extremity duplex venous scans performed between August 1994 and November 1998 were reviewed. All patients were in-patients referred from different specialties due to clinical suspicion of lower extremity deep vein thrombosis. Positive duplex scans were correlated with patients' demographic data (sex, age), medical history (history of malignancy, deep vein thrombosis, and pulmonary embolism) and clinical features (leg swelling, venous insufficiency, calf pain, and leg ulcer). Univariate analysis was performed using the Chi squared test. RESULTS: A total of 345 scans were performed for 313 patients. The mean age was 55 years (range, 19-92 years). Sixty-three patients (49 male, 14 female) had a positive scan, giving a yield of 18.3%. Four factors had a significant association with a positive scan: male sex (P=0.0102), history of malignancy (P=0.0040), history of deep vein thrombosis (P=0.0001), and history of pulmonary embolism (P=0.0265). CONCLUSIONS: Common presenting clinical features do not predict the result of ultrasonographic investigation for deep vein thrombosis. The chance of having a positive scan is significantly higher in male patients and those with a history of malignancy, deep vein thrombosis, or pulmonary embolism.published_or_final_versio

Treatment of a ruptured iliac aneurysm with an endoluminal stent graft.

The management of a 79-year-old man presenting with a ruptured common iliac aneurysm is described. The patient had multiple medical problems including hypertension, ischaemic heart disease, and atrial fibrillation, as well as a left hemispheric stroke 5 years previously. Traditional open surgery was judged unsuitable in this case because of the predicted poor outcome. The patient was subsequently treated successfully with endoluminal stent grafting.published_or_final_versio

Transcranial Doppler Ultrasound Detection of Microemboli as a Predictor of Cerebral Events in Patients with Symptomatic and Asymptomatic Carotid Disease: A Systematic Review and Meta-Analysis.

OBJECTIVE: Identification of patients who will benefit from carotid endarterectomy is not entirely effective, primarily utilising degree of carotid stenosis. This study aimed at determining if microembolic signals (MES) detected by transcranial Doppler ultrasound (TCD) can provide clinically useful information regarding stroke risk in patients with carotid atherosclerosis. METHODS: A meta-analysis of prospective studies was performed. Three analyses were proposed investigating MES detection as a predictor of: stroke or TIA, stroke alone, and stroke or TIA but with an increased positivity threshold. Subgroup analysis was used to compare pre-operative (symptomatic or asymptomatic) patients and peri- or post-operative patients. RESULTS: Twenty-eight studies reported data regarding both MES status and neurological outcome. Of these, 22 papers reported data on stroke and TIA as an outcome, 19 on stroke alone, and eight on stroke and TIA with increased positivity threshold. At the median pre-test probability of 3.0%, the post-test probabilities of a stroke after a positive and negative TCD were 7.1% (95% CI 5-10.1) and 1.2% (95% CI 0.6-2.5), respectively. In addition, the sensitivities and specificities of each outcome showed that increasing the threshold for positivity to 10 MES per hour would make TCD a more clinically useful tool in peri- and post-operative patients. CONCLUSION: TCD provides clinically useful information about stroke risk for patients with carotid disease and is technically feasible in most patients. However, the generally weak level of evidence constituting this review means definitive recommendations cannot be made

The Primary Enveloped Virion of Herpes Simplex Virus 1: Its Role in Nuclear Egress

Many viruses migrate between different cellular compartments for successive stages of assembly. The HSV-1 capsid assembles in the nucleus and then transfers into the cytoplasm. First, the capsid buds through the inner nuclear membrane, becoming coated with nuclear egress complex (NEC) protein. This yields a primary enveloped virion (PEV) whose envelope fuses with the outer nuclear membrane, releasing the capsid into the cytoplasm. We investigated the associated molecular mechanisms by isolating PEVs from US3-null-infected cells and imaging them by cryo-electron microscopy and tomography. (pUS3 is a viral protein kinase in whose absence PEVs accumulate in the perinuclear space.) Unlike mature extracellular virions, PEVs have very few lycoprotein spikes. PEVs are ~20% smaller than mature virions, and the little space available between the capsid and the NEC layer suggests that most tegument proteins are acquired later in the egress pathway. Previous studies have proposed that NEC is organized as hexamers in honeycomb arrays in PEVs, but we find arrays of heptameric rings in extracts from US3-nullinfected cells. In a PEV, NEC contacts the capsid predominantly via the pUL17/pUL25 complexes which are located close to the capsid vertices. Finally, the NEC layer dissociates from the capsid as it leaves the nucleus, possibly in response to pUS3- mediated phosphorylation. Overall, nuclear egress emerges as a process driven by a program of multiple weak interactions

The Open Access Advantage

Hong Kong Open Access Committeepublished_or_final_versio

The Open Access Advantage Revisited

This paper is a revision of one that appeared in 2008, incorporating the many developments and changes that have happened since then.published_or_final_versio

Subassemblies and Asymmetry in Assembly of Herpes Simplex Virus Procapsid

The herpes simplex virus 1 (HSV-1) capsid is a massive particle (~200 MDa; 1,250-Å diameter) with T=16 icosahedral symmetry. It initially assembles as a procapsid with ~4,000 protein subunits of 11 different kinds. The procapsid undergoes major changes in structure and composition as it matures, a process driven by proteolysis and expulsion of the internal scaffolding protein. Assembly also relies on an external scaffolding protein, the triplex, an α2β heterotrimer that coordinates neighboring capsomers in the procapsid and becomes a stabilizing clamp in the mature capsid. To investigate the mechanisms that regulate its assembly, we developed a novel isolation procedure for the metastable procapsid and collected a large set of cryo-electron microscopy data. In addition to procapsids, these preparations contain maturation intermediates, which were distinguished by classifying the images and calculating a three-dimensional reconstruction for each class. Appraisal of the procapsid structure led to a new model for assembly; in it, the protomer (assembly unit) consists of one triplex, surrounded by three major capsid protein (MCP) subunits. The model exploits the triplexes’ departure from 3-fold symmetry to explain the highly skewed MCP hexamers, the triplex orientations at each 3-fold site, and the T=16 architecture. These observations also yielded new insights into maturation

Distribution and Redistribution of HIV-1 Nucleocapsid Protein in Immature, Mature, and Integrase-Inhibited Virions: a Role for Integrase in Maturation

During virion maturation, HIV-1 capsid protein assembles into a conical core containing the viral ribonucleoprotein (vRNP) complex, thought to be composed mainly of the viral RNA and nucleocapsid protein (NC). After infection, the viral RNA is reverse transcribed into double-stranded DNA, which is then incorporated into host chromosomes by integrase (IN) catalysis. Certain IN mutations (class II) and antiviral drugs (allosteric IN inhibitors [ALLINIs]) adversely affect maturation, resulting in virions that contain “eccentric condensates,” electron-dense aggregates located outside seemingly empty capsids. Here we demonstrate that in addition to this mislocalization of electron density, a class II IN mutation and ALLINIs each increase the fraction of virions with malformed capsids (from ∼12% to ∼53%). Eccentric condensates have a high NC content, as demonstrated by “tomo-bubblegram” imaging, a novel labeling technique that exploits the susceptibility of NC to radiation damage. Tomo-bubblegrams also localized NC inside wild-type cores and lining the spherical Gag shell in immature virions. We conclude that eccentric condensates represent nonpackaged vRNPs and that either genetic or pharmacological inhibition of IN can impair vRNP incorporation into mature cores. Supplying IN in trans as part of a Vpr-IN fusion protein partially restored the formation of conical cores with internal electron density and the infectivity of a class II IN deletion mutant virus. Moreover, the ability of ALLINIs to induce eccentric condensate formation required both IN and viral RNA. Based on these observations, we propose a role for IN in initiating core morphogenesis and vRNP incorporation into the mature core during HIV-1 maturation