Nutcracker phenomenon presenting as left varicocele.

published_or_final_versio

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

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

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 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

The Open Access Advantage

Hong Kong Open Access Committeepublished_or_final_versio

Microbiology testing associated with antibiotic dispensing in older community-dwelling adults.

BACKGROUND:It is commonly recommended that microbiological assessment should accompany the use of antibiotics prone to resistance. We sought to estimate the rate of microbiology testing and compare this to dispensing of the World Health Organization classified "watch" group antibiotics in primary care. METHODS:Data from a cohort of older adults (mean age 69 years) were linked to Australian national health insurance (Pharmaceutical Benefits Scheme & Medicare Benefits Schedule) records of community-based antibiotic dispensing and microbiology testing in 2015. Participant characteristics associated with greater watch group antibiotic dispensing and microbiology testing were estimated using adjusted incidence rate ratios (aIRR) and 95% confidence intervals (CI) in multivariable zero-inflated negative binomial regression models. RESULTS:In 2015, among 244,299 participants, there were 63,306 watch group antibiotic prescriptions dispensed and 149,182 microbiology tests conducted; the incidence rate was 0.26 per person-year for watch group antibiotic dispensing and 0.62 for microbiology testing. Of those antibiotic prescriptions, only 19% were accompanied by microbiology testing within - 14 to + 7 days. After adjusting for socio-demographic factors and co-morbidities, individuals with chronic respiratory diseases were more likely to receive watch group antibiotics than those without, e.g. asthma (aIRR:1.59, 95%CI:1.52-1.66) and chronic obstructive pulmonary disease (COPD) (aIRR:2.71, 95%CI:2.48-2.95). However, the rate of microbiology testing was not comparably higher among them (with asthma aIRR:1.03, 95%CI:1.00-1.05; with COPD aIRR:1.00, 95%CI:0.94-1.06). CONCLUSIONS:Priority antibiotics with high resistance risk are commonly dispensed among community-dwelling older adults. The discord between the rate of microbiology testing and antibiotic dispensing in adults with chronic respiratory diseases suggests the potential for excessive empirical prescribing

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