We present a case of a 62-year-old Caucasian male with laryngeal cancer and Ramsay Hunt Syndrome otherwise known as herpes zoster oticus due to reactivation of the varicella zoster virus. Classic findings include the triad of ipsilateral facial paralysis, otic pain, and herpetic lesions in the sensory supply of the facial nerve. The common pathogenesis is associated with anterograde axonal reactivation of the varicella zoster virus in the geniculate ganglion. Unique features of our case include retrograde transaxonal spread of the varicella-zoster virus from the geniculate ganglion into the brainstem and cerebellum including involvement of the abducens nucleus, facial nucleus, middle cerebral peduncle, and inferior cerebellar peduncle. This presented as left facial paralysis, left sixth nerve palsy, horizontal diplopia to the left lateral gaze, profound truncal ataxia, and left-sided dysmetria. Clinical awareness that Ramsay Hunt syndrome may also involve the brainstem and cerebellum is critical in evaluating the clinical neurologic findings and expanding the diagnostic workup to include brain magnetic resonance imaging and cerebrospinal fluid analysis, including varicella zoster polymerase chain reaction. Encephalitis requires longer duration administration of high-dose intravenous acyclovir in conjunction with steroids. Delays in treatment are often associated with unsatisfactory outcomes with extensive residual deficits. Varicella zoster virus (VZV) is a human herpes virus that, during the primary infection, causes chickenpox . After tA 62-year-old Caucasian male with a medical history significant for squamous cell laryngeal cancer in remission, history of tracheostomy, type 2 diabetes mellitus, and hypothyroidism presented to an outside institution with a 3-day history of left ear pain with associated nausea and vomiting. Initial laboratory studies demonstrated elevated nonspecific acute phase reactants. Computed tomography (CT) indicated left middle ear swelling and enhancement of the left soft palate. Fungal cultures were negative. A diagnosis of left malignant otitis externa was made, and appropriate intravenous and topical antimicrobial therapies were initiated. Due to clinical deterioration, the patient was transferred to our institution where initial neurological assessment showed a full left side facial droop, left otic vesicles on the pinna, and gait ataxia. Repeat CT scan was consistent with malignant otitis externa. On hospital day two, the patient's condition continued to worsen and neurological exam indicated left cranial nerve (CN) VI and VII nerve palsies, horizontal diplopia of the left eye, conductive hearing loss, skew deviation, and persistent herpetic lesions on the hard palate and the outer ear . There wDue to suspected multiple CN involvement, contrast brain magnetic resonance imaging (MRI) was conducted followed by a lumbar puncture (LP). Brain MRI showed a hyperintense lesion along the left middle and inferior cerebellar peduncle along the fourth ventricle Figures –4. CerebInitial treatment included empiric antibiotic and antifungal medications; however, after the confirmation of viral etiology, these were discontinued. Intravenous acyclovir 800 mg 5x/day and prednisone 70 mg oral daily was initiated. One day later, the patient showed significant improvement in visual deficits. Mild lateral gaze palsy remained along with full left facial weakness, gait ataxia, and vesicular lesions on the hard palate and ear. He remained in the hospital for 9 days and was discharged on acyclovir 20 mL 5x/day for 14 days.At 4-month follow-up, the patient demonstrated improved balance but had persistent left facial droop and left-sided hearing loss. The remainder of the neurological exam was unremarkable. Due to the recurrence of left otic discharge, the patient was discharged on a 10-day course of 1 g valacyclovir three times/day as an outpatient.We describe a patient with both RHS along with a complicating VZV rhombencephalitis and cerebellitis. Prior to making the diagnosis of RHS, there was concern that the cause of the patient's presentation could be secondary to direct metastasis of his squamous cell laryngeal carcinoma. The potential for malignancy was vaguely supported by the nonspecific contrast enhancement on brain imaging; however, it was excluded after the CSF evaluation was completed. Also the differential diagnosis at the initial stages was direct neurotoxicity secondary to the patient's cisplatin chemotherapy regimen. Considering the classic presentation associated with Ramsay Hunt syndrome, cerebellar involvement, and the lack of distal sensory neuropathy, this was excluded as a potential diagnosis .Central nervous system (CNS) involvement is unusual in Ramsay Hunt syndrome but is associated with immunocompromised states . ClinicaDiagnosis in the cases of concomitant RHS and VZV encephalitis generally consists of the clinical features, brain MRI, and CSF analysis, all of which were used in this case to establish a diagnosis , 15. HowThe standard treatment of RHS itself focuses on acyclovir and prednisone therapy. Of utmost importance in these cases is the timeframe during which the infection is treated. In the study performed by Furuta et al., it was found that RHS patients who received treatment with the combination acyclovir-prednisone within 7 days of clinical presentation had a full facial palsy recovery . Murakam


Perfluoroalkyl substances (PFASs) are widespread industrial pollutants that are extremely persistent in the environment. A previous study in the Danish National Birth Cohort (DNBC) found prenatal perfluorooctanoate (PFOA) exposure was associated with decreased birth weight, but had insufficient statistical power to evaluate adverse birth outcomes. Here, we conducted additional analyses in three samples originating from the DNBC for 3535 mothers and infant pairs to evaluate associations between prenatal PFASs exposures and low birth weight and preterm birth. Maternal plasma concentrations were measured for six types of PFASs in early pregnancy. Several PFASs were associated with a reduction in birth weight and gestational age. We estimated a nearly 2-fold increase in risks of preterm birth for the higher quartiles of PFOA and perflourooctanesulfonate (PFOS) exposure. In spline models, risk of preterm birth was increased for perfluorononanoic acid (PFNA), perfluoroheptane sulfonate (PFHpS) and perfluorodecanoic acid (PFDA) in higher exposure ranges. We also observed some elevated risks for low birth weight but these estimates were less precise. Our findings strengthen the evidence that in-utero PFASs exposures affect fetal growth. Future studies are needed to evaluate whether these associations persist with the decline of PFOA and PFOS in populations and should also investigate newer types of fluorinated compounds introduced more recently. Perfluoroalkyl substances (PFASs) are industrial persistent pollutants that are widespread in the environment . The mosAnimal studies have suggested that prenatal PFASs exposure can affect fetal growth i.e., PFOS and PFOA exposures in-utero can reduce birth weight and gestational age at delivery in rodents ,10,11. SA previous study conducted in the Danish National Birth Cohort (DNBC) found an inverse association between maternal plasma PFOA levels and birth weight , howeverThe DNBC is a nationwide follow-up study of pregnant women and their offspring in Denmark . Pregnann = 6207), non-singleton births (n = 2080), mother who emigrated (n = 51) or died (n = 3), unknown birth outcomes (n = 25), or missing dates of birth (n = 99), and one participant who withdrew from all pregnancies initially enrolled. The source population for this study is further limited to the 83,389 mother-child pairs who completed interview 1 and for whom maternal blood samples were available for PFASs analyses. Previously, three sub-studies have measured PFASs in maternal blood samples in the DNBC [There were 92,576 live-born singletons in the DNBC after excluding unsuccessful pregnancies including abortions and stillbirths  or gestational age <140 days or > 315 days (n = 4). Low birth weight (LBW) was defined as birth weight <2500 g [Birth weight (grams) and gestational age at birth were obtained from the National Hospital Discharge Register at the National Board of Health in Denmark. The information for gestational age recorded in the register was usually based on ultrasound examinations done before 24 weeks of gestation conducted by midwives (~97%) and only few were calculated from the first day of the last menstrual period (LMP). We excluded infants with extreme values of birth weight <500 g or >6800 g  produced by the two laboratories were very high (Pearson correlation r = 0.94 for PFOS and r = 0.95 for PFOA).Comparisons of PFASs measurements in the two laboratories have previously been performed . Althoughttp://www.bsmb.dk) [Information on infant sex, infant birth year (as continuous variable), maternal age , parity  were collected from the medical register, while other potential confounders such as socio-occupational status , pre-pregnancy body mass index , smoking during pregnancy (yes/no) and alcohol intake during pregnancy was recorded in the highly structured questionnaires collected during pregnancy (available at bsmb.dk) . Althougbsmb.dk) ,28, and We used multivariable linear regression to evaluate the expected differences in birth weight (grams) and length of gestation (days) according to maternal plasma PFASs level. In addition, we used multivariable logistic regression to estimate the adjusted odds ratio (OR) and 95% confidence interval (CI) for LBW and preterm birth according to PFASs exposures. The PFASs levels were analyzed as continuous values or categorized in quartiles. For continuous PFASs values, we analyzed log-transformed (base 2) PFASs exposure in the statistical models thus the exposure effect estimate represents an increase per doubling of the PFASs concentration (ng/mL). The PFASs quartile classifications were based on untransformed PFASs values and the lowest quartile was used as the reference. To further evaluate potential non-linear exposure-outcome responses, we fitted restricted cubic spline models with three knots at the 10th, 50th and 90th percentile of the PFASs value on LBW or preterm birth. We also allowed for higher flexibility (4 or 5 knots) in the spline models; but since results did not change substantially, we employed 3 knots to avoid over-fitting. To account for possible laboratory differences or “batch effects”, we added an indicator variable for study sample  when we analyzed PFASs continuously, and we used the study-sample specific cut-off to generate PFASs quartiles.p-values for interaction term between each of the exposure and the potential modifier [All covariates except for infant birth year and gestational age at blood draw (weeks) were introduced into models as categorical variables , and organic food consumption  during pregnancy to evaluate potential confounding by dietary factors . We alsoDemographic and other characteristics of the study participants (unweighted) by study sample are presented in p-value for interaction = 0.05). The negative associations of PFNA or PFDA on gestational age were also stronger among mothers with either lower or higher pre-pregnancy BMI compared with normal weight women .In pooled analyses, we observed that per doubling of exposure in prenatal PFASs (ng/mL) specifically PFOS, PFOA, PFNA and PFHpS were associated with a 45 g, 36 g, 36 g or 39 g decrease in birth weight . A greatSeveral positive associations between prenatal PFASs and preterm birth were observed . The ORsp-value for non-linearity <0.10) for PFOA, PFHxS, PFNA, and PFDA in a spline model of exposure  while PFOS and PFHpS were highly correlated (r = 0.89) (see A non-linear exposure response for LBW was found for PFDA with a slight reduction of odds in the lower exposure range but estimated odds increasing again at higher exposure (>0.2 ng/mL) a. In sen.89) see , even th.89) see .The positive effect estimates between several PFASs and LBW were slightly strengthened using <2650 g as the cut-off while the results became very imprecise with the <2260 g cut-off due to the small number of cases. For preterm birth, the results were also slightly strengthened for PFNA and PFDA using <36 weeks as the cut-off but the effect estimates also became less precise using a <35 weeks cut-off. Our results also remained similar when restricting to samples collected in the first trimester only (data not shown).In this large combined sample from a prospective cohort study in Denmark, prenatal PFASs were generally inversely associated with birth weight and gestational age. Moreover, we found that prenatal exposures to several PFASs may increase the risks for preterm birth, and possibly also LBW but the estimates for LBW were imprecise. Spline models for exposure suggested possible effect on adverse birth outcomes at higher exposure ranges for the less prevalent PFASs in our samples such as PFNA, PFHpS and PFDA. This might be of concerns if these exposures rise in populations with changes in consumer product use of these chemicals ,4,5.2 ng/mL exposure and additionally accounted for possible selection bias due to the sample selection criteria employed.An earlier study in the DNBC  was amonOther cohort studies that investigated the associations regarding prenatal PFASs exposures on fetal growth indicators were mostly small in size and they only assessed PFOS or PFOA exposures ,38. AmonPhysiologically, animal studies have shown the negative effect of prenatal PFASs exposures on birth outcomes and several potential mechanisms have been suggested ,41,42. POur study has several strengths. All three sub-samples were selected from a nationwide well-described cohort of pregnant women and their infants . The PFAThe effect estimates were largely consistent across study samples, but some variations were observed. This could be due to different sampling and selection criteria employed to generate each study sub-sample, or the influence of measurement errors or simply of chance. We adjusted for sampling and selection probabilities using weighted regressions throughout, but some differences in study characteristics across samples may still have remained. A moderate to high correlation between different PFASs make it difficult to disentangle specific exposure effects for each chemical from the effect of the mixtures. Our large sample size allowed us to conduct multi-pollutants analyses, and generally the estimated exposure effects for several PFASs compounds persisted upon co-pollutant adjustments. Some advanced statistical methods for mixture analyses have been proposed ,48, but The observed association may not be causal and can be influenced by bias. There could be unmeasured factors we could not take into considerations leading to residual confounding. When using biomarkers of PFASs, physiological factors that affect accumulation or excretions of PFASs should also be considered. For instance, lower glomerular filtration rate (GFR) in mid- or late-pregnancy has been suggested to be such a possible confounding factor . MothersAny measurement errors in exposures and outcomes are expected to be non-differential and might bias the associations mostly towards the null. Participants were unlikely to be aware of their PFASs levels which limit the possibility of self-selection bias. However, prenatal PFASs exposures may increase risk of miscarriages ,52. Our In conclusion, our analysis using three sub-samples from the DNBC demonstrated that several prenatal PFASs are inversely associated with birth weight and gestational age, and prenatal exposure to several PFASs may increase the risks for preterm birth. Our findings strengthen the evidence that in-utero PFASs exposures might affect fetal growth. Exposure levels of PFOS and PFOA are declining in some western countries but they are still widely detected. Adverse effects on birth outcomes in our samples were also observed in the higher exposure ranges of some of the less commonly detected PFASs such as PFNA and PFDA which might be concerning if exposures to these compounds increase in populations. Considering the ubiquity of PFASs contamination in the environment and in humans, strategies and efforts to prevent PFASs exposures in pregnant women and young infants should continue. Further study is also needed to evaluate whether these associations persist with lower exposure levels for PFOS and PFOA, and substitutes and newer types of fluorinated compounds need to be scrutinized as well.


The aggressive and infiltrating behaviour of signet ring cell (SRC) tumours may be associated with poor prognosis.Despite SRC histology not being an independent predictor for overall or disease-free survival in this study, tumours with an SRC component had a higher rate of irradical (R1/R2) resections and more advanced pathological T-stage after neoadjuvant therapy compared with non-SRC tumours.As biopsies are not always representative for the pheno- and genotype of the entire tumour, they may not be accurate enough to determine the percentage of SRC present.Possible intensification of locoregional therapy, however, may still be needed, and larger, prospective studies should be conducted stratifying for SRC histology to establish nCRT as optimal treatment regimen for oesophageal SRC tumours.


The incidence of surgical site infections (SSIs) after elective tumour orthopaedic surgery in adults is higher than non-oncologic orthopaedic surgery. Their causative microorganisms and antibiotic susceptibilities are also different from the non-oncologic cases; with no apparent predictable microbiological patterns. Clinicians continue to struggle to tailor the optimal prophylactic regimen for the very heterogeneous group of tumour patients. Many clinicians thus prolong the first-and second-generation cephalosporin agents, while a minority chooses to broaden the antimicrobial spectrum by combination prophylaxis. The variability in current practices and surgical techniques is enormous, even within the same setting. The scientific literature lacks adequate retrospective case-studies and there is currently only one prospective randomized trial. In this narrative review, we discuss various perioperative antibiotic concepts in oncologic orthopaedic surgery, including a summary of the state-to-the-art, opinions and difficulties related to the different prophylactic strategies. In elective orthopedic oncologic surgery , surgical site infections SSI; 1) occur much more frequently than after non-oncologic surgeries. The incidence of oncologic SSI has been reported from 4 to 38%  occur muThe reasons for these higher SSI incidences are presumably multifactorial for the majority of episodes: extensive soft tissue dissections and large remaining cavities Staphylococcus aureus and β-hemolytic streptococci are the hallmarks of orthopedic SSIs, while coagulase-negative staphylococci and other skin commensals are witnessed in implant-related infections. Gram-negative pathogens, including anaerobes, are seldom in orthopedic surgery While the perioperative antibiotic prophylaxis is well established for the vast majority of orthopedic interventions, and endorsed by international In this narrative review, we highlight various perioperative prophylactic concepts in elective orthopedic tumor surgery, including a summary of the presumed state-to-the-art, opinions and difficulties. We cover 1) the epidemiology of these SSI's, the skin colonization of multi-resistant germs in these oncologic patients, 2) the differences according to the anatomical localizations, 3) the microbiology and the theoretical minimal antibiotic coverage necessary to prevent SSIs as best as possible, 4) the major prophylaxis strategies would theoretically yield the greater benefit in terms of prevention: enlarging the spectrum or prolonging the standard prophylaxis? In contrast, we do not address infection treatment in vitro experiments, open (pathologic) fracture surgery in the cancer site All authors performed a scientific search for literature on PubMed and Google (Scholar) for publications regarding SSIs among adult oncologic orthopedic patients using the MeSH terms “cancer”, “oncology”, “orthopedic”, “surgery”, “sarcoma”, “bone”, “soft tissue” together with “infection” and “prophylaxis” in English, Turkish, Finnish, French and German languages until 30 June 2019. We also specifically scoured available (orthopedic) SSI prevention guidelines. Even if we first detected the abstracts, we always read the full article. According to international use, we defined SSI as a bacterial infection at the former uninfected surgical operation site occurring up to 30 days after the non-implant-related index surgery, or within one year if an implant became infected. In a next step we hand-searched references of retrieved papers for further articles and excluded pediatric reports, cases with community-acquired infections, repeat publications, animal studies, Community-acquired infections were the opposite of nosocomial  infections, whereas hematogenous infections were due to secondary seeding to the surgical site via a bacteremic spread originating from a remote infection site. We also excluded reports of cosmetic and/or benign lipoma surgeries, because we estimated them distinct from classical (sarcoma) surgery in terms of clinical entities and surgical techniques. Our search strategy was similar to the PARITY review For the sake of practicability, we renounced on differentiating between elective and traumatic oncologic surgery upon pathological fractures, between superficial and deep SSIs discussed later on) in 2012 in descending order) reveal the most publications, with methicillin-resistant S. aureus (MRSA) being a frequent causative oncologic SSI pathogen in Japan compared to other countries. The majority of the publications stem from the last two decades.By 30 June 2019, we retrieved 108 articles, which are sixty more since the extensive and English-language literature review of the PARITY author group  rods Various first-or second generation cephalosporins were the most frequently used prophylactic agents, but their prophylactic durations varied between 1 and 5 days .Interestingly, the orthopaedic oncologic literature does not provide much insight into antibiotic-loaded bone cements during arthroplasty surgery of mega-prostheses We found no comparative studies questioning on the enlargement of the prophylactic antibiotic spectrum. Such a broadening could empirically target methicillin-resistant Gram-positive pathogens, obligate anaerobes or non-fermenting Gram-negative rods; solely or all together. A retrospective case-control reported a 7% SSI risk in spinal metastases surgery by a cefepime prophylaxis of an unknown duration p=0.45) and the study was underpowered. Regarding late infections, the difference was non-existing even in crude group comparison p=0.06). However, the authors noticed significantly higher revision surgeries due to mechanical failures in the titan prostheses group This group mainly consists of silver-coated mega-prostheses in lower extremity cancer surgery, in addition to usual perioperative systemic antibiotic prophylaxis. The difficulty is to determine if silver-coating would be superior to standard systemic antibiotic prophylaxes, in as much as the coating is frequently not applied at the articulating surfaces SwissNoso recommendations, issued by a panel of experts in infection control, do not provide recommendations for cancer surgery in general, let alone specifically for oncologic orthopaedic surgery There are many local There are many retrospective comparative studies assessing the postsurgical SSI risk in oncologic orthopaedic patients, but most fail to introduce antibiotic prophylaxis into their univariate or multivariate models Prophylactic Antibiotic Regimens in Tumour Surgery; ClinicalTrials.gov NCT01479283), comparing two prophylactic cefazolin durations (1 vs. 5 days). This is a blinded, randomized controlled trial, using a parallel two-arm design. It stems from Canada, is multicentric with 37 sites in seven countries, and has one year of active follow-up for each participating patient ClinicalTrials.gov, it still continues with already 600 episodes included, and is scheduled until December 2020. Unless there is protocol modification, patients 15 years of age or older who are undergoing surgical excision and endoprosthetic reconstruction of a primary bone tumor will receive either short (24 h) or long (5 days) duration postoperative antibiotics. Exclusion criteria include prior surgery or infection within the planned operative field, known colonization with methicillin-resistant S. aureus or vancomycin-resistant enterococci at enrolment. The primary outcome will be the risk for deep SSIs in each arm. Secondary outcomes will include type and frequency of antibiotic-related adverse events, patient functional outcomes and quality-of-life scores, reoperation and mortality We only found the announcement of one prospective-randomized trial regarding perioperative antibiotic prophylaxis in adult lower-extremity endoprosthetic tumour surgery. It is named the PARITY trial . Their review could not analyze the impact of the perioperative antibiotic prophylaxis, probably also because of the fact that studies issuing from the same hospital are likely to use the same prophylaxis for all patients. We added twenty more publications in 2019 , that the clinical detection of lower-extremity cancers is more delayed compared to the thinner arms, that the curative surgery in the spine and pelvis is more cumbersome, longer and deeper when compared to the arm, or that the pelvis and calves are in proximity of the genital and intestinal regions, making local Gram-negative skin colonization more likely.As patients with upper extremity cancers remain mobile and are often managed as outpatients before surgery , it could also be that the latter group yields a significantly longer pre-surgical stay with increasing theoretical risk of  multi-resistant skin colonization. These remain speculations. Many research groups investigated the influence of a delay between admission and surgery with the occurrence of subsequent SSI and its pathogen profile. These studies mostly concerned open fractures Pseudomonas aeruginosa and anaerobes), or multi-resistant skin commensals compared to non-oncologic SSIs S. aureus, streptococci  in every article; independently of the setting, the underlying cancer, preexisting antibiotic therapy, prior local radiotherapy or the anatomical localization . We thus question the utility of standard antibiotic prophylaxis, which might not be enough. What are alternative regimens? Basing on theoretical considerations, we think there are five options : a) prolonging the standard prophylaxis beyond the single-shot; b) enlarging the antibiotic spectrum; or c) a combination of a) and b), or avoiding to administer new prophylactic agents in addition to the current therapeutic antimicrobial treatment. This would be a similar situation as in high-grade open fractures, another field of orthopedic and trauma surgery that has been neglected by scientific research for a long time. In high-grade open fractures, neither the prolongation of antibiotic prophylaxis beyond three days Concerning general orthopedic surgery, and especially prosthetic surgery, the literature is full of opinion papers and retrospective studies investigating the possibility of better outcomes with broader prophylaxis What is the recommended prophylaxis, in patients undergoing major orthopedic reconstructions for either tumor or non-neoplastic conditions using mega-prosthesis?” The expert audience acknowledged the lack of scientific data and 93% of them voted that “Until the emergence of further evidence, we recommend the use of routine antibiotic prophylaxis for patients undergoing major reconstruction.” It is unclear how much the orthopedic surgical world is aware of the microbiologic discrepancy between oncologic SSIs, standard prophylaxis and possible solutions. During the first 2013 Philadelphia Consensus Meeting on Periprosthetic Joint Infections, several hundred delegates  debated about unresolved issues in the field of osteo-articular infections. One question was: “S. epidermidis implant infections At last, but comprising an entirely hypothetical option is the concept of an individualized antibiotic prophylaxis. Such a prophylaxis would target known skin colonizers and/or the individual microbiome. Already in non-oncologic orthopedic surgery a minority of pathogens regularly may escape to standard antibiotic prophylaxis. This usual resistance ranges from roughly six In this narrative review, we discuss various perioperative antibiotic concepts in oncologic orthopedic surgery. Most SSI literature in adult elective orthopedic cancer surgery is written by surgeons who operate on these complex patients. Accordingly, the focus of their publications can be different from the major interests of infectious diseases physicians who read them. Many questions of high importance remain open in terms of perioperative prophylaxis, even if the PARITY trial will soon come to its end.The overall SSI risk among orthopedic oncologic surgeries is high; ranging from 10-15% while most literature (and consequently also the authors of this review did not differentiate between deep and pure superficial SSIs


The Heart of Borneo initiative has promoted the integration of protected areas and sustainably-managed forests across Malaysia, Indonesia, and Brunei. Recently, however, member states of the Heart of Borneo have begun pursuing ambitious unilateral infrastructure-development schemes to accelerate economic growth, jeopardizing the underlying goal of trans-boundary integrated conservation. Focusing on Sabah, Malaysia, we highlight conflicts between its Pan-Borneo Highway scheme and the regional integration of protected areas, unprotected intact forests, and conservation-priority forests. Road developments in southern Sabah in particular would drastically reduce protected-area integration across the northern Heart of Borneo region. Such developments would separate two major clusters of protected areas that account for one-quarter of all protected areas within the Heart of Borneo complex. Sabah has proposed forest corridors and highway underpasses as means of retaining ecological connectivity in this context. Connectivity modelling identified numerous overlooked areas for connectivity rehabilitation among intact forest patches following planned road development. While such ‘linear-conservation planning’ might theoretically retain up to 85% of intact-forest connectivity and integrate half of the conservation-priority forests across Sabah, in reality it is very unlikely to achieve meaningful ecological integration. Moreover, such measure would be exceedingly costly if properly implemented–apparently beyond the operating budget of relevant Malaysian authorities. Unless critical road segments are cancelled, planned infrastructure will fragment important conservation landscapes with little recourse for mitigation. This likelihood reinforces earlier calls for the legal recognition of the Heart of Borneo region for conservation planning as well as for enhanced tri-lateral coordination of both conservation and development. Road infrastructure expansion across the Global South is increasingly recognized as a key factor in regional conservation and development planning –3, on paet al. [et al. [Globally, the proliferation of infrastructure mega-projects in the Global South coincides with an increasing prioritization of regional-scale integrated conservation. Internationally, parties to the Convention on Biological Diversity (CBD) have committed to 17% national coverage of “ecologically representative and well-connected systems of protected areas” by 2020 , an incret al.  identify [et al.  indicate [et al.  is fulfi [et al. . Indeed, [et al. , 17–19.  [et al. .The Heart of Borneo initiative (HoB) is indicative of the potential of regionally-integrated conservation schemes to enhance national protected-area coverage. Established in 2007, the HoB formalized cooperation between Malaysian Borneo (Sabah and Sarawak states), Indonesian Borneo , and Brunei to integrate and enhance a 22-million hectare (Mha) trans-boundary network of protected areas (PAs), production forests, and other sustainable forest uses for mutual conservation benefit . The HoBRegional, trans-boundary conservation initiatives such as the HoB are however arguably especially vulnerable to large-scale infrastructure development schemes. On the one hand, the HoB initiative is inherently contingent on international collaboration and territorial integration, as where the full benefit of PAs in a given administrative area depends on the sound management of forests in an adjacent area. Trilateral cooperation in both conservation and development is therefore key. On the other hand, large-scale infrastructure schemes are inherently unilateral, both with respect to the sovereignty of their design and implementation but also their political-administrative insulation from state-level forest management. Thus, in Sabah, Sarawak, and Kalimantan, large-scale development schemes driven by federal economic agenda struggle to reconcile with the HoB. The Sabah Development Corridor, driven by successive Malaysian Plans for industrial development, seeks to quadruple Sabah’s GDP over 2008–2025, partly by expanding a Pan-Borneo highway network throughout the HoB . SimilarHere we describe anticipated changes to the integrity of the HoB that would follow the planned Pan-Borneo network development in Sabah. We highlight the potential impacts of the Pan-Borneo highway on the connectivity of protected areas and intact forests within the northern HoB as well as assess mitigation opportunities. Findings call for improved trilateral conservation planning and highlight a reliance on ‘linear-conservation’ approaches to mitigate planned developments. Recommendations for improved conservation-and-development planning are discussed in the context of infrastructure mega-projects.For intact forest patches in the HoB , we obse4). Such a PA alone could not connect such sets of PAs to each other in the absence of intermediary intact forest, however.PAs wholly within or partially within an intact forest patch were considered inter-connected across that patch . The num1 disconnected from PA3 PA4). Planned new and upgrade roadways were buffered by 1 km and areas of current intact forest patches coincident with the buffer were removed from the extent of intact forest. Thus, an intact forest patch bisected by a buffered roadway would become two intact forest patches. The number and extent of inter-connected PAs amongst these subdivided, post-development intact forest patches were calculated in the same way as for the current intact forest patches. The 1 km buffer distance accounts for local ecological effects and human activities along roadways [To model changes to PA connectivity following road development, planned new and upgrade roadways bisecting an intact forest patch constituted interruptions to the connectivity amongst PAs within that patch on either site of the bisecting roadway (roadways –35.2 counts towards Patch 1a and new Patch 1b). To account for the bisection of PAs, we estimated changes to total inter-connected PA extent per intact forest patch before and after road development. These areal estimates consider only portions of PAs within an intact forest patch and treat PAs as divisible by roadways .PAs were treated as indivisible when determining counts of inter-connected PAs per intact forest patch in order to ensure unambiguous counts before and after road development. Therefore, where a road through a PA would bisect its intact forest patch, the PA would remain integral and count towards the set of PAs in each resultant forest patch  marginally exceeded the localized road effects [ii) constituted a lower ‘stable’ threshold above which IIC values and the number of patch-linkage networks changed relatively gradually (iii) was considered generally applicable to most vertebrates in the absence of local species-specific data. Differences in the distributions of key linkages between these two scenarios highlight the degree to which planned roadways would disconnect major intact forest areas that are adjacent to planned roads and/or bisected by such roads. For each scenario, the importance of each individual linkage for overall regional connectivity was estimated by iteratively removing the linkage and re-calculating the IIC via the Graphab Delta-Metric tool [We explored differences in the regional distributions of key inter-patch linkages amongst two scenarios of road development varying according to the permeability of planned roadways to faunal movements. Both scenarios adopt a 2-km dispersal distance threshold to define linkages between intact forest patches. Only one scenario allows inter-patch linkages to span planned roadways where patches are < 2 km of each other. Linkages across planned roadways are precluded in the other scenario. The 2-km dispersal distance threshold was adopted because it  coradually , and  >30% historic areas of all forest eco-types (in keeping with the Sabah’s commitment to maintain 30% of its extent under protected forest [ii) >60% of historic ranges for select endangered mammals  as well as select endemic tree species, rising to 100% for select critically endangered endemic tree species [i) the human-footprint index [ii) species richness, describing the number of species present; and (iii) forest-carbon stock [et al. [et al. [et al. [The distribution of these key linkages were considered relative to priority conservation forests observed by the Sabah Structure Plan 2033 , 46–48. d forest , 48), rint index , describon stock , represeon stock  were excon stock , as desc [et al. , and weri) relatively short linkages (< 2km) amongst adjacent intact forest patches, as to facilitate hypothetical corridor/underpass development; (ii) extensive areas of contiguous forest relatively unsettled and free of agricultural development between the intact forest patches, as confirmed by visual inspections of high-resolution imagery in Google Earth; and (iii) regional synergy, such that a set of individual sites may link a series of important patches to each other across Sabah. In total, 12 indicative sites were identified , larger PA extent, and/or large intact forest extent , in ordeentified .Most PA connectivity in the HoB is concentrated in a single intact forest patch spanning southern and eastern Sabah, northern and central Kalimantan, eastern Sarawak, and Brunei . This trPlanned road developments in southern Sabah would significantly fragment this trans-boundary patch and interrupt PA connectivity across the northern HoB . Within Planned road development would confine the current trans-boundary patch to far southern Sabah Figs  and 4. TThe two post-development scenarios varying by planned roadway permeability exhibit major differences in their distributions of key inter-patch linkages across the northern HoB. In the scenario in which linkages may span roadways to a limited degree (<2 km), the key linkages largely circumscribe the extent of conservation-priority forest . NotablyIn contrast, for the scenario in which linkages cannot span planned roadways, key linkages adopt an inferior configuration in which conservation-priority forest remains disjointed. These linkages center on only two or three main post-development patches, notably including descendants of the current trans-boundary patch . Furthershould span planned roadways or where, but rather they illustrate how planned roadways are largely situated within major forest regions key to regional connectivity. Accordingly, key linkages invariably span planned roadways to maximize connectivity where allowed–something that is unlikely in practice. Therefore, to the extent that planned roadways are impermeable, reginal connectivity will drastically decline as linkages merely consolidate main patches and their nearby smaller satellites.Each scenario is a hypothetical extreme: planned roadways are neither completely permeable nor completely impermeable to faunal movements. Contrasts between the scenarios do not advocate that linkages Following planned developments, any connectivity between the ‘confined’ trans-boundary patch in southern Sabah and the major patch to its immediate north-east  would beecological re-integration possible via underpasses and corridors would be far more moderate than the structural metrics reported here, as discussed below. The indicative sites are therefore best understood as mitigative options of last resort that complement planned and proposed connectivity zones.Theoretically, corridors and underpasses at the indicative sites would retain ~85% of intact-forest connectivity after road development, as estimated by the proportion of the sum of all ΔIIC values for all linkages accounted for by the sites. Approximately half of this retained connectivity would be attributable to sites 1–3 and 5 alone, flagging these as priority areas , with onThe Pan-Borneo Highway and related roadways in Sabah would unilaterally cut off the head of the HoB by isolating hundreds of thousands of hectares of Sabahan PAs and other intact forest. The greatest challenge to regional HoB integrity is the planned Sapulut-Kalabakan upgrade-highway through the trans-boundary forest patch of southern Sabah .Roadways for the Pan-Borneo Highway were largely planned independently of the planned and proposed connectivity zones in Sabah. Calls for a trilateral HoB Master Plan resonate in this light . A HoB MCompromised ecological planning across the HoB region partly reflects the fact that the HoB is a voluntary agreement lacking force of law. In Malaysia, infrastructure development schemes are designed federally  but elaborated by quasi-independent state plans , within which the ‘HoB vision’ must be approximated under existing environmental laws and policies. The ultimate elaboration of state plans at the local level further challenges the regional HoB vision, as in instances where laws are conflicted or poorly observed. Similar situations characterize Indonesia and Brunei . A trilaPlanned road development in Sabah relies on highway underpasses and forest corridors to retain connectivity across the HoB. Our analysis suggests that Sabah’s current plans overlook various sites where such ‘linear conservation’ would be beneficial. Regardless, the linear-conservation approach is dubious and risky, given limited evidence that species of high conservation value would benefit enough from this approach to offset the direct and indirect impacts of forest-road development , 57. SucPeninsular Malaysia has previously employed forest corridors alongside roadway underpasses as local conservation measures, and Sabah is apparently increasingly adopting this approach. Peninsular Malaysia utilized 25 highway underpasses in conjunction with 17 forest corridors to integrate fragmented conservation landscapes via the Central Forest Spine initiative , 58, 59.Underpasses and corridors are unlikely to be effective mitigating conservation options in Sabah in light of the nature and scale of planned infrastructure development there. In the Central Forest Spine initiative in Peninsular Malaysia , 59, nonFurthermore, constructing extensive networks of underpasses and related corridors explicitly for wildlife movement is likely prohibitively expensive, given the scale of planned developments. The costs of planning and constructing under- or over-passes in Singapore and Peninsular Malaysia have been estimated at $1.2-$32 million USD per 100 meters , 64. HypOther, complementary forms of mitigative conservation planning include enhanced conservation designations for roadside forests . LimitedRecently, Sabah’s Chief Minister affirmed that planned roadway developments should occur along existing routes only, and not extend to intact forest areas, reflecting productive engagement between State agencies and an alliance of local conservationists . While cThe emphasis on infrastructure and conservation planning in the tropics has arguably shifted over recent decades from the preservation of intact forests to the integrated management of degraded landscapes. This shift reflects both the progressive ecological degradation within the tropics but also the increasing scale and complexity of infrastructure mega-projects and the contexts that host them. The Pan-Borneo Highway within the Heart of Borneo is a case in point.Historically, the academic community highlighted the implications of major forest-penetration roads for intact-forest fragmentation –72 leadiOur assessment of the Pan-Borneo Highway resonates with recent BRI assessments , 74, 75 The amplification of planning deficiencies to national or multi-national scales by the BRI and similar initiatives has culminated most recently in unprecedented calls to unite conservation and development priorities into a single rubric , 11, 75.Sabah is planning a Pan-Borneo Highway network to increase economic activity, as are variously other member states of the HoB initiatives. While Sabah has substantially increased its PA extent, the currently planned network would seriously undermine PA and intact-forest connectivity within Sabah and across the northern HoB region, reducing the conservation benefit of individual, isolated PAs and managed forest landscapes. Trilateral spatial planning across the HoB is recommended to forestall and hedge against such outcomes, but it will require coordination amongst HoB member states at a level not yet attained. Meanwhile, Sabah’s commitment to underpasses and forest corridors for conservation mitigation is arguably a futile gesture. It is apparently too geographically selective, too unlikely to facilitate meaningful ecological re-integration, and ultimately too economically costly as a practical solution. We urge that the Sapulut-Kalabakan route within the Pan-Borneo Highway network be reconsidered in particular.S1 FigNotes: ‘Forest Status and Designation’ is according to the Sabah Forestry Department. ‘Protected Areas’ are as defined in the main text, namely as the combined extents of the World Database on Protected Areas and the ‘protected’ forest-use designations observed by the Sabah Forestry Department.(TIF)Click here for additional data file.S2 FigThe integral index of connectivity (top) and corresponding number of networks of intact forest patches and linkages (bottom), for increasing greater inter-patch faunal dispersal distance thresholds across Sabah, northern Kalimantan, and eastern Sarawak. ‘Roaded’ and ‘unroaded’ curves respectively describe scenarios in which planned roadways are and are not developed. Notes: The study area is delineated in (TIFF)Click here for additional data file.S3 FigNotes: Numbered arrows are indicative sites for corridor and road-underpass development that would enhance post-development forest/PA connectivity across Sabah and the northern HoB . The cir(TIF)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.


Uterine rupture is an uncommon obstetric emergency that is potentially fatal to the mother and fetus. Spontaneous rupture of the unscarred gravid uterus in postmenopausal women who achieve pregnancy through in vitro fertilization (IVF) has been infrequently described in the literature. We present the case of a 72-year-old postmenopausal woman, gravida 1 para 0, who conceived by donor oocyte IVF in Europe and subsequently suffered uterine rupture at 22 weeks gestation with large hemoperitoneum. The patient underwent emergent laparotomy, with successful repair of the uterine wall defects. Postmenopausal women face an increased risk of spontaneous uterine rupture and life-threatening bleeding, which is likely due to uterine atrophy and limited uterine capacity. Further research is needed to establish age-appropriate guidelines for selecting treatment candidates. Spontaneous uterine rupture is an uncommon but often fatal obstetric complication related to pregnancy. There is a paucity of literature discussing uterine rupture of the unscarred uterus following in vitro fertilization (IVF), particularly for post-menopausal patients in advanced age. Recent population studies have demonstrated a growing demand of older women seeking infertility treatments such as IVF . In a poA 72-year-old post-menopausal woman, gravida 1 para 0 at 22 weeks gestation, presented to our institution with complaints of nausea, vomiting, and abdominal pain. The patient’s obstetric and gynecologic history included oocyte donation and in vitro fertilization (IVF) using donor sperm in Europe. After treatment, she returned to the United States where she resided and remained asymptomatic until her presentation. The rest of her past medical history was only remarkable for a prior laparoscopic appendectomy for appendicitis.Shortly after her arrival, the patient’s blood pressure decompensated to a low of 85/50 mm Hg in the emergency department. A contrast-enhanced computed tomography (CT) was performed which showed fundal discontinuity and active extravasation of contrast into the peritoneum Figures , 2. AddiUterine rupture has a high rate of maternal mortality, reported up to 13.5% in one single center series. The mortality for the fetus is even higher, reported up to 89.1% as a result of intrauterine death. When compared to a previously scarred uterus, rupture of the unscarred uterus carries higher risks for both the mother as well as the fetus . FortunaHowever, data from a recent population-based study demonstrated a trend of increasing demand for assisted reproductive technology (ART) by older women . In the Spontaneous uterine rupture during the first and second trimester has been reported after IVF and can lead to life-threatening maternal hemorrhage . ReportsIn this report, we presented such case of a 72-year-old postmenopausal woman who was treated outside of the United States with oocyte donation and IVF and suffered a rupture of the previously unscarred uterus at 22 weeks gestation. Commonly reported symptoms alarming an impending uterine rupture in women not undergoing active labor include hypotension, tachycardia, vaginal bleeding, severe abdominal pain and tenderness, hematuria, and postpartum hemorrhage . Our patDespite a growing demand for infertility services, women older than the age of 40 have limited access to ART primarily due to the lack of insurance coverage - a product of age-dependent rationing of medical care . Older pPostmenopausal women face an increased risk of spontaneous uterine rupture and life-threatening bleeding, which is likely due to uterine atrophy and limited uterine capacity. Further research is needed to establish age-appropriate guidelines for selecting treatment candidates.


PDGF) genes are known to have regulatory functions that are essential for proper heart development. In a zebrafish model, Pdgfra was further demonstrated to interact with ethanol during craniofacial development. In this article, we investigated interactions between variants in PDGF genes and periconceptional alcohol exposure on the risk of OHDs by applying log-linear models to 806 OHD case and 995 control families enrolled in the National Birth Defects Prevention Study. The interactions between four variants in PDGFA and maternal binge drinking reached a nominal significance level. The maternal T allele of rs869978 was estimated to increase OHD risk among women who binge drink, while infant genotypes of rs2291591, rs2228230, rs1547904, and rs869978 may reduce the risk. Although none of these associations remain statistically significant after multiple testing adjustment and the estimated maternal effect may be influenced by unknown confounding factors, such as maternal smoking, these findings are consistent with previous animal studies supporting potential interactions between the PDGFRA gene and maternal alcohol exposure. Replication studies with larger sample sizes are needed to further elucidate this potential interplay and its influence on OHD risks.Obstructive heart defects (OHDs) are a major health concern worldwide. The platelet-derived growth factor ( Among all congenital heart defects, right- and left-sided obstructive heart defects (OHDs) are a major health concern since they are the most lethal subtypes of congenital heart defects in infancy2. Although studies have investigated the interaction between maternal exposures and genetic variants on risk of congenital heart defects8, the impact of various gene-environment interactions during cardiogenesis remains largely unknown.More than 85% of congenital heart defects are thought to result from a complex interplay between maternal exposures, genetic susceptibilities, and epigenetic phenomena10. Webster et al. 1984 demonstrated that a relative short exposure to high doses of alcohol during pregnancy in mice can cause congenital heart defects9. Carmichael et al.10 reported that the risks of conotruncal heart defects associated with consuming five or more drinks per drinking occasion were 1.6 for less than once a week, and 2.4 for once a week or more10. However, recent lines of research suggested no association between alcohol exposure and congenital heart defects14. Analysis of the data from 7,076 mothers whose children were affected by congenital heart defects and 7,972 control mothers enrolled in the National Birth Defects Prevention Study (NBDPS) did not show statistically significant increased risks between maternal alcohol consumption and congenital heart defects12. Three recent meta-analyses also suggested that periconceptional alcohol exposure was not associated with congenital heart defects14. From these mixed findings, it is suspected that periconceptional alcohol exposure may indirectly impact the occurrence of congenital heart defects via gene-ethanol interactions.Alcohol exposure has been linked to the risk of congenital heart defects in both mice and human studies16. Similarly, ethanol exposure during gastrulation results in cardiac defects in mouse17. In both of these models, the cardiac defects were rescued by folate administration, suggesting that the genesis of congenital heart defects following ethanol exposure in humans is a complex and multifactorial event. There is growing evidence that gene-ethanol interactions modulate the teratogenic effects of ethanol18, further adding complexity to ethanol-induced congenital heart defects. Animal models have given insight into some of these gene-ethanol interactions, often these ethanol-sensitive loci are genes governing the development of the organ system18.Studies in animal models support the involvement of ethanol exposure in the genesis of congenital heart defects and demonstrate that this genesis is likely to be complex. In zebrafish, ethanol exposure at different stages results in differing heart defectsPDGFRA). Both mouse and zebrafish Pdgfra mutants can cause heart defects21. In zebrafish, ethanol has been shown to interact with Pdgfra, causing apoptosis of the neural crest cell precursors of the face in mutants and heterozygotes21. This study also demonstrated that the interaction was conserved in humans and noted an increase in gross cardiac defects in ethanol-treated zebrafish mutants . Collectively, these studies suggest that variants in the PDGF pathway could modulate the genesis of congenital heart defects in humans.Proper development of both the face and the heart requires the function of the receptor tyrosine kinase in platelet-derived growth factor receptor alpha  and periconceptional alcohol exposure on the risk for OHDs. Maternal and infant genotypes were both investigated, since both are shown to alter the intrauterine environment and simultaneously contribute to OHD development23.Using data from 806 OHD case and 996 control families enrolled in the NBDPS with birth dates between 1997 and 2011, we sought to evaluate interactions between 102 variants in the The final analytic sample includes 3422 individuals from 806 case-parental triads and 996 control-mother dyads. The demographic and lifestyle characteristics of case and control mothers are summarized in Table Among 806 case mothers, 126 (16%) were identified as binge drinkers (see definition in Data Collection); whereas among 996 control mothers, 148 (15%) were identified as binge drinkers. Binge drinking alone was not found to be significantly associated with OHD risk. The odds of giving birth to an infant with OHD among binge drinkers was estimated to be 1.07 times that among non-binge drinkers . Thus, when genotype is not considered there appears to be no relationship between drinking pattern and OHD risk.PDGFRA gene, 58 variants in the PDGFRB gene, and one variant in the PDGFB gene. The maternal genotype of a variant in the PDGFRA gene (rs869978) was identified to associate with the risk of OHDs via an interaction with maternal binge drinking at a nominal significance level (p = 0.0373). Binge drinkers carrying CT genotype for rs869978 had an increased risk of having infants with OHDs compared to those carrying CC genotype (genetic relative risk (GRR): 1.49; 95% CI: 1.05 to 2.12). In contrast, no significant genetic effect was found among non-binge drinkers . Under the assumption of multiplicative risk of alleles , the GRRs for comparing maternal TT genotype to maternal CC genotype of variant rs869978 were estimated to be 2.22  among binge drinkers and 0.98  among non-binge drinkers, respectively. Collectively, these findings suggest a maternal genotype-case phenotype interaction with the maternal T allele of variant rs869978 increasing the risk of OHDs occurring in offspring whose mothers were exposed to binge drinking. After adjustment for multiple testing, the above association was not statistically significant.To investigate the interaction between genetic variant and binge drinking, a log-linear model was fitted for each variant. The final analysis included 43 variants in the Non-binge drinkers included both mothers who had less than four drinks on one occasion and those who did not have any alcohol consumption during the exposure window. To avoid biased results due to a mixed group of non-binge drinkers, we excluded those mothers who had less than four drinks on one occasion, and conducted analyses to compare binge drinkers to non-drinkers. Mothers who were binge drinkers were approximately 1.09 times more likely to give birth to an infant with OHD than those who are non-drinkers . Table Similar to the comparison between binge drinkers and non-binge drinkers, a nominally significant genetic effect was identified for maternal variant rs869978 for binge drinkers versus non-drinkers (p = 0.0242). Here again, the maternal T allele associates with an increased occurrence of OHDs in infants exposed to prenatal ethanol.PDGFRA gene were found to associate with the risk of OHDs through an interaction with maternal binge drinking at a nominal significance level . In each instance, the alternative allele associates with reduced occurrence of OHDs in infants with prenatal alcohol exposures, but not for those without exposure. For example, among binge drinkers, infants carrying the CT genotype for rs2291591 had a decreased risk of OHDs compared to those carrying the CC genotype . In contrast, no significant difference was found among non-drinkers . Similar effects were detected for the other three variants in the same gene. Variants rs2291591, rs2228230, and rs1547904 were determined to be in high linkage disequilibrium , suggesting that these three variants are measuring the same genetic effect. After adjustment for multiple testing, none of the associations reported above were statistically significant.The infant genotypes also interacted with ethanol in this set of analyses. The infant genotypes of four variants  in the PDGF family, multiple variants in the PDGFRA gene were identified to potentially influence risk of OHDs by interacting with maternal binge drinking. None of the variants were found to significantly impact the risk of OHDs among non-binge drinkers or non-drinkers. Our findings indicate that there may be both maternal and infant genotypes that correlate with OHDs. Given that previous research has reached mixed conclusions14, our work suggests that part of these inconclusive results could be due to gene-ethanol interactions masking the overall effect of ethanol. Because the primary goal of our study is gene discovery, and the sample size was relatively small for detecting a small to moderate interaction effect, we have used a nominal threshold for statistical significance. If a Bonferroni correction was used to adjust for multiple testing, none of the SNPs would reach statistical significance. Furthermore, no adjustment was made for confounding effects from other covariates when fitting the model. Although the estimated infant genetic effects were robust in the presence of population stratification or other confounders such as maternal age and smoking, the estimated maternal genetic effects may be susceptible to other confounding effects. Nevertheless, NBDPS is the largest population-based multi-site study of birth defects ever conducted in the United States (US), and we have utilized all samples available to date. The current study is among the first ones to explore the joint effects of both genetic variants and maternal binge drinking on the risk of OHDs. Our findings need to be replicated in follow-up studies when additional independent samples become available.Among 102 variants in the PDGFRA that nominally associated with reduced occurrence of OHDs following alcohol exposure during the periconceptional period. The four identified variants consist of two intron variants, one synonymous variant, and one variant with a combination of intron and missense  and their receptors (PDGFRs) are involved in many cellular processes such as migration, survival and proliferation, and they are critical during developmental processes27. Cardiac development requires Pdgfra in both mouse and zebrafish29. In mouse Pdgfra mutants, cardiac neural crest cells have migratory defects20; and Pdgfrb double mutants have more extensive cardiac neural crest cell migration deficits19. In zebrafish the migration of mesoderm-derived cardiac progenitors requires Pdgfra function . Cardiac neural crest cells do populate the heart in zebrafish16, although it’s unclear if these cells require Pdgfra function. How ethanol may interact with PDGFRA in humans remains an intriguing question that may be elucidated by further analyses in zebrafish.However, the function of The study was approved by the University of Arkansas for Medical Sciences’ Institutional Review Board. The NBDPS was approved by the Institutional Review Boards at the Centers for Disease Control and Prevention and all NBDPS institutions. All study subjects gave informed consent. For minors in legal custody of their parents, informed written consent was obtained from their legal guardian for DNA collection. All methods were performed in accordance with the relevant guidelines and regulations.31. The families included in the current study were identified through population-based birth defects surveillance systems in the states of Arkansas, California, Georgia, Iowa and Texas. A total of 4,101 individuals from 873 case-parental triads and 1,084 control-mother dyads were included. Cases were singleton live-born infants with OHDs. Both right-sided and left-sided OHDs included hypoplastic left heart syndrome, tricuspid atresia, pulmonary valve atresia, coarctation of the aorta, interrupted aortic arch types A and C, aortic stenosis, pulmonary valve stenosis, and Ebstein’s anomaly32. Cases where the pregnancy was affected by a known single gene disorder, chromosomal abnormality, or syndrome were excluded. A classification system developed for NBDPS, which incorporated three dimensions of cardiac phenotype, cardiac complexity, and extracardiac anomalies, was used to classify cases32. Controls were singleton live-born infants without any major structural birth defects. The mothers of all participating families completed interviews.Families were recruited for the NBDPS, a population-based case-control study designed to identify infants with major structural birth defects and evaluate genetic and environmental factors associated with the occurrence of birth defects31. All study materials were available in English and Spanish31. For the current study, we focused on interview information regarding periconceptional alcohol exposure. Based on NIAAA criteria, binge drinkers are defined as mothers who had four or more drinks on one occasion during the exposure window (i.e. from one month prior to conception to three months after conception). We included one month prior to conception in the exposure window to include many mothers who may not know the exact date of conception and may unknowingly continue drinking during the critical period of embryogenesis as up to half of US pregnancies are unplanned34. Non-binge drinkers are mothers who had less than four drinks on one occasion or did not have any alcohol consumption during the exposure window. Non-drinkers are mothers who did not have any alcohol consumption during the exposure window. Once a mother completed the interview, a buccal-cell sample-collection kit with instructions was mailed to the family for collection of DNA from the child, mother and father31.Information regarding multiple maternal exposures and lifestyle factors hypothesized to impact developing embryos was obtained from a 1-hour telephone interview with each case and control mother. The interviews were conducted by female interviewers using a computer assisted telephone questionnairePDGF family of genes  were selected for analysis. DNA was extracted from buccal cell samples using Puregene DNA purification reagents , Genotyping was performed using the HumanOmni5Exome BeadChip . Genotype calls were generated using GenCall, Illumina’s proprietary genotyping algorithm. A total of 4,101 individual samples were genotyped, and 679 samples were removed from analysis due to study ineligibility (n = 16), low genotype call rates (n = 663), resulting in an analytic sample consisting of 3,422 individuals from 806 case-parental triads and 995 control-mother dyads. We excluded 43 non-polymorphic variants, 17 variants with no-call rates > 5%, and 113 variants with minor allele frequencies < 1%. After the quality assessment, the analytical data had 102 variants in total.From the genotyping results of the Illumina HumanOmni5Exome BeadChip, 275 variants from the 36. Based on the hybrid design, the following log-linear (Poisson) model was fitted for each variant37.μj, j = 1. …, 6 are stratum parameters indicating six possible mating types under the assumption of mating symmetry; μj + δj are corresponding stratum parameters for ethanol-exposed families; IE=1) carried by the mother; and IC is the corresponding indicator for infant genetic effects. Indicators IM and IC are defined in this way to assume multiplicative (i.e. log-additive) risk per allele. Under this assumption, the relative risk of carrying two copies of the allele is the square of the relative risk of carrying one copy of the same allele, with zero copies as the reference. This model specification provides population-based inferences related to both maternal and infant genotypes, and additional family-based evidence related to infant genotypes that is robust to population admixture, and allows estimation of gene-ethanol interactions and inclusion of incomplete families using the Expectation-Maximization (EM) algorithm for handling missing genotypes. Comparisons were made between families of mothers who were binge drinkers vs. non-binge drinkers, and between families of mothers who were binge drinkers vs. non-drinkers. Statistical significance was assessed as p-value ≤ 0.05. We used R statistical software v3.2.3  for computing summary statistics, and LEM38 statistical software to fit log-linear models with incomplete family genotype data. Patterns of linkage disequilibrium (LD) between important variants from the same gene were constructed using HaploView 4.239.Summary statistics were expressed as means (standard deviation) for continuous variables, and counts (percentage) for categorical variables. The means of continuous variables were compared using the two-sample t-test, while the proportions of categorical variables were compared using the chi-squared test. Because both case-parental triads and control-mother dyads were enrolled and genotyped in our study, a hybrid design where case-parental triads were augmented by control-parental dyads, provided optimal power for studying both the maternal and infant genetic effects36. It is worthwhile to note that the infant genetic effects are estimated using the case-parents triads. By conditioning on parental genotypes, the transmissions of alleles to affected offspring can be tested against the null hypothesis of random transmission (i.e. Mendel’s law). Such a family-based association test strategy is robust to population stratification and other confounding factors, such as maternal age and smoking. However, the maternal genetic effects uses a population-based association test strategy by contrasting between case mothers and control mothers, and thus, are susceptible to unknown confounding factors. Meanwhile, the log-linear model partition family units into strata of gene-by-environment combinations, and does not allow estimation of “main effect” for additional covariates.As discussed comprehensively elsewhere, the log-linear model being used here has a few unique strengths and limitations


Thyroid-associated orbitopathy is characterised on cross-sectional imaging by symmetric extraocular muscle enlargement sparing the musculotendinous junction. We report a case of this imaging finding in a biochemically euthyroid patient with metastatic squamous cell carcinoma of the lung undiagnosed at time of presentation. A 63-year-old male presented to the emergency department with an acute episode of blurry vision and two months of headache and intermittent nausea. The patient denied any pain or infectious symptoms. Eye examination revealed bilateral proptosis with lid retraction, ophthalmoplegia in all directions, reduced visual acuity but no visual field defects. Physical examination was otherwise unremarkable.A non-enhanced CT of the head was performed to further evaluate. This revealed significant enlargement of all extraocular muscles involving the left and right sides symmetrically  with spaSubsequent thyroid function tests, however, were within normal limits. Anti-thyroid peroxidase and anti-thyroglobulin antibodies were negative.On revisitation of the patient’s history, 22 kg of unintentional weight loss over the preceding 3 months and a 40 pack-year smoking history were elicited. A screening chest radiograph revealed a large right middle lobe mass .−1 respectively but all other serum electrolytes, including ionised calcium, were within normal limits. Paraneoplastic autoantibodies, including anti-Hu, anti-Ri, anti-Yo, anti-PCA-2, anti-VGCC and anti-VGKC, were negative.No alternative or additional findings for the patient’s orbitopathy were demonstrated on a contrast-enhanced MRI of the head and orbits . Serum vContrast-enhanced CT of the chest, abdomen and pelvis revealed a solitary right middle lobe mass with ipsilateral and contralateral enlarged mediastinal lymph nodes. An endobronchial ultrasound-guided biopsy of an enlarged subcarinal lymph node and right middle lobe brushings and washings were subsequently performed; histopathological findings were consistent with primary lung squamous cell carcinoma of the right middle lobe with mediastinal nodal metastatic disease.The differential for bilateral symmetric extraocular muscle enlargement can initially be narrowed by evaluating for involvement of the musculotendinous junction, with sparing suggestive of thyroid-associated orbitopathy. Given the distribution of involvement and absence of an infiltrative process causing this enlargement on MRI, other differentials such as lymphoma, metastasis, pseudotumour, sarcoidosis and amyloidosis were considered less likely.A treatment plan with curative intent comprised of 60 Gy in 30 fractions of radiotherapy and concurrent carboplatin and paclitaxel was prescribed. Ophthalmoplegia and visual symptoms improved with lubricating eye drops and 2 mg of oral dexamethasone daily. Post-treatment imaging was performed approximately 4 months after initial presentation. Chest radiograph revealed reduction in size of the primary right middle lobe malignancy with surrounding likely radiotherapy-related changes . Contras1 Although there are published case reports of exophthalmos associated with primary lung malignancy, none to date have been associated with the CT and MRI orbital findings demonstrated in the current case.2,3 Concurrent response of the extraocular muscle enlargement to chemoradiotherapy for the right middle lobe primary malignancy on follow-up imaging reaffirms this association.Symmetric enlargement of all the extraocular muscles with sparing of the myotendinous junctions is a typical feature of Graves disease.4–6 A German language article reported a case of enlargement of all the extraocular muscles associated with known hormonally inactive paraganglioma and suggested a paraneoplastic immune reaction as the cause.7 Unfortunately, the patient refused any treatment, precluding assessment as to whether orbitopathy would improve with treatment of the paraganglioma, and died 18 months later.Lymphoma and metastasis have been reported to involve a single muscle, pseudotumours usually cause enlargement of the muscle and tendinous insertion, and MRI in sarcoidosis typically demonstrates enlarged, enhancing lacrimal glands.8 Imaging should be targeted based on clinical suspicion; a heavy smoking history prompted a screening chest radiograph in the current case, which proved critical in this patient’s care.When imaging is consistent with thyroid-associated orbitopathy, and clinical and biochemical findings are incongruent, we suggest an occult malignancy should be sought. Contrast-enhanced MRI can define the structures involved. Paraneoplastic autoantibodies are variably helpful, given they are specific for paraneoplastic neurological disorders, particularly in the setting of any lung malignancy other than small cell carcinoma.This is the first reported case of subsequently discovered primary lung squamous cell carcinoma presenting with imaging proven bilateral symmetric extraocular muscle enlargement typical of Graves disease in the absence of clinical and biochemical evidence of Graves disease.Enlargement of all extraocular muscles sparing the musculotendinous junctions and involving the left and right orbits symmetrically is typically associated with Graves disease.Thyroid-associated orbitopathy in the absence of thyroid disease and presence of malignancy is rare but has been previously reported.If imaging findings are entirely typical of thyroid-associated orbitopathy and clinical and biochemical assessment is incongruent, imaging, preferably targeted, should be performed with the aim of revealing an occult malignancy.


The use of intravenous vitamin C (IVC) for cancer therapy has long been an area of intense controversy. Despite this, high dose IVC has been administered for decades by complementary health care practitioners and physicians, with little evidence base resulting in inconsistent clinical practice. In this review we pose a series of questions of relevance to both researchers and clinicians, and also patients themselves, in order to identify current gaps in our knowledge. These questions include: Do oncology patients have compromised vitamin C status? Is intravenous the optimal route of vitamin C administration? Is IVC safe? Does IVC interfere with chemotherapy or radiotherapy? Does IVC decrease the toxic side effects of chemotherapy and improve quality of life? What are the relevant mechanisms of action of IVC? What are the optimal doses, frequency, and duration of IVC therapy? Researchers have made massive strides over the last 20 years and have addressed many of these important aspects, such as the best route for administration, safety, interactions with chemotherapy, quality of life, and potential mechanisms of action. However, we still do not know the answers to a number of fundamental questions around best clinical practice, such as how much, how often and for how long to administer IVC to oncology patients. These questions point the way forward for both basic research and future clinical trials. Over the years, numerous epidemiological studies have highlighted a decreased incidence of cancer and improved survival in patients with higher dietary intakes of vitamin C or higher plasma levels of the vitamin . AlthougTreatment of cancer, in contrast, is thought to require much higher doses of vitamin C than normal dietary intakes . In factin vitro, preclinical and clinical studies being undertaken  have consistently shown that patients with cancer have lower mean plasma vitamin C status than healthy controls . It has been noted that administration of some anticancer therapies, such as cisplatin, fluorouracil, nilotinib, and interleukin-2, can significantly lower the vitamin C status of oncology patients and result in scurvy-like symptoms in some cases . These high concentrations are relatively transient, however, due to rapid clearance by the kidneys, resulting in a half-life of about 2 h in circulation  deficiency is typically screened for prior to high dose IVC administration, due to two case reports of hemolytic anemia in G6PD deficient individuals following 80 g IVC administration . The lowIntravenous vitamin C has been shown to interfere with many point-of-care glucose meters, even at low gram doses . IVC canPotential interactions between vitamin C and chemotherapeutic agents have long been a matter of debate . BecauseTable 4) (Table 4).Animal studies have indicated that concurrent administration of vitamin C to numerous different chemotherapeutic agents  synergistically decreased xenograft tumor growth, including in a chemotherapy resistant pancreatic tumor model, and synergistically increased survival (Table 4) . No diffTable 4) . AdminisTable 4) . InteresTable 5), and in many cases decreased off-target toxicity and improved health-related quality of life were observed . Vitamin C administration decreased white blood cell loss, weight loss, ascites accumulation, hepatotoxicity, reticulocytosis, lipid oxidation, and cardiomyopathy induced by the chemotherapeutic agents. In a murine ovarian cancer model, a synergistic decrease in ascites accumulation was observed with high dose vitamin C administration in combination with carboplatin and paclitaxel  in conjunction with high-dose IVC (75–100 g two times per week) . Adversedose IVC . Thus, Idose IVC .Since the early 1970s and 1980s, clinicians have reported improved subjective quality of life in patients following administration of both high dose oral and IVC . More reIn vitro, vitamin C (in the form of the ascorbate anion) is able to reduce transition metal ions, such as ferric and cupric cations, which are present in buffers or in cell culture media. The reduced transition metal ions are then able to generate hydrogen peroxide through reduction of oxygen to the superoxide radical, which can react with itself to form hydrogen peroxide. However, whether catalytically available transition metal ions are found in vivo and can cause enhanced oxidative stress is still a matter of some debate since iron and copper are normally sequestered in transport and storage proteins such as transferrin, ferritin and ceruloplasmin  concentrations of vitamin C to cell culture media exhibits differential cytotoxicity toward various cancer cell lines, but not toward normal cultured cells , as evidenced by protection via exogenously added catalase  (in vivo (Pharmacokinetic studies in oncology patients have provided insight into the doses of IVC required to generate high (millimolar) concentrations of vitamin C in plasma (Table 3) . It is g (N-acetyl cysteine inhibited the anti-tumor effect of high-dose vitamin C administration (Gulo knockout mice and guinea pigs) can also synthesize their own vitamin C. As yet, there is little evidence to indicate that the proposed ‘pro-oxidant’ mechanism is occurring in oncology patients administered IVC  to murine models has been shown to decrease tumor growth and enhance survival (Table 4) . The ‘prTable 4) , 2008. Fstration . As suchered IVC .Gulo knockout mice and guinea pigs, have indicated that oral dosing  (Table 4). Since hydrogen peroxide is not detected following oral or low dose IVC administration   and low 3–5 g/L)  exhibit stration , this sustration . Analysistration , 2016a,bGulo knockout mice with melanoma and breast tumors following supplementation with low dose oral vitamin C   , 2013. Digure 1) . Increasigure 1) . Since eFigure 1)  . HIF-1α igure 1) , 2016a,bigure 1) , and enhigure 1) .Figure 1) (Recent research has uncovered a role for vitamin C in epigenetic regulation via acting as a cofactor for DNA and histone demethylases which belong to the same family of enzymes as the collagen and HIF hydroxylases . Vitaminigure 1) . Researcigure 1) . Thus, eigure 1) .Vitamin C is also a cofactor for several Jumonji C domain-containing histone demethylases (JHDM) that catalyze histone demethylation . Methyla2-isoprostanes, a marker of systemic oxidative stress  , a frequency of approximately twice a week (range of 1–7 times per week), and about 19 treatments per patient (range of 1–80 treatments) . BecauseTable 5) . Lower ITable 5) .Although the ‘pro-oxidant’ activity of IVC has yet to be conclusively demonstrated in humans, there may be alternate rationales for administering high dose IVC. Solid tumors exhibit dysregulated blood supply which limits diffusion of oxygen and other nutrients to the core of the tumors. Utilizing a well-established multicell-layered, three-dimensional pharmacokinetic model, Preclinical studies indicate that a single infusion of vitamin C is not as effective as multiple infusions and a higher frequency of administration appears to be more beneficial . For exa•Do oncology patients have compromised vitamin C status? Yes, studies consistently show that patients with cancer have lower mean circulating vitamin C levels than healthy volunteers. These patients also exhibit higher rates of hypovitaminosis C and deficiency. Furthermore, chemotherapy can impact negatively on the vitamin C status of oncology patients. Because of vitamin C’s supportive functions in the body, increasing the vitamin C status of oncology patients is likely to be of benefit.•Is IV the optimal route for vitamin C administration? Yes, IV administration of vitamin C can provide significantly higher peak plasma concentrations because it bypasses the regulated intestinal uptake of oral vitamin C. These higher concentrations are believed to be required for some of the proposed anti-cancer mechanisms of vitamin C and may also enhance diffusion of the vitamin into the hypoxic core of solid tumors.•Is IVC safe? Yes, IVC is remarkably safe, considering the massive (>75 g) doses that are often administered. However, there are several currently known situations where caution is warranted. These include patients with impaired renal function due to their inability to adequately clear high IVC doses from circulation, and patients with G6PD deficiency due to inability to detoxify oxidative stress generated by high dose IVC administration. Caution is also required for patients requiring regular glucose monitoring due to the potential for IVC to interfere with point-of-care glucose monitors.•Does IVC interfere with chemotherapy or radiotherapy? Clinical trials indicate that IVC does not adversely interfere with chemotherapy and pre-clinical studies indicate that it may in fact act synergistically in combination with different chemotherapeutic agents. There is as yet limited research around interference with radiotherapy, with conflicting results likely due to the timing of the interventions.•Does IVC decrease the toxic side effects of chemotherapy and improve quality of life? Both pre-clinical and clinical studies indicate that IVC can decrease the off-target toxicity of chemotherapeutic agents, likely through its antioxidant and anti-inflammatory activities, without affecting the anti-cancer activities of the chemotherapeutic agents. The reduction in specific chemotherapy-related side-effects results in an overall improvement in the health-related quality of life of oncology patients.•What are the relevant mechanisms of action of IVC? A number of plausible anti-cancer mechanisms have been proposed, such as indirect generation of hydrogen peroxide, enzyme cofactor activities , as well as antioxidant and anti-inflammatory functions. Different cancers likely respond differently to IVC therapy depending upon their underlying mechanisms. Thus, future work should focus on tailoring IVC regimens to specific cancers or cancer subtypes, e.g., hematological cancers that are driven specifically by TET mutations may respond more readily to IVC therapy.•What are the optimal doses, frequency, and duration of IVC therapy? Although these are the most relevant questions clinically, there is still little consensus as to how much, how often and for how long to administer IVC to oncology patients. The different proposed mechanisms of action provide some insight into dosing, with higher doses (>50 g/d) being required for some anti-cancer mechanisms, and lower doses (≤10 g/d) being sufficient for decreasing symptoms and improving quality of life. Pre-clinical studies indicate that more frequent dosing exhibits enhanced efficacy. However, depending on the underlying mechanisms involved, it is possible that anti-tumor activity may require long term treatment and follow-up, e.g., over years rather than just the few weeks or months of most clinical trials. It is unlikely that future large scale IVC RCTs will be carried out due to the prohibitive costs. Nevertheless, smaller scale studies, if well designed, have the potential to contribute relevant and translatable findings to inform good clinical practice.AC conceived and wrote the review. JC contributed clinical input.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Brunsting-Perry pemphigoid is a rare autoimmune blistering skin disease. Similar to nonmelanoma skin cancers, Brunsting-Perry pemphigoid has a predilection for the head and neck. Herein, a case of solitary Brunsting-Perry pemphigoid treated as cutaneous squamous cell carcinoma (SCC) with subsequent excision is reported. Brunsting-Perry pemphigoid, an autoimmune blistering disease with only about 60 reported cases, is considered a subtype of either cicatricial pemphigoid, bullous pemphigoid or epidermolysis bullosa acquisita . FurtherSkin cancer is often managed in primary care and specialties without the involvement of dermatologists . It is cA 76-years old female Caucasian patient without a history of skin cancer was referred from primary care to a secondary hospital with an 8-months history of a tender, sometimes weeping scalp lesion. The topical treatment with fusidic acid cream 2% and miconazole nitrate 2% + hydrocortisone 1% cream improved the lesion partially but it never subsided.The patient presented to the hospital with an erythematous, crusting and lesion measuring 2 x 2 cm on the vertex of the scalp Figure .SCC was suspected, and the lesion was removed completely with subsequent split skin grafting.Histopathology revealed a subepidermal blister with a chronic band-like inflammatory cell infiltrate with scattered eosinophils in the dermis without any sign of malignancy Figure .Three months later, the patient was referred to the Dermatology department, where a well-healed scar without any pathological findings was noticed. At this stage, direct immunofluorescence of the lesion could not be requested, as it was excised completely and formalin fixed, auto-antibodies to BP180 and BP230 were not be detected in the patient’s blood. The retrospective diagnosis of Brunsting-Perry pemphigoid was made after taking into consideration the patient’s history, the clinical manifestation, and the pathological findings.Brunsting-Perry pemphigoid is an unusual differential diagnosis of nonmelanoma skin cancer. Monihan et al. reported three cases of Brunsting-Perry pemphigoid simulating superficial basal cell carcinomas . EspeciaThe reported findings highlight the importance of histopathological examination of skin lesions with an unusual history or presentation prior to excision. Additionally, they emphasize that surgeons involved in skin cancer management must have appropriate knowledge about the differential diagnoses of nonmelanoma skin cancers aiming to avoid unnecessary excision.