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Analysis of the genetic pathway leading to formation of ectopic apical ectodermal ridges in mouse Engrailed-1 mutant limbs.

The apical ectodermal ridge (AER), a rim of thickened ectodermal cells at the interface between the dorsal and ventral domains of the limb bud, is required for limb outgrowth and patterning. We have previously shown that the limbs of En1 mutant mice display dorsal-ventral and proximal-distal abnormalities, the latter being reflected in the appearance of a broadened AER and formation of ectopic ventral digits. A detailed genetic analysis of wild-type, En1 and Wnt7a mutant limb buds during AER development has delineated a role for En1 in normal AER formation. Our studies support previous suggestions that AER maturation involves the compression of an early broad ventral domain of limb ectoderm into a narrow rim at the tip and further show that En1 plays a critical role in the compaction phase. Loss of En1 leads to a delay in the distal shift and stratification of cells in the ventral half of the AER. At later stages, this often leads to development of a secondary ventral AER, which can promote formation of an ectopic digit. The second AER forms at the juxtaposition of the ventral border of the broadened mutant AER and the distal border of an ectopic Lmx1b expression domain. Analysis of En1/Wnt7a double mutants demonstrates that the dorsalizing gene Wnt7a is required for the formation of the ectopic AERs in En1 mutants and for ectopic expression of Lmx1b in the ventral mesenchyme. We suggest a model whereby, in En1 mutants, ectopic ventral Wnt7a and/or Lmx1b expression leads to the transformation of ventral cells in the broadened AER to a more dorsal phenotype. This leads to induction of a second zone of compaction ventrally, which in some cases goes on to form an autonomous secondary AER.

Animals↗

FGF8 induces formation of an ectopic isthmic organizer and isthmocerebellar development via a repressive effect on Otx2 expression.

Beads containing recombinant FGF8 (FGF8-beads) were implanted in the prospective caudal diencephalon or midbrain of chick embryos at stages 9-12. This induced the neuroepithelium rostral and caudal to the FGF8-bead to form two ectopic, mirror-image midbrains. Furthermore, cells in direct contact with the bead formed an outgrowth that protruded laterally from the neural tube. Tissue within such lateral outgrowths developed proximally into isthmic nuclei and distally into a cerebellum-like structure. These morphogenetic effects were apparently due to FGF8-mediated changes in gene expression in the vicinity of the bead, including a repressive effect on Otx2 and an inductive effect on En1, Fgf8 and Wnt1 expression. The ectopic Fgf8 and Wnt1 expression domains formed nearly complete concentric rings around the FGF8-bead, with the Wnt1 ring outermost. These observations suggest that FGF8 induces the formation of a ring-like ectopic signaling center (organizer) in the lateral wall of the brain, similar to the one that normally encircles the neural tube at the isthmic constriction, which is located at the boundary between the prospective midbrain and hindbrain. This ectopic isthmic organizer apparently sends long-range patterning signals both rostrally and caudally, resulting in the development of the two ectopic midbrains. Interestingly, our data suggest that these inductive signals spread readily in a caudal direction, but are inhibited from spreading rostrally across diencephalic neuromere boundaries. These results provide insights into the mechanism by which FGF8 induces an ectopic organizer and suggest that a negative feedback loop between Fgf8 and Otx2 plays a key role in patterning the midbrain and anterior hindbrain.

Animals↗

Para osteo arthropathy--ectopic ossification of healing tendon about the rodent ankle joint: histologic and type V collagen changes.

Ectopic bone formation, or para osteo arthropathy (POA), is commonly seen in humans following lesions to the central nervous system. The condition also occurs after severe trauma, burns, or tetanus, and, rarely, after poliomyelitis or cauda equina lesions. The lack of a suitable laboratory animal model has hampered study of its etiology and treatment. The lesion occurs just above the rodent ankle joint 7 weeks after repair of the severed achilles tendon. Tendon repair using a single silk suture resulted in ectopic calcification in 22 of 23 animals. Ectopic ossification, with extensive mineralization, occurred in 11 animals, 5 of which showed bone marrow. Ectopic mineralization was moderate in 8 others, minimal in 4, and absent in one. Collagen typing thrice during healing indicated that type V collagen increased by one-third at 10 days, doubled at 20 days, and returned to near normal amounts at 50 days. Since type V collagen is a major component of the nonfibrous collagen of blood vessels, increased amounts of type V collagen are consistent with the presence of many new blood vessels in the granulation tissue at 10 and 20 days. Vascularity is less dense at 50 days when ectopic mineralization and new bone formation are observed. These findings suggest that POA and the degree of maturation of healing tendon may be linked to reduced amounts of type V collagen. It is concluded that the sutured tendon of the rodent ankle joint offers an animal model by which to study ectopic bone formation, or para osteo arthropathy.

Achilles Tendon↗

Thoracic ectopic kidney in a child: a case report.

Congenital thoracic ectopic kidney is a very rare developmental anomaly and the rarest form of all ectopic kidneys. It is usually asymptomatic and discovered incidentally on a routine chest radiography. We report a thoracic ectopic kidney in a 19-month-old boy, which initially presented as a well demarcated mass at the base of the right lung on chest x-ray. Intravenous pyelography (IVP) and thoraco-abdominal computed tomography (CT) demonstrated a normal functioning transdiaphragmatic thoracic ectopic right kidney, but technetium-99m DTPA and DMSA scintigraphy demonstrated pelvic stasis. We hereby discuss the features of congenital thoracic ectopic kidney and review the literature. Although it is extremely rare, thoracic ectopic kidney should be considered in differential diagnosis of a mass with a well demarcated superior margin in the lower part of the thorax, and renal scintigraphy must be performed even if CT and IVP results are normal.

Diagnosis, Differential↗

[In vitro study of prolactin secretion by ectopic endometrial stromal cells].

OBJECTIVE: To investigate the relationship between prolactin (PRL) secretion by ectopic endometrial stromal cells and elevated PRL concentrations of peritoneal fluid in patients with endometriosis. METHODS: Twelve samples of each ectopic endometrium and normal endometrium were separated and cultured in vitro. After stimulated with progesterone(10(-8) mol/L) for 6 days, PRL levels in the media of cultured stromal cells from both tissue types were measured by enzyme-labeled immunosorbent assay(ELISA). A study of correlation between PRL level in culture supernatant of stromal cells from ectopic endometrium and American Fertility Society (AFS) classification of endometriosis score was performed. The expression of PRL protein of stromal cells from both tissue types were determined by immunocytochemical method. RESULTS: PRL was secreted in similar concentrations by stromal cells from both tissue types. The mean levels of PRL in ectopic and normal endometria were (21.8 +/- 8.0) and (24.5 +/- 7.9) micrograms.L-1.6 d-1 per, respectively (P > 0.05). There is significant positive correlation between PRL secretion by ectopic endometrial stromal cells and the scoring of endometriosis (P < 0.05). There were no significant difference in the immunostaining integral score of PRL between the two groups. CONCLUSION: Production of PRL by ectopic implants of endometriosis is likely to be a contributing factor of the elevated peritoneal fluid PRL in patients with endometriosis.

Adult↗

[Study on the distribution of lymphocyte subsets in the eutopic and ectopic endometrium of women with endometriosis].

OBJECTIVE: To investigate the abnormal distribution of lymphocytes in eutopic and ectopic endometrium of patients with endometriosis and its significance. METHODS: In 43 cases, biopsies of ectopic tissues were taken by laparoscopy and laparotomy from patients with endometriosis and eutopic endometrium by curettage at the same time. In 19 cases, eutopic endometrium was taken from hysterectomy for myomatous uterus. Immunohistochemical techniques were employed to demonstrate the difference in the number and ratio of the lymphocyte subsets between the patients with endometriosis and the controls. RESULTS: In the patients with endometriosis, in the proliferative phase, ectopic endometrium contained respectively CD3+ CD8+ T cells and CD68+ macrophages (67.2 +/- 13.5)/5 HP, (45.0 +/- 14.0)/5 HP and (37.2 +/- 10.6)/5 HP, significantly higher then that in the eutopic endometrium (52.4 +/- 11.3)/5 HP (P < 0.01), (32.5 +/- 10.0)/5 HP (P < 0.05), and (30.7 +/- 10.3)/5 HP, and also higher as compared with the control group (52.1 +/- 14.9)/5 HP (P < 0.05), (28.9 +/- 12.7)/5 HP (P < 0.01), (26.3 +/- 9.3)/5 HP (P < 0.05); in the secretory phade, CD8+/CD4+, and CD68+ content was respectively 3.5 +/- 1.2, (40.3 +/- 12.2)/5 HP, higher than that in the control group, 3.2 +/- 0.8 (P < 0.05), (28.6 +/- 10.6)/5 HP (P < 0.01). The number of macrophages was also significantly increased. No cyclic changes in the number of lymphocytes in each subpopulation in ectopic endometrium were found. CONCLUSIONS: In the patients with endometriosis, the changes in T lymphocytes and macrophages are mainly on the endometriotic sites. The infiltration of many lymphocytes and macrophages into the ectopic endometrium formed a chronic inflammatory process. The lymphocytes are not able to clear the ectopic endometrium in the late stages of endometrium, on the contrary, they stimulate the further growth of the endometrium.

Adult↗

Ectopic posterior pituitary lobe and periventricular heterotopia: cerebral malformations with the same underlying mechanism?

BACKGROUND AND PURPOSE: Ectopic posterior pituitary lobe often occurs in children with growth hormone deficiency and is part of the spectrum associated with septo-optic dysplasia. Some cases of septo-optic dysplasia are caused by homozygous mutations in the homeobox gene HESX1, whereas heterozygous mutations are associated with milder phenotypes. To date, HESX1 is the only gene associated with ectopic posterior pituitary lobe. We describe an association between ectopic posterior pituitary lobe and periventricular heterotopia in four children without classic features of septo-optic dysplasia and suggest possible mechanisms on the basis of a review of pituitary embryology and recent molecular genetic advances. METHODS: Among 20 children with ectopic posterior pituitary lobe, four had associated periventricular heterotopia. We herein review the clinical and MR imaging findings of these four children. Mutation screening of HESX1 was performed in two. RESULTS: All four children had growth hormone deficiency. None had visual or neurologic disturbances. MR images showed a range of pituitary appearances, with scattered discrete periventricular heterotopia in each case. Other abnormalities were limited to small suprasellar lipomas and callosal dysgenesis. A heterozygous HESX1 mutation was present in one case. CONCLUSION: The coexistence of ectopic posterior pituitary lobe and periventricular heterotopia suggests they have a common underlying genetic basis that is due to gene expression at different locations and stages of development. The presence of a heterozygous HESX1 mutation in one case suggests this gene is important in the development of both ectopic posterior pituitary lobe and periventricular heterotopia and supports their place in the spectrum of septo-optic dysplasia. Further analysis of HESX1 and other genes in related developmental pathways will elucidate their roles in the development of both malformations.

Basic Helix-Loop-Helix Proteins↗

[Medical treatment of unruptured ectopic pregnancy].

BACKGROUND: Ectopic pregnancy is the implantation of fertilized ovum on any tissue other than the endometrial lining of the uterus. OBJECTIVE: To evaluate the effectiveness and safeness of methotrexate in the treatment of unruptured ectopic pregnancy. MATERIALS AND METHODS: From January 2000 to October 2002 five patients were diagnosed with unruptured ectopic pregnancy in Hospital Juarez de Mexico. The inclusion criteria were: hemodynamic stability, gestational sac of < 40 mm, serum beta-hCG concentration < 15,000 mIU/L and future fertility desire. Systemic methotrexate was administered as an intramuscular injection of 50 mg. Evaluation was based on transvaginal ultrasonography, beta-hCG levels and hysterosalpingography. RESULTS: Five patients with unruptured ectopic pregnancy were treated with methotrexate. Successful rate, after one or two injections, was 100% (5 patients). The size of ectopic pregnancy as estimated by ultrasonographic was 33.33 mm. Negligible plasma beta-hCG values were reached 45.6 +/- 19.85 days after the time of treatment. Ultrasonographic scanning demonstrated progressive disorganization and the gestational sac disappeared at 134 days after treatment. There were no adverse effects from the chemotherapy. In 3 of 4 women who underwent hysterosalpingography following treatment, patency of the affected tube was observed. Three women experienced an intrauterine pregnancy spontaneously in the methotrexate group. CONCLUSIONS: Systemic methotrexate treatment is safety and effective in the treatment of unruptured ectopic pregnancy, for woman with future desire of fertility and if it has unruptured, conservative treatment using methotrexate is an excellent choice.

Abortifacient Agents, Nonsteroidal↗

[Effect of gestrinone on growth and apoptosis in isolated ectopic endometrium cells in vitro].

OBJECTIVE: To investigate the effects of gestrinone on growth and apoptosis, as well as the expression of phosphatase and tension homologue deleted on chromosome 10 (PTEN) in isolated ectopic endometrium cells in vitro and the underlying mechanisms. METHODS: Ectopic endometrium cells were cultured and exposed to gestrinone of different doses of 0, 10(-6) and 10(-4) mol/L respectively. The inhibition of the cells during 48 hours was determined by methylthiazolyl tetrazolium (MTT) assay, and the cell growth curve was made. Gestrinone was administered to the cells and at 24 hours the morphological changes were observed by transmission electron microscopy and the apoptosis rate, cell cycle and PTEN expression were monitored by flow cytometry (FCM) at the same time. RESULTS: Gestrinone at different concentrations could inhibit the growth and proliferation of ectopic endometrium cells in a dose- and time-dependent manner. The inhibition rate of cell growth after exposed to gestrinone for 8, 16, 24, 32, 40 and 48 h was 99.6%, 87.3%, 79.8%, 62.3%, 51.7% and 44.2% in the 10(-6) mol/L group, and 99.2%, 77.1%, 69.6%, 51.1%, 33.7% and 23.6% in the 10(-4) mol/L group (P < 0.05), and cell growth curve was changed accordingly. After 24 hour exposure to gestrinone from 10(-6) to 10(-4) mol/l, apoptotic changes of cells were observed under transmission electron microscope. FCM showed that after the exposure to gestrinone, the apoptotic rate of ectopic endometrium cells was 1.3% in 10(-6) mol/L group and 15.0% in 10(4) mol/L group. It was significantly increased when compared with the 0 mol/L group, the apoptotic rate of which was 0% (P < 0.05). The level of PTEN expression of the ectopic endometrium cells was 60.6% after treated with 0 mol/L gestrinone, while in 10(-6) and 10(-4) mol/l groups the level of PTEN expression was increased to 75.3% and 85.7%, significantly higher than that of the 0 mol/L group (P < 0.05). CONCLUSION: Gestrinone can significantly inhibit the growth and proliferation of ectopic endometrium cells, and this effect was related to increase of PTEN expression.

Adult↗

Triggering of ventricular ectopic beats by emotional, physical, and meteorologic stress: role of age, sex, medications, and chronic risk factors.

AIM: To investigate the association of a single ventricular ectopic beat with physical, emotional, or meteorologic stress and the role of age, sex, antiarrhythmic and other medicament therapy and participant characteristics. METHODS: The study included 457 participants who were consecutively assigned to undergo continuous 24-hour Holter monitoring and who completed a structured questionnaire about their physical activity and mental stress. Multiple regression analysis of data on 11 meteorologic parameters, participants' baseline characteristics, and medications they used was performed for subgroups according to sex and age, with 65 years as age limit. RESULTS: Wind speed, low relative humidity, increasing relative humidity, and emotional stress were independent predictors of ventricular ectopic beat, whereas warm front passage showed a protective effect in all participant subgroups (P<0.05 in all cases). Physical activity was an independent predictor of ventricular ectopic beat in women (P=0.02) and cold front passage in men P=0.003). The circadian variation in frequency of ventricular ectopic beats persisted in all subgroups after adjustments for external triggers (P<0.001 in all cases). Among chronic risk factors, familial background and previous myocardial infarction were independent predictors of ventricular ectopic beat in men and younger (P<0.05 in all cases). Nitrates (P<0.03 in all cases) and angiotensin converting enzyme inhibitors (P<0.02 in all cases) exerted protective effect in younger participants as well as did beta-blockers in the elderly (P<0.003 in all cases). CONCLUSION: In addition to existence of an endogenous, external triggering-independent circadian pattern, physical, emotional, and meteorologic stress may act as triggers of ventricular ectopic beat in a manner that differs from triggering more complex arrhythmias. Familial background seems to have a significant impact on arrhythmogenesis in men.

Age Factors↗

Ectopic osteogenesis in the rectus sheath.

Although was published many cases of ectopic osteogenesis of traumatic, neurogenic cause or hereditable form, the etiology of ectopic osteogenesis remaining unknown. We present ectopic osteogenesis in the rectus abdominal sheath. The study material was represented from fragments of ectopic bones discovered in rectus sheath of four patients suffering iterative surgical abdominal interventions. The pieces of ectopic bone were decalcified and then were made to the standard techniques (paraffin inclusion, general techniques dyeing). The process of ectopic osteogenesis was analyzed through microscopically study to seriated sections of discovered piece, finding the presence of the hematopoesis foci. We conclude that is important identifying and characterizing the osteoinductor agents because these allowed the study of osteogenesis to the cellular level and make an estimation of the abnormally bone developing mechanisms. A possible osteoinductor factor has been considerate the non-absorbable wound closure material.

Aged↗

Gestational trophoblastic disease in ectopic pregnancy: A case series.

OBJECTIVE: To describe 6 cases of gestational trophoblastic disease (GTD) in ectopic pregnancy admitted to Hospital Universitario de Caracas (HUC). STUDY DESIGN: Medical records of 6 patients admitted to the Obstetrics and Gynecology Department, HUC, from 1996 to 2004 were reviewed. They underwent surgery with a diagnosis of ectopic pregnancy, and histologic analysis revealed GTD. Clinical trends were analyzed. RESULTS: The prevalence of GTD in ectopic pregnancy was 0.16:1,000 deliveries. The mean patient age was 29 years. The preceding gestation was a term delivery in 4 and abortion in 2. The mean gestational age at admission was 8 weeks. All patients complained of abdominal pain, and 3 of them also had vaginal bleeding. Ultrasound revealed an adnexal tumor in 5 cases; this tumor and hemoperitoneum (6 cases) were the most frequent surgical findings. Histopathologic diagnosis was partial mole in 5 and choriocarcinoma in 1. Four patients were lost to follow-up. CONCLUSION: In this series the prevalence of ectopic GTD was high. The condition can mimic the usual symptoms of ectopic pregnancy, especially when a hemoperitoneum is present. It is important to apply strict histologic criteria for GTD when a sample of ectopic pregnancy is analyzed and to monitor those patients with careful human chorionic gonadotropin follow-up.

Adult↗

Methotrexate treatment of unruptured ectopic pregnancy: a report of 100 cases.

In an ongoing clinical trial, 100 patients with an unruptured ectopic pregnancy of 3.5 cm or less in greatest dimension were treated with an outpatient protocol of methotrexate and citrovorum factor chemotherapy. Methotrexate and citrovorum were given on alternating days until the hCG titer had decreased by 15% on 2 consecutive days. The patients ranged in age from 16-40 years, gravidity from 1-8, and parity from 0-5. Twenty-three patients had a previous ectopic pregnancy. Of the 100 patients, 96 (96%) received methotrexate/citrovorum as primary therapy and four (4%) were treated for persistent hCG titers after a conservative surgical procedure. The tubal pregnancies of patient nos. 1-50 were confirmed by laparoscopy, whereas patient nos. 51-100 were diagnosed according to a nonlaparoscopic algorithm. Four patients of 100 failed medical therapy and required surgery. Of these, one had an ectopic pregnancy with cardiac activity, one ruptured after intercourse, and the remaining two cases had no specific identifiable risk factors. Of the ectopic pregnancies with cardiac activity, 80% were successfully treated. Five patients (5%) had methotrexate-related side effects, all after the fourth dose, but none required treatment for these side effects. Hysterosalpingograms done on 58 patients subsequently demonstrated tubal patency in 84.5% on the involved side. To date, 37 pregnancies have occurred in this group, of which 31 (89.2%) were intrauterine and four (10.8%) were recurrent ectopic pregnancies. We conclude that methotrexate/citrovorum is safe, effective, and helps to preserve reproductive performance when used as primary therapy for unruptured ectopic pregnancy and for treatment of persistent disease following a conservative surgical procedure.

Adolescent↗

[Ectopic ureter].

Ectopic ureter is quite a rare malformation, and it can be more or less serious depending on its anatomy (monolateral or bilateral ectopy, duplicated ureter, single ureter) and the associated malformations. It's more common in female patients. Ectopic ureteral orifice can be either intravesical (bladder neck) or, more often, extravesical. Ectopia in women is more frequently found in the urethra and the vaginal vestibule; much less frequently in vagina and in uterus. In men it is mostly found in the posterior urethra; in the male genital tract is very rare. In most cases ectopic ureter is associated with pyelo-ureteral complete duplication: the upper kidney usually works badly or doesn't work at all, due to renal dysplasia or pyelonephritis. More rarely ureteral ectopia affects a single urinary system and can be monolateral or, in the most serious forms, bilateral. The main clinical signs are urinary incontinence accompanied by regular micturition (more exactly pseudoincontinence) in the female patients, and urinary infection. In the male there is no urinary incontinence. Authors report their experience about 54 ectopic ureters in 51 children. Treatment is always by surgery: the choice has to be made between conservative or radical attitude. 38 total exeresis of the ectopic excretory pathway (upper heminephroureterectomy or nephroureterectomy), 9 ureteral reimplantations, 1 uretero-pyeloanastomosis have been done. Outcome is always satisfactory in monolateral forms, more uncertain in bilateral forms with single ectopic ureter, due to incontinence and reduced bladder capacity problems and the possible associated renal failure.

Female↗

Innervation and behaviour of ectopic limbs in Xenopus.

The hindlimb bud of Xenopus tadpoles was replaced with a forelimb bud, or vice versa, prior to axon invasion of the limb. Ectopic hindlimbs supported 94% as many brachial motoneurons as the remaining forelimb, and ectopic forelimbs supported 46% as many lumbar motoneurons as the remaining hindlimbs, on average, after the period of motoneuron death. The patterns of movement of ectopic limbs were characteristic of the innervating spinal cord segments, and not the limbs. The anatomical patterns of nerve trunks were characteristic of the ectopic limbs, and not the sources of innervation. HRP transport studies showed a resemblance between the locations of lumbar motoneurons supplying ectopic forelimb muscles and those supplying the homologous muscles of the hindlimb. It was concluded that motoneurons could survive the period of cell death following connection to muscles for which their patterns of activity were inappropriate, and the projections to ectopic limb muscles were specific although the nerve paths within the limbs were different.

Animals↗

[Diagnostic and treatment characteristics of ectopic atrial tachycardia].

Reported here are 162 cases of atrial ectopic tachycardia, a specific type of the supraventricular arrhythmia, which is characterized by the distinct P waves on the ECG, which follow at the rate of 400 and more per minute. Although atrial ectopic tachycardia is similar to the supraventricular paroxysmal tachycardia and atrial flutter, it differs from them by the mechanism of the development. Atrial ectopic tachycardia is caused by the failure or weakening the sinus node and the appearance of the ectopic focus in the atria. Such arrhythmia occurs in the following 4 types: with atrial to ventricular excitation ratio 1:1; with incomplete atrio-ventricular block; with complete atrioventricular block; and in combination with atrial fibrillation. Atrial ectopic tachycardia often takes lingering course and is hardly responsive to the medical treatment. The cases of arrhythmia, characterized by the broad P waves on the ECG tend to the progressive course. 17 cases of atrial ectopic tachycardia treated by electrostimulation (ES) which had 100% positive effect are presented and ES advantages over the drug therapy are underlined. The frequent transition of this arrhythmia into the atrial fibrillation is outlined.

Cardiovascular Agents↗

[The allorhythmic distribution of ectopic ventricular beats. Observations on the electrogenesis and dynamics of concealed ventricular extrasystole].

BACKGROUND: A regular distribution of ventricular ectopic beats is thought to be a relatively uncommon phenomenon, known as "concealed extrasystole". Several experimental studies suggest that the phenomenon originates from a "protected" ventricular focus. The aim of the present study was to evaluate the 24-hour ECG monitoring incidence of ventricular concealed extrasystole in patients with highly frequent ventricular ectopic beats, looking for signs useful in postulating the electrogenesis of the arrhythmia. METHODS: The 24-hour ECGs of 10 patients (pts) with highly frequent ventricular extrasystoles were analysed, searching for significant sequences in the distribution of ectopic beats (i.e., ectopic beats separated by a number of interectopic sinus beats fulfilling one of the formulas of concealed extrasystole). RESULTS: Five cases (50%) showed an allorhythmic distribution resulting in a prevalent pattern of concealed bigeminy (2n-1) in 3 cases, and concealed trigeminy (3n-1) in 2 cases. The phenomenon, however, showed a dynamic behaviour, alternating the distributions from patterns of concealed bigeminy to concealed trigeminy or less common patterns, and vice versa. The evidence of the pure ectopic cycle and mathematically related interectopic intervals in 2 cases, the variability of coupling intervals, and the presence of fusion beats in the remaining 3 cases, strongly suggests a parasystolic origin of the phenomenon. CONCLUSIONS: The results suggest the following: Concealed extrasystole is a relatively common phenomenon, at least in patients with highly frequent ventricular extrasystoles; the phenomenon, however, is somewhat underestimated due to prevalent quantitative, instead of qualitative, Holter monitoring analyses. Among patients with allorhythmically distributed ventricular extrasystoles, none showed only one pattern of distribution. In fact, each single patient showed two or more patterns throughout the 24-hour recordings. Changes from one pattern to another is governed by several factors, such as sinus heart rate and/or the influence of electrotonic "modulation" upon the ectopic focus. Ventricular extrasystoles with regular allorhythmic distribution show a significantly higher variability of coupling intervals than the others (p = 0.005).

Adolescent↗

Ectopic extramammary Paget's disease affecting the upper abdomen.

We present 57-year-old man in whom ectopic extrammary Paget's disease (EMPD) affected the upper abdomen. Although the clinical appearance was suggestive of Bowen's disease or superficial basal cell epithelioma (BCE), the biopsy specimen showed EMPD histologically. Only 12 cases of ectopic EMPD have been reported (including this case). In our 20 year experience of 129 EMPD, this is the first ectopic case. Thus, the frequency of ectopic EMPD is 0.78% (one of 129) in our study. The male/female ratio in the reported 12 cases is 2: 1, nearly the same as EMPD in general (2.1: 1, in our 129 cases). The mean age of the 12 patients is 65.8 years, which is not significantly different from ordinary EMPD (66.4 years, in our 129 cases). Comparing ectopic EMPD to ordinary EMPD, clinically and histologically, we could find no difference. As they appear to be the same disease, ectopic and ordinary EMPD may share similar origins and mechanisms of occurrence. We support the hypothesis that Paget's cells originate from the remaining pluripotential germinative cells which are able to differentiate into many kinds of secreting glands.

Abdomen↗