La Classe Research Articles

HLA Class I Supertype Classification Based on Structural Similarity.

HLA class I proteins, a critical component in adaptive immunity, bind and present intracellular Ags to CD8+ T cells. The extreme polymorphism of HLA genes and associated peptide binding specificities leads to challenges in various endeavors, including neoantigen vaccine development, disease association studies, and HLA typing. Supertype classification, defined by clustering functionally similar HLA alleles, has proven helpful in reducing the complexity of distinguishing alleles. However, determining supertypes via experiments is impractical, and current in silico classification methods exhibit limitations in stability and functional relevance. In this study, by incorporating three-dimensional structures we present a method for classifying HLA class I molecules with improved breadth, accuracy, stability, and flexibility. Critical for these advances is our finding that structural similarity highly correlates with peptide binding specificity. The new classification should be broadly useful in peptide-based vaccine development and HLA-disease association studies.

On the revision of historical collections of three-dimensional models of foraminifers from the Paleontological Museum of St Petersburg State University

Two collections of plaster models of foraminifera from the Paleontological Museum of St. Petersburg State University were studied. The first one (No. ПЛ ОФ 721) is represented by 95 objects. The time of its acquisition and authorship were unknown, some of the models were kept without labels, there was no catalog and records of its receipt. The collection has not been used for teaching or exposure in the museum. As it turned out the creator of the original collection was Academician Alcide d'Orbigny, who first described foraminifers as a separate group of animals in 1826 in the monograph “Tableau méthodique de la classe des Céphalopodes”. The 100 plaster foraminiferal models were made by him to illustrate the classification the new group. The original d'Orbigny’s collection is kept in the National Museum of Natural History in Paris, and its copies were acquired by museums and universities in different countries. The copy of the d'Orbigny collection of the Paleontological Museum of St. Petersburg State University was probably made by the German trading company “Dr. F. Krantz, Rheinisches Mineralien-Kontor”. It was acquired by the St. Petersburg Imperial University for the Geological Cabinet (museum), which were created since 1870 by Professor A.A. Inostrantsev. Based on literary sources, the history of revisions of the d'Orbigny collection has been restored. That made it possible to correct errors in the museum labels, as well as to establish the original names of species depicted as models and bring them into line with the now accepted foraminiferal taxonomy. The second collection (No. ПЛ ОФ 75) is only a part (15 objects) of the collection of 100 models made by Václav Frič to illustrate foraminiferal classification scheme by the Austrian paleontologist August von Reuss. It was purchased for the Geological Cabinet of the Higher Women's (Bestuzhev) Courses and subsequently entered the Department of Paleontology, established at Petrograd University in 1919. As a result of the revision, the species affiliation of the species depicted as the models was established in accordance with the modern system of foraminifera.

S3567 No Barrett's, No Way! A Case of De novo Esophageal Adenocarcinoma

Introduction: Instances of esophageal adenocarcinoma have been increasing at a more drastic rate in the United States and Western Europe in recent years. This calls for more aggressive and comprehensive screening processes for patients with chronic reflux and for those found to have Barrett’s esophagus. Barrett’s esophagus is widely accepted as a precursor to adenocarcinoma of the esophagus, but this case provides a caveat to this rule of thumb. Case Description/Methods: This is a case of a 63-year-old woman who initially presented with severe GERD and was complaining of reflux and regurgitation, as well as nocturnal coughing and wheezing. An endoscopy was conducted revealing LA class 3 esophagitis, a large hiatal hernia, and a distal esophageal inflammatory nodule. The patient was treated aggressively with a combination of a daily PPI and a nightly H2RA. A three-month follow-up endoscopy revealed improvement of her esophagitis, which was downgraded to LA class 1. There was no evidence of Barrett’s esophagus, and the esophageal nodule had healed. Despite this treatment plan the patient was still complaining of regurgitation. An upper GI series revealed a 5 cm hiatal hernia with reflux on water siphon test and valsalva maneuver. Subsequently, a laparoscopic partial fundoplication was performed with complete resolution of all symptoms and successful discontinuance of all acid suppression medications. 2 and ½ years later the patient presented with new onset dysphasia. An upper endoscopy was subsequently performed which revealed a large adenocarcinoma of the distal esophagus and 2 satellite lesions above the adenocarcinoma. Discussion: This case highlights an infrequent presentation of de novo adenocarcinoma with no evidence of Barrett’s esophagus in a conservative time interval. In the chance that the endoscopist may have missed a short segment Barrett’s because of sampling error, the standard of care would have been a 3-year interval surveillance endoscopy. A repeat endoscopy was performed in 2.5 years regardless of no evidence of Barrett’s; the standard of care was not sufficient in this case. This patient exhibited LA class 3-4 distal esophagitis and despite healing, still developed an advanced adenocarcinoma. This may indicate that there is an alternative pathway to esophageal adenocarcinoma in patients with such severe reflux. This case should provide support to potentially screen patients more aggressively who present with severe reflux.Figure 1.: Row 1: initial endoscopy Row 2: second endoscopy Row 3: third endoscopy

Formative Autonomy: Lessons from Elio Petri

AbstractJohn Baldacchino's discussion of the concept of autonomy in this article runs on the dual track of the arts and education. His aim is to engage with the notion of autonomy in terms of what human beings invent (through art) and know (through education) by what they share as free and intelligent beings who live convivially. Following Luigi Pareyson's argument that by form one means a living organism endowed by its own legality (and thereby its own autonomy), Baldacchino offers an analysis of Elio Petri's film La classe operaia va in Paradiso (The Working Class Goes to Heaven) as context for this discussion, which adds a third dimension to the notion of autonomy: that of the political. Here, autonomy is presented as a triangulation of sorts, where what we mean by the autonomous stands for our artistic, educational, and political dispositions (and abilities) to mediate and represent a number of immediate questions with yet‐to‐be‐found answers.

Magnetic sphincter augmentation with hiatal hernia repair: long term outcomes.

Magnetic sphincter augmentation (MSA) is a safe and effective treatment for patients with gastroesophageal reflux disease (GERD). MSA was initially indicated for patients with GERD and concomitant hiatal hernias < 3cm. However, excellent short- and intermediate-term outcomes following MSA and hiatal hernia repair in patients with hiatal hernias ≥ 3cm have been reported. The purpose of this study is to assess long-term outcomes for this patient population. A retrospective review was performed of patients with GERD and hiatal hernias ≥ 3cm who underwent MSA and hiatal hernia repair. Patients were treated at two tertiary medical centers between May 2009 and December 2016. Follow up included annual video esophagram, upper endoscopy, or both. Outcomes included pre- and post-operative GERD health-related quality of life (GERD-HRQL) scores, length and regression of Barrett's esophagus, resolution of esophagitis, need for endoscopic dilations or implant removal, and clinically significant hiatal hernia recurrence (> 2cm) on videoesophagram or endoscopy. Seventy-nine patients (53% female) with a median age of 65.56 (58.42-69.80) years were included. Median follow up was 2.98 (interquartile range 1.90-3.32) years. Median DeMeester scores decreased from 42.45 (29.12-60.73) to 9.10 (3.05-24.30) (p < 0.001). Severity of esophagitis (e.g. LA class C to class B) significantly improved (p < 0.01). Forty percent of patients with Barrett's esophagus experienced regression (p < 0.01). Median GERD-HRQL scores improved from 21 to 2. Five (6.3%) hiatal hernia recurrences occurred, and 1 required re-operation. Age, body mass index, size of the initial hiatal hernia, and sex had no significant effect on whether a patient developed a recurrence. Magnetic sphincter augmentation in conjunction with large hiatal hernia repairs for patients with GERD achieves excellent long-term radiographic and clinical results, and a low overall need for reoperation, without the need for mesh.

S0444 Concomitant TIF With Hiatal Hernia Repair: A Collaborative Single Center Experience

INTRODUCTION: Transoral incisionless fundoplication (TIF) is an attractive alternative to the traditional surgical fundoplications for the treatment of gastroesophageal reflux disease (GERD). Ideal candidates are limited to patients with hiatal hernia (HH), diaphragmatic hiatus (DH) ≤ 2cm, and Hill Grade (HG) I or II because TIF does not address the HH component of GERD. A novel approach of TIF immediately preceded by HH repair, coined concomitant TIF (cTIF), has emerged as a possible solution to address these limitations. The purpose of this study is to assess the efficacy, safety and feasibility of cTIF using a collaborative approach between Interventional Gastroenterology and Foregut Surgery. METHODS: Subjects with a HH or DH too large to undergo TIF (>2 cm), Barrett’s esophagus, LA class C esophagitis or a DeMeester score >50 were selected for cTIF. Subjects underwent HH repair by a surgeon followed by TIF by a gastroenterologist inone combined procedure. Variables studied included age, BMI, HH size, Proton Pump Inhibitor (PPI) or H2 blocker (H2B) use pre and post procedure, and symptoms based on the Reflux Disease Questionnaire (RDQ), GERD Health Related Quality of Life (HRQL) Index and the Reflux Symptom Index (RSI). RESULTS: 34 subjects underwent cTIF, and of those 18 patients had follow up data greater than 6 months. At the time of cTIF, mean age was 59.8 and 17 were male. Mean HH measurement was 2.7 cm. Pre-cTIF, 30 subjects were on PPIs. There was 100% success rate in performing TIF after hiatus repair. 12 months post cTIF, 86% of patients were off PPI. RDQ for symptom frequency was 17.4 pre-cTIF and 4.78 post-cTIF (P < 0.01). RDQ for symptom severity was 16.7 pre-cTIF and 4.56 post-cTIF (P < 0.06). GERD-HRQL for heartburn severity was 23.3 pre-cTIF and 7.37 post-cTIF (P < 0.01). GERD-HRQL for regurgitation severity was 14.3 pre-cTIF and 0 post-cTIF (P = 0.05). RSI was 17.7 pre-cTIF and 8.1 post-cTIF (P < 0.01). CONCLUSION: These early results suggest that concomitant HH repair and TIF appear to be safe and effective in patients with HH or diaphragmatic hiatus too large to undergo TIF alone and severe esophagitis. Many of these patients would not have met traditional criteria for complete or even partial fundoplication and so these patients may be receiving surgical therapy earlier in the disease spectrum. Prospective randomized studies comparing cTIF to laparoscopic Nissen Fundoplication are warranted.

3216 SMA Syndrome and Small Bowel Obstruction

INTRODUCTION: Superior mesenteric artery (SMA) syndrome is a condition in which the third portion of the duodenum, between the abdominal aorta and SMA, is compressed. The disease is rare, as incidence rates range from 0.1% to 0.3%. It is more prevalent in females aged 10 to 39 years old. Symptoms include severe weight loss, epigastric pain, nausea, and vomiting. SMA syndrome is an uncommon cause of small bowel obstruction (SBO). This case describes a patient with known SMA syndrome who presented with acute symptoms of SBO. CASE DESCRIPTION/METHODS: A 36-year-old male with past medical history of polysubstance abuse, hypertension, GERD, psychiatric disorders (bipolar, anxiety, depression), GI bleeds, and SMA syndrome presented with worsening abdominal pain for two weeks. Pain was described as dull and constant with radiation to his lower back. Associated symptoms included worsening nausea and coffee ground hematemesis, as well as dark stools and decreased appetite. The patient was hemodynamically stable. NG tube was placed to help with decompression. He was given IV fluids and started on pantoprazole 40 mg BID IV. CT abdomen with contrast showed a 4 mm obstruction at the third portion of the duodenum consistent with SMA syndrome and a second jejunal area of transition. General surgery deemed him to not be an appropriate surgical candidate, and medical management was recommended. EGD demonstrated a collapse of the duodenal mucosa at the third to fourth portion of the duodenum with moderate chronic appearing dilation of the duodenum proximal to this area. A small sliding hiatal hernia and LA class D esophagitis were also seen. He was started on sucralfate 1 gm QID PO and switched to pantoprazole 40 mg daily PO upon discharge. Liquid diet was advanced as tolerated. Once his symptoms improved, he was discharged and instructed to follow up with a GI physician. DISCUSSION: SMA syndrome should be considered in the differential for young adults presenting with symptoms of SBO due to the morbidity and mortality associated with malnutrition, dehydration, and other complications, such as gastric perforation and hemorrhage. Diagnosis is made based on clinical symptoms and radiologic imaging. Initial treatment is non-operative medical management with fluid resuscitation, TPN, NG tube, and electrolyte correction. Laparoscopic duodenojejunostomy is the most common surgical intervention used when medical management fails. In this case, the patient was able to have improvement in symptoms with medical management alone.

A Case of Systemic Sclerosis Mimicking Achalasia

Systemic sclerosis (SS) may be associated with GERD symptoms and dysphagia related to esophageal dysmotility or a peptic stricture in 50 - 90% of patients. HRM may show esophageal aperistalsis of the smooth muscle with a low LESp. We present 2 cases of SS presenting with HRM findings characteristic of type I Achalasia; onepatient with symptomatic dysphagia and the other patient with symptomatic GERD and endoscopic esophagitis. Both patients have diffuse SS, Raynaud's phenomenon, interstitial lung disease, GERD and positive SS serologies. Case 1 is a 66 year-old female who developed dysphagia 8 years following SS diagnosis. BaS noted esophageal atony, no strictures and a patulous GEJ, with a normal EGD. GERD symptoms improved with PPIs but she developed progressive solid-food dysphagia without weight loss. Re-evaluation 4 years later revealed a normal EGD while HRM showed aperistalsis, normal LESp with a ?IRP mimicking type I achalasia. Timed BaS demonstrated mild mid-esophageal dilation (3 cm), tapering at the distal esophagus with minimal barium retention at 5 minutes (Fig. 1). Repeat EGD for possible pneumatic dilation, demonstrated a mildly patulous LES that was easily distended following air insufflation and no resistance w ith endoscopic passage through the GEJ. Case 2 is a 54 year old patient with an 11 year history of SSc and GERD but no dysphagia with a mildly dilated esophagus with intraluminal debris (Fig. 2). HRM showed aperistalsis, normal LESp, and elevated IRP (Fig 3). Most recent EGD revealed LA Class B esophagitis. Caution should be exercised in making the diagnosis of achalasia in SS patients. Full evaluation must include a timed barium study, and EGD to be certain that one is dealing with GEJ obstruction. Measurement of the LESp and relaxation are dependent upon: (1) the crural diaphragm which does not relax during swallowing, (2) the intrabolus pressure generated by the fluid passing through the GEJ, and (3) the cephalad movement of esophagus related to longitudinal muscle contraction which shortens the esophagus and momentarily pulls the stomach into the GEJ during swallowing. It is possible that in SS with a dilated esophagus and no muscle contraction, the esophagus did not shorten and LES remained stationary at the level of the crural diaphragm. Few cases exists of SS having HRM criteria for achalasia. These 2 cases presents a hypothesis for further research in SS patients having HRM criteria for achalasia.1722_A Figure 1. Mild esophageal dilation with distal esophageal tapering and minimal barium retention in case 11722_B Figure 2. Mild esophageal dilation with intraluminal debris in case 21722_C Figure 3. Representative esophageal topography of elevated IRP in case 2

Quality of life and associated factors in patients with chronic Chagas disease.

To evaluate the quality of life (QoL) of patients with Chagas disease (CD) and the association between QoL domains and several clinical, socioeconomic and lifestyle characteristics of this population. Cross-sectional observational study conducted from March 2014 to March 2017 including a total of 361 outpatients followed at Evandro Chagas National Institute of Infectious Disease, Brazil. QoL was assessed using the Portuguese shorter version of the original WHO Quality of Life questionnaire (WHOQOL-BREF). Information about clinical CD presentation, presence of comorbidities, functional class, previous benznidazole treatment, socioeconomic profile and lifestyle was also obtained. Environment and physical domains presented the worst QoL scores, while the social relationship domain presented the highest score. Multivariate regression analysis demonstrated that variables independently associated with QoL were functional class, sex, clinical presentation of CD, sleep duration, schooling, physical activity level, smoking, income per capita and residents by domicile. The low socioeconomic status and the physical limitations imposed by the disease presented an important impact on the QoL reduction among CD patients, especially on environment and physical domains. Strategies to improve QoL among CD patients should be tailored and consider many different variables to maximise improvements not only of patients' physical but also of their mental health.

A Black Esophagus

A 54-year-old woman with type II diabetes mellitus presented with a 3-day history of vomiting and mild abdominal pain. She was afebrile, tachycardic and severely hypertensive. Her abdomen was non-tender and without guarding. Laboratory evaluation revealed hyperglycemia, acidosis, acute kidney injury and elevated troponin. She was admitted with a diagnosis of diabetic ketoacidosis and hypertensive emergency. Overnight, she developed melena. Upper endoscopy revealed an esophagus with black necrotic tissue from 23cm to 32cm from the incisors, ending abruptly at the gastroesophageal junction. The patient was kept nothing per mouth and started on intravenous pantoprazole. Repeat endoscopy 6 days later showed healing of the esophageal necrosis and ulceration. Her diet was advanced, and she was switched to oral pantoprazole. Two weeks later, repeat endoscopy revealed LA class D esophagitis, which appeared substantially improved. Acute esophageal necrosis (AEN) is a rare condition with prevalence between 0.001 to 0.2%. It is characterized by circumferential black mucosa in the esophagus. It most commonly manifests as upper gastrointestinal bleeding, but it can also cause dysphagia, chest pain, or epigastric pain. Risk factors include male sex, age, cardiovascular disease, hemodynamic compromise, gastric outlet obstruction, alcohol ingestion, malnutrition, diabetes, renal insufficiency, hypoxemia, and hypercoagulable state. Diagnosis is based on the findings of upper endoscopy with the appearance of black necrotic tissue, mostly in the distal esophagus, and terminates at the gastroesophageal junction. Histology is not required for diagnosis, but it can be helpful to rule out other causes. Etiology is multifactorial, including tissue hypoperfusion due to an ischemic insult, impaired local barrier defenses, and acid reflux. Management is conservative with bowel rest, acid suppression, and hydration with restoring hemodynamic stability. Treating the coexisting medical condition is crucial, as AEN has been associated with different medical conditions, including diabetic ketoacidosis. Complications include esophageal stricture, mediastinitis, infection or abscess, and esophageal perforation. Death has been reported, with a mortality rate of 6% due to AEN, and as high as 32% due to the underlying medical condition. Therefore, high clinical suspicion and appropriate diagnosis and management are important to save the patient's life.FigureFigureFigure

La Classe américaine

On 31 December 1993, French pay TV channel Canal+ broadcast a 70-minute film called La Classe américaine, directed by Michel Hazanavicius and Dominique Mézerette. They took excerpts from about fifty Warner Bros. productions, edited them to build a story and had the characters (played by A-list actors such as John Wayne and James Stewart) dubbed over by well-known French voice actors, resulting in what is known technically as a ‘détournement’, combining the techniques of film collage and dubbing. This paper sketches the origins and the production context of this very unusual audiovisual object, relying on insights from film theory, with particular reference to adaptation techniques like remixes and collages. The analysis also shows how meaning and humour are created through the montage of originally completely disconnected scenes and the addition of funny or crude dialogues that one would not expect from cinema legends like John Wayne. A final part highlights the film’s cult status and its influence on the creation of more détournements.

Improved Transgenic Mouse Model for Studying HLA Class I Antigen Presentation.

HLA class I (HLA-I) transgenic mice have proven to be useful models for studying human MHC-related immune responses over the last two decades. However, differences in the processing and presentation machinery between humans and mice may have profound effects on HLA-I restricted antigen presentation. In this study, we generated a novel human TAP-LMP (hTAP-LMP) gene cluster transgenic mouse model carrying an intact human TAP complex and two human immunoproteasome LMP subunits, PSMB8/PSMB9. By crossing the hTAP-LMP strain with different HLA-I transgenic mice, we found that the expression levels of human HLA-I molecules, especially the A3 supertype members (e.g., A11 and A33), were remarkably enhanced in corresponding HLA-I/hTAP-LMP transgenic mice. Moreover, we found that humanized processing and presentation machinery increased antigen presentation of HLA-A11-restricted epitopes and promoted the rapid reduction of hepatitis B virus (HBV) infection in HLA-A11/hTAP-LMP mice. Together, our study highlights that HLA-I/hTAP-LMP mice are an improved model for studying antigen presentation of HLA-I molecules and their related CTL responses.

Acute Superior Mesenteric Artery Syndrome: Value of Early Diagnosis

Superior mesenteric artery (SMA) syndrome is a rare cause of proximal small bowel obstruction characterized by compression of the third portion of the duodenum due to narrowing of the space between the superior mesenteric artery and aorta. This is primarily attributed to loss of the intervening mesenteric fat pad. A 42 year old African American woman with uncontrolled type 1 Diabetes Mellitus presented with shortness of breath, abdominal pain associated with nausea and vomiting of 5 days duration, and recent 40 lb weight loss. EGD and colonoscopy at an outside hospital was negative. BMI was 16.5, and epigastrum was tender without guarding or rebound. Labs: remarkable for glucose 795, anion gap 34 and positive serum ketones. DKA was treated and resolved. However, vomiting persisted despite antiemetic and prokinetic agents. Amylase was 197 and lipase 1068. CT abdomen revealed an unremarkable pancreas, markedly dilated stomach and 2nd duodenum with air fluid levels, wall enhancement, and copious intraabdominal fluid. This was concerning for gastric outlet obstruction. EGD revealed LA class C esophagitis in the distal third of the esophagus and hiatus hernia. Stasis ulcers were seen in the cardia and fundus. Duodenum was dilated and hyperemic but passable to an area of normal jejunum. Abdominal MRI showed dilatation of the stomach extending to the mid third portion of the duodenum where it became collapsed at the level of the SMA. Aortomesenteric angle was 80. Impression: SMA syndrome. The patient was transferred to the surgical service but managed conservatively with hydration, high caloric diet, and her symptoms improved. On follow up, she was noted to have a 2.7kg weight gain and reported complete resolution of her symptoms. Our patient had several risk factors for SMA syndrome including age, asthenic habitus and 40lb weight loss, which may have been due to diabetes. Clinical presentation with symptoms of nausea, vomiting and abdominal pain was typical but nonspecific. Prolonged SMA syndrome may result in a patulous duodenum that must be decompressed by surgical duodenojejunostomy. Patients with acute SMA syndrome, such as our patient, often respond to conservative treatment such as nasogastric decompression, hydration, electrolyte correction, left lateral decubitus positioning and nutritional support to facilitate weight gain. High index of suspicion and early diagnosis are needed to prevent permanent disability due to this rare condition.

An Atypical Endoscopic Presentation of Zollinger-Ellison Syndrome

Zollinger-Ellison syndrome (ZES) is a rare condition characterized by gastrointestinal (GI) ulceration due to a gastrin-secreting tumor and hyper-secretion of gastric acid. Recent studies have shown thickened gastric folds and duodenal ulcers as the two most common endoscopic findings occurring in up to 80.3% and 15.3% of patients. We present a case of ZES with atypical endoscopic findings. A 52 year-old female with type 2 diabetes and hypertension presented with peri-umbilical pain. She described 7 out of 10, dull, aching pain with brown, mucus-like emesis. In the emergency department (ED), she was diagnosed with diverticulitis, prescribed antibiotics, and discharged. Due to severe nausea she did not finish the medications. She returned to the ED in 5 days with worsening pain. A CT abdomen/pelvis with contrast showed a 6.5x4.6x5.5 cm lobular enhancing mass lateral to the 4th part of the duodenum with multiple enlarged lymph nodes and wall thickening of the duodenum, suspicious for malignancy. Gastroenterology was consulted. Push enteroscopy showed severe LA class D esophagitis, and a normal stomach. The proximal duodenum had erosions and small clean based ulcers. Distal to the duodenal bulb, circumferential ulcers were seen with overlying eschar on each duodenal and proximal jejunal fold. There was a high suspicion for ZES given the CT and endoscopic findings. Fasting serum gastrin level was 3804 pg/mL (normal).Figure 1Figure 2Figure 3GI ulcerations are common endoscopic findings in ZES with 91-93% having peptic or duodenal ulcers when diagnosed. ZES is usually characterized by solitary ulcers < 1cm in diameter, with the majority in the 1st part of the duodenum. However, it is not uncommon for ulcers to be located in the distal duodenum or jejunum. Circumferential ulcers of the small bowel are often related to non-steroidal anti-inflammatory medications, or thiazide potassium-chloride use. In this case of Zollinger-Ellison we found multiple, circumferential ulcers extending from the duodenal bulb to the jejunum, which has not been previously reported endoscopically.

L'autunno (caldo) non è una stagione televisiva

The article analyzes representations of 1969 - the so-called Autunno caldo - in the Italian television, from 1970 to 2000. More specifically, the focus of the survey are sceneggiati and Tv films, compared with movies where workers are the main characters (like La classe operaia va in paradiso, for example). The aim of the article is to understand how Italian television contributes to define the representation of industrial workers in the collective imagination. For this reason the main sources are Tv fictions, that have a bardic function unlike news or journalistic programs.

Acute Esophageal Necrosis in Alcohol Abuse and Diabetic Ketoacidosis

Introduction: Acute esophageal necrosis (AEN) is a rare disorder with approximately 112 cases reported. AEN has a mortality rate of over 30% and most commonly presents with signs of upper GI bleed. AEN is caused by hypoperfusion of the esophagus leading to mucosal damage. Some risk factors include age, male gender, diabetes mellitus, alcohol ingestion and malnutrition. Here we present a case of severe esophageal necrosis in the setting of diabetic ketoacidosis (DKA) and alcohol abuse. A 55-year-old male with poorly controlled diabetes and alcohol abuse presented with chest pain, nausea and vomiting, and severe DKA. He subsequently developed upper GI bleed with melena requiring blood transfusion. Urgent EGD showed large hiatal hernia with severe diffuse LA class D esophagitis with black exudates (Figures), involving the entire esophagus. Patient improved clinically with aggressive PPI and topical therapy. EGD 3 weeks later demonstrated healing of the esophagitis. Our case is an example of classic AEN. Patient’s ongoing alcohol abuse, poorly controlled diabetes, and large hiatal hernia most likely contributed to severity of the disease with involvement of most of the esophagus. Current therapy for AEN includes supportive treatment such as hydration and antacids and management of underlying conditions. In this case, despite the high mortality rates associated with AEN, our patient’s condition resolved within 3 weeks of diagnosis after supportive treatment and management of DKA.Figure 1Figure 2

‘GHOSTS, SCARS AND GODS’: BRINGING THE ITALIAN SPECTATOR INTO VIEW

In contention with the contradictions of poststructuralism, and as a kind of commentary to an article published contemporaneously by Roland Barthes in France, Pier Paolo Pasolini wrote of political engagement, ‘‘‘Sospendere il senso’’: ecco una stupenda epigrafe per quella che potrebbe essere una nuova descrizione dell’impegno, del mandato dello scrittore’. For Barthes, the writer should construct meanings (‘construire des sens’), but leave them open (‘ne pas les remplir’), thus allowing the completion of the meaning (signifiO) to take place beyond the author. Restricting ourselves to cinema, rather than literature (though not coincidentally Pasolini writes this in his noted article, ‘La fine dell’avanguardia’, where he exposes the intrinsic capacity of film to reflect the real, thus transcending literature), this ‘epigraph’ offers a very provocative revision of how engagement works, categorically shifting the attention away from the writer (or at least her mandato). The significance of this suggestion is well illustrated by the return made to this part of the essay by scholars of impegno more recently: in Fragments of Impegno, Jennifer Burns quotes Pasolini directly, reading his work more explicitly in terms of the need to shift the functioning of impegno ‘from an author-centric towards a reader-centric paradigm’ (p. 35). Almost ten years later, the same point (this time in citation of Burns) is picked up by Pierpaolo Antonello and Florian Mussgnug in the volume Postmodern Impegno, once again calling directly for a greater authority for the reader (or, in our case, spectator). In relation to cinema d’impegno specifically, ‘sospendere il senso’ is no doubt a highly tense and problematic process, first and foremost because, for Pasolini and Barthes, it appears contradictorily to remain an authorial act (‘il mandato dell autore’). Moreover, this is a process which does not lend itself to any familiar historical logic: when the models of engagement that we know in the Italian case are the paternalistic auteur films of directors likeFrancescoRosi, it appearsuncomfortable, albeitnot impossible, toarticulate in any obvious terms how the spectator could ‘bring’ the engagement theoretically to just any text. In other words, films such as those of Rosi come with explicit political aims, and their signifiO is relatively well established, with little room for interpretative manoeuvre. The sheer volume of possible films that could be considered ‘impegnati’ when ‘sospendendo il senso’ would moreover become overwhelming, and perhaps insulting to our familiar genre of Political Cinema: suddenly La classe operaia va in paradise (Elio Petri, 1971) and Il caso Mattei (Francesco Rosi, 1972) could go hand in hand with, for instance, Ti amo in tutte le lingue del mondo (Leonardo Pieraccioni, 2005), an episode of Un medico in famiglia (1998–present), or the video for Meno male che Silvio c’O (2008). The Italianist, 34. 2, 265–267, June 2014

Pierre Cochereau: Organist of Notre-Dame by Anthony Hammond (review)

Cochereau: Organist of Notre-Dame. By Anthony Hammond. (Eastman Studies in Music, vol. 91.) Rochester, NY: University of Rochester Press, 2012. [x, 346 p. ISBN 9781580464055. $85.] Music ex- amples, illustrations, work lists, appendices, bibliography, index.The French organist, improviser, com- poser, and pedagogue Cochereau (1924-1984) was, in his lifetime, feted, re- viled, and generally successful. Because he wrote little and published seldom, Coche- reau's legacy as a composer rests almost en- tirely on the improvisations with which he concluded his recitals and amplified church services at Notre-Dame de Paris, where he was organist from 1955. Cochereau has been held accountable by some for the long neglect, then perhaps overly radical renova- tion of the historic Cavaille-Coll instrument at Notre-Dame. He further provoked with his idiosyncratic recordings of early music, such as multiple renditions of Francois Couperin's Messe pour les couvents and Messe pour les paroisses, usually played excruciat- ingly slowly and occasionally with their lively dotted rhythms (notes inegales) simply ignored and played straight.Cochereau is mostly forgotten today ex- cept for his recorded improvisations, which are thrilling, and for charming quirks such as his penchant for touring rural France with his own portatif organ, which he towed in a custom-made trailer. Anthony Hammond has taken up the challenge of examining Cochereau anew and from many angles, constructing a layered and af- fectionate portrait not only of this signifi- cant and gifted musician but of the musical and cultural environments in which he smoothly operated.Hammond is not impeded by the lack of secondary literature. In fact, he is clever enough to benefit from Cochereau being not widely known or at least not well under- stood. This is not a biography, although there is a life-and-career chapter; rather, Hammond lets an impression of Coche- reau's legacy build gradually and organi- cally by approaching his subject through the various musical and administrative roles Cochereau played in his life, in six chapters and five appendices. These last include the first complete list of Cochereau's record- ings of works by other composers as well as of Cochereau's own improvisations and film soundtracks.Cochereau was educated largely at the Paris Conservatoire. He studied harmony with Maurice Durufle, analysis and aes- thetics with Olivier Messiaen, and organ with Marcel Dupre from 1943 to 1950. For a long span of chapter 2, Cochereau's name does not appear at all. Instead, Hammond revels in the administrative doc- uments Dupre generated at the Conserva- toire, now in the collection of the Biblio- theque nationale de France. Exam notes and sample extemporization plans (how to accompany Gregorian chant, how to impro- vise a fugue) illustrate the text. Nearly every page of chapter 2 contains a music exam- ple, a diagram, or a table. I question why this was thought necessary, as there is al- ready a masterful two-volume documentary study of these and similar materials, Odile Jutten's 871-page-long L'enseignement de l'improvisation a la classe d'orgue du Con- servatoire de Paris, 1819-1986. D'apres la the- matique de concours et d'examens (Villeneuve d'Ascq: Presses universitaires du Sep- tentrion, 2000). It is true that Jutten's study is a synthesis, gathering the perspectives of many teachers and students, whereas Hammond prefers to concentrate on Cochereau alone. Still, Hammond does not add much to our knowledge of Dupre's teaching methods and the chapter does not serve his project; instead, it bears the unappetizing taint of having been too much research to throw away.Chapter 3, Pierre Cochereau as Inter- preter, is more original and much more satisfying. Breaking down Cochereau's repertoire by composer, Hammond evalu- ates the recordings for content (fidelity to the score, choice of organ) and offers some context (the writing of the sleeve notes by Thurston Dart, various musicologists' opin- ions on rhythmic flexibility in baroque music at the time of recording). …

“This is a Matter of Numbers, Not of Heart”. Re-signing Shock Labor in 1970s Film

The 1970s mark a turning point in the representation of “exemplary workers”, shock workers and work heroes, who had for years been part of the enterprise to increase (mainly) industrial production in state socialist countries and beyond. From its very beginnings, shock labor was inseparable from its representation in the mass media, mainly documentaries and propaganda films. In contrast, in the early 1970s, post-war work successes turn into a caput mortuum, a worthless residue of early “official” socialism. Accordingly, the image of the shock labor movement and of shock workers-as-innovators turns out to be interesting material for artists and filmmakers, who resurrect and rediscover this long-forgotten idea, turning it into an instrument of criticism of the system that advocated it, without criticizing the movement’s most prominent actors. Yugoslav, Polish and Italian directors Bahrudin Bata Cengic, Andrzej Wajda and Elio Petri in their films Slike iz života udarnika (Images from the Life of a Shock Worker, 1972), Czlowiek z marmuru (Man of Marble, 1976) and La classe operaia va in paradiso (Lulu the Tool, 1972) respectively, re-sign the essence of work heroism. The problem of increasing production quotas, a “good and happy family life” accompanied by indispensable cultural education and the inclusion of workers in political life are some of the prevailing topics these directors use to build their own eclectic, critical as well as apologetic vision of the shock labor past or present. Key words: shock labor, Stakhanovism, film, Alija Sirotanovic, socialism, Slike iz života udarnika

HLA-B*44 Is Associated with a Lower Viral Set Point and Slow CD4 Decline in a Cohort of Chinese Homosexual Men Acutely Infected with HIV-1

HLA class I alleles have been shown to have differential impacts on the viral load and the outcome of HIV-1 disease progression. In this study, HLA class I types from residents of China with acute HIV-1 infection, diagnosed between 2006 and 2011, were identified and the association between expression of individual HLA alleles and the level of the set point viral load was analyzed. A lower level of set point viral load was found to be associated with the Bw4 homozygote on HLA-B alleles. B*44 and B*57 alleles have also been found to be associated with lower set point viral load. The set point viral load of B*44-positive individuals homozygous for Bw4 was significantly lower than that of B*44-negative individuals homozygous for Bw4 (P = 0.030). The CD4 count declined to <350 in fewer B*44-positive individuals than B*44-negative individuals (X(2) = 7.295, P = 0.026). B*44-positive individuals had a lower magnitude of p24 pool-specific T cell responses than B*44-negative individuals homozygous for Bw4, though this was not statistically significant. The p24 pool-specific T cell responses were also inversely correlated with lower viral load (rs = -0.88, P = 0.033). Six peptides within p24 were recognized to induce the specific-T cell response in B*44-positive individuals, and the peptide breadth of response was same as that in B*44-negative individuals homozygous for Bw4, but the median magnitude of specific-T cell responses to the recognized peptides in B*44-positive individuals was lower than that in B*44-negative individuals homozygous for Bw4 (P = 0.049). These findings imply that weak p24-specific CD8(+) T cell responses might play an important role in the control of HIV viremia in B*44 allele-positive individuals. Such studies might contribute to the development of future therapeutic strategies that take into account the genetic background of the patients.