Anatomical planes: Are we teaching accurate surface anatomy?

Anatomical planes used in clinical practice and teaching anatomy are largely derived from cadaver studies. Numerous inconsistencies in clinically important surface markings exist between and within anatomical reference texts. The aim of this study was to reassess the accuracy of common anatomical planes in vivo using computed tomographic (CT) imaging. CT scans of the trunk in supine adults at end tidal inspiration were analyzed by dual consensus reporting to determine the anatomy of five anatomical planes: sternal angle, transpyloric, subcostal, supracristal, and the plane of the pubic crest. Patients with kyphosis, scoliosis, or abnormal lordosis, distorting space‐occupying lesions, or visceromegaly were excluded. Among 153 thoracic CT scans (mean age 63 years, 53% female), the sternal angle was most common at T4 (females) or T4/5 (males) vertebral level, and the tracheal bifurcation, aortic arch, and pulmonary trunk were most often below this plane. In 108 abdominal CT scans (mean age 60 years, 59% female), the subcostal and supracristal planes were most often at L2 (58%) and L4 (69%), respectively. In 52 thoracoabdominal CT scans (mean age 61 years, 56% female), the transpyloric plane was between lower L1 and upper L2 (75%); in this plane were the superior mesenteric artery (56%), formation of the portal vein (53%), tip of the ninth rib (60%), and the left renal hilum (54%), but the right renal hilum and gallbladder fundus were more often below. The surface anatomy of anatomical planes needs revising in the light of results from living subjects using modern imaging techniques. Clin. Anat. 25:819–826, 2012. © 2012 Wiley Periodicals, Inc     

Acute mountain sickness: Is there a lag period before symptoms?

The present study was designed to determine if symptoms of acute mountain sickness are presented within six hours after arrival at high altitude. Seventeen male subjects, 23–30 years, were studied. The subjects were professional soccer players, life-long residents at low altitudes except one player who was playing soccer in a team at 3400 m (512 mm Hg of Barometric Pressure) during an entire year in 1995. The players were transported by a commercial airline from Lima (150 m) to Cusco (3400 m). The trip lasted 1 hour. Heart rate and arterial oxygen saturation were measured at rest in Lima (150 m), at the time of arrival at Cusco, and at 4 and 6 hours after arrival at 3400 m. On day 6 at high altitude, the physical performance during a soccer game was assessed. The symptoms of acute mountain sickness (AMS) were assessed 6 hours after arrival at Cusco with a self-administered questionnaire, and thereafter each 24-hours up to 5 days of exposure to high altitude. The following symptoms were assessed: headache, gastrointestinal symptoms, dizziness, fatigue, and sleep abnormalities. AMS was defined by a Lake-Louise score ⩾4 (self-assessment only). Thirty five percent of the soccer players developed AMS within 6 hours after arrival by air at 3400 m altitude. Arterial oxygen saturation at arrival was higher in those player who developed AMS within 6 hours after arrival (94.3 ± 0.94% vs 90.8 ± 2.36; P < 0.001). From arrival to 6 hours of exposure to altitude, there was a significant fall in arterial oxygen saturation in those men who developed AMS than in those who did not. Results from the stepwise multiple regression (R² = 0.59; P < 0.04) and logistic regression (R² = 0.48; P < 0.0019) analyses showed that the difference between arterial oxygen saturation at sea level and at arrival at Cusco was a predictor for the development of AMS within 6 hours upon arrival at altitude. This suggests that the lower the difference between arterial oxygen saturation at sea level and at arrival, the higher the probability to develop AMS within 6 hours after arrival at 3400 m. The presentation of AMS, however, does not predict low performance in physical activity at high altitude. Am. J. Hum. Biol. 10:669–677, 1998. © 1998 Wiley-Liss, Inc.     

Drug labels: Are they a readable material?

OBJECTIVE: This study aims to evaluate cardiovascular drug labels from the perspective of how readable the text materials are. METHODS: Comparison of drug labels written in accordance with the 1997 Brazilian legislation with those written in accordance with the 2003 Brazilian legislation, with journalistic text and scientific essays using as tool the Flesch Index. RESULTS: The journalistic text had an average Flesch Index of 62.6%; the scientific essays, 23.5%; the drug labels written in accordance with the old legislation, 43.8%; and those written in accordance with the most recent legislation, 47.2%. CONCLUSION: Drug labels are more readable than scientific essays and less readable than journalistic texts; they were classified as difficult to read. PRACTICE IMPLICATIONS: Text readability formulas are an objective measure that may improve the search for better-written communication materials and thereby a greater understanding of drug labels by patients. However, a more detailed validation of an objective measure of text evaluation should be considered by the health authorities of each country, with their own language as basis.     

When does mechanical plantar stimulation promote sensory re-weighing: standing on a firm or compliant surface?

The purpose of this study was to investigate the effect of different types of mechanical stimulation of the sole on standing postural stability in healthy, young adults. Fifty subjects (34 women, 16 men; mean age 23 ± 2 (mean ± SE)) stood barefoot on fixed force plates both with open and closed eyes on firm surface and then on compliant surface (foam). A modified clinical test of sensory interaction on balance protocol was employed to assess the center of gravity (COG) excursions along anteroposterior (AP) and mediolateral (ML) axes on each surface and visual condition. After the baseline measurement, a stimulation was applied with an elastic spiked layer topped to the firm and then foam surface, and the COG excursions were measured during the stimulation, and then at least 30 min after the stimulation of the spiked layer, we used 10 min of manual static and glide pressure applied to the plantar surface of both feet. Immediately after manual stimulation, static balance parameters were measured again. Results showed that after manual stimulation, the sway path with closed eyes decreased significantly on the AP and ML directions on firm surface conditions. The spiked layer caused significantly decreased sway path on firm platform in both directions, but it was ineffective on compliant surface. Our results established that the activation of plantar mechanoreceptors by 10-min manual stimulation can partially compensate subjects for the absence of visual input and the lack of accurate pressure information from the supporting surface, too.     

Significance of flat epithelial atypia on mammotome core needle biopsy: Should it be excised?

The aim of this study was to determine the morphologic types, associations, and significance of flat epithelial atypia (FEA) with or without atypical ductal hyperplasia (ADH) in mammotome core needle biopsies. We evaluated the correlation of FEA in core biopsies with follow-up excision biopsies to predict the likelihood of upgrade to carcinoma. We also investigated the utility of Ki-67 in predicting which lesions were associated with carcinoma in the excisional biopsies. Core biopsies with a diagnosis of atypia were categorized as pure FEA, pure ADH, or both. The following parameters were recorded: indication for core biopsies, presence of microcalcifications, inflammation, and stromal changes. A total of 60 core biopsies from 56 patients were studied. Pure ADH, pure FEA, and concomitant FEA and ADH were seen in 13%, 23%, and 64% of core biopsies, respectively. The most common architectural pattern of FEA resembled blunt duct adenosis (52%), followed by cystically dilated ducts with secretions (38%) and apocrine features (10%). Chronic inflammation and stromal changes were noted in 29% and 36% of FEA, respectively. Excisional biopsies in 48 of 56 patients demonstrated ductal carcinoma in situ and/or invasive carcinoma in 10 patients (21%), lobular carcinoma in situ or atypical lobular hyperplasia in 5 (11%), residual ADH in 11 (23%), and no atypia in 24 patients (50%). Three (21%) of 14 pure FEA upgraded to ductal carcinoma in situ and/or invasive carcinoma on excisional biopsy. The staining for Ki-67 in FEA/ADH was similar regardless of whether they were upgraded to carcinoma or not. In summary, we found a strong association between FEA and ADH, which may reflect a biologic progression. Most FEAs have a low-power appearance of a well-circumscribed group of ducts. Chronic inflammation and stromal changes are present in a subset of cases. Flat epithelial atypia shows a risk of upgrade to carcinoma similar to that of ADH and, hence, should be recognized and warrants a follow-up excision.     

Are we estimating the adverse effects of shock-wave lithotripsy on a faulty scale?

The adverse effect of shock-wave lithotripsy (SWL) for renal stones on blood pressure is currently defined as its post-treatment increase. On the contrary, we hypothesize that even mild, unilateral renal obstruction initiates an increase in blood pressure. Then, in absence of treatment-induced injury, the stone removal should decrease the blood pressure. We derived the formula to assess the expected change in the mean arterial pressure following relief of renal obstruction without affecting the kidney functions. The predictions were well replicated in the cohort of patients with renal stone treated with parenchyma-saving open surgery, with 6.4 mmHg decrease at 3 months. On the contrary, in SWL cohort, instead of the expected 4.7 mmHg decrease, the blood pressure was unchanged. In conclusion, the absence of decrease in blood pressure is a very common adverse effect of SWL, leading to an epidemiologically significant increase in the risk of arterial vascular events.     

Unacknowledged adverse transfusion reactions: Are they a mine to dig?

Objectives

Haemovigilance has long tried to characterize and understand transfusion reactions in order to prevent them. Unacknowledged ones are now a minority but they question us. Are they the result of incomplete clinical setting and/or insufficient medical reasoning, or can they contain real new entities we have not yet understood?

Protein adsorption onto polyester surfaces: is there a need for surface activation?

Surface hydrolysis of polyester scaffolds is a convenient technique suggested to promote protein adsorption for improving cell attachment. We have, therefore, investigated the effect of hydrolysis of polyester surfaces for protein adsorption to clarify the conditions needed. Three polyesters, poly(ethylene terephthalate) (PET), poly(lactic acid) (PLA), and poly(glycolic acid) (PGA), were selected. Adsorption was investigated by X-ray photoelectron spectroscopy (XPS), scanning electron microscopy (SEM), and quartz crystal microbalance (QCM). Hydrolyzed PET adsorbed significantly more proteins than nonhydrolyzed. Degradable polymers adsorbed at higher rates when the polymers were hydrolyzed prior to adsorption, but the same amount as nonhydrolyzed, suggesting spontaneous hydrolysis during the adsorption. XPS shows that hydrolysis prior to absorption for PET results in a surface nitrogen composition of approximately 14%, similar to pure protein (16%). Nonhydrolyzed PET surfaces showed only approximately 7% nitrogen, indicating protein layers thinner than approximately 10 nm. Adsorption to PLA and PGA shows nitrogen contents of 14-15% in both cases. SEM revealed striking differences in morphology of the protein coating. Hydrolyzed or spontaneously hydrolyzable surfaces display a pronounced fibrous structure while nonhydrolyzed surfaces give smooth structures. In combination, the results show that surface hydrolysis increase adsorption rate, but not the amount of proteins on polyesters that degrades in vivo. Surface treatment of nondegradable polyester increases the total amount of proteins and induces the formation of fibrous protein structures. Post hydrolysis treatment by acetic acid, replacing the counter-ion to a proton, further enhances protein attachment. Finally, cell attachment experiments verifies that protein adsorption increase the cell attachment to polyester surfaces.     

A lump on the tongue: a diagnostic dilemma?

This paper is a case report of an oral lesion detected in a female patient in her twenties. The aetiology and pathology was not immediately clear-cut but the patient's history provided a clue to its origins and histopathological examination confirmed the diagnosis. It was a "Pregnancy Tumour" which had failed to regress after parturition. This case report will make medical and dental practitioners more aware of lumps and lesions in the mouth. It will also provide a more rational and scientific approach to the management of "Pregnancy Tumours".     

Controlling the uncontrolled: Are there incidental experimenter effects on physiologic responding?

The degree to which experimenters shape participant behavior has long been of interest in experimental social science research. Here, we extend this question to the domain of peripheral psychophysiology, where experimenters often have direct, physical contact with participants, yet researchers do not consistently test for their influence. We describe analytic tools for examining experimenter effects in peripheral physiology. Using these tools, we investigate nine data sets totaling 1,341 participants and 160 experimenters across different roles (e.g., lead research assistants, evaluators, confederates) to demonstrate how researchers can test for experimenter effects in participant autonomic nervous system activity during baseline recordings and reactivity to study tasks. Our results showed (a) little to no significant variance in participants’ physiological reactivity due to their experimenters, and (b) little to no evidence that three characteristics of experimenters that are well known to shape interpersonal interactions—status (using five studies with 682 total participants), gender (using two studies with 359 total participants), and race (in two studies with 554 total participants)—influenced participants’ physiology. We highlight several reasons that experimenter effects in physiological data are still cause for concern, including the fact that experimenters in these studies were already restricted on a number of characteristics (e.g., age, education). We present recommendations for examining and reducing experimenter effects in physiological data and discuss implications for replication.     

Provision of counseling on diabetes self-management: Are there any age disparities?

Objective

To determine whether there are any age-related disparities in the frequency of provision of counseling and education for diabetes care in a large HMO in Central Texas.

Methods

EMR search from 13 primary care clinics on patients aged ≥18 years (n = 1300) who had been diagnosed with type 2 diabetes.

Results

There were no significant age differences in the frequency of provision of counseling about HBGM, diet, smoking or diabetes education. However, there were significant age differences in the provision of exercise counseling. Patients aged ≥75 were significantly less likely to have been provided exercise counseling than those aged <65 (adjusted OR = 0.60; 95% CI = 0.37–0.98). The mean HbA1c for patients aged ≥75 and 65–74 were significantly lower than that of patients aged <65 (8.9 vs. 9.0 vs. 9.7; P < 0.001).

Conclusion

While age-related variations in self-management protocols were not found, the provision of formal diabetes education was low (29.4%). The persistence of key risk factors in later life (e.g., obesity) underscores the need for better self-management protocols for older adults.

Practice Implications

Additional efforts on strategies to increase counseling about lifestyle habits and diabetes self-management care by appropriate health care providers is needed. Diabetes counseling should be individually tailored in older population.     

Human binucleate hepatocytes: Are they a defence during chronic liver diseases?

Binucleate cells are commonly found in various human organs including liver, salivary glands and endometrium, but their functional advantage remains unknown. The increased occurrence of binucleate hepatocytes during the necro-inflammation stage of progressive chronic hepatitis and its end-stage of cirrhosis, but their absence in hepatocellular carcinoma (HCC), has led us to hypothesise that they may be an index of the severity of hepatic illness rather than the result of errors occurring during the course of the cell cycle. This hypothesis is supported by the immunohistochemical analysis of retinol-binding protein expression, and the different life cycles of hepatitis B virus in mononucleate and binucleate hepatocytes. If founded, this hypothesis would add to our understanding of the relationship between binucleate hepatocytes and the evolution of chronic liver disease, and promises the ideation of new criteria for identifying potential HCC patients.     

Thymosin β4 and Cardiac Regeneration: Are We Missing a Beat?

Epicardial resident stem cells are known to differentiate into cardiomyocytes during cardiac development, amongst other cell types. Whether epicardium-derived progenitor cells (EPDCs) retain this plasticity in the adult heart has been the topic of heated scientific debate. Priming with thymosin beta 4, a peptide which has been suggested to be critical for cardiac development and to have cardio-protective properties, was recently shown to induce differentiation of EPDCs into cardiomyocytes in a small animal model of myocardial infarction. This finding is in stark contrast to another recent study in which thymosin beta 4 treatment following myocardial infarction did not induce cardiomyocyte differentiation of EPDCs. While EPDCs seem to exhibit overall cardio-protective effects on the heart following myocardial infarction, they have not been shown to differentiate into cardiomyocytes in a clinically relevant setting. It will be important to understand why the ability of one therapeutic agent to induce cardiomyocyte differentiation of EPDCs seemingly depends on a single variable, i.e. the time of administration. Furthermore, in light of a recent report, it appears that thymosin beta 4 may be dispensable for cardiac development.     

Inhibitory receptors on eosinophils: a direct hit to a possible Achilles heel?

Since their discovery, much data have been accumulated on eosinophil differentiation, morphology, trafficking, and anatomical location(s) in health and disease. Although "classic" activation pathways (such as cytokines, chemokines, proinflammatory components, and adhesion molecules) regulating eosinophil activation have been widely explored, the presence of other activation molecules that might be disease specific is limited. Furthermore, the expression and function of inhibitory receptors on eosinophils have received scant attention. The need to identify new pathways that regulate eosinophil activation is a crucial goal as it can expand our knowledge on this peculiar cell and provide insights into important queries regarding the physiologic function of eosinophils. Over the past several years, it has become increasingly apparent that eosinophils express several receptors belonging to the immunoglobulin superfamily. In this review, we summarize the current knowledge on the expression and function of new pathways that govern eosinophil activation. In addition, we will propose some hypotheses regarding the ability to use these pathways as a future therapeutic approach. In conclusion, we assume that targeting inhibitory receptors on eosinophils may provide opportunities for immunoregulatory therapy in the near future.