Evaluation of otoscopy simulation as a training tool for real-time remote otoscopy

Objective: Teleotoscopy requires the assistance of telehealth facilitators; but their training requirements remain to be determined. We evaluated the use of an otoscopy simulator to train facilitators to remote otoscopies sent via the Internet using a teleaudiology platform. Design: Neurotologists experts were asked to identify images using the otoscopy simulator and to perform an identification task of significant anatomical landmarks. The experts were asked to repeat those tasks remotely, with the help of facilitators who either received basic training, or no training prior to the experiment. Study sample: Three experts, three trained facilitators and three untrained facilitators participated in this study. Results: The use of an otoscopy simulator in addition to remote otoscopy yielded a good inter- and intrarater agreement (κ between 0.81–1, and 0.80–0.87, respectively). The accuracy of diagnosis was high on-site (11.7% error) and remotely (0% error). The time required for landmark identification task was not increased when performed remotely with a trained facilitator versus on-site otoscopy (9.3 versus 9.2?s/landmark). Conversely, the lack of training of facilitators increased significantly this time (15.6?s/landmark, p?Conclusion: An otoscopic simulator coupled to teleaudiology software can be used to efficiently train both experts and facilitators to perform remote otoscopy.     

Pulsed High–Intensity-focused US and Tissue Plasminogen Activator (TPA) Versus TPA Alone for Thrombolysis of Occluded Bypass Graft in Swine

PurposeProsthetic arteriovenous or arterial-arterial bypass grafts can thrombose and be resistant to revascularization. A thrombosed bypass graft model was created to evaluate the potential therapeutic enhancement and safety profile of pulsed high–intensity-focused ultrasound (pHIFU) on pharmaceutical thrombolysis.Materials and MethodsIn swine, a right carotid-carotid expanded polytetrafluoroethylene bypass graft was surgically constructed, containing a 40% stenosis at its distal end to induce graft thrombosis. The revascularization procedure was performed 7 days after surgery. After model development and dose response experiments (n = 11), two cohorts were studied: pHIFU with tissue plasminogen activator (TPA; n = 4) and sham pHIFU with TPA (n = 3). The experiments were identical in both groups except no energy was delivered in the sham pHIFU group. Serial angiograms were obtained in all cases. The area of graft opacified by contrast medium on angiograms was quantified with digital image processing software. A blinded reviewer calculated the change in the graft area opacified by contrast medium and expressed it as a percentage, representing percentage of thrombolysis.ResultsCombining pHIFU with 0.5 mg of TPA resulted in a 52% ± 4% increase in thrombolysis on angiograms obtained at 30 minutes, compared with a 9% ± 14% increase with sham pHIFU and 0.5 mg TPA (P = .003). Histopathologic examination demonstrated no differences between the groups.ConclusionsThrombolysis of occluded bypass grafts was significantly increased when combining pHIFU and TPA versus sham pHIFU and TPA. These results suggest that application of pHIFU may augment thrombolysis with a reduced time and dose.     

MICA‐129 Met/Val polymorphism could be a genetic biomarker for Familial Breast Cancer in the Tunisian population

Identification of candidate genes associated with susceptibility of breast cancer can have a significant impact at a cancer management national healthcare systems level, making genetic testing more affordable and cost‐effective. We have previously shown that the major histocompatibility complex class I‐related chain A (MICA) was related to breast cancer and plays an important role in modulating immune response mechanisms through NKG2D receptor activation. Compared to our previous study, in this work, we recruited a new cohort composed of 354 unrelated Tunisian women affected by breast cancer and 380 age‐matched women as controls, all genotyped for MICA‐129 Met/Val (rs 1051792). Subsequently, we exanimated the distribution of this polymorphism in ten families. As a result, an association was found between the Val allele and Val/Val genotype and the risk of breast cancer (p = 2.5 × 10^–15; OR = 2.40; p = 6.5 × 10^–13; OR = 3.03, respectively). Stratified analysis with age and family history of cancer revealed an association between the Val/Val genotype and younger patients <40 years (p = .003; OR = 2.03). Among those patients having a family history of cancer, 68% had a Val/Val genotype (p = .02; OR = 1.82). In the family study, an analyse of pedigrees revealed that the majority of families showed the development of breast cancer at a young age. Moreover, all patients diagnosed with early‐onset breast cancer had a Val/Val genotype. Our results lead us to propose that this polymorphism may be an inherited genetic biomarker contributing to an increased breast cancer risk in Tunisian women.     

Heteroclitic properties of mixed alpha- and aza-beta3-peptides mimicking a supradominant CD4 T cell epitope presented by nucleosome

Recent studies have revealed that peptide analogues containing modified peptide bonds might replace poorly stable natural peptides in therapeutic strategies. Using the model peptide 88-99 of histone H4, which contains a supradominant epitope recognized by Th cells induced to nucleosomes, we have generated twelve analogues containing aza-beta(3)-amino acid residue substitutions. The ability of this new class of peptidomimetics corresponding to the Psi[CONHNRCH(2)] modification to be recognized by T cells primed with the parent peptide was examined in BALB/c mice. An Ala-scan study revealed that residues 88 to 92 were essential for keeping antigenic activity of the nominal peptide. In good agreement, the six aza-beta(3)-analogues encompassing substitutions in the region 89-92 were antigenically inactive. Analogues PsiG94 and PsiG99 were both antigenic and immunogenic, though at levels that were slightly lower to that of the parent peptide. However, the remaining analogues PsiR95, PsiL97, PsiY98 and PsiL97-Y98 were strongly recognized by T cells generated to the homologous peptides. The PsiL97-Y98 analogue, in particular, strongly activated CD4(+) T cells as visualized in CFSE dilution assay. T cells primed to these four analogues and recalled with the nominal peptide secreted high levels of either IL-2 (PsiR95, PsiY98) or IFN-gamma (PsiL97, PsiL97-Y98). This result, supported by molecular modeling, suggests that TCRs of T cells primed to these four analogues recognized the parent peptide associated with the MHC I-A(d)/I-E(d) molecules. Since these T cells produce a distinct cytokine pattern when they are recalled with the parent sequence, this new class of analogues may have valuable applications in the context of self-tolerance and autoimmunity.     

Classical and "non-classical" cardiovascular risk factors in Tunisian patients with end stage renal disease: prevalence and association with cardiovascular events

This study was aimed to determine the prevalence of several classical and non-classical cardiovascular risk factors, and to test their association with cardiovascular events in Tunisian patients with end-stage renal disease. A total of 35 chronic renal failure, 50 hemodialysed and 30 renal transplant recipient patients and 31 healthy subjects were included. Hypertension, elevated plasma concentrations of total homocysteine, fibrinogen, C-reactive protein, and lipoprotein(a) were highly prevalent in patients, whereas, smoking, hypertriglyceridemia, hypercholesterolemia, hypoHDLemia, and hypoalbuminemia were less common. In univariate analysis, cardiovascular events were associated with age, hypertension, and the top quartile of the total homocysteine and C-reactive protein values. When controlling for several potential confounding factors, cardiovascular events remained associated with age, hypertension (OR, 7.07; 95% CI, 1.76-28.34; P=0.01), and the top quartile of total homocysteine (OR, 10.41; 95% CI, 2.61-41.55; P=0.001) and C-reactive protein (OR, 3.99; 95% CI, 1.06-14.99; P=0.04).     

Lupus erythematosus in children: a report of six cases

The clinical features of childhood discoid lupus erythematosus (DLE) are similar to those of adult DLE in presentation and chronic course. However, children have a particularly high levels of transition to systemic disease. Systemic lupus erythematosus (SLE) is the most common rheumatic disease associated with significant morbidity and mortality in children. This is a retrospective study reporting all cases of childhood lupus erythematosus observed in the dermatology department of Habib Thameur Hospital over a 14-year period. From 1989 to 2003, six cases of childhood lupus erythematosus are included, three patients with discoid lupus erythematosus (2 girls, 1 boy), and three patients with systemic lupus erythematosus (2 boys, 1 girl). The mean age of onset was 12 years (range 10-16 years). Skin manifestations were localized in sun exposed areas in both discoid and systemic lupus erythematosus. Photosensitivity was noted in all cases. The diagnosis was confirmed by histopathologic examination, direct immunofluorescence, and immunologic findings. Treatment included sun avoidance, oral hydroxychloroquine, and topical and systemic steroids. An average follow-up time was 18.1 months (1-96 months). The severity of onset of SLE is usually greater in children than adults. We note that lupus erythematosus is not a static disease and progression from DLE to SLE is possible.