Increased serum CA 19-9 antibodies in Sjögren's syndrome

A 67-year-old woman with a history of thyroiditis presented with recent intermittent epigastric pain and nausea. Hyperamylasaemia, oedema of the pancreas, and high serum levels of lipase and CA 19-9 were found. Xerostomia and dry eyes developed later, accompanied by an abnormal Schirmer''s test. The diagnosis of Sjögren''s syndrome was confirmed by increased anti-Ro and anti-La antibodies and the histological findings of parotid gland biopsy. Two additional cases of Sjögren''s syndrome with elevated serum CA 19-9 are also described. These observations of elevated serum lipase and serum CA 19-9 in Sjögren''s syndrome without evidence of malignancy may reflect pancreatic involvement in this disorder.     

Improving handoff communications in critical care: utilizing simulation-based training toward process improvement in managing patient risk

BACKGROUND: A patient admitted to the medical step-down unit experienced severe hypoglycemia due to an infusion of a higher-than-ordered insulin dose. The event could have been prevented if the insulin syringe pump was checked during the nursing shift handoff. METHODS: Risk management exploration included direct observations of nursing shift handoffs, which highlighted common deficiencies in the process. This led to the development and implementation of a handoff protocol and the incorporation of handoff training into a simulation-based teamwork and communication workshop. A second round of observations took place 6 to 8 weeks following training. RESULTS: The intervention demonstrated an increase in the incidence of nurses communicating crucial information during handoffs, including patient name, events that had occurred during the previous shift, and treatment goals for the next shift. However, there was no change in the incidence of checking the monitor alarms and the mechanical ventilator. CONCLUSIONS: Simulation-based training can be incorporated into the risk management process and can contribute to patient safety practice.     

Autosomal recessive microcephaly with neonatal myoclonic seizures: Clinical and MRI findings

We describe an infant who was born to a consanguineous couple of Palestinian origin. The patient had severe microcephaly, myoclonic seizures, hypsarrythmia, spasticity, hypertonicity, and profound mental retardation. A similar case was reported in another unrelated Palestinian family, suggesting that this condition may be endemic. The condition resembles early onset myoclonic seizures and spasticity described by Tolmie et al.: Am J Med Genet 27:583–594 [1987]. To the best of our knowledge, only four pairs of sibs have been described with this syndrome; however, to date no magnetic resonance imaging (MRI) findings were reported for this condition. We present the clinical and radiological findings in the patients, including the first report of MRI findings. Am. J. Med. Genet. 80:136–139, 1998. © 1998 Wiley-Liss, Inc.     

The medial border of the tibial tuberosity as an auxiliary tool for tibial component rotational alignment during total knee arthroplasty (TKA)

Purpose

The objective of this study was to quantify the amount of ensuing internal rotation of the tibial component when positioned along the medial border of the tibial tubercle, thus establishing a reproducible intraoperative reference for tibial component rotational alignment during total knee arthroplasty (TKA).

Methods

The angle formed from the tibial geometric centre to the intersection of both lines from the middle of the tibial tuberosity and its medial border was measured in 50 patients. The geometric centre was determined on an axial CT slice at 10 mm below the lateral tibial plateau and transposed to a slice at the level of the most prominent part of the tibial tuberosity. Similar measurements were taken in 25 patients after TKA, in order to simulate the intraoperative appearance of the tibia after making its proximal resection.

Results

This angle was found to be similar (n.s.) in normal and post-TKA tibiae [median 20.4° (range 15°–24°) vs. 20.7° (range 16°–25°), respectively]. In 89.3 % of the patients, the angle ranged from 17° to 24°. No statistical difference (p n.s.) was found between women and men in both normal [median ?20.7° (range 16°–25°) vs. 19.9° (range 15°–24°)] and post-TKA tibiae [median 21.4° (range 19°–24°) vs. 20° (range 16°–25°)].

Conclusion

This study found that in 90 % of the patients, the medial border of the tibial tuberosity is internally rotated 17°–24° in relation to the line connecting the middle of the tuberosity to the tibial geometric centre. Since this anatomical landmark may be more easily identifiable intraoperatively than the commonly used “medial 1/3”, it can provide a better quantitative reference point and help surgeons achieve a more accurate tibial implant rotational position.

Level of evidence

Cohort and case control studies, Level III.

     

High and low mammographic density human breast tissues maintain histological differential in murine tissue engineering chambers

Mammographic density (MD) is the area of breast tissue that appears radiologically white on mammography. Although high MD is a strong risk factor for breast cancer, independent of BRCA1/2 mutation status, the molecular basis of high MD and its associated breast cancer risk is poorly understood. MD studies will benefit from an animal model, where hormonal, gene and drug perturbations on MD can be measured in a preclinical context. High and low MD tissues were selectively sampled by stereotactic biopsy from operative specimens of high-risk women undergoing prophylactic mastectomy. The high and low MD tissues were transferred into separate vascularised biochambers in the groins of SCID mice. Chamber material was harvested after 6 weeks for histological analyses and immunohistochemistry for cytokeratins, vimentin and a human-specific mitochondrial antigen. Within-individual analysis was performed in replicate mice, eliminating confounding by age, body mass index and process-related factors, and comparisons were made to the parental human tissue. Maintenance of differential MD post-propagation was assessed radiographically. Immunohistochemical staining confirmed the preservation of human glandular and stromal components in the murine biochambers, with maintenance of radiographic MD differential. Propagated high MD regions had higher stromal (p = 0.0002) and lower adipose (p = 0.0006) composition, reflecting the findings in the original human breast tissue, although glands appeared small and non-complex in both high and low MD groups. No significant differences were observed in glandular area (p = 0.4) or count (p = 0.4) between high and low MD biochamber tissues. Human mammary glandular and stromal tissues were viably maintained in murine biochambers, with preservation of differential radiographic density and histological features. Our study provides a murine model for future studies into the biomolecular basis of MD as a risk factor for breast cancer.     

The results of corrective osteotomy for valgus arthritic knees

Purpose

To evaluate the results of corrective varus osteotomy in the treatment of arthritic knees with valgus deformity.

Methods

The data were retrieved from a literature review. Each relevant study was screened for demographic details, surgical techniques, follow-up periods, clinical outcomes, and complications.

Results

A total of 27 publications describing the results of varus osteotomies for valgus arthritic knees were reviewed. All were small case series studies, variable in their patient population, surgical techniques, rehabilitation protocols, follow-up periods, clinical assessments and were categorized as level IV of scientific evidence.

Conclusion

The role of varus osteotomy remains poorly defined. The literature generally supports this procedure in active and cooperative patients to reduce pain and delay the need for knee replacement. New techniques hold promising results regarding shortening of rehabilitation time and low reoperation and complication rates.

Level of evidence

IV.     

Histopathological periodic acid-schiff stains of nail clippings as a second-line diagnostic tool in onychomycosis

The diagnosis of onychomycosis, using direct microscopy and fungal cultures, is often negative despite the presence of disease. Periodic acid-Schiff (PAS) staining of nail clippings, using histopathological processing, may be positive in these cases. It is not always clear, however, whether the fungal elements detected by PAS staining are pathogenic fungi or some are saprophytes. We aimed to study the efficacy of histopathological PAS staining of nail clippings as a second-line diagnostic tool in onychomycosis. The study included 100 consecutive cases in which direct microscopy and fungal cultures from suspected onychomycosis were negative on one occasion or more. The obtained nail clippings were processed for routine histology, stained with hematoxylin and eosin and PAS, and examined microscopically. Of the 100 cases, 38 (38%) showed positive fungal elements. As a result, 9 patients had sought and received oral antifungal therapy and all achieved complete clinical cure. The histological examination also revealed parakeratosis and globules of plasma, which were statistically significantly more common in the fungal infected nail samples. This may indicate an ongoing inflammatory process associated with onychomycosis. Neutrophils and bacteria were not statistically and significantly more common in the fungal infected nails. We conclude that as a second-line diagnostic tool, PAS stain of nail clippings increases markedly the diagnostic yield of onychomycosis and, consequently, the outcome of therapy.     

Epithelial-mesenchymal Plasticity in Breast Cancer Metastasis

Transitions between epithelial and mesenchymal states, which we have termed Epithelial Mesenchymal Plasticity (EMP), are important     

A novel dynamic matrix detachment model reveals a shift from apoptosis to necrosis in melanoma cells

Anchorage-independence is a hallmark of invasive cancer. The setback of the classical poly-HEMA static matrix detachment (SMD) anoikis model is the absence of dynamic fluid circulation, resulting in cell aggregates. We addressed this problem by developing a novel 3D cell culture dynamic matrix detachment (DMD) model with a turbulent-free laminar flow, yielding a very low shear stress. In this study, we focused on melanoma cells where apoptosis was evaluated both via annexin V flow cytometry and caspase cleavage. The DMD model was superior to SMD in the induction of melanoma cell death and in revealing a shift from apoptosis to necrotic cell death, as evident by failure to activate caspase 9 and a decrease in annexin V stain. Combination of DMD with cisplatin could further accentuate necrotic cell death in cisplatin-resistant melanoma cells. Thus, the DMD model may be a useful matrix deprivation model to identify necrotic vs. apoptotic cell death pathways.