Intra-operative quick insulin assay to confirm complete resection of insulinomas guided by selective arterial calcium injection (SACI)

Background and aims Insulinomas are rare endocrine disorders. Pre-operatively, conventional imaging techniques often fail to localise the tumor. In addition, due to the lack of quick insulin assays, intra-operative confirmation of complete resection was impossible until recently. Materials and methods Six patients with biochemical evidence of an insulinoma underwent pre-operative localisation studies and selective arterial calcium injection (SACI). In addition, insulin was measured before surgery and every 10–15 min after resection of the tumor using a quick insulin assay. Results Pre-operative localisation studies identified the tumor correctly as follows: endosonography: three of four, magnetic resonance imaging: two of four and SACI: six of six. Tumors in the head and body were enucleated while those in the tail were resected (n = 2, each). Those three patients, in whom magnetic resonance imaging and/or endosonography could localise the tumors pre-operatively, underwent laparoscopic surgery while the remaining three patients underwent open surgery. Intra-operatively, insulin dropped to normal levels within 20 min in all cases. After a follow-up of 0.8–3 years, all patients remained biochemically cured. Conclusions Pre-operatively, SACI appears to be a very sensitive localisation technique and may be most helpful in guiding the surgeon if conventional imaging techniques fail to localise the tumor. Complete removal of an insulinoma can be reliably predicted using a quick insulin assay. This paper was presented at the 2nd Biennial Meeting of the European Society of Endocrine Surgeons (ESES), May 18–20, 2006, Krakow, Poland.     

Prevalence of dietary supplement use in adults with chronic renal insufficiency.

OBJECTIVE: There are currently no studies that have investigated dietary supplement use in the chronic renal insufficiency (CRI) population. The objectives of this study were to determine the prevalence of dietary supplement use in a sample of adults with CRI and to examine whether the prevalence of dietary supplement use was higher in the earlier stages of CRI. DESIGN AND SETTING: Cross-sectional survey conducted at an outpatient nephrology clinic. PATIENTS: Adults (n = 100) with varying degrees of CRI. INTERVENTION: Interview-administered questionnaire. MAIN OUTCOME MEASURES: The questionnaire contained questions related to the use of dietary supplements, attitudes, and beliefs about dietary supplements, as well as medical and demographic data including gender, age, body weight, smoking status, concurrent chronic conditions, prescribed medications, serum creatinine, estimated glomerular filtration rate (GFR), etiology of CRI, income, and education level. RESULTS: The prevalence of dietary supplement use was 45%, with the most frequent use occurring in subjects with a mild to moderate degree of renal insufficiency. There were no significant differences in gender, age, body mass index, smoking status, number of concurrent chronic conditions, number of prescribed medications, income, or education level between supplement users and supplement nonusers. Further analysis of dietary supplement use showed that the number of supplements used ranged from 1 to 5 or more supplements per day, with an overall total of 36 different supplements. Dietary supplement users were significantly more concerned with their health than were supplement nonusers. The most frequent sources of supplement information were physicians and printed material; however, 75% of the dietary supplement users desired further information about their dietary supplements. CONCLUSION: This is the first study to investigate the use of dietary supplements in adults with CRI, and it provides valuable information for health care professionals regarding the dietary supplement use of their patients with CRI.     

Anomalous head posture with early-onset homonymous hemianopia

PURPOSE: We have noted the frequent finding of an ipsilateral head turn in children with early-onset homonymous hemianopia. We report a series of patients with these findings and propose a theory to explain this association. METHODS: Ten patients with early-onset homonymous hemianopia and anomalous head posture were examined. Head computed tomography and magnetic resonance imaging confirmed a cerebral lesion as the cause of the hemianopia in all patients. RESULTS: All patients had onset of central nervous system disease prenatally or before age 18 months. A head turn toward the visual field defect with a gaze preference contralateral to the visual field defect was present in all patients. CONCLUSIONS: Early-onset homonymous hemianopia should be included in the differential diagnosis of anomalous head posture.     

Fluorescence immunohistochemistry and confocal scanning laser microscopy

We have developed a reliable technique for labeling and examining neural structures in soft tissues associated with articular joints and have tested it in human wrist joints under various specimen-related conditions. The labeling protocol employs an immunohistochemical process with a panneuronal marker (PGP 9.5) as the primary antibody and Alexa Fluor 488 as the fluorescing secondary antibody. Imaging was done using a confocal laser scanning microscope, which produced exceptionally detailed three-dimensional images of nerve endings and transiting nerve fibers from thick sections of wrist joint ligaments obtained from human cadavers. The protocol provided a practical postmortem window for specimen acquisition and processing without significant apparent worsening of image quality. The images produced are resistant to fading with repeated exposure to a fluorescent light source, which gives many opportunities for observation. Background staining is minimal, producing high contrast labeling of target tissues, which, in turn, enhances image analysis.     

Managing COPD: no more nihilism!

This special issue of Patient Education and Counseling is long overdue. During most of the last two decades asthma, and notably asthma self-management has been in the spotlight, while COPD has had to endure a nihilistic approach. The first sign that interest was shifting to the treatment of COPD came from a few large randomized trials on the use of inhaled corticosteroids (ICS) in COPD. Although these studies demonstrated a moderate effect of ICS in COPD, it has become clear that true improvements in the management of this chronic disease will have to come from behavioral interventions. This special issue of Patient Education and Counseling is dedicated solely to the non-pharmaceutical management of COPD. It addresses many issues related to behavioral therapy, such as smoking cessation, exercise training, nutritional aspects, and self-management programs, including action plans to self-treat exacerbations. With the availability of all the treatment and management options, described in this special issue, a nihilistic attitude toward the patient with COPD is no longer justified.     

An efficient SNP system for mouse genome scanning and elucidating strain relationships

A set of 1638 informative SNP markers easily assayed by the Amplifluor genotyping system were tested in 102 mouse strains, including the majority of the common and wild-derived inbred strains available from The Jackson Laboratory. Selected from publicly available databases, the markers are on average ~1.5 Mb apart and, whenever possible, represent the rare allele in at least two strains. Amplifluor assays were developed for each marker and performed on two independent DNA samples from each strain. The mean number of polymorphisms between strains was 608±136 SD. Several tests indicate that the markers provide an effective system for performing genome scans and quantitative trait loci analyses in all but the most closely related strains. Additionally, the markers revealed several subtle differences between closely related mouse strains, including the groups of several 129, BALB, C3H, C57, and DBA strains, and a group of wild-derived inbred strains representing several Mus musculus subspecies. Applying a neighbor-joining method to the data, we constructed a mouse strain family tree, which in most cases confirmed existing genealogies.     

Depletion of long-lived lymphocytes in old New Zealand black mice

Labelling studies with tritiated thymidine in NZB mice revealed that old mice of this strain with established Coombs positive haemolytic anaemia were depleted predominantly of long-lived small lymphocytes. Lymphopoiesis in the bonemarrow was relatively less affected suggesting that the peripheral destruction or deviation of re-circulating lymphocytes and not a precursor cell deficiency may account for the depletion of these cells. Old NZB mice in which the development of Coombs positive haemolytic anaemia, but not other disease features, has been prevented by thymectomy and treatment with anti-lymphocyte globulin several months earlier were equally deficient in this population of lymphocytes. C57BL mice, subjected to the same regime largely regenerated this population during the subsequent 12 months and rejected skin homografts in the same time as young controls of the same strain. Loss of lymphocytes responsible for antigen recognition would account for the impaired cellular immunity of old NZB mice observed in this study and described earlier by other authors. This process appears to accompany the progression of the spontaneous disease in this strain.     

Nanopattern-induced changes in morphology and motility of smooth muscle cells

Cells are known to be surrounded by nanoscale topography in their natural extracellular environment. The cell behavior, including morphology, proliferation, and motility of bovine pulmonary artery smooth muscle cells (SMC) were studied on poly(methyl methacrylate) (PMMA) and poly(dimethylsiloxane) (PDMS) surfaces comprising nanopatterned gratings with 350 nm linewidth, 700 nm pitch, and 350 nm depth. More than 90% of the cells aligned to the gratings, and were significantly elongated compared to the SMC cultured on non-patterned surfaces. The nuclei were also elongated and aligned. Proliferation of the cells was significantly reduced on the nanopatterned surfaces. The polarization of microtubule organizing centers (MTOC), which are associated with cell migration, of SMC cultured on nanopatterned surfaces showed a preference towards the axis of cell alignment in an in vitro wound healing assay. In contrast, the MTOC of SMC on non-patterned surfaces preferentially polarized towards the wound edge. It is proposed that this nanoimprinting technology will provide a valuable platform for studies in cell-substrate interactions and for development of medical devices with nanoscale features.     

Nursing constraint models for electronic health records: a vision for domain knowledge governance

Various forms of electronic health records (EHRs) are currently being introduced in several countries. Nurses are primary stakeholders and need to ensure that their information and knowledge needs are being met by such systems information sharing between health care providers to enable them to improve the quality and efficiency of health care service delivery for all subjects of care. The latest international EHR standards have adopted the openEHR approach of two-level modelling. The first level is a stable information model determining structure, while the second level consists of constraint models or 'archetypes' that reflect the specifications or clinician rules for how clinical information needs to be represented to enable unambiguous data sharing. The current state of play in terms of international health informatics standards development activities is providing the nursing profession with a unique opportunity and challenge. Much work has been undertaken internationally in the area of nursing terminologies and evidence-based practice. This paper argues that to make the most of these emerging technologies and EHRs we must now concentrate on developing a process to identify, document, implement, manage and govern our nursing domain knowledge as well as contribute to the development of relevant international standards. It is argued that one comprehensive nursing terminology, such as the ICNP or SNOMED CT is simply too complex and too difficult to maintain. As the openEHR archetype approach does not rely heavily on big standardised terminologies, it offers more flexibility during standardisation of clinical concepts and it ensures open, future-proof electronic health records. We conclude that it is highly desirable for the nursing profession to adopt this openEHR approach as a means of documenting and governing the nursing profession's domain knowledge. It is essential for the nursing profession to develop its domain knowledge constraint models (archetypes) collaboratively in an international context.