Acral myxoinflammatory fibroblastic sarcoma: A case report and literature review

Acral myxoinflammatory fibroplastic sarcoma is an extremely rare soft-tissue sarcoma. It typically presents as an inflammatory mass in the distal extremities of adult patients. The authors present a review of the available literature as well as a discussion on the surgical management of a patient with acral myxoinflammatory fibroplastic sarcoma who originally requested conservative management but ultimately required a two-digit ray amputation after local recurrence.     

Catheter use and infection reduction in plastic surgery

BACKGROUND:

Catheter-associated urinary tract infections (CAUTI) are the most common hospital-associated infection and can result in increased health care costs, morbidity and even mortality. In 2009, The Scott & White Memorial Hospital/Texas A&M Health Science Center (Texas, USA) system’s CAUTI rate placed it in the upper quartile (ie, highest rate) for the country, necessitating a system-wide change.

OBJECTIVE:

To design and implement a guideline to reduce the incidence of CAUTI.

METHODS:

A multidisciplinary team was formed and completed both a root cause analysis and a review of the available literature. Consolidating the best evidence, the team formulated a best practice guideline detailing the proper indications for insertion of, improper use of and techniques to minimize infection with catheters. Included as part of this protocol was nursing and patient education, changes in identifying patients with a catheter and automatic termination orders. Three-, six- and 12-month reviews identifying additional opportunities for improvement at the end of 2010 were completed.

RESULTS:

In 2009, the hospital’s CAUTI rate was 1.46 per 1000 catheter days. In 2011 – the first complete year of the finalized guideline – the hospital’s CAUTI rate was 0.52 per 1000 catheter days, ranking the institution in the bottom quartile (ie, lowest rate) for the country. The surgery and plastic surgery subgroup analyses also demonstrated statistically significant reduction in both catheter use and CAUTI.

CONCLUSION:

The incidence of CAUTI was successfully reduced at The Texas A&M Healthcare Center. The guideline, its development and how it applies to plastic surgery patients are discussed.     

Assessment of estrus cyclicity in the Asian elephant (Elephas maximus) by measurement of fecal progesterone metabolite 5α-P-3OH, using a non-invasive assay

Reproductive management of the Asian elephant (Elephas maximus) is important for its conservation. To monitor its estrous cyclicity, we earlier used an indirect ELISA to show that levels of fecal progesterone (P(4))-metabolite (allopregnanolone: 5α-P-3OH) in semi-captive females sampled randomly positively correlated with serum P(4) levels [12]. In this longitudinal study (51 weeks), we measured levels of fecal 5α-P-3OH and serum P(4) in seven semi-captive female elephants. Females exhibited three types of hormonal profiles. Four females showed cyclical patterns of fecal 5α-P-3OH and serum P(4) typical of normal estrous cycles, two showed acyclic pattern while one showed high values indicative of a pregnant animal. Values for anestrous or follicular phases were ≤ 0.3 μg g(-1) (5α-P-3OH) and ≤ 0.3 ng mL(-1) (P(4)); for luteal phase 0.32-11.09 μg g(-1) (5α-P-3OH) and 0.32-1.48 ng mL(-1) (P(4)); for pregnancy 1.41-7.38 μg g(-1) (5α-P-3OH) and 0.39-1.6 ng mL(-1) (P(4)). A positive correlation (t = 8.8, p < 0.01, n = 321) between levels of fecal 5α-P-3OH and serum P(4) was observed. A random sample of 30 free-ranging female elephants showed fecal 5α-P-3OH values of 0.06-23.4 μg g(-1), indicating them to be in different stages of estrous cyclicity. This study is the first to assess the reproductive phases of female Asian elephants based on the correlative-patterns of both the fecal 5α-P-3OH and serum P(4) values over multiple estrous cycles. This has a potential application in the reproductive management and conservation of Asian elephants.     

64 slice computed tomography-a novel diagnostic method for evaluation of patients after coronary artery bypass grafts

ObjectiveMultislice computed tomography (CT) is widely used in analysing the native coronary arteries. The usefulness of 64 slice CT in patients with coronary artery bypass grafts (CABG) is analysed in the present study.Materials and methodsSixty-five patients (59 [92%] males and 6 [8%] females with the mean age of 59 ± 9.1 years) underwent 64 slice CT and a total of 186 bypass grafts (62 arterial and 124 venous grafts) were analysed using 64 slice CT. Bypass grafts and native vessels with the diameter of >1.5 mm were evaluated for the presence of significant stenosis of >70%. In all patients invasive coronary angiogram was done.ResultsOn the whole 43 venous grafts and 3 arterial grafts were found to be occluded. Majority of the grafts were occluded at the ostium. It was observed that the 64 slice CT was 90% sensitive and 96% specific for the evaluation of bypass grafts. It had 95% positive predictive value and 93% negative predictive value for predicting the luminal narrowing of grafts. For the assessment of arterial graft, it was 80% sensitive, 100% specific with a positive predictive value of 100% and negative predictive value of 93%. For the evaluation of venous grafts, the sensitivity, specificity, positive, and negative predictive value were 94%, 94%, 93%, and 94%, respectively.ConclusionWe conclude that the 64 slice CT is a highly reliable diagnostic tool with a very high negative predictive value for evaluating patients following CABG.     

Signal transducer and activator of transcription-3/suppressor of cytokine signaling-3 (STAT3/SOCS3) axis in myeloid cells regulates neuroinflammation

Suppressor of cytokine signaling (SOCS) proteins are feedback inhibitors of the JAK/STAT pathway. SOCS3 has a crucial role in inhibiting STAT3 activation, cytokine signaling, and inflammatory gene expression in macrophages/microglia. To determine the role of SOCS3 in myeloid cells in neuroinflammation, mice with conditional SOCS3 deletion in myeloid cells (LysMCre-SOCS3(fl/fl)) were tested for experimental autoimmune encephalomyelitis (EAE). The myeloid-specific SOCS3-deficient mice are vulnerable to myelin oligodendrocyte glycoprotein (MOG)-induced EAE, with a severe, nonresolving atypical form of disease. In vivo, enhanced infiltration of inflammatory cells and demyelination is prominent in the cerebellum of myeloid-specific SOCS3-deficient mice, as is enhanced STAT3 signaling and expression of inflammatory cytokines/chemokines and an immune response dominated by Th1 and Th17 cells. In vitro, SOCS3-deficient macrophages exhibit heightened STAT3 activation and are polarized toward the classical M1 phenotype. SOCS3-deficient M1 macrophages provide the microenvironment to polarize Th1 and Th17 cells and induce neuronal death. Furthermore, adoptive transfer of M2 macrophages into myeloid SOCS3-deficient mice leads to delayed onset and reduced severity of atypical EAE by decreasing STAT3 activation, Th1/Th17 cells, and proinflammatory mediators in the cerebellum. These findings indicate that myeloid cell SOCS3 provides protection from EAE through deactivation of neuroinflammatory responses.     

Pathogenesis and transmission of swine origin A(H3N2)v influenza viruses in ferrets

Recent isolation of a novel swine-origin influenza A H3N2 variant virus [A(H3N2)v] from humans in the United States has raised concern over the pandemic potential of these viruses. Here, we analyzed the virulence, transmissibility, and receptor-binding preference of four A(H3N2)v influenza viruses isolated from humans in 2009, 2010, and 2011. High titers of infectious virus were detected in nasal turbinates and nasal wash samples of A(H3N2)v-inoculated ferrets. All four A(H3N2)v viruses possessed the capacity to spread efficiently between cohoused ferrets, and the 2010 and 2011 A(H3N2)v isolates transmitted efficiently to naïve ferrets by respiratory droplets. A dose-dependent glycan array analysis of A(H3N2)v showed a predominant binding to α2-6–sialylated glycans, similar to human-adapted influenza A viruses. We further tested the viral replication efficiency of A(H3N2)v viruses in a relevant cell line, Calu-3, derived from human bronchial epithelium. The A(H3N2)v viruses replicated in Calu-3 cells to significantly higher titers compared with five common seasonal H3N2 influenza viruses. These findings suggest that A(H3N2)v viruses have the capacity for efficient replication and transmission in mammals and underscore the need for continued public health surveillance.Seasonal epidemics and periodic pandemics are an ever-present international public health burden. During seasonal epidemics, the risk for hospitalization and death are highest among persons at either end of the age spectrum as well as for individuals with underlying medical conditions (1, 2). Although the overall impact of the 2009 influenza pandemic, caused by an H1N1 virus [A(H1N1)pdm09] was more modest than those of prior pandemics, the disproportionate disease burden among children and younger adults distinguished this pandemic from seasonal influenza (3–5). The A(H1N1)pdm09 virus emerged from swine, with a unique constellation of genes from human, avian, and swine influenza viruses not previously observed in nature. Swine represent a unique host because of their ability to be infected by influenza viruses from multiple species and serve as a reservoir for specific subtypes of influenza capable of infecting humans (6–8). Triple-reassortant swine (TRS) H1N1 viruses, which share host gene-lineage origins with A(H1N1)pdm09 viruses, have been responsible for sporadic human cases since 2005 (9, 10). The emergence of the A(H1N1)pdm09 virus, to which the majority of children and younger adults had little preexisting immunity, highlights the public health threat posed by other swine-origin influenza virus subtypes.H3N2 viruses have circulated in humans since their pandemic emergence in 1968 and are generally associated with uncomplicated disease in young healthy adults. However, epidemics caused by H3N2 viruses have been more severe than those caused by seasonal H1N1 or influenza B viruses (11, 12). In 1997–1998, human H3N2 viruses infected swine and spread widely in North American swine (6–8). In particular, TRS H3N2 viruses with a human lineage polymerase subunit polymerase basic 1 (PB1) gene, avian lineage PB2 and polymerase acidic (PA) genes, and swine lineage nucleoprotein (NP), matrix (M), and nonstructural (NS) genes, referred to as the triple-reassortant internal gene (TRIG) constellation, have been isolated widely in pigs throughout the United States (6–8, 13). From the late 1990s to 2009, these novel variants of H3N2 viruses [A(H3N2)v] were limited to transmission among swine, with only occasional detections of transmission to humans (14). However, between September and November 2010, five cases of human infection with the novel swine-origin A(H3N2)v were reported (15). Although all five recovered fully from their illness, two of the five cases were hospitalized. In 2011, 12 additional human cases were documented in the United States, with limited human-to-human transmission in some cases (15–17). The 2011 A(H3N2)v viruses are similar to other A(H3N2)v viruses isolated from previous human infections over the past 2 y but are unique in that the M gene is derived from the A(H1N1)pdm09 virus. Antigenic characterization showed that the A(H3N2)v viruses are distinct from current seasonal H3N2 viruses but exhibit a low degree of serologic cross-reactivity with human H3N2 viruses that circulated in the early 1990s (6, 8, 13), suggesting that children born after this time period may be particularly susceptible to infection.The use of the ferret model has become indispensable for understanding the virulence and transmission of influenza viruses (18–20), partly because ferrets and humans share similar lung physiology as well as because human and avian influenza viruses exhibit similar patterns of binding to sialic acids, the receptor for influenza viruses distributed throughout the respiratory tract in both species (21, 22). In this study, we used glycan microarrays to determine the receptor-binding preference of the A(H3N2)v viruses isolated from humans. The culture model of bronchial epithelial Calu-3 cells was used to assess viral replication, and the ferret model was used to assess pathogenicity and transmissibility. Notably, the 2010 and 2011 swine-origin H3N2 viruses replicated even more efficiently than human seasonal influenza viruses in human airway Calu-3 cells and exhibited efficient respiratory-droplet (RD) transmission in ferrets. These findings suggest that swine-origin H3N2 viruses have the potential to cause additional human disease.     

The evolution of thyroid function with puberty

Objective This study was planned to describe thyroid functional status in different stages of puberty. Study design We collected data from five schools across different geographical zones of Delhi. All children who consented were evaluated for anthropometry, pubertal stage, goitre status, serum free T3 (FT3), free T4 (FT4), TSH, anti‐TPO (thyroid peroxidase) antibodies and thyroid ultrasound. From this sample, a disease‐ and risk‐free or ‘reference population’ was obtained by excluding those with history of thyroid disease or use of thyroid medications, family history of thyroid disease, goitre, hypoechogenicity or nodularity on ultrasound or positive antithyroid antibodies. Results The ‘total population’ comprised 3722 children; the ‘reference population’ comprised 2134 subjects. The mean, median, 3rd and 97th percentiles of serum FT3, FT4 and TSH for each stage of puberty were obtained. In both boys and girls, FT3 increased with entry into puberty and either stayed constant or declined marginally after stage 3 of puberty. In contrast, in both genders, FT4 decreased with entry into puberty and stayed relatively constant after stage 3 of puberty. TSH levels declined through puberty in boys, but remained largely unchanged in girls. An increased conversion of T4 to T3 is the possible explanation for this finding. Conclusions This large community‐based study in school‐age children using strict exclusion criteria provides data of thyroid function in the various stages of puberty. There is no evidence of ‘thyroidarche’ during or preceding puberty.     

Unintended Consequences of a Standard Admission Order Set on Venous Thromboembolism Prophylaxis and Patient Outcomes

BACKGROUND  

Standard order sets often increase the use of desirable interventions for patients likely to benefit from them. Whether such order sets also increase misuse of these interventions in patients potentially harmed by them is unknown. We measured the association between a paper-based standard admission order set with a venous thromboembolism pharmacoprophylaxis (VTEP) module and use of VTEP for patients likely to benefit from it as well as patients with unclear benefit or potential harm from it.