Tobacco use following liver transplantation for alcoholic liver disease: an underestimated problem.

Alcohol and tobacco use commonly co-occur, with at least 90% of those with an alcohol problem also using tobacco. Thus, 3 years ago when we discovered higher rate of late deaths due to lung and oropharyngeal cancer in patients who had received a transplant for alcoholic liver disease (ALD), we hypothesized that these patients were continuing to expose themselves to tobacco after liver transplantation (post-LTX) and that this behavior was increasing their risk for cancer. We subsequently began a prospective investigation of post-LTX tobacco use in patients having undergone LTX for ALD (n = 172). For 33 recipients we had data starting from our first assessment at 3 months post-LTX and for this subgroup we report on the details of the timing of tobacco use resumption and the redevelopment of nicotine addiction. We found that on average more than 40% are smoking across all time periods. ALD recipients resume smoking early post-LTX, increase their consumption over time, and quickly become tobacco dependent. These data highlight an underrecognized serious health risk for these patients and demonstrate our need for more stringent clinical monitoring and intervention for tobacco use in the pre- and post-LTX periods.     

Hypoxia and HIF-1α expression in the epiphyseal cartilage following ischemic injury to the immature femoral head

HIF-1α has been shown to be a central mediator of cellular response to hypoxia. The role it plays after ischemic injury to the immature femoral head is unknown. The purpose of this study was to determine the region of the femoral head affected by hypoxia following ischemic injury to the immature femoral head and to determine the site of HIF-1α activation and revascularization. We hypothesize that the epiphyseal cartilage, rather than the bony epiphysis, is the site of HIF-1α activation following ischemic osteonecrosis and that the epiphyseal cartilage plays an important role in the revascularization process.Materials and methodsFemoral head osteonecrosis was surgically induced in 56 immature pigs. Hypoxyprobe staining, cell viability assay, HIF-1α western blot, RT-qPCR of HIF-1α, VEGF, VEGFR2, and PECAM, and micro-CT assessments of microfil-infused femoral heads were performed.ResultsSevere hypoxia was present in the bony epiphysis and the lower part of the epiphyseal cartilage following ischemia. In the bony epiphysis, extensive cell death and tissue necrosis was observed with degradation of proteins and RNAs which precluded further analysis. In the epiphyseal cartilage, the loss of cell viability was limited to its deep layer with the remainder of the cartilage remaining viable. Furthermore, the cartilage from the ischemic side showed a significant increase in HIF-1α protein level and HIF-1α expression. VEGF expression in the cartilage was dramatically and significantly increased at 24 h, 2 and 4 weeks (p < 0.05 for all) with 5 to 10 fold increase being observed on the ischemic side compared to the normal side. PECAM and VEGFR2 expressions in the cartilage were both significantly decreased at 24 h but returned to the normal levels by 2 and 4 weeks, respectively. Micro-CT showed revascularization of the cartilage on the ischemic side with the vessel volume/total volume equaling the normal side by 4 weeks.ConclusionsAcute ischemic injury to the immature femoral head induced severe hypoxia and cell death in the bony epiphysis and the deep layer of the epiphyseal cartilage. Viable chondrocytes in the superficial layer of the epiphyseal cartilage showed HIF-1α activation and VEGF upregulation with subsequent revascularization occurring in the cartilage.     

Diagnosis of breast cancer in women age 40 and younger: delays in diagnosis result from underuse of genetic testing and breast imaging

Background

The impact of newer breast imaging technologies and genetic testing on the detection of breast cancer in women age 40 and younger remains unknown.

Methods

A records review identified 628 women age 40 and younger diagnosed with breast cancer from 1996 to 2008. Patient and tumor characteristics, means of diagnosis, imaging results, and genetic testing were examined.

Results

Tumors were first detected by self-examination in 71%, with a median invasive tumor size of 2.0 cm. Imaging performed at or after diagnosis visualized most tumors; mammography visualized 86%, magnetic resonance imaging (MRI) visualized 96%, and mammography plus MRI visualized more than 98% of tumors. For 81% of patients, the mammogram at diagnosis was their first mammogram. Although 50% had a family history of breast or ovarian cancer, few underwent genetic testing before their cancer diagnosis; 61 of 247 (25%) ultimately tested had a BRCA mutation.

Conclusions

Better use of genetic testing, mammography, and MRI could improve breast cancer detection in young women.     

Multimethod Evaluation of Information and Communication Technologies in Health in the Context of Wicked Problems and Sociotechnical Theory

Objective

Few research designs look at the deep structure of complex social systems. We report the design and implementation of a multimethod evaluation model to assess the impact of computerized order entry systems on both the technical and social systems within a health care organization.

Design

We designed a multimethod evaluation model informed by sociotechnical theory and an appreciation of the nature of wicked problems. We mobilized this model to assess the impact of an electronic medication management system via a three-year program of research at a major academic hospital.

Measurements

Model components include measurements relating to three dimensions of system impact: safety and quality, organizational culture, and work and communication patterns.

Results

Application of the evaluation model required the development and testing of purpose-built measurement tools such as software to collect multidimensional work measurement data. The model applied established research methods including medication error audits and social network analysis. Design features of these tools and techniques are described, along with the practical challenges of their implementation. The distinctiveness of doing research within a unique paradigm of complex systems, explicating the wickedness and the dimensionality of sociotechnical theory, is articulated.

Conclusion

Designing an effective evaluation model requires a deep understanding of the nature and complexity of the problems that information technology interventions in health care are trying to address. Adopting a sociotechnical perspective for model generation improves our ability to develop evaluation models that are adaptive and sensitive to the characteristics of wicked problems and provides a strong theoretical basis from which to analyze and interpret findings.     

Hairdressers presenting to an occupational dermatology clinic in Melbourne,Australia

Background. Hairdressers constitute one of the largest occupational groups attending our occupational dermatology clinic in Melbourne, Australia. Objectives. To perform a retrospective review of the clinical assessments of hairdressers and trainee hairdressers attending our clinic, including patch testing results. Patients/materials/methods. We used our clinic database to identify trainee and qualified hairdressers who had attended our occupational dermatology clinic between January 1993 and December 2010. Results. One hundred and sixty‐four hairdressers and hairdressing apprentices were identified. One hundred and fifty‐seven had a diagnosis of occupational contact dermatitis (OCD), with allergic contact dermatitis being the primary diagnosis in 71% and irritant contact dermatitis in 20%. Involvement of more than one body part was suggestive of allergic contact dermatitis (p = 0.05). Sixty‐five per cent of participants were found to have more than one factor contributing to their OCD. Allergic contact dermatitis was more common in apprentices than in qualified hairdressers. Ammonium persulfate, p‐phenylenediamine, toluene‐2,5‐diamine and glyceryl monothioglycolate were the most common occupational allergens. Nickel allergy was seen in 31% of hairdressers, but considered to be occupationally relevant in only 3%. Conclusions. Multiple sensitizations and multiple factors contributing to OCD in hairdressers are common. More needs to be done to prevent the development of OCD in hairdressers in our geographical region.     

Intralymphatic granulomas in lymphoedema secondary to anogenital granulomatosis

The granulomatous inflammation seen in filariasis, orofacial granulomatosis (OFG), rosacea and sarcoidosis can be associated with lymphoedema. In the setting of OFG, the finding of intralymphatic granulomas has been reported as a possible mechanism for lymphoedema. Anogenital granulomatosis (AGG) is a similar chronic inflammatory condition of unknown pathogenesis. It presents as granulomatous genital or anoperineal inflammation and associated lymphoedema, with histological findings of non‐caseating granulomas and a perivascular infiltrate. We report a case of AGG and lymphoedema with intralymphatic granulomas seen on biopsy. This finding is unique and we propose that the intralymphatic granulomatous inflammation causes a partial or complete occlusion of lymphatic drainage, thus resulting in the clinical situation of lymphoedema.     

Case for diagnosis

The chondroid syringoma is a rare benign tumor, also called mixed cutaneous tumor by the presence of epithelial and mesenchymal components, consisting of sweat elements in cartilaginous, collagenous, myxoid or osseous stroma, among others. It mainly affects middle-aged men and is characterized by asymptomatic and slowgrowing, dermal or subcutaneous nodules. The most common locations are the head and neck. It is rare on the extremities. There are reports of malignant variants predominantly in women, located on the extremities. We report a case of a female patient with a lesion on the toe, with excellent outcome after surgical treatment.     

Bone mineral density: Methods of measurement and its influence on primary stability of miniscrews

Objective:To verify whether bone mineral density (BMD) of cortical bone, trabecular bone, and total bone influence the primary stability of orthodontic miniscrews and to verify whether there is a correlation between the measurement of BMD by cone-beam computed tomography (CBCT) and central dual-energy x-ray absorptiometry (DEXA).Materials and Methods:Twenty bovine bone sections were extracted from the pubic and iliac bones from regions with cortical thicknesses of approximately 1 mm. The BMD of the total bone block was evaluated using two methods: CBCT and DEXA. The BMD of cortical, trabecular, and total bone in the region of interest (ROI) were also evaluated by CBCT. After scanning the bone blocks, 20 self-drilling miniscrews (INP®) 1.4 mm in diameter and 6 mm long were inserted into them. The peak implant insertion torque (IT) was registered. After this, the pull-out test (PS) was performed and the maximum force registered. The Pearson correlation test was applied to verify the correlations between variables.Results:The BMD of the total bone block verified by CBCT and DEXA showed a positive and strong correlation (r  =  0.866, P  =  .000). The BMD of the ROI for cortical bone influenced the IT (r  =  0.518, P  =  .40) and the PS of miniscrews (r  =  0.713, P  =  .001, Table 2). However, the total bone BMD (verified by CBCT and DEXA) and trabecular bone BMD presented weak and not statistically significant correlations with primary stability.Conclusions:There was a positive correlation between total bone block BMD measured by DEXA and CBCT. The cortical BMD influenced the IT and PS.     

Sex-specific alterations in neutrophil apoptosis: the role of estradiol and progesterone

Women are conferred with greater immunologic and survival benefits compared to men. Female sex steroids contribute to this sexual dimorphism. Furthermore, during human pregnancy when female sex hormones are elevated, neutrophil apoptosis is delayed. This study examines the specific effects of estradiol and progesterone on neutrophil apoptosis and function in healthy adult men and women. We also examined the contribution of these hormones to the persistence and resolution of an inflammatory response. Spontaneous apoptosis was significantly decreased in women compared with men. Physiologic doses of estradiol and progesterone caused a further delay in spontaneous apoptosis in both men and women but did not diminish Fas antibody-induced apoptosis. The delay in apoptosis was mediated at the level of the mitochondria with decreased release of cytochrome c, which may alter caspase cleavage and activity. There were no associated alterations in neutrophil CD11b, but production of reactive oxygen intermediates (ROIs) in women was increased. Thus, female sex hormones mediate delayed neutrophil apoptosis in both sexes and enhance female intracellular production of ROIs. Modulating hormonal responses may be an effective therapeutic tool in combating inflammatory diseases.