Sclerosing Hemangioma of the Lung in a Young Woman with Cutaneous Melanoma: The Role of Electron Microscopy in Preventing an Erroneous Diagnosis of Metastasis

A young woman with a melanoma of the left forearm was found to have a right lung mass. This was initially interpreted as metastatic melanoma on the basis of clinical, radiographic, and light microscopic features, together with positive staining of tumor cells with antibody HMB-45. Electron microscopic examination performed for confirmation of the diagnosis revealed no evidence of melanocytic differentiation. Instead, there were features suggestive of the alternative diagnosis of sclerosing hemangioma (SH). This diagnosis was confirmed with additional immunocytochemical stains. To the authors' knowledge this is the first report of HMB-45 positivity in SH. This case illustrates a potentially disastrous diagnostic pitfall in interpreting lung tumors in patients with melanoma, and the vital role of electron microscopy in resolving conflicting and/or misleading immunocytochemical results.     

Differential effects of p38- and extracellular signal-regulated kinase mitogen-activated protein kinase inhibitors on inducible nitric oxide synthase and tumor necrosis factor production in murine macrophages stimulated with Streptococcus pneumoniae

The role of p38- and extracellular signal-regulated kinase (ERK) mitogen-activated protein (MAP) kinase pathways in the up-regulation of inducible nitric oxide synthase (iNOS) and tumor necrosis factor (TNF) production in macrophages stimulated with Streptococcus pneumoniae was examined. Inhibitors of p38 kinases effected significant decreases in the accumulation of iNOS protein in macrophages challenged with pneumococcal cell wall preparations or antibiotic-killed pneumococci, even when added up to 6 h after bacterial challenge. In contrast, ERK pathway inhibitors failed to inhibit pneumococcus-induced iNOS protein accumulation. ERK pathway inhibitors significantly reduced TNF secretion when added at the same time as pneumococcal challenge, and inhibitors of both ERK and p38 pathways reduced TNF secretion when added to the macrophages 1 h before stimulation. These data confirm the importance of the p38 and ERK MAP kinase pathways in macrophage activation by bacterial products but indicate that these 2 kinase pathways regulate different macrophage responses in a temporally distinct manner.     

Violent typologies among women inpatients with severe mental illness

Purpose

Extant severe mental illness (SMI) and physical violence literature focus disproportionately on community-based men samples. To address this empirical imbalance, the current study explored violence towards others and oneself among women inpatients with SMI. As those with SMI are more likely to be victims than perpetrators of violence, victimisation was also an important factor assessed in this study.

Methods

The study used a quantitative within-subject cross-sectional design. Data were extracted from 5675 inpatient women cases between 2009 and 2013.

Results

Women with a manic disorder (without psychotic features) were 4.5 times, whilst those with psychotic disorders were 2 times, more likely to be physically violent to others compared to those with major mood disorders. Conversely, women with a major mood disorders were 4.8 times and 7.5 times more likely to engage in violence towards oneself (deliberate self-harm), compared to those with psychotic disorder and manic disorders, respectively. The past victimisation increased the likelihood of later physical violence.

Conclusion

The data illuminate differential risk factors among women inpatients with SMI that may help predict violence occurring towards others and oneself and allow gender comparisons with the established literature.

     

Plasma Leptin Levels in Children Hospitalized with Cholera in Bangladesh

Vibrio cholerae, the cause of cholera, induces both innate and adaptive immune responses in infected humans. Leptin is a hormone that plays a role in both metabolism and mediating immune responses. We characterized leptin levels in 11 children with cholera in Bangladesh, assessing leptin levels on days 2, 7, 30, and 180 following cholera. We found that patients at the acute stage of cholera had significantly lower plasma leptin levels than matched controls, and compared with levels in late convalescence. We then assessed immune responses to V. cholerae antigens in 74 children with cholera, correlating these responses to plasma leptin levels on day 2 of illness. In multivariate analysis, we found an association between day 2 leptin levels and development of later anti-cholera toxin B subunit (CtxB) responses. This finding appeared to be limited to children with better nutritional status. Interestingly, we found no association between leptin levels and antibody responses to V. cholerae lipopolysaccharide, a T cell–independent antigen. Our results suggest that leptin levels may be associated with cholera, including the development of immune responses to T cell–dependent antigens.     

Rectal compliance as a routine measurement

PURPOSE: The clinical impact of rectal compliance and sensitivity measurement is not clear. The aim of this study was to measure the rectal compliance in different patient groups compared with controls and to establish the clinical effect of rectal compliance. METHODS: Anorectal function tests were performed in 974 consecutive patients (284 men). Normal values were obtained from 24 controls. Rectal compliance measurement was performed by filling a latex rectal balloon with water at a rate of 60 ml per minute. Volume and intraballoon pressure were measured. Volume and pressure at three sensitivity thresholds were recorded for analysis: first sensation, urge, and maximal toleration. At maximal toleration, the rectal compliance (volume/pressure) was calculated. Proctoscopy, anal manometry, anal mucosal sensitivity, and anal endosonography were also performed as part of our anorectal function tests. RESULTS: No effect of age or gender was observed in either controls or patients. Patients with fecal incontinence had a higher volume at first sensation and a higher pressure at maximal toleration (P=0.03), the presence of a sphincter defect or low or normal anal pressures made no difference. Patients with constipation had a larger volume at first sensation and urge (P<0.0001 andP<0.01). Patients with a rectocele had a larger volume at first sensation (P=0.004). Patients with rectal prolapse did not differ from controls; after rectopexy, rectal compliance decreased (P<0.0003). Patients with inflammatory bowel disease had a lower rectal compliance, most pronounced in active proctitis (P=0.003). Patients with ileoanal pouches also had a lower compliance (P<0.0001). In the 17 patients where a maximal toleration volume<60 ml was found, 11 had complaints of fecal incontinence, and 6 had a stoma. In 31 patients a maximal toleration volume between 60 and 100 ml was found; 12 patients had complaints of fecal incontinence, and 6 had a stoma. Proctitis or pouchitis was the main cause for a small compliance. All 29 patients who had a maximal toleration volume>500 ml had complaints of constipation. No correlation between rectal and anal mucosal sensitivity was found. CONCLUSION: Rectal compliance measurement with a latex balloon is easily feasible. In this series of 974 patients, some patient groups showed an abnormal rectal visceral sensitivity and compliance, but there was an overlap with controls. Rectal compliance measurement gave a good clinical impression about the contribution of the rectum to the anorectal problem. Patients with proctitis and pouchitis had the smallest rectal compliance. A maximal toleration volume<60 ml always led to fecal incontinence, and stomas should be considered for such patients. A maximal toleration volume>500 ml was only seen in constipated patients, and therapy should be given to prevent further damage to the pelvic floor. Values close to or within the normal range rule out the rectum as an important factor in the anorectal problem of the patient.Drs. Sloots and Poen were supported by a grant from Janssen-Cilag. Presented at the meeting of the Dutch Society of Gastroenterology, Veldhoven, the Netherlands, October 7 to 8, 1999.     

Athletic Trainers' Familiarity With and Perceptions of Academic Accommodations in Secondary School Athletes After Sport-Related Concussion

Context:

Sport-related concussion can affect athletes'' sport participation and academic success. With the recent emphasis on cognitive rest, student-athletes may benefit from academic accommodations (AA) in the classroom; however, athletic trainers'' (ATs'') perceived familiarity with, and use of, AA is unknown.

Objective:

To assess secondary school ATs'' perceived familiarity with, attitudes and beliefs about, and incorporation of AA for student-athletes after sport-related concussion. A secondary purpose was to determine whether employment status altered familiarity and use of AA.

Design:

Cross-sectional study.

Setting:

Online survey.

Patients or Other Participants:

Of 3286 possible respondents, 851 secondary school ATs accessed the survey (response rate = 25.9%; 308 men [36.2%], 376 women [44.2%], 167 respondents [19.6%] with sex information missing; age = 37.3 ± 10.1 years).

Main Outcome Measure(s):

Participants were solicited via e-mail to complete the Beliefs, Attitudes and Knowledge Following Pediatric Athlete Concussion among Athletic Trainers employed in the secondary school setting (BAKPAC-AT) survey. The BAKPAC-AT assessed ATs'' perceived familiarity, perceptions, and roles regarding 504 plans, Individualized Education Programs (IEPs), and returning student-athletes to the classroom. Independent variables were employment status (full time versus part time), employment model (direct versus outreach), years certified, and years of experience in the secondary school setting. The dependent variables were participants'' responses to the AA questions. Spearman rank-correlation coefficients were used to assess relationships and Mann-Whitney U and χ² tests (P < .05) were used to identify differences.

Results:

Respondents reported that approximately 41% of the student-athletes whose sport-related concussions they managed received AA. Respondents employed directly by the school were more familiar with 504 plans (P < .001) and IEPs (P < .001) and had a greater belief that ATs should have a role in AA. Both the number of years certified and the years of experience at the secondary school were significantly correlated with perceived familiarity regarding 504 plans and IEPs.

Conclusions:

The ATs employed directly by secondary schools and those with more experience as secondary school ATs were more familiar with AA. Understanding AA is important for all ATs because cognitive rest and “return to learn” are becoming more widely recommended in concussion management.Key Words: adolescent sport-related concussions, concussion management, 504 plans, Individualized Education Programs

Key Points

• The patients in nearly one-half of the sport-related concussion cases managed by secondary school athletic trainers received academic accommodations.
• For proper management of and successful recovery from concussions, academic accommodations are often important.
• Athletic trainers should become more familiar with academic accommodations to ensure that student-athletes can return successfully to the classroom.

The Centers for Disease Control and Prevention estimated that 1.6 to 3.8 million sport- and recreational-related concussions occurred annually in the United States.¹ For high school athletes, an estimated 8.9% of all injuries are concussions.² Early recognition and appropriate management of these prevalent injuries are especially important in adolescents to reduce the risk of more serious conditions and to facilitate proper recovery.³ In the secondary school setting, that recognition and management are often components of athletic training services, delivered by certified or state-licensed (or both) athletic trainers (ATs) who frequently assist with concussion management from initial evaluation through return to play. With the increased occurrence of concussions,¹ it is imperative that best practices for proper management of the injuries be implemented and that those practices be consistent with expert recommendations and guidelines.The signs and symptoms of concussion can broadly affect the student-athlete''s life both in and out of athletic participation.⁴ After a concussion, the student-athlete may experience an array of clinical signs and symptoms. Those symptoms may include cognitive deficits,^5,6 such as poor concentration and difficulty remembering, sensitivity to noise and light, dizziness, and most commonly, headaches.^4,7–10 Unfortunately for the student-athlete, those signs and symptoms can be exacerbated by any activity requiring cognitive demand, such as watching TV, listening to music, reading, playing video games, and even performing school work. In fact, normal academic demands are a major source of cognitive exertion in student-athletes after sport-related concussion.Effectively managing this complex and often-unpredictable collection of signs and symptoms can be aided through the use of individualized concussion-management plans, especially those plans that encourage a return to school in an appropriate and stepwise manner.^11,12 One important component of such an individualized plan is cognitive rest. Cognitive rest is imperative for the healing process because it allows the brain time to recover without exacerbating symptoms.¹³ Consensus guidelines,¹⁴ expert opinion,^15,16 and some evidence¹³ suggested that cognitive rest is beneficial in recovery. However, a common limitation of individualized concussion-management plans is that they typically omit or place less emphasis on components that are unrelated to athletics, such as limiting cognitive activity and modifying cognitive demands, specifically in academics.¹⁷ That lack is problematic because although abundant published research pertains to acute diagnosis, management, and return to play after a concussion, little research about school reintegration or return to learn has been conducted to date. Consequently, comprehensive concussion-management guidelines for student-athletes often fail to include information about both return to play and school and home functioning.⁷One way of modifying cognitive demands is through academic accommodations (AA). Academic accommodations can include both informal alterations in classroom activity and formal accommodations, such as 504 plans and Individualized Education Programs (IEPs).⁴ One distinction between informal and formal accommodations is the temporary nature of the former. Informal accommodations allow the student-athlete to receive accommodations in school immediately after a concussion and are intended to provide temporary modifications to enhance academic performance and to aid in physical recovery.⁴ Informal accommodations include longer testing periods, homework extensions, lighter school days and breaks throughout the day, excused absences, relief from light and noise when necessary, excused practices or gym classes, and other arrangements.⁴ With selected informal AA, the student-athlete can recover and improve in the classroom over time.^13,15 Section 504 plans and IEPs are formal plans that guarantee students academic assistance as well as protection from discrimination in response to an identified disability.¹⁸Although formal accommodations are available to all high school students, including student-athletes, it is unclear how familiar ATs are with AA. Therefore, the purpose of our study was to assess the perceived familiarity with and perceptions of ATs employed in the secondary school setting (SSATs) regarding AA for adolescent student-athletes after sport-related concussion. Secondary and tertiary purposes were to determine the availability of academic-support teams in secondary schools and whether employment status altered familiarity with, and use of, AA.     

Nutrition as a Vehicle for Cardiovascular Translational Research

It is becoming increasingly evident that poor nutrition plays an important role in inducing cardiovascular disease. Just as importantly, data now support the contention that appropriate nutritional interventions may have just as important an effect in preventing or delaying the appearance of cardiovascular disease. If this is indeed true, then it is critical that these advances in our knowledge of the effects of nutritional interventions be translated into effective strategies to combat cardiovascular disease. It is argued in this paper, with a few specific examples, that the translation of nutritional interventions can provide powerful approaches to alleviating the clinical challenges currently facing us today in the cardiovascular field. Furthermore, the value-added economic advantages of translating nutritional strategies on a wide scale into the public become another intriguing argument to further support investigations in this growing field.