The role of swab and tissue culture in the diagnosis of implantable cardiac device infection

BACKGROUND: The isolation of a pathogen is vital in the diagnosis and treatment of a device infection. A swab culture, despite poor sensitivity, is the most common method used in specimen collection. OBJECTIVE: To determine the relative value of swab and tissue specimen cultures in patients with implantable cardiac pacemakers and defibrillators. DESIGN: Prospective patient cohort study. SETTING: A 1,000-bed tertiary referral center in Cleveland, Ohio. PATIENTS: Consecutive patients with implantable cardiac pacemaker or defibrillator presenting for lead extraction from October 1, 2000 to March 31, 2001. METHODS: Tissue and swab cultures were prospectively collected during pacemaker and implantable defibrillator surgeries that required lead extraction. Clinical manifestations, microbiology, and echocardiographic data were recorded in patients with and without a clinical diagnosis of device system infection. RESULTS: Seventy-one patients with implantable pacemaker (n = 49, 69%), implantable defibrillator (n = 18, 25%), or both devices (n = 4, 6%) requiring lead extraction had pocket swab and tissue cultures for analysis. Infection was evident clinically in 35 (49%) of the patients and absent in the remainder. The most common bacteria isolated were coagulase-negative Staphylococcus (37%) and Staphylococcus aureus (10%). Patients with clinical infection had positive cultures more frequently (P = 0.002) by pocket tissue culture (n = 24, 69%) than by swab culture (n = 11, 31%). However, patients without clinical infections had positive cultures at similar rates by pocket tissue culture (n = 10, 28%) and by swab culture (n = 8, 22%; P = 0.48). Patients without clinical infection were not treated with other than perioperative antibiotics, and did not develop clinical infections. CONCLUSION: Pocket tissue cultures are more effective than pocket swab cultures for the isolation and identification of the infectious pathogens in cardiac device infections. Positive cultures by pocket swab or tissue cultures in the absence of clinical signs and symptoms of infection does not imply infection or the need for specific therapy.     

Control strategies for finger movement during touch-typing The role of the extrinsic muscles during a keystroke

A single keystroke during touch-typing is a rapid, goal-directed motion of the fingertip which consists of two single-direction movements. The neural control and the role of the finger extrinsic musculature during typing have not yet been explained. The fingertip motion and force, and the intramuscular electromyographic (EMG) activity (fine-wire) of the index finger extrinsic musculature were measured during touch-typing by ten experienced typists. The motions and forces were repeatable qualitatively across keystrokes. A three-burst EMG pattern was observed during a single keystroke. The three bursts were: (1) a burst of extensor activity lifted the finger before the keystroke; (2) a burst of flexor activity followed while the fingertip was moving downward; and (3) a second burst of extensor activity occurred as the fingertip reached the end of key travel. The timing of the third burst suggests the role of the extensors is to remove the fingertip from the keyswitch rather than stop the downward motion of the finger. The collision with the end of key travel stops the downward finger motion. The timing of the finger flexor EMG activity, burst 2, suggests that the flexor contraction principally overcomes the activation force of the keyswitch rather than accelerates the finger downward as expected. Received: 1 April 1997 / Accepted: 29 December 1997     

Relative expression of progesterone receptors A and B in endometrioid cancers of the endometrium

The nuclear receptor for the female hormone progesterone (PR) is widely expressed in uterine cancer. PR is expressed as two proteins (PRA and PRB) with different functions, and in vitro evidence reveals PRA to inhibit PRB function, so the cellular ratio of PRA:PRB is likely to be an important determinant of progesterone action. The relative expression of PRA and B and their involvement in the pathogenesis of endometrial cancer is not known. The aims of this study were to determine PRA and B expression by dual immunofluorescent histochemistry in endometrial adenocarcinomas compared with expression in normal and hyperplastic glands, and to correlate expression in tumors with clinical features including grade. Significantly lower PR levels were found in tumors compared with normal glands and areas of complex atypical hyperplasia within the same specimen. The normal glands expressed both of the isoforms at similar levels, whereas there was increased predominance of one isoform in hyperplastic areas and in tumors, which suggested that the loss of coordinated expression of PR isoforms was an early event in tumor progression. The majority of tumors [27 (58%) of 46] expressed only one PR isoform, and the proportion expressing either PRA or B was the same [14 (30%) of 46, and 13 (28%) of 46, respectively]. One-half of all tumors ([23 (50%) of 46] expressed either PRA only or a predominance of PRA, and a few tumors [10 (22%) of 46] expressed comparable levels of PRA and B. Similar levels of PRA and B were noted only in FIGO grade 1 tumors, whereas higher grades (2 and 3) were associated with a predominance of one isoform. In summary, expression of only one PR isoform was common in endometrial cancers, which indicates that the decreased PR levels observed in these cancers arise from the loss of one PR isoform. Expression of a single PR isoform was associated with higher clinical grade, which suggests a relationship between the loss of PR isoform expression and features of poorer prognosis. Disruption of relative PR isoform expression was observed in complex atypical hyperplasia, which suggests that early alterations in the ratio of PRA:PRB may precede and/or be implicated in the development of endometrial adenocarcinoma. Alterations in the ratio of PR isoform expression are likely to cause disordered regulation of target genes, resulting in altered progestin action in the uterus, and this may be involved in the pathogenesis of endometrial cancer.     

Mammographic breast density decreases after bariatric surgery

Purpose

To describe imaging findings, detection rates, and tumor characteristics of breast cancers in a large series of patients with BRCA1 and BRCA2 mutations to potentially streamline screening strategies.

Methods

An IRB-approved, HIPAA-compliant retrospective analysis of 496 BRCA mutation carriers diagnosed with breast carcinoma from 1999 to 2013 was performed. Institutional database and electronic medical records were reviewed for mammography and MRI imaging. Patient and tumor characteristics including age at diagnosis, tumor histology, grade, receptor, and nodal status were recorded.

Results

Tumors in BRCA1 mutation carriers were associated exhibited significantly higher nuclear and histological grade compared to BRCA2 (p < 0.001). Triple-negative tumors were more frequent in BRCA1 mutation carriers, whereas hormone receptor-positive tumors were more frequent in BRCA2 mutation carriers (p < 0.001). BRCA2 mutation carriers more frequently presented with ductal carcinoma in situ (DCIS) alone 14% (35/246) and cancers more frequently exhibiting calcifications (p < 0.001). Mammography detected fewer cancers in BRCA1 mutation carriers compared to BRCA2 (p = 0.04): 81% (186/231) BRCA1 versus 89% (212/237) BRCA2. MRI detected 99% cancers in each group. Mammography detected cancer in two patients with false-negative MRI (1 invasive cancer, 1 DCIS). Detection rates on both mammography and MRI did not significantly differ for women over 40 years and women below 40 years.

Conclusions

Breast cancers in BRCA1 mutation carriers are associated with more aggressive tumor characteristics compared to BRCA2 and are less well seen on mammography. Mammography rarely identified cancers not visible on MRI. Thus, the omission of mammography in BRCA1 mutation carriers screened with MRI can be considered.

     

The effect of pancreatic islet transplantation on progression of diabetic retinopathy and neuropathy

INTRODUCTION: Pancreatic islet transplantation (PIT) has only become an effective treatment for type 1 diabetes mellitus within the past 4 years. As a result, the long-term effects of PIT on progression of diabetic neuropathy and retinopathy are unknown. The benefit of halting or improving diabetic neuropathy and retinopathy is of particular interest since most PIT recipients have not developed the advanced complications of diabetes. Herein, we describe the improvement and stabilization of diabetic neuropathy and retinopathy in 12 PIT recipients. PATIENTS AND METHODS: Between January 1, 2002, and June 30, 2004, there have been 12 patients who have received PIT. Currently, there are eight patients who have sufficient follow-up to assess the progression of diabetic retinopathy and neuropathy. To assess for disease progression, patients were examined by a single ophthalmologist and single neurologist throughout the study period. Eye exams were performed using a slit-lamp exam while neurological status was assessed using electromyelograms and clinical exams. RESULTS: All PIT recipients had decreases in hemoglobin A(1)C and increases in serum C-peptide. All study patients had stabilization of their retinopathic disease. One patient demonstrated improvement of retinopathy at 1 year posttransplant. Fifty percent of patients demonstrated improvement or stabilization of their diabetic neuropathy. One patient had mild reinnervation of the fingers and wrist extensors by clinical exam 1 year posttransplant. Four patients exhibited an average decrease of 19% in sural nerve conduction velocities. CONCLUSION: Our series has demonstrated that all PIT recipients have had stabilization of their diabetic retinopathy and that 50% of patients exhibited stabilization or even improvement of their diabetic neuropathy.     

Thermographic observations in unilateral carpal tunnel syndrome: report of 61 cases.

This study was undertaken to assess the sensitivity and specificity of thermographic diagnosis of unilateral carpal tunnel syndrome in a patient population large enough to permit meaningful statistical analysis. Sixty-one persons with clinical diagnoses of unilateral carpal tunnel syndrome confirmed by electrodiagnostic examination and 40 symptom-free volunteers underwent standard thermographic examinations. The thermographic images were then randomly sorted and interpreted by an experienced physician thermographer. Fifty-seven of the 61 patients with carpal tunnel syndrome were found to have thermographic abnormalities, while only one of the control group was found to have such an abnormality. Individual area sensitivity was highest in the dorsal area, but addition of other regions increased this measure; specificity ranged between 98% and 100%. These findings would appear to confirm the value of thermography in the diagnosis of unilateral carpal tunnel syndrome.     

Behavioral and physiological consequences of unilateral ablation of the nucleus isthmi in the leopard frog

Unilateral lesions of the nucleus isthmi result in a scotoma to visually presented prey and threat stimuli in the contralateral monocular visual field. There is a correlation between the size of the scotoma and the amount of n. isthmi ablated. Following the lesion, there is a regression of the scotoma in the nasal part of the visual field which then stabilizes. Upon longer behavioral examination, the animals can be divided into two classes: (1) animals in which the scotoma remains relatively stable in size for up to two years, and (2) animals which recover from the scotoma. In the latter group, there tends to be damage to both the n. isthmi and the posterodorsal tegmental nucleus which lies mediocaudal to the n. isthmi. Electrophysiological recording from positions within the area of the optic tectum representing the scotoma reveal an average threefold increase in the size of the multiunit receptive fields compared to mirror image positions in the contralateral optic tectum.     

Suboptimal non-inflammatory concentrations of haptens may elicit a contact sensitivity reaction when used as a mix

Contact dermatitis is a cutaneous inflammatory reaction mediated by hapten-specific T cells. We used a murine model to investigate the contact sensitivity reaction elicited by different concentrations (optimal and suboptimal) of the haptens DNFB and oxazolone applied singly or in combination. The simultaneous application of DNFB and oxazolone at optimal concentrations (0.2% and 0.4% respectively) did not significantly increase the ear swelling response induced by each of the allergens when applied singly. No contact sensitivity response was observed when the haptens were tested individually at subthreshold concentrations (0.05% and 0.1% respectively). However mixing the 2 molecules at the same concentrations gave rise to a clinical contact sensitivity reaction. The simultaneous application of the haptens at a 2× higher, but still suboptimal concentrations (0.1% and 0.2% respectively), elicited an inflammatory response that was significantly greater than the responses elicited by either of the haptens when applied separately. These results suggest that a "false-positive" reaction to a mix may reveal a genuine sensitization to the constituents.