Conserving resources in the diagnosis of intraoral fibroepithelial polyps

Fibroepithelial polyps (FEPs) are common, benign intraoral lesions that tend to develop slowly at predictable sites, often in response to local irritation or trauma. Historical precedent often results in referral to oral and maxillofacial surgery (OMFS) departments for biopsy, often irrespective of symptoms, and histological assessment. OMFS and pathology services are struggling to cope with an increasing workload that will potentially lead to widespread delays to diagnosis and treatment. Over the past 20 years, clinical pathways and guidance have been developed to ensure that healthcare interventions, such as the removal of third molars, tonsils, skin tags, and benign moles, are evidence-based, have a net patient benefit, and ensure the best use of finite NHS resources. However, no such guidance exists for intraoral lesions and we regard this as an oversight. We analysed the removal of 682 FEPs over a seven-year period and report sensitivities of 92.4% for a “confirmed clinical suspicion of an FEP” and 99.7% for a “confirmed clinical suspicion of a benign diagnosis”. The incidence of non-benign disease was 0.3%. Primary care dentists should be able to diagnose and monitor FEPs and refer only if symptoms are serious or in high-risk patients or sites. Adopting this practice across the UK could free up to 1825 four-hour OMFS clinics, 405 hours of consultant histopathologists’ time, and recurring savings to the NHS estimated to be in the region of £620 000/annum. We believe that the removal of FEPs should be reclassified as an “intervention not normally funded”, and the time and resources put to better use treating patients with lesions of questionable pathology.     

Odontogenic cysts: classification,histological features and a practical approach to common diagnostic problems

The epithelial remnants of tooth development give rise to an impressive range of cystic lesions, termed odontogenic cysts. They are classified based on their distinct clinical, radiological and histological features, a process that has not been without controversy. We will attempt to explain the basis of the debate behind the changing classification of odontogenic cysts, describing their aetiology, clinical and histological features, along with common pitfalls that can confuse the diagnostic process. More common diagnostic challenges, such as the effects of inflammation and mucous change, will be explored in detail. An attempt will be made to distil the diagnostic process into simple algorithmic steps to narrow down the differential diagnoses of this fascinating group of lesions. We will demonstrate the importance of careful consideration of the clinical and radiological features that can help prevent misclassification, ensuring appropriate management and follow-up for this diverse group of lesions.     

Impact and Predictors of Noncircular Left Ventricular Outflow Tract Shapes on Estimating Aortic Stenosis Severity by Means of Continuity Equations

Determining aortic stenosis (AS) severity is clinically important. Calculating aortic valve (AV) area by means of the continuity equation assumes a circular left ventricular outflow tract (LVOT). The full impact of this assumption in calculating AV area is unknown. Predictors of noncircular LVOT shape in patients with AS are undefined.In 109 adult patients with AS who underwent multiplanar transesophageal echocardiography, we calculated AV area by means of the standard continuity method and by a modified method involving planimetric LVOT area.We found 54 circular, 37 horizontal-oval, 8 vertical-oval, and 10 irregular LVOTs. Area derived by direct planimetry correlated better with the modified than the standard continuity method (r=0.89 vs r=0.85; both P=0.0001). Valve areas of patients with mild, moderate, or severe AS by planimetry were more often mischaracterized with use of the standard than modified method (29 vs 18; P <0.0001). Horizontal-oval AV area derived by planimetry (1.28 ± 0.55 cm²) was underestimated by the standard method (1.05 ± 0.47 cm²; P=0.001), but not by the modified method. Congenital AV morphology and low cardiac index were the only multivariate predictors of horizontal-oval shape. Low cardiac index was the only predictor of noncircular shape.More than half our patients with AS had noncircular LVOTs. Using the modified method reduces mischaracterizations of AS severity. Congenital AV morphology and low cardiac index predict horizontal-oval or noncircular shape. These data suggest the value of direct LVOT measurement to calculate AS severity in patients who have congenital AV or a low cardiac index.     

Nanoparticle albumin bound-paclitaxel for treatment of advanced non-small cell lung cancer: an evaluation of the clinical evidence

Introduction: Nanoparticle albumin-bound paclitaxel (nab-paclitaxel), a microtubule inhibitor, has demonstrated clinical efficacy in the treatment of advanced non-small cell lung cancer (NSCLC) either as monotherapy or in combination. Nab-paclitaxel was developed to reduce the toxicities associated with solvent-bound paclitaxel (sb-paclitaxel).

Areas covered: This review first focuses on the clinical trials evaluating the efficacy and tolerability of nab-paclitaxel in NSCLC at different settings. The approval of nab-paclitaxel in combination with carboplatin at the front-line setting for advanced NSCLC was based on the key phase III study, which showed that nab-paclitaxel/carboplatin was associated with superior overall response rate and favorable toxicity profile compared to sb-paclitaxel/carboplatin. The review also addresses the nab-paclitaxel pharmacology, other combinations (e.g. immunotherapy with PD-1/PD-L1 inhibitors), potential biomarkers (e.g. caveolin-1), and special subgroups (e.g. the elderly, squamous histology).

Expert opinion: Existing data has established the role of nab-paclitaxel in the management of advanced NSCLC. Emerging evidence, such as preliminary results from Keynote-407 and IMpower 131 studies, indicates that novel combinations of nab-paclitaxel/carboplatin and PD-1/PD-L1 inhibitors could further improve clinical benefits with manageable toxicity. Nevertheless, in order to better position nab-paclitaxel and to improve patient selection, future studies are warranted to further understand its mechanism of action, predictive biomarkers, and potential synergism with other agents.     

人血浆作为真皮支架对自体皮肤增殖的影响：组织学和免疫组织化学试验●☆

背景：组织工程是一个多学科研究的交叉学科，其目标是使人体损伤的组织和器官再生，通过这种假设，几乎所有的动物组织都可以在实验室进行培养。一般的方法是从需要移植的患者身上提取干细胞，在一定的支持条件下允许其生长、增殖、生产为可替换的组织。另一方面，寻找细胞能够互相联结并形成分层结构的合适的支持条件，如基质或支架等非常必要。目前用于烧烫伤治疗的材料有很多种，如胶原，透明质酸、纤维蛋白和聚乳酸及其共聚物。 目的：讨论以新型的生物材料自体血浆为支架对自体成纤维细胞和角质化细胞生长、扩张、增殖的影响。 设计：建立一种真皮再生的方法，将自体成纤维细胞浸于人血浆基质中，排除各种影响样本安全性和排斥反应的问题，应用同样的方法在新的真皮上获取角质化细胞。 时间及地点：实验于2008年在意大利曼多瓦C. Poma医院动物工厂完成。 材料：人角质化细胞和成纤维细胞取自1例58岁乳房切除患者的皮肤碎片。实验得到C. Poma医院独立伦理委员会批准，患者知情同意。 方法：从自体活组织皮肤样本中分离人角质化细胞和成纤维细胞，置于培养瓶中增殖，随后将自体血浆作为皮肤移植形成构造的支架，免疫和免疫组织化学特征显示与正常皮肤相似。 主要观察指标：将血浆样本用甲醛固定，埋入石蜡，苏木精-伊红染色，用显微镜进行细胞计数。所有样本均经免疫组织化学评估。 结果：在血浆基质上获得了多层规则形状的角质化细胞和成纤维细胞，基底膜的形成说明自体血浆是角质化细胞和成纤维细胞的生长、分化、扩展的良好支架，真皮和表皮细胞联结重建皮肤移植与正常皮肤无异。 结论：血浆作为角质化细胞和成纤维细胞分化、扩展的支架表现出良好的性能，同时实验还特别发现成纤维细胞浓缩血浆可以暂时替代皮肤，也是角质化细胞生长的强有力的支架。此外血浆还具有廉价，易于制备等优点。自体角质化细胞和成纤维细胞及自体血浆的应用，可以避免血种类型的免疫排斥反应。这种治疗方法给有慢性缺损并且需要连续移植的患者带来了希望。 doi:10.3969/j.issn.1673-8225.2009.47.001     

老年人视网膜中央血管在前部视神经的解剖特征

目的：观察老年人前部视神经视网膜中央血管的解剖特征。 方法：通过组织连续切片和计算机影像分析，观察60~82岁老年人的18只眼球标本中无解剖变异的视网膜中央动脉(CRA)15条，视网膜中央静脉（CRV）23条在筛板前、筛板区及筛板后的管径变化。 结果：老年人筛板前、筛板区、筛板后CRA平均面积的均值分别为（12.70,17.40,18.00）×10^-3mm^2_;平均周长的均值分别为0.56，0.56，0.57mm，平均周长之间相比无显著差异。CRV平均面积的均值分别为（7.00，5.40，7.90）×10^-3mm²；平均周长的均值分别为0.44，0.38，0.41mm；CRV平均周长筛板前与筛板区相比，筛板区与筛板后相比均有显著差异。 结论：老年人CRA眼球内外管径一致；CRV在筛板区管径最小。 （中华眼底病杂志，1997，13：213-214）
     

胎儿脑动脉分叉部中层平滑肌细胞的结构特点

目的探讨人类胚胎脑动脉分叉部中层平滑肌细胞(smoothmusclecell,SMC)的构筑发育过程及特点。方法收集12~28周人类胚胎共17例,胎龄各相差1周,男女不限。对不同胎龄胚胎Willis环周围的脑动脉分叉部行三维组织切片,观察中层SMC的构筑发育过程及其有无先天缺陷。结果胎儿Willis环周各脑动脉中层SMC在1.1~9.0层之间;70.6%的胎儿在脑动脉个别分叉部发现中层SMC缺陷;所取标本的30.3%发现中层SMC缺陷。结论胎儿脑动脉中层SMC随胎龄增长而增多,但28周内不超过9.0层;本研究发现胎儿脑动脉分叉部存在先天性SMC缺陷,这将有助于对脑动脉瘤病因假说的理解和验证。