Diffuse intramuscular lipomatosis of a lower limb

Patient. A 40-year-old man presented with a swelling of the left thigh which had been increasing in size over 10 months. Surgery confirmed a diagnosis of lipoma. After 6 months, another swelling appeared, this time in the left calf. Ultrasound-guided biopsies revealed that the tissue showed appearances consistent with intramuscular lipoma. No further surgery was performed and the man is to be reviewed regularly, with possible debulking if necessary.

Discussion. This case presents an atypical case of lipomatosis. Magnetic resonance imaging is useful for assessing the extent of the lesion.

Positive nucleic acid amplification tests for Neisseria gonorrhoeae in young people tested as part of the National Chlamydia Screening Programme

Little information is available on the prevalence of Neisseria gonorrhoeae (GC) infections outside genitourinary (GU) medicine clinics. A number of National Chlamydia Screening Programme areas now carry out simultaneous testing for Chlamydia trachomatis (CT) and GC in a single sample using nucleic acid amplification tests (NAATs). The aim of this study was to gather together data on dual testing from community settings. Information was collected from five programme areas. A total of 219,412 results were recorded with 18,370 CT positives, 1226 GC positives and among these 554 were with dual CT/GC infection. These figures highlight the fact that substantial numbers of positive GC NAAT results are found outside GU settings. An assessment of both the prevalence of GC and the proportion of extra cases that can be detected in all settings is needed, together with the implementation of robust plans to confirm, treat and manage these patients.

Testing the NKT cell hypothesis in lenalidomide-treated myelodysplastic syndrome patients

Myelodysplastic syndrome (MDS) comprises a group of clonal bone marrow disorders characterized by ineffective hematopoiesis and increased predisposition to acute myeloid leukemia. The causes of MDS remain poorly defined, but several studies have reported the NKT cell compartment of patients with MDS is deficient in number and functionally defective. In support of a central role for NKT cells, a pilot clinical study reported that lenalidomide (an approved treatment for MDS) increased NKT cell numbers in patients with MDS, and several in vitro studies showed lenalidomide specifically promoted NKT cell proliferation and cytokine production. We tested this in a much larger study and confirm a moderate in vitro augmentation of some NKT cell functions by lenalidomide, but find no impact on the NKT cell compartment of patients treated with lenalidomide, despite a consistently positive clinical response. We further show that the frequency and cytokine production of NKT cells is normal in patients with MDS before treatment and remains stable throughout 10 months of lenalidomide therapy. Collectively, our data challenge the concept that NKT cell defects contribute to the development of MDS, and show that a clinical response to lenalidomide is not dependent on modulation of NKT cell frequency or function.

The frequency, manifestations, and duration of prolonged cytopenias after first-line fludarabine combination chemotherapy

BACKGROUND

Fludarabine-based chemoimmunotherapy has well-recognised efficacy and short-term toxicity in the treatment of lymphoid malignancies. However, the presence and significance of prolonged cytopenias after completion of treatment have not been thoroughly quantified.

METHODS

Sixty-one patients receiving initial therapy with fludarabine-based regimens were categorised according to the presence of post-treatment cytopenias (haemoglobin <110-130 g/l depending on sex and age, neutrophils <2.0 x 10(9)/l, or platelets <140 x 10(9)/l) lasting >3 months.

RESULTS

Persistent cytopenias unrelated to persistent disease were found in 43% of patients. Cytopenias were associated with clinically important rates of infection and transfusion requirement (P = 0.03) and predicted for worse overall survival (61% versus 96% at 60 months, P = 0.05). Increasing age predicted for persistent cytopenias (P = 0.02), but the presence of pretreatment cytopenias and delivered dose intensity were not predictive. The median times to resolution of anaemia, neutropenia, and thrombocytopenia were 7, 9, and 10 months, respectively.

CONCLUSIONS

Cytopenias often persist >3 months after first-line fludarabine combination therapy and can lead to important clinical sequelae. Although cytopenias generally resolve over time, treating physicians should be aware of these factors when considering fludarabine combination chemotherapy and when documenting treatment response status in chronic lymphocytic leukaemia.

Diagnosis, management and prevalence estimation of gonorrhoea: influences of Aptima Combo 2 assay with alternative target confirmation

Case-notes and laboratory data were retrospectively reviewed for influences of dual testing by Aptima Combo 2 (AC2) for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) on the diagnosis, management and prevalence estimation of gonorrhoea in the genitourinary (GU) medicine clinic and community. NG positives by AC2 were confirmed by Aptima Gonococcus assay. Unconfirmed positives were rare. Our study showed that in the GU medicine clinic, AC2 detected about 20% extra cases of NG beyond culture. For best standard of care, NG culture and microscopy are still required in some patients to ensure that treatment is rapid and appropriate. Compared to self-referral at the GU medicine clinic, community tests made a substantial contribution to the overall number of NG cases found (40 community versus 35 Macclesfield GU medicine clinic). The ratio of female to male NG cases found was significantly higher (P = 0.002) in the community (13 M, 27 F) than at the GU medicine clinic (25 M, 10 F). In the community, over 60% of NG infections occurred in chlamydia-negative patients. The overall prevalence of NG in the GU medicine clinic was 1.3%, the true prevalence being much lower at 0.9% on primary test. Prevalence in the community was 0.4%. Data from dual testing in the community can clarify NG prevalence beyond the existing KC60 (sexually transmitted infections) reports.

Scanning hall probe microscopy (SHPM) using quartz crystal AFM feedback

Scanning Hall Probe Microscopy (SHPM) is a quantitative and non-invasive technique for imaging localized surface magnetic field fluctuations such as ferromagnetic domains with high spatial and magnetic field resolution of approximately 50 nm and 7 mG/Hz(1/2) at room temperature. In the SHPM technique, scanning tunneling microscope (STM) or atomic force microscope (AFM) feedback is used to keep the Hall sensor in close proximity of the sample surface. However, STM tracking SHPM requires conductive samples; therefore the insulating substrates have to be coated with a thin layer of gold. This constraint can be eliminated with the AFM feedback using sophisticated Hall probes that are integrated with AFM cantilevers. However it is very difficult to micro fabricate these sensors. In this work, we have eliminated the difficulty in the cantilever-Hall probe integration process, just by gluing a Hall Probe chip to a quartz crystal tuning fork force sensor. The Hall sensor chip is simply glued at the end of a 32.768 kHz or 100 kHz Quartz crystal, which is used as force sensor. An LT-SHPM system is used to scan the samples. The sensor assembly is dithered at the resonance frequency using a digital Phase Locked Loop circuit and frequency shifts are used for AFM tracking. SHPM electronics is modified to detect AFM topography and the frequency shift, along with the magnetic field image. Magnetic domains and topography of an Iron Garnet thin film crystal, NdFeB demagnetised magnet and hard disk samples are presented at room temperature. The performance is found to be comparable with the SHPM using STM feedback.

One size fits all? A process evaluation—the turn of the ‘story’ in smoking cessation

OBJECTIVES

This qualitative process evaluation aimed to make explicit the assumptions shaping the practice of smoking cessation groups using the medium of the story, and assessed the smokers' perceptions of the value of the new method in their attempts to quit smoking.

STUDY DESIGN

This narrative analysis represents a holistic-content perspective and considers the multiple narratives of the smoking cessation groups, as both context and content, and provides unique insights into the assumptions that inform smoking cessation. The analysis of stories is "a unique means to get inside the world of health promotion practice" (Riley T, Hawe P. Researching practice: the methodological case for narrative inquiry. Health Educ Res 2005;20:226-36).

METHODS

Data were firstly collected by observing a snapshot of 12 existing smoking cessation groups in a low-income community over six weeks. Secondly, five debriefing sessions were held with the group facilitator to unpack the assumptions informing the practice. Thirdly, 11 interviewees were purposively selected out of a total group sample of 67 in order to assess their perceptions and experience of the groups. These 11 interviewees were people who had made use of the service at least three times within six consecutive months.

RESULTS

The findings of this study challenge current smoking cessation guidelines (West R, McNeill A, Raw M. Smoking cessation guidelines for Scotland 2004 update. Edinburgh, Scotland: ASH Scotland and NHS Health Scotland; 2004) and suggest highly structured standardized 6-8 week programmes in smoking cessation are insufficient to meet the needs of many smokers. Stories are used to both locate the process of change within people's daily lives as well as to enable people to engage in a supportive process with others. The intention to change is perceived by many smokers to be unstable and requires opportunities for longer-term support. Flexibility in their attendance and ongoing support to both make the decision to stop and stay stopped is clearly valued by the participants. In addition, including people at the different stages of change seems to be positive and the participants appear to incorporate without difficulty those who are still smoking with those who have stopped. Many find the insights of those at the different stages very valuable in their own attempts to quit. Current practices of excluding smokers who are still unsure of their own motivation are challenged.

CONCLUSIONS

The hypotheses generated by the work suggest that flexible services that offer support to a range of smokers are beneficial and valued. In addition, programmes that are tailored to the individual's context and culture, as well as the individual's personal life situation, through the medium of the story, are valued and acceptable to the participants.

Clinical, neuropathological and immunohistochemical features of sporadic and variant forms of Creutzfeldt-Jakob disease in the squirrel monkey (Saimiri sciureus)

The squirrel monkey (Saimiri sciureus) has been shown to be nearly as susceptible as the chimpanzee to experimentally induced Creutzfeldt-Jakob disease (CJD), and has been used extensively in diagnostic and pathogenetic studies. However, no information is available concerning the clinicopathological characteristics of different strains of human transmissible spongiform encephalopathy (TSE) in this species, in particular, strains of sporadic and variant CJD (sCJD and vCJD, respectively). Brain homogenates from patients with sCJD or vCJD were inoculated intracerebrally at dilutions of 10(-1) or 10(-3) into the left frontal cortex of squirrel monkeys. Animals were kept under continuous clinical surveillance during the preclinical and clinical phases of disease, and regularly underwent standardized behavioural testing. Brains from three animals in the sCJD and vCJD groups were examined histopathologically and immunohistochemically for the presence of pathognomonic misfolded protein (PrP(TSE)). Overall, incubation periods and durations of illness were slightly shorter in monkeys infected with sCJD than in those infected with vCJD, but the earliest signs of illness (ataxia and tremors) were the same in both groups. Clinical disease in the sCJD monkeys was somewhat more severe and of shorter duration. Post-mortem examinations revealed distinctive patterns of spongiform change and PrP(TSE) distribution in the brains of sCJD and vCJD animals, similar to those seen in humans except that amyloid plaques were not present. PrP(TSE) was uniformly absent from peripheral lymphoid tissues in both groups of animals. Human strains of sCJD and vCJD cause distinguishable clinicopathological features in the squirrel monkey that can provide a baseline for the evaluation of future therapeutic studies.

In vivo tracking of macrophage activated killer cells to sites of metastatic ovarian carcinoma

Radio-labelling of blood cells is an established technique for evaluating in vivo migration of normal cells to sites of pathology such as infection and haemorrhage. A limitation of cellular immunotherapies to induce anti-tumour responses is in part due to the uncertain ability of cellular effectors to reach their intended target. We extended the approach of cell radiolabelling to accurately examine the in vivo distribution of cellular immunotherapy with ex-vivo macrophage activated killer (MAK) cells. We describe the use of two methods of cell labelling for tracking the destination of autologous-derived macrophage activated killer (MAK) cells linked to the bi-specific antibody MDX-H210 delivered either by intravenous (i.v.) or intraperitoneal (i.p.) injection in ten patients with peritoneal relapse of epithelial ovarian carcinoma. Our results demonstrate the feasibility of generating high numbers and purity of GMP quality MAK cells, which can be radiolabelled with (18)F-FDG or (111)In-oxime. MAK cell administration produced minimal infusional toxicity and demonstrated a reproducible pattern of in vivo distribution and active in vivo tracking to sites of known tumour following 8 of 16 i.v. infusions or 4 of 6 i.p. infusions. However, the leakage of (18)F-FDG limited the ability to confidently confirm the tracking of MAK cells to tumour in all cases and improved PET labels are required. The addition of MDX-H210 bispecific antibody did not alter the distribution of cells to tumour sites, but did accelerate the clearance of i.v. administered MAK cells from the pulmonary circulation. This data demonstrates that cellular cancer immunotherapies may be successfully delivered to the sites of active tumour following either i.v. or i.p. injection in a proportion of patients with metastatic cancer. Incorporation of tracking studies in early cycles of cellular immunotherapy may allow selection of patients who demonstrate successful targeting of the immunotherapy for ongoing treatment.

Radiation induced angiosarcoma a sequela of radiotherapy for breast cancer following conservative surgery

Radiation induced angiosarcomas (RIA) can affect breast cancer patients who had radiotherapy following conservative breast surgery. They are very rare tumors and often their diagnosis is delayed due to their benign appearance and difficulty in differentiation from radiation induced skin changes. Therefore it is very important that clinicians are aware of their existence. We report here a case of RIA followed by discussion and review of literature.

Do we know what people die of in the emergency department?

OBJECTIVE

To establish the discrepancy rate between the predicted cause of death and the actual cause of death as determined by postmortem examination result, for all deaths in the emergency department reported to the Scottish Procurator Fiscal and subsequently undergoing postmortem examination.

METHODS

A prospective study of all patients who were dead on arrival or died in the emergency department of a busy Glasgow hospital over a 12 month period. The most senior emergency physician present at the time of death predicted the cause of death. This was then compared to the actual postmortem examination determined cause of death and was considered either to be correct or incorrect.

RESULTS

During the study period, 146 patients were pronounced dead in the department. Of these, 81 patients (age range 39-99 years, median 71; male:female 2.5:1) had death certificates issued, 63 patients (age range 26 days to 99 years, median 48; male:female 2.4:1) had a postmortem performed by the forensic pathologist, and two patients underwent a "view and grant". Of the 63 deaths reported to the Procurator Fiscal, the emergency physician attributed 51 (80.1%) to non-trauma, 9 (14.2%) to trauma, and in 3 (4.7%) cases were uncertain. Of the 63 (39.7%) deaths, 25 were inaccurately predicted (99% confidence interval 24.3% to 56.6%; p<0.0)1. Cardiovascular related and drugs poisoning deaths occurred most commonly. They were also the most accurately predicted cause of deaths. Intracranial events, pulmonary thromboembolism, and airway obstruction were also frequently predicted, but were often wrong.

CONCLUSIONS

This study highlights the difficulties in accurately identifying cause of death for patients who die suddenly. This could have implications for the accuracy of health service statistics.

Influence of exciton dynamics on the interference of two photons from a microcavity single-photon source

One- and two-photon interference visibilities observed with the exciton emission from a quantum dot microcavity single-photon source are sensitive to the excitation conditions. In particular, the coherence time of the source is reduced with increasing pump power or excitation of the barrier layers. Furthermore, the two-photon interference visibility is affected by a long lived population of the biexciton state in the dot. This suggests that two-photon interference may be improved by controlling the exciton dynamics in the dot or by improved temporal resolution of the detection set-up.

Terahertz quantum cascade laser as local oscillator in a heterodyne receiver

Terahertz quantum cascade lasers have been investigated with respect to their performance as a local oscillator in a heterodyne receiver. The beam profile has been measured and transformed in to a close to Gaussian profile resulting in a good matching between the field patterns of the quantum cascade laser and the antenna of a superconducting hot electron bolometric mixer. Noise temperature measurements with the hot electron bolometer and a 2.5 THz quantum cascade laser yielded the same result as with a gas laser as local oscillator.

High performance single photon sources from photolithographically defined pillar microcavities

We demonstrate that single photons can be generated from single InAs/GaAs quantum dots in photolithographically defined pillar microcavities. Pillars with a 1.9 microm diameter cavity show a four fold enhancement in the radiative decay rate due to the Purcell effect and a photon collection efficiency into a lens of up to 10%. Measurements of the second order correlation function reveal a greater than fifty fold reduction in the multi-photon emission rate compared to a laser of the same intensity.