Correlates of epidermal nerve fiber densities in HIV-associated distal sensory polyneuropathy

OBJECTIVE

To demonstrate the relationship between epidermal nerve fiber density (ENFD) in the leg and the phenotype of HIV-associated distal sensory polyneuropathy (HIV-DSP) in a multicenter prospective study (ACTG A5117).

METHODS

A total of 101 HIV-infected adults, with CD4 cell count <300 cells/mm(3) and who had received antiretroviral therapy (ART) for at least 15 consecutive weeks, underwent standardized clinical and electrophysiologic assessment. All 101 subjects were biopsied at the distal leg (DL) and 99 at the proximal thigh (PT) at baseline. ENFD was assessed by skin biopsy using PGP9.5 immunostaining. Associations of ENFD with demographics, ART treatment, Total Neuropathy Score (TNS), sural sensory nerve action potential (SNAP) amplitude and conduction velocity, quantitative sensory testing (QST) measures, and neuropathic pain were explored.

RESULTS

ENFD at the DL site correlated with neuropathy severity as gauged by TNS (p < 0.01), the level of neuropathic pain quantified by the Gracely Pain Scale (GPS) (p = 0.01) and Visual Analogue Scale (VAS) (p = 0.01), sural SNAP amplitude (p < 0.01), and toe cooling (p < 0.01) and vibration (p = 0.02) detection thresholds. ENFD did not correlate with neurotoxic ART exposure, CD4 cell count, or plasma HIV-1 viral load.

CONCLUSIONS

In subjects with advanced HIV-1 infection, epidermal nerve fiber density (ENFD) assessment correlates with the clinical and electrophysiologic severity of distal sensory polyneuropathy (DSP). ENFD did not correlate with previously established risk factors for HIV-DSP, including CD4 cell count, plasma HIV-1 viral load, and neurotoxic antiretroviral therapy exposure.

The results of a structured diagnostic pathway designed to minimise the chance of breast cancer misdiagnosis

AIM

To describe results from a structured clinic pathway designed to minimise inaccuracies and diagnostic delays in the diagnosis of breast cancer.

METHODS

Patients referred to our breast clinic undergo clinical, imaging and biopsy assessment according to a standard protocol. Over 4 years, patients who were discharged with a benign diagnosis and later found to have breast cancer were reviewed.

RESULTS

A total of 4366 new referrals were seen in the symptomatic breast clinic and 571 (13%) new cancers were diagnosed. Fourteen of the new cancer patients had been seen in the clinic previously (range 7-48 months) and discharged with a benign diagnosis. None of these tumours appeared to result from misdiagnosis of a lesion previously assessed to be benign. The rate of development of cancer in the cohort discharged with a benign diagnosis was closely similar to that in the normal United Kingdom population.

CONCLUSIONS

A structured breast clinic pathway can produce a rate of diagnostic accuracy closely approaching 100%.

Geometric approach to segmentation and protein localization in cell culture assays

Cell-based fluorescence imaging assays are heterogeneous and require the collection of a large number of images for detailed quantitative analysis. Complexities arise as a result of variation in spatial nonuniformity, shape, overlapping compartments and scale (size). A new technique and methodology has been developed and tested for delineating subcellular morphology and partitioning overlapping compartments at multiple scales. This system is packaged as an integrated software platform for quantifying images that are obtained through fluorescence microscopy. Proposed methods are model based, leveraging geometric shape properties of subcellular compartments and corresponding protein localization. From the morphological perspective, convexity constraint is imposed to delineate and partition nuclear compartments. From the protein localization perspective, radial symmetry is imposed to localize punctate protein events at submicron resolution. Convexity constraint is imposed against boundary information, which are extracted through a combination of zero-crossing and gradient operator. If the convexity constraint fails for the boundary then positive curvature maxima are localized along the contour and the entire blob is partitioned into disjointed convex objects representing individual nuclear compartment, by enforcing geometric constraints. Nuclear compartments provide the context for protein localization, which may be diffuse or punctate. Punctate signal are localized through iterative voting and radial symmetries for improved reliability and robustness. The technique has been tested against 196 images that were generated to study centrosome abnormalities. Corresponding computed representations are compared against manual counts for validation.

Intraoperative monitoring study of ipsilateral motor evoked potentials in scoliosis surgery

Ipsilateral motor evoked potentials (MEPs) in spinal cord surgery intraoperative monitoring is not well studied. We show that ipsilateral MEPs have significantly larger amplitudes and were elicited with lower stimulation intensities than contralateral MEPs. The possible underlying mechanisms are discussed based on current knowledge of corticospinal pathways. Ipsilateral MEPs may provide additional information on the integrity of descending motor tracts during spinal surgery monitoring.

Tomografía por emisión de positrones/tomografía computarizada: artefactos y pitfalls en pacientes con cáncer

Diagnostic accuracy and correct initial staging (or restaging) are fundamental in the management of oncological patients and can directly influence therapeutic decisions. The combination of positron-emission tomography (PET) and computed tomography (CT) in a single scanner (PET/TC) represents an important achievement in the fields of oncology, nuclear medicine, and radiology. These scanners allow morphologic images (obtained by CT) to be fused and correlated with metabolic images (obtained by PET) to a high degree of accuracy. In addition to an understanding of the physiopathology of cancer and the behavior of the different types of neoplasms, the correct interpretation of PET/CT images requires in-depth knowledge of the physiological distribution of the F-18 fluorodeoxyglucose molecule (FDG, currently the most widely used marker in oncology), of the frequent physiological variations in its distribution, and of the possible causes of non-malignant pathological FDG uptake. Furthermore, the use of CT data to correct attenuation and reconstruct PET images in PET/CT scanners can generate some characteristic artifacts specific to this new diagnostic tool, and these can lead to misinterpretation with potential therapeutic implications. This article reviews and illustrates some of the most common artifacts and pitfalls that can appear in PET/CT studies. The detection and correct interpretation of these findings are essential for the appropriate management of oncologic patients.

Ethnicity as a determinant of asthma-related quality of life in a multiracial country

In a multiracial country like Malaysia, ethnicity may influence the measurement of health-related quality of life (HRQL) in asthmatic patients. We invited 131 adult patients [44 Malays, 42 Chinese and 45 Indians; mean (95% CI) age: 43 (40.2-45.7) yrs; 28.2% male] with moderate-to-severe persistent asthma followed up in an urban-based hospital outpatient clinic to complete a disease-specific HRQL questionnaire [St Georges' Respiratory Questionnaire (SGRQ)] and to provide socio-demographic and asthma-related data. Indians reported significantly worse SGRQ total score, compared to Malays [mean (95% CI) difference: 10.15 (0.51-19.78); p = 0.037] and SGRQ activity score, compared to Malays [13.50 (1.95-25.05); p = 0.019] and Chinese [11.88 (0.19-25.05); p = 0.046]. Further analysis using multivariate linear regression showed that Indian ethnicity remained independently associated with SGRQ scores. Our finding highlights the relevance of ethnicity in assessing HRQL of asthmatic patients in a multiracial country such as Malaysia.

Gastric epithelioid haemangioendothelioma: a rare cause of upper gastrointestinal bleeding

Vascular tumours of the stomach are rare, representing 0.9%-3.3% of all gastric neoplasms. A 58 year old man was admitted as an emergency with a one day history of haematemesis and melaena. He underwent an emergency laparotomy for a tumour in the lesser curve of the stomach. The tumour showed the characteristic histological and immunohistochemical features of epithelioid haemangioendothelioma. Surgery in the form of wide excision seems to be the treatment of choice for this rare neoplasm. This case highlights the difficulty in diagnosing this rare tumour preoperatively and emphasises the need for long term follow up in view of its uncertain metastatic potential.

Splenic rupture following colonoscopy: Rare in the UK?

Splenic injury following colonoscopy is rare, with only 28 cases reported so far in the English language literature. Direct trauma during colonoscopy or traction on the spleno-colic ligament is the proposed mechanism of injury. Computed tomography (CT) of the abdomen is usually considered to be the most sensitive and specific modality for diagnosis. We report a case of a 56-year-old female, who was diagnosed having a splenic rupture following a routine colonoscopy for investigation of anaemia. She underwent an emergency laparotomy with splenectomy and made a satisfactory recovery post-operatively. We wish to highlight that there should be a high index of suspicion of splenic rupture in patients presenting with abdominal pain and demonstrating a positive Kehr's sign following colonoscopy. Only two case reports from the United Kingdom have been published, raising the possibility of under-reporting of such cases.

The 'wandering' abdominal lump: intussusception up to splenic flexure of an ileocaecal adenocarcinoma

A63-year old woman presented with a 4-day history of watery diarrhoea that was preceded by acute constipation. This was associated with intermittent colicky abdominal pain and one episode of fresh rectal bleeding on the previous day. Past history included haemorrhoids, cholecystectomy and reflux disease with no significant family history of cancer. She was seen in the accident and emergency department with a mass in right iliac fossa (RIF), which was managed as scabylous mass owing to the history of constipation.

The next day, the woman came back with continued symptoms. On this occasion, she had a firm, mobile mass, now palpable in the left hypochondrium associated with abdominal distension. Rectal examination revealed an empty rectum. Haematological and biochemical tests including tumour markers were essentially normal. Plain X-ray of the abdomen revealed a partial small bowel obstruction and the patient was commenced on conservative management.

The following day, although her symptoms resolved, the mobile abdominal mass was still persistent but now palpable in the RIF. An ultrasound examination of the abdomen and pelvis showed ‘a pseudo-kidney’ sign in the RIF (Figure 1). An unprepared contrast enema revealed a possible neoplastic lesion at the splenic flexure (Figure 2). Helical computed tomography showed a ‘bowel within bowel’ appearance in the left hypochondrium with proximally-dilated small bowel loops (Figure 3).

She underwent a laparotomy, which showed a mobile, ileocaecal tumour with intussusception reaching the splenic flexure. There was no evidence of disseminated disease. An extended right hemicolectomy with en-bloc resection of the intussuscepting mass was performed. She had an uneventful postoperative period.

Pathological examination of the resected specimen revealed a 4.0 cm × 4.5 cm × 3.0 cm nodular tumour of the ileocaecal valve with intussusception of a 6.0 cm length of terminal ileum. Histological examination showed a moderately well differentiated adenocarcinoma with clear resection margins (Figure 4). There was no nodal or vascular invasion. Pathological staging of the tumour was Dukes' A, T2 (tumor confined to bowel wall), N0 (no tumor deposit in 11 lymph node harvested) (0/11), M0 (no distance metastasis).

Detection of plasmid DNA vectors following gene transfer to the murine airways

Non-viral gene therapy is being considered as a treatment for cystic fibrosis. In clinical studies and in studies using the mouse airways as a model, current formulations result in only transient transgene expression. A number of reasons for this have been proposed including the loss of plasmid DNA from cells. The aim of these studies was to investigate why transgene expression from non-viral vectors is transient in the mouse lung. Plasmid DNA encoding the luciferase reporter gene was complexed with the cationic lipid GL67 and delivered to the mouse airways. The persistence of plasmid DNA in the mouse lungs was investigated using quantitative PCR and Southern hybridization. Results showed that intact plasmid DNA persisted in the mouse lung in the absence of any detectable luciferase activity. The de novo methylation of plasmid DNA in vivo was investigated as a potential cause of this transient gene expression but results suggested that plasmid DNA does not become de novo methylated in the mouse lung. Therefore processes other than the loss of plasmid DNA from the lung or the de novo methylation of plasmid DNA vectors must be responsible for the transient transgene expression.

Intensive care use by critically ill obstetric patients: a five-year review

This is a retrospective analysis of all obstetric admissions to the surgical intensive care unit over the five-year period beginning July 1, 1994. The admission diagnosis, mode of delivery, anaesthetic employed and patient outcome were assessed. There were 43 obstetric admissions during this period, with 38 deliveries. This represents 0.32% of the deliveries in this hospital during the study period. The median duration of stay was three days (range 1-21). Haemorrhage and pregnancy-induced hypertension accounted for the majority of obstetric complications. Anaesthesia may have contributed to the admission of eight patients. Eight patients had more than one admission diagnosis. There were two deaths and one case of major morbidity (hypoxic encephalopathy) in this series. Prolonged ventilation and/or inotropic support were generally not required. In conclusion, approximately 3 per 1000 maternities require intensive care in this institution. The majority are discharged after a short stay with good outcome.

Neutron capture cross section measurement of 151Sm at the CERN neutron time of flight facility (n_TOF)

The151Sm(n,gamma)152Sm cross section has been measured at the spallation neutron facility n_TOF at CERN in the energy range from 1 eV to 1 MeV. The new facility combines excellent resolution in neutron time-of-flight, low repetition rates, and an unsurpassed instantaneous luminosity, resulting in rather favorable signal/background ratios. The 151Sm cross section is of importance for characterizing neutron capture nucleosynthesis in asymptotic giant branch stars. At a thermal energy of kT=30 keV the Maxwellian averaged cross section of this unstable isotope (t(1/2)=93 yr) was determined to be 3100+/-160 mb, significantly larger than theoretical predictions.

Comprehensive health assessment for newly arrived refugee children in Australia

Providing appropriate and responsive care to refugees from diverse backgrounds and with unique health needs is challenging. Refugee children may present with a wide range of conditions, which may be unfamiliar to health professionals in developed countries. Additionally, refugees may experience unfamiliarity with the Australian health system and distrust of authority figures and/or medical practitioners. This article provides an overview of the priority areas in health and health management for paediatric refugee patients for paediatricians as well as other relevant health care providers caring for this group. Specific issues covered include general health assessment, infectious diseases, immunization, growth and nutrition, oral health, development and disability, mental health and child protection. Comprehensive health assessment can assist in identifying children at risk of poor health and to provide them with timely and effective care, advocacy and appropriate referral.

An issue of access: delivering equitable health care for newly arrived refugee children in Australia

Newly arrived refugees and asylum seekers are faced with many difficulties in accessing effective health care when settling in Australia. Cultural, language and financial constraints, lack of awareness of available services, and lack of health provider understanding of the complex health concerns of refugees can all contribute to limiting access to health care. Understanding the complexities of a new health care system under these circumstances and finding a regular health provider may be difficult. In some cases there may be a fundamental distrust of government services. The different levels of health entitlements by visa category and (for some) detention on arrival in Australia may further complicate the provision and use of health services for providers and patients. Children are particularly at risk of suboptimal health care due to the impact of these factors combined with the effect of resettlement stresses on parents' ability to care for their children. Unaccompanied and separated children, and those in detention experience additional challenges in accessing care. This article aims to increase awareness among health professionals caring for refugee children of the challenges faced by this group in accessing and receiving effective health care in Australia. Particular consideration is given to the issues of equity, rights of asylum seekers, communication and cultural sensitivities in health care provision, and addressing barriers to health care. The aim of the paper is to alert practitioners to the complex issues surrounding the delivery of health care to refugee children and provide realistic recommendations to guide practice.

The importance of high resolution chromosome analysis in the diagnosis of birth defects: case reports of holoproscencephaly and cystic hygroma

INTRODUCTION

The goal of cytogenetics is the detection of chromosomal abnormalities, achieved by the analysis of adequate numbers of metaphases at the appropriate bands per haploid set (BPHS).

CLINICAL PICTURE

Two cases presented here include a foetal blood sample (FBS) of a 33-week-old referred with holoproscencephaly by ultrasonography, and an amniotic fluid (AF) specimen of a 14-week-old foetus with cystic hygroma, cardiac and renal defects.

OUTCOME

The FBS had a deletion at 18p11.31. Another laboratory had earlier given a normal cytogenetic result on its AF sample. In the second case, an unbalanced 46,XY,der(5)ins(5;3) (q33.1;q26.2q27)mat karyotype was obtained with the AF sample. In both cases, the abnormalities were more obvious when band levels were > or =450 BPHS.

CONCLUSION

This report underscores the importance of obtaining longer chromosome preparations above the current recommended 400 BPHS for prenatal specimens. This is particularly important in cases with abnormal ultrasound findings suggestive of an underlying chromosomal pathology.

Are we overusing ultrasound in non-traumatic acute abdominal pain?

BACKGROUND

Ultrasound is being used increasingly in the assessment of acute non-traumatic abdominal pain as it is non-invasive and does not carry the risk of radiation. However, the inappropriate use of ultrasound can lead to a delayed or incorrect diagnosis, more work for the personnel involved, and increased hospital costs.

METHODS

A prospective study was conducted to analyse the clinical indications for requesting an ultrasound in those admitted to a district general hospital with acute non-traumatic abdominal pain, and to assess whether there is a correlation between clinical and laboratory findings and ultrasound results. A total of 110 patients were studied during a three month period.

RESULTS

The results suggest that ultrasound is useful in the investigation of suspected biliary colic and abdominal masses. However, the yield of ultrasound in other patients with acute non-traumatic abdominal pain is low. This study also suggests that the yield of "positive" reports on ultrasound is significantly higher in patients with localised abdominal pain and tenderness and in those with acute abdominal pain and a raised white cell count or raised liver function tests. The yield of positive reports in patients with acute abdominal pain was found to be lower those less than 25 years of age than in older patients.