57-Year-Old Male Veteran with Recurrent Fevers

A 57-year-old male veteran presented to the emergency department for recurrent fevers for 10 days. The patient was febrile but had an overall benign physical exam. This interesting case explores the broad differential diagnosis and evaluation in a patient who presents with fever of unknown origin.

Coherent Control of Trapped-Ion Qubits with Localized Electric Fields

We present a new method for coherent control of trapped ion qubits in separate interaction regions of a multizone trap by simultaneously applying an electric field and a spin-dependent gradient. Both the phase and amplitude of the effective single-qubit rotation depend on the electric field, which can be localized to each zone. We demonstrate this interaction on a single ion using both laser-based and magnetic-field gradients in a surface-electrode ion trap, and measure the localization of the electric field.

Mixed-Model Curriculum for Nerve Block Education in Emergency Medicine Residency

Introduction With the rising opioid epidemic, there has been a push for multimodal pain management within the emergency department. Nerve blocks have been shown to be an effective pain management strategy for many conditions, with improved success when used with ultrasound. However, there is no generally accepted method for teaching residents how to perform nerve blocks. Materials and methods Seventeen residents from a single academic center were enrolled. The residents were surveyed pre-intervention regarding demographics, confidence, and use of nerve blocks. The residents then completed a mixed-model curriculum that included an electronic module (e-module) on three plane nerve blocks and a practice session. Three months later, residents were tested on their ability to independently perform the nerve blocks and resurveyed regarding confidence and use. Results Of the 56 residents in the program, 17 enrolled in the study; 16 participated in the first session, and nine participated in the second session. Each resident had < four ultrasound-guided nerve blocks prior to participation with a slight increase in the total number of nerve blocks after the sessions. Residents were able to perform, on average, 4.8 of seven tasks independently. Residents who completed the study reported feeling more confident in their ability to perform ultrasound-guided nerve blocks (p = 0.01) and to complete associated tasks (p < 0.01). Conclusion This educational model resulted in residents completing the majority of tasks independently with improved confidence in ultrasound-guided nerve blocks. There was only a slight increase in clinically performed blocks.

Ultrasound in Pregnancy

This article reviews the use of ultrasound in pregnancy pertinent to the emergency physician. The techniques for transabdominal and transvaginal studies are detailed including approaches to gestational dating. Diagnosis of ectopic pregnancy is reviewed focusing on the potential pitfalls: reliance on beta-human chorionic gonadotropin, pseudogestational sac, interstitial pregnancy, and heterotopic pregnancy. Techniques for the identification of placental issues and presenting parts during the second and third trimesters are reviewed. Ultrasound is a safe and effective tool for the experienced emergency physician and is integral to providing high-quality care to pregnant women.

POCUS for Diastolic Dysfunction: A Review of the Literature

Emergency and critical care physicians frequently encounter patients presenting with dyspnea and normal left ventricular systolic function who may benefit from early diastolic evaluation to determine acute patient management. The current American Society of Echocardiography Guidelines approach to diastolic evaluation is often impractical for point of care ultrasound (POCUS) evaluation, and few studies have evaluated the potential use of a simplified approach. This article reviews the literature on the use of a simplified diastolic evaluation to assist in determining acute patient management.

Which Way Would You Slice It? Evaluation of 3 Educational Models for the Loop Drainage Technique

INTRODUCTION

Emergency department visits for cutaneous abscesses are increasing. It is important for healthcare professionals to be proficient in identifying and treating abscesses. Loop drainage technique (LDT) is a newer technique which has been described in several articles but limited resources for teaching have been studied. The objective of this study was to compare 3 models for learning and teaching the LDT.

METHODS

This was a prospective survey study of a convenience sample of emergency medicine residents at a large urban academic center. Residents volunteered to participate during a scheduled cadaver and simulation session. After a self-directed review of the LDT, each participant performed ultrasound visualization and then the LDT on 3 simulated abscesses: a cadaveric model, a commercial abscess pad, and a homemade phantom. Participants completed pre- and post-simulation surveys.

RESULTS

Of 57 residents, 28 participated in the 1-day simulation. The majority (57.1%, p < 0.009) preferred the cadaver model for learning the LDT, and 78.6% reported it to have the most realistic physical examination for an abscess (p = 0.001). Prior to participation, 0% of residents felt proficient performing LDT. After participation, 46.4% of residents felt proficient and 78.6% reported intent to use in clinical practice (p < 0.001).

CONCLUSIONS

Simulation is an effective educational tool for both learning new skills and improving procedural competency. Residents found cadavers provided the most realistic physical examination, and the majority preferred it for learning the LDT. However, cadavers are not always accessible, an important factor when considering various educational settings.

An ultralow-noise superconducting radio-frequency ion trap for frequency metrology with highly charged ions

We present a novel ultrastable superconducting radio-frequency (RF) ion trap realized as a combination of an RF cavity and a linear Paul trap. Its RF quadrupole mode at 34.52 MHz reaches a quality factor of Q ≈ 2.3 × 10⁵ at a temperature of 4.1 K and is used to radially confine ions in an ultralow-noise pseudopotential. This concept is expected to strongly suppress motional heating rates and related frequency shifts that limit the ultimate accuracy achieved in advanced ion traps for frequency metrology. Running with its low-vibration cryogenic cooling system, electron-beam ion trap, and deceleration beamline supplying highly charged ions (HCIs), the superconducting trap offers ideal conditions for optical frequency metrology with ionic species. We report its proof-of-principle operation as a quadrupole-mass filter with HCIs and trapping of Doppler-cooled ⁹Be⁺ Coulomb crystals.

'Diagnosis of Boerhaave's Syndrome With Aid of Bedside Ultrasound

BACKGROUND

Boerhaave's syndrome is characterized by transmural rupture of the distal esophagus in the setting of increased intraluminal pressures combined with negative intrathoracic pressure. It is a rare condition with high mortality (20-50% mortality rate).

CASE REPORT

This is a case of a 47-year-old man who appeared acutely ill, presenting with shortness of breath, chest and abdominal pain, and diagnosed with Boerhaave's syndrome with the assistance of bedside ultrasound. WHY SHOULD AN EMERGENCY PHYSICIANS BE AWARE OF THIS?: Emergency physicians must have a heightened suspicion of this diagnosis in patients presenting with chest and abdominal pain and can use bedside ultrasound skills to aid with diagnosis.

Two pulmonary emboli in a psych pod

BACKGROUND

A female patient known to have schizoaffective disorder self-presented to an emergency department in a state of acute agitation and paranoia shortly after a 35-day inpatient stay at a psychiatric facility.

CASE REPORT

The patient exhibited no signs or complaints of dyspnea or hypoxia, but later collapsed and became hypoxic after sleeping comfortably with sedation for 12 h in the psychiatric unit. She was intubated and a computed tomography angiogram revealed bilateral lobar pulmonary emboli and right heart strain.

CONCLUSION

Psychiatric hospitalizations, medications, diagnoses and relevant sequelae increase venous thromboembolism risk more than many realize.

36-year-old Male with Syncope

CASE PRESENTATION

A 36-year-old incarcerated male presented to the emergency department (ED) after an episode concerning for syncope. The patient had nystagmus and ataxia on initial examination.

DISCUSSION

There is a broad differential diagnosis for syncope, and for patients presenting to the ED we tend to focus on cardiogenic and neurologic causes. This case takes the reader through the differential diagnosis and systemic work-up of a patient presenting to the ED with syncope.

A cryogenic radio-frequency ion trap for quantum logic spectroscopy of highly charged ions

A cryogenic radio-frequency ion trap system designed for quantum logic spectroscopy of highly charged ions (HCI) is presented. It includes a segmented linear Paul trap, an in-vacuum imaging lens, and a helical resonator. We demonstrate ground state cooling of all three modes of motion of a single ⁹Be⁺ ion and determine their heating rates as well as excess axial micromotion. The trap shows one of the lowest levels of electric field noise published to date. We investigate the magnetic-field noise suppression in cryogenic shields made from segmented copper, the resulting magnetic field stability at the ion position and the resulting coherence time. Using this trap in conjunction with an electron beam ion trap and a deceleration beamline, we have been able to trap single highly charged Ar¹³⁺ (Ar XIV) ions concurrently with single Be⁺ ions, a key prerequisite for the first quantum logic spectroscopy of a HCI. This major stepping stone allows us to push highly-charged-ion spectroscopic precision from the gigahertz to the hertz level and below.

Closed-cycle, low-vibration 4 K cryostat for ion traps and other applications

In vacuo cryogenic environments are ideal for applications requiring both low temperatures and extremely low particle densities. This enables reaching long storage and coherence times, for example, in ion traps, essential requirements for experiments with highly charged ions, quantum computation, and optical clocks. We have developed a novel cryostat continuously refrigerated with a pulse-tube cryocooler and providing the lowest vibration level reported for such a closed-cycle system with 1 W cooling power for a <5 K experiment. A decoupling system suppresses vibrations from the cryocooler by three orders of magnitude down to a level of 10 nm peak amplitudes in the horizontal plane. Heat loads of about 40 W (at 45 K) and 1 W (at 4 K) are transferred from an experimental chamber, mounted on an optical table, to the cryocooler through a vacuum-insulated massive 120 kg inertial copper pendulum. The 1.4 m long pendulum allows installation of the cryocooler in a separate, acoustically isolated machine room. At the experimental chamber, we measured the residual vibrations using an interferometric setup. The positioning of the 4 K elements is reproduced to better than a few micrometer after a full thermal cycle to room temperature. Extreme high vacuum on the 10^-15 mbar level is achieved. In collaboration with the Max-Planck-Institut für Kernphysik, such a setup is now in operation at the Physikalisch-Technische Bundesanstalt for a next-generation optical clock experiment using highly charged ions.

Soy isoflavones and their metabolites modulate cytokine-induced natural killer cell function

Soybeans are a rich source of isoflavones that have been linked with anti-inflammatory processes and various health benefits. However, specific mechanisms whereby soy bioactives impact immune cell subsets are unclear. Isoflavones, such as genistein and daidzein, are metabolized by microbes to bioactive metabolites as O-desmethylangolensin (O-DMA) and equol, whose presence has been linked to health benefits. We examined how soy isoflavones and metabolites impact natural killer (NK) cell signaling and function. We observe no impact of isoflavones on viability of healthy donor peripheral blood mononuclear cells (PBMCs) or NK cells, even at high (25 µM) concentrations. However, pre-treatment of PBMCs with physiologically-relevant concentrations of genistein (p = 0.0023) and equol (p = 0.006) decreases interleukin (IL)-12/IL-18-induced interferon-gamma (IFN-γ) production versus controls. Detailed cellular analyses indicate genistein and equol decrease IL-12/IL-18-induced IFN-γ production by human NK cell subsets, but do not consistently alter cytotoxicity. At the level of signal transduction, genistein decreases IL-12/IL-18-induced total phosphorylated tyrosine, and phosphorylation MAPK pathway components. Further, genistein limits IL-12/IL-18-mediated upregulation of IL-18Rα expression on NK cells (p = 0.0109). Finally, in vivo studies revealed that C57BL/6 mice fed a soy-enriched diet produce less plasma IFN-γ following administration of IL-12/IL-18 versus control-fed animals (p < 0.0001). This study provides insight into how dietary soy modulates NK cell functions.

Pediatric ADHD Medication Exposures Reported to US Poison Control Centers

: media-1vid110.1542/5754332180001PEDS-VA_2017-3872Video Abstract OBJECTIVES: To describe the characteristics and trends of exposures to attention-deficit/hyperactivity disorder (ADHD) medications among individuals 0 to 19 years old reported to US poison control centers.

METHODS

National Poison Data System data from 2000 through 2014 were retrospectively analyzed to examine pediatric ADHD medication exposures.

RESULTS

From 2000 through 2014, there were 156 365 exposures reported to US poison control centers related to ADHD medications. The overall rate of reported exposures increased 71.2% from 2000 to 2011, followed by a 6.2% decrease from 2011 to 2014. Three-fourths (76.0%) of exposures involved children ≤12 years old. Methylphenidate and amphetamine medications accounted for 46.2% and 44.5% of exposures, respectively. The most common reason for exposure was therapeutic error (41.6%). Intentional medication exposures (including suspected suicide and medication abuse and/or misuse) were reported most often among adolescents (13-19 years old), accounting for 50.2% of exposures in this age group. Overall, the majority of exposed individuals (60.4%) did not receive health care facility treatment; however, 6.2% were admitted to a hospital for medical treatment, and there were 3 deaths. The increasing number and rate of reported ADHD medication exposures during the study period is consistent with increasing trends in ADHD diagnosis and medication prescribing. Exposures associated with suspected suicide or medication abuse and/or misuse among adolescents are of particular concern.

CONCLUSIONS

Unintentional and intentional pediatric exposures to ADHD medications are an increasing problem in the United States, affecting children of all ages.

Outbreak of encephalitic listeriosis in red-legged partridges (Alectoris rufa)

An outbreak of neurological disease was investigated in red-legged partridges between 8 and 28 days of age. Clinical signs included torticollis, head tilt and incoordination and over an initial eight day period approximately 30-40 fatalities occurred per day. No significant gross post mortem findings were detected. Histopathological examination of the brain and bacterial cultures followed by partial sequencing confirmed a diagnosis of encephalitis due to Listeria monocytogenes. Further isolates were obtained from follow-up carcasses, environmental samples and pooled tissue samples of newly imported day-old chicks prior to placement on farm. These isolates had the same antibiotic resistance pattern as the isolate of the initial post mortem submission and belonged to the same fluorescent amplified fragment length polymorphism (fAFLP) subtype. This suggested that the isolates were very closely related or identical and that the pathogen had entered the farm with the imported day-old chicks, resulting in disease manifestation in partridges between 8 and 28 days of age. Reports of outbreaks of encephalitic listeriosis in avian species are rare and this is to the best of our knowledge the first reported outbreak in red-legged partridges.

Frequency Comparison of [Formula: see text] Ion Optical Clocks at PTB and NPL via GPS PPP

We used precise point positioning, a well-established GPS carrier-phase frequency transfer method to perform a direct remote comparison of two optical frequency standards based on single laser-cooled [Formula: see text] ions operated at the National Physical Laboratory (NPL), U.K. and the Physikalisch-Technische Bundesanstalt (PTB), Germany. At both institutes, an active hydrogen maser serves as a flywheel oscillator which is connected to a GPS receiver as an external frequency reference and compared simultaneously to a realization of the unperturbed frequency of the (2)S1/2(F=0)-(2)D3/2(F=2) electric quadrupole transition in [Formula: see text] via an optical femtosecond frequency comb. To profit from long coherent GPS-link measurements, we extrapolate the fractional frequency difference over the various data gaps in the optical clock to maser comparisons which introduces maser noise to the frequency comparison but improves the uncertainty from the GPS-link instability. We determined the total statistical uncertainty consisting of the GPS-link uncertainty and the extrapolation uncertainties for several extrapolation schemes. Using the extrapolation scheme with the smallest combined uncertainty, we find a fractional frequency difference [Formula: see text] of -1.3×10(-15) with a combined uncertainty of 1.2×10(-15) for a total measurement time of 67 h. This result is consistent with an agreement of the frequencies realized by both optical clocks and with recent absolute frequency measurements against caesium fountain clocks within the corresponding uncertainties.

Mathematics interventions for children and adolescents with Down syndrome: a research synthesis

BACKGROUND

Many children and adolescents with Down syndrome fail to achieve proficiency in mathematics. Researchers have suggested that tailoring interventions based on the behavioural phenotype may enhance efficacy.

METHOD

The research questions that guided this review were (1) what types of mathematics interventions have been empirically evaluated with children and adolescents with Down syndrome?; (2) do the studies demonstrate sufficient methodological rigor?; (3) is there evidence of efficacy for the evaluated mathematics interventions?; and (4) to what extent have researchers considered aspects of the behavioural phenotype in selecting, designing and/or implementing mathematics interventions for children and adolescents with Down syndrome? Nine studies published between 1989 and 2012 were identified for inclusion.

RESULTS

Interventions predominantly focused on early mathematics skills and reported positive outcomes. However, no study met criteria for methodological rigor. Further, no authors explicitly considered the behavioural phenotype.

CONCLUSIONS

Additional research using rigorous experimental designs is needed to evaluate the efficacy of mathematics interventions for children and adolescents with Down syndrome. Suggestions for considering the behavioural phenotype in future research are provided.

Enhanced bioavailability of lycopene when consumed as cis-isomers from tangerine compared to red tomato juice, a randomized, cross-over clinical trial

SCOPE

Tangerine tomatoes (Solanum lycopersicum) are rich in tetra-cis-lycopene resulting from natural variation in carotenoid isomerase. Our objective was to compare the bioavailability of lycopene from tangerine to red tomato juice, and elucidate physical deposition forms of these isomers in tomatoes by light and electron microscopy.

METHODS AND RESULTS

Following a randomized cross-over design, subjects (n = 11, 6 M/5 F) consumed two meals delivering 10 mg lycopene from tangerine (94% cis) or red tomato juice (10% cis). Blood was sampled over 12 h and triglyceride-rich lipoprotein fractions of plasma were isolated and analyzed using HPLC-DAD-MS/MS. Lycopene was crystalline in red tomato chromoplasts and globular in tangerine tomatoes. With tangerine tomato juice we observed a marked 8.5-fold increase in lycopene bioavailability compared to red tomato juice (p < 0.001). Fractional absorption was 47.70 ± 8.81% from tangerine and 4.98 ± 1.92% from red tomato juices. Large heterogeneity was observed among subjects.

CONCLUSION

Lycopene is markedly more bioavailable from tangerine than from red tomato juice, consistent with a predominance of cis-lycopene isomers and presence in chromoplasts in a lipid dissolved globular state. These results justify using tangerine tomatoes as a lycopene source in studies examining the potential health benefits of lycopene-rich foods.

Frequency ratio of two optical clock transitions in 171Yb+ and constraints on the time variation of fundamental constants

Singly ionized ytterbium, with ultranarrow optical clock transitions at 467 and 436 nm, is a convenient system for the realization of optical atomic clocks and tests of present-day variation of fundamental constants. We present the first direct measurement of the frequency ratio of these two clock transitions, without reference to a cesium primary standard, and using the same single ion of 171Yb+. The absolute frequencies of both transitions are also presented, each with a relative standard uncertainty of 6×10(-16). Combining our results with those from other experiments, we report a threefold improvement in the constraint on the time variation of the proton-to-electron mass ratio, μ/μ=0.2(1.1)×10(-16)  yr(-1), along with an improved constraint on time variation of the fine structure constant, α/α=-0.7(2.1)×10(-17)  yr(-1).

Demonstration of Ornithobacterium rhinotracheale in pheasants (Phasianus colchicus) with pneumonia and airsacculitis

Outbreaks of respiratory disease were investigated in reared pheasants (Phasianus colchicus) aged approximately 18 to 32 weeks, released into the semi-wild on four shooting estates in southern England. The clinical signs in the affected birds included swelling of the face and eyes, loss of condition, gasping respirations and coughing. The gross pathology findings included sinusitis, airsacculitis, pleural oedema and lung lesions. The histopathological findings in the affected lungs were characterized by a granulomatous pneumonia. Ornithobacterium rhinotracheale (ORT) was isolated from respiratory tract tissues, and 16S rRNA gene sequencing on three isolates revealed two distinct genotypes, one previously associated with some electrophoretic type (ET) 1 strains and the other a novel genotype that clustered among sequences previously associated with ET 3, ET 4, ET 5 and ET 6 isolates. The localization of ORT within the lung tissue was demonstrated by fluorescent in-situ hybridization in the bronchial exudate of three cases, although not within the granulomatous lesions themselves. In each case, ORT was identified as part of a complex of other respiratory agents including avian paramyxovirus type 2, avian coronavirus, Mycoplasma gallisepticum, Mycoplasma synoviae and other Mycoplasma species, Escherichia coli, Pasteurella multocida, other Pasteurellaceae and Syngamus trachea, suggesting synergism with other agents. Exposure to other intercurrent factors, including adverse weather conditions and internal parasitism, may also have exacerbated the severity of disease.

[Reduced port surgery : Developing a safe pathway to single port access surgery]

"Scarfree" surgery is a desired goal in the world of laparoscopy and interventional endoscopy. One possibility to achieve this goal is abdominal access via a natural orifice (natural orifice transluminal endoscopic surgery, NOTES); however, this procedure and its applications lack an appropriate platform. Further possibilities are reduced port techniques or single port access surgery, which result in minimal scarring. Development and continued growth in this area cover a broad spectrum. Although acceptance has been demonstrated, the technique must be adopted in a safe and effective manner and must be economically and ecologically safe. This article gives an overview of the development of the technique, the learning curve, and new applications for this new technique. An English full-text version of this article is available at SpringerLink as supplemental.

Internet gambling and pornography: illustrative examples of the psychological consequences of communication anarchy

Two areas of Internet behavior, gambling and pornography distribution, are examined for what they reveal about the profound social and psychological changes caused by recent advances in communication technology. The overview of these domains clearly shows that there will be an expected increase in people presenting for treatment with Internet behavior related difficulties, and that their treatment will be, at present, uninformed by any specific empirical research. These two domains are used as examples to illustrate how the Internet is creating a paradigm shift in the basic nature of an individual's relationships to local, state, and federal governments. It is no longer possible for people, even minors, to be fully protected by their governments from material deemed harmful by the community one lives in. This is demonstrated by a review of the current availability, in millions of homes nationwide, of the opportunity to experience Internet casino gambling and to acquire pornographic material not sold in United States adult bookstores. The psychological effect of the increased need for individual responsibility in the access to potentially harmful domains is not well understood at this time. This article is a call for the kind of basic research that will delineate the base rates for pathological involvement in online gambling and pornography, as a means of discovering the potential negative psychological consequences of the inability to regulate Internet content.

Infant oral health education in U.S. dental school curricula

PURPOSE

This study was performed to determine didactic and clinical curricular content about infant oral health in predoctoral pediatric dentistry programs.

METHODS

54 dental school departments of pediatric dentistry were surveyed about: 1) curricular content devoted to teaching infant oral health (IOH) and age of first dental visit; 2) methods used to teach IOH and hours dedicated to each method; and 3) whether students receive hands-on experiences with infants.

RESULTS

Eighty-six percent of programs teach students to see infants at 12 months of age or younger. Curricular time ranged from 15 minutes to 13 hours (mean = 2 hrs, 20 min, median = 1 hr, 45 min). All programs used lectures; other formats included handouts, demonstration and small group seminar. Fifty percent provide clinical experiences, albeit they are not uniform for all students. One-fourth provides uniform, clinical hands-on experiences with infant oral examinations.

CONCLUSIONS

The findings indicate varying degrees of acceptance about teaching infant oral health in our dental schools.

A Case of Malingering: Feigning a Painful Disorder in the Presence of True Medical Illness

The potential for malingering must always be considered among patients presenting with pain. When malingering is identified, care may be discontinued. This case report describes a patient who feigned sickle cell crisis, a painful condition, in the presence of other identifiable and potentially painful medical illnesses.

R-domain interactions with distal regions of CFTR lead to phosphorylation and activation

Cystic fibrosis is caused by the aberrant function of the cystic fibrosis transmembrane conductance regulator (CFTR) protein. We examined whether intramolecular binding interactions involving the regulatory (R) domain contributed to CFTR regulation and function. When the R-domain (amino acids 596-836) was coexpressed with Delta1-836 CFTR (a carboxyl hemi-CFTR beginning immediately after the R-domain), strong binding between the two polypeptides was exhibited. The R-domain that co-immunoprecipitated with Delta1-836 exhibited a slower mobility on SDS-PAGE that resulted from phosphorylation of the protein. A larger CFTR polypeptide that included the R-domain (M837X) also exhibited a phosphorylation-dependent mobility shift when coexpressed with Delta1-836. Moreover, coexpression of M837X and Delta1-836 led to enhanced halide permeability in living cells. The activity, unlike in full-length CFTR, was present without forskolin activation, but still sensitive to the PKA inhibitor, Rp-8-CPT-cAMPS. This PKA inhibition of activity was found to be dependent on the carboxy region of the R-domain, amino acids 723-836. Our results indicate that the R-domain binds CFTR residues after amino acid 836 and that this binding facilitates phosphorylation and CFTR activation. We have also characterized a subdomain within CFTR (residues 723-837) that is necessary for PKA-dependent constitutive activation. Finally, these experiments demonstrate that constitutive CFTR activity can be accomplished by at least two mechanisms: (1) direct modulation of the R-domain to abrogate PKA regulation and (2) modifications that increase R-domain susceptibility to steady-state phosphorylation through PKA.

Margin status and excision of cervical intraepithelial neoplasia: a review

Excisional biopsy of the cervix for diagnosis and treatment of cervical neoplasia is common. Management of patients with involved margins of resection is unresolved. Data concerning use of thermal techniques show that this technique yields equivalent results in most cases. Important exceptions are microinvasive squamous disease and adenocarcinoma. Conservative management of involved squamous margins is possible. Techniques for follow-up include cytology, colposcopy, and endocervical curettage. Adenocarcinoma in situ (AIS) should be treated with cold-knife conization. The standard of care for AIS is hysterectomy except in certain specific indications. Data concerning technique, follow-up, use of endocervical curettage, and the need for reexcision will be presented.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader will be able to compare the efficacy of the various excisional procedures in the treatment of cervical dysplasia, list the indications for additional surgery after positive margins on cervical excisions, and describe the proper management of a patient with adenocarcinoma in situ.

Tricorrectional bunionectomy for hallux abducto valgus. A comprehensive outcome study

A longitudinal outcome study of the tricorrectional bunionectomy with AO screw fixation for the correction of hallux abducto valgus was undertaken involving 84 consecutive patients (121 feet) with a mean age of 48.4 years who underwent the procedure over a 6-month period. Preoperative and postoperative measurements of forefoot angles were calculated, with the following mean results obtained: intermetatarsal angle of 14.46 degrees corrected to 5.72 degrees, hallux abductus angle of 26.38 degrees corrected to 11.65 degrees, proximal articular set angle of 19.85 degrees corrected to 6.06 degrees, and tibial sesamoid position of 4.75 corrected to 1.87. The average time to return to athletic shoes was 12.63 days. Postoperative complications were minor, with no delayed unions, malunions, hematomas, bone infections, or hallux varus. Long-term follow-up (mean, 21.33 months) using the American Orthopaedic Foot and Ankle Society's objective Hallux Metatarsophalangeal-Interphalangeal Scale revealed an overall mean score of 88.94 points out of a possible 100. An excellent mean result of 95 points out of a possible 100 on the subjective patient rating scale was also reported.

Allelotype analysis of uterine leiomyoma: localization of a potential tumor suppressor gene to a 4-cM region of chromosome 7q

Uterine leiomyoma is a benign smooth muscle tumor of the myometrium and is the most commonly encountered neoplasm in women of reproductive age. As for most benign tumors, the pathogenesis of leiomyoma remains obscure, especially at the molecular genetic level. The purpose of this study was to perform a genome-wide allelotype analysis to identify potential sites of tumor suppressor gene inactivation. Fifty-two cases of uterine leiomyoma were subjected to allelotype analysis by using matched pairs of tumor and blood DNA. Loss of heterozygosity (LOH) was assessed at 61 microsatellite markers distributed throughout the genome and representing all 41 chromosome arms. In general, LOH was very rare except on chromosome 7q, where LOH was observed in 34% of all informative tumors. Fine-deletion mapping with 25 microsatellite markers from the 7q22 region revealed a minimal deletion unit of approximately 4 cM, bounded by the markers D7S2453 proximally and D7S496 distally, that probably harbors a novel tumor suppressor gene involved in the etiology of this tumor.

The mechanism underlying cystic fibrosis transmembrane conductance regulator transport from the endoplasmic reticulum to the proteasome includes Sec61beta and a cytosolic, deglycosylated intermediary

Endoplasmic reticulum (ER) degradation pathways can selectively route proteins away from folding and maturation. Both soluble and integral membrane proteins can be targeted from the ER to proteasomal degradation in this fashion. The cystic fibrosis transmembrane conductance regulator (CFTR) is an integral, multidomain membrane protein localized to the apical surface of epithelial cells that functions to facilitate Cl- transport. CFTR was among the first membrane proteins for which a role of the proteasome in ER-related degradation was described. However, the signals that route CFTR to ubiquitination and subsequent degradation are not known. Moreover, limited information is available concerning the subcellular localization of polyubiquitinated CFTR or mechanisms underlying retrograde dislocation of CFTR from the ER membrane to the proteasome either before or after ubiquitination. In the present study, we show that proteasome inhibition with clasto-lactacystin beta-lactone (4 microM, 1 h) stabilizes the presence of a deglycosylated CFTR intermediate for up to 5 h without increasing the core glycosylated (band B) form of CFTR. Deglycosylated CFTR is present under the same conditions that result in accumulation of polyubiquitinated CFTR. Moreover, the deglycosylated form of both wild type and DeltaF508 CFTR can be found in the cytosolic fraction. Both the level and stability of cytosolic, deglycosylated CFTR are increased by proteasome blockade. During retrograde translocation from the ER to the cytosol, CFTR associates with the Sec61 trimeric complex. Sec61 is the key component of the mammalian co-translational protein translocation system and has been proposed to function as a two way channel that transports proteins both into the ER and back to the cytosol for degradation. We show that the level of the Sec61.CFTR complexes are highest when CFTR degradation proceeds at the greatest rate (approximately 90 min after pulse labeling). Quantities of Sec61.CFTR complexes are also increased by inhibition of the proteasome. Based on these results, we propose a model in which complex membrane proteins such as CFTR are transported through the Sec61 trimeric complex back to the cytosol, escorted by the beta subunit of Sec61, and degraded by the proteasome or by other proteolytic systems.

Cystic fibrosis transmembrane conductance regulator (CFTR) nucleotide-binding domain 1 (NBD-1) and CFTR truncated within NBD-1 target to the epithelial plasma membrane and increase anion permeability

The cystic fibrosis transmembrane conductance regulator (CFTR) is a member of the traffic ATPase family that includes multiple proteins characterized by (1) ATP binding, (2) conserved transmembrane (TM) motifs and nucleotide binding domains (NBDs), and (3) molecular transport of small molecules across the cell membrane. While CFTR NBD-1 mediates ATP binding and hydrolysis, the membrane topology and function of this domain in living eukaryotic cells remains uncertain. In these studies, we have expressed wild-type CFTR NBD-1 (amino acids 433-586) or NBD-1 containing the DeltaF508 mutation transiently in COS-7 cells and established that the domain is situated across the plasma membrane by four independent assays; namely, extracellular chymotrypsin digestion, surface protein biotinylation, confocal immunofluorescent microscopy, and functional measurements of cell membrane anion permeability. Functional studies indicate that basal halide permeability is enhanced above control conditions following wild-type or DeltaF508 NBD-1 expression in three different epithelial cell lines. Furthermore, when clinically relevant CFTR proteins truncated within NBD-1 (R553X or G542X) are expressed, surface localization and enhanced halide permeability are again established. Together, these findings suggest that isolated CFTR NBD-1 (with or without the DeltaF508 mutation) is capable of targeting the epithelial cell membrane and enhancing cellular halide permeability. Furthermore, CFTR truncated at position 553 or 542 and possessing the majority of NBD-1 demonstrates surface localization and also confers increased halide permeability. These findings indicate that targeting to the plasma membrane and assumption of a transmembrane configuration are innate properties of the CFTR NBD-1. The results also support the notion that components of the halide-selective pore of CFTR reside within NBD-1.

Cell to cell contact is not required for bystander cell killing by Escherichia coli purine nucleoside phosphorylase

Expression of Escherichia coli purine nucleoside phosphorylase (PNP) activates prodrugs and kills entire populations of mammalian cells, even when as few as 1% of the cells express this gene. This phenomenon of bystander killing has been previously investigated for herpes simplex virus-thymidine kinase (HSV-TK) and has been shown to require cell to cell contact. Using silicon rings to separate E. coli PNP expressing cells from non-expressing cells sharing the same medium, we demonstrate that bystander cell killing by E. coli PNP does not require cell-cell contact. Initially, cells expressing E. coli PNP convert the non-toxic prodrug, 6-methylpurine-2'-deoxyriboside (MeP-dR) to the highly toxic membrane permeable toxin, 6-methylpurine (MeP). As the expressing cells die, E. coli PNP is released into the culture medium, retains activity, and continues precursor conversion extracellularly (as determined by reverse phase high performance liquid chromatography of both prodrug and toxin). Bystander killing can also be observed in the absence of extracellular E. coli PNP by removing the MeP-dR prior to death of the expressing cells. In this case, 100% of cultured cells die when as few as 3% of the cells of a population express E. coli PNP. Blocking nucleoside transport with nitrobenzylthioinosine reduces MeP-dR mediated cell killing but not MeP cell killing. These mechanisms differ fundamentally from those previously reported for the HSV-TK gene.

Cycles of dose-intensive chemotherapy with peripheral stem cell support in persistent or recurrent platinum-sensitive ovarian cancer

OBJECTIVE

The objective was to determine the toxicity and surgically documented response rate of sequential high-dose chemotherapy with peripheral stem cell support in patients with persistent or recurrent cisplatin-sensitive ovarian cancer.

METHODS

Fourteen patients (average age, 45 years) were treated with cyclophosphamide (4.5 g/m2), followed by granulocyte colony-stimulating factor (G-CSF)-stimulated peripheral stem cell harvests. The subsequent regimen prescribed three courses of carboplatin (1 g/m2) and cyclophosphamide (1.5 g/m2 with 2-mercaptoethanesulfonate) every 2 weeks with stem cell support. This was followed by three courses of paclitaxel at 250 mg/m2 every 2 weeks with G-CSF support only. Six patients were entered on the basis of a positive second-look laparotomy and 8 patients had a first recurrence after at least a 6-month disease-free interval.

RESULTS

Fourteen patients were entered and 12 patients completed all planned courses of therapy (mean time, 13 weeks). Normal hematopoiesis was reestablished after each cycle. Hospitalization for neutropenic fever occurred in 11/93 cycles (11.8%). Thirteen patients required blood transfusions and in 12 patients platelet transfusions were given. One patient had grade 3 neurotoxicity. An initial elevated CA 125 returned to normal in 7/8 patients (88%) and 71% of patients with measurable disease responded to therapy. There were 2 pathologic complete responders (PCR), making the PCR rate 2/14 or 14% (0-35%).

CONCLUSION

Although this regimen was well tolerated and clinical response rates were high, the surgically documented response rate was not clearly superior to conventional salvage regimens in platinum-sensitive patients.

In vivo gene therapy of cancer with E. coli purine nucleoside phosphorylase

We have developed a new strategy for the gene therapy of cancer based on the activation of purine nucleoside analogs by transduced E. coli purine nucleoside phosphorylase (PNP, E.C. 2.4.2.1). The approach is designed to generate antimetabolites intracellularly that would be too toxic for systemic administration. To determine whether this strategy could be used to kill tumor cells without host toxicity, nude mice bearing human malignant D54MG glioma tumors expressing E. coli PNP (D54-PNP) were treated with either 6-methylpurine-2'-deoxyriboside (MeP-dR) or arabinofuranosyl-2-fluoroadenine monophosphate (F-araAMP, fludarabine, a precursor of F-araA). Both prodrugs exhibited significant antitumor activity against established D54-PNP tumors at doses that produced no discernible systemic toxicity. Significantly, MeP-dR was curative against this slow growing solid tumor after only 3 doses. The antitumor effects showed a dose dependence on both the amount of prodrug given and the level of E. coli PNP expression within tumor xenografts. These results indicated that a strategy using E. coli PNP to create highly toxic, membrane permeant compounds that kill both replicating and nonreplicating cells is feasible in vivo, further supporting development of this cancer gene therapy approach.

Relationship of preoperative antiendotoxin core antibodies and adverse outcomes following cardiac surgery

OBJECTIVE

To test the hypothesis that low serum antiendotoxin core antibody (EndoCAb) level is an independent predictor of adverse outcome following cardiac surgery.

DESIGN

Prospective, blinded, cohort study.

SETTING

Tertiary care medical center.

SUBJECTS

A total of 301 patients undergoing coronary artery bypass graft surgery and/or valvular heart surgery.

DESIGN

Preoperative serum was assayed for IgM EndoCAb, IgG EndoCAb, total IgM, and total IgG levels. Known preoperative risk factors were assessed, and patients were assigned a risk score using a validated method.

MAIN OUTCOME MEASURE

A major complication, defined as either in-hospital death or postoperative length of stay greater than 10 days.

RESULTS

Overall, a major complication occurred in 34 patients (11.3%). Lower IgM EndoCAb level independently predicted (P=.002) increased risk of major complication over and above the effects of preoperative risk score (P=.02), total IgG level (P=.07), and all other known perioperative risk factors. In contrast, IgG Endo-CAb and total IgM concentrations did not predict outcome. No association existed between risk score and level of IgM EndoCAb.

CONCLUSION

There is marked preoperative variability in humoral immunity against endotoxin core, which is not accounted for by differences in known preoperative risk factors. In this study, low levels of IgMEndoCAb were an important independent predictor of adverse postoperative outcome, which supports the theory that endotoxemia is a cause of postoperative morbidity.

Deletion mapping of two potential chromosome 14 tumor suppressor gene loci in ovarian carcinoma

Previous allelotyping studies of epithelial ovarian carcinoma suggest that loss of heterozygosity on chromosome 14q may be a common genetic alteration in this tumor type. The purpose of this study was to determine a precise frequency of chromosome 14q allelic loss in ovarian carcinomas and to define a minimal region(s) of deletion. Seventy-six ovarian carcinomas representative of the complete spectrum of grade, stage, and histological subtype were selected for PCR-based deletion mapping analysis using 15 highly polymorphic microsatellite markers spanning the length of this chromosome arm. Loss of heterozygosity was observed in 49% of the tumors studied, placing 14q among the most frequently affected chromosomal regions in ovarian cancer. Deletions were observed in all tumor grades and stages and in all histological subtypes except tumors of low malignant potential. Deletion of the entire chromosome arm was rare; the majority of tumors displayed partial losses, providing an informative basis for detailed deletion mapping. Two distinct minimal regions of deletion were delineated. One region was defined by markers D14S80 and D14S75 at 14q12-13, and the other region was defined by markers D14S65 and D14S267 at 14q32. These data implicate the involvement of two tumor suppressor genes on chromosome 14q in a substantial fraction of ovarian carcinomas.

Depression and pain: Assessment and therapeutic strategies

Many patients with pain also suffer from depression. The exact relationship between these two problems is unclear but it appears that, in many patients, the depression may not simply be secondary to the pain. When these problems coexist, successful management requires the proper assessment and treatment of both. This paper discusses depressive disorders associated with pain and their treatment, with special focus on medication management.

Effect of surgical debulking on survival in stage IV ovarian cancer

In order to determine whether optimal surgical debulking in Stage IV epithelial ovarian cancer impacts survival, a retrospective review of patients treated at the University of Pennsylvania Cancer Center (UPCC) from 1984 to 1995 diagnosed with Stage IV epithelial ovarian cancer was performed. Data were collected regarding grade, histology, reason for allocation to Stage IV, extent of surgery performed and residual disease at initial staging procedure, major perioperative complications, first-line chemotherapy regimen, length of inpatient hospital stay, outcome at second-look laparotomy, follow-up, and survival. For the purposes of this study, optimal cytoreduction was defined as a residual disease of 2 cm or less. Forty-seven patients with Stage IV epithelial ovarian cancer identified in the Society of Gynecologic Oncologists (SGO) Database at UPCC are included. Fourteen of 47 (30%) were optimally cytoreduced at the time of their staging procedure. Twenty-six of 47 (55%) were deemed Stage IV by virtue of positive pleural effusion cytology only. Twenty-one of 47 (45%) had intraparenchymal liver involvement or metastatic disease outside of the abdomen. The median survival of the suboptimally debulked group was 17 months, while median survival in the optimal group was 37 months (P = 0.0295). These data suggest that Stage IV epithelial ovarian cancer patients with less than 2 cm residual disease have a survival advantage over patients with greater than 2 cm residual.

Racial differences in survival from gynecologic cancer

OBJECTIVE

To determine whether survival from gynecologic cancer is different between African-American and white patients at an inner-city hospital with both a large clinic and a private service.

METHODS

We studied 538 patients (89 African American, 449 white) diagnosed with cervical, uterine, or ovarian cancer at a single institution from January 1, 1989 through December 31, 1993. Information was obtained on age, stage, site of disease, histology, and type of health insurance (public or commercial). Insurance coverage was used as a proxy for socioeconomic status. Overall survival was estimated by the method of Kaplan and Meier and compared by the log-rank test. Cox proportional hazard modeling was used to evaluate the effects of multiple factors on survival.

RESULTS

African-American patients were significantly older and were more likely to have cervical cancer and public insurance than white patients. Overall survival was worse for African-American patients than for white patients (P < .05). However, stage for stage, there was no significant difference in survival between the groups. There was also no difference when patients were grouped by insurance status. African Americans had a significantly worse survival for cervical cancer than whites, and African-American patients older than 65 years had a worse survival than whites of similar age. On multivariate analysis, only stage and insurance coverage were significant predictors of survival.

CONCLUSIONS

African-American patients with gynecologic cancer at our institution have worse overall survival than white patients. The survival difference seems to be due predominantly to differences in socioeconomic status and stage at diagnosis.