Embedded microcomputer-based force plate system validation when evaluating lameness severity differentiation under an induced synovitis model in lactating dairy cattle.

Bovine lameness has relatively large negative economic and welfare implications on the U.S. dairy industry. Due to the ramifications, early lameness detection will aid in assisting dairy producers to mitigate downstream effects through early treatment. The objective of this study was to determine the minimum standing time required among 2-, 3-, 4-, 5-, and 10 min time intervals to obtain an accurate weight distribution estimate for each leg when attempting to detect lameness. An embedded microcomputer-based force plate system was developed to measure vertical forces from individual cow limb weight distribution to detect bovine lameness when utilizing an induced synovitis lameness model. The force plate has four quadrants, with each load cell quadrant measuring the force placed on it from a single limb. The force plate recorded weight (kg) every second from each load cell quadrant, after which, a 60 s moving average for weight distribution was calculated. A sequential study design was employed to evaluate non-lame and induced lameness to ensure time requirements were consistent. Prior to induction, the force plate system was used to measure weight distribution every second for 15 min. After lameness induction, additional 15 min increments were recorded every 24 h for seven days. Lameness was induced by injecting the left hind distal interphalangeal joint in three cows with amphotericin B, 12 h prior to the start of the study. Data were analyzed using a linear mixed effect that included the fixed effects of day relative to lameness induction, time period, foot and injected foot. Cow within replicate was included as a random effect. Cumulative minutes were assessed up to 15 min by comparing the least square rolling 60 s cumulative means expressed as a percentage of each animal's BW percentage placed on each leg for 2-, 3-, 4-, 5-, and 10 min intervals. Results indicate that the minimum time needed for accurate lameness detection in cows was 2 min.

Steerable THz pulses from thin emitters via optical pulse-front tilt.

A new method of steering THz pulses radiated from a thin emitter excited by tilted optical pulse-fronts has been developed theoretically and validated in a proof-of-concept experiment. This steering technique is potentially efficient and rapid, and it should benefit from a THz-pulse energy that can scale with optical-beam size and magnitude. Conversely, the method employed for measuring the steered THz pulses is also capable of characterizing the pulse-front tilt of an optical beam.

Liver disease as a cause of thrombocytopenia.

BACKGROUND: Liver disease is frequently missed as the cause for a patient's thrombocytopenia. AIM: To evaluate the role of liver disease in causing thrombocytopenia within a tertiary hospital. DESIGN: A hospital-based retrospective study. METHODS: Analysis of medical records of outpatients and inpatients with a platelet count <100 × 10(9)/l seen at St Mary's Hospital, London in October 2011, was conducted. Cause for thrombocytopenia was determined in each case and patients with liver disease were analysed further looking at factors associated with their low platelet count. RESULTS: In total, 223 patients were included in this study, 109 of them were outpatients and 114 were inpatients. The mean age was 57.1 years (range 22-106), 64% male and 36% female. Liver disease was the cause for thrombocytopenia in 58% of outpatients. Overall, 92 patients with liver disease were identified; cirrhosis and/or splenomegaly were present in 78%, a further 8% were on interferon therapy. Thrombocytopenia was not explained by the extent of liver disease in 8%, significantly more in hepatitis C than other causes of liver disease (P < 0.05). Factors correlating with low platelet count in patients with liver disease were spleen size (P < 0.05) and serum bilirubin (P < 0.001). There were none, or mild abnormalities only in liver function tests in 19 patients with liver disease-associated thrombocytopenia. CONCLUSION: Liver disease should be considered in all patients with an unknown cause of thrombocytopenia. Advanced liver disease does not have to be present for thrombocytopenia to develop. All patients with unexplained thrombocytopenia should be evaluated to see if liver disease is present, even when liver function tests are normal.

Long-term outcomes of a fistula initiative: sustaining "fistula culture".

From 1998 to 2003, a low cost fistula initiative at Allegheny General Hospital increased the rate of AV fistulas from 32% to 72%. We present an additional 25 months of vascular access data, with stratification of results by gender and long-term patient survival data. These data show the self-sustaining nature of 'fistula culture' in an urban hemodialysis unit, and the survival benefits that result from increased fistula rates.

AV fistula rates: changing the culture of vascular access.

PURPOSE: Data from the United States Renal Data System show about 30% of prevailing hemodialysis (HD) patients use arteriovenous fistulae (AVF), which falls far short of the Kidney Disease Outcomes Quality Initiative (K/DOQI) goals of 40-50%. Recent initiatives to increase the use of AVF in HD patients have been criticized as unachievable under realistic practice conditions. METHODS: A multidisciplinary effort to increase AVF use was undertaken at an outpatient HD center beginning in 1998. Strategies focused on education and recruitment of patients in both inpatient and outpatient settings, preservation of veins, pre-operative vein mapping, and education of staff. RESULTS: AVF rates increased from 32%, to 72% over 6 years. The percentage of prosthetic grafts decreased from 40% to 13%. Central venous catheters fell from 28% to 15%. Among residual patients with catheters, 77% had maturing fistulae, as well. Infection rates in the dialysis unit decreased by 39%. Bacteremia declined by 47%. These improvements have been sustainable over the past 12 months. CONCLUSIONS: Adherence to a strategic program similar to the Fistula First Initiative can increase fistula rates under ordinary practice conditions. High fistula rates can be achieved in male and female patients. Unanimous commitment among all members of the health care team is needed. Reduction in the risks of infection, bacteremia, endocarditis, and death may be derived from achievable changes in practice.

Introduction to DNA analysis.

This article discusses the specific use of DNA analysis as one scientific method used in solving crime. Case studies presented here provide examples of crime investigations where the use of DNA analysis can prove beneficial.

Managing chronic hepatitis C acquired through intravenous drug use.

We retrospectively reviewed the provision and uptake of hospital services for 253 current and ex-intravenous drug users with hepatitis C virus (HCV). Overall, 237 attended at least one clinic (mean age 32 years, 70% male, 43% on maintenance methadone); 81% had evidence of active viral replication and 137 agreed to a liver biopsy to assess disease severity. Of these 137, 24% had mild chronic hepatitis with a low risk of progression to cirrhosis, but 9% had cirrhosis (mean age 40 years, mean time since initial intravenous drug use 15.8 years). Only 50 of the 100 patients in whom antiviral therapy was indicated, commenced treatment; 18 (36%) have had a sustained virological response. The natural history or response to treatment of chronic HCV in those who acquire it through intravenous drug use is not different to that previously reported for post-transfusion HCV. However, a substantial proportion default from follow-up or decline further intervention. As intravenous drug use is now the main risk factor for acquisition of HCV, these data have implications for future delivery of care aimed at limiting the morbidity of chronic HCV, and limiting the spread of hepatitis C virus infection amongst intravenous drug users.

Time for a new paradigm in pediatric medical education: teaching neonatal resuscitation in a simulated delivery room environment.

OBJECTIVES: Acquisition and maintenance of the skills necessary for successful resuscitation of the neonate are typically accomplished by a combination of completion of standardized training courses using textbooks, videotape, and manikins together with active participation in the resuscitation of human neonates in the real delivery room. We developed a simulation-based training program in neonatal resuscitation (NeoSim) to bridge the gap between textbook and real life and to assess trainee satisfaction with the elements of this program. METHODS: Thirty-eight subjects (physicians and nurses) participated in 1 of 9 full-day NeoSim programs combining didactic instruction with active, hands-on participation in intensive scenarios involving life-like neonatal and maternal manikins and real medical equipment. Subjects were asked to complete an extensive evaluation of all elements of the program on its conclusion. RESULTS: The subjects expressed high levels of satisfaction with nearly all aspects of this novel program. Responses to open-ended questions were especially enthusiastic in describing the realistic nature of simulation-based training. The major limitation of the program was the lack of fidelity of the neonatal manikin to a human neonate. CONCLUSION: Realistic simulation-based training in neonatal resuscitation is possible using current technology, is well received by trainees, and offers benefits not inherent in traditional paradigms of medical education.

Heterozygosity for hereditary hemochromatosis is associated with more fibrosis in chronic hepatitis C.

Hepatic iron has been associated with more aggressive liver disease in chronic viral hepatitis. We evaluated whether the recently described C282Y mutation of the hemochromatosis gene, designated HFE (responsible for at least 83% of hereditary hemochromatosis), was associated with more advanced liver disease in chronic hepatitis C. One hundred thirty-seven patients with biopsy-proven chronic hepatitis C were studied and liver biopsies scored for necroinflammation (grade 0-18) and fibrosis (stage 0-6). Genomic DNA was amplified by polymerase chain reaction and the C282Y mutation identified by restriction with RsaI and electrophoretic separation of restriction fragments. Ten (7.3%) patients had the C282Y mutation. No C282Y homozygous patients were identified. Age, sex distribution, and estimated weekly alcohol consumption were not significantly different between those with and without the mutation. Serum ferritin was higher in the heterozygotes (mean, 339 microg/L) compared with homozygous wild types (153 microg/L; P = .0005). In the majority of patients, liver iron was graded 0 out of 4, but hepatocyte iron staining was more commonly present in heterozygotes compared with homozygous normals (30% compared with 4% [P = .02]). Liver disease was more advanced in those with the mutant allele (mean fibrosis stage: 3.6, compared with wild type: 1.5 [P = .01]). Cirrhosis was found more often in those with the mutation (40%) compared with those without (8.7%) (P = .01; odds ratio: 7.6 [1.9-31.2]). There was no significant difference in inflammation scores between heterozygotes and wild type (mean, 5.4 compared with 4.1). Hepatitis C virus (HCV)-RNA titers were measured by branched DNA assay (HCV RNA 2.0-Chiron), and there was no difference between heterozygous and homozygous normal patients. Thus, despite relatively minor increases in iron stores, individuals who are heterozygous for hemochromatosis appear to develop more fibrosis in chronic hepatitis C. Venesection may be useful therapy in this subgroup.

Primary ameloblastoma of the sinonasal tract: a clinicopathologic study of 24 cases.

BACKGROUND: Ameloblastomas are locally aggressive jaw tumors with a high propensity for recurrence and are believed to arise from the remnants of odontogenic epithelium. Extragnathic ameloblastomas are unusual and primary sinonasal tract origin is extraordinarily uncommon. METHODS: Twenty-four cases of ameloblastoma confined to the sinonasal tract were retrieved from the Otorhinolaryngic-Head & Neck Pathology and Oral-Maxillofacial Pathology Tumor Registries of the Armed Forces Institute of Pathology between 1956 and 1996. RESULTS: The patients included 5 females and 19 males with an age range of 43-81 years, with a mean age at presentation of 59.7 years. The patients presented with an enlarging mass in the maxillary sinus or nasal cavity (n = 24), sinusitis (n = 9), or epistaxis (n = 8). Unilateral opacification of the maxillary sinus (n = 12) was the most common radiographic finding. Histologically, the tumors exhibited the characteristic features of ameloblastoma, including peripherally palisaded columnar cells with reverse polarity. The majority of the tumors showed a plexiform growth pattern. Fifteen tumors demonstrated surface epithelial derivation. Surgical excision is the treatment of choice, ranging from conservative surgery (polypectomy) to more aggressive surgery (radical maxillectomy). Five patients experienced at least 1 recurrence, usually within 1 year of initial surgery. With follow-up intervals of up to 44 years (mean, 9.5 years), all 24 patients were alive without evidence of disease or had died of unrelated causes, without evidence of disease. CONCLUSIONS: Primary ameloblastoma of the sinonasal tract is rare. In contrast to their gnathic counterparts, sinonasal tract tumors have a predilection for older age men. Therapy should be directed toward complete surgical resection to prevent local tumor recurrence.

Outcome of post-transfusion hepatitis C: disease severity in blood-component recipients and their implicated donors.

The UK 'Look-back Program' identifies recipients of blood products from hepatitis C antibody (anti-HCV) positive donors. Of 60 such recipients tested by the Newcastle Transfusion Service, 28(46.7%) were anti-HCV-negative, 25(41.7%) were anti-HCV-positive, and seven (11.6%) had equivocal serology. We studied 29 anti-HCV-positive/indeterminate recipients and eight of their implicated donors, using serial liver function tests (LFTs), liver histology when clinically indicated, HCV RNA and serotyping. Presumed resolved hepatitis C, with persistently normal LFTs and negative HCV RNA, was found in 28%, of whom 63% had indeterminate anti-HCV by RIBA (1 band of 4 detected on third-generation recombinant immunoblot assay). Resolved hepatitis C was significantly more common in women (p < 0.05) and tended to be associated with younger age at transfusion. There was complete concordance in serotype between donor-recipient pairs. There was no correlation in disease severity between recipients and their implicated donors, nor between recipients from the same donor. A history of alcohol consumption above recommended 'safe' limits (median 30 units) was associated with more severe histological disease (p < 0.01). Host factors, including gender and alcohol consumption, may be important in determining the wide variability in outcome of post-transfusion hepatitis C.

Preventing endoscopic retrograde cholangiopancreatography related sepsis: a randomized controlled trial comparing two antibiotic regimes.

Current antibiotic prophylaxis for endoscopic retrograde cholangiopancreatography (ERCP) is not standardized and may be inadequate. We aimed to evaluate the efficacy of 3 days of additional oral antibiotics in the prevention of ERCP-related sepsis. One hundred and fifty-six patients were randomized prospectively to receive either intravenous ticarcillin and clavulinic acid (Timentin; SmithKline Beecham, Dandenong, Victoria, Australia), pre-ERCP (group I) or Timentin and 3 days of oral amoxycillin and clavulinic acid (Augmentin; SmithKline Beecham, Dandenong, Victoria, Australia), group II). Blood cultures were taken 30 min after the procedure. The occurrence of sepsis, defined as a temperature over 38 degrees C, occurring in the first 7 days was recorded and the risk factors for the development of sepsis were evaluated. Four patients had significant positive blood cultures despite the prior administration of Timentin. Sepsis occurred in 10% of group I patients, but only 3% of group II patients (relative risk 3.30; 95% confidence intervals 0.74-14.8). The performance of sphincterotomy and the presence of common bile duct stones were significant risk factors for the development of sepsis. We would recommend 3 days of additional oral Augmentin after a single dose of intravenous antibiotics in patients at increased risk of sepsis, which would include those with bile duct stones and/or those undergoing a therapeutic procedure.

Sclerosing polycystic adenosis of major salivary glands. A clinicopathologic analysis of nine cases.

We describe nine cases of a histologically distinct and previously unreported lesion of the major salivary glands. The patients ranged in age from 12 to 63 years and included four males, five females. The lesions were slow-growing masses in the parotid gland (eight cases) and submandibular gland (one case). The clinical impression in each case was a benign salivary gland tumor. Grossly, the lesions were discrete, pale, rubbery nodules embedded within the salivary gland parenchyma. Microscopically, the lesions were unencapsulated, circumscribed masses of sclerotic and hyalinized collagenous tissue. Irregularly distributed throughout the collagenous tissue in a vaguely lobular pattern were hyperplastic ductal and acinar elements that were usually accompanied by cystically ectatic ducts. The dilated ducts frequently showed apocrine-like metaplasia and epithelial hyperplasia, which often formed transluminal bridges in a cribriform pattern. This epithelial hyperplasia sometimes surrounded eosinophilic globules as seen in so-called collagenous spherulosis. The combination of fibrosis, epithelial hyperplasia, and cystic changes were reminiscent of fibrocystic changes of the breast. Focally, acinar elements contained large, intensely eosinophilic, periodic acid-Schiff's-positive, intracytoplasmic granules believed to represent altered zymogen granules. A sparse to focally intense lymphocytic infiltrate accompanied the epithelial proliferations. Previous interpretations of these masses have included mucoepidermoid carcinoma, low-grade adenocarcinoma, benign adenoma, and mixed tumor. The limited available follow-up suggests that this process has a favorable prognosis despite recurrences in two cases. It is postulated that these lesions represent a pseudoneoplastic condition that results in both fibrosis and epithelial proliferation. We suggest the term sclerosing polycystic adenosis for these rare lesions.

Langerhans cell histiocytosis of the thyroid: a series of seven cases and a review of the literature.

Langerhans cell histiocytosis is a rare disorder, with a few reports describing isolated thyroid gland involvement. We report seven cases, which included four females and three males ranging in age from 2 months to 55 years, with a median age of 37 years. Histologically, the cases demonstrated either diffuse or focal involvement of the thyroid gland by Langerhans cell histiocytes, characterized by bean-shaped, lobated, folded nuclei. In association with the histiocytic infiltrate, there was a prominent eosinophilic cellular component, as well as destruction of the thyroid follicles. All cases occurred in a background of lymphocytic thyroiditis. One case demonstrated adenomatoid nodules, whereas another had a microscopic papillary carcinoma. Immunohistochemical staining demonstrated positive reactivity with S-100 protein, lysozyme, and KP-1. Four patients with isolated thyroid disease, treated by surgical resection alone, are alive without systemic disease from 3 to 19 years after initial presentation. The three patients with systemic disease died within 1 year of the initial diagnosis with disease-related complications. Localized disease portends a favorable prognosis as compared to the thyroid involvement as part of systemic disease.

Outpatient liver biopsy using ultrasound guidance and the Biopty gun is safe and cost effective.

BACKGROUND: The need for liver biopsy is increasing with the increasing availability of treatments for liver disease, in particular interferon. For this reason the procedure must be efficient and economical, as well as safe. AIMS: Firstly to assess the safety of outpatient liver biopsy when performed with ultrasound guidance and the 'Biopty' gun. Secondly, to compare the cost of an outpatient and inpatient procedure. METHODS: Two hundred and fifty consecutive liver biopsies performed over a two year period at St Vincent's Hospital, Melbourne were reviewed retrospectively. Indications, histological findings and complications were recorded. RESULTS: Seventy per cent of the biopsies were performed as an outpatient procedure. There were no major complications. Four patients experienced prolonged pain post biopsy. The average cost for an outpatient biopsy was $351, the cost of an inpatient (overnight stay) was $690. CONCLUSION: Outpatient liver biopsy is safe and cost effective, with minor complications in 1.6%. The routine use of ultrasound guidance and the Biopty gun is likely to contribute to these favourable results.

Evaluation of blood donors with equivocal hepatitis C serological results.

OBJECTIVE: To characterise blood donors with equivocal hepatitis C serological results and to develop an algorithm for their diagnosis and follow-up. DESIGN: Prospective case survey. SUBJECTS AND SETTING: 100 consecutive blood donors referred to the St Vincent's Hospital Liver Clinic, Victoria, with equivocal hepatitis C serological results (positive result for second generation Abbott Enzyme Immunoassay 2.0, but at least one negative result on supplemental testing by first generation Abbott neutralisation assay and Abbott Supplemental Assay for antibody to specific viral antigens). OUTCOME MEASURES: Percutaneous risk factors for hepatitis C exposure, peak serum alanine aminotransferase (ALT) levels, results of alternative immunoassay (Monolisa) and polymerase chain reaction (PCR) to detect hepatitis C viraemia. RESULTS: Thirty subjects had positive results for alternative immunoassay. A risk factor was identified for 32 subjects and was significantly associated (P < 0.01) with positive results for alternative immunoassay (23/32) and PCR (11/32), abnormal ALT levels (7/32), and strong reactivity on initial immunoassay (23/32). Presence of antibodies to both structural and non-structural antigens was also associated with risk factors and positive alternative immunoassay results. CONCLUSIONS: A definitive diagnosis was possible in 87% of subjects. A diagnosis of hepatitis C infection was based on positive alternative immunoassay results together with positive PCR results or presence of a risk factor. Hepatitis C was excluded for 60% of patients. The diagnosis for the remaining 13% remained indeterminate, indicating the need for a definitive diagnostic test for hepatitis C.