Extranodal MALT Lymphoma of the Right Triceps Muscle following Influenza Vaccine Injection: A Rare Case with an Interesting Presentation.

The study describes a case of a 67-year-old female who developed a Stage I E marginal zone lymphoma of the right triceps muscle 1 month after influenza vaccination at the same site. She was treated with single modality, involved field radiation therapy (IFRT) to 4000 cGy in 20 fractions with excellent response and no evidence of disease after one year followup.

Stanford V program for locally extensive and advanced Hodgkin lymphoma: the Memorial Sloan-Kettering Cancer Center experience.

BACKGROUND: The Stanford group has reported excellent results with the Stanford V regimen for patients with bulky and/or advanced Hodgkin lymphoma (HL). However, Gobbi reported markedly inferior failure-free survival (FFS) comparing Stanford V to other regimens but included major deviations from the original program. We retrospectively examined whether treatment at our institution carefully following Stanford V guidelines would confirm the original Stanford outcome data. PATIENTS AND METHODS: From June 1995 to May 2002, 126 patients with either locally extensive or advanced HL were treated with the 12-week Stanford V chemotherapy program followed by 36-Gy involved-field radiotherapy to sites initially > or =5 cm and/or to macroscopic splenic disease. Overall, 26% had stage IV disease and 20% had international prognostic score (IPS) > or =4. Overall survival (OS), disease-specific survival, progression-free survival (PFS), FFS, and freedom from second relapse (FF2R) were determined. RESULTS: The 5- and 7-year OS were 90% and 88%, respectively. The 5-year FFS was 78%. IPS > or =4 was a significant independent predictor of worse OS and PFS. The FF2R was 64% at 3 years. CONCLUSION: Stanford V with appropriate radiotherapy is a highly effective regimen for locally extensive and advanced HL.

Islands of speciation or mirages in the desert? Examining the role of restricted recombination in maintaining species.

Over the past decade, many studies documented high genetic divergence between closely related species in genomic regions experiencing restricted recombination in hybrids, such as within chromosomal rearrangements or areas adjacent to centromeres. Such regions have been called 'islands of speciation' because of their presumed role in maintaining the integrity of species despite gene flow elsewhere in the genome. Here, we review alternative explanations for such patterns. Segregation of ancestral variation or artifacts of nucleotide diversity within species can readily lead to higher F(ST) in regions of restricted recombination than other parts of the genome, even in the complete absence of interspecies gene flow, and thereby cause investigators to erroneously conclude that islands of speciation exist. We conclude by discussing strengths and weaknesses of various means for testing the role of restricted recombination in maintaining species.

Treatment of BXSB-Yaa mice with IL-21R-Fc fusion protein minimally attenuates systemic lupus erythematosus.

Interleukin-21 (IL-21) is a pleiotropic cytokine whose function is only now being unraveled. Abundant evidence indicates that activated CD4 T cells are the primary, if not the only, source of IL-21. While it is clear that IL-21 is actively transcribed by naïve activated T cells, recent studies have shown that IL-21 potentially promotes a developmental shift of naïve T cells toward the Th2 phenotype. BXSB-Yaa mice develop an autoimmune syndrome similar to systemic lupus erythematosus (SLE), affecting males earlier than females on account of the presence of the Yaa (Y-linked autoimmune acceleration) locus. Previous results indicate the elevation of IL-21 expression by BXSB-Yaa mice at an age when the early characteristics of autoimmune processes first become evident. We set out to determine whether IL-21 was necessary for disease progression in BXSB-Yaa mice. Mice were treated for 24 weeks with soluble IL-21R-Fc in order to therapeutically neutralize the IL-21 present. The results overall suggest a biphasic effect of IL-21, negatively influencing survival early on and positively influencing survival at later stages. We propose that IL-21 exerts a pleiotropic effect in which it promotes the protective effects of CD8+ suppressor cells in the early disease phase and then promotes the humoral components of SLE in the later disease stages. This experiment provides preliminary evidence for a role of IL-21 in modulating the severity of SLE in BXSB-Yaa mice.

Spitting in the ear: a falsified disease using video evidence.

We present the case of Munchausen's syndrome by proxy (MSBP) in which the mother spat and placed blood in her child's ear, and videoed the result, in order to gain the attentions of the medical profession. This is the first case report of this kind and may represent a disturbing trend in the use of digital photography and video to support factitious illnesses.

Impaired beta cell glucose sensitivity and whole-body insulin sensitivity as predictors of hyperglycaemia in non-diabetic subjects.

AIMS/HYPOTHESIS: The aim of this prospective study was to investigate predictors of deteriorating glucose tolerance in subjects of British extraction. METHODS: A total of 156 non-diabetic subjects (86 with a family history of type 2 diabetes) underwent a 75-g OGTT and anthropometric assessment at baseline and 5 years later. Pancreatic beta cell function and whole-body insulin sensitivity were studied by model assessment. Subjects were classified as progressors if glucose tolerance moved one or more steps from normal, impaired fasting glucose, impaired glucose tolerance and diabetes over the follow-up period. RESULTS: At baseline, the progressors (n=22) had increased adiposity and a higher proportion of familial diabetes and abnormal glucose tolerance than non-progressors. Baseline pancreatic beta cell sensitivity to changes in glucose (p<0.02) and whole-body insulin sensitivity (p<0.0001) were decreased in the progressors. Logistic regression revealed that baseline and follow-up changes in beta cell glucose sensitivity and insulin sensitivity, rather than the classical clinical predictors (adiposity, familial diabetes and glucose levels), were the key independent predictors of progression (explaining over 50% of the progression). CONCLUSIONS/INTERPRETATION: Impaired pancreatic beta cell glucose sensing and whole-body insulin sensitivity predict progression to hyperglycaemia. Strikingly, these pathophysiological changes override the importance of the clinical risk factors and highlight potential metabolic targets for prevention strategies.

Rosiglitazone improves insulin sensitivity, glucose tolerance and ambulatory blood pressure in subjects with impaired glucose tolerance.

AIMS: To determine the effects of rosiglitazone on insulin sensitivity, glucose tolerance and ambulatory blood pressure when administered to subjects with persistent impaired glucose tolerance (IGT). METHODS: Eighteen subjects with persistent IGT were randomized to receive rosiglitazone 4 mg twice daily or matching placebo for 12 weeks. Evaluation at baseline and at the end of treatment included measurement of whole body insulin sensitivity during a euglycaemic hyperinsulinaemic clamp and deriving an insulin sensitivity index. Changes in glucose and insulin concentration were determined after oral glucose tolerance test (OGTT) and mixed meal tolerance tests, and 24-h ambulatory blood pressure was monitored. RESULTS: Rosiglitazone significantly improved the insulin sensitivity index by 2.26 micro g/kg per min per pmol/l relative to placebo (P = 0.0003). Four of nine subjects receiving rosiglitazone reverted to normal glucose tolerance and 5/9 remained IGT, although four of these had improved 2-h glucose values. In the placebo group, 1/9 subjects progressed to Type 2 diabetes and 8/9 remained IGT. Following OGTT and meal tolerance test, glucose and insulin area under curve were reduced over 3 and 4 h, respectively. Compared with placebo, ambulatory blood pressure decreased significantly in the rosiglitazone group by 10 mmHg systolic (P = 0.0066) and 8 mmHg diastolic (P = 0.0126). CONCLUSIONS: Consistent with its effects in patients with Type 2 diabetes, rosiglitazone substantially improved whole body insulin sensitivity and the glycaemic and insulinaemic responses to an OGTT and meal tolerance test in subjects with persistent IGT. Furthermore, rosiglitazone reduced systolic and diastolic ambulatory blood pressure in these subjects.

A lifecourse study of risk for hyperinsulinaemia, dyslipidaemia and obesity (the central metabolic syndrome) at age 49-51 years.

AIMS: Suboptimal maternal nutrition and catch-up growth in early childhood predispose to insulin resistance and other components of metabolic syndrome in later life. A central metabolic syndrome (CMS) has been identified comprising obesity, dyslipidaemia and insulin resistance. This study was designed to investigate determinants of risk for CMS. METHODS: Persons born in Newcastle in May and June 1947 (n = 358) were followed to 1996-1998. A lifecourse approach was used to estimate the proportion of variance in a summary measure of CMS at age 49-51 years accounted for by factors operating at different stages of life. RESULTS: After adjustment for other early life variables, childhood catch-up growth in men accounted for significant variation in the CMS score independent of adult lifestyle. In adulthood, exercise level in men and smoking in both genders were independently associated with CMS. Over two-thirds of explained variation in the CMS score in women, and almost half in men, was accounted for exclusively by factors measured in adulthood. CONCLUSIONS: While risk for CMS in men is compounded by early life disadvantage, promotion of a healthier adult lifestyle and a reduction in the number of people taking up smoking would appear to be the public health interventions most likely to reduce the prevalence of CMS in middle age.

The effects of pyridostigmine bromide, permethrin, and DEET alone, or in combination, on fixed-ratio and fixed-interval behavior in male and female rats.

Concurrent exposure to pyridostigmine bromide (PB), permethrin (PERM) and/or N,N-diethyl-m-toluamide (DEET) may have contributed to the development of a syndrome that appears to have afflicted military personnel who served during the Gulf War. The present experiment sought to evaluate the behavioral effects of these compounds alone, or in various combinations, in male and female rats. Subjects were exposed to a multiple fixed-ratio (FR) 50, fixed-interval (FI) 2-min schedule of reinforcement. PB dose-dependently decreased FR and FI response rates. FR responding was disrupted by lower doses and there were no differences between the sexes. PERM vehicle administration decreased response rates maintained by both schedules of reinforcement; this was offset by an increase in response rate after the administration of the intermediate dose of PERM. The highest dose of PERM decreased both FR and FI response rates. FR rates in male rats were more disrupted than those in female rats. Only the highest dose of DEET decreased FR and FI response rates in male and female rats. FR rates were more disrupted in female rats than in male rats. Synergistic effects were only observed when FI response rates decreased in male rats upon exposure to half the low dose of PB with half the low dose of PERM or half the low dose of PB with half the low dose of DEET. The results of this experiment thus show that small doses of PB, PERM and DEET disrupt well-established, schedule-controlled behavior in male and female rats in a schedule- and gender-dependent manner; schedule-dependent and gender-dependent synergistic effects were also observed. The mechanism by which the compounds exert these behavioral effects remains to be determined.

The effects of pyridostigmine bromide on progressive ratio performance in male and female rats.

Small doses of pyridostigmine bromide (PB) affect the acquisition and maintenance of food-maintained behavior in laboratory animals. The present experiment was designed to investigate the effects of this drug on food motivation. Male and female rats were trained to respond on a progressive-ratio schedule of reinforcement and treated with different doses of PB. PB dose-dependently decreased breaking points and response rates in male and female rats. Gender differences were not observed. The results indicate that decreased food motivation may be a factor that contributes to the behavioral effects of PB administration.

Risk of cardiovascular disease measured by carotid intima-media thickness at age 49-51: lifecourse study.

OBJECTIVE: To quantify the direct and indirect effects of fetal life, childhood, and adult life on risk of cardiovascular disease at age 49-51 years. DESIGN: Follow up study of the "Newcastle thousand families" birth cohort established in 1947. PARTICIPANTS: 154 men and 193 women who completed a health and lifestyle questionnaire and attended for clinical examination between October 1996 and December 1998. MAIN OUTCOME MEASURES: Correlations between mean intima-media thickness of the carotid artery (carotid intima-media thickness) and family history, birth weight, and socioeconomic position around birth; socioeconomic position, growth, illness, and adverse life events in childhood; and adult socioeconomic position, lifestyle, and biological risk markers. Proportions of variance in carotid intima-media thickness that were accounted for by each stage of the lifecourse. RESULTS: Socioeconomic position at birth and birth weight were negatively associated with carotid intima-media thickness, although only social class at birth in women was a statistically significant covariate independent of adult lifestyle. These early life variables accounted directly for 2.2% of total variance in men and 2.0% in women. More variation in carotid intima-media thickness was explained by adult socioeconomic position and lifestyle, which accounted directly and indirectly for 3.4% of variance in men (95% confidence interval 0.5% to 6.2%) and 7.6% in women (2.1% to 13.0%). Biological risk markers measured in adulthood independently accounted for a further 9.5% of variance in men (2.4% to 14.2%) and 4.9% in women (1.6% to 7.4%). CONCLUSIONS: Adult lifestyle and biological risk markers were the most important determinants of the cardiovascular health of the study members of the Newcastle thousand families cohort at age 49-51 years. The limited overall effect of early life factors may reflect the postwar birth year of this cohort.

A comparison of faces scales for the measurement of pediatric pain: children's and parents' ratings.

Faces scales have become the most popular approach to eliciting children's self-reports of pain, although different formats are available. The present study examined: (a) the potential for bias in children's self-reported ratings of clinical pain when using scales with smiling rather than neutral 'no pain' faces; (b) levels of agreement between child and parent reports of pain using different faces scales; and (c) preferences for scales by children and parents. Participants were 75 children between the ages of 5 and 12 years undergoing venepuncture, and their parents. Following venepuncture, children and parents independently rated the child's pain using five different randomly presented faces scales and indicated which of the scales they preferred and why. Children's ratings across scales were very highly correlated; however, they rated significantly more pain when using scales with a smiling rather than a neutral 'no pain' face. Girls reported significantly greater levels of pain than boys, regardless of scale type. There were no age differences in children's pain reports. Parents' ratings across scales were also highly correlated; however, parents also had higher pain ratings using scales with smiling 'no pain' faces. The level of agreement between child and parent reports of pain was low and did not vary as a function of the scale type used; parents overestimated their children's pain using all five scales. Children and parents preferred scales that they perceived to be happy and cartoon-like. The results of this study indicate that subtle variations in the format of faces scales do influence children's and parents' ratings of pain in clinical settings.

Postoperative pain expression in preschool children: validation of the child facial coding system.

OBJECTIVE: The purposes of the study were threefold: (a) to determine whether a measurement system based on facial expression would be useful in the assessment of post-operative pain in young children; (b) to examine construct validity in terms of structure, consistency, and dynamics of the facial display; and (c) to evaluate concurrent validity in terms of associations with global judgments of the children's pain. PATIENTS: One hundred children between the ages of 13 and 74 months were video-taped for a maximum of 1 hour after arrival in the postanesthesia care unit (PACU) at British Columbia's Children's Hospital. OUTCOME MEASURES: Videotapes were edited into 20-second blocks, randomly selected from each 2-minute time period taped during the hour following surgery, and coded for the presence or absence of 13 facial actions in the Child Facial Coding System (CFCS). RESULTS: Facial expressions were characterized primarily by the following constellation of actions: open lips, lowered brows, a deepened nasolabial furrow, mouth stretched wide in both horizontal and vertical directions, eyes squeezed shut or squinted, and raised cheeks. A principal components analysis indicated that these actions comprised a single factor, accounting for 55% of the variance in CFCS actions. Facial action summary scores were correlated with a visual analog rating of global pain, confirming that the CFCS has convergent validity. Facial action summary scores, i.e., pain displays, were at their lowest immediately after admittance to the PACU and just before the child's release from the PACU. CONCLUSIONS: The present study demonstrated that the CFCS serves as a valid measurement tool for persistent pain in children.

Egg development, hatching and early life-history of Dissonus manteri (Copepoda), parasitic on the gills of coral trout, Plectropomus leopardus.

The early life-history of Dissonus manteri differs markedly from that of Caligidae and from that of its congener Dissonus nudiventris. The uniseriate egg strings are of typical caligid form, but the stage hatching from the egg is a preecdysis nauplius which moults immediately to the copepodid. The empty naupliar cuticle remains tethered to the egg string by a pair of posterior threads which attach to the internal surface of the egg membrane. The duration of egg development is 112 h and the mean duration of hatching is 5.2 h at 25 degrees C. Aeration and water movement are important for successful hatching. Under these conditions, hatching success is 94.8%, but decreases to 48.4% in static water with no aeration. Mean survival time of the copepodid in the absence of a host is 41.4 h at 25 degrees C. The reduction of early free-living stages in the life-cycle and the high survival rate from egg to copepodid could be important in future coral trout aquaculture, since the potential for re-infection by this parasite is very high.

Pain management of junctional epidermolysis bullosa in an 11-year-Old boy.

Epidermolysis bullosa is a group of hereditary blistering disorders for which there is no definitive therapy. Wound care is an important component of management. Regular dressing changes are required to protect blistered and eroded skin, and to prevent secondary infection and sepsis. These dressing changes can be very painful for patients with extensive erosions. We report our experience of pain management in an 11-year-old boy with severe junctional epidermolysis bullosa. Amitryptiline and cognitive behavioral techniques were effective in relieving chronic pain and discomfort. Oral midazolam 0.33 mg/kg administered 20 minutes prior to baths and dressing changes substantially improved his tolerance of wound care.

Manager, manage thyself!

As the environment surrounding the delivery of health care remains unpredictable, nurse managers are challenged to create new and innovative ways to meet the demands before them. The ever-increasing challenges and decreasing resources can have great impact on the stress level of even the most seasoned nurse manager. This article offers nurse managers 10 useful strategies to enhance their stress management skills. The key for successful stress management is taking time to care for oneself and thus remain an effective leader in the organization.

Synthetic graft placement in the treatment of fascial dehiscence with necrosis and infection.

OBJECTIVE: The objective of this study was to describe the use of synthetic grafts in repairing fascial dehiscence complicated by fascial necrosis and infection after obstetric and gynecologic operations. STUDY DESIGN: A retrospective review of the operating room records at Hutzel Hospital (Detroit, Mich) was performed to find all cases of fascial dehiscence repaired during a 6-year period between January 1, 1991, and December 31, 1996. Patients with partial or complete disruption of the fascia with evidence of fascial necrosis and infection were included in this study. Demographic information; the initial surgical procedure, including type of incision; suture material; use of synthetic graft and closure technique for repair of dehiscence; postoperative complications, microbiologic results; antibiotic therapy; subsequent operations; length of hospital stay; and late complications were recorded. RESULTS: During the study period 52 patients underwent repair of fascial dehiscence; 36 of these had concurrent fascial necrosis and infection, including 4 women with necrotizing fasciitis. Eighteen patients were from the obstetric service and 18 were from the benign or cancer gynecology service. Ninety-one bacterial isolates were recovered from the infected wounds. Extensive fascial resection precluded closure without tension in 18 cases and necessitated synthetic graft placement to prevent evisceration. Graft materials included polypropylene (11 cases) and polyglactin (7 cases). Late complications of graft placement included extrusion of the graft in 3 patients and incisional hernia in 1. CONCLUSIONS: Extensive fascial débridement with resection prevents primary closure of wound dehiscence. Synthetic grafts permit primary closure of large fascial defects and can be used with extensive débridement in the presence of infection.

Early life and later determinants of adult disease: a 50 year follow-up study of the Newcastle Thousand Families cohort.

The relative contribution of socioeconomic, behavioural and biological factors operating in fetal and infant life, childhood and adulthood to risk for cardiovascular disease, respiratory diseases and non-insulin-dependent diabetes in middle age has become an important research issue. All 1142 babies born in Newcastle upon Tyne in May and June 1947 were recruited into a prospective cohort study of child health (the 'Thousand Families' study) and followed in great detail to the age of 15 y, with a brief further follow up at age 22 y. Children from poorer families were at greatest risk of severe respiratory tract infection in infancy. Children from professional and managerial families were on average taller and heavier throughout childhood than those from semi- and unskilled manual social classes. Repeated infections in early childhood greatly increased the risk of developing chronic respiratory disease by age 15 y. This paper outlines a new investigation designed to trace surviving members of this cohort and to chart the relationships between their socioeconomic circumstances, lifestyles, experiences and health from birth through to the present day. Existing data on socioeconomic circumstances and infections in infancy and childhood, infant nutrition, birthweight and physical development to age 22 y will be linked to information gained from a new study. This comprises a postal questionnaire survey of study members' adult health, socioeconomic circumstances and lifestyle, and a hospital based clinical examination including heart and lung function, glucose tolerance, blood lipids and anthropometric measurements at age 49-51 y. Out of a target sample of 979 people for whom sufficient data are available on the first year of life, 866 (88%) have been traced and 649 are still resident in the North of England. Those study members who have been traced are highly representative of the original cohort. The Thousand Families cohort provides a unique opportunity for detailed epidemiological study because of the wealth of data available on infant and childhood socioeconomic and family circumstances, all of which was collected prospectively. In addition, there has been comparatively little loss to follow-up since 1948.

Sheina orri (Myodocopa: Cypridinidae), an ostracod parasitic on the gills of the epaulette shark, Hemiscyllium ocellatum (Elasmobranchii: Hemiscyllidae).

The cypridinid ostracod, Sheina orri, was found on the gills of healthy epaulette sharks, Hemiscyllium ocellatum, collected from the Great Barrier Reef, Australia. Seventeen of the 28 fish examined had ostracods attached to their gills. Detailed investigation of the gills and ostracods using light microscopy and scanning electron microscopy revealed that ostracods anchor themselves to the gill tissues using their mandibular and maxillular claws. These claws appear to be adapted for this purpose and the process of attachment causes some damage to the host tissues. The observation that ostracods were often located in distinct pockets, formed by local distortion of shark respiratory lamellae, strongly suggests that they had been attached to the gills for considerable time.