One-day diagnosis for hepatobiliary and pancreatic lesions: An innovative patient-centered care pathway organization.

OBJECTIVE: Reducing the time required for diagnosis is one of the major challenges to improving and accelerating the management of patients. The aim of this work is to describe an organizational innovation in the management of patients with hepatobiliary or pancreatic diseases, and to report the initial results. MATERIALS AND METHODS: A multidisciplinary and multi-professional working group designed and instituted a patient-centered organizational system that optimizes the investigation of liver and pancreatic diseases, in order to achieve diagnosis in one day. From January 2017 to June 2017, all patients referred for consultation for hepatobiliary or pancreatic pathology were included in this new management pathway. Data were collected prospectively in a standardized form. RESULTS: Fifty-six patients with hepatobiliary or pancreatic disease were evaluated in the program during dedicated slots over a total of 20 days. Of these, four patients underwent evaluation in the program twice. The average number of patient slots in the program was three per day (range: 1-5). An additional computed tomography (CT) and/or magnetic resonance imaging (MRI) was required in 23 (41.7%) of the visits. These imaging studies were performed the same day, including nine patients who required both types of imaging (16.7% of cases). "One-day diagnosis" established an accurate diagnosis by the end of the day in 49 patient encounters (81.7%). Overall assessment of this organization was considered excellent by 46 (83%) of patients. CONCLUSION: An organizational innovation has made it possible to effectively diagnose hepatobiliary or pancreatic pathology within one day in the majority of cases, with good patient satisfaction. It is now necessary to evaluate the medico-economic aspect of this organization, and more generally to develop a methodology for multidimensional evaluation of organizational innovations.

Fatal form of phaeochromocytoma presenting as acute pyelonephritis.

We report the case of a young man who presented with a clinical picture of acute pyelonephritis. Within 3 h of admission, the patient developed acute respiratory distress associated with tachycardia and shock, and he was transferred to the intensive care unit. Mechanical ventilation of the lungs and symptomatic treatment were started immediately. Abdominal ultrasound revealed the presence of an adrenal tumour with central necrosis indicating a probable phaeochromocytoma. There was no sign of pyelonephritis. Ventricular fibrillation followed by asystole occurred soon after admission. The suddenness of the patient's death did not allow time for further investigation and therapy. The severity of the clinical signs was probably related to a massive release of catecholamines because of necrosis of the tumour, which may have been worsened by the diagnostic procedures performed to investigate the clinical symptoms and signs of acute pyelonephritis.

Paraboloid of axolotl retinal photoreceptor and bovine pituitary thyrotropin fraction share an antigen.

Lenses of newts (genera Notophthalmus, Triturus, Cynops) regenerate from irises in the presence of retinae of larval frogs (Rana) or adult salamanders (Hynobius, Ambystoma), species which are themselves incapable of lens regeneration from the iris. In newts, bovine pituitary thyrotropin preparation NIH-TSH-B8 can also stimulate lens regeneration from the iris. An antiserum against NIH-TSH-B7 (purified as is NIH-TSH-B8), absorbed with bovine lutropin preparation NIH-LH-B9, cross-reacts with bovine retinal glycoprotein extracts in immunodiffusion tests, and with retinal photoreceptor cells of the axolotl (Ambystoma mexicanum), as evidenced by immunofluorescence. In normal adult eyes and in eyes 21 days after lens removal, the paraboloid portion of the photoreceptor inner segments, and in some cases the perinuclear cytoplasm of the photoreceptor cells, contained the antigen. The cross-reacting antigen appears to be different from thyrotropin, and also different from the basic and acidic retinal fibroblast growth factors. However, immunodiffusion reveals a precipitation arc with retina-derived growth factor fraction III (EDGF III). If bovine pituitary thyrotropin preparations produce lens regeneration, and if these preparations cross-react with an antigen in the retinal photoreceptors, the retinal antigen may be involved in the stimulation of lens regeneration as well.

Axolotl retina and lens development: mutual tissue stimulation and autonomous failure in the eyeless mutant retina.

During eye development in the axolotl (Ambystoma mexicanum Shaw), morphogenetic movements bring together tissues from head epidermis, neuroectoderm and neural crest. The stages 0 to 14 of axolotl eye development were expanded from Rabl's (1898) stages 1 to 10 and correlated with Harrison's (1969) stages. At the onset of neurulation (stage 13 of Harrison), the head epidermis is already determined to form skin, and the neuroectoderm is committed to form brain, because these tissues develop autonomously in 60% Leibovitz L-15 culture medium. However, a sequence of mutual tissue interactions is necessary to stimulate eye development. When head epidermis and neuroectoderm were cocultured, eyes developed, containing retinas with photoreceptors (stage 8) and lenses with secondary lens fibres (stage 8). The first event needed in this case appears to be the secretion of a growth factor from the head epidermis which stimulates retina development from the neuroectoderm. When neuroectoderm cultures were exposed to nondialysable extracts (30 micrograms ml-1) of an adult epidermis derivative, the bovine cornea, pigmented retinas (stage 6) and at higher concentrations (3000 micrograms ml-1) neural retinas developed (stage 6). In turn, lens formation is stimulated in the head epidermis by a retina-derived growth factor. A mutation that causes adult eyelessness (e eyeless, nonlethal, recessive) affects the earliest event in eye development (stage 1a), while a mutation that causes arrest of eye development (mi microphthalmic, lethal, recessive) acts in a later event (stage 8). Two possibilities have been considered in the case of mutation e: either the head epidermis does not secrete sufficient amounts of active growth factor, or the presumptive retina itself is defective. The latter statement turned out to be correct, because mutant e neural plates rarely developed early retina stages (stage 5) in organ culture when combined with wild-type head epidermis. On the other hand, wild-type neural plates formed advanced retinas (stage 8) in all cases when combined with mutant e head epidermis. As expected, no retina or lens developed when both neural plate and head epidermis were from mutant e donors. The heterozygous presence of genes e and r (renal insufficiency, lethal, recessive) produces duplications of the presumptive retina at the optic stalk. This observation is consistent with the notion that the mutation e, assisted by the r locus, causes a primary failure in the presumptive retinal region.

Lens regeneration from cultured newt irises stimulated by retina-derived growth factors (EDGFs).

It has been shown that lens regeneration from the iris of the newt Notophthalmus viridescens is dependent on the presence of neural retinal tissue in organ culture and in vivo. The recent discovery of various eye-derived growth factors (EDGFs) in the bovine retina [14] prompted us to investigate whether one of these factors may be involved in the stimulation of lens regeneration. Dorsal irises were cultured for 20 days in serum-supplemented diluted Eagle's medium. Growth factors from bovine retina of various degrees of purification were added. Lens regeneration was assessed on the basis of morphological lens-regeneration stages and by immunofluorescent detection of a lens-specific marker protein, alpha-crystallin. Crude isotonic retinal extract at 80-800 micrograms/ml significantly augmented lens regeneration. Very similar results were obtained when EDGF III, the nonretained retinal factor after heparin-affinity chromatography, was present at 2-20 micrograms/ml. Lens regeneration was also significantly increased when EDGF II, the retinal form of acidic fibroblast growth factor (aFGF) at 50-500 ng/ml was added to the cultures. On the other hand, EDGF I at 4-40 ng/ml and brain basic FGF at 5-50 ng/ml did not seem to significantly stimulate lens regeneration under the conditions used. Our results suggest that at least two retina-derived growth factors (EDGF II and III) can stimulate lens regeneration. These growth factors may be the putative signal that is naturally produced by the retina during lens regeneration in the newt.

Comparison of newt lens regeneration stimulating activity in preparations of mammalian thyrotropin and fibroblast growth factor purified by various methods.

Irises of the newt Notophthalmus viridescens will regenerate a new lens in organ culture in the presence of the bovine thyrotropin preparation NIH-TSH-B8. It is not certain, however, whether thyrotropin itself is responsible for this stimulatory effect. To elucidate this problem further we compared the lens regeneration stimulating activity of thyrotropin preparations from several species, prepared by various methods. The lowest effective concentrations were approximately 3.0 micrograms ml-1 for the bovine NIH-TSH-B8 and 1.4 micrograms ml-1 for the ovine NIAMDD-oTSH-9 preparations. At those lowest concentrations, lenses with elongating lens fiber cells (stage 6) and enlarged lens fiber core (stage 8) were obtained, respectively, and the lens-fiber-specific protein gamma-crystallin was present in both cases. The crude bovine thyrotropin fraction, Sigma-TS-10, stimulated lens regeneration only at the highest concentration, 1400 micrograms ml-1. Bovine Pierce-bTSH, the purest thyrotropin preparation, stimulated lens regeneration sporadically at the lower concentration of 0.04 micrograms ml-1 up to the advanced stage 9 with large lens fiber core and flattened lens epithelium in one of nineteen irises. The pituitary fibroblast growth factor is a known contaminant of thyrotropin preparations. The preparation CR-FGF-40002 at concentrations between 0.001 and 0.1 microgram ml-1 did not promote lens regeneration. Therefore, the lens regeneration stimulating activity in thyrotropin preparations is not attributable to the fibroblast growth factor, and may also be independent of thyrotropin because the lens regeneration stimulating activity is not proportional to the thyrotropic activity in the preparations examined.

Banding differences between tiger salamander and axolotl chromosomes.

The Hoechst 33258 - Giemsa banding patterns were compared on axolotl (Ambystoma mexicanum Shaw) and axolotl - tiger salamander (Ambystoma tigrinum Green) species hybrid prophase chromosomes. Approximately 369 bands per haploid chromosome set were seen in the axolotl and about 344 bands in the tiger salamander. In the haploid set of 14 chromosomes, chromosome 3 has a constant short or q-arm terminal constriction at the location of the nucleolar organizer. Chromosomes 14 Z and W carry the sex determinants, the female being the heterogametic sex (ZW). The banding patterns of chromosomes 1, 6, 11, and 14 Z of the two species are apparently indistinguishable by our banding method. In the axolotl, chromosome 9 has a small long or p-arm terminal deletion. In the tiger salamander, the remaining 10 chromosomes have terminal or internal deletions. No translocations or inversions seem to have occurred since the gene pool separation of the two closely related species.