Nurses' attitudes, behaviours, and enablers of intravenous to oral switching (IVOS) of antibiotics: a mixed-methods survey of nursing staff in secondary care hospitals across the Midlands region of England.

BACKGROUND: Intravenous (IV) antibiotic use in secondary care in England is widespread. Timely appropriate intravenous to oral switch (IVOS) has the potential to deliver significant clinical and operational benefits. To date, antimicrobial stewardship (AMS) efforts around IVOS have not focused on the nursing staff who administer antibiotics, which represents a significant gap in AMS programmes. AIM: To determine the involvement of bedside nurses in acute trusts in the Midlands region of England in IVOS in their organizations and describe their views regarding how to improve IVOS. METHODS: An anonymous self-administered mixed-methods online survey was developed and distributed to nursing staff in acute trusts via antimicrobial stewardship networks between March and May 2023. Quantitative data was analysed to describe participant demographics and behaviours, whereas barriers and enablers to IVOS were explored through thematic content analysis of responses to open-ended questions. FINDINGS: A total of 545 nursing staff responded to the survey. The majority (65.3%) routinely suggested IVOS to clinicians, despite only 50.6% being aware of local IVOS policies. One-third (34.7%) did not suggest IVOS, relying on doctors, believing their patients needed IV treatment, or lacked knowledge and skills to request IVOS. Content analysis of suggestions for improving the rate of IVOS proposed three major themes (People, Process, System) and identified that education and training, improved confidence and interprofessional relationships, and prompts were important drivers. CONCLUSION: Nursing staff suggest IVOS to other clinicians, but more education and resources are needed to enable and empower them in this role.

DFT insights into LaFeO3 with Mn substitution: A promising path to energy-efficient magneto-optical applications.

In recent years, the demand for electronic materials has significantly increased, driven by industrial needs and the pursuit of cost-efficient alternatives. This comprehensive study investigates the effects of Mn substitution on LaFeO3 through the implementation of the GGA approach in density functional theory. The research findings demonstrate remarkable consistency with the experimental outcomes reported in the existing literature pertaining to the studied compounds. However, this study unveils novel insights into the mechanical and optical characteristics of the doped structures, which have not been previously reported. The structural stability is rigorously examined through multiple stability criteria, encompassing structural optimization, tests of elastic stability, and enthalpy of formation calculations. Furthermore, the electronic and optical properties of the compounds exhibit exceptional improvements in conductivity and reflectivity as a result of the doping process. The band structure analysis reveals the presence of a Moss-Burstein shift. Investigation of the magnetic properties indicates an increase in the magnetic moment value due to the Fe-Mn degeneracy resulting from increased Mn content. Mechanical analysis of the elastic moduli B, G, and Y demonstrates an enhanced strength and metal-like conductivity, attributed to the induced anharmonicity. Moreover, the internal strain factor suggests a higher degree of bond flexibility, implying potential applications of these compounds in flexible electronics.

A Region-Based Deep Level Set Formulation for Vertebral Bone Segmentation of Osteoporotic Fractures.

Accurate segmentation of the vertebrae from medical images plays an important role in computer-aided diagnoses (CADs). It provides an initial and early diagnosis of various vertebral abnormalities to doctors and radiologists. Vertebrae segmentation is very important but difficult task in medical imaging due to low-contrast imaging and noise. It becomes more challenging when dealing with fractured (osteoporotic) cases. This work is dedicated to address the challenging problem of vertebra segmentation. In the past, various segmentation techniques of vertebrae have been proposed. Recently, deep learning techniques have been introduced in biomedical image processing for segmentation and characterization of several abnormalities. These techniques are becoming popular for segmentation purposes due to their robustness and accuracy. In this paper, we present a novel combination of traditional region-based level set with deep learning framework in order to predict shape of vertebral bones accurately; thus, it would be able to handle the fractured cases efficiently. We termed this novel Framework as "FU-Net" which is a powerful and practical framework to handle fractured vertebrae segmentation efficiently. The proposed method was successfully evaluated on two different challenging datasets: (1) 20 CT scans, 15 healthy cases, and 5 fractured cases provided at spine segmentation challenge CSI 2014; (2) 25 CT image data (both healthy and fractured cases) provided at spine segmentation challenge CSI 2016 or xVertSeg.v1 challenge. We have achieved promising results on our proposed technique especially on fractured cases. Dice score was found to be 96.4 ± 0.8% without fractured cases and 92.8 ± 1.9% with fractured cases in CSI 2014 dataset (lumber and thoracic). Similarly, dice score was 95.2 ± 1.9% on 15 CT dataset (with given ground truths) and 95.4 ± 2.1% on total 25 CT dataset for CSI 2016 datasets (with 10 annotated CT datasets). The proposed technique outperformed other state-of-the-art techniques and handled the fractured cases for the first time efficiently.

Thyroid cytopathology: updates and molecular testing.

The utility of fine needle aspiration (FNA) is well described in the context of evaluating thyroid lesions. Among the various international systems of classification of thyroid cytology, the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) has also provided a sound framework to standardize the reporting of FNA cytology results. New molecular evidence and clinical studies demonstrated the need for revision of the nomenclature resulting in introduction of new categories, such as the noninvasive follicular thyroid neoplasms with papillary-like nuclear features (NIFTP). Indeterminate thyroid cytology results pose a challenge for further management and the continued development of molecular markers may aid in the management of indeterminate thyroid lesions.

Russell body gastritis.

Russell body gastritis is caused by an accumulation of plasma cells within the gastric mucosa. These plasma cells are characterized by eosinophilic cytoplasmic inclusions of immunoglobulin which are called "Russell bodies". We report a case of Russell body gastritis in a 28-year-old male who presented with abdominal pain and rectal bleeding. Endoscopy showed erosions with edema and vascular congestion in the gastric body and antrum. The biopsy showed chronic gastritis with plasma cell infiltration of the lamina propria. Many plasma cells contained cytoplasmic Russell bodies which stained positive for CD138, CD79a, Kappa and lambda light chains. The Russell bodies were negative for pancytokeratin, excluding signet ring cell carcinoma. Russell body gastritis is an uncommon, benign reactive condition.

Performance, intestinal permeability, and gene expression of selected tight junction proteins in broiler chickens fed reduced protein diets supplemented with arginine, glutamine, and glycine subjected to a leaky gut model.

Changing dietary protein and amino acids may impact intestinal barrier function. Experiments were conducted in broiler chickens to evaluate supplementation of L-glutamine, glycine, and L-arginine in a reduced protein (RP) diet. Experiment 1 examined the growth performance of broilers fed 5 dietary treatments: 1) a standard diet; 2) an RP diet (193.9 g/kg CP in grower and 176.9 g/kg CP in finisher); 3) RP diet supplemented with 10 g/kg L-Gln; 4) RP diet supplemented with 10 g/kg Gly; 5) RP diet supplemented with 5 g/kg L-Arg. Each experimental diet was replicated 6 times with 10 birds per replicate. In a subset of 96 birds, experiment 2 tested the 4 RP diets with and without dexamethasone (DEX) to induce leaky gut. Each diet was replicated 24 times. Fluorescein isothiocyanate dextran (FITC-d) was used to test intestinal permeability (IP). Gene expression of selected tight junction proteins in ileal and jejunal tissues was assayed by quantitative PCR. From day 7 to 35, the RP diet increased feed intake (FI) (P < 0.05) and body weight gain (BWG) compared with the standard diet while Gln reduced FI and BWG (P < 0.05) compared with RP. Gly had no effect on BWG or FCR. Supplementation of Arg improved FCR from day 21 to 35 and day 7 to 35. In experiment 2, Arg tended to lower FITC-d (P = 0.086). DEX increased passage of FITC-d into the serum (P < 0.001). The villi surface area was increased in birds fed higher Arg (P < 0.05). DEX and diet interacted (P < 0.01) for jejunal claudin-3 mRNA level where DEX upregulated claudin-3 for all diets except the Arg diet. In summary, with a moderate reduction of protein, satisfactory performance can be obtained. Although Gln and Gly had no demonstrable positive effect on IP and performance of broilers, increasing the dietary Arg by approximately 140% improved FCR and showed indications of improved intestinal barrier function of birds fed an RP diet under a stress model.

Validation of the size morphology site access score in endoscopic mucosal resection of large polyps in a district general hospital.

BACKGROUND: Polyp assessment is multimodal and is vital prior to endoscopic mucosal resection. The size, morphology, site and access (SMSA) score has been validated in specialist endoscopic institutions. this study investigated the ability of this score to predict incomplete endoscopic resection of large colorectal polyps in a district general hospital. METHODS: Consecutive patients undergoing endoscopic mucosal resection of large (≥ 20 mm) colorectal polyps at Worthing Hospital. Clinical, endoscopic and histological data were taken from prospective databases. The primary outcome of the study was to investigate the correlation of the SMSA score with incomplete endoscopic resection. RESULTS: Between February 2015 and August 2018, 114 patients underwent colorectal endoscopic mucosal resection. Of these, 67 (59%) were male. The median (interquartile range) age of the study population was 72 years (65-78 years). Some 17 lesions (15%) were pedunculated, 76 (67%) were sessile and 21 were (18%) flat; 84 polyps (77%) were located in the left colon/rectum, with the remainder in the right colon; 51 lesions (45%) were 20-30 mm, 27 (24%) were 30-40 mm and 36 (31%) were greater than 40 mm in diameter. When reclassified into the SMSA score, 9 of the polyps (8%) were level 2, 64 (56%) were level 3 and 41 (36%) were level 4. Incomplete resection was clinically diagnosed in 9/114 (8%). The SMSA score was positively correlated with incomplete endoscopic resection, but not with additional procedure usage, complications or advanced histology. CONCLUSIONS: Many patients with large polyps can be managed outside of specialist units. This study has validated that the SMSA score was associated with incomplete endoscopic mucosal resection for large polyps in a district general hospital setting.

Reduced protein diet and amino acid concentration alter intestinal barrier function and performance of broiler chickens with or without synthetic glucocorticoid.

Little is known about the effect of low-protein (LP) diets on intestinal barrier function and permeability. In the first part of this study, starting on day 9 of age, the growth performance of the birds fed 3 experimental diets in each phase of feeding (G/F: grower/finisher) was investigated. Three experimental diets were as follows: LP (170/150 g/kg CP) fortified with essential amino acids (EAA), standard protein (SP), (202/190 g/kg), and high protein (HP) (220/210 g/kg). LP and SP diets contained a similar level of EAA concentration, while the HP diet contained 10% above the Ross 308 specifications. Each diet was replicated 6 times (10 male birds per replicate). The second part investigated intestinal permeability (IP) and function on additional 72 birds. On days 14, 16, and 20, a total of 36 birds (12 birds per diet) were injected with dexamethasone (DEX) to induce leaky gut. Birds fed LP diets had lower body weight gain (BWG) and higher feed conversion ratio (FCR) compared with SP and HP diets in both grower and finisher phases of feeding. For the challenge part, DEX increased the FCR independent of diets. Diet and DEX interacted for BWG, whereby the effect of diets was only evident in sham-injected birds. Birds fed LP had a higher fluorescein isothiocyanate dextran (FITC-d) concentration indicating a more permeable intestine compared to HP, but similar to SP. DEX increased FITC-d concentration in all dietary treatments. Birds fed LP had less ileal zonula occludens-2 (ZO-2) expression in comparison with SP, but not HP. DEX increased the expression of Claudin3 and ZO-2 and reduced Claudin1 (P < 0.05) and junctional adhesion molecule 2 in the ileum. Expression of ileal Na+-dependent glucose transporter 1 (SGLT1) was upregulated in LP fed group. It is concluded that compared with SP, IP can be maintained in LP by supplementing EAA. However, when compared with HP, feeding birds with LP may lead to a higher IP. DEX had a profound independent effect on intestinal barrier function.

Reduced fasting periods increase intestinal permeability in chickens.

Fasting of up to 24 hr has been shown to increase intestinal permeability (IP) in chickens. The aim of this study was to determine whether fasting duration of 4.5 and 9 hr increased IP and whether l-glutamine (a non-essential amino acid) supplementation before fasting provided some protection of barrier function as shown in other species. Ross 308 male broilers (n = 96) were fed either a control diet or the same diet supplemented with 1% glutamine from d0 to d38 post-hatch. On d37, the birds were assigned to single-bird metabolism cages and were fasted for either 0, 4.5, 9 or 19.5 hr. This study design was 2 × 4 factorial with two levels of glutamine and four levels of fasting. Birds in the 0-hr fasting group had free access to feed. All birds had ad libitum access to water. To measure IP on day 38, following their respective fasting periods, birds were administered two separate oral gavages of fluorescein isothiocyanate dextran (FITC-d) followed by lactulose, mannitol and rhamnose (LMR) sugars, 60 min apart. Whole blood was collected from the jugular vein 90 min post-LMR sugar gavage. FITC-d and L/M/R ratios were measured by spectrophotometry and high-performance ionic chromatography respectively. Lipopolysaccharide (LPS) endotoxins in plasma of the birds fed the control diet were also measured using chicken-specific LPS antibody ELISA. Serum FITC-d and plasma L/M and L/R ratios for 4.5, 9 and 19.5 hr were significantly (p < .05) higher compared to the non-fasting group. However, IP was not different in the glutamine-supplemented group (p > .05) compared to the control group. LPS concentrations measured by the ELISA were below the detectable range. We conclude that fasting periods of 4.5 and 9 hr increased IP compared to non-fasted birds and dietary glutamine supplementation did not ameliorate changes in IP.

Gene expression and morphological changes in the intestinal mucosa associated with increased permeability induced by short-term fasting in chickens.

Short-term fasting for 4.5 and 9 hr has been demonstrated to increase intestinal permeability (IP) in chickens. This study aimed to investigate the effects of 0, 4.5, 9 and 19.5 hr fasting on intestinal gene expression and villus-crypt architecture of enterocytes in jejunal and ileal samples. On day 38, Ross-308 male birds were fasted according to their group and then euthanised. Two separate intestinal sections (each 2 cm long, jejunum and ileum) were collected. One section was utilised for villus height and crypt depth measurements. The second section was snap-frozen in liquid nitrogen for quantitative polymerase chain reaction (qPCR) analysis of tight junction proteins (TJP) including claudin-1, claudin-3, occludin, zonula occludens (ZO-1, ZO-2), junctional adhesion molecules (JAM) and E-cadherin. Additionally genes involved in enterocyte protection including glucagon-like peptide (GLP-2), heat-shock protein (HSP-70), intestinal alkaline phosphatase (IAP), mammalian target of rapamycin (mTOR), toll-like receptors (TLR-4), mucin (MUC-2), cluster differentiation (CD-36) and fatty acid-binding protein (FABP-6) were also analysed. Normally distributed data were analysed using one-way analysis of variance ANOVA. Other data were analysed by non-parametric one-way ANOVA. Villus height and crypt depth were increased (p < .05) only in the ileum after fasting for 4.5 and 9 hr compared with non-fasting group. mRNA expression of claudin-3 was significantly reduced in the ileum of birds fasted for 9 and 19.5 hr, suggesting a role in IP modulation. However, all other TJP genes examined were not statistically different from control. Nevertheless, ileal FABP-6 of all fasted groups was significantly reduced, which could possibly be due to reduced bile acid production during fasting.

Reliability of musculoskeletal ultrasound imaging to measure supraspinatus tendon thickness in healthy subjects.

[Purpose] The purpose of this study was to assess intra-rater and inter-rater reliability of musculoskeletal ultrasound (MSKUS) as a tool to measure supraspinatus tendon thickness in healthy subjects. [Subjects and Methods] Twenty healthy subjects were assessed in similar sitting position. Two experienced musculoskeletal ultrasound specialists measured supraspinatus tendon thickness. Tendon was measured twice in one day by each of two raters with an interval of one hour for within day reliability and was re-measured following one week for between days reliability. Data analysis was performed using the intraclass correlation coefficient (ICC) and standard error of measurement (SEM). [Results] Results reflected excellent within day intra-rater and inter-rater reliability with Mean ± standard deviation (SD)=5.14 ± 0.83 and 5.17 ± 0.78, ICC (2,1)=0.89-0.93 and ICC (2,2)=0.98 (0.95-0.99) and SEM=0.18-0.18 and 0.17 while between days intra-rater rater and inter-rater reliability with Mean ± SD=5.14 ± 0.83 and 5.17 ± 0.78, ICC(2,1)=0.88-0.90 and ICC(2,2)=0.95 (0.88-0.98), SEM=0.17-0.38 and 0.17 [Conclusion] The results of the current study indicate that MSKUS is a reliable tool for measuring supraspinatus tendon thickness in healthy subjects.

New biomarkers for increased intestinal permeability induced by dextran sodium sulphate and fasting in chickens.

Increased intestinal permeability (IP) can lead to compromised health in chickens. As there is limited literature on in vivo biomarkers to assess increased IP in chickens, the objective of this study was to identify a reliable biomarker of IP using DSS ingestion and fasting models. Male Ross chickens (n = 48) were reared until day 14 on the floor pen in an animal care facility, randomized into the following groups: control, DSS and fasting (each with n = 16), and then placed in metabolism cages. DSS was administered in drinking water at 0.75% from days 16 to 21, while controls and fasted groups received water. All birds had free access to feed and water except the birds in the fasting group that were denied feed for 19.5 h on day 20. On day 21, all chickens were given two separate oral gavages comprising fluorescein isothiocyanate dextran (FITC-d, 2.2 mg in 1 ml/bird) at time zero and lactulose, mannitol and rhamnose (LMR) sugars (0.25 g L, 0.05 g M and 0.05 g R in 2 ml/bird) at 60 min. Whole blood was collected from the brachial vein in a syringe 90 min post-LMR sugar gavage. Serum FITC-d and plasma LMR sugar concentrations were measured by spectrophotometry and high-performance ion chromatography respectively. Plasma concentrations of intestinal fatty acid binding protein, diamine oxidase, tight junction protein (TJP), d-lactate and faecal α-antitrypsin inhibitor concentration were also analysed by ELISA. FITC-d increased significantly (p < 0.05) after fasting compared with control. L/M and L/R ratios for fasting and L/M ratio for DSS increased compared with control chickens (p < 0.05). TJP in plasma was significantly increased due to fasting but not DSS treatment, compared with controls. Other tests did not indicate changes in IP (p > 0.05). We concluded that FITC-d and LMR sugar tests can be used in chickens to assess changes in IP.

Intestinal permeability induced by lipopolysaccharide and measured by lactulose, rhamnose and mannitol sugars in chickens.

Increased intestinal permeability (IP) can lead to compromised health. Limited in vivo IP research has been conducted in chickens. The objectives of the current study were to develop a model of increased IP utilizing lipopolysaccharide (LPS Escherichia coli O55:B5) and to evaluate IP changes using the lactulose, mannitol and rhamnose (LMR) sugar permeability test. In addition, fluorescein isothiocyanate dextran (FITC-d), d-lactate, zonula occludens (ZO-1) and diamine oxidase (DAO) permeability tests were employed. Male Ross chickens were reared until day 14 on the floor in an animal care facility and then transferred to individual cages in three separate experiments. In each of experiments 1 and 2, 36 chicks were randomly allocated to receive either saline (control) or LPS (n=18/group). Lactulose, mannitol and rhamnose sugar concentration in blood was measured at 0, 30, 60, 90, 120 and 180 min in experiment 1, at 60, 90 and 120 min in experiment 2 and at 90 min in experiment 3 (n=16/group). Lipopolysaccharide was injected intraperitoneally at doses of 0.5, 1 and 1 mg/kg BW in experiments 1, 2 and 3, respectively, on days 16, 18 and 20, whereas control received sterile saline. On day 21, only birds in experiments 1 and 2 were fasted for 19.5 h. Chicks were orally gavaged with the LMR sugars (0.25 gL, 0.05 gM, 0.05 gR/bird) followed by blood collection (from the brachial vein) as per time point for each experiment. Only in experiment 3, were birds given an additional oral gavage of FITC-d (2.2 mg/ml per bird) 60 min after the first gavage. Plasma d-lactate, ZO-1 and DAO concentrations were also determined by ELISA in experiment 3 (n=10). Administration of LPS did not affect IP as measured by the LMR sugar test compared with control. This was also confirmed by FITC-d and DAO levels in experiment 3 (P>0.05). The plasma levels of d-lactate were decreased (P<0.05). Plasma levels of ZO-1 were increased in the third experiment only and did not change in the first two experiments. Lipopolysaccharide at doses of 0.5 and 1 mg/kg did not increase IP in this model system. In conclusion, the LMR sugar can be detected in blood 90 min after the oral gavage. Further studies are needed for the applicability of LMR sugars tests.

Influence of Access, Anticoagulant, and Bleeding Definition on Outcomes of Primary Percutaneous Coronary Intervention: Early Experience of an US Academic Center.

Background We aimed to carry out comparison of different bleeding avoidance strategies in doing primary percutaneous coronary intervention (PPCI) using either radial or femoral as access of choice and either bivalirudin or unfractionated heparin as anticoagulant of choice. In this analysis, we analyzed the influence of major bleeding definition on bleeding outcomes as well. Methods We did a retrospective analysis of 139 patients with ST-segment elevation myocardial infarction (STEMI) who had PPCI in our academic center from January 2010 till October 2013. The primary outcome at 30 days was a composite of death from any cause or stent thrombosis or non-coronary artery bypass grafting (CABG) related major bleeding (CathPCI Registry definition) and secondary outcomes were individual components of primary outcome and the hospital length of stay. Results There was no significant difference among different access/anticoagulant combinations with regards to primary outcome (22% in radial/bivalirudin vs. 5% in radial/heparin vs. 17% in femoral/bivalirudin vs. 28% in femoral/heparin group; p = 0.2) as well as its individual components except the hospital length of stay (2.56 vs. 3 vs. 3.97 vs. 4.4 days each; p < 0.0001). The overall rate of major bleeding was 11.5%. When we use HORIZON-AMI bleeding definition, it went up to 25 % due to one particular component (p < 0.004). Conclusions This single center observational study doing PPCI did not show any superiority of one bleeding avoidance strategy over others with regard to primary outcome and its individual components except the hospital length of stay. It also shows the importance of bleeding definition on bleeding outcomes.

Cytologic features of solid pseudopapillary neoplasms of the pancreas: a single institutional experience based on evaluation of diagnostic utility of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA).

BACKGROUND: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is an important modality for diagnosing solid and cystic pancreatic lesions. The objectives of this retrospective study are to review the cytologic criteria used to diagnose pancreatic solid pseudopapillary neoplasms (SPNs) and to evaluate the utility of EUS-FNA by correlating cytologic and histologic samples. CASE REVIEWS: Of the 924 pancreatic FNAs performed at our institution from January 2002 through February 2013, four histologically confirmed cases of SPN were identified; three had an initial cytologic diagnosis of SPN. All four cases lacked on-site evaluation. Cytologic smears were assessed by two reviewers for the presence of a cellular aspirate, fibrovascular stalks lined by neoplastic cells with pale to finely granular cytoplasm, and monotonous, oval nuclei containing delicate chromatin, inconspicuous nucleoli, and grooves and inclusions. Three cases were diagnosed as SPN on cytologic examination and confirmed histologically. The remaining case was deemed a pancreatic endocrine neoplasm on cytology, but SPN on final histology. The most consistent cytologic feature we encountered was the presence of a cellular aspirate containing fibrovascular stalks lined by monotonous neoplastic cells with oval nuclei and nuclear grooves. CONCLUSION: We conclude that EUS-FNA is an effective diagnostic tool in the diagnosis of pancreatic SPNs.

Inflammatory myofibroblastic tumour: a rare entity with wide differential diagnosis.

Inflammatory myofibroblastic tumour (IMT) is a rare, distinctive mesenchymal neoplasm. Grossly, it appears as a circumscribed mass with a rubbery to firm cut surface. Microscopically, it is characterized by a spindle cell proliferation within a myxoid stroma with admixed plasma cells, lymphocytes and eosinophils. Immunohistochemical staining is usually positive for vimentin, smooth muscle actin (SMA) and anaplastic lymphoma kinase (ALK). ALK gene rearrangement is present in approximately 50-70% IMTs. The standard treatment is surgical resection, and it is essential to differentiate IMT from benign and malignant mimickers so that appropriate therapy may be provided. Clinical and radiological follow-up is required to detect recurrence.

Is it safe for pregnant health-care professionals to handle cytotoxic drugs? A review of the literature and recommendations.

The information related to health risks to foetuses due to the handling of chemotherapeutic agents by nurses during pregnancy is limited. The risks involved can be reduced significantly if nurses adhere to standard safety precautions while handling cytotoxic drugs. Nurses in patient areas where chemotherapy is administered are at constant low-level risk of exposure. The authors tried to gather evidence in this article from the recent literature to help to formalise policies for pregnant mothers working in these settings.

Ameloblastic fibrosarcoma: a rare malignant odontogenic tumor.

INTRODUCTION: Ameloblastic fibrosarcoma (AFS) is a rare malignant odontogenic tumor. It can arise de novo, however one-third of cases may arise from a recurrent ameloblastic fibroma, in which case they appear to present at an older age. CASE REPORT: A 16-year-old female presented with one month history of right mandibular mass. Computerized tomography (CT) scan showed a large destructive mass. A biopsy of the mass was performed. Histologically, it consisted of a mixed epithelial-mesenchymal odontogenic neoplasm composed of benign islands of well-differentiated ameloblastic epithelium within a malignant fibrous stroma consisting of spindle cells or fibroblasts with a brisk mitotic activity. The malignant spindle cell proliferation showed positive staining with p-53 and a high proliferation index with ki-67. A diagnosis of AFS was rendered. CONCLUSION: The differential diagnosis includes other odontogenic sarcomas, ameloblastic carcinosarcoma and spindle cell carcinoma. Treatment of choice is wide surgical excision, with long-term follow-up. Postoperative chemotherapy and radiotherapy has been used successfully in a few reported cases. AFS is a locally aggressive malignant tumor, with regional and distant metastases being uncommon.