Ratio of anogenital warts between different anatomical sites in homosexual and heterosexual individuals in Australia, 2002-2013: implications for susceptibility of different anatomical sites to genital warts.

There is little known regarding the transmissibility of human papillomavirus (HPV) between different sites in men who have sex with men (MSM) and heterosexual individuals. We conducted a retrospective analysis investigating all new patients attending the Melbourne Sexual Health Centre in Australia between 2002 and 2013. We describe the prevalence and ratio of the first episode of anogenital warts in MSM and heterosexual males and females. The proportion of new MSM clients with anal and penile warts was 4·0% (362/8978) and 1·6% (141/8978), respectively; which gave an anal-to-penile wart ratio of 1:2·6. About 13·7% (1656/12112) of heterosexual males had penile warts and 10·0% (1121/11166) of females had vulval warts, which yielded a penile-to-vulval wart ratio of 1:0·7. Penile-anal transmission has a higher ratio than penile-vulval transmission, suggesting that the anal epithelium may be more susceptible to HPV infection than the vulval epithelium in females; these ratios are important in modelling the control of HPV in MSM.

Widely tunable midinfrared difference frequency generation in orientation-patterned GaAs pumped with a femtosecond Tm-fiber system.

We demonstrate a midinfrared source tunable from 6.7 to 12.7 µm via difference frequency generation (DFG) in orientation-patterned GaAs, with 1.3 mW average output power. The input pulses are generated via Raman self-frequency shift of a femtosecond Tm-doped-fiber laser system in a fluoride fiber. We numerically model the DFG process and show good agreement between simulations and experiments. We use this numerical model to show an improved design using longer pump pulses.

Diagnosis of pyogenic liver abscess by abdominal ultrasonography in the emergency department.

BACKGROUND: Delayed diagnosis of pyogenic liver abscess remains a challenging problem in the emergency department because of the associated high morbidity and mortality. OBJECTIVE: To evaluate the sensitivity of ultrasono-graphy in the diagnosis of pyogenic liver abscess in patients presenting to the emergency department and the factors that may influence this sensitivity. METHODS: A retrospective study was conducted in patients diagnosed with pyogenic liver abscess in the emergency department (ED) of a tertiary care teaching hospital for a period of 5 years. Between May 2001 and April 2006, 268 patients diagnosed with pyogenic liver abscess were evaluated by ultrasonography and/or CT scanning. The age, sex, clinical presentation, location and number of abscesses and the underlying disease of these two groups were compared. RESULTS: Of the 268 patients admitted via the ED who were discharged or died with a diagnosis of pyogenic liver abscess, there was a predominance of men (M/F 173/95) and the mean age was 57.6 years (range 17-90). 38 had false negative findings on ultrasonography (sensitivity 85.8%) and required abdominal CT scanning for definitive diagnosis. In the other 230 cases, ultrasonography alone was sufficient for diagnosis. Location of the abscess in segments 4 and 5 of the liver raised the sensitivity of ultrasound for diagnosis, while location in segment 8 was most associated with delayed diagnosis by ultrasonography. Right costal angle knocking pain was significant for pyogenic liver abscess even if ultrasound was negative. CONCLUSIONS: The size and location of the liver abscess and the underlying comorbid diseases may affect the diagnostic sensitivity of ultrasound for pyogenic liver abscess in clinical practice. A high index of suspicion should be maintained in patients with diabetes mellitus, previous biliary tract intervention or gastrointestinal malignancy. Follow-up CT scanning is recommended if right flank knocking pain is present, even if ultrasonography is non-revealing. A diagnostic protocol for liver abscess may be feasible in the future.

Salivary gland anlage tumor in a neonate presenting with respiratory distress: radiographic and pathologic correlation.

We present a case of congenital salivary gland anlage tumor (SGAT) of the nasal septum in a 2-week-old infant who had difficulty breathing through her nose since birth. CT and MR imaging demonstrated a circumscribed mass within the nasal cavity that did not communicate with the intracranial compartment. Differential diagnosis and clinical significance of recognizing this rare lesion are reviewed.

Rhabdomyolysis in 119 students after repetitive exercise.

Exercise induced rhabdomyolysis is well known, but has rarely been reported in high school students. This is the report of 119 cases in high school students who exercised vigorously (120 push ups in five minutes) in cold weather. Most of them developed muscle pain and dark urine within two to four days of the exercise.

A novel sample holder allowing atomic force microscopy on transmission electron microscopy specimen grids: repetitive, direct correlation between AFM and TEM images.

A novel sample holder that allows atomic force microscopy (AFM) to be performed on transmission electron microscope (TEM) grids is described. Consequently, AFM and TEM images were repeatedly obtained on exactly the same sample area. For both techniques, a thin carbon film was used as the imaging substrate. Although these techniques have been previously used in conjunction, AFM and TEM images on exactly the same area have not been repeatedly obtained for any system. Correlation of AFM and TEM images is useful for work where the three-dimensional topographical information provided by the AFM could be used to better interpret the two-dimensional images provided by the TEM and vice versa. To demonstrate the applicability of such correlation, new results pertaining to a fibrillar collagen system are summarized.

Successful external cardioversion of atrial fibrillation in patients referred to an electrophysiologist for internal cardioversion.

BACKGROUND: Internal cardioversion of atrial fibrillation with direct current energy has become an increasingly employed technique for patients who fail external cardioversion. HYPOTHESIS: The purpose of this study was to determine whether internal cardioversion could be avoided by careful attention to cardioversion technique in a group of patients referred specifically for internal cardioversion after failed external cardioversion by community cardiologists. METHODS: We performed external cardioversion utilizing two operators applying significant pressure to the thorax with up to 360 J prior to the planned internal cardioversion in 20 patients referred for internal cardioversion after failed attempts at external cardioversion. RESULTS: Sixteen patients (80%) were successfully cardioverted and avoided the risk, inconvenience, and cost of internal cardioversion. CONCLUSION: External cardioversion with significant anterior paddle pressure by two operators can decrease the need for internal cardioversion in a significant portion of patients referred to electrophysiologists for internal cardioversion and should be considered prior to an invasive procedure.

Arthroscopic suture tying: A comparison of knot types and suture materials.

PURPOSE: The purpose of this study was to determine the structural properties of 3 arthroscopically tied knots using 2 different suture materials: the French knot, the Duncan loop knot, and the original Revo knot. TYPE OF STUDY: Cohort analytic study. METHODS: The sutures used were No. 1 PDS II, an absorbent monofilament, and No. 1 Ethibond (Ethicon, Somerville, NJ), a braided nonabsorbent material. The resulting 6 suture-knot combinations were individually tested to failure in both open- and closed-loop configurations. RESULTS: The French knot showed the greatest strength compared with the Duncan loop and the Revo knot with both No. 1 Ethibond and No. 1 PDS II sutures (P <.05). The No. 1 Ethibond exhibited higher initial stiffness than the No. 1 PDS II for all 3 knot types (P <.05). Results were similar for both open and closed-loop configurations. Also, the French knot failed predominantly by suture breakage instead of knot slippage for both suture materials. CONCLUSIONS: The results of this study suggest that, among the suture and knot combinations investigated in this study, the arthroscopic repair of musculoskeletal injuries should be performed using the French knot and No. 1 Ethibond suture.

Effect of radiofrequency current on previously implanted pacemaker and defibrillator ventricular lead systems.

We compared the response of endocardial lead systems to radiofrequency (RF) current delivered during atrio-ventricular junction ablation (AVJA) for atrial fibrillation with uncontrolled ventricular rate in 107 patients. The mean age was 67 +/- 11 years and the mean ejection fraction 42 +/- 15%. Patients were divided into 3 groups based on the type of ventricular lead present at the time of ablation: a previously implanted defibrillator lead (group 3, n = 13), a previously implanted pacemaker lead (group 2, n = 46) or a temporary lead (group 1, n = 48), which was subsequently followed by a permanent lead implantation. During AVJA, a median of 5 RF applications (44 +/- 8 W) were given via 4-5-mm electrodes. All but 1 patient had right-sided lesions, while 6 patients also had left sided lesions. Ventricular pacing thresholds were evaluated immediately pre- and post-ablation at 24 hours and at 1 to 3 months. Increases in ventricular pacing voltage thresholds were noted in all 3 groups over time, with the greatest mean increase in group 3 patients: [table: see text]. A greater than 2-fold increase in pacing thresholds was observed only with previously implanted leads, usually within the first 48 hours. It occurred significantly more often in patients with group 3 (6/13 [46%]) compared to group 2 (6/46 [13%], odds ratio 7.6, P = 0.006). A progressive rise in pacing threshold required lead revision in 2/13 group 3 patients (15%) and 2/46 group 2 patients (4%). While RF current has only minor effects on pacing threshold in most patients with previously implanted ventricular lead systems, clinically important alterations requiring device reprogramming or lead revision may occur. Group 3 are significantly more vulnerable to RF current, though the mechanisms are unclear. Group 1 during AVJA, followed by permanent lead implantation appears advisable. Pts with a previously implanted group 3 who require AVJA should be monitored closely.

Time and cost analysis of repacking medications in unit-of-use containers.

OBJECTIVES: To evaluate the effects of repacking drugs in unit-of-use containers in community pharmacies. The purpose of this study was to examine whether unit-of-use repacking reduces routine mechanical "counting and pouring" to allow more time for pharmaceutical care. DESIGN: Simulation pilot study to evaluate the differences between the existing and proposed systems. Based on the literature, four variables--optimum pack size, time savings, packaging costs, and shelving requirements--were selected for evaluation. Historical prescription data from a chain were used in determining the sample drugs and their optimum pack sizes. Workflow analysis and time study were used to estimate the time savings. Manufacturer bottles, repack bottles, and shelves were measured to determine the impact of using unit-of-use containers on storage requirements. SETTING: Three community pharmacies in a major drugstore chain in Cincinnati, Ohio. RESULTS: The 25 fastest-moving solid oral dosage forms, representing 21.6% of all drugs dispensed by the chain, were selected as the sample drugs for the study. The workflow analysis and time study revealed that 0.79 minutes could be saved per prescription if repacked drugs were used. There was an increased cost of approximately $0.05 for every repack bottle used in place of a prescription vial. It was calculated that repacking in unit-of-use containers would increase storage requirements in the pharmacy by 2.5 times if current inventory levels were maintained. CONCLUSION: Repacking drugs in unit-of-use containers is potentially an inexpensive method to increase usable time in the pharmacy that does not require an increase in personnel or the purchase of additional technology at the store level.

Atypical atrial flutter originating in the right atrial free wall.

BACKGROUND: Data from experimental models of atrial flutter indicate that macro-reentrant circuits may be confined by anatomic and functional barriers remote from the tricuspid annulus-eustachian ridge atrial isthmus. Data characterizing the various forms of atypical atrial flutter in humans are limited. METHODS AND RESULTS: In 6 of 160 consecutive patients referred for ablation of counterclockwise and/or clockwise typical atrial flutter, an additional atypical atrial flutter was mapped to the right atrial free wall. Five patients had no prior cardiac surgery. Incisional atrial tachycardia was excluded in the remaining patient. High-density electroanatomic maps of the reentrant circuit were obtained in 3 patients. Radiofrequency energy application from a discrete midlateral right atrial central line of conduction block to the inferior vena cava terminated and prevented the reinduction of atypical atrial flutter in each patient. Atrial flutter has not recurred in any patient (follow-up, 18+/-17 months; range, 3 to 40 months). CONCLUSIONS: Atrial flutter can arise in the right atrial free wall. This form of atypical atrial flutter could account for spontaneous or inducible atrial flutter observed in patients referred for ablation and is eliminated with linear ablation directed at the inferolateral right atrium.

Retrograde fast pathway ablation for atrioventricular nodal reentry associated with markedly prolonged PR intervals.

Three patients with typical atrioventricular nodal reentrant tachycardia (AVNRT) and markedly prolonged PR intervals (>300 ms) without dual pathway physiology at baseline or during isoproterenol infusion underwent successful fast pathway ablation and remained asymptomatic without recurrent AVNRT, atrioventricular block, or symptomatic bradycardia for a mean of 19 months. In patients with recurrent AVNRT and markedly prolonged PR intervals, selective ablation of the retrograde fast pathway can eliminate AVNRT without further impairment of anterograde atrioventricular nodal function.

Endemic blastomycosis in Mississippi: epidemiological and clinical studies.

In order to clarify the epidemiology and clinical spectrum of endemic blastomycosis, we reviewed the charts of 326 culture and/or histologically proven cases of blastomycosis in Mississippi from 1979 to 1988. Cases were dispersed throughout the state, but counties in central and south-central Mississippi reported 63% of all blastomycosis cases. The average annual incidence rate was 1.3 cases per 100,000 population. The majority of cases were in men (male to female ratio 1.7:1), and most patients were aged in their third through seventh decades (82%). Outdoor occupations were noted for only 28.9% of cases. Cases occurred throughout the year with no significant seasonal peak. Although 55% saw a physician within 7 days of onset of illness, 29% presented after 1 month. Despite early presentation, diagnosis was often delayed for more than 1 month (43.3%). Single organs were involved in 82.8% of cases. For all cases, organ systems involved included lungs (91.4%), skin (18.1%), bone (4.3%), genitourinary system (1.8%), and central nervous system (1.2%). The presence of skin or bone disease was associated with multiorgan involvement. Thirty-three patients died (11.5%), 6 of whom received no therapy. Patients who died were significantly older than those who survived. A successful outcome without relapse was noted in 86.5% of amphotericin B-treated patients and in 81.7% of ketoconazole-treated patients. The relapse rate for ketoconazole-treated patients was higher than for amphotericin B-treated patients (14% and 3.9% respectively).

Re-engineering a pharmacy work system and layout to facilitate patient counseling.

The development and evaluation of a new work system and facility design for a chain of community pharmacies are described. A new work system was developed to optimize utilization of pharmacist and technician time and allow the pharmacy to increase patient counseling without adding personnel. In the new system, pharmacists would review prescriptions, check technicians' work, and dispense prescriptions, counseling patients as needed; technicians would enter prescriptions into the pharmacy computer and fill them. The existing work system and design were evaluated in June and July of 1992 by observing, classifying, and recording activities of pharmacy personnel three days per week at six pharmacies in the chain. Pharmacy designs that would work with the new work system were created by a university design class after consultation with representatives of the pharmacy chain and the university's college of pharmacy. The pharmacy chain selected one design, and a detailed floor plan and specifications were created. To test how the new design and system would work at each of the six test pharmacies, a computer simulation program was developed and verified by using the data collected on the existing pharmacy operations. Computer simulation showed that, with the new design and system, increasing patient counseling would increase patient waiting time slightly but would not require additional personnel. The layout and work system in a chain of community pharmacies were redesigned to facilitate patient counseling and make the best use of employee time.

A modified free gracilis flap in the rat.

We present in this paper the use of a combined neurovascularized flap of gracilis muscle and inguinal skin in the rat with the femoral vessels and obturator nerve serving as the pedicles. The epigastric, saphenous, and muscular branch vessels arising from the femoral vessels were preserved, and a portion of adductor magnus muscle was included in the flap to protect the delicate muscle vessels at their origins. The inguinal skin and muscle flap both had independent blood supplies, thus separate assessment of muscle and skin rejection was possible in the single transplanted "packet." The muscle flap with the reconnected motor nerve regained contractile ability upon nerve stimulation within 30 days after the iso-transplantation. The results suggest that the modified gracilis myocutaneous flap provides an ideal model for transplantation research.

Listerial infections in patients with systemic lupus erythematosus.

Infection with Listeria monocytogenes is known to occur more frequently in immunosuppressed patients, including those receiving high-dose prednisone or cytotoxic therapy for collagen vascular disease. We reviewed three cases of listeriosis and systemic lupus erythematosus (SLE) seen at our institution, in addition to five cases reported in the English literature. Seven of the eight patients had non-CNS listerial infections. All patients but one had associated risk factors of either renal failure or pregnancy. From our review, we found that listeriosis is uncommon in SLE, and patients without renal failure or pregnancy do not seem to be at increased risk for listeriosis. Although most patients were treated with high-dose prednisone, with or without cytotoxic drugs, the role of immunosuppression by these drugs as a risk factor for listeriosis remained unclear.

[Preliminary study of cartilage repair with autologous periosteum and fibrin adhesive system].

The potential surgical transplantation with autogenous periosteal grafts and Fibrin Adhesive System (FAS) was attempted in a rabbit model. The grafts were taken from the tibia, transplanted and fixed with FAS to artificial full-thickness (0.4 x 0.3 cm) defect on the femoral condyle. Histologic and ultrastructural findings revealed chondrocyte regeneration in the control, grafted, and graft/FAS treated group at week 6; however, chondrogenesis of the reparative tissue was best demonstrated in the graft/FAS group. At week 12, the interface between the reparative tissue and the surrounding tissue was invisible in the FAS/graft group, as compared with the well-defined interface in the grafted group and the control. The results strongly suggest that FAS-treated periosteal transplant is a potential model for the repair of articular cartilage defects. Although the results are preliminary, all seem promising in the clinical aspects.