Nasopharyngeal malignant melanoma masquerading in the gallbladder: the importance of histological assessment.

Metastatic melanoma of the gallbladder is a rare entity that is often diagnosed late, leading to a poor prognosis. The disease may present insidiously as acute cholecystitis or remain asymptomatic. Optimal management remains unclear but surgical resection is considered the mainstay of treatment for this condition. We report the case of a 47-year-old man who suffered a protracted course of generalised abdominal symptoms eventually culminating in a diagnosis of acute cholecystitis. Following an emergency laparoscopic cholecystectomy, the histology revealed a melanoma with an unknown primary. Subsequently this was traced to the nasopharynx. Because of the presence of concurrent liver metastasis, systemic immunotherapy with palliative intent was commenced following a multidisciplinary team discussion. This case highlights the importance of sending clinical specimens for histological analysis. We argue against selectively choosing which specimens to send for histology because radiological and/or intraoperative macroscopic inspection of resected tissue alone can result in a missed diagnosis.

Characteristics of Orthopaedic Sports Medicine Fellowship Directors.

BACKGROUND: No study in the orthopaedic literature has analyzed the demographic characteristics or surgical training of sports medicine fellowship directors (FDs). Objective determinations as to what makes a physician qualified for this leadership position remain unclear; thus, it is important to identify these qualities as future physicians look to fill these roles. PURPOSE: To illustrate characteristics common among sports medicine FDs. STUDY DESIGN: Cross-sectional study. METHODS: The 2020 Accreditation Council for Graduate Medical Education Fellowship Directory was used to identify the FDs for all orthopaedic sports medicine fellowship programs in the United States. The characteristics and educational background data for FDs were gathered by 2 independent reviewers from up-to-date curricula vitarum, Web of Science, and institutional biographies and consolidated into 1 database. Data points gathered included age, sex, residency/fellowship training location and graduation year, name of current institution, length of time at current institution, time since training completion until being appointed FD, length of time in current FD role, and personal research H-index. RESULTS: We identified 90 current orthopaedic sports medicine FDs. The mean Scopus H-index was 24.1 (median, 17). The mean age of FDs was 55.4 years; 87 of 90 (96.7%) were male and 3 (3.3%) were female; and 79/90 (87.8%) were White and 3/90 (3.3%) were African-American. The mean time to complete residency was 5.1 years (range, 5.0-6.0 years), and the most attended residency programs were the Hospital for Special Surgery (n = 9), the Harvard Combined Orthopaedic Residency Program (n = 5), and Duke University Medical Center (n = 4). The mean time required to complete a fellowship was 1.1 years (range, 1.0-2.0 years), and the fellowship programs that produced the most future FDs were the American Sports Medicine Institute (n = 11), the Steadman Hawkins Clinic (Vail) (n = 8), the Kerlan-Jobe Orthopaedic Clinic (n = 7), and the Hospital for Special Surgery (n = 7). The mean time from completion of fellowship to appointment as a FD was 12.8 years (range, 1-39 years). CONCLUSION: Women and minority groups are largely underrepresented among leadership positions in the field of orthopaedic sports medicine.

Open Abdominal Aortic Aneurysm Replacement in the Awake Patient.

Nonintubated aortic surgery using various techniques has been reported, but despite publication of favorable outcomes in select patient groups, awake aortic surgery remains unpopular. Our patient had an abdominal aortic aneurysm that was unsuitable for endovascular repair. Because of the significant respiratory disease, general anesthesia represented an unacceptably high risk. As a result, he underwent open AAA repair via a retroperitoneal approach with the aid of epidural anesthesia. Here, we highlight the benefits of the procedure which offer a select cohort of patients the chance of life-saving surgery.

Using coherent X-ray ptychography to probe medium-range order.

Characterization of microscopic structural order and in particular medium range order (MRO) in amorphous materials is challenging. A new technique is demonstrated that allows analysis of MRO using X-rays. Diffraction data were collected from a sample consisting of densely packed polystyrene-latex micro-spheres. Ptychography is used to reconstruct the sample transmission function and fluctuation microscopy applied to characterize structural order producing a detailed `fluctuation map' allowing analysis of the sample at two distinct length scales. Independent verification is provided via X-ray diffractometry. Simulations of dense random packing of spheres have also been used to explore the origin of the structural order measured.

Systematic review and meta-analysis of outcomes following emergency surgery for Clostridium difficile colitis.

BACKGROUND: Only a small proportion of patients with severe Clostridium difficile infection (CDI) undergo emergency surgery, the timing and nature of which is unclear. The aim of this study was to describe the operations performed and to identify factors predictive of death following emergency surgery for CDI. METHODS: A systematic review of published literature was performed for studies comparing survivors and non-survivors of emergency surgery for CDI. Meta-analysis was carried out for 30-day and in-hospital mortality. RESULTS: Overall 31 studies were included, which presented data on a total of 1433 patients undergoing emergency surgery for CDI. Some 1·1 per cent of all patients with CDI and 29·9 per cent with severe CDI underwent emergency surgery, although rates varied between studies (0·2-7·6 and 2·2-86 per cent respectively). The most commonly performed operation was total colectomy with end ileostomy (89·0 per cent, 1247 of 1401 detailed surgical procedures). When total colectomy with end ileostomy was not performed, reoperation to resect further bowel was needed in 15·9 per cent (20 of 126). Where described, the 30-day mortality rate was 41·3 per cent (160 of 387). Meta-analysis of high-quality studies revealed that the strongest predictors of postoperative death were those relating to preoperative physiological status: preoperative intubation, acute renal failure, multiple organ failure and shock requiring vasopressors. CONCLUSION: This systematic review supports total colectomy with end ileostomy as the primary surgical treatment for patients with severe CDI; other surgical procedures are associated with high rates of reoperation and mortality. Less extensive surgery may have a role in selected patients with earlier-stage disease.

Intrathoracic myxosarcoma in a dog.

A 3-year-old Labrador retriever dog was presented with pyrexia, dyspnoea and tachycardia. A pleural effusion was detected radiographically and ultrasonography showed pleural fluid with floating material. The fluid was drained, revealing a soft tissue mass adjacent to the left ventricle. The aspirated fluid had a proteinaceous and gelatinous appearance. Cytological examination revealed atypical mesenchymal cells in a dense eosinophilic background, interpreted as consistent with the presence of a matrix-secreting tumour, probably a myxosarcoma. Thoracoscopy confirmed the presence of the mass adjacent to the left ventricle, but showed additional smaller pleural masses. Microscopical and immunohistochemical evaluation of a biopsy sample from the mass supported the diagnosis of a myxosarcoma, which was further confirmed by transmission electron microscopy.

Pneumonyssoides species infestation in two Pekingese dogs in the UK.

Two male, neutered, Pekingese dogs aged four years and 12 years were presented for acute-onset nasal pruritus and sneezing following a visit to a beach in northern Scotland. Routine nasal investigations revealed the presence of the canine nasal mite Pneumonyssoides both by direct visualisation and histopathologically. Resolution of clinical signs was observed following selamectin treatment. To the authors' knowledge, this report describes the first cases of Pneumonyssoides infestation in non-travelled UK dogs.

Are the Brookhill-Wilk patents impediments to market growth in cybersurgery?

BACKGROUND: In the past, many surgeons could practise their craft with little or no knowledge of patent law. But in the world of robotic and computerized surgery, this is increasingly a myopic approach, because the principle means of protecting high-tech surgical instruments is through the application of patent law. The issue is: does the Brookhill-Wilk patent, which covers the performance of remote robotic surgery, impede the growth of cybersurgery? METHODS: Review of the Brookhill-Wilk patent and relevant law. RESULTS: Patent law, which first took its form in the Middle Ages, attempts to balance the rewarding of innovation with the stifling of market growth. Using US patent law as a model, it would appear that the Brookhill-Wilk patent, a particular example of a medical process patent, could inhibit the growth of cybersurgery, as potential sums of money could be demanded by the patent holder from anyone who practises cybersurgery. However, two recent US Supreme Court cases appear to have seriously undermined the validity of a number of medical process patents, including the Brookhill-Wilk patent. CONCLUSION: Based on recent changes in patent law, it is not expected that Brookhill-Wilk patent will hinder the growth of cybersurgery.

Nutritional challenges in head and neck cancer.

In head and neck cancer patients malnutrition impacts on quality of life, complications of therapy and also prognosis, in part via altered immunity. Dysphagia assessment is extremely valuable but more work is needed to optimize the rehabilitation of the incompetent swallow in this particular patient group. Proper nutritional assessment is mandatory pre-/peri-/post-treatment. The range and palatability of nutritional supplements has greatly increased over the past few years. Many of the early problems of percutaneous gastrostomy feeding have been addressed but complication rates still remain high. As accelerated radiotherapy and chemoradiation techniques become more widely advocated, nutrition is likely to become increasingly important. The authorship includes two otolaryngologists, a nutritionist and a speech and language therapist with an interest in head and neck dysphagia, thereby aiming to provide a broad perspective of these issues. However, there appears to be a lack of prospective evaluation of many aspects of dysphagia/nutrition in head and neck cancer, which needs to be addressed.

Bioadhesive, rheological, lubricant and other aspects of an oral gel formulation intended for the treatment of xerostomia.

Xerostomia is commonly known as 'dry mouth' and is characterised by a reduction or loss in salivary production. A bioadhesive gel for its localised treatment was formulated to help enhance the residence time of the product, based on the polymer Carbopol 974P. The bioadhesion of various formulations was evaluated on different mucosal substrates, as simulations of the oral mucosa of xerostomic patients. Depending on the type of model substrate used, the mechanism of bioadhesion could alter. When the rheology of various formulations was examined, changes in bioadhesion were more easily interpreted, as the presence of other excipients caused an alteration in the rheological profile, with a change from a fully expanded and partially cross-linked system to an entangled system. Improving the lubricity of the product was considered important, with optimum incorporation of vegetable oil causing a desirable lowering of the observed friction of the product. The final complex formulation developed also contained salivary levels of electrolytes to help remineralisation of teeth, fluoride to prevent caries, zinc to enhance taste sensation, triclosan as the main anti-microbial/anti-inflammatory agent and non-cariogenic sweeteners with lemon flavour to increase the palatability of the product while stimulating any residual salivary function.

A prospective randomised controlled trial of nutritional supplementation in malnourished elderly in the community: clinical and health economic outcomes.

BACKGROUND & AIMS: Malnutrition is common in sick elderly people on admission to hospital and in the community. We conducted a randomised controlled trial to determine if nutritional supplementation after discharge from hospital improved nutritional status and functional outcomes, or reduced health-care costs. METHODS: Elderly malnourished subjects were randomised to 8 weeks of supplementation or no supplementation post discharge, and followed up for 24 weeks. Weight, body mass index, anthropometrics, handgrip strength, quality of life and requirements for health-care professionals' services and social services were measured throughout the study. RESULTS: Nutritional status improved significantly from baseline to week 24 in the intervention group (P<0.05), but not in the control group. There was no significant difference in nutritional status between groups at week 24. Handgrip strength improved significantly in the intervention group during supplementation, and was significantly different from that of the control group at week 8, but decreased thereafter. There was no significant difference in quality of life or health economic outcomes between groups at week 24. CONCLUSIONS: In already malnourished elderly subjects, it may be too late to expect to improve function or quality of life or to reduce health-care costs simply by providing nutritional supplements after hospitalisation. Prevention is key. All elderly patients should be nutritionally assessed as part of their routine care, and appropriate intervention initiated early.

Dietary vitamin K influences intra-individual variability in anticoagulant response to warfarin.

The relationship between dietary intake of vitamin K, fat, plasma vitamin K concentrations and anticoagulation response to warfarin within individuals, as well as the contribution of dietary vitamin K to differences in warfarin dose requirements between individuals were investigated in 53 patients on warfarin therapy who had stably controlled anticoagulation. Each patient completed a dietary record of all foods consumed on a daily basis for 4 weeks. Each week a blood sample was taken for measurement of the international normalized ratio (INR), plasma vitamin K, triglycerides and warfarin enantiomer concentrations. The patients' genotype for CYP2C9 was also determined. Regression analysis of the data showed that, for each increase of 100 microg in the daily dietary intake of vitamin K averaged over 4 d, the INR was reduced by 0.2. There was no correlation between warfarin daily dose and average daily dietary vitamin K intake when calculated over 28 d. The regression model for warfarin dose showed that, while dietary vitamin K had no effect, CYP2C9 genotype (P = 2%) and age (P < 1%) significantly contributed to inter-patient variability in warfarin dose requirements. A consistent intake of vitamin K could reduce intrapatient variability in anticoagulation response and thus improve the safety of warfarin therapy.

A prospective study of the workload of a newly formed PEG advice team.

BACKGROUND: A multidisciplinary advice team may be the optimal way of providing the long-term nutritional and percutaneous endoscopic gastrostomy (PEG)-related care for patients dependent on PEG feeding but the workload involved is unknown. AIM: To study prospectively the workload of a proactive, multidisciplinary PEG advice team over a 2-year period. METHODS: Separate documentation from main case notes of each episode of the team's contact with PEG or potential PEG patients, including assessment, advice and therapy given, from the time of its establishment, for four consecutive 6-monthly periods. RESULTS: During the audit, 89 patients were referred to the team for consideration of PEG insertion and PEGs were placed in 74. Eighty-nine additional patients were referred for follow up having had a PEG placed elsewhere. During the four audit periods the rate of new PEG insertions increased by 53%, the rate of PEG replacements by 315%, and the number of patients under the team increased from 16 to 70, an increase of 337%. Numbers of inpatient and outpatient consultations, and visits to other institutions by members of the team increased commensurately. CONCLUSIONS: The rapidly increasing workload of the team suggests it is playing a valued role but there are significant resource implications.

Prevalence of malnutrition on admission to four hospitals in England. The Malnutrition Prevalence Group.

AIMS: The primary objective was to estimate prevalence of malnutrition on admission to four hospitals. Secondary objectives included assessing the relationship between nutritional status and length of hospital stay, numbers of new prescriptions, new infections and disease severity. METHODS: We entered eligible patients according to predefined quotas for elective and emergency admissions to 23 specialties. We measured height, weight, Body Mass Index and anthropometrics, and recorded history of unintentional weight loss. Patients who had lost > or = 10% of their body weight, had a Body Mass Index <20, or had a Body Mass Index <20 with one anthropometric measurement <15th centile were considered malnourished. RESULTS: Of 1611 eligible patients, 761 did not participate; 269 were too ill; 256 could not be weighed; and 236 refused consent. Eight hundred and fifty were subsequently evaluated. Prevalence of malnutrition on admission was 20%. Length of stay, new prescriptions and infections and disease severity were significantly higher in the malnourished. CONCLUSIONS: One patient in every five admitted to hospital is malnourished. Although this figure is unacceptably high, it may underestimate true prevalence. Malnutrition was associated with increased length of stay, new prescriptions and infections. Malnutrition may also have contributed to disease severity.