Abdominal cyst of unclear aetiology: gastrointestinal stromal tumour or reactivation of abdominal tuberculosis.

Differential diagnosis of a new abdominal mass is broad and includes infection, malignancy and other inflammatory processes. Definitive diagnosis may be challenging without invasive biopsy, as history, physical exam and imaging may be non-specific. A 69-year-old man with a history of abdominal tuberculosis presented with a new painful abdominal cyst consistent with reactivation of tuberculosis versus new malignancy. Investigations revealed 4+ acid-fast bacilli from the aspirate suggestive of tuberculosis, but no improvement was noted on antituberculous therapy. Core needle biopsy noted c-KIT-positive spindle cells, diagnostic for a gastrointestinal stromal tumour, while cultures grew non-tuberculous mycobacteria.

Sloughing skin in intravenous drug user.

A 32 year old female, an active intravenous drug user, was admitted for fever, myalgias and an erythematous macular rash on her distal extremities. She quickly decompensated and developed septic shock. Her examination was significant for a progressive rash which within two days developed bullae and necrosis with progression to a confluent rash involving her palms and soles (Figs. 1 and 2). Her rash involved nearly one third of her body with what was equivalent to a third degree burn. Her labs were significant for leukocytosis with bandemia, elevated liver function tests with worsening thrombocytopenia and fibrinogen levels consistent with disseminated intravascular coagulation (DIC) Her transthoracic echocardiogram (Fig. 3) showed a 5 cm vegetation on the tricuspid valve. Her blood cultures were positive for methicillin-sensitive Staphylococcus aureus. She was meeting the clinical criteria for toxic shock syndrome (TSS) and subsequent testing for toxic shock syndrome toxin antibody was positive. She was treated with antibiotics and intravenous gamma globulin (IVIG). Due to her worsening rash she was transferred to a burns unit. She was diagnosed with Purpura fulminans (PF) which is a skin manifestation of DIC and has a rare association with Staphylococcus aureus infection.The main focus of this case report is to emphasise this rare association, prompt an early diagnosis and referral to prevent life threatening complications.

Echocardiographic measurements alone do not provide accurate non-invasive selection of annuloplasty band size for robotic mitral valve repair.

BACKGROUND AND AIM OF THE STUDY: Successful mitral valve repair (MVP) is dependent on accurate annuloplasty band sizing. This is difficult and time-consuming when performed via port-access, or through a 4-cm minithoracotomy used in robotically assisted MVP. With the goal of moving toward a less-invasive approach and minimizing cross-clamp time, an attempt was made to determine annuloplasty band size using transesophageal echocardiography (TEE) alone. METHODS: The intertrigonal distance (ITD) was determined by dividing the left ventricular outflow tract diameter (LVOT: measured on standard midesophageal aortic valve long-axis view) by 0.8. The ITD was compared to a nomogram developed to select the best Cosgrove-Edwards annuloplasty band size. RESULTS: Between July and October, 2004, 11 patients (mean age 52.6 +/- 17.9 years; four Barlow's valves with bileaflet prolapse, four posterior leaflet prolapses, one anterior leaflet prolapse, one rheumatic, one dilated annulus) undergoing robotically assisted MVP had the annuloplasty band chosen using TEE alone. Seven patients (63.6%) had no or mild mitral regurgitation (MR) on postoperative TEE. Three patients (27.2%) had some systolic anterior motion (SAM), with one (Barlow's valve) requiring a second repair (same operation). One patient (9.1%, rheumatic) had grade 2+ MR on postoperative TEE. CONCLUSION: In this small case series, a substantial proportion of patients had suboptimal immediate postoperative results. This suggests that selection of the annuloplasty band should not be based on a single echocardiographic variable as it depends on the etiology of the MR, and other dimensions of the mitral valve. Further studies are ongoing to develop a non-invasive method for the selection of annuloplasty band size.

Paleocene-Eocene thermal maximum and the opening of the Northeast Atlantic.

The Paleocene-Eocene thermal maximum (PETM) has been attributed to a sudden release of carbon dioxide and/or methane. 40Ar/39Ar age determinations show that the Danish Ash-17 deposit, which overlies the PETM by about 450,000 years in the Atlantic, and the Skraenterne Formation Tuff, representing the end of 1 +/- 0.5 million years of massive volcanism in East Greenland, are coeval. The relative age of Danish Ash-17 thus places the PETM onset after the beginning of massive flood basalt volcanism at 56.1 +/- 0.4 million years ago but within error of the estimated continental breakup time of 55.5 +/- 0.3 million years ago, marked by the eruption of mid-ocean ridge basalt-like flows. These correlations support the view that the PETM was triggered by greenhouse gas release during magma interaction with basin-filling carbon-rich sedimentary rocks proximal to the embryonic plate boundary between Greenland and Europe.

Nursing resources: a major determinant of nosocomial infection?

PURPOSE OF REVIEW: There is growing concern that changes in nurse workforce and hospital-restructuring interventions negatively impact on patient outcomes. This review focuses on the association between understaffing and health-care-associated infections. RECENT FINDINGS: There is a large number of studies showing that overcrowding, understaffing or a misbalance between workload and resources are important determinants of nosocomial infections and cross-transmission of microorganisms. Importantly, not only the number of staff but also the level of their training affects outcomes. The nurse workforce is ageing, mainly due to fewer individuals' engaging in a nursing career. This phenomenon, combined with cost-driven downsizing, contributes to a nursing shortage, and this tendency is not expected to revert unless important system changes are implemented. The causal pathway between understaffing and infection is complex, and factors might include lack of time to comply with infection control recommendations, job dissatisfaction, job-related burnout, absenteeism and a high staff turnover. SUMMARY: The evidence that cost-driven downsizing and changes in staffing patterns causes harm to patients cannot be ignored, and should not be considered as an inevitable outcome. More research is needed to better define the optimal patient-to-nurse ratio in various hospital settings and to estimate the economical impact of the nursing shortage. All quality-improvement interventions should carefully take into account systems and processes to be successful, as the issue of staffing is essentially a structural problem.

The Emperor Seamounts: southward motion of the Hawaiian hotspot plume in Earth's mantle.

The Hawaiian-Emperor hotspot track has a prominent bend, which has served as the basis for the theory that the Hawaiian hotspot, fixed in the deep mantle, traced a change in plate motion. However, paleomagnetic and radiometric age data from samples recovered by ocean drilling define an age-progressive paleolatitude history, indicating that the Emperor Seamount trend was principally formed by the rapid motion (over 40 millimeters per year) of the Hawaiian hotspot plume during Late Cretaceous to early-Tertiary times (81 to 47 million years ago). Evidence for motion of the Hawaiian plume affects models of mantle convection and plate tectonics, changing our understanding of terrestrial dynamics.