Biomedical subjects
Publications and source records attributed to N Walsh.
The successful establishment of primary care groups will demand sensitivity from managers. It is important to acknowledge, and mourn, what is being lost by ending the old arrangements. People do not resist change itself, but the losses and endings it involves. Despite the tight timetable, management should be participative rather than directive.
Because of the well-known difficulty in distinguishing between Spitz nevi and spitzoid malignant melanomas at the microscopic level, the critical importance of this task notwithstanding, expert dermatopathologists across the world have strenuously endeavored to identify histopathologic criteria that would assist microscopists in this effort. Many reports itemizing such criteria are extant. The objective of the current study was to determine which of these criteria serve as the most consistent discriminators. Using a population of 11 spitzoid melanomas and 12 Spitz nevi, we evaluated six sets of criteria purported to be helpful in differentiating between these entities. Overall, we found that six features had significant distinguishing capacity, namely, (1) Kamino bodies, (2) a brisk mitotic rate, (3) mitoses close to the base of the lesion, (4) abnormal mitoses, (5) symmetry, and (6) uniformity of nests from side to side. It is noteworthy that the first three of these rank among the six criteria itemized repeatedly in 50% or more of the sets of criteria evaluated.
Despite developments in general hospital liaison psychiatry over the past 20 years, joint care still remains underdeveloped in Europe. Psychiatry continues to move from the mental hospital to the general hospital unit without the parallel evolution of combined medical and psychiatric. An inpatient unit that provides both medical and psychiatric care may provide an essential integration of care that can benefit a select group of patients. The aims of this study were to prospectively evaluate the profile, treatment, and follow-up of patients admitted to the joint-care unit, and to examine the difficulties associated with the treatment of these patients on a joint unit. Eighty-nine patients were admitted to the joint care unit over a 6-month period. Their median length of stay was 2 days (range 1-52 days). Fifty-six (50%) were female. The majority (68) (76%) of the group were admitted following acts of deliberate self-harm. The overall predominant psychiatric diagnosis was depression (41) (46%). During admission, 23 (26%) patients were found to have behavioral and psychiatric problems that were difficult to manage on the ward. Eleven patients caused difficulties for staff relating to the management of their physical illness. Thirty-six (33%) patients were referred for further psychiatric inpatient care from the joint-care unit. The extra burden of these patients' care was felt to fall on the staff working on the psychiatric unit. The joint care unit provided a combined psychiatric and medical service. It was used predominantly by patients following acts of deliberate self-harm. Joint care allowed a comprehensive assessment and initiation of treatment of this patient group as well as a learning experience for medical and nursing staff. The inclusion of such a unit is a worthwhile consideration in any general hospital psychiatric service, with advanced planning easing staff workload.
Experimental data suggest that formation of thromboxane A2 may be suppressed during administration of a glycoprotein IIb/IIIa antagonist. We determined the dose of one such compound, fradafiban, required to provide > 80% occupancy of the platelet glycoprotein IIb/IIIa and examined its effects on thromboxane A2 formation in patients undergoing PTCA. The dose response to fradafiban and additional effects of aspirin were explored initially in patients with stable coronary artery disease. Fradafiban induced a dose-dependent inhibition of platelet aggregation that correlated with fibrinogen receptor occupancy and plasma drug concentration. Addition of aspirin 300 mg had no effect on these parameters. At the highest dose, mean fibrinogen receptor occupancy was 89.7 +/- 1.2% (n = 3) at 4 hours and platelet aggregation had decreased by 93.4 +/- 2.7%. Eighteen patients undergoing coronary angioplasty were randomized to receive either aspirin 330 mg or that dose of fradafiban producing > 80% fibrinogen receptor occupancy. Platelet aggregation was suppressed throughout the infusion of fradafiban to a greater extent than with aspirin. However, there was a marked increase in urinary excretion of 11-dehydrothromboxane B2 in patients treated with fradafiban: from 1973 +/- 889 to a peak of 9760 +/- 3509 pg/mg creatinine (P = .0046). Despite this evidence of continued platelet activation in vivo, there were no cases of coronary thrombosis. In conclusion, fradafiban suppresses platelet aggregation and may be a useful alternative to aspirin in the prevention of thrombotic events in patients undergoing PTCA. However, there is continued formation of thromboxane A2, which may continue to exert its effects as a potent vasoconstrictor and vascular smooth muscle mitogen.
We have demonstrated high definition and improved resolution using a novel scanning system integrated with a commercial ultrasound machine. The result is a volumetric 3D ultrasound data set that can be visualized using standard techniques. Unlike other 3D ultrasound images, image quality is improved from standard 2D data. Image definition and bandwidth is improved using patent pending techniques. The system can be used to image patients or wounded soldiers for general imaging of anatomy such as abdominal organs, extremities, and the neck. Although the risks associated with x-ray carcinogenesis are relatively low at diagnostic dose levels, concerns remain for individuals in high risk categories. In addition, cost and portability of CT and MRI machines can be prohibitive. In comparison, ultrasound can provide portable, low-cost, non-ionizing imaging. Previous clinical trials comparing ultrasound to CT were used to demonstrate qualitative and quantitative improvements of ultrasound using the Sandia technologies. Transverse leg images demonstrated much higher clarity and lower noise than is seen in traditional ultrasound images. An x-ray CT scan was provided of the same cross-section for comparison. The results of our most recent trials demonstrate the advantages of 3D ultrasound and motion compensation compared with 2D ultrasound. Metal objects can also be observed within the anatomy.
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BACKGROUND: Satellite cell necrosis is a histopathologic hallmark of cutaneous graft-versus-host disease (GVHD) after allogeneic bone marrow transplantation. Although this interaction of lymphocytes with keratinocytes has features of immune cytolytic destruction, the details of the process are not known. OBJECTIVE: Our purpose was to investigate whether apoptosis is involved in the process of GVHD. METHODS: We used TdT-mediated dUTP-biotin nick end labeling (TUNEL) technique with biotinylated nucleotides. Formalin-fixed, paraffin-embedded sections from skin biopsy specimens of patients with GVHD and normal skin were studied. RESULTS: Labeling of scattered individual keratinocytes in the epidermis and adnexal epithelium undergoing cytolytic degeneration and a proportion of the adjacent lymphocytes was noted in all specimens of GVHD. CONCLUSION: The positive staining of keratinocytes by the TUNEL method indicates that cell destruction in cutaneous GVHD involves apoptosis.
The frequency with which malignant melanomas arise in association with preexisting melanocytic nevi has been studied extensively. We opted to evaluate new aspects of this association. In particular, we addressed the relative proportions of acquired versus congenital nevi involved and categorized the acquired nevi according to morphological type. Approximately 23% of the melanomas (29 of 124) in this group arose in association with preexisting nevi of which 55% (n = 16) were acquired and 28% (n = 8) were congenital (small). In 17% (n = 5) a distinction could not confidently be made. Of the acquired nevi, the vast majority were of Clark's type. It is clear that a relatively small proportion of melanomas as a whole are associated with preexisting nevi, and this number should be kept in perspective in devising strategies for early detection and prevention. The involvement of Clark's nevi in this regard is known, but to date the role of small congenital nevi has been underrecognized.
Malnutrition in hospital is often unrecognized. A nutrition team aims to teach simple methods of detecting malnutrition. On a single day all medical in-patients underwent a nutritional assessment. Eighty-four patients (43 men), median age 71 years (range 28-97), were assessed. The most common diagnoses were cardiac disease (26), stroke/dementia (12), non-malignant lung disease (9) and malignancy (6). A weight loss of more than 10% (%WL) was found in 17/65 (26%) and a body mass index (BMI) of less than 19 kg/m2 in 13/69 (19%). A mid-arm muscle circumference (MAMC) less than the fifth percentile occurred in 16/83 (19%) patients. Percentage weight loss alone detected seven patients of whom four were overweight (BMI > 25 kg/m2), BMI alone detected three patients, and MAMC alone eight patients of whom three could not be weighed and three had fluid retention. There was fluid retention in 35/84 (42%) patients of whom nine were malnourished (six detected by BMI and/or %WL, and three by MAMC alone). All three measurements were made in 64 patients, six (9%) of whom were detected as malnourished by all three methods. Combining the three measurements 29/84 (35%) of patients were malnourished and only 28% of these patients had been assessed by a dietitian. BMI and %WL detect most patients but fluid retention may limit their accuracy. MAMC is useful in those who cannot be weighed or who have fluid retention.
We present a case of a young female patient who for 8 years was believed to have discoid lupus erythematosus of the skin and oral mucosae. Only after her infant son had a near-fatal pulmonary infection was the diagnosis of chronic granulomatous disease made and her lupus erythematosus-like mucocutaneous lesions recognized as manifestations of her carrier status for chronic granulomatous disease. The purpose of this report is to raise awareness of and better characterize the mucocutaneous manifestations of carriers of chronic granulomatous disease. Early identification of carriers permits genetic counseling and prenatal diagnosis and forewarns pediatricians so that they can provide better care for affected infants.
STUDY DESIGN: In a prospective, single-blinded study, the incidence of false-positive screening tests for sacroiliac joint dysfunction was investigated using the standing flexion, seated flexion, and Gillet tests in 101 asymptomatic subjects. OBJECTIVES: This study determined if these commonly used sacroiliac screening tests can be abnormal in an asymptomatic population. SUMMARY OF BACKGROUND DATA: The sacroiliac joint is a potential source of back and leg pain. One condition affecting this joint is termed sacroiliac joint dysfunction. Diagnosis of this is made primarily by physical examination using screening tests as preliminary diagnostic tools. These screening tests evaluate for asymmetry in sacroiliac motion due to a relative, unilateral hypomobility in one the sacroiliac joints. The specificity of these tests, however, has not been thoroughly evaluated in a well-selected asymptomatic population. METHODS: A single-blinded examiner performed the standing flexion, seated flexion, and Gillet tests on all subjects. An asymptomatic and a symptomatic group were studied. RESULTS: Overall, 20% of asymptomatic individuals had positive findings in one or more of these tests. The specific percentage of false positives are reported by test, age, sex, and side. CONCLUSION: This study suggests that asymmetry in sacroiliac motion due to relative hypomobility as determined by these tests can occur in asymptomatic joints. Obviously, one should not rely solely on these tests to diagnose symptomatic sacroiliac dysfunction.
A case is presented of a laterally occurring thyroglossal cyst. In conventional teaching, thyroglossal duct remnants occupy the midline, or a position adjacent to the midline, and are found in a line marking the descent of the thyroid anlage and move upwards on protruding the tongue. Laterally presenting thyroglossal duct remnants are unusual.
Melanin synthesis is a biologic property unique to the melanocyte. It is highly elevated in malignant melanoma with the production of both eumelanin (brown/black pigment) and pheomelanin (yellow/red pigment), dihydroxyindole (DHI) and cysteinyldopa (CD), respectively, being major precursors. Melanin metabolites are often released in the urine of patients with disseminated melanoma metastasis (melanuria). To establish a better method for the detection of occult melanoma this study compares the plasma levels of a pheomelanin metabolite, 5-S-CD, and a eumelanin metabolite, 6-hydroxy-5-methoxyindole-2-carboxylic acid (6H5MI2C), in melanoma and non-melanoma patients and correlates them with tumor thickness and melanoma metastasis. We found a) that the normal plasma levels of 5-S-CD and 6H5M12C are less than 2.22 ng/ml and 1.04 ng/ml, respectively; b) that the group with the normal 6H5MI2C plasma level does not have any metastasis, whereas a normal 5-S-CD level is seen in both non-melanoma and melanoma patients with and without metastasis; c) that a high plasma 6H5MI2C level is seen in all melanoma patients with tumor thickness more than 3.0 mm regardless of the presence or absence of metastasis, whereas in thinner melanoma patients this is seen only in positive metastasis group; and d) that all melanoma patients with positive metastases showed a high plasma 6H5MI2C level (more than 1.75 ng/ml). We conclude that the measurement of plasma levels of melanin metabolites provides a method for detecting occult melanoma metastasis and estimating the prognosis of melanoma patients, plasma 6H5MI2C level being more sensitive and reliable than that of 5-S-CD, and its increased level being a high risk factor.
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Merkel cells (MCs) have been a subject of investigation in human and animal studies for over a century, but their origin, function(s), and exact distribution in human skin remain largely unknown. The objectives of the present study were to quantify these cutaneous neuroendocrine cells in fetal and adult human skin, using an immunohistochemical marker (neuron-specific enolase) and morphometric methods. Our results indicate that, in postnatal life, MC are sparsely distributed along the undersurface of epidermal and occasionally adnexal epithelium in an approximate range of 0.1-1.0 MCs per centimeter of basal zone. They are most numerous on volar skin and least on genital skin, and on the face they have a primarily perifollicular orientation. Fetal samples have shown that MCs appear between the 15th and 18th week of gestation and are most abundant on volar skin. They appear to arise within the epidermis, and are initially numerous and later diminish with increasing gestational age. Their predominance in intrauterine life suggests a functional role in growth and development.
The emergence of consultation psychiatry as an important psychiatric subspecialty is in part due to the siting of psychiatric units in general hospitals, the manifest advances in medical technology and the increasing elderly population needing specialist care. This paper describes an evaluation of all referrals to a liaison psychiatry unit in a 550 bed general hospital over a six month period. 205 requests for psychiatric consultation were received, which represented 2% of all admissions. There was considerable variation between departments with regard to the referral rate. Management most often consisted of advice, with over 50% of patients being subsequently referred for ongoing psychiatric care.
BACKGROUND AND DESIGN: This article introduces a rapid high-performance liquid chromatographic assay to measure urinary pheomelanin and eumelanin metabolites, 5-S-cysteinyldopa and indoles, 5(6)-hydroxy-6(5)-methoxyindole-2-carboxylic acid. RESULTS: Our high-performance liquid chromatographic study clearly showed (1) urine of melanoma patients with positive metastasis revealed significant amounts of 5-S-cysteinyldopa and indoles (5,6-dihydroxyindole-2-carboxylic acid plus 6-hydroxy-5-methoxyindole-2-carboxylic acid) above 1 mumol/d and 2 mumol/d, respectively; and (2) in patients with metastasis-free melanoma these melanin metabolites might be excreted into the urine but always less than the two values cited above. CONCLUSIONS: As there is a discrepancy regarding the specificity of 5-S-cysteinyldopa as a marker for estimation of melanoma metastasis, high-performance liquid chromatographic measurement of urinary indoles will provide an additional assay in the detection of melanoma metastasis from an early stage. Both melanoma markers were increased in the urine of patients with metastatic melanoma.
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