Traumatic Mid-substance Isolated Vastus Medialis Rupture in a Young Athlete: A Case Report.

CASE: This is the first documented case of an isolated traumatic vastus medialis rupture that occurred in a 14-year-old athlete after direct impact during play. Imaging confirmed a rare mid-substance rupture. The patient underwent conservative management with physical therapy augmented by blood flow restriction therapy (BFRT) and platelet-poor plasma (PPP) injection to regain full function. CONCLUSION: Isolated quadriceps mid-substance tears are rare. Determining an appropriate treatment technique for mid-substance tears is complex. This case documents the use of nonoperative management with BFRT and PPP to achieve full recovery and early return to play in a young athlete.

Early Fractional Ablative Laser for Skin Cancer Excision Scars: A Randomized Split-Scar Study.

BACKGROUND: Fractional ablative laser resurfacing has been shown to improve the final cosmetic appearance of surgical scars, but optimal timing is unknown. OBJECTIVE: To compare surgical scars treated with fractional carbon dioxide (CO 2 ) laser performed on Day 0 and Day 14. METHODS: Prospective, randomized, split-scar, physician-blinded study of 30 surgical scars on the limbs. Scars halves received fractional CO 2 laser on either Day 0 or Day 14. Scar assessment at 6 months evaluated patient preference, physician modified Manchester Scar Scale (MMSS) score, and quantitative scar analysis on histology (fractal dimension [F D ] and lacunarity [L] analysis). RESULTS: There was no significant difference in patient assessment (54% preferred Day 0 side, 46% preferred Day 14 side, p = .58) or physician assessment (mean MMSS 8.4 for Day 0 vs 8.7 for Day 14, p = .28). Fractal dimensions were similar for both interventions (mean 1.778 for Day 0 vs 1.781 for Day 14, p = .80). Lacunarity was similar for both interventions (mean 0.368 for Day 0 vs 0.345 for Day 14, p = .44). LIMITATIONS: Single-center study with wounds limited to limbs of skin Phototype I-II subjects; 4 of whom were lost to follow-up. CONCLUSION: Intraoperative CO 2 laser is noninferior to Day 14 laser resurfacing for surgical scar treatment.

Pathology in Practice.

In collaboration with the American College of Veterinary Pathologists.

Characterizing circulating nucleosomes in the plasma of dogs with lymphoma.

BACKGROUND: Nucleosomes consist of DNA wrapped around a histone octamer core like beads on a string so that DNA can be condensed as chromatin into chromosomes. Diseases such as cancer or inflammation lead to cell death where chromatin is fragmentated and released as mononucleosomes into the blood. The Nu.Q™ H3.1 assay measures total nucleosome concentration in plasma of humans and has been used to detect and identify cancer even at early stages. The objectives of this study were to determine if nucleosome levels could be used to distinguish between healthy dogs and dogs with various stages of lymphoma (LSA) using the Nu.Q™ H3.1 assay. A total of 126 dogs diagnosed with LSA and 134 healthy controls were recruited for this study. Plasma was collected from each dog and stored in K2-EDTA tubes. The LSA patient samples were recruited from TAMU or purchased from various biobanks. All control cases were recruited from TAMU. RESULTS: Dogs with LSA had an approximately 7-fold increase in their plasma nucleosome concentrations compared to controls (AUC 87.8%). Nucleosome concentrations increased with cancer stage and dogs with B cell lymphomas had significantly higher nucleosome concentrations than dogs with T cell lymphomas. CONCLUSIONS: The Nu.Q™ H3.1 assay was able to reliably detect elevated nucleosome concentrations in the plasma of dogs with LSA. Furthermore, it appears that nucleosomes are useful for differentiating cancer from healthy individuals in canines.

Effect of pH on the Quantification of Common Chemistry Analytes in Body Fluid Specimens Using the Roche cobas Analyzer for Clinical Diagnostic Testing.

OBJECTIVES: To determine the influence of pH on recovery of analytes in body fluids (BFs), investigate the mechanism of pH interference, measure the frequency of abnormal-pH BFs received, and compare pH measured by meter and paper. METHODS: We performed pH titration in residual BFs. A low-pH BF was spiked and neutralized to investigate pH interference. We measured analytes on a Roche cobas c501 analyzer (Roche Diagnostics) and calculated the percent recovery. Measurement of pH using a meter and paper was conducted on 122 BF samples received in the laboratory. RESULTS: Enzyme activity in BFs was unaffected when pH = 7.4-8.5 lactate dehydrogenase, pH = 7.3-10.2 amylase, pH = 6.0-9.9 lipase, and pH = 1.3-11.7 all other analytes. BFs had mean (range) pH of 8.0 (5.1-8.9), with a mean (range) difference (paper ‒ meter) of ‒0.4 (‒0.6 to 1.1). CONCLUSIONS: Irreversible loss of enzyme activity occurs in BFs at low pH. Few clinical BFs have pH < 7.0, but laboratories should incorporate pH measurement in BF workflows.

Cholinergic urticaria with anaphylaxis: hazardous duty of a deployed US marine.

Cholinergic urticaria (CU) is triggered by a rise in body temperature and can be complicated by bronchial hyperresponsiveness and anaphylaxis. It primarily affects young adults who actively engage in strenuous exercise, such as servicemen and servicewomen. If the patient reports a history of wheezing or difficulty breathing with urticaria, a water challenge test in a warm bath can be performed to confirm the presence of anaphylaxis. The test should be conducted in an environment in which the patient's airway can be secured and epinephrine can be administered if necessary. Nonsedating antihistamines commonly are used to treat CU, but few other treatments have been thoroughly evaluated for cases that are refractory to antihistamines. We present the case of a 27-year-old US Marine with CU and anaphylaxis confirmed by a water challenge test in a warm bath.

Survey to assess the role of pharmacy technicians and nonpharmacist staff in the operation of research pharmacies.

PURPOSE: Results of a survey assessing trends and innovations in the use of pharmacy technicians and other nonpharmacist staff in the research pharmacy setting are reported. METHODS: A Web-based survey was distributed to Internet communities of members of the American Society of Health-System Pharmacists and the University Health-System Consortium involved in investigational drug research and related practice areas. The survey collected data on the characteristics of institutions with pharmacy department staff dedicated to such research activities and the participation of pharmacists, technicians, and other staff in key areas of research pharmacy operations. RESULTS: Survey responses from 51 institutions were included in the data analysis. Overall, the reported distribution of assigned responsibility for most evaluated research pharmacy tasks reflected traditional divisions of pharmacist and technician duties, with technicians performing tasks subject to a pharmacist check or pharmacists completing tasks alone. However, some institutions reported allowing technicians to perform a number of key tasks without direct pharmacist supervision, primarily in the areas of inventory management and sponsor monitoring and auditing; almost half of the surveyed institutions reported technician involvement in teaching activities. In general, the reported use of "tech-check-tech" arrangements in research pharmacies was very limited. Some responding institutions reported the innovative use of nonpharmacist staff (e.g., paid interns, students and residents on rotation). CONCLUSION: Although the majority of research pharmacy tasks related to direct patient care are performed by or under the direct supervision of pharmacists, a variety of other essential tasks are typically assigned to pharmacy technicians and other nonpharmacist staff.

An anatomic study of the coracoid process as it relates to bone transfer procedures.

INTRODUCTION: The Latarjet and Bristow procedures address recurrent anterior shoulder instability in the context of a significant bony defect. However, the bony and soft tissue anatomy of the coracoid as they relate to coracoid transfer procedures has not yet been defined. The purpose of this study was to describe the soft tissue attachments of the coracoid as they relate to the bony anatomy and to define the average amount of bone available for use in coracoid transfer. METHODS: Ten paired fresh frozen shoulders from deceased donors were dissected, exposing the coracoid, lateral clavicle, and acromion, along with the coracoid soft tissue attachments. The bony dimensions of the coracoid and the locations and sizes of the soft tissue footprints of the coracoid were measured. RESULTS: The mean maximum length of the coracoid available for transfer (ie, distance from the coracoid tip to the anterior border of the coracoclavicular ligament) was 28.5 mm. The mean distance from the coracoid tip to the anterior pectoralis minor was 4.6 mm, to the posterior pectoralis minor was 17.7 mm, to the anterior coracoacromial ligament was 7.8 mm, and to the posterior coracoacromial ligament was 25.7 mm. CONCLUSION: Average dimensions of the bony coracoid and average locations and sizes of coracoid soft tissue footprints are provided. This anatomic description of the coracoid bony anatomy and its soft tissue insertions allows surgeons to correlate the location of their coracoid osteotomy with the soft tissue implications of the coracoid transfer as the native anatomy is manipulated in these nonanatomic procedures.

Lymphangioma of the finger in a child: a report of two cases.

Lymphangioma is a benign congenital tumor rarely experienced in the upper extremity. There are few reports of the outcomes of treatment of this tumor to guide treatment when it occurs in the finger. Treatment of this disease is challenging. This report presents two cases of lymphangioma in the fingers of children.

Randomized prospective study comparing tri-cortical iliac crest autograft to allograft in the lateral column lengthening component for operative correction of adult acquired flatfoot deformity.

BACKGROUND: Operative treatment of stage II posterior tibial tendon insufficiency (PTTI) is controversial. Many soft-tissue and bony procedures and various combinations of the two have been reported for treatment of stage II PTTI. Orthopaedists recognize the lateral column lengthening component of the procedure as a successful reconstructive technique. The use of cortical allograft for lateral column lengthening in the correction of pes planus in the pediatric patient population has been routine. In the adult population, however, tricortical iliac crest autograft has been the bone graft of choice. Harvest of this autograft can precipitate significant morbidity and cost. Therefore, we undertook this randomized controlled trial to compare graft incorporation and healing of allograft and autograft in the lateral column lengthening component of adult flatfoot reconstruction. METHODS: Lateral column lengthening was done as a component of operative correction for stage II PTTI in adult patients (older than 18 years) by two surgeons using similar procedures. The patients were randomized to either the allograft or autograft procedures. The primary endpoint was graft incorporation and healing as assessed by radiographs. RESULTS: The study included 33 randomized feet in 31 patients. We followed 18 feet in the allograft group and 15 in the autograft group to the point of union. There were 21 women and 10 men. There were no delayed unions, nonunions, or hardware failures. All patients in both groups achieved bony union by the 12-week followup evaluation. Two superficial foot infections were successfully treated with oral antibiotics. Two patients in the autograft group continued to have hip donor site pain at 3 months. CONCLUSIONS: This study suggests that union rates of allograft and autograft (iliac crest bone graft) are equal. The use of allograft in the lateral column lengthening component of operative correction of adult stage II PTTI appears to be a viable alternative to the use of iliac crest autograft and eliminates the morbidity and increased cost associated with autograft harvest.

Pseudoporphyria as a result of voriconazole use: a case report.

Voriconazole, a second-generation triazole, has recently been approved by the Food and Drug Administration (FDA) to treat invasive aspergillosis and refractory infections with Scedosporium apiospermum or Fusarium spp. The reported side-effects of voriconazole include visual changes, headaches, elevated hepatic enzymes, Steven-Johnson syndrome, toxic epidermal necrolysis, chelitis, photosensitivity, discoid lupus erythematosus and anaphylactoid infusion reactions. Pseudoporphyria was first described in association with nalidixic acid. It has the same clinical and histologic features as porphyria cutanea tarda (PCT) but is distinguished by normal porphyrin levels in the serum, urine and stool. We present the case of a patient who developed pseudoporphyria after receiving treatment with voriconazole.

Secondary erythermalgia in an HIV-1-positive patient.

This report describes an HIV-1-positive patient who presented to the dermatology clinic with a 2-year history of secondary erythermalgia. A review of salient clinical features, disease classification, associated diseases, pathogenesis, and treatment of this disorder is presented.