Predictors of glycemic control after decline of insulin therapy by patients with type 2 diabetes.

AIM: Decline of insulin therapy by patients is common but poorly investigated. We conducted this study to determine patient and treatment characteristics predictive of glycemic control after declining clinician recommendation to initiate insulin therapy. METHODS: We retrospectively studied adults with type 2 diabetes mellitus treated at two academic medical centers between 1993 and 2014 who declined their healthcare provider recommendation to initiate insulin. RESULTS: In a multivariable analysis of 300 study patients adjusted for demographics, comorbidities and clustering within providers, higher baseline HbA1c (OR 1.85; 95% CI 1.40 to 2.39; p < 0.001) and lifestyle changes (OR 8.39; 95% CI 3.26 to 21.55; p < 0.001) were associated with greater, while non-adherence to diabetes medications (OR 0.014; 95% CI 0.0025 to 0.085; p < 0.001) and discontinuation of a non-insulin diabetes medication (OR 0.30; 95% CI 0.11 to 0.80; p = 0.016) were associated with lower probability of HbA1c decrease after declining insulin therapy. CONCLUSION: We identified patient characteristics and treatment strategies associated with success and failure of glycemic control after insulin therapy decline by the patient. This information can assist in selection of optimal therapeutic approaches for these individuals.

Primary breast lymphoma with sudden death.

Primary breast lymphoma is a rare form of extranodal lymphoma. B cells constitute the most common type involving the breast. T cells represents only 3%. Even though lymphomas have a high predilection to metastasize to the heart, there are no specific clinical or radiological findings, and most of the cases are diagnosed at autopsy. We discuss the case of a 49-year-old woman with primary breast lymphoma who presented with sudden death. Autopsy revealed a primary T-cell lymphoma of the breast with tumoral infiltration of the atrioventricular node and transmural myocardial permeation with focal necrosis.

Postmortem findings in eight cases of influenza A/H1N1.

In March and early April 2009, cases of a new swine-origin influenza A (H1N1) virus were diagnosed in Mexico and the United States. Influenza virus presents as a respiratory infection with high morbidity and mortality. We describe the postmortem findings of eight confirmed cases of influenza A/H1N1 in a medical examiner setting. The eight cases falling under the jurisdiction of the Harris County Medical Examiner (Houston, TX, USA) with confirmed influenza A/H1N1 infection between June and September 2009 were included in this study. All cases were males between 6 months and 54 years of age. All adult patients had a body mass index from 31 to 49.8 kg/m(2). Five cases had comorbid conditions including one case with sleep apnea and mental retardation, three cases with chronic ethanolism, and one case with thymoma, sarcoidosis, and myasthenia gravis. The remaining three cases had no pre-existing medical conditions. All patients presented with severe flu-like symptoms; yet, only five were febrile. Rapid influenza diagnostic tests were performed in three cases by primary-care physicians, two of which were negative. None of the patients received antiviral medication. The average disease duration time was 8.2 days (3-14 days). A wide range of histopathological findings including tracheitis, necrotizing bronchiolitis, alveolitis, intra-alveolar hemorrhage, and hyaline membranes, both in a focal and in a diffuse distribution, were identified. Influenza A/H1N1 viral infection presents with a wide range of histological findings in a diffuse or focal distribution; most consistently with tracheitis, necrotizing bronchiolitis, and alveolitis with extensive alveolar hemorrhage. These histopathological findings at autopsy along with a clinical history of flu-like symptoms should raise suspicion for influenza A/H1N1 infection, and postmortem analysis by the reverse transcription-polymerase chain reaction (RT-PCR) is recommended for an accurate diagnosis.

Actinomyces sp. en muestras de placa bacteriana de personas adultas jóvenes y adultas mayores / Actinomyces sp. in samples of bacterial plaque in young adults and the elderly

Introducción y Objetivo: Los Actinomyces se asocian a diversas patologías bucodentales; su presencia varía con la higiene oral, el flujo salival y los movimientos de los músculos periorales; aspectos potencialmente comprometidos en ancianos. El objetivo de este trabajo fue identificar la presencia los Actinomyces sp en la placa dentobacteriana y determinar la asociación de su presenciacon la edad. Materiales y Métodos: Se realizó un estudio observacional analítico de corte transversal. La muestra la integraron 100 personas que cumplieron con los criterios establecidos. Se recolectaron variables sociodemográficas, condición sistémica; presencia y cantidad de Actinomyces sp y Actinomyces viscosus; a nivel oral: Condición periodontal (IPCNT), caries radicular (RCI) e higiene oral (ICP). En el análisis univariado se calcularon las medidas de resumen según la naturaleza de las variables; el bivariado relacionó presencia de Actinomyces sp con cada variable en estudio, mediante test de Chi cuadrado o test exacto de Fisher para variables cualitativas y prueba t de student y Ude Mann Whitney para las cuantitativas. Resultados: En el 13.9% (14) de los pacientes se aisló Actinomyces sp, y la especie Actinomyces viscosus en el 4% (4) de los sujetos. Los Actinomyces spse observaron con mayor frecuencia en personas comprometidas sistémicamente (92.9%) y entrelos sujetos con una higiene dental regular (78.6%). Conclusión: La presencia de Actinomyces enla población evaluada no parece asociarse con la edad; sin embargo, los sujetos en los que se aislóeste microorganismo podrían tener mayor riesgo de desarrollar abscesos cervico-faciales o patologíaa nivel respiratorio o gastrointestinal.

Introduction and Objective: Actinomyces are associated to several oral diseases; their levels vary with oral hygiene, salivary flow and movements of perioral muscles; these tissues could be affected in the elderly. The objective of this study was to identify the presence of Actinomyces sp in bacterial oral plaque and to determine its association with age. Materials and Methods: An analytical observational study was carried out with a sample consistent of one-hundred individuals who complied with established criteria. Social-demographics, systemic condition, oral presence and amount of Actinomyces sp and Actinomyces viscosus, periodontal disease (IPCNT), root decay (RCI) and oral hygiene (ICP) variables were evaluated. In the univariate analysis, calculation of summary measures according to the nature of the variables was done. Actinomyces sp presence was related to each variable in study, by Chi square or Fisher Exact test for qualitative variables, and t-test and U Mann Whitney test for quantitative variables. Results: In 13.9% (14) of patients, Actinomyces sp was isolated, and Actinomyces viscosus in 4% (4) of subjects. Actinomyces sp were observed most frequently in individuals with systemic compromise (92.9%), and in subjects with deficient dental hygiene (78.6%). Conclusion: Presence of Actinomyces in the evaluated population does not seem to be associated with age. Nevertheless, subjects in which the microorganism was isolated could be at a major risk of developing cervico-facial abscesses or remote pathologies at a respiratory or gastrointestinal level.

Cytologic features of subependymal giant cell astrocytom: a review of 7 cases.

OBJECTIVE: To describe the cytologic features of subependymal giant cell astrocytoma (SEGA) on smears and analyze cytomorphologic parameters that may help in reaching the diagnosis of SEGA. STUDY DESIGN: Cytologic smears of 7 cases of SEGA were reviewed and graded semi-quantitatively for 11 cytologic features: clustering, cytoplasmic fibrillary processes (fibrillarity), cellularity, small prominent nudcleoli, binucleation or multinucleation, "strap cells", spindle-shaped cells, mitoses, intranuclear inclusions, nuclear atypia and perivascular palisading/pseudorosettes. Corresponding histologic sections were also reviewed. RESULTS: The study included 5 male and 2 female patients with an average age of 8.3 years (range, 3-16) at surgery. Cytologic examination revealed loosely cohesive clusters of large cells possessing round to oval nuclei with no or minimal atypia; fine, evenly distributed chromatin; and abundant eosinophilic cytoplasm enmeshed in abundant thin, hairlike processes. Predominant features included hypercellularity, cell clustering, and fibrillarity. Binucleation or multinucleation; small, prominent nucleoli; and strap cells were often seen. Although common in histologic sections, perivascular palisading/pseudorosettes and spindled astrocytic cells were rarely noted on smears. CONCLUSION: The cytologic features of SEGA are highly characteristic and thus are of great use in supporting a diagnosis of SEGA and in excluding mimics, primarily gemistocytic astrocytoma and ependymoma.

Ovarian cancers overexpress the antimicrobial protein hCAP-18 and its derivative LL-37 increases ovarian cancer cell proliferation and invasion.

The role of the pro-inflammatory peptide, LL-37, and its pro-form, human cationic antimicrobial protein 18 (hCAP-18), in cancer development and progression is poorly understood. In damaged and inflamed tissue, LL-37 functions as a chemoattractant, mitogen and pro-angiogenic factor suggesting that the peptide may potentiate tumor progression. The aim of this study was to characterize the distribution of hCAP-18/LL-37 in normal and cancerous ovarian tissue and to examine the effects of LL-37 on ovarian cancer cells. Expression of hCAP-18/LL-37 was localized to immune and granulosa cells of normal ovarian tissue. By contrast, ovarian tumors displayed significantly higher levels of hCAP-18/LL-37 where expression was observed in tumor and stromal cells. Protein expression was statistically compared to the degree of immune cell infiltration and microvessel density in epithelial-derived ovarian tumors and a significant correlation was observed for both. It was demonstrated that ovarian tumor tissue lysates and ovarian cancer cell lines express hCAP-18/LL-37. Treatment of ovarian cancer cell lines with recombinant LL-37 stimulated proliferation, chemotaxis, invasion and matrix metalloproteinase expression. These data demonstrate for the first time that hCAP-18/LL-37 is significantly overexpressed in ovarian tumors and suggest LL-37 may contribute to ovarian tumorigenesis through direct stimulation of tumor cells, initiation of angiogenesis and recruitment of immune cells. These data provide further evidence of the existing relationship between pro-inflammatory molecules and ovarian cancer progression.

Postoperative cranial fasciitis. Report of two cases and review of the literature.

The authors report two cases of cranial fasciitis occurring at prior craniotomy sites. They review the presentation and pathological features associated with cranial fasciitis and describe two unusual cases and their treatment. The first case is that of a 16-year-old girl who underwent suboccipital craniectomy for resection of medulloblastoma and 14 months later was found to have a 4-cm nontender mass at the incision site, with evidence of skull erosion on neuroimaging. Resection of the mass revealed cranial fasciitis. The patient later developed two more lesions in the cranial region, as well as lesions on the chest wall and abdomen consistent with nodular fasciitis; all of the lesions were resected. The second case is that of a 61-year-old man who underwent suboccipital craniectomy for hypertensive hemorrhage and 2 years later was found to have an enlarging mass at the incision site, causing compression of the cerebellum. The mass was resected and found to be consistent with cranial fasciitis. Cranial fasciitis is a rare, benign lesion of the cranial region. It is histologically identical to nodular fasciitis, a self-limiting fibroblastic process of the superficial and deep fascia. Although most cases of cranial fasciitis are reported to occur spontaneously in the very young, the two cases reported here involved older patients and lesions that developed at prior craniotomy sites in a delayed fashion, a phenomenon not previously reported. Interestingly, one patient exhibited lesions in other areas as well.

Erythropoietin, a hypoxia-regulated factor, elicits a pro-angiogenic program in human mesenchymal stem cells.

OBJECTIVE: The ability of erythropoietin (EPO) to elicit a pro-angiogenic effect on human mesenchymal stem cells (hMSC) was tested. hMSC are currently under study as therapeutic delivery agents that target tumor vessels. Hypoxia favors the differentiation of hMSC towards a pro-angiogenic program. However, the classical angiogenic factors, vascular endothelial growth factor and basic fibroblast growth factor, are not fully capable of restoring this effect. The hypoxia-regulated factor, EPO, induces angiogenesis in endothelial cells. Here, EPO's pro-angiogenic effect on hMSC was analyzed. METHODS: hMSC were tested for EPO receptor expression by western blot, immunofluorescence, and flow cytometry assays. Downstream receptor signaling components JAK and STAT were measured by standard assays. Pro-angiogenesis effects mediated by EPO treatment of hMSC were measured by proliferation, cytokine, or pro-angiogenesis factor secretion, metalloprotease activation, migration, invasion, wound healing, and tubule formation assays. RESULTS: hMSC express the cognate EPO receptor and are capable of promoting angiogenesis following EPO treatment in all the angiogenesis assays tested. EPO-treated hMSC proliferate and secrete pro-angiogenesis factors more readily than untreated hMSC. EPO leads to increased hMSC chemotaxis, migration, and activation of matrix metalloprotease-2. This treatment causes greater recruitment of vessels as measured in an in vivo angiogenesis assay. CONCLUSION: EPO is capable of eliciting a pro-angiogenesis program in hMSC that instigates secretion of angiogenic factors and the subsequent recruitment of endothelium. This study defines a novel mechanism for tumor cell recruitment of blood vessels that is important to consider in the design of stem cell-based therapies.

Medulloepithelioma: Two unusual locations.

Reported herein are two cases of medulloepithelioma (ME) occurring in very unusual locations. Case 1 involved a 44-year-old man who presented with leg pain and urinary incontinence. Spine magnetic resonance imaging (MRI) showed an enhancing epidural and intradural lumbosacral mass. He underwent L3-S2 laminectomy with partial tumor resection. Approximately 2 months following surgery, he developed leptomeningeal spread of the tumor, and died 2 months later. Case 2 involved a 22-month-old girl who presented with painless left proptosis. MRI demonstrated diffuse, fusiform, and contrast-enhancing enlargement of the left optic nerve. Following biopsy, she was treated with chemotherapy. Histologically, the tumors in both cases consisted of primitive pseudostratified neuroepithelial cells, arranged in papillary, tubular, or trabecular configurations. A PAS-stained external limiting membrane (ELM) of the neuroepithelia was present. In case 1 there were scattered cartilaginous nodules within the tumor, in keeping with the diagnosis of a teratoid ME. Immunohistochemically, the tumor cells were positive for synaptophysin, nestin, microtubule-associated protein-2, CD56, CD10, glial fibrillary acidic protein (focal), and S-100 protein (focal). The main differential diagnoses include an immature teratoma and an optic nerve glioma in cases 1 and 2, respectively. Histological demonstration of the ELM by PAS stain is a simple but useful technique.

Epidemiología y patología de la leucemia/linfoma de células T del adulto en Cali y el suroccidente colombiano / Epidemiology and pathology of the adult T-cell Lymphoma in Cali and Colombian Southwest

Introducción: Este estudio se realizó con el fin de obtener un acercamiento con la epidemiología geográfica de las neoplasias linfoide en Cali y el suroccidente colombiano, con atención especial en la leucemia linfoma de células T del adulto. Materiales y métodos: Se utilizó información del Registro Poblacional de Cáncer de Cali, de las personas con linfoma no Hodgkin y leucemia linfoides entre 1987 y 1996 procedentes de la costa pacífica. Se obtuvo material incluido en parafina de los pacientes con linfoma no Hodgkin del departamento de Patología, del Hospital Universitario del Valle, con el próposito de investigar secuencias provirales para HTLV-I usando técnicas biomoleculares. Además, se obtuvieron muestras de sangre de voluntarios nativos de Tumaco que representan niveles socioecónomicos bajo, medio y alto, y se analizaron para anticuerpos contra HTLV-I/II con una prueba de imunoabsorción ligada con enzimas (ELISA, Abbott®) y confirmados por Western blot. Resultados: La tasa de incidencia global para linfoma no Hodgkin es al menos dos veces mayor para leucemias en ambos sexos y no ha mostrado cambios notables, mientras la leucemia linfoide ha aumentado en ambos sexos, de manera más notoria en mujeres. La tasa de incidencia para linfoma no Hodgkin aumenta con la edad en ambos sexos. Cinco de 75 casos de linfoma fueron positivos para secuencia de HTLV-I por PCR, en los especímenes tisulares y ninguno de los pacientes tenía prueba serológica para HTLV; 18 (5.1/100) de las 356 personas fueron positivas serológicamente para anticuerpos contra el HTLV-I muestreadas en Tumaco.Conclusiones: Varios casos de ATL pueden pasar desapercibidos en pacientes con linfoma no Hodgkin en quienes la asociación no había sido sospechada. La seroprevalencia de HTLV-I en Tumaco es más alta en mujeres. Merece la pena continuar investigando la intercurrencia con infecciones u otros factores medioambientales que facilitarían una progresión rápida de portadores ATL en habitantes del área

De novo paracentric inversion (X)(q26q28) with features mimicking Prader-Willi syndrome.

Different genetic and non-genetic disorders, including several chromosomal abnormalities, may mimic Prader-Willi syndrome (PWS). We report on an 11-year-old girl with features reminiscent of PWS due to an unreported de novo paracentric inversion Xq26q28. Microdeletion 15q11-q13 and maternal uniparental disomy 15 were ruled out. The importance of chromosomal studies in addition to molecular analysis on patients with features suggestive of PWS is stressed.

Epstein-Barr virus-associated gastric carcinoma in Cali, Colombia.

To estimate the incidence of Epstein-Barr virus-associated gastric carcinoma (EBV-GC) in Colombia and to clarify its clinicopathological features, we examined 178 consecutive gastric carcinoma cases, diagnosed during the period from 1996 to 1998, at Hospital Universitario del Valle in Cali, Colombia. The mean age of the cases was 60 years in males and 58 years in females. Using in situ hybridization assay of EBV-encoded small RNA-1 in paraffin-embedded tissue samples, we identified 23 cases of EBV-GC (13%). After excluding remnant carcinoma, which was found to be EBV-negative in this series, there were 19 (18%) male and 4 (6%) female EBV-GC cases, and the male predominance was statistically significant (P=0.004). The proportion of EBV-GCs decreased with age (P for trend = 0.022). Using sex- and age-specific proportions of EBV-GCs estimated by logistic models and gastric cancer incidence in Cali, which was obtained from tumor registry during the period 1987-1991, we estimated sex- and age-specific incidence of EBV-GCs. The incidence of EBV-GCs (per 100,000 person-years) was 4.1 and 1.4 among men and women, respectively, after age adjustment using the standard world population. Pathological features of EBV-GCs were also examined. EBV-GCs accounted for 33% (8/24) of carcinomas located in the stomach cardia, 14% (6/43) of carcinomas in the middle-part of the stomach, and 7% (6/81) of carcinomas in the antrum. The difference by tumor location was statistically significant (P=0.009). Histology-specific analysis using Lauren classification revealed that the proportion of EBV-GCs was not different in intestinal- and diffuse-type carcinomas (13% in both types). When the classification scheme of the Japanese Research Society for Gastric Cancer was used, EBV-GCs were identified more frequently in moderately differentiated tubular adenocarcinoma, and solid poorly differentiated adenocarcinoma when compared to other histological types. No lymphoepitelioma-like histology was found in the present series. The frequency of EBV-GC was slightly higher in advanced tumors, which involved serosa. Further analysis of clinico-pathological features of EBV-GC using a larger number of cases would give invaluable insights into its etiology.

EXIT procedure: a case report.

The EXIT (Ex-Utero Intrapartum Treatment) procedure is an extremely valuable tool in providing time to secure the airway in infants with large fetal neck masses and abnormalities of the upper airway which impede resuscitation. The fetus is partially delivered while maintaining utero-placental-fetal circulation. We report the use of this technique in a case of huge cystic hygromas of the neck and chest due to a nuchal bleb-lethal dysplasia. Although severe pulmonary hypoplasia precluded an optimal outcome, this report shows that this procedure is technically feasible. We believe this to be the first case performed and reported in Louisiana.