Circulating miRNAs as non-invasive biomarkers to predict aggressive prostate cancer after radical prostatectomy.

BACKGROUND: Prostate cancer is an extremely heterogeneous disease. Despite being clinically similar, some tumours are more likely to recur after surgery compared to others. Distinguishing those that need adjuvant or salvage radiotherapy will improve patient outcomes. The goal of this study was to identify circulating microRNA that could independently predict prostate cancer patient risk stratification after radical prostatectomy. METHODS: Seventy-eight prostate cancer patients were recruited at the Odette Cancer Centre in Sunnybrook Health Sciences Centre. All patients had previously undergone radical prostatectomy. Blood samples were collected simultaneously for PSA testing and miRNA analysis using NanoString nCounter technology. Of the 78 samples, 75 had acceptable miRNA quantity and quality. Patients were stratified into high- and low-risk categories based on Gleason score, pathological T stage, surgical margin status, and diagnostic PSA: patients with Gleason ≥ 8; pT3a and positive margin; pT3b and any margin; or diagnostic PSA > 20 µg/mL were classified as high-risk (n = 44) and all other patients were classified as low-risk (n = 31). RESULTS: Using our patient dataset, we identified a four-miRNA signature (miR-17, miR-20a, miR-20b, miR-106a) that can distinguish high- and low-risk patients, in addition to their pathological tumour stage. High expression of these miRNAs is associated with shorter time to biochemical recurrence in the TCGA dataset. These miRNAs confer an aggressive phenotype upon overexpression in vitro. CONCLUSIONS: This proof-of-principle report highlights the potential of circulating miRNAs to independently predict risk stratification of prostate cancer patients after radical prostatectomy.

Stricturoplasty-a bowel-sparing option for long segment small bowel Crohn's disease.

Stricturoplasty is a surgical option for management of severe stricturing Crohn's disease of the small bowel. It avoids the need for small bowel resection and the associated metabolic complications. This report contrasts the indications and technical aspects of two different stricturoplasty techniques. Case 1 describes an extensive Michelassi (side-to-side isoperistaltic) stricturoplasty performed for a 100 cm segment of diseased small bowel in a 45-year-old patient. Case 2 describes the performance of 12 Heineke-Mikulicz stricturoplasties in a 23-year-old patient with multiple short fibrotic strictures.

Case of unrecognised food bone ingestion with dual site intestinal perforations.

Food bone perforation of the bowel is a relatively rare diagnosis. Its presentation is non-specific and often misdiagnosed. We present a case where a food bone perforation in both the large and small bowel was diagnosed on CT scan. A successful outcome was achieved with surgical treatment.

Salmonellosis as a differential diagnosis.

With a low incidence of Salmonella infection, salmonellosis is an uncommon problem in Scotland. It occurs in both immune-compromised and immune-competent patients. We present two cases of salmonellosis in immune-competent patients who had had a history of gastroenteritis. Diagnosis was delayed in one patient; however, both patients received appropriate treatment and made good recovery following their respective illnesses. Apart from acting as a reminder to consider salmonellosis as a differential diagnosis when managing patients with infective process, the cases also highlight the importance of concise history taking, and the importance of cultures-and-sensitivities in managing infectious cases.

Pharmacotherapy of diabetic foot osteomyelitis.

Diabetic foot osteomyelitis (DFO) complicates about 20% of diabetic foot infections (DFIs) and increases the risk of lower extremity amputation. This contentious infection is important to discuss, given the frequency with which diabetes mellitus and its complications occur and the devastating consequences of amputation. The diagnosis and management of DFO is complicated by the diverse presentations, delayed recognition, poorly defined diagnostic criteria, and lack of validated treatment regimens. Major issues of concern include when to undertake bone resection surgery and which antimicrobial agents to use, by what route, and for how long. Patients in whom DFO is suspected are best cared for by a multidisciplinary team, including infectious disease physicians or clinical microbiologists, orthopaedic, plastic and vascular surgeons, diabetologists, primary care physicians, podiatrists and specialist (especially tissue viability) nurses. Such multidisciplinary teams have repeatedly been shown to improve disease outcomes. We herein analyse the limited, and recently published, literature on the pharmacotherapy of DFO and put it into the broader context of management of DFI and osteomyelitis.

Ectopic pancreatic-type malignancy presenting in a Meckel's diverticulum: a case report and review of the literature.

BACKGROUND: Neoplasms arising from Meckel's diverticulae reported in the literature are mainly carcinoid tumours, gastrointestinal stromal tumours, and gastric or intestinal adenocarcinomas. CASE PRESENTATION: We describe a 50-year-old man who presented with rectal bleeding and anaemia, later found to be caused by a pancreatic adenocarcinoma arising from ectopic pancreatic tissue in a Meckel's diverticulum. The tumour was unfortunately highly aggressive, and the patient passed away within 5 months of symptom onset. CONCLUSION: We believe this is the first case of pancreatic adenocarcinoma in a Meckel's diverticulum to be reported in the literature. The diagnosis of Meckel's should be considered in patients with acute gastrointestinal complaints; when found incidentally at laparotomy, it should be carefully examined for any gross abnormality and resection should be considered.

Delay from symptom onset increases the conversion rate in laparoscopic cholecystectomy for acute cholecystitis.

BACKGROUND: Randomized trials suggest that laparoscopic cholecystectomy should be performed on first admission for acute cholecystitis. However, this is not widely practiced, possibly because of a perceived high conversion rate. We hypothesized that delay from onset of symptoms may increase the conversion rate. METHODS: We performed a retrospective case note review of patients undergoing emergency cholecystectomy in a single institution between January 2002 and December 2005. We analyzed whether delay from onset of symptoms was related to the conversion rate in patients with a histopathological diagnosis of acute cholecystitis. RESULTS: Of patients who underwent emergency laparoscopic cholecystectomy in our institution, 32.4% (197/608) had acute cholecystitis on histopathology. The conversion rate of those with acute cholecystitis was considerably higher (24.4%) than for those with other pathologies (6.3%). For patients with acute cholecystitis, the conversion rates increased with duration of symptoms: 9.5%, 16.1%, 38.9%, and 38.6% for delays of 0-2 days, 3-4 days, 5-6 days, and > 6 days from symptom onset, respectively (chi-square for trend = 14.27, DF = 1, p = 0.00016). Most conversions were due to the presence of acute inflammatory adhesions. CONCLUSIONS: Early intervention for acute cholecystitis (preferably within 2 days of onset of symptoms) is most likely to result in successful laparoscopic cholecystectomy; increasing delay is associated with conversion to open surgery.

Use of a clinical event monitor to prevent and detect medication errors.

Errors in health care facilities are common and often unrecognized. We have used our clinical event monitor to prevent and detect medication errors by scrutinizing electronic messages sent to it when any medication order is written in our facility. A growing collection of medication safety rules covering dose limit errors, laboratory monitoring, and other topics may be applied to each medication order message to provide an additional layer of protection beyond existing order checks, reminders, and alerts available within our computer-based record system. During a typical day the event monitor receives 4802 messages, of which 4719 pertain to medication orders. We have found the clinical event monitor to be a valuable tool for clinicians and quality management groups charged with improving medication safety.

The challenges of early discharge. Common newborn problems in the first few weeks of life.

In a thorough discussion of a published series on early discharge, Britton, Britton and Beebe note that methodological limitations, study design problems and heterogeneity sorely limit the conclusions that may be drawn from published studies about early discharge. These authors found that the 1980 recommendations of the AAP about early discharge are still appropriate. They recommend individualizing the discharge decision based on mother-infant health, as well as on psychosocial and socioeconomic factors. These authors apparently seek to temper the headlong rush to early discharge with an awareness of the wider societal context within which childbirth must be understood. Although the literature paints a positive picture of early home discharge, existing research still lacks the statistical power and scientific evidence to support this practice. There are many positive reasons for the early discharge of a mother-infant dyad, but they may have nothing to do with monetary savings. As with many things we do in our clinical practice, there is much room for the input of nurse practitioners, not only in providing care, but also in the shaping of health care policy.

Economic advantages of breast-feeding in an HMO: setting a pilot study.

We performed a pilot study on newborns randomly chosen from term singleton deliveries born to mothers in an HMO group between September 1992 and August 1993. Breast-fed infants were breast-feeding at 6 months (n = 41), whereas bottle-fed infants were bottle-fed from birth (n = 107), Medical care and costs for the first 12 months were retrospectively analyzed, including office visits, drug prescriptions, and hospitalizations. Both groups had similar numbers of office visits and pharmacy costs. Breast-fed infants had fewer inpatient admissions (0.13 vs. 0.20 discharges per 1,000 babies), and their average total medical costs were $200 less than those of bottle-fed infants. Extrapolating to the total number of deliveries during this period, an increase in breast-feeding from the current rate (17%) to the Healthy People 2000 goal (50%) could save up to $140,000 annually.

Community photoscreening of six to nine month old infants for amblyopiogenic risk factors.

Photorefraction (PR) is gaining acceptance as potentially the most effective objective screening technique for amblyopia risk factors in the preverbal child. This study determined the validity and feasibility of using the Auckland eccentric photorefractor in the detection of amblyopiogenic factors in six to nine month old infants in an established community-based vision screening program. Photographs were analysed and compared to results of clinical examination including cycloplegic refraction. Amblyopia risk factors were present in 7.2% of the infants clinically examined. Analysis only of readable photographs in children who were also clinically examined, gave sensitivities ranging from 71% to 79%, and specificities ranging from 81% to 86%. Inclusion in the analysis of photo-failures lowered sensitivity figures to 56% to 61%, and specificity to 63% to 70%. Photofailures were predominantly due to poor operator technique. Calculation of kappa scores indicated fair observer reliability. In conclusion, PR could provide a feasible and sufficiently reliable screening technique in the infant, but requires adequate training and auditing of screening personnel performance for optimum effectiveness.

ADA's focus: carving a niche in healthcare reform.

Healthcare reform was the pressing topic at the 76th Annual American Dietetic Association (ADA) meeting and exhibition held in Anaheim, California, in late October. Explained ADA President Susan Calvert Finn, Ph.D., R.D., about the program content, "This meeting, by addressing new evidence of the link between diet and disease, as well as the role of nutrition services as a preventive health strategy, is extremely relevant to today's healthcare reform discussions. The connection between diet and disease will be highlighted so policy makers working on the healthcare reform bill will understand the medical importance of our research."

Healthcare reform: second opinions. If you must insure part-timers. Part 1.

One of the central goals of the Clinton healthcare reform proposal is to provide insurance coverage for all Americans. This will be possible largely by requiring all employers to pay insurance for all their employees, including part-timers. The proposed plan requires all employers to offer full medical benefit packages to any employee who works more than 30 hours a week, and to cover employees who work 10 to 30 hours a week on a prorated basis. The following are foodservice operators' opinions on how this legislation, if passed, will affect their operations.

The flood ... foodservice directors in the Midwest test their endurance during one of the worst floods this century.

The summer of 1993 will be remembered as the time when record amounts of rain flooded the Mississippi and its tributary rivers, causing one of the decade's worst natural disasters. Accounts from the hard-hit Des Moines area exemplify what many foodservice operators and their staff did to help their customers and neighbors struck by the disaster.

Tuberculous meningitis in the elderly.

Six cases of tuberculous meningitis, all occurring in patients over the age of 65, are described. All patients presented with an acute illness, primarily with a confusional state. Headache was a symptom in only two patients and the cases were not confined to ethnic minority groups. The mortality was 50%.