Detection of driver mutations in BRAF can aid in diagnosis and early treatment of dedifferentiated metastatic melanoma.

Dedifferentiated metastatic melanoma can pose a significant diagnostic challenge, especially if the history of primary melanoma is not known or is remote. BRAF and NRAS mutations are common melanoma driver mutations that are usually sequenced to evaluate for treatment targets. We evaluated whether BRAF and NRAS mutational testing could contribute to the diagnosis of dedifferentiated metastatic melanoma when immunostains are negative. Seven patients with melanoma who had an additional diagnosis of poorly differentiated sarcoma with negative melanocytic immunostains were tested for BRAF and NRAS mutations. Three patients showed identical BRAF mutations in the melanoma and the poorly differentiated sarcoma and hence were re-classified as metastatic dedifferentiated melanoma. In these three patients, there was an average delay of 7 months before appropriate testing, workup and treatment for metastatic melanoma was initiated. Two of these patients currently have stable metastatic disease and show sustained therapeutic response to melanoma-specific treatment including BRAF inhibitors. BRAF mutational analysis should therefore be considered in cases of poorly differentiated sarcoma, especially if there is a known history of melanoma or with unusual localization of disease. The administration of melanoma-specific treatments in such dedifferentiated cases can show therapeutic response, highlighting the importance of rendering accurate diagnoses on such cases.

Hybrid total hip arthroplasty for multiple epiphyseal dysplasia.

BACKGROUND: Multiple Ephiphyseal Dysplasia (MED) is a rare autosomal dominant skeletal dysplasia that causes deformation of the epiphysis of the involved joints. The hips are invariably affected and symptoms due to incapacitating early onset degenerative hip disease often begin between the second and fourth decade of life. Literature regarding the clinical and radiographical outcomes after total hip arthroplasty in this young population are very scarce. Hypothesis in patients with multiple epiphyseal dysplasia and early onset degenerative hip disease, hybrid total hip arthroplasty is a safe and reliable procedure. PATIENTS AND METHODS: We followed 10 hybrid total hip arthroplasties in 6 patients with respect to the early and medium term complications. The average age at surgery was 32 years old (17 to 41). All stems were cemented polished straight tapered stems, all cups were porous coated uncemented cups. The mean duration of follow-up was 10.3 (7-14, SD2.8) years. Clinical outcomes were measured using the Charnley modification of the Merle d'Aubigné-Postel grading system and VAS-scores. RESULTS: No early complications and no revisions occurred and patients significantly improved for pain, function and mobility. The Charnley, Merle d'Aubigné and Postel hip scores significantly improved from 9.6 points pre-operatively (range: 8-11 points) to 17 points (range: 16-18 points) and the VAS-score significantly improved after surgery from respectively 7 at rest and 8.5 during activity preoperatively to 1 at rest and 1.5 during activity postoperatively. Radiographic evaluation showed no cases of radiolucency around the cemented femoral components. No migration or subsidence of the components was noted. With regard to the acetabular component, osteolysis was noted in 4 hips, but serial radiographs showed no progression or migration of the component and the patients were completely pain free. CONCLUSION: Hybrid total hip arthroplasty is a viable treatment option in multiple epiphyseal dysplasia patients, with excellent mid-term clinical and radiographical outcomes. LEVEL OF EVIDENCE: Level IV, retrospective study.

Combination of acid phosphatase positivity and rimmed vacuoles as useful markers in the diagnosis of adult-onset Pompe disease lacking specific clinical and pathological features.

INTRODUCTION: The clinical and histological presentations of the adult form of Pompe disease may be atypical. In such cases, identifying histological signs that point to the diagnosis would be crucial to avoid a delay in care. The aim of our study was to investigate the presence of rimmed vacuoles and acid phosphatase positivity in muscle biopsies of patients with late-onset Pompe disease. MATERIAL AND METHODS: We retrospectively studied muscle biopsies of all cases of the adult form of Pompe disease diagnosed at the University Hospital of Caen. Three of these four cases showed atypical clinical signs, and diagnosis was established tardily based on family history or systematic analysis of acid maltase activity. RESULTS: All biopsies showed some rimmed vacuoles. The acid phosphatase reaction showed positive inclusions and labelled vacuoles in biopsies of all patients. CONCLUSIONS: The presence of rimmed vacuoles and acid phosphatase positivity in muscle biopsy should suggest the diagnosis of the adult form of Pompe disease, this is decisive since effective therapy is available.

Immune-mediated necrotizing myopathy.

BACKGROUND: Immune-mediated necrotizing myopathy (IMNM) is a newly identified subgroup of idiopathic inflammatory myopathies. It is defined as a rare and severe disease, with symmetrical and proximal muscle weakness and a characteristic histology. An autoimmune aspect of IMNM is suggested by its association with autoantibodies directed against signal recognition particle (SRP) and 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) in the majority of patients. Statin use is strongly associated with anti-HMGCR-positive IMNM. The pathophysiological mechanisms of this disease are still poorly understood, and as a result, no therapeutic strategy has been validated to date. OBJECTIVE: The aim of this article is to provide an overview of the current knowledge about epidemiology, clinical features, and pathophysiology of IMNM, as well as treatment strategies. RESULTS AND CONCLUSION: IMNM is a subject of widespread interest, with quick and meaningful advances being made. In recent years, huge progress has been made in terms of diagnosis and patient management. However, the understanding of pathophysiological mechanisms and treatment strategies still requires further investigation.

Restless legs syndrome associated with exercise intolerance: Data from a retrospective observational clinical neuromuscular center study.

INTRODUCTION: Exercise intolerance (EI) is a frequent motive for seeking neuromuscular consultation and may be a sign of metabolic disease or, rarely, muscular dystrophy. The diagnosis is not established in many patients with a typical clinical presentation. Nevertheless, some of them complain of sleep disorders and more especially of restless legs syndrome (RLS). OBJECTIVE: The objective of our study was to estimate the frequency of RLS in patients presenting with EI. METHODS: Our retrospective observational study included all patients seen in the center from 2005 to 2011, who were subsequently investigated for EI in the neuromuscular department of the Caen University hospital. Data were collected on clinical RLS and muscular investigations (creatine kinase [CK], EMG, maximal exercise tests magnetic resonance imaging [MRI] and muscle biopsy obtained along with muscle exploration). RESULTS: Of the 318 patient records analyzed, 84 showed patients accurately complaining of EI. RLS was diagnosed in 25 of these patients (29.7%). This percentage was significantly higher (P<0.001) than found in the general population. Improvement was seen in 91.3% of the patients receiving specific treatment. CONCLUSION: RLS can sometimes present with pain, potentially worsening with exercise, inappropriately leading to a hypothesis of EI. Clinicians should thus explore the possible diagnosis of RLS when a muscular disease is not found in patients presenting with such symptoms.

Fluorescence in situ hybridization (FISH) as an aid for the diagnosis of graft-versus-host disease in two multivisceral organ transplant patients.

We herein describe 2 cases of adult multivisceral transplant patients who developed graft-versus-host disease manifesting predominantly as lichenoid skin papules and plaques. The diagnosis was supported by histopathology but ultimately corroborated by the utilization of the fluorescence in situ hybridization (FISH) technique using X and Y chromosome probes on unstained biopsy slides. In both cases, FISH revealed a high percentage of donor-derived cells as part of the inflammatory infiltrate in the skin biopsy. This report adds to the previous publications showing the utility of FISH in corroborating the diagnosis of graft-versus-host disease in transplant patients with unmatched sex donor.

Structural heterogeneity and pressure-relaxation in compressed borosilicate glasses by in situ small angle X-ray scattering.

We report on Brillouin and in situ small angle X-ray scattering (SAXS) analyses of topological heterogeneity in compressed sodium borosilicate glasses. SAXS intensity extrapolated to very low angular regimes, I(q = 0), is related to compressibility. From Brillouin scattering and analyses of the elastic properties of the glass, the Landau-Placzek ratio is determined and taken as a direct reflection of the amplitude of frozen-in density fluctuations. It is demonstrated that with increasing fictive pressure, topological (mid- and long-range) homogeneity of the glass increases significantly. Heating and cooling as well as isothermal scans were performed to follow the evolution of density fluctuations upon pressure recovery. For a sample with a fictive pressure p(f) of 470 MPa, complete recovery to p(f) = 0.1 MPa was observed to occur close to the glass transition temperature. The values of fictive and apparent fictive temperature, respectively, as obtained via the intersection method from plots of I(q = 0) vs. temperature were found in good agreement with previous calorimetric analyses. Isothermal scans suggest that mid- and long-range recovery govern macroscopic density relaxation.

Hip resurfacing arthroplasty: current status and future perspectives.

Hip resurfacing arthroplasty (HRA) is a concept of hip replacement that allows treating young active patients with a femoral bone preserving procedure. The proposed advantages of resuming an active lifestyle with increased frequency and duration of sports activities have been shown to be realistic. The 30-year cost-effectiveness in young male patients has been shown to be higher in resurfacing compared to conventional total hip replacement (THA). However, prognosticators of an inferior outcome have also been identified. The most important patient related factors are secondary osteoarthritis as the indication for surgery such as post-childhood hip disorders or AVN, female gender, smaller component sizes and older age (>65 years for males and >55 years for females). In addition, surgical technique (approach and cementing technique) and component design are also important determinant factors for the risk of failure. Moreover, concerns have surfaced with respect to high metal ion concentrations and metal ion hypersensitivities. In addition, the presumed ease of revising HRA has not reflected in improved or equal survivorship in comparison to a primary THA. This highlights the importance of identifying patient-, surgery-, and implant-related prognosticators for success or failure of HRA. Rather than vilifying the concept of hip resurfacing, detailed in depth analysis should be used to specify indications and improve implant design and surgical techniques.

Progression of toxic epidermal necrolysis after tanning bed exposure.

BACKGROUND: In addition to recreational tanning bed use, UV radiation exposures are sometimes sought to self-treat skin conditions. The ability of tanning bed radiation exposure to trigger toxic epidermal necrolysis has not been reported. OBSERVATIONS: A young woman attempted to treat a self-limiting drug hypersensitivity reaction via tanning bed radiation exposure, which resulted in a systemic toxic epidermal necrolysis-like reaction. Studies with cultured keratinocytes and an epithelial cell line reveal that UV-A radiation can synergize with other stimuli such as phorbol esters or interleukin 1 to produce large amounts of tumor necrosis factor, providing a potential mechanism for this exaggerated reaction. CONCLUSION: In addition to inducing photodamage and skin cancer, tanning bed radiation exposure can trigger a toxic epidermal necrolysis-like reaction, possibly via the exaggerated production of keratinocyte cytokines such as tumor necrosis factor.

An algorithm for the surgical treatment of periprosthetic fractures of the femur around a well-fixed femoral component.

The use of plate-and-cable constructs to treat periprosthetic fractures around a well-fixed femoral component in total hip replacements has been reported to have high rates of failure. Our aim was to evaluate the results of a surgical treatment algorithm to use these lateral constructs reliably in Vancouver type-B1 and type-C fractures. The joint was dislocated and the stability of the femoral component was meticulously evaluated in 45 type-B1 fractures. This led to the identification of nine (20%) unstable components. The fracture was considered to be suitable for single plate-and-cable fixation by a direct reduction technique if the integrity of the medial cortex could be restored. Union was achieved in 29 of 30 fractures (97%) at a mean of 6.4 months (3 to 30) in 29 type-B1 and five type-C fractures. Three patients developed an infection and one construct failed. Using this algorithm plate-and-cable constructs can be used safely, but indirect reduction with minimal soft-tissue damage could lead to shorter times to union and lower rates of complications.

[Transesophageal electrophysiological study in non sedated children younger than 11 years with a Wolff-Parkinson-White syndrome]. / Etude électrophysiologique par voie transoesophagienne chez des enfants de moins de 11 ans, non sédatés, ayant un syndrome de Wolff-Parkinson-White.

UNLABELLED: The electrophysiological evaluation of Wolff-Parkinson-White syndrome (WPW) is recommended in children aged more than five years to detect a risk of life-threatening arrhythmia. The purposes of the study were to determine the feasibility of transesophageal EPS in a child between six and 10 years in out-patient clinic. METHODS: Electrophysiological study (EPS) was indicated in 22 children, aged six to 10 years, with a manifest WPW either for no documented tachycardia (n=7), unexplained dizziness (n=2) or for a sportive authorization in 10 asymptomatic children. Two of the last children had a history of permanent tachycardia after the birth but were asymptomatic since the age of one year without drugs. RESULTS: EPS was performed in all children. The main difficulty lied in passing the catheter through the mouth. Programmed stimulation at cycle length of 380 ms was performed in all children to avoid high rates of pacing when the conduction through the accessory pathway (AP) and normal AV system was evaluated. Isoproterenol was not required in five children, because they developed a catecholaminergic sinus tachycardia. The AP refractory period was determined in all children between 200 and 270 ms. Orthodromic reentrant tachycardia (RT) was induced in 11 children, three asymptomatic children (27%), seven complaining of tachycardia and one with syncope. Rapid antidromic tachycardia was induced in this last child with dizziness. Atrial fibrillation was never induced. CONCLUSIONS: Esophageal EPS can be performed without sedation in a young child six to 10-year-old with a shortened protocol of stimulation, which was capable to clearly evaluate the WPW-related risks.

Large scale purification protocol for carnocin KZ 213 from Carnobacterium piscicola.

Large scale purification of a class IIa bacteriocin has been developed to recover pure carnocin KZ 213 produced by Carnobacterium piscicola 213. Most previous protocols reported in the literature for the purification of small peptides have used reversed phase chromatography but scale-up is difficult. The first step of this new protocol is hydrophobic interaction chromatography, the second and third steps are cation exchange chromatography. The protocol leads to a complete recovery of carnocin KZ 213 with 95% purity and to a concentration factor of 83. From 10 l culture supernatant, 5.8 mg carnocin KZ 213 have been produced with a specific activity of 8,500 UA g(-1). The protocol is easy to implement for larger volumes.

Retrograde popliteal approach to common femoral vein stenosis in an intravenous drug user with hostile groin: a case report.

Intravenous (IV) drug abuse is a common problem in our society. One complication of this practice is venous stenosis, endovascular management of which can be technically challenging especially in patients with a hostile groin. We describe an ipsilateral retrograde popliteal approach in a 26-year-old IV drug user presenting with swelling of the left leg secondary to common femoral vein stenosis. This approach represents the next best method following failed contralateral/cross-bifurcation access and is a safe, convenient alternative offering a "straight run" at the lesion.

Distortion correction for a double inversion-recovery sequence with an echo-planar imaging readout.

A double inversion-recovery (DIR) sequence with an echo-planar imaging (EPI) readout can be used to image selectively the grey matter of the brain, and this has previously been applied to improve the sensitivity of the statistical analysis of functional magnetic resonance imaging (fMRI) data. If a procedure were to be implemented to remove the distortions that are inherent in the EPI-based fMRI data set, then a similar technique would have to be applied to the DIR-EPI image also to ensure that it matches the geometry of the functional data. A comparison of candidate methodologies for correcting distortions in DIR-EPI images, based on the reversed-gradient method, is presented. A corrected image could be calculated from two DIR-EPI images acquired with k-space traversal in opposite directions, but that method was not able to cope with the large regions of low signal intensity corresponding to the nulled white matter. It was found that the optimal procedure to apply the reversed-gradient method to DIR-EPI images was to acquire two additional EPI images (without the two inversion pulses) with opposite-direction k-space traversal; the distortion-correction information calculated from those EPI images was then applied to the DIR-EPI data.

Ramularia collo-cygni: the biology of an emerging pathogen of barley.

Ramularia collo-cygni is now recognized as an important pathogen of barley in Northern Europe and New Zealand. It induces necrotic spotting and premature leaf senescence, leading to loss of green leaf area in crops, and can result in substantial yield losses. The fungus produces a number of anthraquinone toxins called rubellins, which act as host nonspecific toxins with photodynamic activity. These toxins induce lipid peroxidation and are possibly the cause of the chlorosis and necrosis observed in leaves infected with R. collo-cygni. The fact that the fungus can remain latent in barley plants until flowering, coupled with its very slow growth in vitro, makes it difficult to detect in crops. As a result, the epidemiology of this pathogen remains poorly understood. However, the recent development of rapid and reliable PCR methods for specific detection of R. collo-cygni offers the prospect of increased understanding of its epidemiology and improved disease control.

Impact of incidental magnetization transfer effects on inversion-recovery sequences that use a fast spin-echo readout.

Multislice MR images obtained using a fast spin-echo (FSE) readout are strongly affected by magnetization transfer (MT) effects, which will cause a decrease in the observed longitudinal relaxation times for tissues with a large bound water component. This is pertinent for FSE-based inversion-recovery (IR) sequences, as it would be expected to cause a change in the required inversion times. Furthermore, the effect will be greater as the number of slices that are acquired within the repetition time (TR) is increased. A pseudo-3D IR-FSE sequence was used to obtain images of a phantom consisting of thermally crosslinked bovine serum albumin. It was found that increasing the number of slabs acquired per TR period led to a decrease in the inversion time that maximally suppressed the signal from the MT phantom; this was not the case for water. This has important consequences for any IR imaging sequence that uses an FSE readout.

Production, formulation and antagonistic activity of the biocontrol like-yeast Aureobasidium pullulans against Penicillium expansum.

Aureobasidium pullulans (de Bary) Arnaud (Ach 1-1) was grown in a glucose fed-batch fermentor to 106 g dry wt l(-1) in 48 h. The cells were dried in a fluidized bed dryer with a final viability of 62%. After 7 months at 4 degrees C, the viability was 28% of the initial value (= 2.3 x 10(10 )c.f.u. g(-1) dry matter). A protection level of 89% was achieved with the biomass preparation at 1 x 10(8 )c.f.u. ml(-1) after 28 and 7 days for apples stored respectively at 5 and 25 degrees C against Penicillium expansum. Our process is suitable to produce large quantities of the strain Ach 1-1 as biological control agent for apple preservation.

Recovery of nuclease produced by Lactococcus lactis using expanded bed ion exchange chromatography.

Expanded bed-ionic exchange chromatography (EB-IEC) was used for the recovery and purification of recombinant staphylococcal nuclease secreted by Lactococcus lactis. At the end of the fermentation process, the nuclease activity reached 39 U ml(-1). The EB-IEC performances were firstly evaluated with clarified culture broth. The isocratic elution with 0.5 M NaCl led to approximately 80% of nuclease recovery. Proceeding with 3-fold bed expansion resulted in a reduction of the resin capacity by a factor of 32% compared to the process in a packed bed configuration. Simplification of the early purification steps was reached by loading immediately the unclarified culture broth previously diluted to reduce conductivity. Presence of Cells did not affect the chromatography performances resulting in 55-fold purification with the same yield.

A semi-active milling procedure in view of preparing implantation beds in robot-assisted orthopaedic surgery.

Bone cutting in total joint reconstructions requires a high accuracy to obtain a well-functioning and long-lasting prosthesis. Hence robot assistance can be useful to increase the precision of the surgical actions. A drawback of current robot systems is that they autonomously machine the bone, in that way ignoring the surgeon's experience and introducing a safety risk. This paper presents a semi-active milling procedure to overcome that drawback. In this procedure the surgeon controls robot motion by exerting forces on a force-controlled lever that is attached to the robot end effector. Meanwhile the robot constrains tool motion to the planned motion and generates a tool feed determined by the feed force that the surgeon executes. As a case study the presented milling procedure has been implemented on a laboratory set-up for robot-assisted preparation of the acetabulum in total hip arthroplasty. Two machining methods have been considered. In the first method the surgeon determines both milling trajectory and feed by the forces that he/she executes on the force-controlled lever. In the second method the cavity is machined contour by contour, and the surgeon only provides the feed. Machining experiments have shown that the first method results in large surface irregularities and is not useful. The second method, however, results in accurate cavity preparation and has therefore potential to be implemented in future robot systems.

Evolution of the longitudinal magnetization for pulse sequences using a fast spin-echo readout: application to fluid-attenuated inversion-recovery and double inversion-recovery sequences.

The fast spin-echo (FSE) sequence is frequently used as a fast data-readout technique in conjunction with other pulse sequence elements, such as in fluid-attenuated inversion-recovery (FLAIR) and double inversion-recovery (DIR) sequences. In order to implement those pulse sequences, an understanding is required of how the longitudinal magnetization evolves during the FSE part of the sequence. This evolution has been addressed to a certain extent by previous publications, but the DIR literature in particular appears to be replete with approximations to the exact expression for the longitudinal magnetization, and several papers contain errors. Equations are therefore presented here for the evolution of the longitudinal magnetization for a FSE readout. These are then applied to calculate the magnetization available immediately prior to the 90 degrees imaging pulse for the FLAIR-FSE and DIR-FSE pulse sequences.