Diagnostic value of immunohistochemistry on formalin-fixed, paraffin-embedded skin biopsy specimens for bullous pemphigoid.

BACKGROUND: Direct immunofluorescence microscopy (DIF) studies constitute the gold standard for diagnosis of bullous pemphigoid (BP) but depend on the availability of specialized laboratories and often on an additional skin biopsy specimen. OBJECTIVES: To assess the value of immunohistochemical analyses (IHCA) in the diagnosis of BP using formalin-fixed, paraffin-embedded skin biopsy specimens as an alternative to DIF; and to study the correlation between the results of IHCA and the presence of histological subepidermal blister formation and of circulating autoantibodies by indirect immunofluorescence studies using split skin or by enzyme-linked immunosorbent assays. METHODS: We included all patients newly diagnosed with BP evaluated between 2008 and 2010. There were 51 consecutive skin biopsy specimens obtained from 38 patients with BP with positive DIF. RESULTS: By IHCA, deposits of immunoreactants were found in 45% of all tested cases. Deposits of C3d, IgG, IgM, IgE and IgA were found in 37%, 23%, 2%, 0% and 0% of cases, respectively. Deposits of C3d and/or IgG were found in 79% of the 24 cases with a blister and in 83% of the 12 cases with subepidermal blistering and positive immunoserological analyses, respectively. CONCLUSIONS: In contrast to previous studies, our findings in an unselected patient cohort indicate that IHCA are not sufficiently sensitive to replace DIF studies for confirming the diagnosis of BP. IHCA sensitivity significantly increases in the presence of histological blistering and/or of circulating autoantibodies. IHCA represents a potential rescue diagnostic technique only if specialized laboratories and/or a second biopsy specimen for DIF are unavailable.

A randomised controlled trial of the efficacy of supported employment.

OBJECTIVE: Although numerous randomised controlled trials indicated the superiority of supported employment (SE), we still have too little evidence that SE is more effective than traditional vocational rehabilitation programmes (TVR) in Western European countries with highly developed social security and welfare systems, sophisticated rehabilitation programmes and high thresholds to the open labour market. The aim of this study is to prove the efficacy of SE in Switzerland. METHOD: Following a 2-week intake assessment, 100 unemployed persons with stabilised severe mental illness (SMI) were randomly assigned to either the SE programme (n=46) or to the most viable locally available TVR (n=54). Follow-up lasted 24 months. RESULTS: After the first year, the rate of competitive employment reached a mean level of 48.2% in the SE group and of 18.5% in the TVR group. 58.7% of the SE group were ever competitively employed as opposed to 25.9% of the TVR group. In the second year, SE group participants were competitively employed for 24.5 weeks as compared with 10.2 in the TVR group. The groups showed no significant differences in the non-vocational outcome criteria. CONCLUSION: The SE programme in Switzerland also proved more effective than TVR and seems to be applicable to the socio-economic context of Western European countries.

Validity of CT classification on management of occult pneumothorax: a prospective study.

OBJECTIVE: In the setting of blunt trauma, abdominal CT, which routinely includes images of the lower thorax, frequently reveals pneumothoraces that have not been detected on routine supine chest radiographs. Proper management of these occult pneumothoraces remains controversial. The purpose of this study was to test the hypothesis that small (minuscule) to moderate (anterior) radiographically occult pneumothoraces can be safely managed without chest tube placement for patients in whom the need for positive pressure ventilation is not anticipated. SUBJECTS AND METHODS: We undertook a prospective study in which 44 occult pneumothoraces were classified into three groups, minuscule, anterior, or anterolateral, according to size and location on CT scans. Choice of initial management (tube thoracostomy versus close observation) was based in part on this classification system and in part on individual circumstances of a surgeon's decision. RESULTS: Of the 44 pneumothoraces found in 36 patients, 16 pneumothoraces were minuscule, 20 were anterior, and eight were anterolateral. Thirteen minuscule pneumothoraces and 11 anterior pneumothoraces initially managed with observation did not require subsequent tube thoracostomy. All eight patients with anterolateral pneumothoraces underwent tube thoracostomy. CONCLUSION: Most small (minuscule) occult pneumothoraces can successfully be managed with close observation. The risk that the pneumothorax will progress is slight. Moderate-sized (anterior) pneumothoraces may also be successfully managed without initial placement of a chest tube if the patient is not to undergo positive pressure ventilation.

Association of hiatal hernia and gastroesophageal reflux: correlation between presence and size of hiatal hernia and 24-hour pH monitoring of the esophagus.

OBJECTIVE: The relationship of hiatal hernia to gastroesophageal reflux disease remains controversial. Previous endoscopic and radiologic studies of hiatal hernia and reflux esophagitis have shown that hiatal hernia is a poor predictor of the presence of endoscopic esophagitis, especially for smaller hernias. Similar correlations with 24-hr pH monitoring have not been done. The purpose of this study was to determine if there is a correlation between the presence and size of hiatal hernias and gastroesophageal reflux using 24-hr pH monitoring as a measure of the degree of reflux. MATERIALS AND METHODS: We reviewed the barium esophagograms and the results of pH monitoring of the esophagus in 319 patients (161 women and 158 men; mean age, 51 years). The presence and size of hiatal hernia were determined from the radiographic examination; size was categorized as "minimal" or "larger" (> or = 2 cm axial length). An abnormal result of pH monitoring was defined as a pH less than 4 for 6% or more of the 24-hr observation time. RESULTS: Abnormal results of pH monitoring were found in 61 (31%) of 199 patients with hiatal hernia compared with 21 (18%) of 120 patients without hiatal hernia (p < .05). Abnormal findings of pH monitoring were present in 33 (35%) of 95 patients with a larger hiatal hernia versus 28 (27%) of 104 patients with a minimal hiatal hernia (p > .05); a significant difference (p < .05) was observed when patients without hiatal hernia were compared with those with a larger hiatal hernia. CONCLUSION: Most patients in this study had normal results of pH monitoring of the esophagus regardless of the presence or absence of hiatal hernia. However, patients with larger hiatal hernias were more likely to have abnormal findings on pH monitoring; hiatal hernias of minimal size were a poorer predictor of the presence of abnormal gastroesophageal reflux.

Ultrasonography: usefulness in localization of the Norplant contraceptive implant system.

Norplant is a levonorgestrel-containing contraceptive system that consists of six small capsules (2.4 x 34 mm), which are placed subdermally. Owing to the relative newness of this contraceptive modality, problems with removal of the Norplant implants are just beginning to be reported; these consist primarily of inability to locate and remove all six implant capsules upon discontinuation. Ultrasonographic images of 14 women with the Norplant system in place were obtained in the axial and longitudinal planes. On axial view the capsules consisted of discrete circular individual areas of high echogenicity with prominent posterior shadowing. Capsules scanned in a longitudinal plane demonstrated echogenicity of the superior and inferior capsular walls, giving a tubular appearance. It was possible to demonstrate the depth of capsule placement, spatial relation to surrounding capsules, and orientation in relation to the skin surface. Ultrasonography therefore may provide a useful, noninvasive method for localization of nonpalpable Norplant implants, thus facilitating removal.

Residency and fellowship training in radiology: survey of all United States programs.

RATIONALE AND OBJECTIVES: We surveyed radiology training programs to determine current requirements for a clinical internship year, recent changes in the clinical internship requirement, current number of residents, percentage of residents with preradiology clinical experience, number of current first-year fellows, and percentage of residents entering fellowships. METHODS: Survey forms were sent to all 208 U.S. diagnostic radiology programs and were followed up by telephone and facsimile transmission. RESULTS: Survey response rate was 100%. One hundred programs (48%) require an internship, whereas 108 programs (52%) do not. Of programs without a clinical internship requirement, 33 (31%) have eliminated this requirement within the last 5 years. The clinical year requirement varied greatly by region. A total of 3983 residents are training at present, and 29% did not complete a clinical internship. Currently, 650 fellows are in training. Approximately 68% of graduating residents are entering fellowships. CONCLUSIONS: Many residency programs have recently discontinued the clinical internship year requirement. Changes in Medicare reimbursement of resident salaries may be one factor promoting this change. During the past 4 years, the number of radiology residents training per year has increased. The percentage of residents entering radiology without an internship year has increased by 6% during the past 4 years. An increasing number of graduating residents are entering fellowships.

In vitro stability of an unconstrained total elbow prosthesis. Influence of axial loading and joint flexion angle.

Total elbow arthroplasty is often used to replace elbow joints that have been severely damaged by arthritis or trauma. A great disparity of designs exists, however, in currently available elbow prostheses. This study evaluated the intrinsic stability of one popular resurfacing implant, the Capitellocondylar (Johnson and Johnson Orthopaedics, Inc., New Brunswick, NJ) total elbow. The in vitro response of this unconstrained prosthesis to valgus-varus and supination-pronation loading was investigated using a materials testing machine. The influence of compressive loading and flexion angle on the intrinsic stability of the prosthesis was studied. The Capitellocondylar prosthesis was found to have little intrinsic constraint, relying on external forces for component stabilization. Dislocations were common at 111 N of compressive loading, while larger loads progressively stabilized the prosthesis. Joint flexion angle had little influence on the intrinsic constraint of the implant except to increase varus stability at lower flexion angles. The Capitellocondylar total elbow prosthesis, as designed by F. C. Ewald, behaves as an unconstrained implant. Adequate soft tissue supports, which are properly balanced to provide controlled loading, are essential to prevent instability of this arthroplasty.

Stereological and functional analysis of liver mitochondria from rats with secondary biliary cirrhosis: impaired mitochondrial metabolism and increased mitochondrial content per hepatocyte.

Mitochondrial and cytosolic functions were studied in vivo and in perfused livers from rats with secondary biliary cirrhosis induced by bile duct ligation for 5 wk and in sham-operated controls. The livers were stereologically analyzed, and mitochondrial and cytosolic functions were related to liver structure. Oxygen consumption by perfused livers expressed per stereologically determined mitochondrial volume was decreased by 49% in bile duct-ligated rats compared with control rats. Glucose production (expressed per mitochondrial volume) was reduced by more than 90% in bile duct ligation, whereas urea production was not affected. Lactate production, a cytosolic function, was increased fivefold in bile duct ligation, and both the lactate/pyruvate and the beta-hydroxybutyrate/aceto-acetate ratios were increased in the liver perfusate of bile duct-ligated rats. In comparison with control rats, the stereologically determined mitochondrial volume fraction per hepatocyte was increased by 28% in bile duct-ligated rats. Activities of mitochondrial enzymes expressed per area of mitochondrial membrane or per mitochondrial volume were either unchanged (ATPase, cytochrome c oxidase and glutamate dehydrogenase) or decreased (monoamine oxidase) in bile duct ligation. Thus in comparison with control rats, mitochondrial metabolism is impaired in perfused livers from bile duct-ligated rats; increased mitochondrial volume per hepatocyte may represent a strategy to maintain hepatic energy metabolism in rats with secondary biliary cirrhosis.

Blood-cadmium levels in normotensive and untreated hypertensive humans.

Administration of cadmium to laboratory animals causes hypertension. Necropsy specimens of the liver and kidneys of human patients who had had hypertension were previously reported as showing elevated cadmium concentrations. In the present study living normal humans were found to have a blood-cadmium level of 3-4 +/- 0-5 ng/ml, while a matched group of living untreated hypertensive humans had a blood-cadmium of 11-1 +/- 1-5 ng/ml. All of the normal subjects had blood-cadmium levels below 8-0 ng/ml, while 13 of the 17 hypertensive patients had blood-cadmium levels over 8-0 ng/ml.