Sarcoid-like reaction in malignant melanoma exacerbated with pembrolizumab therapy case report.

Sarcoid Like Reaction (SLR) is a localized non-caseating epithelioid granulomatous reaction seen secondary to certain immunotherapies and malignancies. Invasive melanoma, while being associated with onset of sarcoidosis, has not shown to directly induce SLR in the literature. We present the case of a 68-year-old male with malignant melanoma, who was found to have SLR prior to starting immunotherapy, which worsened while on pembrolizumab. This case highlights the challenge of distinguishing between drug-induced SLR and melanoma-induced SLR, and the implications in terms of management.

Overcoming barriers to secondary prevention in hip fracture patients: An electronic referral and management system for osteoporosis.

BACKGROUND: Numerous studies have shown that osteoporosis is both under diagnosed and under treated in patients with fragility fractures. We describe the use of an electronic automated referral system to enable multidisciplinary assessment and treatment of osteoporosis in patients admitted with fragility fracture of the hip. METHODS: An electronic referral system was developed from the hospital's trauma software database. This automatically refers patients admitted with fragility fracture of the hip to osteoporosis services. Data were collected prospectively from May to July 2007, when referral was dependent on members of the orthopaedic team and from August to October 2007, after the implementation of the electronic referral system. Primary outcomes were presence of a referral to osteoporosis services, organisation of bone density scan and follow up appointment in patients less than 75 years, and treatment with osteoporosis medication in patients greater than 75 years of age. RESULTS: There were a total of 90 patients, 47 in the non-intervention group and 43 in the intervention group. In the non-intervention group 8/47 patients (17%) were referred to osteoporosis services whilst 43/43 (100%) were referred in the intervention group. Of patients greater than 75 years, 10/32 (31.3%) were started on a bisphosphonate in the non-intervention group compared to 28/34 (82.4%) in the intervention group. Of patients less than 75 years, 1/15 (7%) in the non-intervention group had a DEXA scan booked and appropriate follow up arranged, compared to 7/9 (78%) in the intervention group. There was significant difference between both groups in all outcomes (p<0.0001). CONCLUSION: We present an electronic system which facilitates delivery of osteoporosis services and significantly improves management of osteoporosis in patients admitted with fragility fracture. We recommend the use of such programmes to facilitate multidisciplinary assessment and treatment of osteoporosis in orthopaedic trauma patients.

Development of electronic software for the management of trauma patients on the orthopaedic unit.

INTRODUCTION: Continuity of patient care is an essential prerequisite for the successful running of a trauma surgery service. This is becoming increasingly difficult because of the new working arrangements of junior doctors. Handover is now central to ensure continuity of care following shift change over. The purpose of this study was to compare the quality of information handed over using the traditional ad hoc method of a handover sheet versus a web-based electronic software programme. It was hoped that through improved quality of handover the new system would have a positive impact on clinical care, risk and time management. METHODS: Data was prospectively collected and analyzed using the SPSS 14 statistical package. The handover data of 350 patients using a paper-based system was compared to the data of 357 cases using the web-based system. Key data included basic demographic data, responsible surgeon, location of patient, injury site including site, whether fractures were open or closed, concomitant injuries and the treatment plan. A survey was conducted amongst health care providers to assess the impact of the new software. RESULTS: With the introduction of the electronic handover system, patients with missing demographic data reduced from 35.1% to 0.8% (p<0.0001) and missing patient location from 18.6% to 3.6% (p<0.0001). Missing consultant information and missing diagnosis dropped from 12.9% to 2.0% (p<0.0001) and from 11.7% to 0.8% (p<0.0001), respectively. The missing information regarding side and anatomical site of the injury was reduced from 31.4% to 0.8% (p<0.0001) and from 13.7% to 1.1% (p<0.0001), respectively. In 96.6% of paper ad hoc handovers it was not stated whether the injury was 'closed' or 'open', whereas in the electronic group this information was evident in all 357 patients (p<0.0001). A treatment plan was included only in 52.3% of paper handovers compared to 94.7% (p<0.0001) of electronic handovers. A survey revealed 96% of members of the trauma team felt an improvement of handover since the introduction of the software, and 94% of members were satisfied with the software. CONCLUSIONS: The findings of our study show that the use of web-based electronic software is effective in facilitating and improving the quality of information passed during handover. Structured software also aids in improving work flow amongst the trauma team. We argue that an improvement in the quality of handover is an improvement in clinical practice.

Patterns of gene-specific and total transcriptional activity during the Plasmodium falciparum intraerythrocytic developmental cycle.

The relationships among gene regulatory mechanisms in the malaria parasite Plasmodium falciparum throughout its asexual intraerythrocytic developmental cycle (IDC) remain poorly understood. To investigate the level and nature of transcriptional activity and its role in controlling gene expression during the IDC, we performed nuclear run-on on whole-transcriptome samples from time points throughout the IDC and found a peak in RNA polymerase II-dependent transcriptional activity related to both the number of nuclei per parasite and variable transcriptional activity per nucleus over time. These differential total transcriptional activity levels allowed the calculation of the absolute transcriptional activities of individual genes from gene-specific nuclear run-on hybridization data. For half of the genes analyzed, sense-strand transcriptional activity peaked at the same time point as total activity. The antisense strands of several genes were substantially transcribed. Comparison of the transcriptional activity of the sense strand of each gene to its steady-state RNA abundance across the time points assayed revealed both correlations and discrepancies, implying transcriptional and posttranscriptional regulation, respectively. Our results demonstrate that such comparisons can effectively indicate gene regulatory mechanisms in P. falciparum and suggest that genes with diverse transcriptional activity levels and patterns combine to produce total transcriptional activity levels tied to parasite development during the IDC.

Vitreous cryopreservation maintains the viscoelastic property of human vascular grafts.

Assess the effects of cryopreservation (cryo) and vitrification (vitro) on the viscoelastic properties of blood vessels. Human external Iliac artery vessels were harvested from liver organ donors (n=8). In each case the vessel was segmented into 3 equal parts, which were randomly placed in one of 3 categories: Fresh (stored in 4 degrees C UW for 6 h), Cryo (Placed in 10% Dulbecco's modified Eagle medium (DMEM) and slowly frozen to -196 degrees C), or Vitro (Placed in 40% DMEM and rapidly cooled to -196 degrees C). A pulsatile flow circuit was used to perfuse arterial segments at physiological pulse pressure and flow. Intraluminal pressure was measured using a Millar Mikro-tip catheter transducer, and vessel wall motion was determined with duplex ultrasonography coupled with a novel echo-locked vessel wall tracking system. Diametrical compliance (DC), Petersons elastic modulus (Ep), and stiffness index (beta) were then calculated for each of the three groups over 3 mean pressure ranging from 40 to 80 mmHg. The change in the viscous component of arterial wall (lag phase angle, theta) was calculated from hysteresis plots. No significant changes were observed in the elastic properties of fresh and vitrified vessels (P>0.05 for each of DC, Ep, and beta). Similarly, variation in the wall viscosity between fresh and vitrified vessels appeared to be nonsignificant (theta=12.60+/-4.04 vs. 17.60+/-1.14, respectively). In contrast, statistical analysis of results obtained for cryopreserved vessels to the fresh vessels showed significant reduction in elastic parameter values. There was also a significant increase in the phase angle theta of the cryopreserved vessels (theta=24.30+/-6.32; P<0.001) compared with fresh vessel. Results suggest that vitrification maintains both elastic and viscous components of the mechanical properties of vascular grafts, which is positively correlated with their functional patency. In contrast, damage caused during cryopreservation significantly affects the overall tensile strength and elasticity of the vessel (i.e., Ep and beta), the dynamic properties (DC), and appears to significantly affect the viscous component of the vessel wall (theta), which is likely reduce the patency of the graft for transplantation purposes.