Graduate students' perspectives on the role of faculty advisors in helping students with mental health problems.

Objective: Graduate students are more likely to experience mental illness than their peers in the general population. One potential source of support for personal issues and/or mental illness is a graduate student's faculty advisor. Although the relationship between faculty advisors and graduate students can positively influence the success and overall well-being of graduate students, graduate students may be reluctant to disclose mental health issues to their advisors. This study explores graduate students' perspectives on factors that influence their decision to disclose, or not to disclose, personal mental health information to their faculty advisor. Participants: The participants for this study were 28 graduate students from three universities in the southern United States. Methods: Four semi-structured focus groups were conducted over Zoom. Results: Thematic analysis of a series of focus groups with graduate students identified several consistent themes related to this disclosure decision-making process. Conclusions: Results have implications for mental health literacy and interpersonal communication interventions for those charged with mentoring graduate students.

Baseline serum levels of IgA anti-cyclic citrullinated protein antibodies in early rheumatoid arthritis predict radiographic progression after 11 years of treatment: a secondary analysis of the CIMESTRA study.

OBJECTIVE: Smoking and periodontitis are risk factors for developing rheumatoid arthritis (RA), suggesting a break of tolerance on mucosal surfaces. Immunoglobulin A (IgA) antibodies are part of the mucosal immune system. The dominant autoantibodies in RA are anti-cyclic citrullinated protein antibodies (ACPAs), and IgG and IgA subclasses exist simultaneously. This study aimed to investigate the association of ACPA IgA subtypes with disease activity and long-term radiographic outcomes in RA, compared with ACPA IgG. METHOD: Total ACPA IgG, IgA, IgA1, and IgA2 were quantified in serum from patients with early RA (n = 97). Patient characteristics, IgM rheumatoid factor (IgM-RF) status, clinical and biochemical disease activity scores, and radiographic status evaluated by total Sharp score (TSS), were assessed at baseline and after 2 and 11 years of treatment. RESULTS: All patients with ACPA IgA also had ACPA IgG. ACPA IgA positivity was associated with IgM-RF and male gender. Both ACPA IgA and IgG levels at baseline were weakly associated with disease activity markers. Baseline ACPA IgA and IgG did not show a linear correlation with radiographic status after 10 years, but could predict radiographic progression (ΔTSS ≥ 5 from 0 to 11 years), with positive likelihood ratios of 3.7 and 4.0, respectively. CONCLUSION: ACPA IgA and IgG were weakly associated with disease activity in early RA. RA patients with a ΔTSS ≥ 5 after 11 years of treatment had higher ACPA IgG and ACPA IgA levels at baseline; however, none of the ACPA subtypes was superior in predicting long-term radiographic progression.

Multicentre study of the risk of invasive cancer and use of sentinel node biopsy in women with a preoperative diagnosis of ductal carcinoma in situ.

BACKGROUND: Ductal carcinoma in situ (DCIS) in the breast that is diagnosed by biopsy implies a risk of upstaging to invasive carcinoma (IC) on final pathology. These patients require a sentinel lymph node biopsy (SLNB) for axillary staging. A two-stage procedure is not always feasible and precise selection of patients who should be offered SLNB is crucial. The aims were: to determine the rate of upstaging, and use of redundant and required SLNB in women with a preoperative diagnosis of DCIS; and to identify patient and tumour characteristics that increase the risk of upstaging. METHODS: Patients with DCIS treated between 2008 and 2016 were identified using Orbit operation planning system software, and those suitable for the study were selected based on review of the medical records. Upstaging rates and proportions of redundant and required SLNBs were calculated. Associations between clinicopathological characteristics and upstaging were analysed using univariable and multivariable logistic regression analyses. RESULTS: Of 1368 patients initially identified, 975 women with a preoperative diagnosis of DCIS were included in the study. Tumours in 246 of these patients (25·2 per cent) were upstaged to IC. Redundant SLNB was performed in 392 of 975 women (40·2 per cent). Forty-four patients (4·5 per cent) with a final diagnosis of IC were not offered SLNB and thus potentially undertreated. In adjusted analysis, DCIS size, palpability and mass formation identified by breast imaging were associated with increased risk of upstaging. The Van Nuys classification was not associated with upstaging. CONCLUSION: Most patients with IC on final pathology underwent SLNB, but a considerable number of patients with DCIS had a redundant SLNB. Lesion size, palpability and mass formation, but not Van Nuys classification group, are suggested risk factors for upstaging.

ANTECEDENTES: El carcinoma ductal in situ (ductal carcinoma in situ, DCIS) de mama que se diagnostica mediante biopsia implica un riesgo de infraestadiaje de un carcinoma invasivo (invasive carcinoma, IC) en la anatomía patológica final. Estas pacientes requieren una biopsia del ganglio linfático centinela (sentinel lymph node biopsy, SLNB) para la estadificación axilar. Dado que un procedimiento en dos etapas no siempre es factible, la selección precisa de pacientes a las que se debe ofrecer SLNB es crucial. El objetivo del estudio era determinar la tasa de infraestadiaje inicial y el uso repetido/requerido de SLNB en mujeres con un diagnóstico preoperatorio de CDIS. Además, se identificarán las características del paciente y del tumor que aumentan el riesgo de necesidad de re-estadificación. MÉTODOS: Un total de 1.368 mujeres con DCIS tratadas entre 2008-2016 fueron identificadas utilizando el programa informático de la planificación de las intervenciones hospitalarias. Después de la revisión de los registros médicos, se incluyeron 975 pacientes en la cohorte del estudio. Se calcularon las tasas de infraestadiaje y la proporción del uso repetido/requerido de SLNB. Las asociaciones entre las características clinicopatológicas y la necesidad de re-estadificación se analizaron mediante análisis de regresión logística univariable y multivariable. RESULTADOS: De 975 pacientes diagnosticados inicialmente de DCIS, 246 (25,2%) fueron re-estadiados a IC. Se realizó SLNB repetidas en 392 (40,2%) de estos pacientes. En 44 pacientes (4,5%) con un diagnóstico final de IC no se les ofreció la SLNB y, por lo tanto, pudieron estar potencialmente infratratados. En el análisis ajustado, el tamaño del DCIS, la palpabilidad y la presencia de una masa en las imágenes radiológicas de la mama se asociaron con un mayor riesgo de necesidad de re-estadificación por infraestadiaje inicial. La clasificación de Van Nuys no se asoció con la re-estadificación. CONCLUSIÓN: La mayoría de pacientes con IC en la patología final se sometieron a SLNB, sin embargo, un número considerable de pacientes con DCIS se sometieron a SLNB repetidas. El tamaño de la lesión, la palpabilidad y la presencia de masa, aunque no el grupo de clasificación de Van Nuys, se consideran factores de riesgo relacionados con infraestadiaje inicial y necesidad de re-estadificación final.

Histamine-release test in angioedema patients without urticaria - a retrospective cohort study of 404 patients.

Summary: A subset of patients with angioedema (AE) and urticaria has histamine releasing autoantibodies. The histamine release test (HR-test) has been used as a tool in chronic urticaria to define the autoimmune subgroup and may possibly guide the clinician to a more personalized therapy, like omalizumab and cyclosporine. The prevalence and value of positive histamine releasing autoantibodies in monosymptomatic AE is sparsely described in the literature. The purpose of this study was to report the prevalence of positive histamine releasing autoantibodies in a cohort of patients with recurrent AE and evaluate the usefulness of this test in AE patients. We performed a retrospective cohort study of 612 patients referred due to AE between 1995 and 2013. HR-test results were available in 404 patients. In the sub-group of patients with AE and urticaria, 17.3% had a positive HR-test but only 4.3% of patients with mono-symptomatic AE had a positive HR-test. No statistically significant treatment benefits of antihistamines, corticosteroids or adrenaline were found comparing patients with angioedema +/- urticaria based on the result of the HR-test (negative / positive). Thus, the HR-test result cannot be used as predictor of the efficacy of anti-allergic treatment.

Development and quantification of measures for risky and delayed food and monetary outcome choices.

Probability discounting (PD) measures risky choice patterns between smaller, more certain vs. larger, less certain outcomes. PD is associated with obesity as well as higher intake of foods high in fat and sugar. We developed and validated a brief PD task specifically for food-related choices-the Probabilistic Food Choice Questionnaire (PFCQ). We also validated a brief, existing PD monetary measure, the Probabilistic Monetary Choice Questionnaire (PMCQ) by comparing it to a titrating PD task. Participants (N = 110) were randomly assigned to either a food or money condition. Those assigned to the food condition completed the PFCQ and a more established, adjusting-amount PD task for hypothetical food outcomes. Those assigned to the money condition completed the PMCQ and a more established, adjusting-amount PD task. Participants also completed delay discounting (DD) tasks for the same outcome commodity. The PFCQ and adjusting-amount PD tasks strongly correlated across three magnitudes suggesting that the PFCQ may be a satisfactory and briefer measure for risky food choice. The PMCQ also showed significant correlations with the adjusting-amount monetary PD task, supporting its use for a brief measure of monetary discounting. For DD, the choice questionnaires demonstrated significant correlations with the adjusting-amount DD procedures, replicating previous research.

A prospective cohort study of 122 adult patients presenting to an otolaryngologist's office with globus pharyngeus.

OBJECTIVES: To investigate the epidemiology of globus pharyngeus in adult patients presenting to the otolaryngologist's office. Also, the predictors of persisting symptoms, prevalence of anxiety and the effect of clinical assessment were analysed. DESIGN: This was a prospective cohort study. Follow-up was carried out using a postal questionnaire. SETTING: One otolaryngologists' office comprising three medical doctors. PARTICIPANTS: A total of 122 consecutive globus patients presenting to one otolaryngology office in a 1-year period. MAIN OUTCOME MEASURES: Globus incidence, gender and age distribution, predictors of persisting symptoms and the patient's health-related concerns. RESULTS: 3.8% of first-time visits were regarding globus. The mean age was 48 years [range 20-88 years], and a female predominance was found (ratio 1.49). Eighty-four per cent experienced anxiety, mainly due to fear of cancer. The most common pathological findings were reflux (15.6%) and post-infectious inflammation (10.6%). 21.4% of questionnaire responders reported full remission of their symptoms. Three predictors regarding symptom persistence were identified: male gender (OR 1.52), smoking (OR 3.4) and difficulties in breathing (OR 8.7). Patients with concomitant foreign body sensation were less likely to have persisting symptoms (OR 0.42). No cases of malignant disease were encountered. 94.7% was reassured by the office visit. CONCLUSION: The incidence of globus is 3.8% in the otolaryngologist's office. Female gender and concomitant foreign body sensation were predictive for presenting to the clinic even if symptom remission had occurred. Male gender, smoking and self-perceived breathing difficulties were predictive for persisting symptoms. Globus is an anxiety-causing symptom, but reassurance is provided by clinical examination by the otolaryngologist.

From Brain Disease to Brain Health: Primary Prevention of Alzheimer's Disease and Related Disorders in a Health System Using an Electronic Medical Record-Based Approach.

BACKGROUND: Alzheimer's disease and aging brain disorders are progressive, often fatal neurodegenerative diseases. Successful aging, modern lifestyles and behaviors have combined to result in an expected epidemic. Risks for these diseases include genetic, medical, and lifestyle factors; over 20 modifiable risks have been reported. OBJECTIVES: We aim to primarily prevent Alzheimer's disease and related disorders through electronic medical record (EMR)-based screening, risk assessments, interventions, and surveillance. DESIGN: We identified modifiable risks; developed human, systems and infrastructural resources; developed interventions; and targeted at-risk groups for the intervention. SETTING: A Community Based Health System. PARTICIPANTS: In year one (June 2015 to May 2016), 133 at-risk patients received brain health services with the goal of delaying or preventing Alzheimer's disease and related disorders. MEASUREMENTS: We created mechanisms to identify patients at high risk of neurodegenerative disease; EMR-based structured clinical documentation support tools to evaluate risk factors and history; evidence-based interventions to modify risk; and the capacity for annual surveillance, pragmatic trials, and practice-based and genomic research using the EMR. RESULTS: This paper describes our Center for Brain Health, our EMR tools, and our first year of healthy but at-risk patients. CONCLUSION: We are translating research into primary prevention of Alzheimer's disease and related disorders in our health system and aim to shift the paradigm in Neurology from brain disease to brain health.

Presence and localization of bacteria in the bovine endometrium postpartum using fluorescence in situ hybridization.

The aim of this study was to investigate bacterial invasiveness of the bovine endometrium during the postpartum period. Fluorescence in situ hybridization was applied to endometrial biopsies using probes for Fusobacterium necrophorum, Porphyromonas levii, Trueperella pyogenes, Escherichia coli and a probe for bacteria in general (the overall domain Bacteria) to determine their tissue localization. Holstein cows were sampled at three time points postpartum (T1: 4-12 days postpartum, T2: 24-32 days postpartum and T3: 46-54 days postpartum). At T1, cows were clinically scored as having a uterine infection based on presence of a brownish, fetid vaginal discharge or as normal if having normal lochia. An endometrial biopsy was taken from all cows at T1 (n = 57). Endometrial biopsies were taken from the same cows at T2 and T3 if allowed by the size of the cervical canal and if the cow had not been inseminated. Fifty and 39 biopsies were obtained at T2 and T3, respectively. The biopsies were evaluated for inflammation and for presence and localization of bacteria. When analyzed by the probe for the entire domain Bacteria, bacteria were found in most biopsies irrespectively of time (T1: 79.0%, T2: 82.0%, T3: 89.7%). Fusobacterium necrophorum and Porphyromonas levii were often present in the endometrium at T1 (61.1% and 47.8%, respectively), but the prevalence decreased significantly over time. Trueperella pyogenes and Escherichia coli were less prevalent at T1 (8.8% and 10.5%, respectively) and their prevalence also decreased significantly over time. Fusobacterium necrophorum and Porphyromonas levii were often co-localized intraepithelially or in the lamina propria. Trueperella pyogenes and Escherichia coli were located only on the endometrial surface. Due to the high prevalence of tissue invasiveness, these findings emphasize the importance of Fusobacterium necrophorum and Porphyromonas levii in postpartum uterine disease of cattle and indicate that tissue invasiveness is an important aspect of the pathogenesis.

A Pharmacokinetic and Safety Study of Trebananib, an Fc-Fusion Peptibody, in Patients With Advanced Solid Tumors and Varying Degrees of Renal Dysfunction.

Clearance of trebananib (AMG 386), a 64-kD antiangiogenic peptibody, has been associated with estimated glomerular filtration rate (eGFR). We prospectively evaluated trebananib pharmacokinetics and safety/tolerability in advanced solid tumor patients with varying degrees of renal function. Patients were assigned to normal renal function, mild, moderate, or severe renal dysfunction cohorts based on eGFR, received trebananib 15 mg/kg i.v. weekly, and underwent week 1 and week 5 pharmacokinetic and weekly safety assessments. For 28 patients, trebananib clearance decreased from normal renal function (1.52 mL/hr/kg), to mild (1.20 mL/hr/kg), moderate (0.79 mL/hr/kg), and severe (0.53 mL/hr/kg) renal dysfunction (P ≤ 0.001). Treatment-related adverse events showed no association with clearance. Trebananib clearance was proportional to eGFR and unrelated to pretreatment protein excretion. These data confirm a role for renal clearance of a recombinant peptibody with molecular weight <69 kD and support a longer dosing interval for patients with severe renal dysfunction.

Genomic Diversity of Mycobacterium tuberculosis Complex Strains in Cantabria (Spain), a Moderate TB Incidence Setting.

BACKGROUND: Tuberculosis (TB) control strategies are focused mainly on prevention, early diagnosis, compliance to treatment and contact tracing. The objectives of this study were to explore the frequency and risk factors of recent transmission of clinical isolates of Mycobacterium tuberculosis complex (MTBC) in Cantabria in Northern Spain from 2012 through 2013 and to analyze their clonal complexity for better understanding of the transmission dynamics in a moderate TB incidence setting. METHODS: DNA from 85 out of 87 isolates from bacteriologically confirmed cases of MTBC infection were extracted directly from frozen stocks and genotyped using the mycobacterial interspersed repetitive units-variable number tandem repeat (MIRU-VNTR) method. The MIRU-VNTRplus database tool was used to identify clusters and lineages and to build a neighbor joining (NJ) phylogenetic tree. In addition, data were compared to the SITVIT2 database at the Pasteur Institute of Guadeloupe. RESULTS: The rate of recent transmission was calculated to 24%. Clustering was associated with being Spanish-born. A high prevalence of isolates of the Euro-American lineage was found. In addition, MIRU-VNTR profiles of the studied isolates corresponded to previously found MIRU-VNTR types in other countries, including Spain, Belgium, Great Britain, USA, Croatia, South Africa and The Netherlands. Six of the strains analyzed represented clonal variants. CONCLUSION: Transmission of MTBC is well controlled in Cantabria. The majority of TB patients were born in Spain. The population structure of MTBC in Cantabria has a low diversity of major clonal lineages with the Euro-American lineage predominating.

Direct DNA Extraction from Mycobacterium tuberculosis Frozen Stocks as a Reculture-Independent Approach to Whole-Genome Sequencing.

Culturing before DNA extraction represents a major time-consuming step in whole-genome sequencing of slow-growing bacteria, such as Mycobacterium tuberculosis. We report a workflow to extract DNA from frozen isolates without reculturing. Prepared libraries and sequence data were comparable with results from recultured aliquots of the same stocks.

Mycobacterium tuberculosis outbreak strain of Danish origin spreading at worrying rates among greenland-born persons in Denmark and Greenland.

Transmission of Mycobacterium tuberculosis continues at high rates among Greenland-born persons in Greenland and Denmark, with 203 and 450 notified cases per 10(5) population, respectively, in the year 2010. Here, we document that the predominant M. tuberculosis outbreak strain C2/1112-15 of Danish origin has been transmitted to Greenland-born persons in Denmark and subsequently to Greenland, where it is spreading at worrying rates and adding to the already heavy tuberculosis burden in this population group. It is now clear that the C2/1112-15 strain is able to gain new territories using a new population group as the "vehicle." Thus, it might have the ability to spread even further, considering the potential clinical consequences of strain diversity such as that seen in the widely spread Beijing genotype. The introduction of the predominant M. tuberculosis outbreak strain C2/1112-15 into the Arctic circumpolar region is a worrying tendency which deserves attention. We need to monitor whether this strain already has, or will, spread to other countries.

Antigen-induced cytokine and chemokine release test for tuberculosis infection using adsorption of stimulated whole blood on filter paper and multiplex analysis.

BACKGROUND: In vitro stimulation of whole blood or isolated blood cells with specific antigens is used for several purposes. Immediately following incubation with antigens, samples have to be centrifuged to stop the reactions by remaining cells and the supernatant refrigerated or analysed directly to preserve the analytes of interest, which makes samples difficult to prepare outside laboratories. We have tested whether spotting whole blood on filter paper after activation can be used in one of the tests for Mycobacterium tuberculosis infection (MTI), the QuantiFERON®-TB Gold In Tube test (QFT), where the spotting technique can make it suitable for use in locations without facilities like a centrifuge and a refrigerator. MATERIALS AND METHODS: Samples from 22 individuals undergoing screening for MTI and 10 healthy controls were incubated, centrifuged and IFN-γ measured by Enzyme-linked immunosorbent assay (ELISA), as described in the kit insert. In parallel, activated blood was spotted on filter paper (Schleicher & Schuell) and dried. The dried blood spot samples were analysed for 21 inflammatory markers with an in-house assay based on Luminex technology. RESULTS: Our multiplex measurements of inflammatory markers in samples from suspected MTI patients confirmed the IFN-γ findings in the QFT. IL-2, GM-CSF, IL-5, and IL-1ß were also found as useful markers for MTI. We were not able to distinguish between active tuberculosis and latent MTI. CONCLUSION: Applying blood on filter paper after incubation makes in vitro stimulation tests feasible in locations where heat and electricity is unavailable.

Successful weight loss in two adult patients diagnosed with late-onset long-chain Fatty Acid oxidation defect.

UNLABELLED: Patients with long-chain fatty acid oxidation defect (LCFAOD) cannot tolerate fasting and are restricted in their physical activity, hence their increased risk of obesity. Experts therefore advise avoidance of catabolic situations and discourage weight reduction in these patients.Two patients with late-diagnosed LCFAOD undergoing treatment at two academic centers successfully lost weight under supervision of a metabolic dietitian. Patient 1 (male, 47 years) diagnosed with CPT 2 deficiency lost 10 kg body weight in a 3-month period with the help of an energy and LCT-restricted, MCT- and carbohydrate-rich diet in combination with an exercise program. CK levels, C16, C18, and C18:1 levels of his acylcarnitine profile and his blood pressure decreased during the period of weight reduction. Patient 2 (male, 39 years) has a VLCAD deficiency. Dietary advice was energy and LCT restriction, MCT and carbohydrate-enriched food with raw cornstarch added during the night. Patient 2 lost almost 40 kg body weight to 87.6 kg (BMI 25.1) in 2 years. CK, insulin, TG, and ALAT blood levels decreased. CONCLUSION: Weight reduction without loss of metabolic control seems possible in late-onset LCFAOD patients. No metabolic crisis occurred in these two patients, while the positive effects of weight reduction were clear. The residual enzyme function in late-onset LCFAOD may be one of the reasons that metabolic decompensation was prevented. In addition, dietary adjustments to prevent excessive fatty acid oxidation likely contributed as well. Therefore, expert supervision by a dietician specialized in metabolic diseases is recommended. Concise SentenceContrary to the current literature, weight loss in patients with late-diagnosed LCFAOD can be successful. A description of two FOAD patients who lost weight without encountering negative side effects at two academic centers is given.

Combined IL-12 receptor and IgA deficiency in an adult man intestinally infested by an unknown, non-cultivable mycobacterium.

Interleukin-12 receptor deficiency is a well-described cause of human susceptibility to infection with low-virulent mycobacteria and Salmonella species. We identified a male patient presenting in his late forties with severe gastroenteropathy because of outbred infestation by a previously unknown mycobacterium. In addition to selective IgA deficiency, the patient was found to carry a not previously described R283X homozygous mutation in his IL12RΒ1 gene. Two of his sisters, a brother, and his four children were healthy, heterozygous carriers of the mutation. In this patient, the combination of two deficiencies could promote illness. Even though the IgA deficiency in itself does not predispose to mycobacterial disease, the lack of secreted IgA may have disturbed the intestinal homoeostasis and increased the susceptibility to the low-virulent mycobacterium that the patient was not able to clear because of his IL12R deficiency. Antimycobacterial chemotherapy and interferon-γ treatment for 2 years significantly improved his condition. This is the first description of IL12RΒ1 deficiency combined with another immunodeficiency, and we suggest that combinatory defects may circumvent the otherwise low penetrance of IL12RB1 deficiency.

Is training essential for interpreting cardiac computed tomography?

BACKGROUND: Cardiac computed tomography (CT) has gained increasing acceptance for diagnosing obstructive coronary artery disease (CAD). Several guidelines have been published on required education for proficiency in the interpretation of these examinations. PURPOSE: To describe the learning-curve effect of the interpretation of 100 consecutive cardiac CT examinations aimed at diagnosing CAD. The diagnostic accuracy of radiologists and radiographers was also compared. MATERIAL AND METHODS: Two radiologists and two radiographers, all with no prior experience in evaluation of cardiac CT, independently underwent a dedicated training program of 100 examinations randomized into 10 blocks (sessions), with 10 cases in each. They independently evaluated the coronary arteries regarding significant obstructive CAD. After every session, individual feedback on diagnostic accuracy and comparison with the corresponding invasive coronary angiography (currently regarded as the gold standard to detect coronary lesions) was given. The time required for interpretation was recorded. RESULTS: The mean review time decreased (P<0.0001) successively during the 10 sessions for all the observers together. The first session had a mean review time of 32 min, and the last session 16 min. No significant improvement in sensitivity, specificity, or negative predictive value (NPV) was observed. For positive predictive value (PPV), there was an improvement for the radiologists (P<0.05), but not for the radiographers. The radiographers had a higher total specificity compared to the radiologists (P<0.01). CONCLUSION: The review time for novices in cardiac CT was approximately halved during the first 100 cases, with maintained accuracy. There was a learning-curve effect in PPV for the radiologists. The diagnostic accuracy of dedicated radiographers indicates that they might be considered to be included as part of the evaluation team.

A prospective study of medically treated acute type B aortic dissection.

OBJECTIVE: To study prospectively aneurysm formation, need of surgery, incidence of rupture and mortality in patients with conservatively treated acute type B aortic dissection. METHODS: All patients referred to us with acute type B dissection between January 1990 and December 2001 were candidates for this prospective treatment and follow-up study. Patients deemed not to be in need of acute surgical repair were included after aggressive antihypertensive treatment. The follow-up protocol included close blood pressure control, clinic visits with physical examination, chest x-ray and spiral CT or MRI at 3 and 6 months and annually thereafter. RESULTS: Sixty-six patients were followed for a mean of 79 months (range 22-179). The actuarial survival rate was 82% at 5 years and 69% at 10 years. Eighty-five percent remained free from dissection-related death at 5 years and 82% at 10 years. Ten patients (15%) developed aneurysm (>6 cm) of the dissected aorta. Three of these 10 patients died from aortic rupture and 2 underwent elective surgical repair. Of the 56 patients without aneurysm, one died from rupture and one died suddenly for causes unknown. One patient was treated with endovascular stent-graft. Five patients sustained a new type A aortic dissection which in all but one were fatal. In 26 patients the initial dissection was categorized as intramural hematoma. Twelve of these patients had, in addition to the hematoma, areas with localized dissection/ulcer-like projection. The latter was found to be a predictor of aortic event (dissection-related death, rupture, new type A aortic dissection, aneurysm formation) during follow-up, as was an initial diameter of >4.0 cm at first CT-scan during the acute event. CONCLUSIONS: Conservatively treated acute type B dissection has a low incidence of aneurysm formation and rupture during the chronic phase. These results must be matched or improved upon before endovascular stent-grafting or early aortic surgical repair can be regarded as the primary treatment of choice.

Immunogenicity of kappa-casein and glycomacropeptide.

Glycomacropeptide (GMP), arising from the cleavage of kappa-casein by chymosin or pepsin, has been correlated with a wide variety of biological activities including immunosuppression capacity, inhibition of pathogen invasion, and induction of satiety. Due to the interest in exploiting such potential of GMP, we aimed at characterizing the immunogenic properties of GMP as an indication of its potential allergenicity. Immunogenicity of kappa-casein and GMP were investigated using 2 animal models based on different routes of immunization: 1) mice immunized intraperitoneally or subcutaneously with either kappa-casein, polymerized GMP, GMP coupled to the immunogenic carrier ovalbumin, or GMP alone; 2) mice coadministered kappa-casein or GMP and cholera toxin. The specific antibody response to GMP was evaluated as well as the antigen-specific T-cell response. The results demonstrated that immunization or feeding with kappa-casein induced GMP-specific antibodies, whereas GMP per se lacked immunogenicity independently of the mode of presentation. The size of the presented form of GMP did not influence its immunogenicity. Because the results showed that GMP did not induce a specific T-cell response, we postulate that GMP lacks the ability to stimulate antigen-specific T cells.

Transesophageal endoscopic ultrasound/fine-needle aspiration diagnosis of a malignant adrenal gland in a patient with non-small cell lung cancer and a negative CT scan.

Adrenal metastasis is only seen on CT scan is less than 5% of patients with otherwise resectable NSCLS, but this diagnosis has a major impact on treatment and prognosis. We present a case of a patient with NSCLC and an adrenal metastasis, which was diagnosed by EUS/FNA of an enlarged adrenal gland, who had false-negative CT scan for adrenal metastasis. PET was not performed. Prospective studies are needed to assess the incremental yield of EUS/FNA over upper abdominal CT scan and PET for detecting left adrenal metastasis in patients with suspected or proven otherwise respectable NSCLC.

Interstitial lung disease, a common manifestation of newly diagnosed polymyositis and dermatomyositis.

OBJECTIVES: To estimate the prevalence and predictors of interstitial lung disease in newly diagnosed polymyositis and dermatomyositis. METHODS: A prospective study in which consecutive patients with newly diagnosed poly- and dermatomyositis, regardless of clinical symptoms of pulmonary disease, were investigated with chest x ray, high resolution computed tomography (HRCT), pulmonary function tests, and biochemical and autoantibody analysis. Patients with inclusion body myositis, malignancy, other defined inflammatory connective tissue diseases (CTDs), or antibody profile indicating other CTDs were excluded. RESULTS: Between March 1998 and September 2000, 26 new cases of poly- or dermatomyositis were diagnosed; 17 of those patients were included in the study. Interstitial lung disease (ILD), defined as radiological signs on chest x ray examination/HRCT or restrictive ventilatory defect, were found in 11 (65%) patients and were more common in men than in women. Arthritis and occurrence of anti-Jo-1 antibodies were found more often in patients with ILD than in those without. There was no statistically significant association between respiratory symptoms, other serological or laboratory variables and ILD. CONCLUSIONS: ILD is a common early manifestation in patients with poly- and dermatomyositis and is not always related to clinical symptoms. Chest x ray examination, HRCT, pulmonary function tests, and analysis of anti-Jo-1 antibodies should be included in the initial investigation of patients with myositis regardless of respiratory symptoms.