Additional Clinical Cases Research Articles

A Round Ligament Mesothelial Cyst Imitating an Inguinal Hernia in a Woman of Reproductive Age

Objective. A wide range of lesions, including a mesothelial cyst of the uterine round ligament, are included in the differential diagnosis of a groin mass. Our study emphasizes the rarity of this ailment and the significance of correct preoperative diagnosis in guiding our treatment approach. Case Report. A 43-year-old female patient, presented to our hospital with a five-year his- tory of swelling and slight discomfort in the right groin. A nonreducible inguinal mass with greater projection during a Val- salva maneuver was found. An abdominal CT scan revealed a well-defined lesion located near the right horn of the uterus and extending through the inguinal canal. The patient was brought to the operating room with the clinical suspicion of an inguinal hernia. A soft mass measuring 4.5×2×1.8cm was discovered in the right round ligament, and it was surgically removed. Histo- pathological examination confirmed a mesothelial cystic lesion. The patient’s condition, after a period of 12 months, continues to be satisfactory. Conclusion. Few cases of uterine round ligament mesothelial cysts have been reported worldwide. Their cause is unknown, and preoperative diagnosis is unreliable. Resection relieves symptoms, and histological examination of the surgical specimen confirms the diagnosis. Additional clinical cases are needed to create a systematic clinical approach.

Single-retainer all-ceramic resin-bonded fixed dental prostheses: Long-term outcomes in the esthetic zone.

To present an update on the concept of cantilevered single-retainer all-ceramic resin-bonded fixed dental prostheses (RBFDPs) first presented 25 years ago in the Journal of Esthetic Dentistry. The initially presented case of the concept was followed clinically over 26 years and is presented along with two additional clinical long-term cases using varying methods to obtain an esthetic and hygienic ovate pontic design. Veneered alumina and zirconia ceramic (3mol% yttria-tetragonal zirconia polycrystalline ceramic; 3Y-TZP) was used and bonded with a phosphate monomer containing luting resin after 50 μm alumina particle air-abrasion at 0.25 MPa pressure. The restorations replacing incisors did not debond and soft tissues in the pontic area were maintained over 26 years. Cantilevered single-retainer all-ceramic RBFDPs today made from veneered 3Y-TZP zirconia ceramic can be considered a standard of care for the replacement of single incisors and provide an excellent esthetic outcome with a long-term preservation of soft tissues in the pontic area. Bonding nonretentive oxides ceramics such as alumina and zirconia ceramic with phosphate monomer containing luting resins after alumina particle air-abrasion is durable over decades. This proves that bonding to zirconia ceramic is not of any problem when adequate methods are used. Single-retainer zirconia ceramic RBFDPs maintain soft tissues in the edentulous area of single missing incisors and often deem implants unessential for this indication.

Importation of plasma and use of apheresis platelets as risk reduction measures for variant Creutzfeldt-Jakob disease: The SaBTO review.

Following recognition that blood, blood components, tissues and organs donated by infected donors could transmit infectious prions causing variant Creutzfeldt-Jakob Disease (vCJD), several risk reduction measures were introduced in the UK. The Advisory Committee on the Safety of Blood, Tissues and Organs (SaBTO) established a working group to review the measures in place. Factors considered included: ethical issues around the current provisions and potential changes; operational issues for blood establishments and hospitals; a review from the Advisory Committee on Dangerous Pathogens (ACDP) showing the downward trend in the estimated number of future cases of vCJD; and cost-effectiveness. The working group recommended that the current vCJD risk reduction measures for individuals born after 1995 or with thrombotic thrombocytopenic purpura (TTP) could be withdrawn. After consultation with stakeholders, SaBTO accepted these proposals which allow more equal provision of components, less operational complexity and risk, and more resources to be deployed elsewhere in the NHS. The potential saving on plasma will be £500 m and moving to using pooled platelets in additive solution for all recipients will bring potential savings of £280 m over the next 50 to 60 years. There could be small number of additional clinical cases of vCJD: 1-2 (<1-14; 95% CI) from plasma and 3-4 (<1 to 45; 95% CI) from platelets. Local and national guidelines will still be applied for managing individual conditions. UK Ministers for Health accepted SaBTO's recommendations on 9 Sept 2019 and implementation began immediately. This paper describes the review and rationale leading to these recommendations.

Modeling transmission dynamics and effectiveness of worker screening programs for SARS-CoV-2 in pork processing plants.

Pork processing plants were apparent hotspots for SARS-CoV2 in the spring of 2020. As a result, the swine industry was confronted with a major occupational health, financial, and animal welfare crisis. The objective of this work was to describe the epidemiological situation within processing plants, develop mathematical models to simulate transmission in these plants, and test the effectiveness of routine PCR screening at minimizing SARS-CoV2 circulation. Cumulative incidence of clinical (PCR-confirmed) disease plateaued at ~2.5% to 25% across the three plants studied here. For larger outbreaks, antibody prevalence was approximately 30% to 40%. Secondly, we developed a mathematical model that accounts for asymptomatic, pre-symptomatic, and background “community” transmission. By calibrating this model to observed epidemiological data, we estimated the initial reproduction number (R) of the virus. Across plants, R generally ranged between 2 and 4 during the initial phase, but subsequently declined to ~1 after two to three weeks, most likely as a result of implementation/compliance with biosecurity measures in combination with population immunity. Using the calibrated model to simulate a range of possible scenarios, we show that the effectiveness of routine PCR-screening at minimizing disease spread was far more influenced by testing frequency than by delays in results, R, or background community transmission rates. Testing every three days generally averted about 25% to 40% of clinical cases across a range of assumptions, while testing every 14 days typically averted 7 to 13% of clinical cases. However, the absolute number of additional clinical cases expected and averted was influenced by whether there was residual immunity from a previous peak (i.e., routine testing is implemented after the workforce had experienced an initial outbreak). In contrast, when using PCR-screening to prevent outbreaks or in the early stages of an outbreak, even frequent testing may not prevent a large outbreak within the workforce. This research helps to identify protocols that minimize risk to occupational safety and health and support continuity of business for U.S. processing plants. While the model was calibrated to meat processing plants, the structure of the model and insights about testing are generalizable to other settings where large number of people work in close proximity.

The Association Between CTLA-4, CD80/86, and CD28 Gene Polymorphisms and Rheumatoid Arthritis: An Original Study and Meta-Analysis.

Background: Rheumatoid arthritis (RA) is related to several pivotal susceptibility genes, including cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and costimulatory molecule (CD80/CD86) genes. Although the connection between polymorphisms of CTLA-4 and CD86 genes in different populations of RA have been studied extensively, the results are controversial.Objective: To clarify the correlation in the Chinese Han population between CTLA-4, CD80/86, and CD28 gene polymorphisms, and RA susceptibility.Methods: A case-control study (574 RA patients and 804 controls) was conducted to determine the correlation between CTLA-4 rs231775 and rs16840252 gene polymorphisms, CD86 rs17281995 gene polymorphisms, and the risk of RA for the Chinese Han population. Furthermore, an additional meta-analysis, including three single nucleotide polymorphisms (SNPs) (CTLA-4 rs231775, CTLA-4 rs3087243, and CTLA-4 rs5742909) from 32 citations, including 43 studies, 24,703 cases and 23,825 controls was performed to elucidate the relationship between known SNPs in the CTLA-4 genes and RA for more robust conclusions.Results: The results showed that CTLA-4 rs231775 gene polymorphism decreased the RA risk (GA vs. AA, OR = 0.77, P = 0.025), whereas CTLA-4 rs16840252 and CD86 rs17281995 gene polymorphisms were not related to RA susceptibility. Stratification analyses by RF, ACPA, CRP, ESR, DAS28, and functional class identified significant associations for CTLA-4 rs231775 and rs16840252 gene polymorphisms in the RF-positive and RF-negative groups. A meta-analysis of the literature on CTLA-4 gene polymorphisms and RA risk revealed that the risk of RA was decreased by CTLA-4 rs231775 gene polymorphisms.Conclusions: The CTLA-4 rs231775 gene polymorphism decreased the risk of RA, whereas CTLA-4 rs16840252 and CD86 rs17281995 gene polymorphisms were not related to RA risk. A meta-analysis indicated that CTLA-4 rs231775 and rs3087243 gene polymorphisms decreased the risk of RA. To support these analytical results, additional clinical cases should be investigated in further studies.

Anatomical variations of the innervated radial artery superficial palmar branch flap: A series of 28 clinical cases.

BackgroundThe innervated radial artery superficial palmar branch (iRASP) flap was designed to provide consistent innervation by the palmar cutaneous branch of the median nerve (PCMN) to a glabrous skin flap. The iRASP flap is used to achieve coverage of diverse volar defects of digits. However, unexpected anatomical variations can affect flap survival and outcomes.MethodsCases in which patients received iRASP flaps since April 1, 2014 were retrospectively investigated by reviewing the operation notes and intraoperative photographs. The injury type, flap dimensions, arterial and neural anatomy, secondary procedures, and complications were evaluated.ResultsTwenty-eight cases were reviewed, and no flap failures were observed. The observed anatomical variations were the absence of a direct skin perforator, large-diameter radial artery superficial palmar branch (RASP), and the PCMN not being a single branch. Debulking procedures were performed in 16 cases (57.1%) due to flap bulkiness.ConclusionsIn some cases, an excessively large RASP artery was observed, even when there was no direct skin perforator from the RASP or variation in the PCMN. These findings should facilitate application of the iRASP flap, as well as any surgical procedures that involve potential damage to the PCMN in the inter-thenar crease region. Additional clinical cases will provide further clarification regarding potential anatomical variations.

Correction of Motion Artifacts Using a Multiscale Fully Convolutional Neural Network.

Motion artifacts are a frequent source of image degradation in the clinical application of MR imaging (MRI). Here we implement and validate an MRI motion-artifact correction method using a multiscale fully convolutional neural network. The network was trained to identify motion artifacts in axial T2-weighted spin-echo images of the brain. Using an extensive data augmentation scheme and a motion artifact simulation pipeline, we created a synthetic training dataset of 93,600 images based on only 16 artifact-free clinical MRI cases. A blinded reader study using a unique test dataset of 28 additional clinical MRI cases with real patient motion was conducted to evaluate the performance of the network. Application of the network resulted in notably improved image quality without the loss of morphologic information. For synthetic test data, the average reduction in mean squared error was 41.84%. The blinded reader study on the real-world test data resulted in significant reduction in mean artifact scores across all cases (P < .03). Retrospective correction of motion artifacts using a multiscale fully convolutional network is promising and may mitigate the substantial motion-related problems in the clinical MRI workflow.

Interpretation of risk loci from genome-wide association studies of Alzheimer's disease.

Alzheimer's disease is a debilitating and highly heritable neurological condition. As such, genetic studies have sought to understand the genetic architecture of Alzheimer's disease since the 1990s, with successively larger genome-wide association studies (GWAS) and meta-analyses. These studies started with a small sample size of 1086 individuals in 2007, which was able to identify only the APOE locus. In 2013, the International Genomics of Alzheimer's Project (IGAP) did a meta-analysis of all existing GWAS using data from 74 046 individuals, which stood as the largest Alzheimer's disease GWAS until 2018. This meta-analysis discovered 19 susceptibility loci for Alzheimer's disease in populations of European ancestry. Three new Alzheimer's disease GWAS published in 2018 and 2019, which used larger sample sizes and proxy phenotypes from biobanks, have substantially increased the number of known susceptibility loci in Alzheimer's disease to 40. The first, an updated GWAS from IGAP, included 94 437 individuals and discovered 24 susceptibility loci. Although IGAP sought to increase sample size by recruiting additional clinical cases and controls, the two other studies used parental family history of Alzheimer's disease to define proxy cases and controls in the UK Biobank for a genome-wide association by proxy, which was meta-analysed with data from GWAS of clinical Alzheimer's disease to attain sample sizes of 388 324 and 534 403 individuals. These two studies identified 27 and 29 susceptibility loci, respectively. However, the three studies were not independent because of the large overlap in their participants, and interpretation can be challenging because different variants and genes were highlighted by each study, even in the same locus. Furthermore, neither the variant with the strongest Alzheimer's disease association nor the nearest gene are necessarily causal. This situation presents difficulties for experimental studies, drug development, and other future research. WHERE NEXT?: The ultimate goal of understanding the genetic architecture of Alzheimer's disease is to characterise novel biological pathways that underly Alzheimer's disease pathogenesis and to identify novel drug targets. GWAS have successfully contributed to the characterisation of the genetic architecture of Alzheimer's disease, with the identification of 40 susceptibility loci; however, this does not equate to the discovery of 40 Alzheimer's disease genes. To identify Alzheimer's disease genes, these loci need to be mapped to variants and genes through functional genomics studies that combine annotation of variants, gene expression, and gene-based or pathway-based analyses. Such studies are ongoing and have validated several genes at Alzheimer's disease loci, but greater sample sizes and cell-type specific data are needed to map all GWAS loci.

Finding the Sweet Spot: An Interactive Workshop on Diabetes Management in Older Adults.

Intensive glucose lowering in older adults with diabetes leads to increased risks with minimal benefits. Surveys indicate that clinician confidence for individualizing glycemic goals and regimens remains low. We created an interactive workshop and clinical tool kit to improve clinician knowledge of safe diabetes management in older adults. Finding the Sweet Spot was a 1-hour workshop taught by pharmacists to medical and pharmacy learners that introduced a five-step framework for diabetes management in older adults. The interactive presentation included cases and a clinical tool kit based on current recommendations from the American Diabetes Association and American Geriatrics Society. Pilot workshops were held for 6 months, allowing for real-time revisions based on feedback; final implementation occurred for 6 months thereafter. We evaluated learner self-efficacy (via a 5-point Likert scale) and knowledge (via multiple-choice questions) of diabetes management in older adults before and after the workshop. Thirty learners participated in Finding the Sweet Spot (70% medicine, 30% pharmacy). The percentage of confident learners increased from 55% to 97% (p < .05) after the workshop. All learners demonstrated improvements in knowledge, with the mean score on the knowledge assessment increasing from 61% to 80% (p < .05). Via open-ended feedback, learners expressed satisfaction and found the clinical tool kit especially helpful. Our Finding the Sweet Spot workshop demonstrated statistically significant changes in self-efficacy and knowledge among learners, indicating that this interactive workshop improves medical and pharmacy provider confidence and skills in caring for older adults with diabetes.

1251. Contaminated Sinks May be an Environmental Source for Serial Transmission of Carbapenem-Resistant Enterobacteriaceae (CRE) to ICU Patients

BackgroundWe performed an investigation after noting an increase in hospital-onset (HO) KPC-producing Enterobacteriaceae (KPC-E) infections in patients admitted to a tertiary referral hospital in North Carolina.MethodsWe defined pre-outbreak (January 1, 2017–June 30, 2017), outbreak (July 1, 2017–October 31, 2017), and post-outbreak (November 1, 2017–March 31, 2018) phases. A clinical case was defined as any positive clinical culture for KPC-E. HO was defined as a positive clinical or surveillance culture collected on hospital day ≥3. Patients were mapped in space and time to inform targeted environmental sampling. Whole-genome sequencing (WGS) was performed on selected KPC K. pneumoniae environmental and patient isolates to determine relatedness.In October 2017, a CRE prevention bundle was implemented that included daily communication of CRE patient movement, increased audits/feedback of HCW compliance with hand hygiene, enhanced cleaning and disinfection in CRE rooms and high-risk units with bleach and UVC disinfection, and weekly rectal surveillance screens in four adult ICUs.Results0.67 clinical cases of KPC-E per month were observed during the pre-outbreak period compared with 3.75 clinical cases of KPC-E per month during the outbreak period. K. pneumoniae was the most common species (Figure 1). Mapping of patients revealed probable direct and indirect transmission between patients in multiple hospital units (Figure 2). three patients who were non-sequentially admitted to the same ICU room over a 12-week span acquired KPC K. pneumoniae (Figure 2). Environmental cultures from the in-room sink drain and P-trap grew KPC K. pneumoniae that was related to the patient isolates by WGS; the sink was removed. Although no additional clinical cases of KPC-E occurred after full implementation of the bundle and sink removal, we continued to observe acquisition of KPC-E rectal colonization in all four ICUs (Figure 3).ConclusionWe describe a multispecies outbreak of KPC-E that was mitigated through evidence-based CRE control measures and removal of a colonized sink. However, ongoing low-level presumed transmission of KPC points to persistent environmental sources. Additional study is needed to understand the prevalence of CRE in hospital sinks, factors that drive drain colonization, and contribution of CRE in a sink to nosocomial transmission. Disclosures All authors: No reported disclosures.

Clinical Assessment of Individualized Glycemic Goals in Patients With Type 2 Diabetes: Formulation of an Algorithm Based on a Survey Among Leading Worldwide Diabetologists.

OBJECTIVEObservations over the past few years have demonstrated the need to adjust glycemic targets based on parameters pertaining to individual patient characteristics and comorbidities. However, the weight and value given to each parameter will clearly vary depending on the experience of the provider, the characteristics of the patient, and the specific clinical situation.RESEARCH DESIGN AND METHODSTo determine if there is current consensus on a global level with regard to identifying these parameters and their relative importance, we conducted a survey among 244 key worldwide opinion-leading diabetologists. Initially, the physicians were to rank the factors they take into consideration when setting their patients' glycemic target according to their relative importance. Subsequently, six clinical vignettes were presented, and the experts were requested to suggest an appropriate glycemic target. The survey results were used to formulate an algorithm according to which an estimate of the patient's glycemic target based on individualized parameters can be computed. Three additional clinical cases were submitted to a new set of experts for validation of the algorithm.RESULTSA total of 151 (61.9%) experts responded to the survey. The parameters “life expectancy” and “risk of hypoglycemia from treatment” were considered to be the most important. “Resources” and “disease duration” ranked the lowest. An algorithm was constructed based on survey results. It was validated by presenting three new cases to 57 leading diabetologists who suggested glycemic targets that were similar to those calculated by the algorithm.CONCLUSIONSThe resultant suggested algorithm is an additional decision-making tool offered to the clinician to supplement clinical decision making when considering a glycemic target for the individual patient with diabetes.

Atlas-guided prostate intensity modulated radiation therapy (IMRT) planning

An atlas-based IMRT planning technique for prostate cancer was developed and evaluated. A multi-dose atlas was built based on the anatomy patterns of the patients, more specifically, the percent distance to the prostate and the concaveness angle formed by the seminal vesicles relative to the anterior-posterior axis. A 70-case dataset was classified using a k-medoids clustering analysis to recognize anatomy pattern variations in the dataset. The best classification, defined by the number of classes or medoids, was determined by the largest value of the average silhouette width. Reference plans from each class formed a multi-dose atlas. The atlas-guided planning (AGP) technique started with matching the new case anatomy pattern to one of the reference cases in the atlas; then a deformable registration between the atlas and new case anatomies transferred the dose from the atlas to the new case to guide inverse planning with full automation. 20 additional clinical cases were re-planned to evaluate the AGP technique. Dosimetric properties between AGP and clinical plans were evaluated. The classification analysis determined that the 5-case atlas would best represent anatomy patterns for the patient cohort. AGP took approximately 1 min on average (corresponding to 70 iterations of optimization) for all cases. When dosimetric parameters were compared, the differences between AGP and clinical plans were less than 3.5%, albeit some statistical significances observed: homogeneity index (p > 0.05), conformity index (p < 0.01), bladder gEUD (p < 0.01), and rectum gEUD (p = 0.02). Atlas-guided treatment planning is feasible and efficient. Atlas predicted dose can effectively guide the optimizer to achieve plan quality comparable to that of clinical plans.

SU‐E‐J‐92: On‐Line Cone Beam CT Based Planning for Emergency and Palliative Radiation Therapy

Purpose:To evaluate and develop the feasibility of on‐line cone beam CT based planning for emergency and palliative radiotherapy treatments.Methods:Subsequent to phantom studies, a case library of 28 clinical megavoltage cone beam CT (MVCBCT) was built to assess dose‐planning accuracies on MVCBCT for all anatomical sites. A simple emergency treatment plan was created on the MVCBCT and copied to its reference CT. The agreement between the dose distributions of each image pair was evaluated by the mean dose difference of the dose volume and the gamma index of the central 2D axial plane. An array of popular urgent and palliative cases was also evaluated for imaging component clearance and field‐of‐view.Results:The treatment cases were categorized into four groups (head and neck, thorax/spine, pelvis and extremities). Dose distributions for head and neck treatments were predicted accurately in all cases with a gamma index of &gt;95% for 2% and 2 mm criteria. Thoracic spine treatments had a gamma index as low as 60% indicating a need for better uniformity correction and tissue density calibration. Small anatomy changes between CT and MVCBCT could contribute to local errors. Pelvis and sacral spine treatment cases had a gamma index between 90% and 98% for 3%/3 mm criteria. The limited FOV became an issue for large pelvis patients. Imaging clearance was difficult for cases where the tumor was positioned far off midline.Conclusion:The MVCBCT based dose planning and delivery approach is feasible in many treatment cases. Dose distributions for head and neck patients are unrestrictedly predictable. Some FOV restrictions apply to other treatment sites. Lung tissue is most challenging for accurate dose calculations given the current imaging filters and corrections. Additional clinical cases for extremities need to be included in the study to assess the full range of site‐specific planning accuracies.This work is supported by Siemens.

Characterization of copy number variation in genomic regions containing STR loci using array comparative genomic hybridization

Short tandem repeat (STR) loci are commonly used in forensic casework, familial analysis for human identification, and for monitoring hematopoietic cell engraftment after bone marrow transplant. Unexpected genetic variation leading to sequence and length differences in STR loci can complicate STR typing, and presents challenges in casework interpretation. Copy number variation (CNV) is a relatively recently identified form of genetic variation consisting of genomic regions present at variable copy numbers within an individual compared to a reference genome. Large scale population studies have demonstrated that likely all individuals carry multiple regions with CNV of 1kb in size or greater in their genome. To date, no study correlating genomic regions containing STR loci with CNV has been conducted. In this study, we analyzed results from 32,850 samples sent for clinical array comparative genomic hybridization (CGH) analysis for the presence of CNV at regions containing the 13 CODIS (Combined DNA Index System) STR, and the Amelogenin X (AMELX) and Amelogenin Y (AMELY) loci. Thirty-two individuals with CNV involving STR loci on chromosomes 2, 4, 7, 11, 12, 13, 16, and 21, and twelve with CNV involving the AMELX/AMELY loci were identified. These results were correlated with data from publicly available databases housing information on CNV identified in normal populations and additional clinical cases. These collective results demonstrate the presence of CNV in regions containing 9 of the 13 CODIS STR and AMELX/Y loci. Further characterization of STR profiles within regions of CNV, additional cataloging of these variants in multiple populations, and contributing such examples to the public domain will provide valuable information for reliable use of these loci.

Clinical Evaluation of Deslorelin to Induce Oestrus, Ovulation and Pregnancy in the Bitch

The aim of this study was to evaluate the practical use of Deslorelin in a clinical setting to induce oestrus and ovulation and to assess pregnancy rates. Sixteen anoestrus bitches that were brought into the clinic were implanted subcutaneously in the ventral abdomen with Deslorelin. Implants were removed after ovulation was assumed to have occurred. All bitches came into oestrus and 13 ovulated. 11 of 16 bitches became pregnant (68.8%) and all continued to term. Average litter size was 7.6 puppies. On average, the implant was in place for 13.8 days.

FISH-negative cryptic PML–RARA rearrangement detected by long-distance polymerase chain reaction and sequencing analyses: a case study and review of the literature

Although a normal karyotype according to conventional cytogenetic analysis in association with cryptic t(15;17) has been infrequently reported in cases of acute promyelocytic leukemia (APL), a fluorescence in situ hybridization (FISH)-negative cryptic PML–RARA rearrangement is even more rare, with only 12 such APL cases of FISH-negative cryptic PML–RARA rearrangements in the literature. Reported here is an additional clinical APL case with a FISH-negative cryptic PML–RARA rearrangement, confirmed by long-distance DNA polymerase chain reaction method. Discussion includes a relevant literature review of similar cases. DNA-PCR can be a useful tool for the analysis of complex and cryptic rearrangements.

IMorphology: integrative, blended teaching of anatomy and diagnostic imaging

In integrated curricula anatomy teaching frequently integrates chronologically with other subjects, but fails to integrate with regard to contents; especially, if higher numbers of students shall be taught in small groups. This was also the case in the first approach at the medical university of vienna, where 720 students are enroled per year. After evaluation giving unsatisfactory results, we have now elaborated the iMorphology‐concept for integrated teaching of anatomy and diagnostic imaging. In the same module, students switch between anatomical preparation of an organ system at the dissection hall and according case‐based learning of diagnostic imaging of the respective organ system guided by radiologists. In the dissection hall, ceiling mounted iMacs provide the students with the images from these cases, additional clinical cases, preparation‐videos, videos of relevant surgical/clinical interventions, animations illucidating developmental processes, and 3D‐reconstructions from cross‐sectinal image series. Assessment combines immanent evaluation of dissection and respective background knowledge, mutual cooperative teaching of students among each other, and diagnostic imaging‐tests using interactive learner response devices. With this blending of learning and testing approaches, we achieve faster, indepth and crosslinked understanding of morphology in a yet very limited time frame.

Towards control of Streptococcus iniae.

Streptococcus iniae is an emerging zoonotic pathogen; such infections generally occur through injuries associated with preparing whole fresh fish for cooking. Those infected to date have been of Asian descent, are usually elderly (average age 68 years), and have had >/=1 underlying conditions that may predispose them to infection. Studies of the foundations of growth characteristics of S. iniae and its interactions with piscine host cells have recently been complemented by molecular studies. Advances in molecular biology have allowed research groups to identify numerous virulence factors and to explore their roles in the progression of S. iniae infection. Many of these virulence factors are homologous to those found in the major human pathogen S. pyogenes. An increased understanding of the properties of these factors and their effect on the success of infection is leading to novel approaches to control S. iniae infection; in particular, vaccination programs at fish farms have reduced the reservoir of infection for additional clinical cases.

WEB ALERT

High Altitude Medicine Guide: www.high-altitude-medicine.com/AMS-medical.html Description: This Web site of high altitude medicine contains quick reference material for climbers, sports medicine physicians, and lay people alike. The information was compiled by a single physician with collaboration by the International Society for Mountain Medicine. Applicable physiology and standard definitions of frequently used terms, such as altered mental status, high-altitude pulmonary edema, and high-altitude cerebral edema, are outlined. There are links to the Lake Louise Criterion for these conditions, as well as a questionnaire created by the Web site's founder for the evaluation of altered mental status in the high-altitude athlete. The information reads well and is easy to navigate. The clinical guide for physicians contains relevant information with helpful links to additional Web sites, recommended readings, and clinical cases. Cost: Free. Spondylitis Association of America: www.spondylitis.org/main.aspx Description: The Spondylitis Association of America (SAA) has put together a very helpful resource and educational center for patients and providers alike with extensive information about seronegative spondyloarthropathies, including ankylosing spondylitis, reactive arthritis, enteropathic arthritis, and psoriatic arthritis. The medical and scientific advisory boards affiliated with this site comprise a group of international rheumatologists. There is ample information for newly diagnosed patients, including videos with disease information, as well as in-depth explanations of disease treatment and complications. There is even a brief section on the effects of diet in these diseases. More educational materials are available for purchase through the Web site. The SAA site also has links to support groups for patients and easy access to current advocacy efforts. There also is a reference section about becoming involved in research efforts across the country. For clinicians, there is a research archive where recent articles from SAA publications are available for reference. Cost: Free. National Ankylosing Spondylitis Society: www.nass.co.uk/index.htm Description: The National Ankylosing Spondylitis Society (NASS) is a charity operated out of the United Kingdom. This site focuses exclusively on ankylosing spondylitis. The Web site has excellent patient information resources that can be of use to patients and clinicians who care for those with ankylosing spondylitis. Perhaps the most useful section of the Web site is the description of useful exercises for those with ankylosing spondylitis. This section has animated computer models illustrating each exercise. This would be a great asset to patients working on a home exercise program or for those who do not have ready access to physical therapists accustomed to working with patients with ankylosing spondylitis. There also are helpful links to educational courses for clinicians and physical therapists as well as information about ongoing studies on ankylosing spondylitis. Cost: Free. U.S. Anti-Doping Agency: www.usada.org Description: This is a practical Web site with specific forms and instructions for sports medicine physicians to assist in treating their Olympic-level athletes. There is an easy-to-use search tool called the Drug Reference Online (DRO) that allows clinicians to look up specific medications on the World Anti-Doping Agency (WADA) prohibited substances list. There also is a printable wallet card for athletes to bring to their physicians that lists all of the banned substances from WADA for that year. There are very helpful forms, such as the therapeutic use exemption forms, that athletes and clinicians can print off the site. There are easy to follow instructions for their use. This is a very self-explanatory Web site with quickly accessible information for clinicians and athletes alike. Cost: Free. Fédération Internationale de Football Association: www.fifa.com Description: The Fédération Internationale de Football Association (FIFA) is an international organization based in Zurich for the advancement and improvement of the sport of soccer. This organization sets forth regulations in its constitution that form the international rules by which the sport operates. The Web site has a particularly useful section on athletes' health. It outlines the injury prevention efforts of the organization and emphasizes proper nutrition. There also is a section devoted solely to the female soccer player. The research efforts of the federation are outlined by the FIFA Medical Research and Assessment Center (F-MARC). The Web site contains an extensive list of applicable research studies for quick reference. Cost: Free.

Molecular diagnosis ofPneumocystis jirovecipneumonia in immunocompromised patients

Pneumocystis jiroveci is the major cause of pneumonia in immunocompromised patients. To evaluate the performance of single and nested-polymerase chain reaction (PCR) methods compared with immunofluorescent assay (IFA) and cytological staining for diagnosis of P. jiroveci infection, the bronchoalveolar lavage (BAL) and sputum samples from 60 immunocompromised patients were studied. Between January 2005 and March 2008, 75 respiratory specimens (41 BAL and 34 sputum samples) were examined for P. jiroveci identification. We used the clinical classification as our diagnostic standard and we considered true positive the definite or probable Pneumocystis pneumonia. Fourteen patients (23.3%) developed Pneumocystis pneumonia. Eleven patients had a positive IFA but only nine were positive by cytological staining. Sixteen patients had a positive detection of P. jiroveci by PCR and nested-PCR. Thirteen of these patients were considered as having a definite Pneumocystis pneumonia and one patient with a probable Pneumocystis pneumonia. Five other patients had a positive detection only by nested-PCR. These patients were classified as no Pneumocystis pneumonia. PCR detection of P. jiroveci is a very sensitive test and will offer a powerful technique in clinical laboratories for the routine diagnosis of Pneumocystis pneumonia. Using the nested-PCR, additional clinical cases can be diagnosed, but there is then an obvious risk of detecting subclinical colonisation by P. jiroveci.