Aggressive meningioma presents as innocuous forehead lesion: a case report

Cutaneous meningiomas are very rare neoplasms. In this case report we document a type III (anaplastic meningioma) presenting as a subcutaneous forehead mass. Anaplastic meningiomas arise from the neuraxis. They are biologically aggressive neoplasms that extend into the dermis or subcutaneous tissue via direct extension through the bone.

Teledermatology in the diagnosis of melanoma

Summary

We conducted a retrospective chart review of US Veterans in the Pacific Northwest area to compute melanoma incidence and Breslow depth at diagnosis. We compared Veterans with access to teledermatology (TD) and those without (non-TD). We identified pathology-confirmed primary melanomas in Veterans who had had at least one encounter at a VA facility during a 3-year study period. The age-adjusted melanoma incidence for all, TD and non-TD Veterans was 36, 15 and 57 per 100,000, respectively. The mean Breslow depth was significantly greater in the TD group ( P = 0.03). Although a higher proportion of thin (Breslow depth ≤1 mm) TD melanomas were mitotically active, this difference was not significant. We also found that 180 (40%) of the non-TD (face-to-face) diagnosed melanomas were from Veterans living in areas where TD was available. This suggests that the higher melanoma incidence in the non-TD group was mainly due to under-utilization of TD services. The study demonstrated that the TD service was not fully utilized in the VISN20 region, although the reasons for this are not clear. Where TD was utilized it tended to diagnose more advanced melanomas with worse initial prognosis.

Issues in validation of a dermatologic surgery simulator

At the University of Washington, we have been developing a suturing simulator using novel finite element model techniques which allow real-time haptic feedback. The issues involved in measuring validity in a suturing model have not been examined in a systematic way. Very few studies exist on the surgical factors that lead to good sutures. We have examined published data on these factors as well as previously studied metrics in suture training. This information has been combined with a review of types of validity (e.g., face, construct, predictive and concurrent) and reliability that must be considered in assessing any surgical simulator.

Virtual reality simulators for dermatologic surgery: measuring their validity as a teaching tool

Surgical simulation is increasingly being considered for training, testing, and possibly credentialing in medicine and surgery. At the University of Washington we have been developing a virtual reality (VR) suturing simulator. In the course of development it must be realized that expensive new technologies should bear the burden of proof of their effectiveness and reliability before they are put into training programs. The purpose of this article is to define the concept of surgical skill and to discuss how it can be measured in the context of validating VR surgical simulators. Specific measures of validity and reliability are reviewed and discussed.

Creating fast finite element models from medical images

The procedure for creating a patient-specific virtual tissue model with finite element (FE) based haptic (force) feedback varies substantially from that which is required for generating a typical volumetric model. In addition to extracting geometrical and texture map data to provide visual realism, it is necessary to obtain information for supporting a FE model. Among many differences, FE-based VR environments require a FE model with appropriate material properties assigned. The FE equation must also be processed in a manner specific to the surgical task in order to maximize deformation and haptic computation speed. We are currently developing methodologies and support software for creating patient-specific models from medical images. The steps for creating such a model are as follows: 1) obtain medical images and texture maps of tissue structures; 2) extract tissue structure contours; 3) generate a 3D mesh from the tissue structure contours; 4) alter mesh based on simulation objectives; 5) assign material properties, boundary nodes and texture maps; 6) generate a fast (or real-time) FE model; and 7) support the tissue models with task-specific tools and training aids. This paper will elaborate on the above steps with particular reference to the creation of suturing simulation software, which will also be described.

Fast finite element modeling for surgical simulation

Given the geometric complexity of anatomical structures, realistic real-time deformation of graphical reconstructions is prohibitively computationally intensive. Instead, real-time deformation of virtual anatomy is roughly approximated through simpler methodologies. Since the graphical interpolations and simple spring models commonly used in these simulations are not based on the biomechanical properties of tissue structures, these "quick and dirty" methods typically do not accurately represent the complex deformations and force-feedback interactions that can take place during surgery. Finite element (FE) analysis is widely regarded as the most appropriate alternative to these methods. Extensive research has been directed toward applying the method to modeling a wide range of biological structures, and a few simple FE models have been incorporated into surgical simulations. However, because of the highly computational nature of the FE method, its direct application to real-time force-feedback and visualization of tissue deformation has not been practical for most simulations. This limitation is primarily due to the overabundance of information provided by the standard FE approaches. If the mathematics is optimized to yield only the information essential for the surgical task, computation time can be drastically reduced. Parallel computation and preprocessing of the model before the simulation begins can also reduce the size of the problem and greatly increase computation speed. Such methodologies are being developed in a combined effort between the Human Interface Technology Laboratory (HIT Lab) and the Mechanical Engineering Department of the University of Washington. We have created computer demonstrations which support real-time interaction with simple finite element soft tissue models. In collaboration with the Division of Dermatology, a real-time skin surgery simulator is being developed using these fast FE methods.

Relative contribution of leukotriene B4 to the neutrophil chemotactic activity produced by the resident human alveolar macrophage

Human alveolar macrophages release chemotactic activity for neutrophils, providing a role for alveolar macrophages in regulating inflammation in the lung. As alveolar macrophages produce large amounts of leukotriene B4 (LTB4), a chemotactically active lipoxygenase product of arachidonic acid, we investigated the contribution of LTB4 to the total neutrophil chemotactic activity produced by these cells. Normal human alveolar macrophages were recovered by bronchoalveolar lavage from healthy volunteers and incubated either with the calcium ionophore A23187 for 1 h, or with opsonized zymosan particles or latex beads for 3 h. Nordihydroguaretic acid (NDGA), a relatively specific lipoxygenase inhibitor, blocked the release of neutrophil chemotactic activity after all three stimuli in a dose-dependent manner. This correlated with blockade of LTB4 production as measured by high performance liquid chromatography using freshly isolated alveolar macrophages, as well as blockade of [3H]LTB4 production by macrophages prelabeled with [3H]arachidonate. Molecular sieve chromatography using Sephadex G-50 confirmed that essentially all of the chemotactic activity in the stimulated macrophage supernatants co-eluted with authentic [3H]LTB4, and that NDGA completely blocked the chemotactic activity in the eluting fractions. Readdition of authentic LTB4 (1 X 10(-7) M) to the NDGA-blocked macrophage supernatants restored the chemotactic activity in the supernatants. The macrophage supernatants did not contain platelet-activating factor-like activity, as measured by the stimulation of [3H]serotonin release from rabbit platelets, and by high performance liquid chromatography. NDGA did not change the protein-secretion profiles of fresh alveolar macrophages, or of macrophages prelabeled with [35S]methionine. The complement (C) components C5adesarg were not detected in any of the supernatants by radioimmunoassay. Concentration of the supernatants by positive pressure filtration (5,000-D membrane) did not augment chemotactic activity in the stimulated supernatants or uncover chemotactic activity in the NDGA-blocked supernatants. As with the 3-h studies, when alveolar macrophages were incubated overnight with opsonized zymosan, all of the increase in chemotactic activity could also be blocked by NDGA. These data indicate that LTB4 is the predominant neutrophil chemotactic factor secreted by the normal resident human alveolar macrophage in response to two major types of stimuli, calcium fluxes across the cell membrane and the phagocytosis of opsonized particulates.

Simian virus 40-transformed adherent cells from human long-term marrow cultures: cloned cell lines produce cells with stromal and hematopoietic characteristics

Adherent cells from long-term marrow cultures from 23 individuals were transformed with wild-type simian virus 40 (SV40). After transformation, cloned cell lines were developed that even after rigorous subcloning invariably produced both stromal cells and round cells. The stromal cells expressed cytoskeletal filaments similar to those of long-term marrow culture adherent cells and produced interstitial and basal lamina collagen types. The round cells had the electron microscopic appearance of primitive hematopoietic cells and when examined with cytochemical stains and monoclonal antibodies to hematopoietic differentiation antigens had reaction patterns suggestive of cells from several lineages. Most round cells expressed the pan-hematopoietic T-200 determinant, and lesser percentages expressed the early T cell antigens CD-1 and CD-3, HLA-DR determinants, the monocytic antigen recognized by Leu M3, and the myeloid antigens detected by monoclonal antibodies 1G10 and 12.8. In addition, when plated in semisolid medium in the presence of a source of colony-stimulating activity, up to 11% of the cells formed colonies consisting of blastlike cells that also expressed hematopoietic cell surface determinants. The data suggest that adherent cells in long-term marrow cultures contain a cell that after transformation by SV40 obligately produces cells with hematopoietic as well as stromalike features.