Idiopathic Subglottic Stenosis Is Associated With More Frequent and Abnormal Squamous Metaplasia

OBJECTIVES

Gain insights into the pathophysiology of idiopathic subglottic stenosis (iSGS) by investigating differences in transcriptome of subglottic mucosal tissue between patients with iSGS and controls, and between tracheal and subglottic tissue within patients.

METHODS

RNA sequencing was conducted on biopsied mucosal samples collected from subglottic and tracheal (in-patient control) regions in iSGS patients, and from subglottis in controls. The gene expression differences were validated on a protein level by (1) staining the tissue samples obtained from a second cohort of patients and controls; and (2) in vitro functional assays using primary subglottic epithelial cells from both iSGS patients and healthy donors.

RESULTS

We found 7 upregulated genes in the subglottic region of iSGS patients relative to both the tracheal mucosa and subglottic region of controls. A gene ontology enrichment analysis found that the epithelial cell differentiation and cornification pathways are significant, involving specifically 3 of the genes: involucrin (IVL), small proline rich protein 1B (SPRR1B), and keratin 16 (KRT16). Involvement of these pathways suggests squamous metaplasia of the epithelium. Histological analyses of epithelium in subglottic mucosal biopsies revealed squamous metaplasia in 41% of the samples from iSGS patients and in 25% from controls. Immunohistochemical evaluation of the samples presented with squamous epithelium revealed increased expression of the protein encoded by SPRR1B, hyperproliferative basal cells, shedding of apical layers, and accompanying lesions in iSGS compared to CTRL. Cultured primary subglottic epithelial cells from iSGS patients had higher proliferation rates compared to healthy donors and squamous metaplastic differentiation formed thinner epithelia with increased expression proteins encoded by INV, SPRR1B, and KRT16, suggesting intrinsic dysfunction of basal cells in iSGS.

CONCLUSIONS

Abnormal squamous differentiation of epithelial cells may contribute to the pathogenesis of iSGS. Patients having metaplastic epithelial phenotype may be sensitive to drugs that reverse it to a normal phenotype.

Factors Associated With Otolaryngologists Performing Tracheotomy

Importance

Tracheotomies are frequently performed by nonotolaryngology services. The factors that determine which specialty performs the procedure are not defined in the literature but may be influenced by tracheotomy approach (open vs percutaneous) and other clinicodemographic factors.

Objective

To evaluate demographic and clinical characteristics associated with tracheotomies performed by otolaryngologists compared with other specialists and to differentiate those factors from factors associated with use of open vs percutaneous tracheotomy.

Design, Setting, and Participants

This multicenter, retrospective cohort study included patients aged 18 years or older who underwent a tracheotomy for cardiopulmonary failure at 1 of 8 US academic institutions between January 1, 2013, and December 31, 2016. Data were analyzed from September 2022 to July 2023.

Exposure

Tracheotomy.

Main Outcomes and Measures

The primary outcome was factors associated with an otolaryngologist performing tracheotomy. The secondary outcome was factors associated with use of the open tracheotomy technique.

Results

A total of 2929 patients (mean [SD] age, 57.2 [17.2] years; 1751 [59.8%] male) who received a tracheotomy for cardiopulmonary failure (652 [22.3%] performed by otolaryngologists and 2277 [77.7%] by another service) were analyzed. Although 1664 of all tracheotomies (56.8%) were performed by an open approach, only 602 open tracheotomies (36.2%) were performed by otolaryngologists. Most tracheotomies performed by otolaryngologists (602 of 652 [92.3%]) used the open technique. Multivariable regression analysis revealed that self-reported Black race (odds ratio [OR], 1.89; 95% CI, 1.52-2.35), history of neck surgery (OR, 2.71; 95% CI, 2.06-3.57), antiplatelet and/or anticoagulation therapy (OR, 1.74; 95% CI, 1.29-2.36), and morbid obesity (OR, 1.54; 95% CI, 1.24-1.92) were associated with greater odds of an otolaryngologist performing tracheotomy. In contrast, history of neck surgery (OR, 1.36; 95% CI, 0.96-1.92), antiplatelet and/or anticoagulation therapy (OR, 0.80; 95% CI, 0.56-1.14), and morbid obesity (OR, 0.94; 95% CI, 0.74-1.19) were not associated with undergoing open tracheotomy when performed by any service, and Black race (OR, 0.56; 95% CI, 0.44-0.71) was associated with lesser odds of an open approach being used. Age-adjusted Charlson Comorbidity Index score greater than 4 was associated with greater odds of both an otolaryngologist performing tracheotomy (OR, 1.26; 95% CI, 1.03-1.53) and use of the open tracheotomy technique (OR, 1.48, 95% CI, 1.21-1.82).

Conclusions and Relevance

In this study, otolaryngologists were significantly more likely than other specialists to perform a tracheotomy for patients with history of neck surgery, morbid obesity, and ongoing anticoagulation therapy. These findings suggest that patients undergoing tracheotomy performed by an otolaryngologist are more likely to present with complex and challenging clinical characteristics.

Is Continued Perioperative Antithrombotic Therapy Safe When Performing Open Tracheostomy?

OBJECTIVES

To date, there are no specific guidelines on antithrombotic therapy (ATT) management, which includes both anticoagulation and antiplatelet medications, for open tracheostomy. The objective of this study was to evaluate whether the use of perioperative antithrombotic medication during open tracheostomy influences the incidence of perioperative or postoperative complications.

METHODS

A retrospective review was conducted of all patients who underwent open tracheostomies at a tertiary care medical center from January 2015 to December 2019. Charts were reviewed for demographics, comorbidities, indication for tracheostomy, ATT use, operative details, and complications.

RESULTS

A total of 217 tracheostomies were evaluated for this study, of which 148 (68.2%) were not on ATT and 69 (31.8%) were on ATT during surgery. No significant difference was observed based on ATT status in perioperative bleeding (P = .983), postoperative bleeding (P = .24), or median days to decannulation (P = .5986). ATT patients were 2.67 times more likely to experience 30-day mortality than those non-ATT patients (P = .035). There was only one death due to hemorrhage in the ATT group. This was unrelated to the tracheostomy. This compares to 2 hemorrhage-related deaths in those not on ATT.

CONCLUSION

There was no significant difference in perioperative or postoperative bleeding based on ATT use. Patients on ATT were significantly more likely to experience 30-day mortality, however only one death was due to hemorrhage in the ATT group and was unrelated to tracheostomy. Therefore, continued perioperative ATT use appears to be safe when performing open tracheostomy.

LEVEL OF EVIDENCE

4.

Clinicodemographic Predictors of Tracheotomy Tube Size and Decannulation: A Multiinstitutional Retrospective Cohort Study on Tracheotomy

OBJECTIVE

We aimed to discern clinico-demographic predictors of large (≥8) tracheostomy tube size placement, and, secondarily, to assess the effect of large tracheostomy tube size and other parameters on odds of decannulation before hospital discharge.

SUMMARY OF BACKGROUND DATA

Factors determining choice of tracheostomy tube size are not well-characterized in the current literature, despite evidence linking large tracheostomy tube size with posttracheotomy tracheal stenosis. The effect of tracheostomy tube size on timing of decannulation is also unknown, an important consideration given reported associations between endotracheal tube size and probability of failed extubation.

METHODS

We collected information pertaining to patients who underwent tracheotomy at 1 of 10 U.S. health care institutions between 2010 and 2019. Tracheostomy tube size was dichotomized (≥8 and <8). Multivariable logistic regression models were fit to identify predictors of (1) large tracheostomy tube size, and (2) decannulation before hospital discharge.

RESULTS

The study included 5307 patients, including 2797 (52.7%) in the large tracheostomy cohort. Patient height (odds ratio [OR] = 1.060 per inch; 95% confidence interval [CI] 1.041-1.070) and obesity (1.37; 95% CI 1.1891.579) were associated with greater odds of large tracheostomy tube; otolaryngology performing the tracheotomy was associated with significantly lower odds of large tracheostomy tube (OR = 0.155; 95% CI 0.131-0.184). Large tracheostomy tube size (OR = 1.036; 95% CI 0.885-1.213) did not affect odds of decannulation.

CONCLUSIONS

Obesity was linked with increased likelihood of large tracheostomy tube size, independent of patient height. Probability of decannulation before hospital discharge is influenced by multiple patient-centric factors, but not by size of tracheostomy tube.

A Heterotopic Mouse Model for Studying Laryngeal Transplantation

Laryngeal heterotopic transplantation, although a technically challenging procedure, offers more scientific analysis and cost benefits compared to other animal models. Although first described by Shipchandler et al. in 2009, this technique is not widely used, possibly due to the difficulties in learning the microsurgical technique and time required to master it. This paper describes the surgical steps in detail, as well as potential pitfalls to avoid, in order to encourage effective use of this technique. In this model, the bilateral carotid arteries of the donor larynx are anastomosed to the recipient carotid artery and external jugular vein, allowing for blood flow through the graft. Blood flow can be confirmed intraoperatively by the visualization of blood filling in the graft bilateral carotid arteries, reddening of the thyroid glands of the graft, and bleeding from micro vessels in the graft. The crucial elements for success include delicate preservation of the graft vessels, making the correct size arteriotomy and venotomy, and using the appropriate number of sutures on the arterial-arterial and arterial-venous anastomoses to secure vessels without leakage and prevent occlusion. Anyone can become proficient in this model with sufficient training and perform the procedure in approximately 3 h. If performed successfully, this model allows for immunologic studies to be performed with ease and at low cost.

Comparing tracheostomy techniques: Bjork flap vs. tracheal window

OBJECTIVES

Various operative techniques are used to perform tracheostomies. The objective of this study was to evaluate patient factors that influence the decision to perform a Bjork flap or a window.

METHODS

A retrospective review was conducted of all patients who underwent tracheostomies from January 2015 to December 2019 at a tertiary care medical center. All patients underwent tracheostomy with either a Bjork flap or a window. Charts were reviewed for demographics, comorbidities, indication for tracheostomy, operative details, and complications.

RESULTS

A total of 217 tracheostomies were evaluated, of which 104 (47.9%) had a Bjork flap and 113 (52.1%) had a window. Bjork flap was significantly more likely to be performed in patients with a higher average body mass index (p = 0.05), requiring ventilatory support (p = 0.0001), or had a stroke (p = 0.0140). A window was used significantly more in patients with prior neck dissection (p = 0.0110) or neck radiation (p < 0.0001). No significant difference was observed for post-op bleeding, returning to the operating room, or days to decannulation. In all tracheostomies, thrombocytopenia was found to significantly correlate with post-op bleeding (p = 0.0006), while blood thinner use did not.

CONCLUSION

Bjork flaps were more likely to be performed in those with a history of prolonged mechanical ventilation and elevated body mass index. Windows were performed more frequently in patients with a head and neck cancer history. Future prospective studies are needed to compare the outcomes of these techniques and their impacts on the trachea long term.

Axillary fine needle aspiration cytology for pre-operative staging of patients with screen-detected invasive breast carcinoma

Introduction

Fine needle aspiration cytology (FNAC) of radiologically abnormal axillary lymph nodes in patients with breast cancer can identify patients suitable for primary axillary clearance (AC) rather than sentinel node biopsy, enabling surgical axillary staging by a single operation. This study assessed the accuracy of FNAC in predicting positive axillary lymph nodes.

Methods

161 patients with screen-detected invasive carcinoma and who had pre-operative FNAC of a radiologically abnormal axillary lymph node were identified from two screening units, The axillary FNAC reports were correlated with sentinel node biopsy and AC reports, and sensitivity, specificity, positive (PPV) and negative (NPV) predictive values were calculated.

Results

FNAC had a moderate sensitivity (66.3%) and NPV (71.8%), and a high specificity (98.7%) and PPV (98.3%). Most patients (86%) had a single axillary operation. The sensitivity was highest in grade 3 (81.8%) and ductal type (77.8%) tumours. The sensitivity was lower in tumours of special type (34.8%), grade 1 tumours (50%) and those without lymphovascular invasion (LVI) (55.9%). The NPV was highest in pT1 (86.7%) and in grade 1 (84.5%) tumours, and lowest (44%) in tumours with LVI. The PPV was 100% in grade 1 and 3 tumours, stage pT2 and pT3 tumours and those without LVI, and was high (>96%) in all other groups. In lymph-node-positive patients, the mean number of lymph nodes involved was higher in the case of a positive (6.4) than negative FNAC (4.4).

Conclusions

FNAC of ultrasonically abnormal axillary lymph nodes achieved surgical staging by a single operation in most patients with screen-detected invasive breast carcinoma, with moderate sensitivity and high specificity.

Sentinel lymph node biopsy in patients with a needle core biopsy diagnosis of ductal carcinoma in situ: is it justified?

BACKGROUND

The incidence of ductal carcinoma in situ (DCIS) has increased markedly with the introduction of population-based mammographic screening. DCIS is usually diagnosed non-operatively. Although sentinel lymph node biopsy (SNB) has become the standard of care for patients with invasive breast carcinoma, its use in patients with DCIS is controversial.

AIM

To examine the justification for offering SNB at the time of primary surgery to patients with a needle core biopsy (NCB) diagnosis of DCIS.

METHODS

A retrospective analysis was performed of 145 patients with an NCB diagnosis of DCIS who had SNB performed at the time of primary surgery. The study focused on rates of SNB positivity and underestimation of invasive carcinoma by NCB, and sought to identify factors that might predict the presence of invasive carcinoma in the excision specimen.

RESULTS

7/145 patients (4.8%) had a positive sentinel lymph node, four macrometastases and three micrometastases. 6/7 patients had invasive carcinoma in the final excision specimen. 55/145 patients (37.9%) with an NCB diagnosis of DCIS had invasive carcinoma in the excision specimen. The median invasive tumour size was 6 mm. A radiological mass and areas of invasion <1 mm, amounting to "at least microinvasion" on NCB were predictive of invasive carcinoma in the excision specimen.

CONCLUSIONS

SNB positivity in pure DCIS is rare. In view of the high rate of underestimation of invasive carcinoma in patients with an NCB diagnosis of DCIS in this study, SNB appears justified in this group of patients.

Merger mania. What will a merger mean to you?

Almost as worrisome as job tenure to survivors of corporate mergers is whether they will be able to work under a completely new set of assumptions. What effect will the merger of two different corporate cultures have on effectiveness, satisfaction and promotability? Even people who believe they know the partner's culture almost as well as their own are often surprised at what happens after a merger takes place. Find out what's likely to happen in a merger by asking a few key questions.

What do you owe your team? Survival tips for people who dread teamwork

Team building and teamwork are well entrenched in the American workplace. If you're independent, shy, or short on time, making decisions with a team may be one of the toughest situations you face. Learn how to get along with the rest of the group even if you don't buy in to the team concept. Teamwork may be one of your most useful career skills.

How to make the pitch for a part-time workload

Are you planning on moving from full-time to part-time hours? You'll need a game plan to negotiate what you want, including establishing a timeline and agreeing on productivity expectations. If you can agree on a reasonable timeframe that doesn't inconvenience anyone or endanger important results or relationships, you have a high probability of getting your boss' okay. If you and the boss can't agree on what you must produce, don't consider part-time work unless you thrive on combat. Once you negotiate your new schedule, consider the issue of managing co-worker resentment. Here are the best hints for keeping co-worker envy and resentment at a manageable level: Don't be secretive; keep a low profile; attend all office frolics; and ask for a trial period.

Someone promised mentors: will you deliver?

What are recruiters promising? Many new hires say that they accepted a job because of a promised mentoring program--one that never materializes, and one that the manager doesn't know was part of the discussions. Where does that leave the manager who may not be aware of this expectation? Faced with anchoring mobile Gen Xers, organizations are exploring mentoring as an inexpensive way to improve retention. But mentoring is not a technique that can be applied like a warm blanket to solve the problems of orientation, training, skills development, and retention. There are two reasons why mentoring isn't foolproof--the mentor and the protégé. If you are considering a mentoring program, or becoming a mentor yourself, here are some points to ponder: (1) If you can't (or won't) do it, give convincing reasons up front; (2) establish the rules of engagement; (3) a mentoring relationship doesn't guarantee loyalty; (4) having a protégé has political risks; (5) you can't force anyone to take advice; and (6) expect a quid pro quo.

The importance of building alliances

This may come as a surprise to Gen-Xers, but on-the-job allies are a political necessity. Information and support from workplace alliances are vital to doing your job. Your peers, boss, subordinates, and even enemies, can and should be in your network of allies. How do you build alliances? It's accomplished by cultivating relationships based on mutual benefit and interest. Information and favors are traded on a quid pro quo basis. Your peers, subordinates, and boss have different needs but they share some goals with you. Goals are the common denominator. Consider the following ways to cultivate your network of allies: Be a reliable news source; offer feedback; be congenial; share expertise; consult; strive to be a role model; don't demand credit; don't wait for recognition; articulate your needs; share a hot idea; save face for someone; and connect people who can help each other.

Small cell malignant melanoma: a variant of naevoid melanoma. Clinicopathological features and histological differential diagnosis

AIMS

To describe the clinical and histopathological features of a rare variant of naevoid melanoma, small cell melanoma, and discuss the histological differential diagnoses.

METHODS

The clinical and histological features of cases of malignant melanoma with the histological features of small (non-Merkel like) melanoma were reviewed and documented. In addition, five cases had available material for immunohistochemistry and this was performed using antibodies to the S100 protein and melan-A, and the HMB-45 antibody.

RESULTS

There were 15 cases of small cell melanoma from 14 (10 female, four male) patients, aged between 30 and 77 (mean, 48.6) years. The trunk was the most common location. In more than half the cases, the provisional diagnosis was melanoma/borderline lesion. All shared similar histological appearances of an intraepidermal component of in situ melanoma and a dermal component of nests of cells with hyperchromatic nuclei and scanty cytoplasm, usually in tightly packed nests. All components (junctional and intradermal) of the lesions investigated by immunohistochemistry were positive both for S100 protein and melan-A. All junctional components were positive with HMB-45, but with variable staining of the dermal components with this antibody.

CONCLUSIONS

Small cell malignant melanoma is postulated to be a distinct histopathological entity and a rare variant of naevoid melanoma. Such lesions can be difficult to interpret and easily missed at scanning magnification because the cells of the dermal component mimic benign naevus cells.

Fired? Here's an exit strategy

Who gets fired in a boom job market? People are fired more often for things they failed to do than for mistakes they made. The new rules of engagement are: There is no probationary period; resistance to technology is a quick ticket out; a lack of emotional commitment to the role you're hired to play is usually fatal; personality defects that keep others from producing are not tolerated. The most common reason for being fired, however, is lack of fit. Whether you're laid off or fired, don't ask for explanations. The fact is, the people with the power to get rid of you don't want you to stay. What matters is maximizing what they'll do for you on departure. To get the most favorable terms with the least financial and ego damage, here's a game plan: (1) Get a favorable reference--in writing--from your boss; (2) gather work samples and good performance appraisals you've received; (3) negotiate for as much severance pay as possible; (4) negotiate for outplacement assistance; (5) gather contact names from co-workers; and (6) leave in style.

Overworked? Lighten your load

Physician executives are suffering from creeping task migration--putting in too many hours for few appreciable results. Controlling this increasing workload has become one of the most important issues in health care, brought on by too few people trying to do too much. The only way to lessen the workload is to take charge, analyze, and act. Bosses won't care about the details. Several suggestions are presented to help physician executives downsize their workload while not reducing their output: (1) Compare your priorities with your boss's; (2) lighten up on the perfectionism; (3) change expectations; (4) look for "orphans" to cut--those projects that nobody is invested in; (5) don't target symbolic events; and (6) use logic to drive change. If you spend the next few months getting rid of the ineffective, inefficient, and redundant, you'll be ahead of the game. This is an ongoing task, and much easier done every three or four months than once a year.

Managing the deliberately mute

The contrast in communication styles and values between Gen-Xers, now mostly in their mid to late twenties, and forty- and fifty-somethings is obvious. Gen-Xers are focused on the assignment and the deadline; their goal is to do good work in a timely manner. But they are highly skeptical that enthusiasm has any influence on the outcome. When we question them about their taciturn manner, they all give us the same two reasons: They really don't care one way or the other and they're convinced that what they say doesn't matter anyhow. This may frustrate a manager charged with getting the buy-in or enthusiastic participation from the troops, but it's a fact. There are, however, ways to get Xers to talk--provided you really want their ideas and opinions and you acknowledge that you hear what they say. Here are the best techniques from those who successfully manage large numbers of the young, including young physicians: (1) Focus on what matters; (2) don't ask if you're not going to act on the feedback; (3) personalize your request for information; and (4) always do a worst case scenario when you need the buy-in.

Immune cell infiltrates and prognosis in primary carcinoma of the lung

The prognostic significance of immune cell infiltrates in surgically resected human lung cancer was investigated in 710 patients. Lymphoid infiltrates were quantified on both standard H&E stained sections and, in a subset of 95 cases, using immunohistochemistry and antibodies to CD3, CD8, CD57, CD68, CD79a and S100 to identify various immune cell types. Subjective grading (low, moderate, high) of lymphoid cell infiltrates on H&E sections of tumour and measurement, using image analysis, of overall level of tumour infiltration by any of the immunohistochemically labelled specific immune cell types of the stained sections showed no prognostic significance. However, when a distinction between peritumoural and intratumoural infiltration by particular cell types was made, intratumoural infiltration by high levels of CD3+ and S100+ cells was associated with longer post-operative survival (P = 0.02 and P = 0.045, respectively). In lung cancer, subjective assessment of tumour lymphoid infiltration and overall levels of infiltration by particular immune cell types carries no prognostic significance. Intratumoural infiltration by relatively high numbers of CD3+ T-lymphocytes and Langerhans cells (S100+) is associated with a better patient outcome.

Are you obsolete?

Are you vulnerable, regardless of length of service at your organization and your unique skill sets? There are ways to test vulnerability and assemble some hard evidence that your management role makes a difference. You need to conduct a self-test for obsolescence. Ask yourself the following questions: Are your skills state-of-the-art? As a manager, how do you compare with others doing the same, or similar, job at competing organizations? Is your role essential? Where does your job fall into the big picture? Can you be replaced easily? If a thorough examination of your skills and your role convinces you that your contribution returns more to the organization than your salary, can you prove it? Consider these strategies: (1) Put together a portfolio, (2) ensure your boss' support, (3) advertise your successes, and (4) cultivate recruiters. The best reason to analyze your value to the organization is that if you are laid off, getting another comparable job--or a better one--will be far less of a hassle.

How to survive a new CEO

A new CEO means everyone in the organization is now a new hire--an unknown entity that must prove he or she can and will enthusiastically, tirelessly support the CEO's agenda. Those who want to stay on the payroll must avoid a business-as-usual attitude and demonstrate that they share the CEO's dedication to change. If you're in a staff job, it's important to show you're essential to the new regime, quickly and convincingly. Some important steps to consider as you plan for the transition include: Do your home-work; anticipate the CEO's needs; be supportive and nonpolitical; be realistic with your direct reports; and appear poised to leave willingly and quietly--and you may not have to.

Selling yourself in a tough health care market

Physician executives are vying for top positions in health care organizations. With so many qualified candidates in the marketplace, how can you differentiate yourself as a strong contender? Recruiters search through hundreds of résumés, not the ten or 20 that many hospital and HMO CEOs have seen. Recruiters--the people who actually find specific candidates--were interviewed to find out what they are looking for. Here are the top items on their checklists: Articulated focus, documented results, competitive intelligence, professional growth, good references, appearance and social skills, responsive and timely, and technical skills.

Understanding the demographics of the evolving workforce

The author discusses the four age cohorts currently in the workplace and the fifth that will arrive by the year 2005: the Pre-Boomers, Boomers, Cuspers, Busters, and Netsters. She describes their workplace and lifestyle characteristics, their social values, and their communication styles. Strategies for motivating and communicating when managing a workforce of diverse ages also are included.

Cyclin D1 expression and HHV8 in Kaposi sarcoma

BACKGROUND

Human herpesvirus 8 (HHV8) appears to be the agent responsible for Kaposi sarcoma. The mechanism remains undetermined but may involve cell cycle regulating genes including D type cyclins which are pivotal in cell cycle progression. Recent HHV8 genetic analysis has revealed the presence of a v-cyclin which is homologous to D type cyclins.

AIMS

First, to assess whether there is an independent relation between endogenous cyclin D1 expression in Kaposi sarcoma and HHV8 status; second to determine whether v-cyclin mRNA expression varies with Kaposi sarcoma stage.

METHODS

Cyclin D1 immunohistochemistry was performed on 17 paraffin embedded Kaposi sarcoma samples from 16 patients. HHV8 status was assessed in 15 of these using nested polymerase chain reaction (PCR) to ORF 26 and the newly described technique of TaqMan PCR. An additional 10 fresh Kaposi sarcoma samples (early and nodular) were examined for HHV8 v-cyclin RNA.

RESULTS

One case, which did not contain amplifiable HHV8, showed strong cyclin D1 staining. The remaining cases were negative or weakly staining; v-cyclin transcript load was higher in early Kaposi sarcoma.

CONCLUSIONS

While endogenous cyclin D1 expression is independent of HHV8 status, v-cyclin transcription is higher in early lesions, supporting the "viral hit" hypothesis.

Mistakes the newly promoted make

Many newly promoted managers make identical mistakes, most of them preventable. Physician executives who are thinking of taking on a bigger job should consider the following eight mistakes: (1) misreading top management's agenda, (2) micromanaging your successor, (3) not updating technical skills, (4) assuming customs and taboos are negotiable, (5) not rewriting your job description to mirror your new role, (6) not mentally moving from management to leadership, (7) not adjusting to relationships, and (8) not identifying a likely successor.

When to counter and when not

It's a booming job market. Currently, job hunters are excited by the opportunities to get all they can, and headhunters and hiring organizations are pressured to find the best recruits. When the market is overheated, as it is, both candidates and recruiters are tempted to trust each other and not sweat the details. They are also tempted to believe that "a good candidate can fit in anywhere." It's time to share some cautionary tales that apply to job hunting physicians. The litany of mistakes extreme prosperity induces are described, including: (1) sloppy, superficial research, (2) rushing the process, (3) relying on things to "work out," and (4) soft peddling performance expectations.

Tamoxifen and the endometrium: review of 102 cases and comparison with HRT-related and non-HRT-related endometrial pathology

Tamoxifen, a synthetic anti-estrogen that paradoxically acts as a partial estrogen agonist on the endometrium, is associated with an increased frequency of proliferative endometrial lesions, including hyperplasias, neoplasms, and polyps. Tamoxifen-related polyps are characteristically multiple and fibrotic. A variety of metaplasias and periglandular stromal condensation may be seen. Relatively few articles have focused on the descriptive morphology of the full range of tamoxifen-associated lesions. The present study further defines the histologic features in both endometrial polyps and nonpolyp endometrium. One hundred and two specimens (including 50 polyps) were reviewed using hormone replacement therapy-related endometrial specimens and conventional polyps as the control groups. The most characteristic findings of tamoxifen-associated lesions included polarized glands along the long axis of polyps (40%), a cambium layer (72%), frequent and diverse metaplasias, staghorn glands (36%), myxoid degeneration (12%), and small glands (36%). Similar morphologic features were identified in the hormone replacement therapy and control groups but to a variable, lesser extent. Overall, the tamoxifen group consisted of 18 cases of hyperplasia (11 complex, 7 simple) and one case each of adenofibroma, adenosarcoma, endometrial stromal sarcoma, and leiomyosarcoma. Although none of the features is diagnostic, the presence of diverse metaplasias, polarized glands, staghorn glands, and a cambium layer strongly suggest tamoxifen exposure especially if a number of these features are present concurrently within the same material.

The art and science of starting a new job

To be successful in a new job out-of-town, physician executives need to develop a plan for a smooth transition into the organization. A checklist to prepare yourself for the new position should include: Updating your research; (2) staying in close contact with your new boss; (3) visiting the office; (4) hiring your own support person; (5) planning the first week; (6) telling the troops how to manage you; (7) making early decisions; and (8) meeting your peers. The focus should be on the job and connecting with your new boss, medical staff, and coworkers--and not exclusively on the environment of your home-to-be.