Repair of a delayed, traumatic dorsal diaphragmatic hernia using a single paracostal approach in a dog

CASE HISTORY

A 1-year-old German Shepherd dog presented for delayed onset of a traumatic, dorsal diaphragmatic hernia of the pars lumborum.

CLINICAL FINDINGS AND TREATMENT

Herniorrhaphy via a ventral midline celiotomy (with and without a paracostal extension) were unsuccessful and the hernia recurred. The hernia was successfully repaired using a single lateral paracostal surgical approach. This approach provided excellent exposure and should be considered for dorsal pars lumborum diaphragmatic hernia repairs.

DIAGNOSIS

Dorsal diaphragmatic hernia of the pars lumborum.

CLINICAL RELEVANCE

Whilst uncommon, tears to the dorsal aspect of the diaphragm should be considered as well as the more common radial or circumferential pars costalis tears. Pre-operative computed tomographic imaging can identify the exact location of the hernia in order to allow the best surgical approach to be determined. A lateral paracostal approach should be considered as an alternative to a ventral midline celiotomy with or without paracostal extension for repair of dorsal diaphragmatic hernias affecting the pars lumborum, as it provides excellent exposure. A single lateral paracostal approach has not been reported previously for diaphragmatic hernia repair in dogs.

Motor Protein Transport Along Inhomogeneous Microtubules

Many cellular processes rely on the cell's ability to transport material to and from the nucleus. Networks consisting of many microtubules and actin filaments are key to this transport. Recently, the inhibition of intracellular transport has been implicated in neurodegenerative diseases such as Alzheimer's disease and Amyotrophic Lateral Sclerosis. Furthermore, microtubules may contain so-called defective regions where motor protein velocity is reduced due to accumulation of other motors and microtubule-associated proteins. In this work, we propose a new mathematical model describing the motion of motor proteins on microtubules which incorporate a defective region. We take a mean-field approach derived from a first principle lattice model to study motor protein dynamics and density profiles. In particular, given a set of model parameters we obtain a closed-form expression for the equilibrium density profile along a given microtubule. We then verify the analytic results using mathematical analysis on the discrete model and Monte Carlo simulations. This work will contribute to the fundamental understanding of inhomogeneous microtubules providing insight into microscopic interactions that may result in the onset of neurodegenerative diseases. Our results for inhomogeneous microtubules are consistent with prior work studying the homogeneous case.

Fibroblastic Subtype has a Favourable Prognosis in Appendicular Osteosarcoma of Dogs

Osteosarcoma (OS) is an aggressive malignant bone neoplasm that occurs mostly in the appendicular skeleton of dogs and people. OS is classified based on the presence of malignant stroma and the formation of extracellular matrix into osteoblastic, chondroblastic and fibroblastic forms. This study investigated the correlation between the three histological subtypes of canine OS and clinical outcome. Additionally, we examined whether there was any difference in the immunolabelling of desmin, S100 and neuron-specific enolase (NSE) between the three histological subtypes. Formalin-fixed and paraffin wax-embedded tissues from 87 dogs with primary OS were available for this study. The survival times were correlated with appendicular OS subtypes in dogs that were treated surgically, received adjuvant chemotherapy and had no pulmonary metastasis at the time of diagnosis. Dogs with an appendicular fibroblastic OS had significantly prolonged mean average survival times (546 ± 105 days) in comparison with dogs having appendicular osteoblastic (257 ± 48 days) or appendicular chondroblastic (170 ± 28 days) OS (P = 0.003, Log Rank). The results also revealed that the appendicular chondroblastic subtype is a significant indicator for poor prognosis in dogs compared with the fibroblastic or osteoblastic subtypes (P = 0.006, Cox regression). Moreover, the findings indicated that there was no significant correlation between the localization of desmin, NSE or S100 and histological subtypes. Importantly, dogs with appendicular fibroblastic OS were found to have a better prognosis when compared with dogs with other subtypes. This may suggest that histological subtypes of appendicular OS have diverse behaviour and could be used to categorize patients for risk-based assessment.

Immunohistochemical Validation of Spontaneously Arising Canine Osteosarcoma as a Model for Human Osteosarcoma

Osteosarcoma (OS) originates from bone-forming mesenchymal cells and represents one of the primary bone tumours. It is the most common primary bone tumour in dogs and man. The characterization of an appropriate natural disease animal model to study human OS is essential to elucidate the pathogenesis of the disease. This study aimed to validate canine OS as a model for the human disease by evaluating immunohistochemically the expression of markers known to be important in human OS. The immunohistochemical panel included vimentin, alkaline phosphatase (ALP), desmin, S100, neuron-specific enolase (NSE), runt-related transcription factor 2 (Runx2) and bone morphogenetic protein 4 (BMP4). Immunohistochemistry was conducted on formalin-fixed, paraffin wax-embedded tissue sections from 59 dogs with confirmed primary OS. Vimentin, ALP, Runx2 and BMP4 were highly expressed by all tumours, while desmin, S100 and NSE were expressed variably. The findings were similar to those described previously for human OS and suggest that canine OS may represent a useful model for the study of the human disease.

Rayleigh approximation to ground state of the Bose and Coulomb glasses

Glasses are rigid systems in which competing interactions prevent simultaneous minimization of local energies. This leads to frustration and highly degenerate ground states the nature and properties of which are still far from being thoroughly understood. We report an analytical approach based on the method of functional equations that allows us to construct the Rayleigh approximation to the ground state of a two-dimensional (2D) random Coulomb system with logarithmic interactions. We realize a model for 2D Coulomb glass as a cylindrical type II superconductor containing randomly located columnar defects (CD) which trap superconducting vortices induced by applied magnetic field. Our findings break ground for analytical studies of glassy systems, marking an important step towards understanding their properties.

Attitudes, knowledge, and behavior of family physicians regarding depression in late life

OBJECTIVES

To assess self-reported knowledge, attitudes, and behaviors of practicing community family physicians regarding identification and management of depression in late life.

DESIGN

We sent a 3-page "fax-back" survey to 768 active physician members of the Maryland Academy of Family Physicians, Baltimore.

MEASUREMENTS

We asked physicians to rate how confident they felt in evaluating several common medical conditions of late life, including depression. The questionnaire included items related to knowledge and treatment practices for depression in older adults.

RESULTS

Two hundred fifteen usable surveys were returned. In general, physicians took responsibility for diagnosing and treating depression. Few physicians reported that they routinely referred the older patient to a psychiatrist to treat depression, and only half thought that consultation was helpful. Physicians responding to the survey were generally aware of alternative presentations of depression in elderly persons, and were well informed about the duration of treatment with medications for depression. Most were using selective serotonin reuptake inhibitors as first-line agents to treat depression. Physicians though that medications for depression were as effective for older patients as for younger patients, but were less optimistic about the effectiveness of psychotherapy. The barriers to identifying and treating depression in older patients most often mentioned by physicians were related to the atypical presentation of depression in older adults. More than half of the physicians rated themselves as "very confident" in evaluating depression. There were few differences in the responses of physicians with and those without a Certificate of Added Qualifications in geriatrics.

CONCLUSIONS

Depression in late life remains a difficult clinical challenge for primary care physicians. These findings are particularly relevant in the face of recent efforts to increase collaboration between primary care physicians and mental health professionals.

EMS agenda for the future: where we are ... where we want to be. EMS Agenda for the Future Steering Committee

During the past 30 years, emergency medical services (EMS) in the United States have experienced explosive growth. The American health care system is now transforming, providing an opportune time to examine what we have learned over the past three decades in order to create a vision for the future of EMS. Over the course of several months, a multidisciplinary steering committee collaborated with hundreds of EMS-interested individuals, organizations, and agencies to develop the "EMS Agenda for the Future." Fourteen EMS attributes were identified as requiring continued development in order to realize the vision established within the Agenda. They are Integration of Health Services, EMS Research, Legislation and Regulation, System Finance, Human Resources, Medical Direction, Education Systems, Public Education, Prevention, Public Access, Communication Systems, Clinical Care, Information Systems, and Evaluation. Discussion of these attributes provides important guidance for achieving a vision for the future of EMS that emphasizes its critical role in American health care.

EMS Agenda for the Future: where we are...where we want to be

During the past 30 years, emergency medical services (EMS) in the United States have experienced explosive growth. The American health care system is now transforming, providing an opportune time to examine what we have learned over the past three decades in order to create a vision for the future of EMS. Over the course of several months, a multidisciplinary steering committee collaborated with hundreds of EMS-interested individuals, organizations, and agencies to develop the EMS Agenda for the Future. Fourteen EMS attributes were identified as requiring continued development in order to realize the vision established within the Agenda. They are integration of health services, EMS research, legislation and regulation, system finance, human resources, medical direction, education systems, public education, prevention, public access, communication systems, clinical care, information systems, and evaluation. Discussion of these attributes provides important guidance for achieving a vision for the future of EMS that emphasizes its critical role in American health care.

The impact of kyphosis on daily functioning

OBJECTIVES

To determine whether moderate or severe kyphosis is associated with decrements in physical function, especially mobility.

DESIGN

Cross-sectional analysis of a cohort study.

SETTING

The Johns Hopkins Functional Status Laboratory, a multidisciplinary, standardized, quantitative assessment center.

PARTICIPANTS

A total of 231 community-dwelling volunteers aged 59 and older who participated in a 1-day evaluation.

MEASUREMENTS

Age, gender, self report of physical function, standardized measurement of: kyphosis (both qualitatively clinical criteria and quantitative assessment), time to walk 5 meters (0.1 seconds), and time to climb a flight of stairs (0.1 seconds) at usual pace.

RESULTS

Using multivariate step-wise regression analysis, the presence and severity of kyphosis, measured qualitatively, was independently associated with time to walk 5 meters and to climb a flight of stairs (P = .015, P < .001, respectively), adjusting for moderate-severe scoliosis, heart rate response to exercise, arthritis, vertigo, age, and gender. Similarly, quantitative kyphosis was associated independently with stair climb time (P = .005). Qualitative kyphosis was also associated with difficulty reaching (OR = 2.21 (95% CI: 1.14 to 4.29)) and difficulty performing heavy housework (OR = 1.64 (95% CI: 1.03 to 2.61)), adjusting for prior diagnosis of moderate-severe scoliosis, prior diagnosis of arthritis, age, and gender.

CONCLUSION

Kyphosis, by both clinical and quantitative assessment, is associated with diminished function, especially performance of mobility tasks. This association should be verified prospectively. If predictive, the impact of kyphosis on physical function should be considered in osteoporosis prevention and treatment counseling.

Increased fall rates in nursing home residents after relocation to a new facility

OBJECTIVE

To examine the change in fall rates after relocation of nursing home residents from one facility to another and to identify resident risk factors for changes in falls following relocation.

DESIGN

Retrospective review of incident reports to identify falls, followed by chart review of a longitudinal cohort.

SETTING

An academic nursing home whose residents and programs moved from a 125-year-old, 233-bed facility to a newly constructed 255-bed facility.

PATIENTS

A total of 210 nursing home residents were moved from one facility to the other. Of these, 133 individuals who lived in the old facility for 9 months before the move and in the new facility for 6 months after the move formed the longitudinal cohort.

RESULTS

In the 3 months after the move, the fall rate increased from 0.34 to 0.70 falls per resident per quarter in the entire nursing home population (P < .001) and subsequently returned to baseline. In the longitudinal subgroup the fall rate went from 0.26 to 0.60 (P < .005). Fall-related injuries in the longitudinal subgroup went from 0.058 injuries per resident per quarter at baseline to 0.15 (P < .001). However, the injury rate per fall did not change. There were no characteristics associated with being a faller in the quarter before the move. Dementia and not being bedbound were associated with being a faller after the move. Individuals who were ambulatory or wheelchair mobile had a significant risk of increasing the number of falls after the move, and individuals with dementia had a strong but insignificant trend in this direction.

CONCLUSIONS

The incidence of falling doubled after relocation of nursing home residents to a new facility. An increase in falls was seen in individuals who were not bedbound. Although nursing home relocation may be a relatively uncommon occurrence, it is reasonable to infer that older individuals who change their living environments are at increased risk for falls and fall-related injuries.

Emergency medical service system development: results of the statewide emergency medical service Technical Assessment Program

STUDY OBJECTIVE

The National Highway Traffic Safety Administration developed the EMS (emergency medical services) Technical Assessment Program to assist states in developing and improving their EMS systems. The main goals of this evaluation were to document the level of improvement in EMS system development following completion of the Technical Assessment Program and to identify necessary program improvements at the National Highway Traffic Safety Administration.

DESIGN

Independent investigators retrospectively reviewed the information in Technical Assessment Program reports from 35 states that participated in the program during a 5-year period.

RESULTS

Training and certification programs for prehospital personnel were the most well-developed elements of EMS systems. Conversely, comprehensive quality management and EMS system evaluation programs were almost uniformly absent (89% of states). Areas of need targeted for improvement included enabling legislation for EMS (60%) or trauma system development (69%), an improved mechanism to assess system resources (71%), an established or updated state EMS plan (80%), aging and unreliable communications equipment (89%), fully operational prehospital data collection systems (89%), and consistent medical oversight for all prehospital providers (92%).

CONCLUSION

Program evaluation revealed that significant recommendation-based changes occurred in all components of EMS systems. The Technical Assessment Program is one tool that states can use to promote EMS system improvements.

Tensile testing of rodlike trabeculae excised from bovine femoral bone

Individual trabeculae, rodlike in form, were excised from bovine femora and tested in tension to obtain stress-strain plots. Tensile grips were constructed to permit such small specimens to be tested and to avoid slippage during the test. Data were collected for 38 specimens. The results of these tests show that rodlike trabeculae obtained from the femora of young bovine animals have an average Young's modulus in tension of approximately 1 GPa. This value is an order of magnitude lower than the corresponding value for cortical bone in the diaphysis of the femur.

Patient perception of cardiovascular surgical patient education

After surgery, 100 adult cardiac surgical patients participated in a study to determine what information was important to them and how well prepared they were. Questionnaires were administered 5 to 10 days after surgery and 1 to 4 weeks after discharge. In general patients received information that they perceived to be important, and they believed that preparation was more than adequate. Patients indicated a need to know more information about medication side effects than they received, and they did not desire as much information about emotional changes or sexual activity as the literature suggested.