Robust, defensible, and fair: The AMEE guide to selection into medical school: AMEE Guide No. 153

Selection is the first assessment of medical education and training. Medical schools must select from a pool of academically successful applicants and ensure that the way in which they choose future clinicians is robust, defensible, fair to all who apply and cost-effective. However, there is no comprehensive and evidence-informed guide to help those tasked with setting up or rejuvenating their local selection process. To address this gap, our guide draws on the latest research, international case studies and consideration of common dilemmas to provide practical guidance for designing, implementing and evaluating an effective medical school selection system. We draw on a model from the field of instructional design to frame the many different activities involved in doing so: the ADDIE model. ADDIE provides a systematic framework of Analysis (of the outcomes to be achieved by the selection process, and the barriers and facilitators to achieving these), Design (what tools and content are needed so the goals of selection are achieved), Development (what materials and resources are needed and available), Implementation (plan [including piloting], do study and adjust) and Evaluation (quality assurance is embedded throughout but the last step involves extensive evaluation of the entire process and its outcomes).HIGHLIGHTSRobust, defensible and fair selection into medical school is essential. This guide systematically covers the processes required to achieve this, from needs analysis through design, development and implementation, to evaluation of the success of a selection process.

Statin-related muscle complications masquerading as soft tissue sarcomas

Musculoskeletal injuries are a known side effect of long-term statin use. These injuries include sudden, atraumatic muscle rupture which can cause extremity hematomas that motivate patients to seek evaluation and physicians to send referrals for oncologic workup. We discuss two cases where malignancy was suspected rather than statin-induced muscle injury. Using these cases as examples, we discuss subtleties between the two diagnoses so that muscle rupture may be considered prior to subspecialist referral. This paper aims to serve as a reminder and guide for physicians who encounter long-term statin users with nonspecific, improving musculoskeletal symptoms and hemorrhagic MRI findings that lack nodular or mass-like enhancements. While referral to orthopedic oncology is always encouraged in cases of uncertainty, it may not always be necessary.

IVC filter placement in patients undergoing surgical treatment of bone or soft-tissue tumors

BACKGROUND AND OBJECTIVES

Patients with cancer to bone or soft tissues undergoing orthopedic procedures may be unable to receive pharmacologic prophylaxis for venous thromboembolism (VTE). Inferior vena cava (IVC) filters may be an effective method to prevent fatal pulmonary embolism (PE) in these patients.

METHODS

Retrospective chart review performed for patients surgically treated for malignant disease of bone or soft tissue who had IVC filter placement. Type of surgery, anatomic region, and development of wound complications requiring repeat surgery were analyzed.

RESULTS

From 2007 to 2018, 286 patients received IVC filters. Ten (3.5%) patients suffered deep vein thrombus (DVT) postoperatively. There was no acute fatal PE. Two patients suffered PE at 2 and 99 days postoperatively. Risk of DVT was comparable following surgery with endoprosthesis versus open reduction and internal fixation (p = 0.056) and with soft tissue versus bone involvement (p = 0.620). Three filter-related complications occurred. Patients disease at the femur had the highest rate of DVT.

CONCLUSIONS

Following treatment of malignant disease of bone or soft-tissues, two patients with IVC filter placement experienced nonfatal PE and three patients experienced filter-related complications. No patients in this series experienced a fatal PE.

Outcomes following periacetabular tumor resection: A 25-year institutional experience

BACKGROUNDS AND OBJECTIVES

Following tumor resection involving the acetabulum (periacetabular), various methods of reconstruction exist. The objective of this study was to analyze functional outcomes and complication rates by extent of periacetabular tumor resection, as well as by method of reconstruction.

METHODS

Twenty-three patients underwent periacetabular resection for a primary pelvic bone tumor from 1993-2018 at a single institution. Complications were documented and functional outcomes were assessed using the Musculoskeletal Tumor Society (MSTS) scoring system.

RESULTS

Mean age was 42.8 ± 22.6 years. Mean follow-up was 107 ± 75 months. MSTS scores were highest in patients with allograft reconstruction (80.2%) and lowest in saddle reconstruction (38.0%). MSTS scores were higher in patients with Type II periacetabular resection alone compared with Type II + additional resection (78.6% vs 60.3%; P = .019). Complications were lower in patients with Type II periacetabular resection alone (75% vs 28.6%; P = .036). Complications were highest following allograft reconstruction (78%) and lowest following hemipelvectomy without reconstruction (20%).

CONCLUSION

Patients who underwent allograft/APC or nonsaddle metallic reconstruction experienced the highest functional outcome scores, but also sustained a higher complication rate than patients with hemipelvectomy without reconstruction. Patients with resection of ilium and/or pubis in addition to the periacetabular region had lower functional outcome scores and higher risk for complication.

0374 Decline in Habitual Sleep Duration Over 10 Years and Worsening Sleep Disparities: Data From NHIS (2006-2015)

Introduction

Despite claims in the media, evidence that habitual sleep has declined in recent years is scant. Few data sources exist that systematically document sleep duration in a nationally representative sample, in the same way, over several years.

Methods

Data from 10 years of the National Health Interview Survey were used (N=305,555). During all years, habitual sleep duration, age, sex, race/ethnicity, and height/weight were recorded in the same way. Weighted regression analyses examined sleep duration as the outcome, year as linear predictor, and sociodemographics as covariates. Then, interaction terms examined whether the linear change associated with years was differentially experienced by different sociodemographic groups.

Results

The linear trend of sleep duration over the past 10 years is a loss of 0.78 minutes per year (95%CI -0.91,-0.64; p<0.0001). After adjustment for age, sex, race/ethnicity and BMI, this remained relatively unchanged at 0.86 minutes (95%CI -0.99,-0.73; p<0.0001). A year-by-race/ethnicity interaction was observed (p<0.05). In stratified analyses, Non-Hispanic Whites showed a loss of 0.68 minutes per year (95%CI -0.84,-0.52, p<0.0001). This was 1.33 minutes/year in Blacks/African-Americans (95%CI -1.74,-0.92; p<0.0001), 1.57 minutes/year in Mexican-Americans (95%CI -1.98,-1.16; p<0.0001), 0.99 minutes/year in other Hispanics/Latinos (95%CI -1.51,-0.47; p<0.0001), 0.74 minutes/year in Asians (95%CI -1.24,-0.25; p=0.003), and 1.80 minutes/year in American Indians/Alaskan Natives (95%CI -3.57,-0.03, p=0.046).

Conclusion

On average, the US population has lost 47 seconds of nightly sleep per year over a 10-year period, equating to about 4.7 hours of sleep per year, but racial/ethnic groups were impacted differently. Compared to Non-Hispanic Whites, Blacks/African-Americans lost 96% more sleep, Mexicans lost 131% more sleep, other Hispanics/Latinos lost 46% more sleep, Asians lost 9% more sleep, and American Indians lost 165% more sleep. Thus, sleep disparities may be widening.

Support

Dr. Grandner is supported by R01MD011600

0376 Demographic and Socioeconomic Implications of Excessive Daytime Sleepiness in the Community

Introduction

Daytime sleepiness impairs daily functioning and may be directly related to insufficient nighttime sleep. Previous studies have assessed disparities in sleep duration and quality, but community-level disparities in daytime sleepiness using validated measures are lacking.

Methods

Data were from the Sleep and Healthy Activity, Diet, Environment, and Socialization (SHADES) study of N=1007 adults age 22-60. Daytime sleepiness was assessed with the Epworth Sleepiness Scale (ESS). Predictors included age, sex, race/ethnicity, education, and social class (“Upper middle class or above,” “Middle class,” “Lower middle class,” “Poor,” or “Very Poor”). One-way ANOVAs evaluated group differences. Stepwise linear modeling evaluated ESS score relative to sociodemographic predictors. Final models included all variables entered together to evaluate independent effects. Finally, habitual sleep duration was entered as an additional covariate.

Results

ESS score was higher among racial/ethnic minorities (p=0.0006), men (p<0.0001), those with less education (p=0.008) and lower social class (p=0.0007), and those who are retired or unable to work (p=0.03); marginal differences were seen according to age (p=0.06). Using a model-building approach, age, sex, race/ethnicity, education, social class, and employment were evaluated. Only race/ethnicity (F=5.1, p=0.0004), education (F=4.8, p=0.003), and social class (F=2.14, p=0.046) incrementally added variance to model R2. No 2-way interactions were found. In the final model, significant predictors included Black/African-American race/ethnicity (B=0.94, p=0.01), some college (B=0.99, p=0.005), and being very poor (B=2.16, p=0.005). When controlling for nocturnal sleep duration, the increased sleepiness associated with being Black/African was attenuated (p=0.06), but the other relationships were still significant.

Conclusion

There is a “sleepiness disparity” in the population associated with race/ethnicity and socioeconomics. Daytime sleepiness in the community is associated with being Black/African-American, having some college, and being “very poor.” The race/ethnicity difference in daytime sleepiness may be partially explained by differences in total sleep time.

Support

This work was supported by a grant from Jazz Pharmaceuticals. The SHADES study was funded by R21ES022931. Dr. Grandner is supported by R01MD011600.

0400 Habitual Sleep, Circadian Misalignment, and Cardiovascular Risk Factors Among Late Adolescents

Introduction

Emerging evidence suggests the potential role of sleep in cardiovascular disease (CVD) risk. Sleep variability and circadian misalignment may represent understudied sleep dimensions, particularly among late adolescents. This study investigated the associations of habitual sleep, circadian misalignment, night-to-night sleep variability with CVD risk factors among late adolescents.

Methods

Using a cross-sectional design, we enrolled 58 healthy, college students (19.22±1.06 years old). Participants completed a 7-day sleep diary, the Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale. Circadian misalignment was assessed using the weekend-weekday differences in sleep duration and midsleep time. Sleep variability was calculated as intra-individual standard deviation of sleep durations. The number of CVD risk factors (BMI, waist circumference, blood pressure, fasting glucose and lipid profile) above subclinical/clinical thresholds was used as a proxy of overall risk. Logistic and generalized linear regression tested the relationships.

Results

Forty-two participants (73%) had at least one elevated CVD risk factors and 19 (34%) were short sleepers (<7 h). On average, the midsleep shifted 54 minutes later on weekends and the intraindividual sleep variability was 1.31 hours. After controlling for age, gender and race, there was a trend towards higher overall CVD risk (β=0.45±0.22, p=0.05) with a greater weekend-weekday discrepancy in sleep duration. For each CVD risk factor, a greater discrepancy in weekend-weekday midsleep times (OR=2.29±0.82, p=0.02) was estimated to increase the odds of high blood pressure. Participants with greater discrepancy in weekday-weekend sleep durations (OR=1.58±0.41, p=0.03) or excessive daytime sleepiness (OR=4.68±3.38, p=0.03) were more likely to have high BMI. Worse sleep quality (higher PSQI scores) was associated with high BMI (OR=1.36±0.19, p=0.03) and waist circumference (OR=1.40±0.24, p=0.04).

Conclusion

This study suggests that circadian misalignment, compared with other sleep characteristics, better predicts cardiovascular risk among late adolescents. Future research is needed to examine the interaction among circadian misalignment, sleep variability and sleep duration on CVD risk.

Support

American Nurse Foundation 18A01422

0134 Self-Reported Sleep is Associated with Central, But Not Peripheral Blood Pressure Values in Healthy Children

Introduction

Shortened and poor quality sleep have emerged as nontraditional risk factors for the development of high blood pressure (BP) in adults, but it is unclear if these relations exist in younger children. Self-report and objective sleep measurements are both clinically relevant and may inform interventions to improve sleep in this population, but do not always coincide with one another. The purpose of this study was to evaluate both self-reported and objective sleep metrics and their associations with central and peripheral BP values in younger children.

Methods

Participants included 21 healthy 7-12-year-old children (10±0.5 yrs, 10M/11F). Self-reported sleep was evaluated using the Children’s Sleep Health Questionnaire and a total sleep score was generated, where a higher score indicates worse sleep (a score >41 indicates a pediatric sleep disorder). Objective sleep was recorded for 7 consecutive days and nights outside of the laboratory via wrist accelerometry and reported as sleep duration (SD) and sleep efficiency (SE). Following sleep monitoring, peripheral BP was measured and using pulse wave analysis (PWA) central BP was estimated, both of which were averaged over 3 trials. Pearson’s r correlations were used to assess relations between self-reported sleep score, objective sleep metrics, and BP values. Significance was set at p<0.05.

Results

Self-reported sleep score averaged 40±1 points, objective SD averaged 7.9±0.1 hours/night, and SE averaged 82±2%. Sleep score was significantly associated with central systolic and diastolic BP (r = .485, p = 0.03, and r = .517, p = 0.02, respectively), but not peripheral BP values. Objective SD and SE were not significantly associated with central or peripheral BP values.

Conclusion

In this sample, self-reported sleep score, but not objective sleep metrics, was associated with higher central BP values in healthy children age 7–12.

Support

Provided in part by P20GM113125.

2018 Ottawa consensus statement: Selection and recruitment to the healthcare professions

Selection and recruitment into healthcare education and practice is a key area of interest for educators with significant developments in research, policy, and practice in recent years. This updated consensus statement, developed through a multi-stage process, examines future opportunities and challenges in selection and recruitment. There is both a gap in the literature around and a compelling case for further theoretical and empirical literature to underpin the development of overall selection philosophes and policies and their enactment. More consistent evidence has emerged regarding the quality of different selection methods. Approaches to selection are context-dependent, requiring the consideration of an institution's philosophy regarding what they are trying to achieve, the communities it purports to serve, along with the system within which they are used. Diversity and globalization issues continue to be critically important topics. Further research is required to explore differential attainment and explain why there are substantial differences in culturally acceptable ways of approaching diversity and widening access. More sophisticated evaluation approaches using multi-disciplinary theoretical frameworks are required to address the issues. Following a discussion of these areas, 10 recommendations are presented to guide future research and practice and to encourage debate between colleagues across the globe.

Correction to: A systematic review of stakeholder views of selection methods for medical schools admission

Following publication of the original article [1], the author report typographical errors in the.

A systematic review of stakeholder views of selection methods for medical schools admission

BACKGROUND

The purpose of this paper is to systematically review the literature with respect to stakeholder views of selection methods for medical school admissions.

METHODS

An electronic search of nine databases was conducted between January 2000-July 2014. Two reviewers independently assessed all titles (n = 1017) and retained abstracts (n = 233) for relevance. Methodological quality of quantitative papers was assessed using the MERSQI instrument. The overall quality of evidence in this field was low. Evidence was synthesised in a narrative review.

RESULTS

Applicants support interviews, and multiple mini interviews (MMIs). There is emerging evidence that situational judgement tests (SJTs) and selection centres (SCs) are also well regarded, but aptitude tests less so. Selectors endorse the use of interviews in general and in particular MMIs judging them to be fair, relevant and appropriate, with emerging evidence of similarly positive reactions to SCs. Aptitude tests and academic records were valued in decisions of whom to call to interview. Medical students prefer interviews based selection to cognitive aptitude tests. They are unconvinced about the transparency and veracity of written applications. Perceptions of organisational justice, which describe views of fairness in organisational processes, appear to be highly influential on stakeholders' views of the acceptability of selection methods. In particular procedural justice (perceived fairness of selection tools in terms of job relevance and characteristics of the test) and distributive justice (perceived fairness of selection outcomes in terms of equal opportunity and equity), appear to be important considerations when deciding on acceptability of selection methods. There were significant gaps with respect to both key stakeholder groups and the range of selection tools assessed.

CONCLUSIONS

Notwithstanding the observed limitations in the quality of research in this field, there appears to be broad concordance of views on the various selection methods, across the diverse stakeholders groups. This review highlights the need for better standards, more appropriate methodologies and for broadening the scope of stakeholder research.

Using a situational judgement test for selection into dental core training: a preliminary analysis

Objective and setting This paper describes the evaluation of a pilot situational judgement test (SJT) for selection into UK Dental Core Training (DCT). The SJT's psychometric properties, group differences based on gender and ethnicity, and candidate reactions were assessed.Methods The SJT targets four non-academic attributes important for success in DCT. Data were collected alongside live selection processes from five Health Education England local teams in the UK (N = 386). Candidates completed the pilot SJT and an evaluation questionnaire to examine their reactions to the test.Results SJT scores were relatively normally distributed and showed acceptable levels of internal reliability (α = 0.68). Difficulty level and partial correlations between scenarios and SJT total score were in the expected ranges (64.61% to 90.03% and r = 0.06 to 0.41, respectively). No group differences were found for gender, and group differences between White and BME candidates were minimal. Most candidates perceived the SJT as relevant to the target role, appropriate and fair.Conclusions This study demonstrated the potential suitability of an SJT for use in DCT selection. Future research should replicate these preliminary findings in other cohorts, and assess the predictive validity of the SJT for predicting key training and practice-based outcomes.

Results of 20 consecutive patients treated with the Repiphysis expandable prosthesis for primary malignant bone

Limb-salvage for primary malignant bone tumors in pediatric patients presents a unique challenge when resection includes an active physis. Early expandable prostheses required open surgical procedures to achieve lengthening. Newer prostheses are capable of achieving expansion without open procedures through the use of an electromagnetic field. This study reports our results with 90 consecutive expansion procedures using the Repiphysis^® prosthesis. We retrospectively reviewed the records of 20 patients (22 limbs) who underwent limb-salvage using the Repiphysis^® prosthesis from 2003 to 2015. There were 9 males and 11 females with a mean age of 9 years and 9 months (6–16 years). Reconstruction included the distal femur in 11 cases, total femur in four, proximal tibia in three, proximal humerus in three, and total humerus in one. Complications were reviewed and functional scores were recorded using the MSTS/ISOLS system. Five patients had a second prosthesis implanted during the course of the study for a total of 27 prostheses. The mean follow-up was 57 (6–148) months. Four patients have not been expanded: three due to death prior to lengthening, and one patient who has not yet developed a leg length discrepancy. Ninety consecutive expansion procedures were performed in 18 limbs in 16 patients. A mean of 9 (5–20) mm was gained per expansion and 4.8 cm per patient who has undergone expansion to date. Seven patients have reached skeletal maturity and have been converted to an adult endoprosthesis. These patients averaged 8 expansions per patient and a mean of 7.4 (1.8–12.9) cm in length gained. There were 15 complications in 11 patients including one dislocation, one contracture, four cases of aseptic loosening, five structural failures (three expansion mechanism failures and two tibial fractures), three deep infections, and one case of local recurrence. The mean MSTS score was 80 % (37–97 %) and the limb retention rate was 95 %. The results of this study are comparable to previous studies involving non-invasive prostheses. This study hopefully provides additional data for clinicians to consider when faced with limb threatening sarcomas in the immature skeleton.

Osteoid osteoma of the thumb: a case report

Osteoid osteoma is a rare occurrence in the hand, and only a small percentage affects the thumb and distal phalanges. An 18-year-old right-hand-dominant man presented to our office with an approximately 1-year history of left thumb pain without any history of trauma. He had seen several doctors previously and undergone multiple diagnostic tests with no definitive diagnosis. Plain radiographs and computed tomography at our institution were consistent with the diagnosis of osteoid osteoma. The patient was treated with surgical excision of the lesion without bone grafting. The diagnosis of osteoid osteoma was confirmed by pathology. At 6 months follow-up, the patient showed complete resolution of pain and full restoration of hand function. This case demonstrates that osteoid osteoma should not be forgotten as a differential diagnosis in patients with finger pain, especially in individuals who have not yet or just recently have reached skeletal maturity.

Evaluation of a noninvasive expandable prosthesis in musculoskeletal oncology patients for the upper and lower limb

The noninvasive expandable prosthesis is used for limb-salvage surgery following tumor resection in skeletally immature patients. The purpose of this retrospective study is to report our experience with the Repiphysis (Wright Medical Technology, Inc; Arlington, Tennessee) noninvasive expandable prosthesis for both the lower extremity and compassionate use in the upper extremity in 12 patients between 2003 and 2008. Twelve prostheses were implanted in 12 patients with an average follow-up of 38 months (range, 12-78 months). Nine patients underwent a total of 38 expansion procedures. Mean total expansion was 4.5 cm (range, 0.8-9.9 cm). No complications of lengthening occurred. Seven nononcologic complications were noted. One infection was reported in 12 patients. The mean MSTS score after rehabilitation was 24.5 (range, 13-30). The Repiphysis noninvasive prosthesis provides acceptable functional outcomes for both upper and lower extremity implantation and appears to have an advantage as compared to conventional expandable prosthetics, which require open procedures that can potentially increase the risk of infection from repeated hardware exposure.

Genome profiling of chondrosarcoma using oligonucleotide array-based comparative genomic hybridization

Chondrosarcomas of the bone are malignant hyaline cartilage-forming tumors with an annual incidence rate of 3.6% of all primary bone malignancies in the United States. Specimens of 25 chondrosarcomas (10 grade I, 9 grade II, 1 grade III, and 5 dedifferentiated) from 23 patients were collected from the Department of Pathology at the University Hospital at UMDNJ-New Jersey Medical School from 1996 to 2007. Array-based comparative genomic hybridization (array-CGH) studies were performed on frozen tumor specimens. Recurrent deletions observed in at least in six tumors were 5q13.2, 5q14.2 approximately q21.3, 6q12 approximately q13, 6q16 approximately q25.3, 9p24.2 approximately q12, and 9p21.3. There was a statistically significant association between high-grade tumor (grade III and dedifferentiated) and the recurrent genetic deletions at 5q14.2 approximately q21.3, 6q16 approximately q25.3, 9p24.2 approximately q12, and 9p21.3. There is consistency between increased levels of aneuploidy and the progression of chondrosarcoma from lower to higher grades.

Effects of atomoxetine on subjective and neurocognitive symptoms of nicotine abstinence

Nicotine dependence has been linked to attention-deficit hyperactivity disorder (ADHD) symptoms in both clinical and general populations. This behavioural pharmacology study used a within-subject, double-blind, crossover design to test the effects of atomoxetine, a medication for ADHD, on nicotine abstinence symptoms. Fifty non treatment-seeking smokers (>/=15 cigarettes/day) completed a baseline session when they were smoking as usual and then two laboratory testing sessions after overnight abstinence and treatment with 7 days of either atomoxetine (1.2 mg/kg) or placebo. During each laboratory session, participants completed subjective measures of abstinence symptoms and performed neurocognitive tasks. In mixed effects models, atomoxetine, compared with placebo, was found to be associated with a reduction in abstinence-induced subjective withdrawal symptoms. Atomoxetine was also associated with significant reductions in self-reported smoking urges amongst smokers who scored high on a baseline measure of smoking for stimulation. However, atomoxetine had no effect on any of the cognitive tasks employed in the study. Thus, atomoxetine may reduce cravings to smoke among smokers who use nicotine to increase arousal.

Single-bone forearm reconstruction for malignant and aggressive tumors

Limb-salvage surgery for malignant and aggressive forearm tumors presents a unique surgical challenge. We performed single-bone forearm reconstructions after extensive resections of the radius and ulna in four patients for such tumors. Radiocarpal arthrodesis was performed in three patients. We recorded the presence of metastases or local recurrences, Musculoskeletal Tumor Society upper extremity scores, and complications. One patient had local recurrence and one died of metastases. The average Musculoskeletal Tumor Society score at the last followup was 26 of 30 (88%; range, 24-28). Complications included wound infection/necrosis, delayed union, nonunion, and acute carpal tunnel syndrome. Single-bone forearm reconstructive surgery provided satisfactory functional outcomes in these four patients, and we believe it is a reasonable treatment option for individuals with malignant or aggressive tumors of the forearm requiring massive bone resection.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

P16 as a marker to differentiate atypical lipomatous tumor/well-differentiated liposarcoma from deep seated lipoma: An immunohistochemical analysis of 51 cases

10070

Background: Atypical lipomatous tumor (ALT)/well-differentiated (WD) liposarcoma is a locally aggressive malignant mesenchymal neoplasm characterized by supernumerary ring and giant marker chromosomes with amplification of MDM2 gene. These cytogenetic characteristics can be very helpful to distinguish ALT from deep-seated lipomas. As ALTs have only rare presence of lipoblasts, they can resemble benign lipomas rendering difficulty in morphological diagnosis. P16INK4 is a specific inhibitor of CDK4/CDK6. CDK6 gene is often found co-amplified with MDM2 gene in ALTs. P16 overexpression is a hallmark of cervical dysplasia. Our study investigates the value of p16 expression in cytogenetically confirmed ALTs and deep-seated lipomas. Design: Fifty-one (51) cases of lipomatous neoplasms, with cytogenetic results, from forty-three (43) patients were collected for the study from the archives in department of pathology, UMDNJ/NJMS during 1998 - 2005. These include 18 cases of deep-seated lipoma, one hibernoma, and 32 cases of ALT / well-differentiated liposarcoma (24 patients, five patients with recurrence, and four cases with de-differentiation). Immunohistochemical staining for p16 was performed on representative paraffin blocks. Staining results were scored according to intensity (negative 0, weak 1+, intermediate 2+, and strong 3+) and percentage of positive cells. Results: Twenty-eight cases (28/32, 87.5%) of ALT/WD liposarcoma, including all four cases of dedifferentiated liposarcoma, showed strong nuclear p16 expression. In cases of recurrence, the primary and recurrent tumor showed the same pattern of p16 staining. Four cases (4/32, 12.5%) of ALT/WD liposarcoma showed negative p16 expression. All cases of deep-seated lipoma (18/18, 100%) and single hibernoma showed negative p16 staining except focal positivity in areas of fat necrosis in two cases (p16 positivity, 87.5 vs. 0%, P <0.00001, Fisher's exact test). Conclusion: 1). P16 appears to be a valuable marker to differentiate ALT and deep-seated lipomas. 2). P16 expression remains unchanged in progression and transformation of ALT. 3). P16 related signal transduction pathway most likely is an early event in tumorogenesis of ALT.

No significant financial relationships to disclose.

Expression of cell cycle, angiogenesis and metastases associated factors in osteosarcoma - immunohistochemical analysis of tissue array in 35 patients

10036

Background: Osteosarcoma is the most common, non-haemopoietic primary malignant tumor of bone. A variety of biological markers have been investigated for their prognostic value with variable results. This study is aimed to assess the prognostic and biological value of biological markers involved in cell cycle checkpoint regulation (p53 family, p16, and PTEN), cell adhesion, motility and invasion (ezrin and beta catenin), angiogenesis (VEGF and PlGF) in tumor samples of osteosarcoma patients. Methods: Thirty-five patients were chosen for the study (ages 6–74 years, median age - 15 years). Among them, 32 were high-grade conventional intramedullary osteosarcoma, and 3 were Paget osteosarcomas. Eight patients presented with metastases. Immunohistochemical analysis was performed on a tissue array of tumor samples with standard protocol. Clinical outcome was measured as events (metastasis or death), chemo-response (stage), and survival by multivariate analysis. Analysis also included our previous reported results of p53, p63 and p73. Results: Staining was assessed based upon semi-quantitative manual scoring. Appropriate staining (nuclear or cytoplasmic) of >5% in tumor cells was considered as positive for all markers. The percentage positivity for the markers is as follows: p53 =29%, p63 =37%, p73= 9%, p16 =60%, PTEN=83%, ezrin =77%, beta catenin =91%, VEGF= 86% and PlGF =54%. There was no association of marker expression with specific subtype or location. Statistical analysis revealed no significant association between the positivity of these markers with clinical outcomes. Expression of ezrin was observed in all eight patients with metastases, although this finding did not approach statistical significance (P = 0.15). There was significant association between ezrin and P63 (P < 0.05). Conclusions: 1. Expression of p53 family proteins, p16, PTEN, ezrin, beta catenin, VEGF, and PlGF are not significant predictors of clinical outcome in osteosarcoma patients. 2. Ezrin may be essential for osteosarcoma metastases. 3. No significant association between VEGF, PlGF and metastases. 4. The positive association between ezrin and P63 is interesting and need to be evaluated further.

No significant financial relationships to disclose.

Immediate reconstruction of oncologic hemipelvectomy defects

BACKGROUND

Soft tissue and bony tumors of the pelvis are rare, but when they occur, treatment presents both an oncologic surgical and a reconstructive challenge. After reconstruction, soft tissue defects can be large and there is usually exposed bone and/or joint. A retroperitoneal abdominal wall defect may also be present. Flap mobilization is generally necessary to eliminate dead space and cover the exposed bone, viscera, and/or prosthetic orthopedic material. We performed immediate reconstruction on 11 patients after radical pelvic resections for tumor.

PATIENTS AND METHODS

Eleven cases of radical pelvic resection and immediate reconstruction were identified during the period from 1992 to 2002 at University Hospital, Newark, New Jersey. All patients were treated by both the orthopedic oncology and plastic surgery teams. A retrospective review of office charts and hospital records was performed. Data were gathered regarding the following: tumor type and oncologic history, extent of resection, reconstructive modality, complications, and outcome.

RESULTS

All patients underwent radical resection of pelvic masses depending on the tumor type and location. Tumor types included chondrosarcoma (6), Paget osteosarcoma (1), giant cell tumor (1), metastatic uterine carcinoma (2), and invasive squamous cell carcinoma arising in a chronic decubitus ulcer (1). The reconstructive procedures performed were the following: rectus abdominus flaps (6), gluteus maximus musculocutaneous flaps (3), and thigh fillet flaps (2). The retroperitoneal defects were repaired with primary tissue approximation of the surrounding available musculature. Additionally, Gore-Tex mesh was used in 2 cases, tensor fascia lata was used in 2 cases, and acellular dermal matrix in 1 case. Blood loss for the combined procedures ranged from 400 mL to 1400 mL. The follow-up period in this series ranged from 24 to 114 months. Complications included skin flap loss with subsequent infection (1), local cellulitis controlled with antibiotics (1), regional recurrence (2). The postoperative course was uneventful for the remainder of the cases.

CONCLUSION

Soft tissue reconstructions after extensive pelvic resections always present as complex reconstructive problems. Reconstruction is dictated by the size of the defects and by tissue availability. The extent and type of resections vary according to tumor size and location. In our experience, local pedicled muscle-based flaps, if available, usually provide adequate tissue mass to eliminate dead space, cover the extent of the wound, and close the retroperitoneal defect. Microvascular tissue transfer is always an option but was reserved in our series for cases with no suitable local alternative.

Association of OPRM1 A118G variant with the relative reinforcing value of nicotine

RATIONALE

The endogenous opioid system has been implicated in substance abuse and response to pharmacotherapies for nicotine and alcohol addiction. We examined (1) the association of the functional OPRM1 A118G variant with the relative reinforcing value of nicotine and (2) the main and interacting effects of the mu-opioid receptor antagonist naltrexone on nicotine reinforcement.

METHODS

In a within-subject, double-blind human laboratory study, 30 smokers of each OPRM1 genotype (A/A vs. A/G or G/G) participated in two experimental sessions following 4 days of orally administered naltrexone 50 mg or placebo. Participants completed a validated assessment of the relative reinforcing value of nicotine. This cigarette choice paradigm assesses self-administration of 0.6 mg nicotine vs. 0.05 mg (denicotinized) cigarettes after a brief period of nicotine abstinence.

RESULTS

The relative reinforcing value of nicotine (number of nicotine cigarette puffs) was predicted by a significant OPRM1 by gender interaction. Among women, the low-activity G allele (A/G and G/G) was associated with a reduced reinforcing value of nicotine; among male smokers, there was no association with genotype. Smokers carrying a G allele were also significantly less likely to differentiate the nicotine vs. denicotinized cigarettes by subjective ratings of satisfaction and strength. No evidence for an effect of naltrexone on nicotine reinforcement was found in the overall sample or in the genotype or gender subgroups.

CONCLUSIONS

This study provides initial evidence for an association of the OPRM1 A118G variant with nicotine reinforcement in women.

Reconstruction of Musculoskeletal Defects Following Oncologic Resection in 76 Patients

Between 1990 and 2002, 76 patients underwent 102 muscle flap reconstructions for extremity sarcomas. The patients had radical resection with immediate reconstruction. Reconstructions were performed by the Musculoskeletal Oncology and Plastic Surgery services. The mean age of our patients was 39.1 years. Patients were studied for a mean of 25.4 months. There were 79 pedicle flaps and 23 free flaps. Complications occurred in 23.7% of patients, including wound necroses, seromas, postoperative bleeding, postoperative infections, and flap loss. Five patients required a secondary flap procedure. The overall flap survival rate was 98%. Three patients had local recurrences. Sixteen patients (21.1%) have died of their disease. Five patients are alive with metastases. In 54 patients, Musculoskeletal Tumor Society (MSTS) functional evaluation scores averaged 27.1 (range, 12-30). In this large series of patients, we have demonstrated that, although minor complications are common, functional limbs can be salvaged following oncologic resection from the extremities.

Cortical chondroblastoma: report of a case and literature review of this lesion reported in unusual locations

Chondroblastoma is a rare benign tumor occurring in adolescence and young adulthood, almost always involving the epiphysis of long bones. A 24-year-old man presented with a discrete soft-tissue lesion penetrating the cortex of the right distal femoral metadiaphyseal region. Biopsy revealed a chondroblastoma, and the patient subsequently underwent a total curettage of the lesion with cancellous bone graft from the iliac crest.

Selecting doctors for postgraduate training in paediatrics using a competency based assessment centre

The design and implementation of an assessment centre in the South Yorkshire and South Humberside deanery for selecting doctors into postgraduate training in paediatric medicine is described. Eleven competency domains were identified in the job analysis. An assessment centre comprising of four exercises was implemented to assess candidates. There were modest relationships between candidates' performance on the various assessment centre exercises. Outcomes based on interview performance were related to, but not the same as, outcomes based on the combined results of the three other assessment centre exercises. Candidates perceived the assessment centre to be a fair selection method. It is concluded that an assessment centre approach to SHO recruitment is feasible and provides a greater breadth and depth of information about candidates than does a structured interview.

Impact of CYP2A6 genotype on pretreatment smoking behaviour and nicotine levels from and usage of nicotine replacement therapy

We investigated the effect of slow metabolism of nicotine, predicted by CYP2A6 genotypes resulting in less than or equal to 50% activity, on baseline smoking behaviours and treatment variables in an open-label nicotine replacement therapy (NRT) clinical trial. Caucasian smokers with CYP2A6 slow vs normal metabolism had lower metabolic activity, indicated by the 3-hydroxycotinine/cotinine ratio (0.23+/-0.17 vs 0.45+/-0.22, P<0.01, respectively). CYP2A6 slow metabolizers also smoked fewer cigarettes per day compared to normal metabolizers (20+/-7 vs 24+/-10, respectively, P<0.04). With nicotine patch use, slow metabolizers had higher nicotine plasma levels compared to normal metabolizers (22.8+/-4.6 vs 15.8+/-7.6 ng/ml, respectively, P=0.02) while using the same numbers of patches/week. With nicotine spray use, where like in smoking the nicotine intake can be easily adjusted to adapt to rates of metabolism, slow metabolizers achieved similar nicotine levels compared to normal metabolizers (5.8+/-4.1 vs 8.0+/-9.1 ng/ml, P=0.82), by using fewer doses of nicotine spray/day (4.8+/-3.6 vs 10.5+/-8.0, respectively, P<0.02). These findings indicate that CYP2A6 genotype influences smoking behaviour in a Caucasian treatment-seeking population and that CYP2A6 genotype affects plasma levels obtained from, and usage of, NRT.

Interaction between variation in the D2 dopamine receptor (DRD2) and the neuronal calcium sensor-1 (FREQ) genes in predicting response to nicotine replacement therapy for tobacco dependence

We have previously demonstrated that a functional dopamine D2 receptor promoter variant (DRD2 -141 Ins/Del) predicts response to nicotine replacement therapy (NRT). The present study extends this finding in the same population of 363 NRT-treated subjects, by examining variation in the gene encoding the neuronal calcium sensor-1 protein (FREQ), which functions to regulate D2 receptor desensitization. The results indicate a statistically significant interaction effect of DRD2-141 and FREQ genotypes on abstinence at the end of the NRT treatment phase; 62% of the smokers with at least one copy of the DRD2 -141 Del allele and two copies of the FREQ rs1054879 A allele were abstinent from smoking, compared to 29-38% abstinence rates for other smokers in the trial. This result suggests that the interaction between variation in the DRD2 and FREQ genes, which both encode components of the D2 dopamine receptor signal transduction pathway, impacts the efficacy of NRT.

HER-2/neu and p53 in osteosarcoma: an immunohistochemical and fluorescence in situ hybridization analysis

The overexpression of HER-2/neu and p53 has been associated with poor outcome in many neoplasms. Their role in patients with osteosarcoma is unclear. We studied the expression of HER-2/neu and p53 in 22 osteosarcoma samples (from 20 patients--2 had locally recurrent disease) biopsied at the University of Medicine and Dentistry of New Jersey (UMDNJ) from 1996-2000 using both immunohistochemical (IHC) and fluorescence in situ hybridization (FISH) analysis. Fourteen patients (14 samples) presented with Stage II and 6 patients (8 samples) presented with Stage III disease. Median follow-up is two years (range one year to five years). Four of 22 (18%) samples showed focal membranous or cytoplasmic positivity for HER-2/neu and six of 22 samples (27%) showed nuclear positivity for p53 by IHC analysis. In contrast, none of 22 tested samples showed gene amplification for HER-2/neu by FISH analysis. Seven of 13 HER-2/neu and p53 negative patients (54%) are currently disease free (between one year to five years). In this sample of patients, the HER-2/neu oncogene is not overexpressed or amplified in osteosarcoma; six of 22 samples (27%) showed overexpression of p53 by IHC analysis. By FISH, none of the samples demonstrated deletion of p53. Neither HER2/neu nor p53 expression was important for the biology of osteosarcoma in this population.

The functional mu opioid receptor (OPRM1) Asn40Asp variant predicts short-term response to nicotine replacement therapy in a clinical trial

To determine whether the functional mu-opioid receptor (OPRM1) Asn40Asp variant predicts the comparative efficacy of different forms of NRT, we conducted a clinical trial of transdermal nicotine (TN) vs nicotine nasal spray (NS) in 320 smokers of European ancestry. Smokers carrying the OPRM1 Asp40 variant (n=82) were significantly more likely than those homozygous for the Asn40 variant (n=238) to be abstinent at the end of treatment, and reported less mood disturbance and weight gain. The genotype effect on treatment outcome was most pronounced among smokers receiving TN, particularly during the 21 mg dose phase. Smokers who carry the OPRM1 Asp40 variant are likely to have a favorable response to TN and may benefit from extended therapy with the 21 mg dose.

Alveolar soft part sarcoma--reciprocal translocation between chromosome 17q25 and Xp11. Report of a case with metastases at presentation and review of the literature

The molecular pathogenesis of alveolar soft part sarcoma, a rare tumor with uncertain histogenesis, was elucidated recently and was shown to be due to a translocation between chromosome 17q25 and Xp11 resulting in a fusion product between TFE3 (a transcription factor gene) at chromosome Xp11 and a novel gene designated as ASPL at chromosome 17q25. This results in the transcriptional dysregulation in the pathogenesis of this neoplasm. Of the 12 cases reported so far, the translocation was due to non-reciprocal translocation in 11 cases with only one case demonstrating a reciprocal translocation with respective fusion products. We report yet another case with reciprocal translocation between chromosomes 17q25 and Xp11 with TFE3/ASPL fusion product who presented with metastatic disease. A standard cytogenetic analysis of primary tumor cells with G-banding revealed an abnormal karyotype: 46, X, t(X;17)(p11;q25)[15]/46,XX[5]. PCR analysis of the frozen tumor tissue revealed a type 1 fusion product as described in the literature. We demonstrate a rare cytogenetic abnormality in ASPS, namely reciprocal translocation between chromosomes 17q25 and Xp11 with demonstration of molecular fusion product between TFE3 and ASPL in a patient who initially presented with pulmonary metastases.

Liquid-based vs. conventional smears in fine needle aspiration of bone and soft tissue tumors

OBJECTIVE

To compare the accuracy of fine needle aspiration cytology of bone and soft tissue tumors utilizing ThinPrep (TP) (Cytyc Corporation, Boxborough, Massachusetts, U.S.A.) vs. conventional smears (CS).

STUDY DESIGN

Fine needle aspiration cytology from bone and soft tissue tumors was processed and assessed for cellularity, nuclear and cytoplasmic preservation, cellular architecture and stromal background with both the TP liquid-based smear technique and conventional methods.

RESULTS

An accurate diagnosis was made in 13% of TP cases as compared to 64% in CS cases.

CONCLUSION

CS of fine needle aspiration sample is far superior to TP in diagnosing tumors of bone and soft tissues. Preservation of cytoplasmic features and cellular architecture was superior in conventionally prepared smears.

Oncoproteins and proliferation markers in synovial sarcomas: a clinicopathologic study of 19 cases

PURPOSE

The objective of this study was to evaluate synovial sarcomas for the expression of oncogenic proteins (Her2/neu, EGFR, Bcl-2, p53) and proliferation markers (Ki-67, Topoisomerase 2alpha), as possible markers of prognostic significance.

METHODS

From 17 patients with synovial sarcomas 19 tumors (15 primary, 2 recurrent, and 2 metastatic) were selected on the basis of characteristic histology, the expression of at least one epithelial marker, and/or the presence of t(X;18). Adequate follow-up was available in all cases.

RESULTS

The tumors were tested immunohistochemically and were found to express multiple oncogenic proteins. Four of 19 synovial sarcomas (21%) demonstrated nuclear over-expression of p53 protein; 18 of 19 tumors (94%) stained positive for Bcl-2; and 13 of 19 tumors (68%) were immunoreactive with EGFR. Of particular interest was the frequent expression of Her2/neu, an oncogenic protein more commonly observed in epithelial neoplasms. Ten of 19 tumors (52%, 7 monophasic and 3 biphasic) showed positive cytoplasmic and membranous staining with Her2/neu (HercepTest, DAKO). The staining intensity ranged from 1+ to 2+. Cellular expression of Her2/neu was independent of EGFR positivity and showed no association with proliferative activity of the tumors. FISH analysis of eight positive cases showed no evidence of Her2/neu gene amplification. Among the non-metastatic tumors, we found a significant correlation between Ki-67 and Topoisomerase 2alpha. Spearman's correlation co-efficient was 0.86 with P=0.001 ( n=17).

CONCLUSIONS

In this relatively small series of cases, we found no definite correlation between the over-expression of Her2/neu and clinical outcome. The over-expression of p53 was significantly associated with clinical outcome (Fisher's exact test, P=0.02).

Desmoplastic fibroma of the rib

Desmoplastic fibroma is a very rare primary tumor of bone, closely related to aggressive fibromatosis of soft tissue. Although considered a benign lesion, it is locally destructive, can extend into the soft tissues, and has a high rate of local recurrences after incomplete surgical excision. Recognition of this entity is important to ensure proper surgical treatment. According to the published data, the tumor is most common in the long tubular bones (56%), the mandible (26%), and the pelvis (14%). Rib involvement by desmoplastic fibroma is extremely rare, and to our knowledge, only 3 cases have been reported in the literature to date. We present the case of a desmoplastic fibroma in the rib of a 19-year-old man, adding a fourth case to the previously reported cases involving this unusual location. The clinical history and the radiological and pathologic findings are presented.