Effects of the scope of practice on family physicians: a systematic review

BACKGROUND

Family medicine is a branch of medicine that manages common and long-term illnesses in children and adults. Family physicians in particular play a major role and their scope of practice is expected to impact patient and population. However, little is known about its impact on physicians. We aimed to assess the effects of scope of practice on family physician outcomes.

METHODS

We performed a systematic review that we reported using PRISMA guidelines. For the inclusion criteria, any study exploring an association between the scope of practice and physician outcomes was considered. Three bibliographic databases Medline, Embase, and ERIC were consulted through OVID interface from their respective inceptions to November, 2020. Two reviewers independently selected studies, extracted data and assessed the risk of bias of studies using appropriate tools. We conducted data synthesis using a narrative form. GRADE was used for evaluating quality of cumulative evidence.

RESULTS

In total, we included 12 studies with 38,732 participants from 6927 citations identified. Eleven of them were cross-sectional, and one was a cohort study with acceptable methodological quality. We found that: 1) family physicians with diverse clinical and nonclinical activities significantly improve their job satisfaction (p<0.05); 2) family physicians with a variety of clinical practices significantly improve their competences and health status (p<0.05); 3) family physicians who perform clinical procedures (mainly extended to gynecological procedures) significantly improve their psychosocial outcomes (e.g., job satisfaction) (p<0.05); and 4) some associations are not statistically significant (e.g., relation between variety of practice settings and outcomes). We observed that the evidence available has a very low level.

CONCLUSIONS

Our findings suggest that the scope of practice may be favorably associated with some family physician outcomes but with a very low level of evidence available. Based on these findings, healthcare system managers could monitor the scope of practice among family physicians and encourage future research in this field.

SYSTEMATIC REVIEW REGISTRATION

Our protocol was registered under the number CRD42019121990 in PROSPERO.

"They heard our voice!" patient engagement councils in community-based primary care practices: a participatory action research pilot study

BACKGROUND

Patient engagement could improve the quality of primary care practices. However, we know little about effective patient engagement strategies. We aimed to assess the acceptability and feasibility of embedding advisory councils of clinicians, managers, patients and caregivers to conduct patient-oriented quality improvement projects in primary care practices.

METHODS

Using a participatory action research approach, we conducted our study in two non-academic primary care practices in Quebec City (Canada). Patient-experts (patients trained in research) were involved in study design, council recruitment and meeting facilitation. Advisory councils were each to include patients and/or caregivers, clinicians and managers. Over six meetings, councils would identify quality improvement priorities and plan projects accordingly. We assessed acceptability and feasibility of the councils using non-participant observations, audio-recordings and self-administered questionnaires. We used descriptive analyses, triangulated qualitative data and performed inductive thematic analysis.

RESULTS

Between December 2017 and June 2018, two advisory councils were formed, each with 11 patients (36% male, mean age 53.8 years), a nurse and a manager practising as a family physician (25% male, mean age 45 years). The six meetings per practice occurred within the study period with a mean of eight patients per meeting. Councils worked on two projects each: the first council on a new information leaflet about clinic organization and operation, and on communications about local public health programs; the second on methods to further engage patients in the practice, and on improving the appointment scheduling system. Median patient satisfaction was 8/10, and 66.7% perceived councils had an impact on practice operations. They considered involvement of a manager, facilitation by patient-experts, and the fostering of mutual respect as key to this impact. Clinicians and managers liked having patients as facilitators and the respect among members. Limiting factors were difficulty focusing on a single feasible project and time constraints. Managers in both practices were committed to pursuing the councils post-study.

CONCLUSION

Our results indicated that embedding advisory councils of clinicians, managers, patients and caregivers to conduct patient-oriented quality improvement projects in primary care practices is both acceptable and feasible. Future research should assess its transferability to other clinical contexts.

Can patients be trained to expect shared decision making in clinical consultations? Feasibility study of a public library program to raise patient awareness

Introduction

Shared decision making (SDM) is a process whereby decisions are made together by patients and/or families and clinicians. Nevertheless, few patients are aware of its proven benefits. This study investigated the feasibility, acceptability and impact of an intervention to raise public awareness of SDM in public libraries.

Materials and methods

A 1.5 hour interactive workshop to be presented in public libraries was co-designed with Quebec City public library network officials, a science communication specialist and physicians. A clinical topic of maximum reach was chosen: antibiotic overuse in treatment of acute respiratory tract infections. The workshop content was designed and a format, whereby a physician presents the information and the science communication specialist invites questions and participation, was devised. The event was advertised to the general public. An evaluation form was used to collect data on participants’ sociodemographics, feasibility and acceptability components and assess a potential impact of the intervention. Facilitators held a post-workshop focus group to qualitatively assess feasibility, acceptability and impact.

Results

All 10 planned workshops were held. Out of 106 eligible public participants, 89 were included in the analysis. Most participants were women (77.6%), retired (46.1%) and over 45 (59.5%). Over 90% of participants considered the workshop content to be relevant, accessible, and clear. They reported substantial average knowledge gain about antibiotics (2.4, 95% Confidence Interval (CI): 2.0–2.8; P < .001) and about SDM (4.0, 95% CI: 3.4–4.5; P < .001). Self-reported knowledge gain about SDM was significantly higher than about antibiotics (4.0 versus 2.4; P < .001). Knowledge gain did not vary by sociodemographic characteristics. The focus group confirmed feasibility and suggested improvements.

Conclusions

A public library intervention is feasible and effective way to increase public awareness of SDM and could be a new approach to implementing SDM by preparing potential patients to ask for it in the consulting room.

How to engage patients in research and quality improvement in community-based primary care settings: protocol for a participatory action research pilot study

PLAIN ENGLISH SUMMARY

Making primary care clinics more patient-centered is key to improving patients' experience of care. If patients themselves were engaged in helping define priorities and suggesting quality improvements in the clinic, care would respond better to their needs. However, patient engagement is a new phenomenon, particularly in community based primary care clinics. How to engage patients in quality improvement in these clinics, or what effect this might have, is not well known. The involvement of patients needs to be adapted to the way these clinics function. The aim of this study is to create and evaluate a new model of patient engagement for quality improvement in community based primary care clinics. Patients, primary care professionals and researchers will create advisory councils in two primary care clinics in Quebec City (Canada). In each clinic, the advisory council will include 12 patients or caregivers registered at the clinic, a clinician and a clinic manager. The advisory council will meet every 6 weeks for a total of six meetings. Two patient-experts will facilitate meetings. During meetings, members of the council will list their needs in order of importance. Then they will suggest improvements in line with these needs. We will study if our advisory council model is well adapted to community based primary care settings and meets participants' expectations. At the end of the study we will be able to offer guidance about engaging patients with health professionals in quality improvement in primary care clinics.

ABSTRACT

Background Involvement of end-users, including patients, managers and clinicians, in identifying quality improvement and research priorities might improve the relevance of projects and increase their impact. Few patient engagement initiatives have taken place in community based primary care practices (CBPCPs) and best practices for engaging patients in such settings are not well defined. The aim of this pilot study is to develop and assess the feasibility of a new collaborative model of advisory council involving clinicians, managers, patients and caregivers in CBPCP to strengthen their capacity to conduct quality improvement and patient-oriented research projects. Methods We will conduct a participatory action research project in two non-academic CBPCPs in Quebec City (Canada). In each CBPCP, the advisory council will include 12 patients or caregivers, a clinician and a clinic manager. Patients or their caregivers will be identified by clinicians and contacted by patient-experts. They will be eligible if they are registered at the practice, motivated, and available to attend meetings. The council will meet every 6 weeks for a total of six meetings. Two patient-experts will guide council members to identify quality improvement priorities and patient-oriented research questions based on their experience in the clinic. They will then be supported to plan actions to target these priorities. Analysis of meetings will be based on feasibility criteria, notes by non-participant observers in log books, audio-recording of the meetings and questionnaires to evaluate council members' perceptions and the likelihood they would engage in such councils. Discussion The results of this study will  be a model of patient engagement and a discussion of factors to improve the model to fit the needs of primary care patients and professionals. This will lay the foundation for a sustainable structure for long-term patient engagement and contribute to the development of a patient-centered and quality-improvement culture in CBPCPs.

Decisional needs assessment of patients with complex care needs in primary care: a participatory systematic mixed studies review protocol

INTRODUCTION

Patients with complex care needs (PCCNs) often suffer from combinations of multiple chronic conditions, mental health problems, drug interactions and social vulnerability, which can lead to healthcare services overuse, underuse or misuse. Typically, PCCNs face interactional issues and unmet decisional needs regarding possible options in a cascade of interrelated decisions involving different stakeholders (themselves, their families, their caregivers, their healthcare practitioners). Gaps in knowledge, values clarification and social support in situations where options need to be deliberated hamper effective decision support interventions. This review aims to (1) assess decisional needs of PCCNs from the perspective of stakeholders, (2) build a taxonomy of these decisional needs and (3) prioritise decisional needs with knowledge users (clinicians, patients and managers).

METHODS AND ANALYSIS

This review will be based on the interprofessional shared decision making (IP-SDM) model and the Ottawa Decision Support Framework. Applying a participatory research approach, we will identify potentially relevant studies through a comprehensive literature search; select relevant ones using eligibility criteria inspired from our previous scoping review on PCCNs; appraise quality using the Mixed Methods Appraisal Tool; conduct a three-step synthesis (sequential exploratory mixed methods design) to build taxonomy of key decisional needs; and integrate these results with those of a parallel PCCNs' qualitative decisional need assessment (semistructured interviews and focus group with stakeholders).

ETHICS AND DISSEMINATION

This systematic review, together with the qualitative study (approved by the Centre Intégré Universitaire de Santé et Service Sociaux du Saguenay-Lac-Saint-Jean ethical committee), will produce a working taxonomy of key decisional needs (ontological contribution), to inform the subsequent user-centred design of a support tool for addressing PCCNs' decisional needs (practical contribution). We will adapt the IP-SDM model, normally dealing with a single decision, for PCCNs who experience cascade of decisions involving different stakeholders (theoretical contribution). Knowledge users will facilitate dissemination of the results in the Canadian primary care network.

PROSPERO REGISTRATION NUMBER

CRD42015020558.

Radiation-induced sarcoma: analysis of 46 cases

A retrospective analysis was performed of 46 cases of sarcoma treated in our institution between 1989 and 2007 that occurred in a previously irradiated area. Eight male and 38 female patients had received radiotherapy, mainly for breast cancer and genitourinary tumours. The interval between irradiation and the diagnosis of sarcoma ranged from 1 to 54 years (median 15 y). The most common clinical findings were a mass, pain and skin dislocation. Angiosarcoma and sarcoma non-otherwise-specified were the most common histological types. Surgical resection was performed in 34 patients (74%) and 5-year survival was 45% when a radical resection was obtained. No 5-year survival was noticed after non-radical resection and in the absence of surgery. Stage and location of the sarcoma were other prognostic factors. Overall 5-year survival was 27% for the whole group.

Ewing's sarcoma: imaging features

AIM

To define an imaging prototype of Ewing's sarcoma (ES).

MATERIALS AND METHODS

Sixty-four patients with a histopathologically and/or genetically proven diagnosis of ES were analyzed for clinical parameters (age, gender and location), radiographic and CT appearance (distribution, matrix, margins, periosteal reaction, articular extension, cortical reaction and the presence of a pathologic fracture). Size, local extension, signal intensity, degree and pattern of enhancement, and the presence of skip metastases were evaluated on MRI. Distant metastases were recorded on bone scintigraphy and chest CT scan.

RESULTS

Patient's age ranged between 7-67 (mean 17.9). Male/female ratio was 2.4/1. Location in the pelvis was most frequent (31%), followed by the femur (20%) and tibia (11%). Most tumors were mixed lytic-sclerotic (75%), and purely lytic in 25%. Plain films and CT scan showed a spiculated periosteal reaction in 50%. A Codman's triangle was seen in 27%. Articular extension was difficult to assess on radiographs. Cortical permeation and destruction is seen in respectively 31 and 42%, whereas cortical thickening is seen in 20%. Pathologic fracture occurred in 7.8%. MRI showed a large mass, with a soft tissue component of more than 50% in 67%. Degree and pattern of enhancement pattern was variable. Signal intensity on T1- and T2-WI was non-specific. Joint involvement was seen in 23%. Isolated involvement of the soft tissue (extraskeletal ES) was seen in 1.5%. Skip metastases at initial presentation were present at initial presentation in 14% and distant metastases in 22%.

CONCLUSIONS

ES occurs in young patients. On radiographs/CT, 37.5% are located in the axial skeleton and 62.5% in the peripheral skeleton. ES is mostly mixed sclerotic-lytic. A spiculated periosteal reaction is most frequent. The most characteristic finding on MRI is the presence of a large soft tissue mass.

Natural course and clinical features of myxoid and round cell liposarcoma (MRCL) - a retrospective single center analysis

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Background and methods: MRCL, the 2nd most common type liposarcoma, represents ∼10 % of adult soft tissue sarcomas. In most pts the karyotypic hallmark is t(12;16)(q13;p11), leading to fusion of CHOP and FUS genes and generation of a hybrid protein. MRCL has unique sensitivity to antineoplastic agent ET-743 (Yondelis, Trabectidin), which induces specific morphological change and long-lasting response. We made a retrospective analysis of MRCL cases in our center. Results: 33 pts had histological diagnosis of MRCL with a mean (mn) follow-up of 45 mo (range, 2–214). By karyotyping or FISH analysis CHOP-FUS fusion was present in 12 and CHOP-EWS in 2 pts. The mn age at diagnosis was 45 yrs (range, 18–71), male:female ratio 1:0.8. Frequent primary sites: lower limb (25), abdomen (5), retroperitoneum (2), neck (2). Stage grouping at diagnosis: IA (2), IB (6), IIA (5), III (14), IV (2), not known (NK) (4). 2 had distant spread, 9 metachronous metastasis with a mn interval of 24 mo (range, 5–84). Main sites involved: abdomen (5), lung (3), bone (3). Surgery was performed with curative intent in 26/28 pts (5 NK), R0 resection in 23. 17/28 pts are alive without disease (16 previously R0-resected). 6/28 are alive with disease, 5 died due to MRCL. Relapse after R0 resection occurred after a mn of 24 mo (range, 5–84). Radiotherapy was used in 15/28 (5NK) with neoadjuvant (1), adjuvant (13) or palliative (3) intent (total doses 50–66 Gy). Chemotherapy (CT) was given in palliative (11) or neoadjuvant (1) fashion, after a mn of 1.3 surgical interventions (range, 0–3). 1st-line CT: doxorubicin- based combinations (7), single-agent doxorubicin (3), ET-743 (1). Best response: PR (5), NC (4), PD (1), NE (1). Mn duration of response was 6.3 mo (range, 1–15). 2nd-line CT: ET-743 (3), other agents (4). Best response: CR (1), PR (1), NC (3), PD (1), NE (1), with mn response duration of 7 mo (range, 1–13). 2 had further CT (PR 1, SD 1). Conclusions: MRCL is a chemosensitive sarcoma with variable clinical course. Local treatment can be curative, but systemic spread is frequent. Pts may respond to conventional CT or new agents such as ET-743. To evaluate the relative value of systemic treatment we need randomized trials in this unique clinical setting.

No significant financial relationships to disclose.

Imaging of malignant bonetumors

Diagnostic imaging plays a pivotal role in the initial detection, characterization, pre-operative assessment and long term follow-up of malignant bone tumors. The purpose of this brief review is to discuss the specific role of the different imaging modalities in the diagnostic work-up of malignant bone tumors. The imaging features, with emphasis on standard radiography, allowing differentiation, of malignant bone tumors, will be highlighted.

Multiple vertebral fluid-fluid levels

We present a case of multiple vertebral metastases, with multiple fluid-fluid levels, from a moderately to poorly differentiated carcinoma of unknown origin. We suggest that fluid-fluid levels in multiple vertebral lesions are highly suggestive of bone metastases.

Selective arterial embolization in the treatment of an aneurysmal bone cyst of the pelvis

This case report deals with an aggressive aneurysmal bone cyst of the pelvis in a 20-year-old man causing considerable destruction of the left ilium and the anterior column of the acetabulum, with extension into the pelvis. The treatment of large pelvic aneurysmal bone cysts is challenging because of local destruction of adjacent structures and because of the risk of severe intraoperative bleeding. Therefore selective preoperative embolization may be a valuable tool in the management of aneurysmal bone cysts.

Non perforated septum supra-patellaris mimicking a soft tissue tumour

Plicae synoviales of the knee are well known to present as anterior knee pain but can also cause blocking, clicking, and swelling of the knee mimicking pathology such as meniscal tears or other internal derangements, and even mono-arthritis. Embryologically, the knee is divided into a medial and lateral compartment and a supra-patellar pouch by thin membranes of synovium. Incomplete involution of these membranes gives rise to a plica. When there is no involution at all, the membrane is called a septum. There are three frequent types of plicae/septa: a suprapatellar, a medial-patellar, and an infra-patellar type. We discuss on a patient with a non perforated septum supra-patellaris which resulted in a swelling above the knee, mistaken for a soft tissue tumour.

Medical image based, preformed titanium membranes for bone reconstructions: design study and first clinical

The currently used intralesional or marginal surgical treatment of a bone tumour in the extremities shows some shortcomings in providing a restoration of the mechanical strength of the bone and the containment of the used filling materials. The use of a medical image based, preformed and custom-made titanium membrane screwed onto the periosteal side of the bone is introduced. This study looks in detail into the design process and the biomechanical evaluation of such a membrane. The buckling strength of the membrane, the strength at the perforation holes and the strength of the screw-bone fixation are tested experimentally. The two latter experiments are performed with different screw types. From the performed tests it appears that a titanium membrane without a wave pattern, of 0.3 mm thickness, fixed to the bone with seven trabecular bone screws (4 mm diameter and 28 mm length) is capable of carrying the anticipated mechanical loads on the reconstructed tibia. The medical image based design methodology and the first clinical application of such a preformed and custom-made titanium membrane are reported and discussed. The feasibility of preformed titanium membranes for bone reconstruction in tumour surgery is demonstrated.

Clinical impact of molecular and cytogenetic findings in synovial sarcoma

Synovial sarcoma is an aggressive soft-tissue tumor that accounts for up to 10% of soft-tissue sarcomas. Cytogenetically, synovial sarcoma is characterized by the t(X;18)(p11;q11), found in more than 95% of the tumors. This translocation results in rearrangements of the SYT gene in 18q11 and one of the SSX1, SSX2, or SSX4 genes in Xp11, creating a SYT/SSX1, SYT/SSX2, or SYT/SSX4 chimeric gene. It has been shown that patients with SYT/SSX1 fusion genes have a shorter metastasis-free survival than do patients with SYT/SSX2. Previous studies have also suggested that clonal evolution may be associated with disease progression. In the present study, RT-PCR analysis showed that all 64 examined synovial sarcomas from 54 patients had SYT-SSX chimeric genes. SYT/SSX1 was found in 40 tumors from 33 patients, SYT/SSX2 in 23 tumors from 20 patients, and SYT/SSX4 in one case. Two patients had variant SYT/SSX2 transcripts, with 57 bp and 141 bp inserts, respectively, between the known SYT and SSX2 sequences. Patients with tumors with SYT/SSX1 fusions had a higher risk of developing metastases compared to those with SYT/SSX2 fusions (P = 0.01). The reciprocal transcripts SSX1/SYT and SSX2/SYT were detected using nested PCR in 11 of the 40 samples with SYT/SSX1 and 5 of the 23 samples with SYT/SSX2, respectively. Among 20 blood samples, SYT/SSX1 and SYT/SSX2 were detected in one sample each. The t(X;18), or variants thereof, was found cytogenetically in all patients but three. Among 32 primary tumors, the t(X;18) or a variant translocation was the sole anomaly in 10. In contrast, of the seven metastatic lesions that were investigated prior to radiotherapy, only one had a t(X;18) as the sole anomaly; all other tumors displayed complex karyotypes. Cytogenetic complexity in primary tumors was, however, not associated with the development of metastases. Tumors with SYT/SSX2 less often (4/12 vs. 7/15) showed complex karyotypes than did tumors with SYT/SSX1, but the difference was not significant. Combining cytogenetic complexity and transcript data, we found that the subgroup of patients with tumors showing simple karyotypes and SYT/SSX2 fusion had the best clinical outcome (2/8 patients developed metastases), and those with tumors showing complex karyotypes together with SYT/SSX1 fusion the worst (6/7 patients developed metastases). This corresponded to 5-year metastasis-free survival rates of 0.58 and 0.0, respectively (P = 0.02).

Candidal vertebral osteomyelitis: report of 6 patients, and a review

The incidence of deep-seated candidal infection is increasing, but candidal vertebral osteomyelitis is still rare. We describe 6 patients recently treated in our hospital. Conservative treatment failed in all. We reviewed the literature and identified 59 additional cases of candidal vertebral osteomyelitis. Candidemia was documented in 61.5% of them. The interval between the diagnosis of candidemia and the onset of symptoms of vertebral osteomyelitis varied widely, from days to >1 year. In patients without documented candidemia, there was a similar interval between the occurrence of risk factors for candidemia (present in 72% of the patients) and the onset of symptoms of vertebral osteomyelitis. Clinical, laboratory, and radiological findings are not specific for candidal spondylodiskitis. Final diagnosis is determined by means of culture of a biopsy specimen from the infected vertebra or disk. Treatment consisted of prolonged antifungal treatment, and it often included surgery. On the basis of our experience (for all 6 patients, initial conservative treatment with only antifungals failed), we recommend consideration of early surgical debridement in combination with prolonged antifungal therapy.

Calcifying/ossifying synovial sarcoma shows t(X;18) with SSX2 involvement and mitochondrial calcifications

AIMS

Synovial sarcoma with extensive calcification and ossification is a rare variant, the ultrastructural, cytogenetic and molecular analysis of which has not been reported previously.

METHODS AND RESULTS

A large mass in the shoulder of a 20-year-old male patient led to a deformity of the chest wall, thus supporting the hypothesis that this is a slowly growing variant of synovial sarcoma. Nevertheless, the patient developed metastatic lung disease 7 months after resection. On histology, the monophasic spindle cell proliferation was in several areas obscured by the massive calcification and ossification. Immunohistochemistry showed keratin, epithelial membrane antigen, vimentin and CD99 expression. The cytogenetic analysis revealed a single t(X;18)(p11.2; q11.2), typical for synovial sarcoma. Additional fluorescence in-situ hybridization revealed SSX2 involvement. At the ultrastructural level, prominent needle-shaped intramitochondrial crystals were present, both in the cytoplasm and in the extracellular matrix.

CONCLUSION

The presence of the t(X;18) with SSX2 involvement definitively characterizes this tumour as a variant of synovial sarcoma. In addition, the needle-like mitochondrial calcifications give a possible clue to the pathogenesis of the extensive metaplastic ossification and calcification.

Metastatic fractures of the tibia

Pathologic fractures of the tibia due to a metastasis are rare. The treatment of an established fracture is sometimes conservative, but more often surgical. The purpose of the surgical procedure is to improve the quality of life and the ambulatory status, to relieve pain and to facilitate activities of daily living and nursing care. Four cases of operatively managed metastatic fractures of the tibia are presented with emphasis on the surgical technique. The scarce literature on metastatic tibial fractures in reviewed. The operative technique to be used does not only depend on the location of the tumor but also on the primary tumor, the response to adjuvant therapy and the life expectancy. For metastatic shaft fractures an intramedullary nail, sometimes augmented with bone cement, is preferred. For distal or proximal fractures a compound osteosynthesis with plates and screws offers a good solution. In the epiphyseal and metaphyseal region of the tibia an amputation or a tumor prosthesis is the procedure of choice.

Cytogenetic-morphologic correlations in aneurysmal bone cyst, giant cell tumor of bone and combined lesions. A report from the CHAMP study group

Aneurysmal bone cyst and giant cell tumor of bone are relatively rare bone tumors that sometimes coexist. We examined the karyotypes of 3 aneurysmal bone cysts, 12 giant cell tumors, and 3 combined lesions. All aneurysmal bone cysts showed involvement of chromosome segments 17p11-13 and/or 16q22. In addition, in 1 of the 3 giant cell tumors with secondary aneurysmal bone cyst, both chromosome bands were rearranged as well, albeit not in a balanced translocation. Seven out of 12 giant cell tumors were characterized by telomeric associations. One giant cell tumor showed a dup(16)(q13q22), suggesting the presence of a (minor) secondary aneurysmal bone cyst component, despite the absence of histological proof. Our results, combined with literature data further substantiate that segments 16q22 and 17p11-13 are nonrandomly involved in at least some aneurysmal bone cysts, irrespective of subtype (primary, secondary, intra/extraosseous, solid or classic). These findings strongly suggest that some aneurysmal bone cysts are true neoplasms. In addition, telomeric associations are the most frequent chromosomal aberrations in giant cell tumor of bone, the significance of which remains elusive. In combined giant cell tumor/aneurysmal bone cyst each component seems to retain its own karyotypic abnormality.

Recurrent chromosome aberrations in fibrous dysplasia of the bone: a report of the CHAMP study group. CHromosomes And MorPhology

The nosologic status of fibrous dysplasia (FD), a well-known and relatively common bone lesion, is controversial. Information collected by the CHromosomes And MorPhology (CHAMP) study group on published and unpublished cases of fibrous dysplasia shows the presence of clonal chromosome changes in at least a proportion of these lesions. The chromosome aberrations found in FD lesions have been quite variable and have included both structural and numerical changes. Two of the three cases investigated at the study group had trisomy 2 as the sole acquired anomaly. Combined with previously published data, +2 and rearrangements involving chromosome band 12p13 have each been detected in 3 of 8 cases with abnormal karyotype of 11 in which chromosomal analysis has been performed, suggesting that FD is a neoplastic lesion rather than a "dysplastic" process, as has been generally believed and as implied by its very name.

Stress fracture of the inferior and superior pubic ramus in a man with anorexia nervosa and hypogonadism

The authors present the case of a 23-year-old athlete with a bifocal stress fracture of the pubis. Bifocal cases are rather rare, therefore an insufficiency fracture was suspected. Further investigation showed osteopenia due to secondary hypogonadotropic hypogonadism caused by anorexia nervosa. This case illustrates the need for awareness of underlying metabolic disorders in very rare cases of stress fractures in athletes.

Validation of the INNO-LIA syphilis kit as a confirmatory assay for Treponema pallidum antibodies

The commercially available diagnostic tests for syphilis are mostly based on the use of extracted antigens of Treponema pallidum. Pronounced cross-reactivities with other spirochete antigens are often reported. The aim of this study was to validate a novel multiparametric assay (the assay performed with the kit) INNO-LIA Syphilis for the confirmation of syphilis antibodies in a set of 840 documented human serum samples. All serum samples were previously tested at the French World Health Organization reference center for venereal diseases (Institute Alfred Fournier, Paris, France), with a consensus result provided for each sample. The study was conducted in two phases, with each phase involving a validation set (500 well-documented serum samples) and an exploratory set (340 serum samples) of serum samples, respectively. By measuring the sensitivity and specificity, we compared the result of the new assay with the consensus result on the basis of the results of a variable number of classical serological methods and clinical information when available. A sensitivity of 99.6% (95% confidence internal [CI], 98.5 to 99.9%) and a specificity of 99.5% (95% CI, 98.1 to 99.9%) were found for the new line immunoassay. Six of seven samples with indeterminate results by classical serology tested positive with the INNO-LIA Syphilis kit. This single multiparametric assay provides reliable confirmatory diagnostic information that must currently be obtained by the performance and interpretation of results of a combination of serological assays.

Collagenous fibroma (desmoplastic fibroblastoma): genetic link with fibroma of tendon sheath?

We observed clonal chromosome abnormalities in two fibrous soft tissue tumors diagnosed as collagenous fibroma (desmoplastic fibroblastoma). The involvement of the same band of the long arm of chromosome 11, 11q12, was observed in both tumors. The presence of hitherto unreported similar chromosomal abnormalities in this tumor supports the neoplastic nature of this lesion. In addition, a possible relationship with fibroma of tendon sheath, which also shows rearrangement of 11q12, is suggested. 11q12 might be a common genetic denominator of benign fibroblastic lesions, such as collagenous fibroma and fibroma of tendon sheath.

Clonal chromosomal changes in juxta-articular myxoma

Cytogenetic analysis of a juxta-articular myxoma revealed two distinct cytogenetically abnormal cell populations: inv(2)(p15q36) and +7, t(8;22)(q11-12; q12-13). These clonal chromosomal changes, the first to be reported in this tumour type, suggest that at least some juxta-articular myxomas are neoplastic rather than reactive in nature.

Langerhans cell histiocytosis of the clavicle: a case report

A case of Langerhans cell histiocytosis in a 47-year-old male presenting as an aggressive appearing lesion of the clavicle is reported. It illustrates the difficulties of the radiological diagnosis of a solitary bone lesion.

Langerhans cell histiocytosis of the cervical spine: case report of an unusual location

An unusual location for Langerhans cell histiocytosis of the cervical spine is presented. The osteolytic lesion, instead of being located in the vertebral body, was visualised in the left lateral mass of the fifth cervical vertebra, extending into the vertebral body and through the interapophyseal joint into the lateral mass of the fourth cervical vertebra.

Osteoid osteoma and osteoblastoma with clonal chromosome changes

We cytogenetically investigated six osteoid osteomas, one osteoblastoma and one aggressive osteoblastoma, and observed clonal structural changes in one osteoid osteoma and in the aggressive osteoblastoma. Clonal chromosome changes had not been reported previously in osteoid osteoma, whereas the only reported chromosome change in osteoblastoma was different from the one presented here.

Synovial chondromatosis: clonal chromosome changes provide further evidence for a neoplastic disorder

Synovial chondromatosis is a rare lesion, which is still believed by most authors to be reactive rather than neoplastic. We report on a case of synovial chondromatosis with clonal chromosomal changes [43,XX,der (1) t (1;13) (p21-22;q21),-6,-13,-14, add(21) (q21)]. The presence of clonal chromosomal changes in this and in three previously reported cases suggests that synovial chondromatosis is a true neoplastic lesion.

Chondroblastoma of the patella with a secondary aneurysmal bone cyst

A case of chondroblastoma of the patella combined with an aneurysmal bone cyst is presented. Chondroblastoma of the patella is an uncommon, benign neoplasm. On the other hand, secondary aneurysmal bone cyst is frequently associated with giant cell tumour of chondroblastoma.

Inflammatory leiomyosarcoma may be characterized by specific near-haploid chromosome changes

Identical near-haploid karyotypes with 28, X, +5, +18, +20, +21, +22 were found in two cases of inflammatory leiomyosarcoma, one of which had been reported previously as malignant fibrous histiocytoma. This abnormality may identify these tumours as a separate entity within this group of sarcomas.

Spontaneous resolution of a solitary osteochondroma

Spontaneous regression or resolution of a solitary osteochondroma is infrequent. A case of a surprisingly fast and complete resolution of an osteochondroma of the distal ulna in a 7-year-old boy is presented, with a review of previously reported cases.

[Prevalence of positive tuberculin test in a population of patients requiring long-term care in a hospital setting]

OBJECTIVE

To determine the prevalence of positive tuberculin tests in a population of patients requiring long-term care in a hospital setting.

DESIGN

Prevalence study: to evaluate reaction to the test among patients who agreed to be included in the study.

SETTING

The study took place in two units of the Enfant-Jésus hospital where patients are admitted for chronic care.

PARTICIPANTS

A total of 108 patients were eligible for the study; 56 agreed to take part. One patient died before the study was completed.

INTERVENTIONS

The tuberculin test consisted of an injection of PPD-T and reading the reaction 48 to 78 hours later. A reaction > 10 mm was considered significant. Patients with insignificant reactions were injected again 2 weeks later in order to evaluate positive response secondary to reactivation of the immune system (booster effect).

MAIN OUTCOME MEASURES

Indications of previous tuberculosis, risk factors for tuberculosis, immunosuppressive medication, length of stay in hospital, size of reaction.

RESULTS

Seventeen tuberculin tests were positive (30.9%); of these, six were positive after the second injection.

CONCLUSION

The prevalence of positive tuberculin tests was high in our elderly population; this finding is comparable to the findings of American studies.

Inflammatory myofibroblastic tumor of bone: report of two cases with evidence of clonal chromosomal changes

Inflammatory myofibroblastic tumor (inflammatory pseudotumor) is a pseudosarcomatous lesion that is recognized with increasing frequency in various anatomic locations. However, this lesion has not been previously reported in bone. We report on two cases of inflammatory myofibroblastic tumor occurring in bone in young adults. Both tumors presented as slightly painful, osteolytic, and well-delineated lesions of the distal femur, with a hyperintense signal on T2-weighted magnetic resonance imaging. The patients had an uneventful recovery after curettage. The follow-up time was 11 months for both patients, and no recurrence was noted. On histologic examination, the lesions were characterized by collagen-rich and generally poorly cellular tissue containing spindled to plump (myo)fibroblast-like cells and a variable admixture of inflammatory cells. Focal calcifications and reactive bone formation were present. Clonal, albeit different, chromosomal changes were found in both cases (47,XY,-9,-12,add(21)(q21),+der(?)t(?;9)(?;q11), +mar,+r and 47, XY, +r/47, idem, add(12)(p13)). The present and other reported cytogenetic findings suggest that inflammatory myofibroblastic tumors could well be neoplastic.

Primary osteorhabdomyosarcoma (malignant mesenchymoma) of bone: a case report and review of the literature

Primary malignant mesenchymoma of bone is a rare neoplasm consisting of two or more unrelated malignant mesenchymal components other than fibrosarcoma or malignant fibrous histiocytoma. The literature reports fewer than 15 cases, most of which were composed of osteosarcoma and liposarcoma. We report an exceedingly rare case of primary malignant mesenchymoma of bone composed of osteosarcoma and rhabdomyosarcoma (osteorhabdomyosarcoma), arising in the right proximal tibia of a 21-year-old woman. We review the literature and compare primary malignant mesenchymoma of bone with dedifferentiated chondrosarcoma and conventional intramedullary osteosarcoma.

Giant schwannoma of the lower leg

Schwannomas are relatively common, benign, peripheral nerve sheath tumours. They usually range in size from 2 to 20 cm, but when localised in the lower legs the maximum length is less than 10 cm. The case reported here was a giant fusiform schwannoma of the left fibular nerve with a length of 25.5 cm. In contrast to the usual findings of giant schwannomas, no cystic, haemorrhagic or necrotic changes could be found by ultrasonography, computed tomography or magnetic resonance imaging. The combination of tumour size, location and radiological presentation is very unusual and, to our knowledge, has never been reported before in the literature.

Additional evidence of a variant translocation t(12;22) with EWS/CHOP fusion in myxoid liposarcoma: clinicopathological features

It is well established that the majority of myxoid/round cell liposarcomas (LPS) are characterized by a reciprocal translocation t(12;16)(q13;p11) which at the molecular level results infusion of the CHOP and FUS/TLS genes. It is assumed that functional characterization of these genes may provide insight into the molecular pathogenesis of this tumour type. This study describes two new cases of myxoid/round cell LPS having a t(12;22). By reverse transcription-polymerase chain reaction (RT-PCR) it has been shown that this leads to fusion between the CHOP and EWS genes, thus indicating involvement of the EWS gene, at least occasionally, in yet another sarcoma type. Combining these two cases with two others which were recently similarly characterized at the molecular level, their clinicopathological features have been compared with cases having the more usual t(12;16). It was not possible to identify any clinical or pathological differences between these molecular genetic subsets. The relevance or significance of these gene fusion products in myxoid/round cell LPS remains to be determined.

Screening a random pentapeptide library, composed of 14 D-amino acids, against the COOH-terminal sequence of fructose-1,6-bisphosphate aldolase from Trypanosoma brucei

A random pentapeptide library composed of 14 D-amino acids, including two unusual amino acids, thus representing 537,824 different peptide sequences anchored on polystyrene beads was created with each bead bearing a single pentapeptide sequence. This library was used for affinity screening against the fructose-1, 6-bisphosphate aldolase of Trypanosoma brucei labeled with biotin as well as versus the COOH-terminal labeled with fluorescein isothiocyanate. The thus selected peptide beads were identified and the appropriate sequences synthesized as peptide amides and evaluated for enzyme activity inhibition. Screening against the whole enzyme did not result in selection of an enzyme inhibitor. However, we demonstrate here that screening against a part of the enzyme involved in the catalytic activity may lead to the discovery of an enzyme inhibitor as well as an enzyme activator. Two low affinity inhibitors, RRVKF-NH2 and KThiKAR-NH2, with an IC50 of approximately 1 mM and approximately 0.2 mM, respectively, were identified. Two other pentapeptides with the sequence SWChaKK-NH2 and SKChaKM-NH2 are able to activate the enzyme fructose-1, 6-bisphosphate aldolase. Thus, successful screening of solid phase libraries can be accomplished using selected sequences of the target enzyme.

Characterization of synthetic human granulocyte chemotactic protein 2: usage of chemokine receptors CXCR1 and CXCR2 and in vivo inflammatory properties

Human granulocyte chemotactic protein 2 (GCP-2) has originally been isolated from cytokine-stimulated osteosarcoma cells as a chemokine coproduced in minute amounts together with interleukin 8. Human GCP-2 (75 residues) was synthesized on a 0.25-mmol scale using Fmoc chemistry. After disulfide bridge formation and purification, monomeric GCP-2 was recovered as a 6-kDa protein; the pure synthetic protein showed a molecular mass of 8076 Da as determined by matrix-assisted laser desorption/ionization mass spectrometry (MALDI-MS). The exact amino acid sequence of synthetic GCP-2 was confirmed by Edman degradation. Synthetic GCP-2 was an equally active (minimal effective concentration of 1-3 nM) chemoattractant for neutrophilic granulocytes as was natural 75-residue GCP-2. At concentrations up to 30 nM, synthetic GCP-2 did not stimulate eosinophil, monocyte, or lymphocyte chemotaxis. GCP-2 induced a dose-dependent increase in [Ca2+]i in neutrophils, 1 nM being the minimal effective concentration. The GCP-2-induced [Ca2+]i increase was completely prevented by pertussis toxin. Prestimulation of neutrophils with equimolar concentrations of purified natural IL-8, GROalpha, GROgamma and ENA-78 abolished the [Ca2+]i increase in response to 1 nM GCP-2. Alternatively, the [Ca2+]i rise induced by these CXC chemokines was inhibited by pretreatment of neutrophils with GCP-2. GCP-2 stimulated [Ca2+]i increases in CXCR1- and CXCR2-transfected cells, demonstrating that GCP-2 binds to both IL-8 receptors. Intradermal injection of synthetic GCP-2 resulted in a dose-dependent neutrophil accumulation and plasma extravasation in rabbit skin. To provoke this skin reaction, GCP-2 (10 pmol/site) was nearly as effective as IL-8, indicating that it is an important complementary mediator of the inflammatory response.

Purification and characterization of a fully active recombinant tobacco cytosolic NADP-dependent isocitrate dehydrogenase in Escherichia coli: evidence for a role for the N-terminal region in enzyme activity

The recently isolated full-length NADP-dependent isocitrate dehydrogenase (ICDH) cDNA encoding the tobacco cytosolic isoenzyme has been cloned into the expression vector pET8c and used to transform Escherichia coli strain BL21 (DE3). The recombinant protein was purified to electrophoretic homogeneity and used to raise polyclonal antibodies. Its kinetic properties were found to be identical to those of the cytosolic ICDH isoenzyme purified from tobacco cell cultures. The recombinant and the endogenous bacterial ICDH could be easily distinguished by their different behaviors during anion-exchange column chromatography and immunological response. An incomplete ICDH-encoding cDNA clone, encoding a protein lacking the first 36 amino acids at the N-terminus, was cloned into the expression vector pKK233-2 and used to transform ICDH-lacking E. coli cells (strain 2004). The truncated, recombinant ICDH produced by the bacteria was found to be inactive.