Oral mucosal melanoma in situ: a case report and review of the literature

Oral mucosal melanoma is a rare presentation of malignant melanoma with a 5-year survival rate of only 15%. Oral mucosal melanoma in situ (OMMIS) is its assumed precursor. This report describes one of only 20 documented cases of OMMIS and outlines how early clinical recognition resulted in prompt histopathological diagnosis and subsequent complete surgical excision. A literature review of existing reported cases, their management, and latest outcomes was also performed, highlighting this rare condition for consideration in the differential diagnosis of pigmented oral pathologies.

A Multidisciplinary Approach for the Management of Portal Vein Thrombosis

Portal venous thrombosis (PVT) is an uncommon disease associated with highly morbid conditions such as intestinal ischemia and portal hypertension. Patients at higher risk of developing PVT include those with cirrhosis, malignancy, or prothrombotic states. The mainstay of treatment is early initiation of anticoagulation. The first case is a 49-year-old female diagnosed with a cecal mass and PVT. She was started on anticoagulation and underwent a right hemicolectomy with several small bowel resections. She developed portal hypertension that required TIPS and mechanical thrombectomy. The second patient is a 65-year-old female found to have PVT. She was anticoagulated with heparin and given systemic TPA. She developed intestinal ischemia and portal hypertension requiring small bowel resection, TIPS, and mechanical thrombectomy. These cases give insight into the impact of a multidisciplinary team approach to PVT. The role and timing of endovascular treatment is not well established and needs to be further investigated.

Standardization of Pediatric Noncardiac Operating Room to Intensive Care Unit Handoffs Improves Communication and Patient Care

OBJECTIVES

Handoffs are critical points in transitioning care between multidisciplinary teams, yet data regarding intensive care unit (ICU) handoffs in pediatric noncardiac surgical patients are lacking. We hypothesized that standardized handoffs from the pediatric operating room (OR) to the ICU would improve physician presence, communication, and patient care parameters.

METHODS

This quality improvement initiative was performed at a tertiary children's hospital. Stakeholders (anesthesiologists, nurses, intensivists, and surgeons) developed a standardized OR to pediatric and neonatal ICU handoff process based on common goals and outcomes of interest. Baseline data were collected before intervention. Implementation was carried out in 2 phases, phase 1 with a written handoff and Phase 2 with a scripted handoff process. Data collected by trained observers included handoff attendance, distractions, and transfer of essential patient information. As a surrogate for outcomes, patient care parameter data were collected for 6 hours after transfer.

RESULTS

After phase 1, surgery and ICU physician attendance increased significantly, distractions decreased, and communication of essential patient data improved. In phase 2 (scripted handoff), attendance continued to rise, distractions remained decreased, and transfer of essential information was still improved compared with baseline. Mean handoff duration did not significantly change throughout the study. Certain patient care parameters (escalation of respiratory support, additional laboratory studies, vasopressor administration, antibiotic administration and timing) remained unchanged compared with baseline. However, the need for resuscitative fluid bolus or blood products significantly decreased after implementation phase 2.

CONCLUSIONS

Standardized handoffs for pediatric noncardiac surgical patients from the OR to the ICU can improve provider attendance and communication.

Improving Awareness of Safe Sleeping Practices for Babies on a Mother and Baby Psychiatric Unit

Introduction

SIDS is the sudden, unexpected and unexplained death of a baby. Safe sleeping practices can help to reduce a baby’s risk of SIDS. At the Coombe Wood Mother & Baby Unit (MBU), it was found that many patients were opting to co-sleep with their babies which contradicts safe sleeping guidelines.

Objectives

To improve patient awareness of the condition SIDS and to implement an interactive training session improving awareness of safe sleeping practices for babies. To improve patients’ confidence in implementing safe sleeping practices for their babies; thus reducing the risk of SIDS occurring.

Methods

The Lullaby Trust™ is a charity that raises awareness of SIDS and provides expert advice on safe sleep for babies. An interactive training session for patients was organised by incorporating published materials from The Lullaby Trust™, facilitated by medical and occupational therapy staff on the MBU. The participants filled out a pre-training and post-training questionnaire to test the effectiveness and quality of the training session.

Results

The participants’ average level of confidence in knowing and applying safe sleeping practices for their babies doubled following the training session (from 2.3→4.8 and 2.6→5 respectively, with 5 meaning “Very Confident.”) The average level of knowledge of SIDS also increased from 1.6→4.4 (with 5 meaning “A Lot” of Knowledge.)

Conclusions

We were surprised at the low level of knowledge and confidence the patients had regarding safe sleeping practices for their babies. This project shows how interactive, ward-based training can be an effective way to engage and stimulate patients into improving the safety of their baby care.

Disclosure

No significant relationships.

Experiences of evidence presentation in court: an insight into the practice of crime scene examiners in England, Wales and Australia

Background

The ability to present complex forensic evidence in a courtroom in a manner that is fully comprehensible to all stakeholders remains problematic. Individual subjective interpretations may impede a collective and correct understanding of the complex environments and the evidence therein presented to them. This is not fully facilitated or assisted in any way with current non-technological evidence presentation methods such as poor resolution black and white photocopies or unidimensional photographs of complex 3D environments. Given the wide availability of relatively cheap technology, such as tablets, smartphones and laptops, there is evidence to suggest that individuals are already used to receiving visually complex information in relatively short periods of time such as is available in a court hearing. courtrooms could learn from this more generic widespread use of technology and have demonstrated their ability to do so in part by their adoption of the use of tablets for Magistrates. The aim of this current study was to identify the types of digital technology being used in courts and to obtain data from police personnel presenting digital evidence in court.

Results

A questionnaire study was conducted in this research to explore current technology used within courtrooms from the perspective of crime scene personnel involved in the presentation of complex crime scene evidence. The study demonstrated that whilst many of the participants currently utilize high-end technological solutions to document their crime scenes, such as 360° photography or laser scanning technologies, their ability to present such evidence was hindered or prevented. This was most likely due to either a lack of existing technology installed in the court, or due to a lack of interoperability between new and existing technology.

Conclusion

This study has contributed to this academic field by publishing real life experiences of crime scene examiner’s, who have used advanced technology to record and evaluate crime scenes but are limited in their scope for sharing this information with the court due to technological insufficiency. Contemporary recording techniques have provided the opportunity for further review of crime scenes, which is considered to be a valuable property over previous documentation practice, which relied upon the competency of the investigator to comprehensively capture the scene, often in a single opportunity.

Simultaneous detection and image capture of biological evidence using a combined 360° camera system with single wavelength laser illumination

Forensic investigators frequently utilise light sources to detect and presumptively identify biological evidence. The instrumentation typically deploys single or multiple wavelength exposures at various intensities, which interact with constituents of biological material, initiating fluorescence or improving contrast between the material and substrate. Documentation using sketches and/or photographic approaches follows detection, which are essential for scene reconstruction. Recent research has demonstrated the simultaneous detection and capture of biological evidence using a 360° camera system combined with an alternate light source exhibiting broad wavelength ranges of light. Single wavelength light sources reportedly offer enhanced sensitivity, due to the increased light intensity and narrower bandwidth of light, although their combined use with a 360° camera system has not yet been explored. Samples of human blood, semen, saliva, and latent fingermarks were deposited on to a variety of substrates. A 360° camera system combined with a laser light source was used to detect and capture the samples. Ten participants were asked to detect the samples on images of the substrates without ground truth knowledge. It was possible to detect and capture biological evidence, although success varied according to substrate colour and light intensity. Advantageously, presumptive screening for biological fluids and the simultaneous location and visualisation of such evidence as part of a 360° panorama of the scene for contextual purposes was permitted. There was no fluorescent response from the fingermarks, although the oblique lighting effects appeared sufficient to aid mark detection in some circumstances. The use of single wavelength illumination clearly facilitates identification of a range of forensically important material. When coupled with a 360-degree camera, this allows for simultaneous identification and recording of such evidence in the context of the whole environment.

[Total laryngopharyngectomy and reconstruction with a jejunum speech siphon : A case report]

Advanced laryngeal and hypopharyngeal carcinomas are associated with a poor prognosis and a pronounced loss of quality of life due to impairment of the swallowing and voice function. The fundamental therapeutic challenge is successful tumor control with concomitant rehabilitation of swallowing and voice functions. Further objectives are a low complications rate (fistula, aspiration) and prompt transfer to the adjuvant radio-oncologic therapy. With these factors in mind, the microvascular anastomosed jejunum speech siphon with a biventer rein has proven to be an effective method of reconstruction following extensive circular laryngopharyngeal resections. In this case report, a typical operative and postoperative course is presented, as are the functional results.

The lived experience of depression among culturally Deaf adults

Culturally Deaf adults lost hearing at early ages, communicate primarily in American Sign Language (ASL), and self-identify as culturally Deaf. Communication barriers lead to isolation, low self-esteem, abuse, and inadequate health care. Screening Deaf patients for depressive symptoms poses challenge. Nurses are rarely familiar with ASL, and depression screening tools aren't easily translated from English to ASL. Consequently, Deaf adults are not adequately screened for depression. Qualitative interviews were conducted with culturally Deaf adults, and certified interpreters helped to enhance understanding. Text was generated from interview transcriptions and researcher observations. No novel depressive symptoms were described. Various ASL signs were used to represent depression; two participants used a unique gesture that had no meaning to others. Childhood experiences leading to depression included sexual or physical abuse, feeling ostracized from family and like a burden. Suicidal gestures communicated severity of depression. Adults felt interpreters were unwelcome during mental health encounters. No participants were asked about depressive symptoms despite frank manifestations of depression. Study describes antecedents and consequences of depressive symptoms among Deaf adults. Understanding symptom manifestations and challenges experienced by Deaf patients helps identify those at risk for depression, thereby reducing morbidity and mortality.

Complex high-resolution linkage disequilibrium and haplotype patterns of single-nucleotide polymorphisms in 2.5 Mb of sequence on human chromosome 21

One approach to identify potentially important segments of the human genome is to search for DNA regions with nonrandom patterns of human sequence variation. Previous studies have investigated these patterns primarily in and around candidate gene regions. Here, we determined patterns of DNA sequence variation in 2.5 Mb of finished sequence from five regions on human chromosome 21. By sequencing 13 individual chromosomes, we identified 1460 single-nucleotide polymorphisms (SNPs) and obtained unambiguous haplotypes for all chromosomes. For all five chromosomal regions, we observed segments with high linkage disequilibrium (LD), extending from 1.7 to>81 kb (average 21.7 kb), disrupted by segments of similar or larger size with no significant LD between SNPs. At least 25% of the contig sequences consisted of segments with high LD between SNPs. Each of these segments was characterized by a restricted number of observed haplotypes,with the major haplotype found in over 60% of all chromosomes. In contrast, the interspersed segments with low LD showed significantly more haplotype patterns. The position and extent of the segments of high LD with restricted haplotype variability did not coincide with the location of coding sequences. Our results indicate that LD and haplotype patterns need to be investigated with closely spaced SNPs throughout the human genome, independent of the location of coding sequences, to reliably identify regions with significant LD useful for disease association studies.

A high-resolution radiation hybrid map of the human genome draft sequence

We have constructed a physical map of the human genome by using a panel of 90 whole-genome radiation hybrids (the TNG panel) in conjunction with 40,322 sequence-tagged sites (STSs) derived from random genomic sequences as well as expressed sequences. Of 36,678 STSs on the TNG radiation hybrid map, only 3604 (9.8%) were absent from the unassembled draft sequence of the human genome. Of 20,030 STSs ordered on the TNG map as well as the assembled human genome draft sequence and the Celera assembled human genome sequence, 36% of the STSs had a discrepant order between the working draft sequence and the Celera sequence. The TNG map order was identical to one of the two sequence orders in 60% of these discrepant cases.

A prospective study of two intravenous catheter securement techniques in a skilled nursing facility

A prospective, controlled study was undertaken in a skilled nursing facility to determine whether a sterile catheter securement device (StatLock i.v., Venetec International, Mission Viejo, CA) would provide better intravenous therapy outcomes than a standard securement technique. The StatLock-device resulted in significantly longer average catheter dwell times (3.95 days versus 2.45 days) and significantly fewer total complications (65 versus 155). In addition, the securement device reduced the total time spent managing a vascular access device by 13.5 minutes per patient. Thus, the StatLock i.v. device improved overall clinical outcomes of i.v. therapy and the quality of care.

Changing nursing practice--trisectoral collaboration in decision making

In an age of cost containment, agency partnerships have become an essential element for future planning and program implementation. This paper describes a trisectoral collaboration of a hospital, health department, university and school of nursing to compare the efficacy and efficiency of referral decisions of hospital staff nurses to those of the public health liaison nurses (LNs). A process to identify decision criteria was undertaken and an educational programme was designed to assist the staff nurses with the referral process and to assure consistency of decision making. The two groups were then compared. The results of the study found staff nurses, using the decision criteria, identified more patients who required public health nursing visits than did the liaison nurses, refusal rate of the patients to participate was no different, staff nurses cost less than LNs and job satisfaction was not significantly altered for either group. In addition to providing information to guide administrative and clinical decision making, the project also provided a learning experience for the staff of three agencies in conducting research and in using evidence-based practice to change traditional practice.

Comparison of liaison and staff nurses in discharge referrals of postpartum patients for public health nursing follow-up

The purpose of this study was to compare hospital staff nurses to public health liaison nurses in the accuracy and cost of postpartum referrals for public health nursing follow-up in the community. In the before phase of the study, public health liaison nurses assessed 304 mothers to determine the need for a follow-up visit by the public health nurse. In the after phase, staff nurses assessed 326 mothers. Public health nurses, unaware of the identity of the referring nurse and the referral decision, judged whether their visit had been required. Staff nurses correctly identified a higher proportion of referrals requiring public health nurse follow-up than liaison nurses. Although they referred more clients who did not require a public health nurse visit, costs of referrals by staff nurses remained lower.

Type I receptors in parotid, colon, and pituitary are aldosterone selective in vivo

Previous in vivo studies have demonstrated that type I receptors in the rat kidney are aldosterone selective, whereas those in the hippocampus do not appear to discriminate between aldosterone and corticosterone. We have injected mature rats with [3H]aldosterone or [3H]corticosterone plus 100-fold excess of RU 28362, with or without unlabeled aldosterone or corticosterone, and compared type I receptor occupancy in two classic mineralocorticoid target tissues (parotid and colon) and in the pituitary. Mature rats were killed 10-180 min after tracer administration; [3H]aldosterone was well taken up and retained in all tissues, whereas [3H]corticosterone was significantly retained only in the pituitary 10 min after tracer administration. To assess a possible role for corticosterone-binding globulin (CBG) in conferring aldosterone specificity on type I receptors, 10-day-old rats (with very low levels of CBG) were similarly injected. In the colon and parotid, [3H]aldosterone binding was at least an order of magnitude higher than that of corticosterone; in the pituitary aldosterone binding was approximately three times that of corticosterone. We interpret these data as evidence that in the parotid and colon type I receptors are aldosterone selective by a non-CBG-requiring mechanism, whereas in the pituitary there appear to be both aldosterone-selective and nonselective type I sites.

Adrenocortical steroids and the brain

In summary, a wide variety of effects of adrenal steroids on the brain have been reported and have been recently and exhaustively reviewed. From the viewpoint of endocrine physiology, however, what is often forgotten is the extraordinary difference in signal level between the two unique products of the adrenal cortex, the mineralocorticoid and glucocorticoid hormones. Levels of cortisol or corticosterone are 2-3 orders of magnitude higher than those of aldosterone, a difference that is tempered by perhaps one order of magnitude by the much higher binding of glucocorticoids to plasma protein. The signal-detecting mechanisms for the lower-intensity signal, i.e. the mineralocorticoid receptor, must therefore have powerful specificity-conferring mechanisms to enable it to recognize, bind, and respond to aldosterone. In vitro studies from a number of laboratories have shown that Type I receptors, in both classic mineralocorticoid target tissues (kidney, parotid, gut) and nontarget tissues (pituitary, hippocampus), cannot distinguish between aldosterone and corticosterone. This finding highlights the problem of aldosterone-selectivity in the kidney (Na+ transport) or the brain (Na+ appetite). In vivo studies, in contrast, show that corticosterone is very poorly taken up and/or retained in kidney, colon, parotid, and pituitary (but not in hippocampus) in mature and 10-day-old (minimal transcortin) rats, whereas aldosterone is well taken up and/or retained by all tissues, evidence for tissue-specific aldosterone selectivity in vivo. Two nonexclusive (i.e. possibly additive) models for such aldosterone selectivity are proposed, one "prebinding" and the other "postbinding". Both models accommodate the experimental findings of the nonselectivity of cytosol preparations in vitro and the stringent specificity seen in in vivo receptor and effector studies. In any real sense, the action of adrenal steroids on the brain is still largely an area of unconnected phenomenology, despite the efforts of a number of talented individuals and groups over the past two decades. Without descriptions of phenomena, even of the most basic ablation and replacement type, we have no chance of making physiological statements. It is equally important, in the attempt to make a coherent physiology, to erect a scaffolding of hypothesis that can be tested against the existing experimental findings and that can serve to suggest further studies in a logical sequence. These hypotheses themselves, and the models used to reify them, may be validated, altered, or rejected by the studies over the next few years.(ABSTRACT TRUNCATED AT 400 WORDS)

Mineralocorticoid specificity of renal type I receptors: in vivo binding studies

We have injected rats with [3H]aldosterone or [3H]corticosterone, plus 100-fold excess of the highly specific glucocorticoid RU 28362, with or without excess unlabeled aldosterone or corticosterone and compared type I receptor occupancy in kidney and hippocampus. Thirty minutes after subcutaneous injection [3H]aldosterone was well retained in renal papilla-inner medulla, renal cortex-outer medulla, and hippocampus; in contrast, [3H]corticosterone was well retained only in hippocampus. Competition studies for [3H]aldosterone binding sites showed corticosterone to be a poor competitor in the kidney compared with hippocampus. Time-course studies, with rats killed 10-180 min after tracer administration, showed very low uptake/retention of [3H]corticosterone by kidney; in hippocampus [3H]corticosterone retention was similar to that of [3H]aldosterone in kidney, and retention of [3H]aldosterone by hippocampus was much more prolonged than of either tracer in any other tissue. Studies in 10-day-old rats, with very low levels of corticosteroid binding globulin (CBG), showed a high degree of aldosterone selectivity in both zones of the kidney, whereas [3H]aldosterone and [3H]corticosterone were equivalently bound in hippocampus. We interpret these data as evidence for a mechanism unrelated to extravascular CBG conferring mineralocorticoid specificity on renal type I receptors and propose two models derived from our findings consistent with such differential selectivity.

Neutrophils are involved in the increased vascular permeability produced by activated complement in man

To investigate the role of neutrophils in complement-induced changes in vascular permeability, skin wheal and flare responses to intradermal injection of autologous activated serum complement were measured in normal and neutropenic subjects. In normal subjects, responses were dose-dependent and were abolished by removal of C5 from serum. Biopsy of a wheal revealed neutrophils adherent to vascular endothelium. In neutropenic subjects (neutrophil count less than 0.5 X 10(9)/l), responses to complement-activated serum or a low molecular weight fraction from it were significantly reduced. This could not be accounted for by a reduction in concentration of C5 conversion products. In one subject with chronic granulomatous disease a normal response was produced. Local injection of the anti-histamine (H1) drug clemastine produced only partial inhibition of responses, while almost totally abolishing histamine-induced wheals. Systemic anti-inflammatory drugs had no effect. The data suggest that the microvascular response to activated complement in man is at least partly due to an interaction between C5 fragments and neutrophils.

Homozygous transcobalamin II deficiency maintained on oral hydroxocobalamin

A case of transcobalamin II (TCII) deficiency in which a total absence of TCII was demonstrated both functionally and immunologically is reported. Unlike previously described patients, this child has been maintained on oral hydroxocobalamin, 2 mg daily, without any parenteral supplementation for the last five years. At the age of six years her development is normal and her health is good. Plasma cobalamin levels are in the range of 3,000 ng/L and most of this appears to be bound to a molecule, which on gel filtration, elutes with albumin. In an extended family study, a clear separation of heterozygotes from both the propositus and from normal subjects suggests that the underlying defect in this condition is confined to a single gene.

Cobalamin and folate binding proteins in human tumour tissue

The serum of an 84 year old man with disseminated carcinoma was found to contain extremely high concentrations of cobalamin and of a cobalamin binding protein with trans-cobalamin I characteristics. Tumour tissue samples obtained at necropsy contained considerably higher concentrations of cobalamin binding protein (R-binder) than normal tissues. Tumour tissues also contained increased concentrations of specific folate binding protein. In all tissues studied a close correlation existed between unsaturated cobalamin and unsaturated folate binding and between total cobalamin and total folate binding. These results suggest related mechanisms for the synthesis of cobalamin binding proteins of the R-binder class and folate binding proteins by tumour tissue.

Inhibition of human neutrophil secondary granule discharge by antiinflammatory agents

Human neutrophil cobalamin binding protein (NCBP) is located exclusively in the neutrophil secondary granules. The soluble stimuli formlymethionyl-leucyl-phenylalanine and the low-molecular-weight complement fragment C5a both promote the dose-dependent release of NCBP from cytochalasin B-treated neutrophils in vitro. The extracellular discharge of NCBP induced by higher secretagogue is inhibited by prior exposure of neutrophils to the corticosteroids hydrocortisone and methylprednisolone and the nonsteroidal antiinflammatory agents indomethacin and ibuprofen. The four antiinflammatory agents function as competitive antagonists of neutrophil secondary granule discharge with a site of action at or near the cell surface. These findings support the hypothesis that antiinflammatory agents prevent neutrophil activation in vitro by inhibition of stimulus-receptor coupling. The significance of these observations with regard to the in vivo actions of these agents remains uncertain, however.

The effects of surgery on the activity of neutrophil granule proteins

Activities of the neutrophil granule-associated proteins beta-glucuronidase, lysozyme and vitamin B12 binding protein were measured, serially, in the cells and serum of 10 patients undergoing total abdominal hysterectomy. The neutrophil leucocytosis which followed total abdominal hysterectomy was accompanied by a fall in the intraneutrophilic activities of all three granule-associated proteins. Intraneutrophilic lysozyme activity and intraneutrophilic vitamin B12 binding capacity were maximally reduced within 4 h of surgery and fell to 62 +/- 13% (mean +/- SEM) and 63 +/- 9% of their preoperative levels, respectively. This contrasted with the activity of intraneutrophilic beta-glucuronidase which was not maximally reduced until 24 h post-surgery when a fall to 80 +/- 6% of the preoperative level was observed. By the fifth postoperative day activities of the three intraneutrophilic granule proteins were increasing and approaching those observed preoperatively. Serum lysozyme and plasma unsaturated vitamin B12 binding capacity (UBBC) rose steadily following surgery and were significantly elevated by the fifth postoperative day. It is suggested that activation and in vivo degranulation of circulating neutrophils may be responsible for these changes in activity of neutrophil granule proteins following surgery.

The discharge of primary and secondary granules during immune phagocytosis by normal and chronic granulocytic leukaemia polymorphonuclear neutrophils

The two types of granule in polymorphonuclear neutrophils may have distinct functions. The primary granule enzymes are responsible for killing and digesting ingested micro-organisms while the secondary granule constituents may have regulatory functions outside the cell. This hypothesis is supported by finding that during immune phagocytosis of a yeast, nearly all of the neutrophil's secondary granule vitamin B12-binding protein is lost from the cell and 80% can be accounted for in the medium. Much less of the primary granule enzymes, beta-glucuronidase and acid phosphatase, are lost from the cells and very little can be detected in the medium. Lysozyme is a constituent of both types of granule and its behaviour is intermediate. There is no difference in the release of these granule constituents from chronic granulocytic leukaemia neutrophils compared with normal neutrophils.

Changes in serum levels of cobalamin and cobalamin analogues in folate deficiency

The recent introduction of radioassays for 'true' cobalamin, as opposed to cobalamin and its analogues, has resulted in significantly lower levels of cobalamin being found in patients with folate deficiency. In study of 81 patients, cobalamin analogue levels were found to increase and cobalamin to decrease as red cell folates decreased. Cobalamin absorption studies in 15 patients with low cobalamin and folate levels were found to be normal in 10 patients, all of whom demonstrated high levels of analogues relative to true cobalamin. We have found that the mean serum cobalamin increased from 210 ng/l (range 100-380) to 309 (150-470) and analogues fell from 226 ng/l (150-280) to 127 (65-190) in folate deficient patients when treated with folic acid. It appears that cobalamin analogue concentrations are increased in folate deficiency, and that in these patients treatment with folic acid alone may correct both the low cobalamin and the high analogue levels.