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A 60-year-old Caucasian man had a 55-year history of recurrent severe epistaxis and later presented with multiple gastrointestinal (GI) bleeding from hereditary hemorrhagic telangiectasia (HHT). Bleeding was exacerbated due to coexistent mild hemophilia A. Despite repeated conventional surgical interventions, tranexamic acid and recombinant factor VIII (FVIII) prophylaxis, bleeding episodes worsened in frequency and severity, resulting in the patient becoming transfusion dependent. The introduction of tamoxifen therapy resulted in reduced transfusion requirement.

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BACKGROUND: Strongylid and ascarid parasites are omnipresent in equine stud farms, and ever-increasing levels of anthelmintic resistance are challenging the industry with finding more sustainable and yet effective parasite control programs. OBJECTIVES: To evaluate egg count levels, bodyweight and equine health under defined parasite control protocols in foals and mares at two Standardbred and two Thoroughbred stud farms. STUDY DESIGN: Longitudinal randomised field trial. METHODS: A total of 93 foals were enrolled and split into two treatment groups, and 99 mares were enrolled and assigned to three treatment groups. All horses underwent a health examination, and episodes of colic or diarrhoea were recorded at each faecal collection date. Bodyweights were assessed using a weight tape, and mares were body condition scored. Group A foals (FA) were dewormed at 2 and 5 months of age with a fenbendazole/ivermectin/praziquantel product, while group B foals (FB) were dewormed on a monthly basis, alternating between the above-mentioned product and an oxfendazole/pyrantel embonate product. Group A mares (MA) were dewormed twice with fenbendazole/ivermectin/praziquantel, group B mares (MB) were dewormed with the same product, when egg counts exceeded 300 strongylid eggs per gram, and group C mares (MC) were dewormed every 2 months, alternating between the two products. Health data were collected monthly for 6 months (foals) and bimonthly for 13 months (mares). Data were analysed with mixed linear models and interpreted at the α = 0.05 significance level. RESULTS: There were no significant bodyweight differences between foal groups, but MA mares were significantly lighter than the other two groups. Very few health incidents were recorded. Foals in group FA had significantly higher ascarid and strongylid egg counts, whereas no significant differences were observed between mare groups. MAIN LIMITATIONS: Study duration limited to one season. CONCLUSIONS: Anthelmintic treatment intensity was lowered from the traditional intensive regimes without measurable negative health consequences for mares and foals.

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We present a very rare case of chronic encapsulated intracerebral hematoma involving the septum pellucidum and the foramen of Monro that by location radiological appearance, and clinical history was mimicking a recurrent astrocytoma or a shunt-related foreign body granuloma. A young adult underwent the resection of a juvenile pilocytic astrocytoma as a child, and with a mass encasing the tip of an old non-functioning ventricular catheter, the differential diagnosis of shunt-related foreign body granuloma versus recurrent low-grade glioma was raised. Although chronic encapsulated intracerebral hematomas have been reported in the literature, the anatomical location of the lesion in the presented case was unique, with radiological and history findings also posing a peculiar diagnostic challenge. Chronic encapsulated intracerebral hematomas are benign entities that may also be found to involve deep and midline supra-tentorial structures usually not prone to spontaneous intraparenchymal hemorrhages. When symptomatic, surgical resection of the hematoma can be both diagnostic and curative.

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BACKGROUND: We conducted a Neisseria meningitidis (Nm) carriage study among men who have sex with men (MSM) to explore possible sexual transmission. METHODS: We paired information on patient characteristics with oropharyngeal, rectal, and urethral Nm culture results to assess associations with Nm carriage among 706 MSM at New York City sexual health clinics. The Nm isolates were characterized by whole genome sequencing. RESULTS: Twenty-three percent (163 of 706) of MSM were Nm carriers. Oropharyngeal carriage was 22.6% (159 of 703), rectal 0.9% (6 of 695), and urethral 0.4% (3 of 696). Oropharyngeal carriage was associated with the following recent (past 30 days) exposures: 3 or more men kissed (adjusted relative risk [aRR], 1.38; 95% confidence interval [CI], 1.03-1.86), performing oral sex (aRR, 1.81; 95% CI, 1.04-3.18), and antibiotic use (aRR, 0.33; 95% CI, 0.19-0.57). Sixteen clonal complexes were identified; 27% belonged to invasive lineages. CONCLUSIONS: Our findings suggest that oral sex and the number of recent kissing partners contribute to Nm carriage in MSM.

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We present a rare case of symptomatic cystic lumbar spinal epidural lipomatosis that required surgical treatment via a minimally invasive tubular laminectomy. To our knowledge this is the first pathology confirmed report of compressive cystic lumbar spinal epidural lipomatosis available in literature.

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Positive patient outcomes require effective teamwork, communication, and technological literacy. These skills vary among the unprecedented five generations in the nursing workforce, spanning the "Silent Generation" nurses deferring retirement to the newest "iGeneration." Nursing professional development educators must understand generational differences; address communication, information technology, and team-building competencies across generations; and promote integration of learner-centered strategies into professional development activities.

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Children receiving care in primarily adult areas, such as emergency or procedural departments, may receive care from nonpediatric nurses. A pediatric resource nurse program offered didactic and hands-on education in pediatric assessment and care. Participants significantly improved self-reported knowledge, skill, and comfort level. Course development and initial learner results are described.

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INTRODUCTION: Low back pain (LBP) is one of the most costly conditions to manage in occupational health. Individuals with chronic or recurring LBP experience difficulties returning to work due to disability. Given the personal and financial cost of LBP, there is a need for effective interventions aimed at preventing LBP in the workplace. The aim of this systematic review was to examine the effectiveness of exercises in decreasing LBP incidence, LBP intensity and the impact of LBP and disability. METHODS: A comprehensive literature search of controlled trials published between 1978 and 2007 was conducted and a total of 15 studies were subsequently reviewed and analyzed. RESULTS: There was strong evidence that exercise was effective in reducing the severity and activity interference from LBP. However, due to the poor methodological quality of studies and conflicting results, there was only limited evidence supporting the use of exercise to prevent LBP episodes in the workplace. Other methodological limitations such as differing combinations of exercise, study populations, participant presentation, workloads and outcome measures; levels of exercise adherence and a lack of reporting on effect sizes, adverse effects, and types of sub-groups, make it difficult to draw definitive conclusions on the efficacy of workplace exercise in preventing LBP. CONCLUSIONS: Only two out of the 15 studies reviewed were high in methodological quality and showed significant reductions in LBP intensity with exercise. Future research is needed to clarify which exercises are effective and the dose-response relationships regarding exercise and outcomes.

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BACKGROUND: Health literacy has a direct effect on health outcomes, but the complexity of diabetes education and time constraints on the health care team have made delivery of this education difficult. METHODS: The Florida Initiative in Telemedicine and Education developed an education website (Brainfood) for multiple literacy levels. The site consists of 19 education units, 15 of which provided gradable test scores; a narrated cartoon provides essential information to low reading level learners. Text is presented at both 4th and 10th grade level. Literacy level of the user is not evaluated; rather, users choose their preferred format. The administrative backbone stores user demographics and test scores. Nurses can receive credit hours for completion of Brainfood, 13 tests required. Results were analyzed by a non-paired t test. RESULTS: Five hundred thirteen users have logged in to the site and clicked "I agree" on an informed consent. Of non-nurses, 145 of 389 took pre-tests (range 89-145 depending on module), and 135 took post-tests (range 84-135). For each of the 15 modules, post-test scores improved significantly (P < 0.001 by non-paired t test). Of nurses, 68 of the 124 took pre-tests (range 26-68), and up to 56 (range 24-56) took post-tests. Post-test scores improved significantly (P < 0.05 by non-paired t test) on 13 modules. Post-test scores improved, but were not statistically significant for "Nutrition 101," a module about very basic nutrition. Web-based education about Type 1 diabetes mellitus improved the knowledge level of all users. Nurses had a lower margin of improvement for most modules as they started with a higher base knowledge level. Non-nurses improved significantly on all modules from pre-test to post-test. Post-test scores for the nurses and non-nurses were indistinguishable. CONCLUSION: Brainfood, a web-based diabetes education program, is educationally sound and effective at delivering Type 1 diabetes mellitus education to both professionals and non-professionals. Web access from non-clinic settings can improve access to high-quality education for learners in remote or underserved locations.

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CONTEXT: The molecular mechanisms of luteolysis and its inhibition during maternal recognition of pregnancy remain unclear. OBJECTIVE: The objective of this study was to investigate the differential regulation of connective tissue growth factor (CTGF) expression in human corpora lutea using in vivo and in vitro models. DESIGN: Corpora lutea from different stages of the luteal phase and after luteal rescue with human chorionic gonadotropin (hCG) were studied. Primary cultures and cocultures of luteinized granulosa cells and luteal fibroblast-like cells were performed. SETTING: This study was performed at the research center of a university teaching hospital. PATIENTS: Women with regular cycles having hysterectomy for nonmalignant conditions and women undergoing oocyte collection for assisted conception were studied. INTERVENTIONS: CTGF localization was determined by in situ hybridization, and expression by quantitative RT-PCR. OUTCOMES: The outcome measures were the effect of hCG on the expression and localization of CTGF mRNA in human corpora lutea and the effect of hCG on CTGF expression in primary cultures of luteinized granulosa cells and luteal fibroblast-like cells. RESULTS: Luteal rescue reduced CTGF expression compared with that in the late luteal phase (P < 0.05). CTGF expression was localized to fibroblast-like cells and endothelial cells of larger blood vessels, not to steroidogenic cells. The expression of CTGF by fibroblast-like cells in vitro was not regulated by hCG. When cocultured with luteinized granulosa cells, fibroblast-like cell CTGF expression was inhibited by hCG (P < 0.001). This effect was independent of stimulated progesterone concentrations and was not blocked by follistatin or indomethacin. Both IL-1alpha (P < 0.05) and cAMP (P < 0.001) inhibited CTGF expression in fibroblast-like cells. CONCLUSIONS: These results provide evidence for negative regulation of CTGF by hCG during luteal rescue mediated by paracrine signals.

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Angiogenesis is essential for normal growth and function of the corpus luteum. The roles of various angiogenic factors in these events are being elucidated. Endocrine gland vascular endothelial growth factor (EG-VEGF) has recently been described in the human ovary. To define the localization of EG-VEGF mRNA in the corpus luteum and determine changes in its expression, dated human corpora lutea were studied at the early, mid-, and late luteal phases. Quantitative RT-PCR was employed to determine changes in EG-VEGF mRNA and compare expression to its related factor prokineticin-2 and the established angiogenic factor, VEGF. In situ hybridization was used to localize sites of production of EG-VEGF. To investigate whether expression of EG-VEGF was under the influence of LH or progesterone, luteinized granulosa cells were stimulated with human chorionic gonadotropin in the presence or absence of a progesterone synthesis inhibitor. EG-VEGF mRNA increased throughout the luteal phase, whereas there was no change in VEGF mRNA. The relative abundance of RNAs based upon PCR signal intensity showed that VEGF and EG-VEGF were highly expressed, whereas expression of prokineticin-2 was low. EG-VEGF mRNA was localized predominantly to granulosa-derived cells of the corpus luteum. Human chorionic gonadotropin stimulated both VEGF and EG-VEGF mRNA in vitro, but the level of expression was not influenced by progesterone. These results establish that in the human corpus luteum EG-VEGF is principally derived from granulosa lutein cells and that its synthesis is highest during the mid- to late luteal phase.

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Glanzmann's thrombasthenia (GT) is an autosomal recessive disorder of platelet function. Conventional management is by platelet transfusion, given before invasive interventions. Alloimmunization resulting in platelet refractoriness and an unpredictable response to platelet infusion have provided particular management difficulties in the past. More recently recombinant (r)VIIa (Novoseven) has a valuable role in the treatment of platelet function disorders. Treatment of a patient with GT during two pregnancies and spinal surgery is reported. An algorithm is presented to provide a structured and consistent approach to treatment.

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A subset of breast carcinomas shows unexplained overexpression of HER-2/neu protein without HER-2/neu gene amplification. These tumors are often scored 2+ by immunohistochemistry (DAKO HercepTest). In vitro, Zonula occludens-1 (ZO-1), a tight junction protein, can upregulate HER-2/neu expression by sequestering a repressor of the HER-2/neu gene promoter. To assess this relation in vivo, we examined the expression of ZO-1 in 2 series of breast carcinomas. In group 1, 35 invasive breast carcinomas previously scored by HercepTest for HER-2/neu status (negative [n = 12], 2+ [n = 13], 3+ [n = 10]) were examined by immunohistochemistry for expression of ZO-1. ZO-1 expression was then correlated with HER-2/neu expression status. Twenty-four of 35 carcinomas (69%) were positive for ZO-1 expression. Frequency of ZO-1 expression did not differ between HER-2/neu-negative carcinomas (67%) and 2+ positive carcinomas (77%). Carcinomas with 3+ HER-2/neu expression were less commonly positive for ZO-1 (60%), but this difference was not significant. Twenty tumors contained ductal carcinoma in situ (DCIS); 18 of 20 DCIS (90%) were positive for ZO-1. Interestingly, in those tumors with ZO-1-positive DCIS, 4 of 18 (22%) were negative for ZO-1 expression in the invasive tumor. In group 2, 31 of 42 (74%) fluorescent in situ hybridization-nonamplified breast carcinomas showed ZO-1 expression, also with no significant difference in frequency between HER-2/neu-positive (by immunohistochemistry) and negative cases. ZO-1 expression does not correlate with HER-2/neu expression in breast carcinomas. Other causes of HER-2/neu protein overexpression should be sought in cases without HER-2/neu gene amplification.

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The morphology of urothelial carcinomas, particularly when poorly differentiated or in metastatic sites, is not distinctive and overlaps significantly with other poorly differentiated nonurothelial carcinomas. Currently, there is no widely used single marker or panel of markers to confirm urothelial origin. We evaluated a panel consisting of antibodies to uroplakin III (UROIII), thrombomodulin (THR), high molecular weight cytokeratin (HMWCK), and cytokeratin 20 (CK20) in a wide range of urothelial tumors. Immunohistochemistry was performed on 112 paraffin-embedded urothelial neoplasms: 14 low malignant potential, 16 low-grade noninvasive, 16 high-grade noninvasive, 36 invasive, and 25 metastatic and 5 small cell carcinomas of the urinary bladder. Tissue microarray analysis was used to examine 498 tissue cores of nonurothelial tumors and normal tissue using antibodies to UROIII, THR, and HMWCK. Overall positive staining results in all urothelial tumors are as follows: UROIII, 64 of 112 (57.1%); THR, 77 of 112 (68.8%); HMWCK, 88 of 110 (80%); and CK20, 53 of 110 (48.2%). The expression of the four markers varied with tumor grade and stage. All small cell carcinomas were negative for all markers. Variant morphologic subtypes showed similar staining as conventional urothelial carcinomas. Tissue microarray analysis showed no UROIII immunoreactivity in tissue cores of nonurothelial tumors. THR was expressed by a limited number of nonurothelial cores (10 of 37 [27%] non-small cell lung carcinomas, 2 of 36 [5.6%] lymphomas). HMWCK was expressed by 43.8% of non-small cell lung carcinomas and essentially absent in other nonurothelial tumor cores. Based on the results of the study, the expression of UROIII in a tumor is essentially diagnostic of urothelial origin; however, it is expressed in only slightly more than half of urothelial tumors. The coexpression of THR, HMWCK, and CK20 strongly suggests urothelial origin. The coexpression of two of three non-UROIII markers (THR, HMWCK, CK20) suggests urothelial origin but requires clinicopathologic correlation. The results of the study indicate a role for an antibody panel that includes UROIII, THR, HMWCK, and CK20 in the diagnosis of urothelial tumors.

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