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Chikungunya virus (CHIKV) is an arthropod-borne virus capable of causing large outbreaks. We aimed to determine the decadal change in the extent of chikungunya virus infection from 2009 to 2019. We implemented a prospective cross-sectional survey in Pune City using a 30-cluster approach with probability-proportion-to-size (PPS) sampling, with blood samples collected from 1654 participants in early 2019. The study also included an additional 799 blood samples from an earlier serosurvey in late 2009. The samples were tested by an in-house anti-CHIKV IgG ELISA assay. The overall seroprevalence in 2019 was 53.2% (95% CI 50.7−55.6) as against 8.5% (95% CI 6.5−10.4) in 2009. A fivefold increase in seroprevalence was observed in a decade (p < 0.00001). The seroprevalence increased significantly with age; however, it did not differ between genders. Modeling of age-stratified seroprevalence data from 2019 coincided with a recent outbreak in 2016 followed by the low-level circulation. The mean estimated force of infection during the outbreak was 35.8% (95% CI 2.9−41.2), and it was 1.2% after the outbreak. To conclude, the study reports a fivefold increase in the seroprevalence of chikungunya infection over a decade in Pune City. The modeling approach considering intermittent outbreaks with continuous low-level circulation was a better fit and coincided with a recent outbreak reported in 2016. Community engagement and effective vector control measures are needed to avert future chikungunya outbreaks.

Background: Ambulatory training is an integral component of internal medicine residency programs, yet details regarding operational processes in resident continuity clinics remain limited., Methods: We surveyed a convenience sample of medical directors of residency practices between 2015 and 2019 (n = 222) to describe and share operational and scheduling processes in internal medicine resident continuity clinics in the US., Results: Among residency practices, support for the medical director role ranged substantially, but was most commonly reported at 11%-20% full-time-equivalent support. By the end of the survey period, the majority of programs (65.1%) reported obtaining patient-centered medical home (PCMH) certification (level 1-3). For new patient appointments, 34.9% of programs reported a 1-7 day wait and 25.8% reported an 8-14 day wait. Wait times for new appointments were generally shorter for PCMH certified practices (P = 0.029). No-show rates were most commonly 26%-50% for new patients and 11%-25% for established patients. Most programs reported that interns see 3-4 patients per ½-day and senior residents see 5-6 patients per ½-day. Most interns and residents maintain a panel size of 51-120 patients., Discussion: Creating high-performing residency clinics requires a focus on core building blocks and operational processes. Based on the survey results and consensus opinion, we provide five summary recommendations related to (1) support for the medical director leadership role, (2) patient-centered and coordinated models of care, (3) support for patient scheduling, (4) recommended visit lengths, and (5) ancillary support, such as social work., Competing Interests: None

Background: Smoking history and its potential association with COVID-19 has attracted many researchers and the lay public alike. However, the studies published to date have several methodological limitations and are mainly from China. We set out to synthesize evidence on smoking and COVID-19 relationship drawn on cohort studies only which are published in non-Chinese population settings., Method: A systematic literature search was undertaken drawn on predefined eligibility criteria and a comprehensive search strategy following the PRISMA guideline between January 2020 and August 2020, excluding preprints and gray literature. Three specific outcomes were examined: smoking history, SARS-CoV2 infection, and COVID-19 severity., Results: Of an eligible 40 full-text studies, 7 cohort studies outside of China were finally included in this literature review through independent reviewing. Four studies were from the UK, 2 from the United States, and 1 from Turkey. The sample size ranged from 200 to more than 5000 participants. The findings broadly point to 1 direction, a higher smoking prevalence and an increased risk of smoking history on both SARS-CoV2 infection and on COVID-19 severity., Conclusion: A smoking history (either current or past) seems to negatively impact both SARS-CoV2 infection and COVID-19 severity. However, such an observation strengthens the argument to continue smoking cessation efforts both for individuals and for the general population health and well-being., Competing Interests: Declaration of Conflicting Interests:The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Objective: Autism spectrum disorder (ASD) is a neurodevelopmental disorder frequently associated with epilepsy and epilepsy is a leading cause of death in ASD patients. Despite growing interest in genetic, neurophysiological and clinical overlaps, data on ictal electroencephalographic (EEG) recordings in ASD are lacking since behavioral disorders often make it difficult to obtain EEG recordings. We examined ictal EEG features in a consecutive series of patients with ASD and epilepsy., Methods: We retrospectively identified 400 consecutive patients with ASD and epilepsy at our Level 4 Epilepsy center between 2015 and 2019; 45 had at least one EEG-recorded seizure captured. Demographics, age of nonfebrile seizure onset, age of ASD diagnosis, language, magnetic resonance imagining findings, genetic testing and EEG studies were reviewed. Seizures were classified by semiologic and electrographic features. Ictal findings were analyzed., Results: A total of 497 seizures were captured in 45 patients: 20 patients with focal onset epilepsy had 126 seizures (median: 1, range: 1-30), 17 patients with generalized onset epilepsy had 88 seizures (median: 2, range: 1-15), 7 patients with Lennox-Gastaut syndrome had 270 seizures (median: 12, range: 1-74) and one patient had both right hemisphere focal and generalized onsets (12 focal, 1 generalized)., Significance: Our study is the first to analyze a large set of ictal data in patients with autism spectrum disorder, a population traditionally difficult to obtain ictal recordings. Our results confirm the diverse spectrum of seizure types and provide clinical-EEG correlates of seizures in ASD patients. Both focal-onset and generalized-onset seizures were recorded, confirming that ASD patients have higher rates of both focal and generalized epilepsy syndromes. Among patients with focal epilepsy, temporal and frontal onsets were frequent, suggesting the possibility of epilepsy surgery or brain stimulation. EEG to classify seizures and epilepsies is critical to determine therapeutic options and effort should be made to obtain EEGs in this heterogenous population., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Competing Interests: There are no conflicts of interest.

Competing Interests: There are no conflicts of interest.

The objective of the present study was to test the hypothesis that nutrient deprivation by effective isolation should inactivate causative saccharolytic bacteria occupying carious lesions. Vital maxillary third molar teeth were prepared by removing only the superficial necrotic material, leaving behind infected dentinal matrix, before the cavity was sealed with glass ionomer cement (GIC). Before sealing, lesions were biopsied to provide reference bacterial DNA for microbial analysis. After an interval of 10-12 months, the teeth were extracted and, after careful removal of GIC restoration, the underlying dentine was biopsied again for post-treatment microbial analysis. Microbial diversity for nine taxa in 45 carious lesions, before and after minimal intervention therapy, was quantified by real-time polymerase chain reaction (PCR). Except for Propionibacterium sp. FMA5, Fusobacterium nucleatum and Pseudoramibacter alactolyticus, representation of all other taxa showed reduction in the post-restoration biopsy samples. However, Propionibacterium sp. FMA5 was the only species predominantly detected in 80% of the pre-intervention, 82% of the post-restoration and 73% of the paired pre- and post-restoration biopsy samples. The median bacterial load for Propionibacterium sp. FMA5, lactobacilli and bacteria from the family Coriobacteriaceae was higher than the median bacterial load for the remaining six taxa. Significant reduction in the median bacterial load for lactobacilli was evident in post-restoration biopsy samples, implying effective control by GIC after minimal intervention. However, the median bacterial load for Propionibacterium sp. FMA5 increased in post-restoration biopsy samples. Incorporation of antimicrobial agents effective against Propionibacterium species FMA5 could add to more effective conservative management of advanced carious lesions.

A pediatric patient was assaulted while being treated at a Level 1 pediatric trauma center, prompting a Centers for Medicare & Medicaid Services site visit. The process of screening for physical abuse and protection of patients was reevaluated and revised, and a new guideline was implemented and shared with referral hospitals. During this same time period, 13 referral hospitals participated in an unrelated federally funded study determining the impact of recognition and care of injured children in states with and without a pediatric emergency care facility recognition program. A pre-post study analysis revealed that screening for abuse doubled during this time period.

Purpose: To analyse feasibility and safety of postoperative interstitial brachytherapy (IBRT) in patients of eyelid cancer treated primarily by surgical excision., Material and Methods: In this series, 8 patients with eyelid cancer were treated using postoperative interstitial brachytherapy. Patients were followed up for local control, cosmetic outcome, and acute and late toxicities. Cosmetic outcome was measured using a 6 point indigenous Cosmesis After Interstitial Brachytherapy (CAIB) scale., Results: The patients were between 23-82 years (median: 71 years). There were 3 females and 5 males, and 3 patients had lesions in upper eyelid. Postoperative high-dose-rate brachytherapy was used in all with 2 catheters implanted in most of them (6 out of 8). Local control was calculated from end of treatment to last follow-up. At last follow-up, all patients remained locally controlled. Two patients had nodal recurrence 6 months after interstitial brachytherapy and were salvaged effectively by external beam radiotherapy. At last follow-up, 7 patients were loco-regionally controlled and one was lost to follow up. All patients had Radiation Therapy Oncology Group (RTOG) grade 1 acute toxicity and 2 had grade 1 Common Terminology Criteria for Adverse Events (CTCAE) version.3 late toxicities. The cosmesis score for the whole group ranged between 0-1 indicating excellent to very good cosmesis., Conclusions: Postoperative high-dose-rate brachytherapy resulted in excellent disease control and cosmesis without significant acute or late toxicities. It is an effective modality for treatment of eyelid cancers in selected patients. Future prospective studies with the validation of CAIB scale would give us more insight to this effective yet often ignored modality of IBRT.

Objective: This study aimed to determine whether healthy children with fractures resulting from minor accidental trauma have a higher prevalence of vitamin D deficiency than that of healthy children without fractures., Methods: This was a prospective case-control study of ambulatory children younger than 18 years with and without fractures in a pediatric emergency department. Evaluation included serum 25-hydroxyvitamin D (25(OH)D) level, complete metabolic panel, and phosphorus level. Vitamin D deficiency was defined as a 25(OH)D level of less than 20 ng/mL and insufficiency less than 30 ng/mL but 20 ng/mL or greater. A level of 30 ng/mL or greater was considered sufficient. Fisher exact test was used to test for association between 25(OH)D level and fracture status. Logistic regression was used to examine the relationship between 25(OH)D levels and the odds of fracture, conditioned on season, age, race, body weight percentile, history of fracture, multivitamin use, and estimated daily milk intake., Results: The sample included 100 case and 100 control patients. There was no statistical difference in median 25(OH)D levels between fracture and control groups (26.7 vs 25.45 ng/mL, P = 0.84). There was no difference in the proportion of patients with sufficient 25(OH)D levels or in the distribution of sufficient, insufficient, and deficient. After adjusting for male sex and season of enrollment, vitamin D sufficiency was not a significant predictor of fracture status in a multiple variable logistic model (odds ratio, 0.94; 95% confidence interval, 0.51-1.77; Wald P = 0.859)., Conclusions: We found no relationship between vitamin D deficiency and fracture risk in our study population.

Objective: This study aimed to determine if a pediatric emergency care facility recognition (PECFR) program improved care processes for injured children younger than 15 years., Methods: A controlled pre-post study design was used. Emergency department (ED) medical records were abstracted from 8 Delaware hospitals and 13 comparison hospitals in North Carolina in 2009 and again in 2013, 1 year after PECFR implementation. Data collected focused on pediatric processes of care, including vital sign assessment, pain assessment and management, treatment procedures, and diagnostic radiation., Results: A majority of 1737 children (97%) had an Injury Severity Score of 9 or lower. Both hospital cohorts significantly increased initial pain assessment documentation over time (P < 0001). For children with extremity immobilization and a pain score of 5 or greater, the interval between pain assessment and pain management was significantly shorter in the Delaware hospitals (P < 0.01) compared with hospitals from North Carolina. A significant reduction in radiation use (flat film and computed tomographic imaging) was also found in Delaware hospitals (P < 0001) compared with the hospitals in North Carolina., Conclusions: Improvements in care to injured children associated with the PECFR program were limited to the interval between pain assessment and pain medication for children with extremity immobilization and to radiation use 1 year after the implementation of the PECFR program.

Introduction: As emergency medicine (EM) has become a more prominent feature in the clinical years of medical school training, national EM clerkship curricula have been published to address the need to standardize students' experiences in the field. However, current national student curricula in EM do not include core pediatric emergency medicine (PEM) concepts., Methods: A workgroup was formed by the Clerkship Directors in Emergency Medicine and the Pediatric Interest Group of the Society of Academic Emergency Medicine to develop a consensus on the content to be covered in EM and PEM student courses., Results: The consensus is presented with the goal of outlining principles of pediatric emergency care and prioritizing students' exposure to the most common and life-threatening illnesses and injuries., Conclusion: This consensus curriculum can serve as a guide to directors of PEM and EM courses to optimize PEM knowledge and skills education.

Purpose: Primary care practices are an ideal setting for reducing national smoking rates because >70% of smokers visit their physician annually, yet smoking cessation counseling is inconsistently delivered to patients. We designed and created a novel software program for handheld computers and hypothesized that it would improve clinicians' ability to provide patient-tailored smoking cessation counseling at the point of care., Methods: A handheld computer software program was created based on smoking cessation guidelines and an adaptation of widely accepted behavioral change theories. The tool was evaluated using a validated before/after survey to measure physician smoking cessation counseling behaviors, knowledge, and comfort/self-efficacy., Results: Participants included 17 physicians (mean age, 41 years; 71% male; 5 resident physicians) from a practice-based research network. After 4 months of use in direct patient care, physicians were more likely to advise patients to stop smoking (P = .049) and reported an increase in use of the "5 As" (P = .03). Improved self-efficacy in counseling patients regarding smoking cessation (P = .006) was seen, as was increased comfort in providing follow-up to patients (P = .04)., Conclusions: Use of a handheld computer software tool improved smoking cessation counseling among physicians and shows promise for translating evidence about smoking cessation counseling into practice and educational settings.

The purpose of the present study was to obtain diverse profiles of Prevotella species associated with gingival sites in an isolated Aboriginal and an urban community by phylogenetic analysis and to establish patterns of association of identified Prevotella species in gingival sites. Species/phylotypes identified from the phylogenetic analysis of near full-length Bacteroidetes 16S rRNA gene sequences cloned from subgingival plaque samples obtained from an Aboriginal community were compared with those from an ethnically diverse urban metropolitan population suffering from periodontal disease. Specific primer sets were designed and validated for 22 distinct Prevotella species from the 24 species/phylotypes identified from both populations. Within the isolated Aboriginal community, gingival sites in adults were colonised by a mean of 15 different Prevotella species. Prevotella sp. oral clone P4PB24, Prevotella intermedia, Prevotella oralis, Prevotella denticola and Prevotella sp. strain P4P62 had the highest association with increasing probing depth in diseased sites (p < 0.05). P. intermedia and Prevotella sp. oral clone P4PB24, the Prevotella species significantly associated with increasing probing depth in diseased gingival sites and also strongly associated with P. gingivalis load (p < 0.05) in diseased gingival sites, showed significant correlation for co-colonisation (r = 0.6). Prevotella sp. oral clone B31FD, showing strong association with P. gingivalis load (p < 0.05) in diseased gingival sites, showed no significant correlation for co-colonisation with any other Prevotella species. This study provides a comprehensive analysis of Prevotella species associated with gingival sites for the informative evaluation of the epidemiology of infection by this genus.

Objectives: To determine the renal size in normal Indian children by sonography., Settings: Pediatric teaching hospital, Mumbai, India., Duration: 1.5 years., Design: Cross-sectional observational study., Participants: 1000 normal Indian children aged 1 month to 12 years., Methods: Sonographic assessment of renal size (length, width and thickness) was performed using Philips real time mechanical sector scanner of 3.5-5 MHz frequency with electronic caliper. The mean renal dimensions and volume were calculated for each age group with ± 2SD. The renal length and calculated renal volume were correlated with somatic parameters like age, weight, height and body surface area. Regression equations were derived for each pair of dependent and independent variables., Results: No statistical difference was found in renal size between sexes and between right and left kidney. A strong correlation was seen between renal size with various somatic parameters, the best correlation was between renal size length and body height (coefficient of correlation=0.9)., Conclusion: This study provides values of renal length (mean ± 2SD) in normal Indian children. Renal length can be easily calculated by derived linear regression equation.

Objectives: A novel wound closure device combining a mesh tape and octylcyanoacrylate (OCA) topical skin adhesive (TSA) was developed to facilitate wound closure and enhance the adhesive's strength. The objective of this study was to determine whether the incidence of wound dehiscence after laceration repair with the new device was equivalent to that after use of a high-viscosity OCA. We hypothesized that the rate of complete wound edge apposition would be equivalent for the two closure devices., Methods: This was a multicenter, randomized clinical trial in nine academic and community emergency departments (EDs) and urgent care centers. Patients with simple traumatic lacerations were included. Lacerations were randomly closed with a high-viscosity OCA or mesh tape-OCA combination. The rate of complete wound edge apposition at 14 days, rates of wound infection at 14 and 30 days, and the percentage of optimally appearing scars at 30 days after closure were assessed. Assuming a maximal clinically acceptable difference for equivalence of 8% in the rate of completely apposed wound edges, a sample of at least 138 patients in the tape-OCA group and at least 69 in the OCA-only group would give 80% power and a one-sided significance level of 5%., Results: During the study period the investigators enrolled 216 subjects, of whom 143 were randomized to the tape-OCA combination and 73 to the OCA-only group. Most wounds were located on the face and the upper extremities. Mean laceration length was similar in patients in both groups (tape-OCA 2.1 cm vs. OCA-only 2.0 cm; difference 0.1 cm, 95% confidence interval [CI] = -0.45 to 0.58 cm). The rate of complete wound edge apposition at 14 days was higher in wounds treated with the tape-OCA combination than in wounds treated with OCA alone (86.0% vs. 78.1%). The upper bound of the one-sided CI was 1.0% for the intention-to-treat population, which was less than the predetermined acceptable difference of less than 8%. There were no between-group differences in rates of infection and optimally appearing scars., Conclusions: When compared with OCA alone, the novel tape-OCA combination is equivalent with regard to complete wound edge apposition and cosmetic appearance., (© 2011 by the Society for Academic Emergency Medicine.)

Purpose: Many nonrandomized studies have suggested better outcome for patients with breast cancer who undergo surgery during the luteal (progestogenic) phase of their menstrual cycle, but this is controversial. We investigated the effect of a single preoperative injection of hydroxyprogesterone in women with operable breast cancer (OBC) in a randomized controlled trial (ClinicalTrials.gov identifier, NCT00123669)., Patients and Methods: One thousand patients with OBC were randomly assigned to receive surgery or an intramuscular injection of depot hydroxyprogesterone 500 mg 5 to 14 days before surgery. Primary and secondary end points were disease-free survival (DFS) and overall survival (OS), respectively. An analysis by axillary lymph node status was preplanned., Results: At a median follow-up of 65 months among 976 eligible patients, 273 recurrences and 202 deaths were recorded. In the progesterone group versus control group, 5-year DFS and OS rates were 73.9% v 70.2% (hazard ratio [HR], 0.87; 95% CI, 0.68 to 1.09; P = .23) and 80.2% v 78.4% (HR, 0.92; 95% CI, 0.69 to 1.21; P = .53), respectively. In 471 node-positive patients, the 5-year DFS and OS rates in the progesterone group versus control group were 65.3% v 54.7% (HR, 0.72; 95% CI, 0.54 to 0.97; P = .02) and 75.7% v 66.8% (HR, 0.70; 95% CI, 0.49 to 0.99; P = .04), respectively. In multivariate analysis, DFS was significantly improved with progesterone in node-positive patients (adjusted HR, 0.71; 95% CI, 0.53 to 0.95; P = .02), whereas there was no significant effect in node-negative patients (P for interaction = .04)., Conclusion: A single injection of hydroxyprogesterone before surgery did not improve outcomes in all women with OBC. This intervention showed significant improvement in node-positive women that may be considered hypothesis generating. If replicated in other studies, this could be a simple and inexpensive intervention, especially in developing countries where the incidence of lymph node metastasis is high.

Background: Many have called for ambulatory training redesign in internal medicine (IM) residencies to increase primary care career outcomes. Many believe dysfunctional, clinic environments are a key barrier to meaningful ambulatory education, but little is actually known about the educational milieu of continuity clinics nationwide., Objective: We wished to describe the infrastructure and educational milieu at resident continuity clinics and assess clinic readiness to meet new IM-RRC requirements., Design: National survey of ACGME accredited IM training programs., Participants: Directors of academic and community-based continuity clinics., Results: Two hundred and twenty-one out of 365 (62%) of clinic directors representing 49% of training programs responded. Wide variation amongst continuity clinics in size, structure and educational organization exist. Clinics below the 25th percentile of total clinic sessions would not meet RRC-IM requirements for total number of clinic sessions. Only two thirds of clinics provided a longitudinal mentor. Forty-three percent of directors reported their trainees felt stressed in the clinic environment and 25% of clinic directors felt overwhelmed., Limitations: The survey used self reported data and was not anonymous. A slight predominance of larger clinics and university based clinics responded. Data may not reflect changes to programs made since 2008., Conclusions: This national survey demonstrates that the continuity clinic experience varies widely across IM programs, with many sites not yet meeting new ACGME requirements. The combination of disadvantaged and ill patients with inadequately resourced clinics, stressed residents, and clinic directors suggests that many sites need substantial reorganization and institutional commitment.New paradigms, encouraged by ACGME requirement changes such as increased separation of inpatient and outpatient duties are needed to improve the continuity clinic experience.

Purpose: Residents will most effectively learn about ambulatory, systems-based practice by working in highly functional ambulatory practices; however, systems experiences in ambulatory training are thought to be highly variable. The authors sought to determine the prevalence of functional-practice characteristics at clinics where residents learn., Method: In 2007, the authors conducted a national survey of medical directors of resident continuity clinics using a comprehensive, Web-based instrument that included both a residency clinic assessment and a practice system assessment (PSA). The authors designed the PSA to estimate the Physician Practice Connections (PPC) score, indicating the readiness of a practice to function as a patient-centered medical home (PCMH)., Results: Of 356 clinic directors or physician representatives responding to an initial inquiry, 221 completed the survey (62%)--representing 185 programs (49% of accredited programs). The majority of clinics were hospital based (139/220; 63%) or hospital supported (41/220; 19%) and were located in urban settings (151/217; 70%). Estimated payer mix categories included Medicare or managed Medicare (169; 29%), Medicaid or managed Medicaid (161; 34%), and self-pay (156; 25%). The mean estimated PPC score was 53 points (of 100; SD = 17.6). Suburban and rural clinics, Veterans Affairs' clinics, federally qualified health centers, and clinics with a higher proportion of patients with commercial insurance or managed Medicare earned higher scores., Conclusions: A substantial portion of residency clinics have elements needed for PCMH recognition. However, clinics struggled with connecting these elements with coordination-of-care processes, suggesting areas for improvement to support better functioning of ambulatory training practices.

The authors describe Charlottesville Health Access (CHA), an initiative to get people who are homeless into the health care system. A community homeless shelter worked with faculty and students from the Univ. of Virginia Schools of Medicine and Nursing to create and run the program.

Glucose-6-phosphate dehydrogenase (G6PD) deficiency affecting erythrocytes is the most common enzymopathy in humans. It requires caution with the intake of oxidizing substances (e.g., medications and foods) because of the threat of hemolysis. Less recognized is the threat of a deficiency in G6PD that alters neutrophil function, which can compromise the killing of microbes by the oxidative burst mechanism. This results from a secondary alteration in the NADPH oxidase pathway. Methicillin-resistant Staphylococcus aureus (MRSA) infection, which is usually observed after exposure in the hospital setting, is becoming increasingly common in a community setting. Here we show the risk of MRSA and G6PD deficiency and discuss the pitfalls of G6PD deficiency.

Background: Targeted sentinel node biopsy has been extensively validated. It has been incorporated into standard guidelines for axillary prediction in women with clinically node-negative operable breast cancer. However, the high cost of the gamma probe and the need for radiocolloid have limited its widespread acceptance in developing countries. We aimed to validate low axillary sampling as a reliable alternative method to sentinel node biopsy in a developing country., Methods: An anatomically guided low axillary sampling removes the lower level I axillary fat with lymph nodes and the method was validated by completing axillary clearance in all women., Results: Three hundred fifty-five women with clinically node-negative operable breast cancer underwent validation of low axillary sampling, with lymph nodes identified in all of them. The median number of nodes identified in low axillary sampling was 5 with overall node-positivity of 32.1% (114 of 355). Ten of these 114 patients were wrongly identified as node-negative by the sampled lymph nodes, i.e. a false-negative rate of 8.8%. Further exploratory analysis showed that 6-node low axillary sampling gave an excellent false-negative rate of 1.5% with 95% sensitivity, which was comparable with the highly targeted sentinel node biopsy technique., Conclusions: With an overall false-negative rate of 8.8% with 5-node low axillary sampling, and even better false-negative rate of 1.5% with 6-node low axillary sampling, axillary sampling is a low-cost technology, which is a reliable alternative to sentinel node biopsy for axillary nodal prediction in clinically node-negative breast cancer.

This study was carried out to observe the trend in hormone receptors over the last 8 years in a tertiary cancer center in India. A total of 11,780 tumors analyzed for hormone receptors over the last 7 years were compared with the results of hormone receptor expression in a prior published study on 798 cases of breast cancer from the same institute. The patient's ages ranged from 18 to 102 years, Sixty percent of the patients were in the age group of 31-50 years. Seventy percent of the tumors were grade III tumors. The percentage of hormone receptor expression in breast cancer in the last 8 years varied from 52 to 57%. The overall receptor expression in the last 8 years shifted within a 5% range, confirming that the hormone receptor expression in Indian patients with breast cancer is low. However, there was redistribution within the pattern of estrogen receptor (ER) and progesterone receptor (PR) expression among tumors showing hormone receptor expression. Breast cancers showing only PR expression reduced dramatically from 21% in the year 1999 to in the year 2006, with a parallel increase in breast cancers showing combined ER and PR positivity (from 25 to 41.8%) and only ER expression (from 7.4 to 10.6%). The hormone receptor expression in breast cancers in India is and continues to be low but the high incidence of only PR-positive tumors in our population reported earlier was misrepresented.

Background: Laparoscopic surgery for anorectal carcinoma is steadily gaining acceptance. While feasibility has already been reported, there are no reports addressing the impact of the actual size of large tumors on laparoscopic resectability., Aim: To assess the feasibility and short-term results (including oncological surrogate end points) of performing laparoscopic abdomino-perineal resection (APR) for large rectal cancers., Materials and Methods: Data of 59 patients undergoing laparoscopic APR (LAPR) for anorectal malignancies were reviewed retrospectively. Outcomes were evaluated considering the surgical procedure, surface area of the tumor and short-term outcomes., Results: Of the 59 cases, LAPR could be completed in 53 (89.8%) patients. Thirty-one (58.4%) patients had Astler-Coller C2 stage disease. The mean surface area of the tumors was 24+/-17.5 (4-83) cm2. The number of median lymph nodes harvested per case was 12 (1-48). Circumferential resection margin (CRM) was positive in 11 (20.7%) patients. No mortality was reported., Conclusion: This appears to be the first report analyzing the impact of the size of the rectal tumor in LAPR. The data clearly indicates that LAPR is not hampered by the size of the tumor. There appears to be a need for preoperative radiotherapy and chemotherapy before undertaking surgery on larger tumors in view of the higher circumferential resection margin positivity.

Multiple factors are driving residency programs to explicitly address practice-based learning and improvement (PBLI), yet few information systems exist to facilitate such training. We developed, implemented, and evaluated a Web-based tool that provides Internal Medicine residents at the University of Virginia Health System with population-based reports about their ambulatory clinical experiences. Residents use Systems and Practice Analysis for Resident Competencies (SPARC) to identify potential areas for practice improvement. Thirty-three (65%) of 51 residents completed a survey assessing SPARC's usefulness, with 94% agreeing that it was a useful educational tool. Twenty-six residents (51%) completed a before-after study indicating increased agreement (5-point Likert scale, with 5=strongly agree) with statements regarding confidence in ability to access population-based data about chronic disease management (mean [SD] 2.5 [1.2] vs. 4.5 [0.5], p < .001, sign test) and information comparing their practice style to that of their peers (2.2 [1.2] vs. 4.6 [0.5], p < .001).

Background/aims: Six Sigma is a 'process excellence' tool targeting continuous improvement achieved by providing a methodology for improving key steps of a process. It is ripe for application into health care since almost all health care processes require a near-zero tolerance for mistakes. The aim of this study is to apply the Six Sigma methodology into a clinical surgical process and to assess the improvement (if any) in the outcomes and patient care., Methodology: The guiding principles of Six Sigma, namely DMAIC (Define, Measure, Analyze, Improve, Control), were used to analyze the impact of double stapling technique (DST) towards improving sphincter preservation rates for rectal cancer., Results: The analysis using the Six Sigma methodology revealed a Sigma score of 2.10 in relation to successful sphincter preservation. This score demonstrates an improvement over the previous technique (73% over previous 54%)., Conclusions: This study represents one of the first clinical applications of Six Sigma in the surgical field. By understanding, accepting, and applying the principles of Six Sigma, we have an opportunity to transfer a very successful management philosophy to facilitate the identification of key steps that can improve outcomes and ultimately patient safety and the quality of surgical care provided.

Pancreaticoduodenectomy remains the recommended procedure for periampullary and pancreatic head tumors. The dissection of the uncinate process from the superior mesenteric vessels is a key step in this surgery. We describe a modification in the existing practice of infracolic division of the jejunum in order to facilitate this step. In this modification, the duodenojejunal (DJ) flexure and the proximal jejunum are delivered into the supracolic compartment and then the jejunum is divided. This exposes the uncinate process completely and facilitates the separation from the Superior Mesenteric Artery (SMA) and the Superior Mesenteric Vein (SMV). We have successfully employed this modified technique for 33 resections since February 2004. This modification of dividing the jejunum in the supracolic compartment is based on sound anatomic and embryologic grounds. It helps in aligning the uncinate process with the jejunal mesentery thereby making the dissection of uncinate process from the superior mesenteric vessels safe and complete.

Chronic arsenic (As) poisoning is a worldwide public health problem. Effects of prolonged exposure to high levels of As in drinking water have been observed and documented in various epidemiological studies from all over the world. The non-malignant cutaneous effects of chronic exposure to inorganic As are well known. A case presenting with multiple cutaneous cancers as well as an internal lung primary in a patient exposed to toxic levels of As in the drinking water is discussed along with a review of literature.

We previously reported evidence that patients with periodontitis have serum antibodies to oral Gram positive bacteria that are cross-reactive with epithelial antigens, including CD24. High level expression of CD24 was confined to the reactive periodontal epithelium and inflamed gingival attachment. As a model for the reactive epithelium of chronic periodontitis, H413 epithelial cells derived from a human oral squamous cell carcinoma were cloned and lines expressing high levels of CD24 were selected. RNA interference protocols were designed to determine if CD24 could modulate intercellular interactions and regulate the biology of these epithelial cells. Knock-down of CD24 protein was demonstrated by Western blot and flow cytometry. The level of mRNA for CD24 was reduced 90% by RNAi treatment as assayed by real-time, reverse transcriptase (RT)-PCR. Gene products known to be important in epithelial biology, including E-cadherin and TGF-beta3 that were demonstrated to undergo altered expression patterns in the periodontal lesion, were investigated. Down-regulation of CD24 mRNA was associated with reduced e-cadherin expression and up-regulated expression of snail, twist, and tgf-beta3. The cells were treated with monoclonal antibodies to CD24 to mimic the action of auto-reactive antibodies to CD24 detected in affected patients. Relative to isotype control antibody, stimulation by anti-CD24 antibodies induced up-regulated expression of e-cadherin and down-regulation of tgf-beta3 as assessed by real-time RT-PCR. No consistent changes for expression of beta-catenin, connexins, integrins, icam-1, tgf-beta1 or tgf-beta2 were observed. CD24 could play an important role in modulating expression of genes that regulate epithelial differentiation in periodontal disease.

Background: Primary angiosarcomas of breast are rare tumors, with a fatal outcome., Material and Methods: We studied histological prognostic factors and c-kit expression by immunohistochemistry (IHC) in 12 angiosarcomas accessioned at a cancer referral center in India., Results: All patients had primary angiosarcoma; no case of secondary angiosarcoma was accessioned during the study period. Median age of patients was 24.5 years. Nine patients had intermediate grade tumors, one a well differentiated tumor and three patients had high-grade tumors. Interesting cases encountered included an epithelioid angiosarcoma and an angiosarcoma arising on the background of a biphasic tumor. Eight patients had lumpectomy, four mastectomy and two patients were given radiotherapy. Of the nine patients (seven type I/II and two high grade) with follow up, eight patients developed disseminated metastases within a year of presentation. The patient with well-differentiated angiosarcoma also died of metastasis albeit after a longer time. On IHC c-kit staining was weakly seen in two cases., Conclusion: Primary angiosarcoma was fatal in young Indian women even in lower grade tumors. The low expression of c-kit on IHC suggests that targeting this protein for therapy may not be successful in treating these tumors., (Copyright (c) 2006 Wiley-Liss, Inc.)

Background: Nasal colonisation with otitis media (OM) pathogens, particularly Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis, is a precursor to the onset of OM. Many children experience asymptomatic nasal carriage of these pathogens whereas others will progress to otitis media with effusion (OME) or suppurative OM. We observed a disparity in the prevalence of suppurative OM between Aboriginal children living in remote communities and non-Aboriginal children attending child-care centres; up to 60% and <1%, respectively. This could not be explained by the less dramatic difference in rates of carriage of respiratory bacterial pathogens (80% vs 50%, respectively). In this study, we measured nasal bacterial load to help explain the different propensity for suppurative OM in these two populations., Methods: Quantitative measures (colony counts and real-time quantitative PCR) of the respiratory pathogens S. pneumoniae, H. influenzae and M. catarrhalis, and total bacterial load were analysed in nasal swabs from Aboriginal children from remote communities, and non-Aboriginal children attending urban child-care centres., Results: In both populations nearly all swabs were positive for at least one of these respiratory pathogens. Using either quantification method, positive correlations between bacterial load and ear state (no OM, OME, or suppurative OM) were observed. This relationship held for single and combined bacterial respiratory pathogens, total bacterial load, and the proportion of respiratory pathogens to total bacterial load. Comparison of Aboriginal and non-Aboriginal children, all with a diagnosis of OME, demonstrated significantly higher loads of S. pneumoniae and M. catarrhalis in the Aboriginal group. The increased bacterial load despite similar clinical condition may predict persistence of middle ear effusions and progression to suppurative OM in the Aboriginal population. Our data also demonstrated the presence of PCR-detectable non-cultivable respiratory pathogens in 36% of nasal swabs. This may have implications for the pathogenesis of OM including persistence of infection despite aggressive therapies., Conclusion: Nasal bacterial load was significantly higher among Aboriginal children and may explain their increased risk of suppurative OM. It was also positively correlated with ear state. We believe that a reduction in bacterial load in high-risk populations may be required before dramatic reductions in OM can be achieved.

Objective: To assess the reading habits and educational resources of primary care internal medicine residents for their ambulatory medicine education., Design: Cross-sectional, multiprogram survey of primary care internal medicine residents., Participants/setting: Second- and third-year residents on ambulatory care rotations at 9 primary care medicine programs (124 eligible residents; 71% response rate)., Measurements and Main Results: Participants were asked open-ended and 5-point Likert-scaled questions about reading habits: time spent reading, preferred resources, and motivating and inhibiting factors. Participants reported reading medical topics for a mean of 4.3+/-3.0 SD hours weekly. Online-only sources were the most frequently utilized medical resource (mean Likert response 4.16+/-0.87). Respondents most commonly cited specific patients' cases (4.38+/-0.65) and preparation for talks (4.08+/-0.89) as motivating factors, and family responsibilities (3.99+/-0.65) and lack of motivation (3.93+/-0.81) as inhibiting factors., Conclusions: To stimulate residents' reading, residency programs should encourage patient- and case-based learning; require teaching assignments; and provide easy access to online curricula.

We developed Systems and Practice Analysis for Resident Competencies (SPARC), a Web-based tool to support teaching the practice-based learning and improvement (PBLI) ACGME competencies. SPARC allows Department of Medicine residents to explore de-identified, population-based data about their patient panels with peer comparisons. Data primarily comes from an existing data warehouse that has been customized for this application. Our preliminary evaluation suggests that it improves residents' abilities in PBLI, is easy to use, and perceived as important and useful by the housestaff.

Introduction: In absence of randomized evidence to support safety of conservative surgery (BCT) in locally advanced breast cancer (LABC), we analyzed a cohort of 664 women with LABC treated during January 1998 to December 2002 at Tata Memorial Hospital, Mumbai, India., Materials and Methods: All were treated with a multimodality regimen comprising of neoadjuvant chemotherapy (NACT) followed by surgery (modified radical mastectomy or BCT) and adjuvant radiotherapy and hormone therapy. The outcome was evaluated to assess safety of BCT., Results: 71% (469/664) women responded to NACT (22% clinical CR and 49% PR) and 28.3% (188/664) underwent BCT. Positive lumpectomy margins were reported in 8.5%, with gross presence of tumor at the margins in 2.3% requiring a revision surgery. At a median follow-up of 30months, local relapse rate was 8% after BCT and 10.7% after mastectomy. The 3-year local DFS was better post-conservation than after mastectomy (87% vs 78%, P=0.02). The disease-free survival (DFS) was also superior after BCT, 72% vs 52% (P<0.001) at 3years and 62% vs 37% (P<0.001) at 5years respectively. On multivariate analysis, presence of lymphatic vascular emboli (LVE) was the major significant predictor of local recurrence (P<0.001, HR 2.52, 95% CI 1.52-4.18). DFS was better after BCT [(P<0.001, HR 2.0 (95% CI 1.38-2.91)]; shorter DFS was noted in LVE positive (HR 1.54, P=0.007) and larger residual disease after NACT (HR 1.13, P=0.001)., Conclusion: BCT is technically feasible and safe post neo-adjuvant chemotherapy in women with LABC with no detriment in outcome.

We previously reported evidence that patients with periodontitis have serum antibodies to oral Gram positive bacteria that are cross-reactive with epithelial antigens. In the present report cross-reactive epithelial antigens including CD24, lactate dehydrogenase A [LDM-A], antioxidant protein 2 [AOP 2] and nuclear factor of activated T cells 5 [NFAT 5], were identified by screening a cDNA expression library with pooled patient sera. Titres of antibodies to CD24 peptide correlated negatively with indices of periodontal disease severity. Strong expression of CD24 in the reactive periodontal epithelium and inflamed gingival attachment contrasted with low to undetectable expression in the external gingival epithelium. In periodontitis, a local action of these auto-reactive antibodies could modulate the regulatory potential associated with expression of CD24 in this epithelium.

Background: The hemoglobin-binding domain (HA2) of the Porphyromonasgingivalis gingipains and hemagglutinins strongly binds hemoglobin and hemin and is thought to play a key role in acquisition of this essential metabolite by the microorganism., Methods: In this report, we partially characterized human anti-HA2 humoral antibodies and their relationship to periodontal disease in an analysis of titer and function., Results: Overall, serum anti-HA2 antibodies were relatively low and dominated by the immunoglobulin M (IgM) isotype. Pre-therapy titers had a direct association with periodontal health. Levels of P. gingivalis in the plaque were directly related to pre-therapy anti-HA2 IgG levels, and were an important covariant in a significant direct relationship between pre- and post-therapy anti-HA2 titers. Post-therapy anti-HA2 IgG antibody titers were directly related to the capacity of serum IgG fractions to neutralize hemoglobin binding by Lys-gingipain (Kgp). Further, lower levels of neutralizing activity post-therapy were directly related to severe periodontitis within the patient cohort., Conclusions: These data suggest that anti-HA2 IgG antibodies correspond directly with periodontal health, possibly through their ability to neutralize P. gingivalis hemoglobin capture. The data also suggest that inadvertent or therapeutic inoculation of P. gingivalis in the plaque may contribute to generation of neutralizing anti-HA2 IgG and improvement of periodontal prognosis., (Copyright Blackwell Munksgaard, 2004)

We describe a patient who presented with a clinical syndrome of limbic encephalitis, narcolepsy, and cataplexy. The anti-Ma2 antibody was positive. Although there was no mass on imaging, orchiectomy was performed in this patient, and testicular carcinoma was found. This is the first known case of limbic encephalitis and anti-Ma2 antibody to be associated with cataplexy and possible narcolepsy. Neurological symptoms precede the diagnosis of cancer in 50% of patients with paraneoplastic syndromes, and clinicians are therefore strongly advised to evaluate patients with neurological symptoms for this condition.

Perturbation of epithelial structure is a prominent but poorly understood feature of the immunopathological response to bacterial antigens which characterizes the destructive lesion of periodontitis. Western analysis of sera from 22 patients with periodontitis detected multiple antigens in extracts of epithelial cells whereas sera from 12 periodontally healthy subjects displayed only trace reaction with epithelial antigens. To investigate a possible relationship between the bacterial flora adjacent to diseased sites and the presence of antibodies reactive with epithelium, subgingival plaque samples were taken from deep periodontal pockets and cultured anaerobically. Gram positive bacteria containing antigens cross-reactive with epithelial cells were reproducibly isolated by probing membrane colony-lifts with affinity-isolated (epithelium-specific) antibodies and identified by 16S rDNA sequence homology as streptococci (S. mitis, S. constellatus and two S. intermedius strains) and Actinomyces (A. georgiae, and A. sp. oral clone). Conversely, when serum from patients with periodontitis was absorbed with the captured bacterial species the number of epithelial antigens recognized was specifically reduced. It was concluded that development of cross-reactive antibodies related to these organisms may contribute to perturbation of the epithelial attachment to the tooth and the progression of periodontitis. These autoreactive antibodies could also be a contributing factor in other diseases affecting epithelia.

Background: Randomized controlled trials have demonstrated that antibiotics provide no benefit for acute bronchitis, yet 55 to 90% of patients who receive this diagnosis are treated with antibiotics. Given substantial data against antibiotics for acute bronchitis, it could be expected that physicians at academic teaching institutions would be less likely to prescribe antibiotics. However, limited data of antibiotic use for acute bronchitis in this setting has been published., Methods: Charts of patients seen between January 1 and October 25, 2000, who received an ICD-9 diagnosis of acute bronchitis or upper respiratory infection (URI) at the University of Virginia internal medicine clinic were reviewed. Patients were excluded if they had no cough, chronic obstructive pulmonary disease, symptoms for > or = 3 weeks, or antibiotics for another reason., Results: Of the 160 patients included in this study, 105 (66%) received an antibiotic. Multivariate analysis revealed that patients with increasing age (P = 0.002), purulent cough (P = 0.003), abnormal exam (P = 0.003), and comorbidities (P = 0.03) were most likely to receive an antibiotic. Smoking, duration of symptoms, gender, and race did not predict antibiotic use (P > 0.05). Macrolides accounted for 68% of antibiotics. Twenty-two (14%) of all patients received a chest radiograph and 72 (45%) received an inhaler. Of those who had chest radiographs negative for signs of infection, 76% received an antibiotic., Conclusion: In our teaching clinic, antibiotics were overused, whereas chest radiographs and inhalers were underused for the evaluation and treatment of acute bronchitis. Recently published guidelines will help curb use of antibiotics, but a more intensive intervention, including physician and patient education is probably necessary.

The authors assessed the efficacy, safety, and tolerability of vagus nerve stimulation (VNS) for refractory epilepsy in 45 adults 50 years of age and older. They determined seizure frequency, adverse effects, and quality of life. At 3 months, 12 patients had a >50% decrease in seizure frequency; at 1 year, 21 of 31 studied individuals had a >50% seizure decrease. Side effects were mild and transient. Quality of life scores improved significantly with time.

A 17-month-old black girl presented to the pediatric emergency department with sudden onset of her hands and feet "drawing up." A diagnosis of vitamin D deficiency rickets with tetany was made on a history of exclusive breast-feeding, low serum calcium, phosphorus, and 25-hydroxyvitamin D levels, and bone radiographs. Nutritional rickets should be considered in the differential diagnosis of acute hypocalcemia.

Objective: Description of coherence patterns of cortical EEG., Methods: EEG recordings were collected from 9 subdural electrode grids implanted in 6 patients undergoing EEG monitoring for refractory epilepsy., Results: Coherence decreased with increasing inter-electrode distance and exhibited considerable variability at the same inter-electrode distances. Analysis of variance demonstrated that both spatial and temporal factors contributed significantly (P < 0.01) to this variability. The spatial factor contributed the largest portion (up to 90%) of the variability, and was modulated by frequency and inter-electrode distance., Conclusion: The finding that the mean frequency modulation was consistent over time for the same pair of electrodes and was different between different pairs of electrodes indicated a spatial-spectral pattern of cortical synchrony. The connections (pairs of electrodes) could be accordingly predicted from their spatial-spectral pattern, which suggested that the spatial heterogeneity of neuronal synchrony was expressed not only by the degree of synchrony, but also by distinct spectral channels of synchrony. A model based on neuronal connection and activation is proposed to account for the observations.

Our purpose was to determine the frequency and predictors of quitting smoking among patients hospitalized on the medical services of a smoke-free hospital. All smokers admitted to the medical services of a single university teaching hospital were eligible and 129 patients were enrolled. A questionnaire detailing demographic information, stages of change, smoking behavior while hospitalized, and intention to remain abstinent on discharge was administered. The primary discharge diagnosis was obtained from the medical record. Patients were followed at 3- and 6-month intervals for continuous abstinence, with expired carbon monoxide confirmation at 6 months. A total of 7% of smoking patients receiving usual medical care were continuously abstinent at 6 months. Of those who relapsed, 45% did so by the time of discharge, 18% within the first week, 20% between 1 week and 3 months, and 10% between 3 and 6 months after discharge. All patients who were abstinent at 6 months had been admitted for coronary artery disease (CAD). Nine of the 38 patients with CAD were abstinent, versus none of 93 with another diagnosis (p <.001). Smokers admitted to a smoke-free hospital had a high rate of relapse, especially early after discharge. Patients admitted for CAD had a greater likelihood of successfully quitting. Designing hospital-based smoking cessation interventions with a focus on early relapse prevention may help improve smoking cessation rates.