Kevin N. Christensen

Morbidity and Mortality Among Older Individuals With Undiagnosed Celiac Disease

BACKGROUND & AIMS Outcomes of undiagnosed celiac disease (CD) are unclear. We evaluated the morbidity and mortality of undiagnosed CD in a population-based sample of individuals 50 years of age and older. METHODS Stored sera from a population-based sample of 16,886 Olmsted County, Minnesota, residents 50 years of age and older were tested for CD based on analysis of tissue transglutaminase and endomysial antibodies. A nested case-control study compared serologically defined subjects with CD with age- and sex-matched, seronegative controls. Medical records were reviewed for comorbid conditions. RESULTS We identified 129 (0.8%) subjects with undiagnosed CD in a cohort of 16,847 older adults. A total of 127 undiagnosed cases (49% men; median age, 63.0 y) and 254 matched controls were included in a systematic evaluation for more than 100 potentially coexisting conditions. Subjects with undiagnosed CD had increased rates of osteoporosis and hypothyroidism, as well as lower body mass index and levels of cholesterol and ferritin. Overall survival was not associated with CD status. During a median follow-up period of 10.3 years after serum samples were collected, 20 cases but no controls were diagnosed with CD (15.2% Kaplan-Meier estimate at 10 years). CONCLUSIONS With the exception of reduced bone health, older adults with undiagnosed CD had limited comorbidity and no increase in mortality compared with controls. Some subjects were diagnosed with CD within a decade of serum collection, indicating that although most cases of undiagnosed CD are clinically silent, some result in symptoms. Undiagnosed CD can confer benefits and liabilities to older individuals.

Anatomy teaching assistants: facilitating teaching skills for medical students through apprenticeship and mentoring.

Background: Significant increase in the literature regarding “residents as teachers” highlights the importance of providing opportunities and implementing guidelines for continuing medical education and professional growth. While most medical students are enthusiastic about their future role as resident-educators, both students and residents feel uncomfortable teaching their peers due to the lack of necessary skills. However, whilst limited and perhaps only available to select individuals, opportunities for developing good teaching practice do exist and may be identified in courses that offer basic sciences. The Department of Anatomy, College of Medicine, Mayo Clinic offers a teaching assistant (TA) elective experience to third- and fourth-year medical students through integrated apprenticeship and mentoring during the Human Structure didactic block. Aim: This article, aims to describe a curriculum for a TA elective within the framework of a basic science course through mentoring and apprenticeship. Results: Opportunities for medical students to become TAs, process of TAs’ recruitment, mentoring and facilitation of teaching and education research skills, a method for providing feedback and debriefing are described. Conclusion: Developing teaching practice based on apprenticeship and mentoring lends to more accountability to both TAs and course faculty by incorporating universal competencies to facilitate the TA experience.

Quantification of gadolinium in fresh skin and serum samples from patients with nephrogenic systemic fibrosis

BACKGROUND Nephrogenic systemic fibrosis (NSF) is a rare, potentially fatal fibrosing disorder associated with renal insufficiency and gadolinium (Gd)-based contrast exposure. The cause remains unknown. To date, all efforts to investigate skin Gd concentrations in patients with NSF have been performed on paraffin-embedded samples, and Gd deposition has not been correlated with disease activity by a statistically significant analysis. OBJECTIVE We sought to: (1) quantify Gd concentration in fresh tissue skin biopsy specimens; (2) quantify and compare synchronous Gd concentration of affected skin and unaffected skin in patients with NSF (n = 13) with a control group (n = 13); and (3) quantify serum Gd. METHODS We used inductively coupled plasma mass spectrometry. RESULTS In patients with NSF, the mean ratio of paired Gd concentrations of affected skin to unaffected skin was 23.1, ranging from 1.2 to 88.9. Mean serum Gd concentrations in patients with NSF were 4.8 ng/mL, which is more than 10 times the level in control patients. A statistically significant correlation existed between serum and affected skin Gd concentrations (r(2) = .74, P < .0001). LIMITATIONS Because of the feasibility of this study, the main limitation was the small sample size (n = 13 affected and 13 control). CONCLUSIONS Determination of Gd concentrations in fresh skin samples and serum using inductively coupled plasma mass spectrometry demonstrates significant differences in the amounts of Gd in involved versus nonlesional skin of patients with NSF. This supports the role of differential free Gd deposition from Gd-based contrast in the pathogenesis of NSF.

Cutaneous depth of the supraorbital nerve: a cadaveric anatomic study with clinical applications to dermatology.

BACKGROUND Common dermatologic procedures performed on the forehead may injure the supraorbital nerve (SON) leading to adverse outcomes. OBJECTIVE To describe SON anatomic course and cutaneous depth. MATERIALS AND METHODS Sixteen cadaver specimens were dissected. RESULTS The supraorbital nerve originated 2.63 ± 0.27 (range, 2.1–3.5) cm from the midline and 0.25 ± 0.16 (range, 0–0.5) cm above the orbital rim. Supraorbital nerve emerged as 1 root dividing into superficial (SON-S) and deep (SON-D) branches. The supraorbital nerve deep branch remained deep to the aponeurosis of the corrugator supercilii and frontalis muscles and coursed laterally toward the scalp. Supraorbital nerve superficial branch emerged nearly perpendicular to the orbital rim and traveled under the corrugator supercilii with an average depth of 0.75 ± 0.16 (range, 0.5–1.1) cm. Supraorbital nerve superficial branches entered the subfrontalis plane at a mean distance of 1.29 ± 0.20 (range, 1.0–1.8) cm above the orbital rim with an average depth of 0.45 ± 0.13 (range, 0.3–0.8) cm. These branches entered the subcutaneous plane by piercing through the frontalis muscle at a mean distance of 2.60 ± 0.32 (range, 1.9–3.2) cm above the orbital rim with an average depth of 0.30 ± 0.10 (range, 0.2–0.6) cm. CONCLUSION The supraorbital nerve depth and course are relevant when performing procedures on the forehead. A thorough understanding of the anatomy and depth of SON-S is critical to help minimize nerve damage and optimize patient counseling.

The Pericardial Space: Obtaining Access and an Approach to Fluoroscopic Anatomy

The pericardial space is now increasingly used as a means and vantage point for mapping and ablating various arrhythmias. In this review, present techniques to access the pericardial space are examined and potential improvements over this technique discussed. The authors then examine in detail the regional anatomy of the pericardial space relevant to the major arrhythmias treated in contemporary electrophysiology. In each of these sections, emphasis is placed on anatomic fluoroscopic correlation and avoiding complications that may result.

Descriptive anatomy of the dominant septal perforators using Dual Source coronary CT angiography

Although clinical outcomes for septal ablation in treating left ventricular outflow tract obstructions are generally favorable, a variety of complications have been reported including a high incidence of right bundle branch block. These complications may be attributed to anatomic variability of the dominant septal perforator. We used Dual Source CT Coronary Angiography (DS‐CTA) to determine the location of the termination point of the dominant septal perforator as well as the distance of the termination point from the mitral annulus in patients undergoing DS‐CTA. One‐hundred‐fourteen DS‐CTA scans were retrospectively reviewed by two observers by consensus. The left ventricle was divided into anterior wall, anterioseptum, and inferioseptum. For each segment, the myocardium was divided into three layers (1) right ventricular side, (2) mid portion, and (3) left ventricular side. The zone of termination of the dominant septal perforator was identified as well as the distance of the termination point from the mitral annulus. The dominant septal perforator terminated in the right ventricular side of the anterioseptum in 86 of the 118 visualized terminations (73%) and in the left ventricular anterior wall in 6 visualized terminations (5%). On average, the dominant septal perforator terminated 26.3 ± 8.6 mm from the mitral annulus. In the majority of cases, the dominant septal perforator terminates in the right ventricular side of anterioseptum. In addition, there is great variability in the distribution of the termination point of the dominant septal perforator from the mitral annulus. Clin. Anat. 23:70–78, 2010.

Comparison of MITF and Melan-A Immunohistochemistry During Mohs Surgery for Lentigo Maligna-Type Melanoma In Situ and Lentigo Maligna Melanoma.

BACKGROUND Mohs micrographic surgery (MMS) with frozen section immunohistochemistry is a treatment option for malignant melanoma in situ (MMIS) and lentigo maligna melanoma (LMM). Melan-A is a cytoplasmic melanocyte immunostain useful on frozen sections but may lack specificity. Microphthalmia transcription factor (MITF) is a more specific nuclear melanocyte immunostain less frequently used in MMS. OBJECTIVE To quantify melanocyte density in chronic sun-damaged skin (CSDS), negative margin, and tumor from patients undergoing MMS for MMIS and LMM using MITF and melan-A. METHODS Sixteen patients with MMIS or LMM had frozen sections from CSDS, negative margin, and 12 tumor samples, stained with MITF and melan-A. Melanocyte counts were performed. RESULTS Chronic sun-damaged skin mean melanocyte count (MMC) for MITF and melan-A was 9.8 and 13.7, respectively, (p < .001). Negative margin MMC for MITF and melan-A was 8.84 and 14.06, respectively, (p < .001). Tumor MMC for MITF and melan-A was 63.5 and 62.4, respectively. CONCLUSION Although both MITF and melan-A facilitate the identification of tumor during MMS for MMIS and LMM, the apparent melanocyte density on tumor-free CSDS appears higher with melan-A than MITF. Microphthalmia transcription factor provides a crisp outline of melanocyte nuclei and is a useful alternative stain to melan-A for MMS of melanoma.

Carbon dioxide laser treatment for Hailey-Hailey disease: a retrospective chart review with patient-reported outcomes.

Hailey–Hailey disease (HHD) is an autosomal dominant genodermatosis that leads to skin breakdown and blister formation, usually in intertriginous areas. Laser ablation is a known surgical treatment for HHD.

Outcomes of basal cell carcinomas directly invading the parotid gland.

BACKGROUND Parotid involvement by basal cell carcinoma (BCC) is rare, and therefore management is controversial. OBJECTIVE To review the treatment and outcomes of patients with BCC involving the parotid by direct infiltration. METHODS AND MATERIALS The authors performed a retrospective chart review of BCC cases involving the parotid. RESULTS From 1994 to 2007, there were 19 cases of BCC involving the parotid gland by direct extension. Nine were primary tumors, and 10 recurrent (nonprimary). Eight tumors were treated with Mohs micrographic surgery (MMS), and 11 with wide local excision (WLE). One patient died of unrelated causes 5 months after treatment, and 2 did not follow up. The remaining 16 cases had an average follow-up of 55.2 months (range, 18–112 months). No primary BCC recurred after treatment. Six of 10 nonprimary BCC (60%) recurred, 2 of 10 metastasized, and 1 of 10 died of metastatic BCC. Two recurrences occurred after MMS, and 4 occurred after WLE with or without parotidectomy. CONCLUSION Mohs micrographic surgery or WLE with intra-operative margin control seems to be an acceptable first-line treatment for primary BCC involving the parotid. Recurrent BCC involving the parotid gland through direct infiltration has high rates of future recurrence, and adjuvant treatment may be required.

M2051 Morbidity and Mortality of Undiagnosed Celiac Disease in Adults Over 50 Years of Age. a Population Based Study

BACKGROUND: Celiac disease (CD) is a common digestive disease although many cases are unrecognized. Approximately 1% of the general population may have undiagnosed CD but the impact of undiagnosed CD on morbidity and mortality is unknown. AIM: To quantify the morbidity and mortality of undiagnosed CD. METHODS: Stored sera from a populationbased cohort of 16,592 Olmsted County, Minnesota residents comprising 85% of adults ≧50 years of age was screened for CD using sequential testing. Participants with known CD were excluded. Tissue transglutaminase (tTGA) antibodies were tested in all subjects; those positive for tTGA had a confirmatory endomysial antibody (EMA) assay. Undiagnosed CD was defined by the presence of both tTGA and EMA antibodies. A nested case-control study compared these serologically defined CD subjects 1:2 to ageand gender-matched control subjects with negative serology. Complete medical records were reviewed for comorbid conditions by reviewers unaware of serum status. Conditional logistic regression was used to identify factors associated with positive serology. The Kaplan Meier (KM) method was used to estimate overall survival and survival free of subsequent diagnosed CD. RESULTS: We identified 127 (0.75%) subjects with undiagnosedCD. After a median (range) of 10.1 (0.212.5) years of follow-up after serum draw, 20 cases (10-yr KM rate 15%) were subsequently diagnosed with CD and excluded from the final analysis, along with their matched controls; no controls were subsequently diagnosed. The remaining 107 cases (53% male, mean age 64.9) and 214 matched controls were included in the association analysis. Among the >100 conditions assessed, few were significantly associated with serology status. Undiagnosed CD patients had an increased risk of osteoporosis, worse bone density scores, and lower ferritin levels. They also had less arthritis, lower BMI, and lower cholesterol levels. Overall survival was not affected. CONCLUSION: With the exception of impaired bone density, adults over 50 years of age whose CD remained undiagnosed did not demonstrate excess comorbidity or mortality compared to controls. In patients with undiagnosed CD over the age of 50 years, ~15% will be diagnosed with CD within 10 years.