Robert J. Esther

Differential antigen preservation during tissue autolysis

Immediate fixation or snap freezing of tissue is ordinarily done to maximize antigen preservation for immunocytochemistry; however, delay in tissue allocation or spontaneous lymph node infarction can render tissue suboptimal for immunostaining. To test the effects of tissue autolysis/necrosis on the preservation of various lymphoid, epithelial, and mesenchymal markers, two lymph nodes (one with reactive lymphoid hyperplasia and one with metastatic ductal breast carcinoma) were evaluated for immunocytochemically demonstrated antigen preservation at 0-, 4-, 8-, 12-, 24-, 48-, and 72-hour intervals of autolysis at 37 degrees C. All specimens were stained by frozen section and formalin-fixed paraffin section immunocytochemical reactions with antibodies against CLA (CD45), UCHL-1 (CD45RO), L-26, kappa, lambda, anti-epithelial keratins (AE-1 and AE-3), epithelial membrane antigen, and vimentin. Frozen sections were additionally stained for Leu-1 (CD5), Leu-2a (CD8), Leu-3a+b (CD4), Leu-4 (CD3), and Leu-14 (CD22). The most resilient lymphoid antigen preservation was observed with CLA and UCHL-1, both exhibiting immunoreactivity at 72 hours in both frozen and fixed preparations. L-26 showed similar reactivity in frozen sections, but detectable antigen was observed only up to 24 hours in formalin-fixed tissue. Leu-2a proved to be the most labile antigen, persisting for only 12 hours in frozen sections. The epithelial markers epithelial membrane antigen and AE-1 exhibited excellent antigenic preservation in both frozen and fixed preparations; AE-3 persisted well in frozen section but was not demonstrated in fixed tissue. Vimentin immunoreactivity was vastly superior in frozen, as compared with fixed, tissue sections. Most antigens showed remarkable preservation despite morphologic degradation; however, differential antigenic resilience was demonstrated. Knowledge of this variation in antigen decay is critical for evaluation of immunoperoxidase phenotypic studies of autolyzed or necrotic tissue.

Osteolipoma: radiological, pathological, and cytogenetic analysis of three cases

Osteolipoma is a rare variant of lipoma consisting of mature adipose tissue and mature lamellar bone. The presence of non-fatty elements may lead to a wide differential diagnosis on radiology including benign and malignant lipomatous and nonlipomatous entities. The pathological diagnosis is also confounded by the presence of heterologous differentiation. Fortunately, most lipomas harbor classic cytogenetic aberrations, and the finding of translocations involving 12q13-15 may aid in the correct diagnosis. We report three cases of osteolipoma with radiological, histological, and cytogenetic correlation.

Wound Complications in Preoperatively Irradiated Soft-Tissue Sarcomas of the Extremities

PURPOSE To determine whether the involvement of plastic surgery and the use of vascularized tissue flaps reduces the frequency of major wound complications after radiation therapy for soft-tissue sarcomas (STS) of the extremities. METHODS AND MATERIALS This retrospective study evaluated patients with STS of the extremities who underwent radiation therapy before surgery. Major complications were defined as secondary operations with anesthesia, seroma/hematoma aspirations, readmission for wound complications, or persistent deep packing. RESULTS Between 1996 and 2010, 73 patients with extremity STS were preoperatively irradiated. Major wound complications occurred in 32% and secondary operations in 16% of patients. Plastic surgery closed 63% of the wounds, and vascularized tissue flaps were used in 22% of closures. When plastic surgery performed closure the frequency of secondary operations trended lower (11% vs 26%; P=.093), but the frequency of major wound complications was not different (28% vs 38%; P=.43). The use of a vascularized tissue flap seemed to have no effect on the frequency of complications. The occurrence of a major wound complication did not affect disease recurrence or survival. For all patients, 3-year local control was 94%, and overall survival was 72%. CONCLUSIONS The rates of wound complications and secondary operations in this study were very similar to previously published results. We were not able to demonstrate a significant relationship between the involvement of plastic surgery and the rate of wound complications, although there was a trend toward reduced secondary operations when plastic surgery was involved in the initial operation. Wound complications were manageable and did not compromise outcomes.

MANAGEMENT OF METASTATIC DISEASE OF OTHER BONES

Metastases to the scapula and distal sites on the upper and lower extremities are infrequent. Although these metastases tend to occur in patients with advanced disease, a distal metastasis is occasionally the sole metastatic location. Distal metastases do not pose an immediate threat to a patients life; however, they may cause significant pain and disability. Appropriate management can considerably enhance function, quality of life, and, occasionally, survival. Seven cases of distal metastasis are presented in this article with discussion of operative and nonoperative approaches to management.

Use of physical restraints in a nineteenth-century state hospital

Archival records of physical restraint usage at the St. Louis Insane Asylum (now the St. Louis State Hospital) were examined from January through June 1885. The demographics of restrained patients were determined from archival admission records. In the 6-month (181-day) sample period, 53 patients accounted for the total of 2,537 incidents of night restraint. Sixty percent of the restrained patients were women and 53% were immigrants. By far most (98.5%) of the incidents of restraint were brought on by violent behaviour (fighting, destroying property, injury to self) while most incidents in modern hospitals result from verbal threats or shouting. When these records were combined with day restraint records from the same 6-month period in 1889, an overall incidence rate of 9.7% per month was estimated. This is similar to rates reported from modern psychiatric hospitals. Possible reasons for the discrepancies and similarities in the types of patients restrained and the activities which brought on restraint in the nineteenth and twentieth centuries are discussed.

Effect of NKISK on tendon lengthening: An in vivo model for various clinically applicable dosing regimens

One proposed mechanism of tendon lengthening is the “sliding fibril” hypothesis, in which tendons lengthen through the sliding of discontinuous fibrils after release of decorin‐fibronectin interfibrillar bonds. The pentapeptide NKISK has been reported to inhibit the binding of decorin, a proteoglycan on the surface of collagen fibrils, to fibronectin, a tissue adhesion molecule, which are thought to play a role in interfibrillar binding. Prior investigations have demonstrated that NKISK produces in vivo tendon lengthening. This study investigates the effect of potential clinically applicable NKISK injection regimens in an in vivo model. One hundred and thirteen male Sprague‐Dawley rats were divided into 15 different treatment groups, each receiving percutaneous patellar tendon injections of NKISK, QKTSK (a “nonsense” pentapeptide), or PBS of varying volumes, concentrations, and injection schedules. Following sacrifice, the patellar tendon lengths were measured in all groups, and biomechanical testing was performed with comparisons made to the contralateral, untreated control limbs. Tendon lengthening was significantly greater (p ≤ 0.05) in nearly all NKISK‐treated tendons as compared to PBS‐ and QKTSK‐treated tendons and was dose‐dependent. Measured lengthening was less in rats whose sacrifice was delayed following the final injection of NKISK, which likely indicates recontraction of lengthened tendons, but they remained significantly longer than the controls. Biomechanical testing did not reveal significant differences in ultimate load, modulus, stiffness, or displacement. This study demonstrates that NKISK given in clinically plausible dosing regimens produces dose‐dependent tendon lengthening in an in vivo setting with minimal effects on the mechanical properties of the treated tendons.

Development and use of a second-year musculoskeletal organ-system curriculum: A forty-year experience

The rationale for a preclinical musculoskeletal course lies in the prevalence of musculoskeletal diseases, injuries, and disorders. More than 30% of Americans have a musculoskeletal condition requiring medical attention, and workers in the United States miss nearly 440 million days of work annually because of musculoskeletal injuries1. Musculoskeletal disorders cost the United States nearly 850 billion dollars yearly and are the leading cause of disability in the United States1. The economic impact of musculoskeletal disorders is also considerable. Yelin et al. estimated that the economic impact was nearly

Soft Tissue Masses for the General Orthopedic Surgeon

200 billion per year, or approximately 2.5% of the annual U.S. gross domestic product2. Moreover, many studies have demonstrated a substantial deficit in musculoskeletal knowledge among recent medical school graduates and other practitioners3-5. There have been calls to reform the preclinical musculoskeletal medical school curriculum6, as well as proposals for a core set of standards for musculoskeletal content7. Two recent studies have described the development of a self-contained preclinical musculoskeletal course for either first or second-year students8,9. Another recent study described the process of curricular reform in the first and second years of medical school without a self-contained musculoskeletal course10. Both were designed with input from educators in several different medical and basic-science specialties, as was ours. The University of Minnesota course included seventeen hours of lecture content, similar to the amount in our course (twenty hours). The authors cited their small-group experience as essential to the success of the course8. The Louisiana State University course spanned six weeks and included forty-four hours of lecture and seventeen hours of small-group teaching9. Both studies emphasized anatomy and physical diagnosis and found substantial improvement in musculoskeletal knowledge and physical examination …

Fringe Benefits Among US Orthopedic Residency Programs Vary Considerably: a National Survey

Soft tissue sarcomas are a rare, heterogeneous group of malignancies that should be included in the differential diagnosis for any patient presenting with a soft tissue mass. This article reviews strategies for differentiating between benign and malignant soft tissue masses. Epidemiology, appropriate workup, and treatment of soft tissue sarcomas are reviewed.

Intraosseous Rosai‐Dorfman disease diagnosed by touch imprint cytology evaluation: A case series

BackgroundResidency programs compete to attract applicants based on numerous factors. Previous research has suggested that medical students consider quality of life among the most important factors in selecting a program. One aspect of workplace quality of life is the cadre of non-monetary benefits offered to employees. However, with federal funding for graduate medical education (GME) under consideration for spending cuts, the source and continuation of such benefits may be in question.Questions/PurposesThis study aimed to determine the level and variability of benefits beyond standard salary and insurance options available to trainees at US orthopedic residency programs and to assess the source of funding for those benefits.MethodsA 26-question survey investigating various benefits and funding sources was circulated by email to all ACGME-accredited orthopedic residency programs.ResultsThe survey was sent to 153 programs and 69 responded (45%). The majority offers their residents discretionary funds (77%) and conference funding (96%), most of which comes from the department, followed by the hospital or GME funding. Forty-one percent of respondents permit their residents to moonlight. The majority of respondents provide meal stipends (93%), free parking (71%), gym benefits (63%), surgical loupes (53%), and maternity/paternity leave beyond vacation time (55%). No statistically significant differences were found among top ranked residencies, top ranked orthopedic hospitals, or academic centers compared to their counterparts.ConclusionWhile some benefits are commonly offered, there is great variation in the availability and level of others. However, these differences were independent of program and hospital reputation as well as academic center status. Departments currently bear a substantial amount of the cost of these benefits internally.