Monday, April 30, 2012

From U Athens: Holy Fools: A Religious Phenomenon of Extreme Behaviour

J Relig Health. 2012 Apr 20. [Epub ahead of print]

Holy Fools: A Religious Phenomenon of Extreme Behaviour.


History of Medicine, Medical School, University of Athens, 51, Themidos St, 15124, Athens, Greece,


Monks in Byzantine times (330-1453 AD) often expressed their faith with extreme manifestations of behaviour, such as living on a high column (stylites), on a tree (dendrites) or in crowded urban centres of the empire pretending to be fools for Christ's sake. These Holy Fools exposed themselves to the ridicule and the mistreatment of the citizens, being protected, however, by their state of insanity to mock and violate moral codes and social conventions. The official Church barely tolerated these religious attitudes as promoting deviations from standard orthodoxy, and the Quinisext Ecumenical Council (592 AD) judged them as dangerous and formally denounced the phenomenon. The two most famous of them in Byzantium were Symeon of Emesa and Andrew of Constantinople, whose lives constitute unique testimonies to insanity and the simulation thereof. The survival and transplantation of the Holy Fools in Russia, called "yurodivye", where they met widespread acceptance, confirm their appeal in specific geographic areas and their endurance over time. We attempt to approach the symbolism of holy lunacy and to analyse the personality trends of these "eccentric" saints.

Malignant Pleural Disease: Diagnosis by Using Diffusion-weighted and Dynamic Contrast-enhanced MR Imaging--Initial Experience

Radiology. 2012 Apr 24. [Epub ahead of print]

Malignant Pleural Disease: Diagnosis by Using Diffusion-weighted and Dynamic Contrast-enhanced MR Imaging--Initial Experience.


Departments of Radiology, Thoracic Surgery, Pneumology, and Pathology, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium.


To investigate the use of diffusion-weighted (DW) imaging for differentiating benign lesions from malignant pleural disease (MPD) and to retrospectively assess dynamic contrast material-enhanced (DCE) magnetic resonance (MR) imaging acquisitions to find out whether combining these measurements with DW imaging could improve the diagnostic value of DW imaging.

Materials and Methods:
This study was approved by the local ethics committee, and all patients provided written informed consent. Thirty-one consecutive patients with pleural abnormalities suspicious for MPD underwent whole-body positron emission tomography (PET)/computed tomography (CT) and thorax MR examinations. Diagnostic thoracoscopy with histopathologic analysis of pleural biopsies served as the reference standard. First-line evaluation of each suspicious lesion was performed by using the apparent diffusion coefficient (ADC) calculated from the DW image, and the optimal cutoff value was found by using receiver operating characteristic curve analysis. Afterward, DCE MR imaging data were used to improve the diagnosis in the range of ADCs where DW imaging results were equivocal.

Sensitivity, specificity, and accuracy of PET/CT for diagnosis of MPD were 100%, 35.3%, and 64.5%. The optimal ADC threshold to differentiate benign lesions from MPD with DW MR imaging was 1.52 × 10(-3) mm(2)/sec, with sensitivity, specificity, and accuracy of 71.4%, 100%, and 87.1%, respectively. This result could be improved to 92.8%, 94.1%, and 93.5%, respectively, when DCE MR imaging data were included in those cases where ADC was between 1.52 and 2.00 × 10(-3) mm(2)/sec. A total of 20 patients had disease diagnosed correctly, nine had disease diagnosed incorrectly, and two cases were undetermined with PET/CT. DW imaging helped stage disease correctly in 27 patients and incorrectly in four. The undetermined cases at PET/CT were correctly diagnosed at MR imaging.

DW imaging is a promising tool for differentiating MPD from benign lesions, with high accuracy, and supplementation with DCE MR imaging seems to further improve sensitivity.

From the Ethics Committee of the American Society of Reproductive Medicine: Fertility treatment when the prognosis is very poor or futile

Fertil Steril. 2012 Apr 25. [Epub ahead of print]

Fertility treatment when the prognosis is very poor or futile: a committee opinion.


American Society for Reproductive Medicine, Birmingham, Alabama.


The Ethics Committee recommends development of evidence-based policies that are patient-centered for each in vitro fertilization (IVF) center. In most cases, the provision of futile therapies is not ethically justifiable. For those treatments with very poor success rates, clinicians must be vigilant in their presentation of risks, benefits, and alternatives. This document was reviewed in January 2012. This version replaces the previous version of this document, published in 2009.

From King's College London: Ethical issues in cosmetic dentistry

Br Dent J. 2012 Apr 27;212(8):365-7. doi: 10.1038/sj.bdj.2012.317.

Ethical issues, dilemmas and controversies in 'cosmetic' or aesthetic dentistry. A personal opinion.


Consultant and Specialist in Restorative Dentistry and Prosthodontics, King's College London Dental Institute at Guy's, King's College and St Thomas' Hospitals.


Stephen Hancocks' elegant editorial of 11 December 2011 raises interesting questions which deserve discussion. Most experienced dentists would agree that the less that is done to teeth for cosmetic reasons, the lesser are the risks of disappointment, failure of expectation, or threat of litigation. Yet there is an increasing number of cases where aesthetics are the primary concern for dentists and patients alike and some patients are consenting to treatment without being properly informed of the destructive nature of the procedures to their sound tooth tissue and structures to achieve the desired 'cosmetic' outcome. This raises ethical issues, as much of this overtreatment is unnecessarily destructive and goes against the healing and caring principles of the dental profession.

Physical workload, leisure-time physical activity, obesity and smoking as predictors of multisite musculoskeletal pain

 2012 Apr 26. [Epub ahead of print]

Physical workload, leisure-time physical activity, obesity and smoking as predictors of multisite musculoskeletal pain. A 2-year prospective study of kitchen workers.


Centre of Expertise for Health and Work Ability, Finnish Institute of Occupational Health, Helsinki, Finland.


The aim of this prospective study was to examine the role of physical workload, leisure-time physical activity,obesity and smoking in predicting the occurrence and course of multisite musculoskeletal pain (MSP).

Data on physical and psychosocial workload, lifestyle factors and MSP were based on questionnaire surveys of 385 Finnish female kitchen workers. MSP (defined as pain at three or more of seven sites) during the past 3 months was measured repeatedly at 3-month intervals over 2 years. Four different patterns (trajectories) in the course of MSP were identified. The authors analysed whether the determinants at baseline predicted the occurrence of MSP (1) at the 2-year follow-up and (2) over the total of nine measurements during the 2 years by exploiting the MSP trajectories. Logistic regression was used.

High physical workload at baseline was an independent predictor of MSP at the 2-year follow-up (OR 3.8, 95% CI 1.7 to 8.5) in a model allowing for age, psychosocial factors at work and lifestyle. High physical workload (OR 2.0, 95% CI 1.0 to 4.0) and moderate (OR 2.4, 95% CI 1.2 to 4.9) or low (OR 2.3, 95% CI 1.1 to 4.7) physical activity predicted persistent MSP. Obesity(OR 2.8, 95% CI 1.0 to 7.8) predicted an increased, and not being obese (OR 3.7, 95% CI 1.1 to 12.7) a decreased, prevalence of MSP in models similarly including all covariates. Smoking had no effect.

The results emphasise the importance of high physical workload, low to moderate physical activity and obesity as potential modifiable risk factors for the occurrence and course of MSP over time.

From Forbes: How George W. Bush Would Have Replaced Obamacare

How George W. Bush Would Have Replaced Obamacare

Avik Roy, Contributor

"But universal coverage is hardly incompatible with market-oriented health care. Indeed, Switzerland shows us that a wholly-private, market-based health insurance system can achieve universal coverage while spending far less money than the United States spends today. It would be a tremendous achievement for conservatives to install a market-based system for universal coverage, one that would stabilize our deficit while solving a genuinely pressing public-policy problem, a problem that today provides unnecessary fodder for socialized solutions.
In sum, then, the Bush plan of 2007 is a worthy foundation for market-based health reform, in that it shows how capping the employer tax exclusion can free up health-care resources for other purposes. But a true plan for replacing Obamcare will use some of those resources to provide tax credits to the uninsured, achieving universal health care.
This may seem like a lot of abstract theorizing. But we are less than two months away from a Supreme Court decision that may throw out Obamacare in its entirety, or dramatically reshape the law’s configuration. The time to consider plausible alternatives is now."

From the LA Times: Who says 'Obamacare' will kill free enterprise? Romney does,0,2873181.story

Who says 'Obamacare' will kill free enterprise? Romney does

April 30, 20125:00 a.m.

"Finally, there’s the question of whether increased government spending means we would “effectively cease to be a free-enterprise society” if we ever passed the 50% mark.
That assertion might come as a surprise to entrepreneurs in Britain, Austria, Sweden and Denmark, all countries where government spending exceeded 50% of GDP in 2011. The conservative Heritage Foundation ranked their economies as “mostly free,” the same category as the United States, even though their government spending was much larger as a share of their economies. (Their governments are larger partly because they all have national health insurance systems.) Heritage also ranked both Ireland and Canada as freer than the United States, even though Ireland’s government spends about 48% of GDP and Canada’s about 40% -- some of it, again, on state-administered health insurance."

From the Great Falls Tribune: 'Obamacare' stifles independence

'Obamacare' stifles independence

"Because the act covers everyone under government-administered health exchanges, businesses and companies can't compete for better benefits. The government unintentionally stifles independence by laying down policies that discourage individuals from earning things with their own effort and trade. It feels that it must bear the responsibility to supply for everyone."

Will Rising Obesity Drive Cultural Change?

Will Rising Obesity Drive Cultural Change?

"Last year, a gradually growing collection of statistics and studies demonstrating weight prejudice in the workplace and in medical settings briefly sparked some penetrating discussions on whether or not legislation should be crafted to protect the obese.

These discourses have not garnered national attention as of yet, and frankly, anti-discrimination legislation may not even be necessary before long. As of 2008, a full 68% of Americans were considered overweight; heavier set individuals were already the majority. In 2010, 35.7% of Americans were obese, and the number is still on the rise. How long until obese individuals become the majority? If and when this occurs, will there be rampant fat discrimination, or will these new demographics effectively drive a change in our culture's views on girth?"

From the Washington Post: What college students need most

The Post’s View

What college students need most

By Editorial BoardPublished: April 29

"The president is right that college access is a critical priority. But the country can’t afford every appealing initiative. Mr. Obama and his allies in Congress could best demonstrate their commitment by explaining how they will pay for the robust Pell program he favors. Instead, he seems more interested in pumping up a sense of emergency to justify a $6 billion-dollar commitment to a less important cause."

From Peter Perrotta and colleagues:Comparison of Analytical and Clinical Performance of Three Methods for Detection of Clostridium difficile

Comparison of Analytical and Clinical Performance of Three Methods for Detection of Clostridium difficile

P Rocco LaSala, MD; Annika M. Svensson, MD, PhD; Amin A. Mohammad, PhD; Peter L. Perrotta, MD

Context.—Diagnostic laboratory testing for Clostridium difficile infection has undergone considerable and rapid evolution during the last decade. The ideal detection method(s), which should exhibit high analytical and clinical sensitivity and specificity, remains undefined.

Objective.—We sought to evaluate the analytical and clinical performance characteristics of three methods for the laboratory detection of C difficile.

Design.—This study used 114 consecutive stool samples to compare three methods of C difficile detection: an enzyme immunoassay (EIA) for toxins A/B, a lateral flow membrane immunoassay for glutamate dehydrogenase (GDH), and a qualitative real-time polymerase chain reaction (PCR) assay. Medical records of all patients having ≥1 positive test result were reviewed to estimate the clinical likelihood of C difficile infection.

Results.—Based upon laboratory result consensus values, analytical sensitivity was significantly higher for GDH (94%) and PCR (94%) assays than for toxin EIA (25%). Analytical specificity was significantly higher for PCR (100%) and EIA (100%) than for GDH assay (93%). In contrast, assay performance based upon clinical probability of C difficile infection suggested lower discriminatory power (ie, clinical specificity) of the more analytically sensitive methods.

Conclusions.—Higher rates of C difficile detection will be realized upon implementation of GDH assay and/or real-time PCR–based testing algorithms than by testing with EIA alone. Further study is required to elucidate potential downstream costs for higher detection rates.

From Rebecca Crowley and colleagues: Perceptual Analysis of the Reading of Dermatopathology Virtual Slides by Pathology Residents

Perceptual Analysis of the Reading of Dermatopathology Virtual Slides by Pathology Residents

Claudia Mello-Thoms, MS, PhD; Carlos AB. Mello, PhD; Olga Medvedeva, MS; Melissa Castine, BS; Elizabeth Legowski, BS; Gregory Gardner, MS; Eugene Tseytlin, MS; Rebecca Crowley, MD, MSIS

Context.—The process by which pathologists arrive at a given diagnosis—a combination of their slide exploration strategy, perceptual information gathering, and cognitive decision making—has not been thoroughly explored, and many questions remain unanswered.

Objective.—To determine how pathology residents learn to diagnose inflammatory skin dermatoses, we contrasted the slide exploration strategy, perceptual capture of relevant histopathologic findings, and cognitive integration of identified features between 2 groups of residents, those who had and those who had not undergone their dermatopathology rotation.

Design.—Residents read a case set of 20 virtual slides (10 depicting nodular and diffuse dermatitis and 10 depicting subepidermal vesicular dermatitis), using an in-house–developed interface. We recorded residents' reports of diagnostic findings, conjectured diagnostic hypotheses, and final (or differential) diagnosis for each case, and time stamped each interaction with the interface. We created search maps of residents' slide exploration strategy.

Results.—No statistically significant differences were observed between the resident groups in the number of correctly or incorrectly reported diagnostic findings, but residents with dermatopathology training generated significantly more correct hypotheses (mean improvement of 88.5%) and correct diagnoses (70% of all correct diagnoses).

Conclusions.—Two types of slide exploration strategy were identified for both groups: (1) a focused and efficient search, observed when the final diagnosis was correct; and (2) a more dispersed, time-consuming strategy, observed when the final diagnosis was incorrect. This difference was statistically significant, and it suggests that initial interpretation of a slide may bias further slide exploration.

From Jeff Medeiros and colleauges: Somatic Deletions of the PolyA Tract in the 3′ Untranslated Region of Epidermal Growth Factor Receptor Are Common in Microsatellite Instability–High Endometrial and Colorectal Carcinomas

Somatic Deletions of the PolyA Tract in the 3′ Untranslated Region of Epidermal Growth Factor Receptor Are Common in Microsatellite Instability–High Endometrial and Colorectal Carcinomas

Deqin Ma MD, PhD; Zhao Chen, PhD; Christopher Nero, MD; Keyur P. Patel, MD, PhD; Emad M. Daoud, BS; Hanyin Cheng, PhD; Bojana Djordjevic, MD; Russell R. Broaddus, MD, PhD; L Jeffrey Medeiros, MD; Asif Rashid, MD, PhD; Rajyalakshmi Luthra, PhD

Context.—Epidermal growth factor receptor (EGFR) is overexpressed in up to 80% of colorectal and endometrial carcinomas. Deletions of the polyA tract in the 3′ untranslated region (3′ UTR) have been reported in microsatellite instability–high (MSI-H) colonic carcinomas, but their impacts on EGFR expression and downstream pathways are unclear. This phenomenon has not been reported in other MSI-H tumors.

Objective.—To assess the 3′ UTR polyA tract of EGFR in both endometrial and colorectal carcinomas and the mutational status of EGFR downstream pathways.

Design.—Ninety-eight colorectal carcinomas and 47 endometrial carcinomas were included. EGFR 3′ UTR polyA status was detected by capillary electrophoresis and Sanger sequencing. EGFR gene expression, EGFR copy numbers, andKRAS and BRAF mutation status were analyzed accordingly.

Results.—The 3′ UTR polyA tract was deleted in 18 of 23 (78%) MSI-H versus 0 of 24 microsatellite-stable endometrial carcinomas (P < .001). Similar observations were seen in colorectal carcinomas, in which 29 of 36 (81%) MSI-H, 1 of 62 (1.6%) microsatellite instability–low, and none of the microsatellite-stable tumors harbored the deletion (P < .001). A moderate increase in EGFR mRNA level was observed in endometrial carcinomas with 3′ UTR polyA deletions versus those with wild-type polyA tract. Amplification of the EGFR gene was not observed. Deletions in polyA tract do not seem to affect the frequency of KRAS and BRAF mutations.

Conclusions.—Deletions of EGFR 3′ UTR polyA are frequent in endometrial and colorectal carcinomas, are confined almost exclusively to MSI-H tumors, and do not affect KRAS and BRAF mutations.

From Manu Jain and colleagues: Multiphoton Microscopy in the Evaluation of Human Bladder Biopsies

Multiphoton Microscopy in the Evaluation of Human Bladder Biopsies

Manu Jain, MD*; Brian D. Robinson, MD*; Douglas S. Scherr, MD; Joshua Sterling, BS; Ming-Ming Lee, BA; James Wysock, MD; Mark A. Rubin, MD; Frederick R. Maxfield, PhD; Warren R. Zipfel, PhD; Watt W. Webb, ScD; Sushmita Mukherjee, PhD

Context.—Multiphoton microscopy (MPM) is a nonlinear imaging approach, providing cellular and subcellular details from fresh (unprocessed) tissue by exciting intrinsic tissue emissions. With miniaturization and substantially decreased cost on the horizon, MPM is an emerging imaging technique with many potential clinical applications.

Objectives.—To assess the imaging ability and diagnostic accuracy of MPM for human bladder biopsies.

Design.—Seventy-seven fresh bladder biopsies were imaged by MPM and subsequently submitted for routine surgical pathology diagnosis. Twelve cases were excluded because of extensive cautery artifact that prohibited definitive diagnosis. Comparison was made between MPM imaging and gold standard sections for each specimen stained with hematoxylin-eosin.

Results.—In 57 of 65 cases (88%), accurate MPM diagnoses (benign or neoplastic) were given based on the architecture and/or the cytologic grade. The sensitivity and specificity of MPM in our study were 90.4% and 76.9%, respectively. A positive (neoplastic) diagnosis on MPM had a high predictive value (94%), and negative (benign) diagnoses were sustained on histopathology in two-thirds of cases. Architecture (papillary versus flat) was correctly determined in 56 of 65 cases (86%), and cytologic grade (benign/low grade versus high grade) was assigned correctly in 38 of 56 cases (68%).

Conclusions.—The MPM images alone provided sufficient detail to classify most lesions as either benign or neoplastic using the same basic diagnostic criteria as histopathology (architecture and cytologic grade). Future developments in MPM technology may provide urologists and pathologists with additional screening and diagnostic tools for early detection of bladder cancer. Additional applications of such emerging technologies warrant exploration.

From BBC: In defense of obscure words

20 April 2012 Last updated at 13:07 ET

A Point of View: In defence of obscure words

"The suspicion that mass media lead to a banal middlebrow culture is as old as the printing press - arguably even older, given that Plato thought that writing was itself an intolerable derogation of the poetry of the spoken word. But from the vantage of each successive wave crest of popularisation, the anxieties of preceding generations seem touchingly premature."