An unusual etiology of a subclavian artery aneurysm

Abstract

A 22-year-old woman presented with a 3-month history of a pulsatile swelling in the right supraclavicular region. A CT angiogram revealed an aneurysm arising from the distal right subclavian artery. At surgery, the subclavian artery was almost entirely replaced by a well-vascularized tumor mass. The vascular tumor along with the native vessel was excised and replaced with a vascular prosthesis. Biopsy was suggestive of an epithelioid hemangioma (EH). In conclusion, an EH is a rare vascular tumor. The presence of vascular hyperplasia with plump endothelial cells protruding into the lumen is the most important discriminator in establishing the diagnosis of EH. Vascular neoplasms presenting as aneurysms should be considered, especially if other etiologies can be excluded.

Comparison of intra-arterial digital subtraction angiography using carbon dioxide by 'home made' delivery system and conventional iodinated contrast media in the evaluation of peripheral arterial occlusive disease of the lower limbs

To prospectively compare the feasibility, safety and diagnostic role of carbon dioxide (CO(2)) digital subtraction angiography (DSA) using a 'home made' delivery system with iodinated contrast medium (ICM) DSA in the evaluation of peripheral arterial occlusive diseases (PAOD) of lower limbs. Twenty-one patients (27 limbs; all men; mean age, 47.6 years) who presented with PAOD of lower limbs underwent DSA using both intra-arterial CO(2) and ICM. Conventional ICM DSA was performed first and used as gold standard. Carbon dioxide was then injected by hand using a locally improvised home made plastic bag delivery system. Patient tolerance was assessed subjectively. Arteries from aortic bifurcation to the ankle were independently evaluated by two radiologists and graded for stenosis using a five-point scale. For each patient, the quality of CO(2) DSA images were compared with the corresponding images of ICM DSA and an overall grade of 'good', 'acceptable' or 'poor' was assigned. Cohen's kappa coefficient was used to determine inter-observer agreement. Carbon dioxide opacified 86.2% (188/195) of major arteries and depicted stenosis adequately in 84.5% (191/226) of arterial segments. A good or acceptable image quality of CO(2) DSA was obtained in over 95% of patients. Infrapopliteal arteries were inadequately visualized. Mild pain was seen in six (28.6%) patients with both contrast agents; one patient developed severe pain during CO(2) DSA. Inter-observer agreement was good (k > 0.75) at 70% of the segments. Administration of CO(2) into lower limb arteries is well tolerated. Carbon dioxide DSA using the locally improvised home made delivery system is a feasible and safe alternative to ICM DSA in the evaluation of PAOD. It provides adequate imaging of arteries of lower extremities except infrapopliteal segments.

An Intronic mutation is associated with prolactinoma in a young boy, decreased penetrance in his large family, and variable effects on MEN1 mRNA and protein

Prolactinomas are rare tumors in prepubertal children. A prolactinoma in a young child may be due to sequence variants in genes that are known to cause these tumors ( MEN1, PRKAR1A, AIP). An 11-year-old boy with a macroprolactinoma was treated with cabergoline and the tumor receded. We studied the patient and his family for genetic causes of this tumor. No mutations were present in the coding sequence of PRKAR1A and AIP. A novel heterozygous substitution (IVS3-7 c>a) was identified in intron 3 of MEN1. We also found an additional PCR amplicon that incorporated the entire intron 3 of the gene (210 bp) in the patient's cDNA. The same amplicon was present with lower intensity in some of the control individuals who were not mutation carriers. Intron 3 harbors an in-frame stop codon and its incorporation is predicted to result in a prematurely terminated protein. We conclude that a novel MEN1 variation was identified in a young boy with prolactinoma and six of his relatives who did not present with prolactinoma or other MEN1 related symptoms. This novel MEN1 variation may be associated with low penetrance of the disease. The IVS3-7 c>a defect is suggested to be pathogenic because it is associated with lower menin levels in the cells of these patients, but its consequences may be mitigated by a variety of factors including changes in transcription and translation of the MEN1 gene.

Undescribed wheat gene for partial leaf rust and stripe rust resistance from Thatcher derivatives RL6058 and 90RN2491 carrying Lr34

Inheritance of partial leaf rust and stripe rust resistance of a Thatcher wheat 90RN2491, earlier reported to carry two doses of the gene pair Lr34-Yr18 and the reference line RL6058 (6*Thatcher/PI58548) for the Lr34-Yr18 gene pair was studied against predominant and highly virulent Indian races. Thatcher derivatives 90RN2491 and RL6058 were intercrossed as well as crossed with the leaf rust and stripe rust susceptible Indian cultivar WL711. The F1, F2 and F3 generations from these crosses were assessed for rust severity against leaf rust race 77-5 and stripe rust race 46S119. The F2 and F3 generations from the crosses of RL6058 and 90RN2491 with WL711, segregated 15 resistant : 1 susceptible (F2) and 7 homozygous resistant : 8 segregating : 1 homozygous susceptible (F3) ratios, respectively, both for leaf rust and stripe rust severity. Therefore, partial resistance against each of the leaf rust and stripe rust races in both RL6058 and 90RN2491 is ascribed to two independently inherited dominant genes. One of the two genes for leaf rust and stripe rust resistance in 90RN2491 and RL6058 is Lr34 and the linked gene Yr18, respectively. The second leaf rust resistance gene in both the Thatcher lines segregated independently of stripe rust resistance. Therefore, it is not Lr34 and it remains unidentified.

Is intravenous urography necessary in the assessment of renal duplex system in children?

OBJECTIVE

Partial or complete duplication of the renal tract may be an incidental finding or may be associated with significant pathology. Accurate assessment is not always easy. This retrospective review was undertaken to determine whether intravenous urography (IVU) in combination with a DMSA renal scan provides significant additional information.

PATIENTS AND METHODS

Eighteen patients referred to our imaging department with a provisional diagnosis on ultrasound of renal tract duplication during a three year period were identified by searching the radiological computer files. The presenting features were urinary infection (13), abdominal pain (3) and abnormal antenatal sonography (2).

RESULTS

Four patients were found not to have renal duplication. There was concordance between the IVU and DMSA scan in seven. Additional clinically relevant information was obtained in three cases. A false negative result from the DMSA scan was found in four children and a false positive result in three.

CONCLUSION

In a significant number of cases of possible renal tract duplication, additional relevant information can be obtained from an IVU. Patient distress is minimised by combining the IVU and DMSA in one single episode of venous access. Review of the radiological images during the investigation allows minimisation of radiation dosage.

Effect of Hemodialysis on Cognitive Function in ESRD Patients

BACKGROUND

Uremia is associated with impairment of different cognitive functions. However the pathogenesis of this cognitive dysfunction is unknown.

OBJECTIVE

In this study, long-latency event related potentials (ERPs) were used to assess changes in cortical function due to hemodialysis treatment.

METHODS

In this cross-sectional study, we measured event related potentials in 15 end stage renal disease (ESRD) patients maintained on hemodialysis, two hours before and two hours after they underwent hemodialysis and compared their data with a strictly age and sex matched healthy control group. The P3 was elicited by using standard auditory "odd-ball" paradigm and the data obtained was statistically analyzed (Wilcoxon signed ranks, Mann Whitney).

RESULTS

Before hemodialysis, the patients' P3 latency (347.73 +/- 39.47 ms) was significantly increased as compared with that of healthy control group (308.4 +/- 13.73 ms) (p = 0.001). After hemodialysis, P3 latency of the patients showed a significant decrease (347.73 +/- 39.47 ms to 325.20 +/- 37.15 ms, p = 0.001). P3 latency after dialysis was not significantly different from controls. No significant correlation was noted between various biochemical parameters (hemoglobin, blood urea, creatinine, uric acid and calcium) and P3 latency or amplitude.

CONCLUSIONS

Removal of uremic toxins by hemodialysis leads to an improvement in cognitive processing.

Retroperitoneal solitary fibrous tumour arising from the pelvis in women – A case report and review of literature

A solitary fibrous tumour is an unusual spindle cell neoplasm that most frequently occurs in the pleura based intrathoracic region. In recent years attention has been drawn towards solitary fibrous tumours arising in extrathoracic sites. They are usually benign but malignant solitary fibrous tumours have also been reported (Nielson et al. 1997). There is far less information about the clinical behaviour of an extra thoracic solitary fibrous tumour unlike intrathoracic tumours which is well reported in many case series (England et al. 1989). Although solitary fibrous tumours are well described lesions, the occurrence of similar tumours in the pelvic retroperitoneum of women and presenting as pelvic mass have been reported only sporadically. Because of the rarity, unpredictable behaviour; lack of information available about the clinical behaviour (recurrence and metastasis) and lack of follow up protocol, we are reporting this case which we encountered along with the review of previously reported cases.

Retention rates of disease-modifying anti-rheumatic drugs in patients with rheumatoid arthritis

INTRODUCTION

Disease-modifying anti-rheumatic drugs (DMARDs) currently form the mainstay of treatment of rheumatoid arthritis (RA). We aimed to evaluate the retention rates of "therapeutic segments" of DMARDs in patients with RA.

METHODS

This was a cross-sectional study of RA patients with at least one year of follow-up. A therapeutic segment is said to begin when one DMARD combination is instituted and it ends with a subsequent change. The disability index for each patient was calculated using a modified health assessment questionnaire. Retention rates were calculated using the Kaplan Meier survival analysis.

RESULTS

375 DMARD courses in 102 patients were analysed. 99 courses were being continued at the time of the study and hence were censored for the purposes of analysis. The respective median (interquartile range [IQR]) retention period for segments containing methotrexate (MTX), sulfasalazine, hydroxychloroquine and leflunomide was 28 (15-45), 12 (3-20), 18 (9-24), 15 (4-32) months. The log-rank statistical test indicated that MTX was retained longer singly (median [IQR] 43 [32-70] months) than in combination (median [IQR] 19 [10-24] months) (p-value is 0.001). The commonest reason for the discontinuation of the DMARD segment was the disease "slipping out" of control (51.1 percent) followed by adverse effects (24.3 percent). Treatment termination on account of disease control was encountered in 16.3 percent of courses only. As many as 63 percent of single DMARD segments were changed because of disease "slip out" as compared to 41 percent of combination DMARD segments. Adverse effects were a more frequent cause of termination of the combination segments (32 vs. 15 percent).

CONCLUSION

MTX, used singly, had the highest retention rates among all the DMARDs used in RA patients. Disease "slip out" and adverse effects frequently required a change of the therapeutic segment.

Evidence for stable transformation of wheat by floral dip in Agrobacterium tumefaciens

Hexaploid wheat, one of the world's most important staple crops, remains a challenge for genetic transformation. We are developing a floral transformation protocol for wheat that does not require tissue culture. This paper presents three transformants in the hard red germplasm line Crocus that have been characterized thoroughly at the molecular level over three to six generations. Wheat spikes at the early boot stage, i.e. the early, mid or late uninucleate microspore stages, were immersed in an infiltration medium of strain C58C1 harboring pDs(Hyg)35S, or strain AGL1 harboring pBECKSred. pDs(Hyg)35S contains the NPTII and hph selectable markers, and transformants were detected using paromomycin spray at the whole plant level, NPTII ELISAs, or selection on medium with hygromycin. Strain AGL1, harboring pBECKSred, which contains the maize anthocyanin regulators, Lc and C1, and the NPTII gene, was also used to produce a Crocus transformant. T1 and T2 seeds with red embryos were selected; T1 and T2 plants were screened by sequential tests for paromomycin resistance and NPTII ELISAs. The transformants were low copy number and showed Mendelian segregation in the T2. Stable transmission of the transgenes over several generations has been demonstrated using Southern analysis. Gene expression in advanced progeny was shown using Reverse Transcriptase-PCR and ELISA assays for NPTII protein expression. This protocol has the potential to reduce the time and expense required for wheat transformation.

Hyperglycaemia as a predictor of outcome during non-invasive ventilation in decompensated COPD

RATIONALE

Hyperglycaemia predicts a poor outcome in Intensive Care Unit (ICU) patients. Whether this is true for respiratory failure necessitating non-invasive ventilation (NIV) is not known.

OBJECTIVES

To determine whether hyperglycaemia within 24 h of admission independently predicts outcome of NIV during acute decompensated ventilatory failure complicating chronic obstructive pulmonary disease (COPD) exacerbations.

METHODS

Patients with COPD presenting with acute hypercapnic respiratory failure at University Hospital Aintree between June 2006 and September 2007 and receiving NIV within 24 h of admission were studied prospectively. Random blood glucose levels were measured before NIV administration.

RESULTS

88 patients (mean baseline pH 7.25, PaCO(2) 10.20 kPa, and PaO(2) 8.19 kPa) met the inclusion criteria, with NIV normalising arterial pH off therapy in 79 (90%). After multivariate logistic regression, the following predicted outcome: baseline respiratory rate (OR 0.91; 95% CI 0.84 to 0.99), random glucose > or = 7 mmol/l (OR 0.07; 95% CI 0.007 to 0.63) and admission APACHE II (Acute Physiology and Chronic Health Evaluation II) score (OR 0.75; 95% CI 0.62 to 0.90). The combination of baseline respiratory rate (RR) <30 breaths/min and random glucose <7 mmol/l increased prediction of NIV success to 97%, whilst use of all three factors was 100% predictive.

CONCLUSIONS

In acute decompensated ventilatory failure complicating COPD, hyperglycaemia upon presentation was associated with a poor outcome. Baseline RR and hyperglycaemia are as good at predicting clinical outcomes as the APACHE II score. Combining these variables increases predictive accuracy, providing a simple method of early risk stratification.

Changes in pediatric renal transplantation after implementation of the revised deceased donor kidney allocation policy

In October 2005, the United Network for Organ Sharing (UNOS) implemented a revised allocation policy requiring that renal allografts from young deceased donors (DDs) (<35 years old) be offered preferentially to pediatric patients (<18 years old). In this study, we compare the pre- and postpolicy quarterly pediatric transplant statistics from 2000 to 2008. The mean number of pediatric renal transplants with young DDs increased after policy implementation from 62.8 to 133 per quarter (p < 0.001), reflecting a change in the proportion of all transplants from young DDs during the study period from 0.33 to 0.63 (p < 0.001). The mean number of pediatric renal transplants from old DDs (> or =35 years old) decreased from 22.4 to 2.6 per quarter (p < 0.001). The proportion of all pediatric renal transplants from living donors decreased from 0.55 to 0.35 (p < 0.001). The proportion from young DDs with five or six mismatched human leukocyte antigen (HLA) loci increased from 0.16 to 0.36 (p < 0.001) while those with 0 to 4 HLA mismatches increased from 0.18 to 0.27 (p < 0.001). Revision of UNOS policy has increased the number of pediatric renal transplants with allografts from young DDs, while increasing HLA-mismatched allografts and decreasing the number from living donors.

Concentration of antibodies to extractable nuclear antigens and disease activity in systemic lupus erythematosus

A hallmark of systemic lupus erythematosus (SLE) is the production of autoantibodies directed against intracellular antigens. Antibodies to double stranded DNA (dsDNA) are most closely associated with the clinical manifestations of the condition and appear to have a direct role in pathogenesis. On the contrary, the relationship between disease activity in SLE and anti-extractable nuclear antigen (ENA) antibodies has not been well demonstrated. Despite this, commercial assays for the quantification of anti-ENA antibodies are now widely available, although their usefulness in clinical practice is not known. The aim of this study was to investigate whether there is an association between disease activity in SLE and concentrations of individual anti-ENA antibodies. A prospective 2-year study of 45 patients with SLE, known to be positive for at least one anti-ENA antibody, was performed. Disease activity was assessed using the SLE Disease Activity Index (SLEDAI). Anti-ENA antibodies were quantified using a commercial antibody detection system. A total of 45 patients were studied over a 2-year period (median number of assessments 5, range 2–9). Of them 29 patients were positive for Ro, 8 for La, 9 for Sm and 27 for RNP antibodies. In the population as a whole, there was a weak relationship between peak SLEDAI score and anti-Sm concentration ( r = 0.57, NS), but no relation with the other anti-ENA antibodies. In a small number of patients, there appeared to be either a positive (Ro, Sm) or negative (La, Sm, RNP) association between ENA antibody concentration and disease activity over time; however, this was not apparent for the majority of individuals. These results show that in SLE, clinically significant changes in disease activity do not correlate well with concentrations of anti-ENA antibodies, either within the population as a whole or on an individual basis. Repeated quantitative measurement of anti-ENA antibodies does not therefore appear to provide useful additional information in assessing disease activity in SLE. The widespread application of commercial quantitative assays to routine clinical practice is not recommended.

Association of constitutively activated hepatocyte growth factor receptor (Met) with resistance to a dual EGFR/Her2 inhibitor in non-small-cell lung cancer cells

There is a pressing need to identify new drug targets and novel approaches for treatment of non-small-cell lung carcinoma (NSCLC). Members of the epidermal growth factor receptor (EGFR) and Met receptor families have been identified as important molecular targets for NSCLC. Two EGFR tyrosine kinase inhibitors (TKIs; erlotinib and gefitinib) are in current clinical use, but a majority of patients do not respond to these targeted therapies. We used receptor TK (RTK) capture arrays to identify receptors active in NSCLC cell lines. As Met and ErbBs were active, we explored the potential therapeutic advantage of combined targeting of Met with ErbB receptor family inhibitors for treatment of NSCLC. We found that Met physically interacts with both EGFR and Her2 in a NSCLC cell line with overexpression/overactivation of Met. Combined use of a dual EGFR/Her2 inhibitor with a Met inhibitor yields maximal growth inhibition compared with the use of EGFR and/or Met inhibitors. This suggests that simultaneous inhibition of multiple RTKs may be needed to effectively abrogate tumour cell growth. Phosphoproteomic analysis by RTK capture arrays may be a valuable tool for identifying the subset of tumours with functional receptor activation, regardless of mechanism.

Heparin-like effect in liver disease and liver transplantation

Liver cirrhosis is characterized by impairment of primary and secondary hemostasis but it is not clear how this impairment is related to the bleeding problems seen in cirrhosis. This delicate hemostatic balance can be perturbed by numerous conditions, such as variceal bleeding, renal failure, or infection/sepsis, which may lead to worsening of coagulation status to date. The role of endogenous heparinoids (glycosaminoglycans) in the coagulopathy of patients who have cirrhosis has been demonstrated by thromboelastography with the addition of heparinase I in patients who have recent variceal bleeding and infection. The heparin-like effect has also been demonstrated to be part of the coagulopathy seen after reperfusion in patients who have cirrhosis and are undergoing liver transplant. Therapeutic implications of these findings are not clear at the moment and the use of drugs able to cleave heparinoids should be explored.

Performance of a modified multi-stage bubble column reactor for lead(II) and biological oxygen demand removal from wastewater using activated rice husk

The excessive release of wastewater into the environment is a major concern worldwide. Adsorption is the one of the most effective technique for treatment of wastewater. In this work activated carbon prepared from rice husk has been used as an adsorbent. In the present investigation a three phase modified multi-stage bubble column reactor (MMBCR) has been designed to remove lead and biochemical oxygen demand (BOD) from wastewater by means of its adsorption onto the surface of activated rice husk. The multi-staging has been achieved by hydrodynamically induced continuous bubble generation, breakup and regeneration. Under optimum conditions, maximum lead and BOD reduction achieved using activated rice husk was 77.15% and 19.05%, respectively. Results showed MMBCR offered appreciated potential benefits for lead removal from wastewater and BOD removal, even this extent of removal is encouraging and the MMBCR can be used a pretreatment unit before subjecting the wastewater to biological treatment.

First Report of Rust on Switchgrass (Panicum virgatum) Caused by Puccinia emaculata in Tennessee

In the spring of 2007, switchgrass accessions and cultivars Alamo, Kanlow, SL-93-2001, and NSL 2001-1 (lowland), Blackwell (upland), and Grenville, Falcon, and Miami (unknown ploidy levels) were sown at the East Tennessee Research and Extension Center in Knoxville for evaluation and controlled hybridizations. In July and August of 2007, uredinia were observed primarily on the upper leaf surfaces, and to a lesser extent on the undersides of leaves, of switchgrass cvs. Alamo, Blackwell, Grenville, Falcon, Kanlow, and Miami. Uredinia were observed on all cultivars and accessions in 2008. Dimensions of spores are reported as mean ± standard deviation. Uredinia were epiphyllous, adaxial, caulicolous, oblong, and the color of cinnamon brown. Urediniospores were globose to broadly ellipsoid, 26.0 ± 3.0 × 23.2 ± 2.4 μm, with a wall that was cinnamon brown, 1.5 to 2.0 μm thick, finely echinulate with three to four equatorial pores, corresponding to Puccinia emaculata Schw. (3). Abundant teliospores were isolated from Grenville, Falcon, and Blackwell, with fewer teliospores isolated from Alamo. Telia were epiphyllous, adaxial, and caulicolous, densely crowded to scattered, oblong, and dark brown to black. Teliospores were dark brown, two-celled, ellipsoid to oblong, 33.6 ± 4.8 μm long with an apical cell width of 17.5 ± 1.2 μm and basal cell width of 15.9 ± 2.5 μm. Teliospore walls were 1.5 to 2.0 μm wide at the sides and 4 to 6 μm apically. Pedicels were brown or colorless and up to approximately one length of the teliospore, 28.5 ± 7.4 μm. Teliospore morphology confirmed the identification of this rust as P. emaculata (3), which has been reported to infect upland and lowland populations of switchgrass (2). A 2,109-bp fragment containing the internal transcribed spacer (ITS) 1, 5.8S, ITS 2, and D1/D2 region of the large subunit ribosomal DNA was sequenced for a specimen on 'Falcon' (GenBank Accession No. EU915294 and BPI No. 878722) from two overlapping PCR fragments amplified with primers PRITS1F (L. A. Castlebury, unpublished data) and ITS4B (1) for one fragment and Rust5.8SF (L. A. Castlebury, unpublished data) and LR7 (4) for the second fragment. No sequences of P. emaculata were available for comparison; however, BLAST searches of the ITS resulted in hits to P. asparagi DC (527 of 576, 91%) and P. andropogonis Schw. (523 of 568, 92%) placing this fungus in the genus Puccinia Pers. The alternate hosts of this rust are species of the Euphorbiaceae (2,3), which are ubiquitous in this area although the aecial stage has not been observed. To our knowledge, this is the first report of P. emaculata on switchgrass in Tennessee. Given the highly susceptible response of certain varieties of switchgrass to this rust in field plots, reduction in total biomass in large acreages is likely and long-standing fields of this perennial grass will compound the problem. References: (1) M. Gardes and T. D. Bruns. Mol. Ecol. 2:113, 1993. (2) D. M. Gustafson et al. Crop Sci. 43:755, 2003. (3) P. Ramachar and G. Cummins. Mycopathol. Mycol. Appl. 25:7, 1965. (4) R. Vilgalys and M. Hester. J. Bacteriol. 172:4238, 1990.

Giant cavernous haemangioma of the spleen presenting as massive splenomegaly and treated by partial splenectomy

Cavernous haemangioma is a rare disorder of the spleen with fewer than 100 cases reported. Only rarely do they attain large sizes. A 36-year-old woman presented with a six-month history of pain in the left hypochondrium and a massive splenomegaly. Ultrasonography, Doppler studies, and computed tomography could not distinguish between a haemangioma and a secondary deposit. Magnetic resonance imaging showed characteristic features of splenic haemangioma with central fibrosis, thrombosis and haemorrhage. Partial splenectomy was done. Intraoperative imprint cytology was negative for malignant cells. Histopathology showed cavernous haemangioma with areas of infarction necrosis. It is extremely rare to have such a massive solitary splenic haemangioma presenting as a giant splenomegaly. Preoperative investigations are often inconclusive and may not distinguish between haemangioma and metastases. Magnetic resonance imaging is the most reliable imaging method. Haemangiomas are treated only when they are symptomatic or very large with an increased risk of haemorrhage. Partial splenectomy is the treatment of choice.