Coincidental diagnosis of tuberculous lymphadenitis: a case report

The aim of this case report was to present a case of multiple calcified tuberculous lymph nodes found on a panoramic radiograph coincidently diagnosed in an endodontic clinic. A detailed discussion on the differential diagnosis of similar such calcification found in the same region is also presented. A 14-year-old girl was referred to our department with the complaint of painless swelling in the left side of the lower jaw. Clinical and radiographical examinations were performed, leading to the initial diagnosis of chronic periapical abscess. The patient's medical history was re-evaluated. Advanced imaging and excisional biopsy were performed in order to confirm the final diagnosis. Regarding the presenting signs and symptoms of bilateral carious mandibular molars, a periapical inflammatory process was considered in the provisional diagnosis. A thorough examination and investigations were suggestive of cervical tuberculous lymphadenitis (scrofula), and the patient underwent excision of the same. The clinician should consider the possibility of chronic granulomatous inflammatory lesions in the differential diagnosis of radiopaque lesions.

Antibiotic susceptibility pattern of staphylococcus aureus and methicillin-resistant staphylococcus aureus in a tertiary care hospital

Background: Methicillin resistant Staphylococcus aureushas emerged as one of the most important nosocomial pathogens. It invokes a tremendous financial burden and enhanced morbidity and mortality due to difficult to treat systemic infections.Aim of this study was to determine antibiotic susceptibility pattern of Staphylococcus aureus and Methicillin resistant Staphylococcus aureus. Materials and Methods: Different clinical specimens were collected and processed for routine culture and antibiotic sensitivity test by standard microbiology techniques. Results: Out of 1173 samples received for microbiological examination, 100 were found to be S. aureus with 19% cases were Methicillin resistant Staphylococcus aureus (MRSA). Fourteen MRSA were found from inpatient and 5 were from outpatient. MRSA was found higher in female than male and maximum number (31.5%) was found in age group 0-10 years. Staphylococcus aureus was 100% sensitive to Vancomycin followed by Amikacin (90%), Gentamycin (83%), and tetracycline (81%). On urine isolates Nitrofurantoin(91.6%) was drug of choice. All the isolates were resistant to Penicillin G. In case of Methicillin resistant Staphylococcus aureus showed 100% sensitive to Vancomycin followed by Amikacin (84.2%), Tetracycline (63.1%), Ciprofloxacin (42%) and Gentamycin (36.8%). Among urine isolates Nitrofutantoin showed 87.5% sensitive followed by Norfloxacin (75%). Conclusion: Methicillin resistant Staphylococcus aureus was found 19% of Staphylococcus aureus isolates. It was most common in females, hospitalized patients and young age group. Vancomycin seems to be drug of choice followed by Amikacin. It would be helpful to formulating and monitoring the antibiotic policy and ensure proper empiric treatment. DOI: http://dx.doi.org/10.3126/jpn.v4i7.10297 Journal of Pathology of Nepal (2014) Vol. 4, 548-551   

Efficacy of spinal ropivacaine versus ropivacaine with fentanyl in transurethral resection operations

Background:

The low-dose ropivacaine provides differential spinal block to reduce adverse hemodynamic effects in elderly patients. Addition of intrathecal fentanyl with ropivacaine may enhance analgesia and early postoperative mobility. The present study was performed to evaluate the efficacy of intrathecal ropivacaine alone and in combination with fentanyl in transurethral resection operation.

Methods:

Sixty male patients aged >50 years of ASA I-III scheduled for elective transurethral resection were included in a prospective, randomized, double-blinded study and they were divided in two groups of 30 each. Group A (n = 30) received intrathecal injection of ropivacaine 2 ml (0.75%) and Group B (n = 30) ropivacaine 1.8 ml (0.75%) with fentanyl 10 μg. The characteristics of onset and regression of sensory and motor blockade, hemodynamic stability, and side effects were observed. Student's t test (for parametric data) and Mann-Whitney U test (for non-parametric data) were used for statistical analyses.

Results:

There were no significant differences between the two groups for patient demographic data, intraoperative hemodynamic parameters, side effects, and satisfaction to patients and surgeon. The highest level of sensory block was at T10 in group A and T9 in group B (P = 0.001). Duration of motor block was longer in group B being 210.51 ± 61.25 min than in group A being 286.25 ± 55.65 min (P < 0.001).

Conclusion:

The addition of fentanyl to ropivacaine may offer the advantage of shorter duration of complete motor block, hemodynamic stability, and without any increase in the frequency of major side effects.

Pantothenate Kinase Associated Neurodegeneration: A Case Report

Pantothenate kinase-associated neurodegeneration (PKAN) is a form of neurodegeneration with brain iron accumulation (NBIA), formerly called Hallervorden-Spatz syndrome. PKAN is the first described inborn error of coenzyme A metabolism. PKAN encompasses two clinical subtypes, classic and atypical. We here report an eight year girl diagnosed as classic PKAN. We also review the literature about PKAN. Key words: Eye of tiger sign; NBIA; Neuroregeneration; Iron Accumulation; Hallevorden Spatz Syndrome DOI: http://dx.doi.org/10.3126/jnps.v32i1.5333   J. Nepal Paediatr. Soc. Vol.32(1) 2012 90-92

Atypical Squamous Cells of Undetermined Significance : A Follow up Study

BACKGROUND

Atypical squamous cells of undetermined significance (ASCUS) is the term in cervical cytology reporting where the changes are suggestive of a sqamous extraepithelial lesion but lack criteria for definition interpretation. Its clinical significance is variable.

METHODS

A one year study in a zonal hospital evaluating all cervical smears received for cytology by two pathologists independently and subsequently reported as per the Bethesda guidelines. The patients were folloed up for six months.

RESULT

A total of 24 (4%) smears were reported as ASCUS out of 604 examined. Of these, 15 were followed up for one year. Mean age was 39 years and 60% were premenopausal. After six months, 11 cases were reported negative for intraepithelial lesion or malignancy and four showed ASCUS on repeat pap smear.

CONCLUSION

ASCUS shows a repression rate of 73%. Colpscopic evaluation should be done only if ASCUS persists. Diligent follow up and biopsy, when indicated is a must.

In vitro Evaluation of Terminalia arjuna on Calcium Phosphate and Calcium Oxalate Crystallization

Urinary stones are one of the oldest and the most common afflictions in humans. This disease has tormented humans since the earliest records of civilization. Ten percent of men and 3 % of women have a stone during their adult lives. Calcium containing stones are the most common comprising about 75 % of all urinary calculi, which may be in the form of pure calcium oxalate (50 %) or calcium phosphate (5 %) or a mixture of both (45 %). A number of plants have been mentioned in the Indian ayurvedic system, which plays a vital role in the inhibition of kidney stones. In the present study, the inhibitory potency of crude extracts or fractions of successive solvent extractions of Terminalia arjuna bark was evaluated on various stages of formation of calcium phosphate and on the growth of calcium oxalate monohydrate crystals in vitro. Results obtained indicated that Terminalia arjuna bark has the potential to inhibit the formation of both calcium phosphate and calcium oxalate crystals in vitro. Butanol fraction of Terminalia arjuna extract was the most effective in inhibiting formation of calcium phosphate and calcium oxalate crystals in vitro.

Pain relief after Frey's procedure for chronic pancreatitis

BACKGROUND

Few studies have addressed long-term pain relief after Frey's procedure (local head resection with lateral pancreaticojejunostomy, LR-LPJ) for chronic pancreatitis. This retrospective study evaluated pain control using a validated score and risk factors associated with failure to achieve complete pain relief following LR-LPJ.

METHODS

Sixty of 134 patients with chronic pancreatitis underwent LR-LPJ and were evaluated prospectively using the Izbicki pain score before surgery, and 1, 2, 5 and 7 years later. Analysis was on an intention-to-treat basis and predictors of complete pain relief were identified by multivariable analysis.

RESULTS

After a median follow-up of 6.4 years, the median pain score was reduced from 46.4 to 10.0 (P < 0.001) with partial or complete pain relief in 75 per cent of patients, and a significant reduction in median number of episodes requiring hospitalization (from 4 to 0; P < 0.001). Preoperative use of opiate medication (odds ratio (OR) 30.14; P = 0.015), continuous pattern of pain (OR 22.65; P = 0.025) and occurrence of postoperative complications (OR 10.52; P = 0.030) were significant predictors of failure to achieve complete pain relief after surgery.

CONCLUSION

Frey's procedure leads to significant and sustained long-term pain relief in patients with chronic pancreatitis. Patients should be referred for surgery before opiates are needed to relieve pain.

HIV type 1 in Fiji is caused by subtypes C and B

The HIV epidemic in Fiji remains largely uncharacterized. By February 2009, there were 294 confirmed cases; the majority occurred among the 20- to 39-year old age group and resulted from heterosexual contact. There are currently no published data concerning HIV subtypes in Fiji. In this study, venous blood samples were collected as dried blood spots from 35 HIV-positive individuals in Fiji. HIV-1 subtype was determined for 27 (77%) samples and the presence of four different subtypes, with multiple introductions of two, was demonstrated. Subtype distribution was as follows: 16 (59%) were subtype C, 9 (33%) were subtype B, 1 (4%) was subtype A, and 1 (4%) was subtype G. Phylogenetic analysis showed a clear segregation of the Fijian subtype C isolates and previously published Papua New Guinea subtype C isolates as well as multiple introductions of subtype B. These findings represent the first HIV-1 subtype data from the Fiji Islands.

Patient controlled sedation during central neuraxial anesthesia

BACKGROUND

Patient controlled sedation (PCS) gives liberty to patients to choose the time of sedative administration to attain a desired level of comfort.

AIMS

The PCS use was evaluated in patients during surgery under central neuraxial blockade.

SETTINGS AND DESIGN

Prospective, cross-sectional, clinical study on consecutive patients in a tertiary care university hospital.

MATERIALS AND METHODS

PCS technique, using propofol (1%) 2 ml in 2 min was used in 160 adult patients undergoing urologic procedures under central neuraxial block. We observed the time to first PCS activation by patient, duration of surgery, propofol dose, sedation score, hemodynamic stability, patient's acceptability, and the factors correlating with the PCS use.

STATISTICAL ANALYSIS USED

Non-parametric two-tailed Pearson's test, univariate correlation analysis for the factors favoring PCS use followed by multivariate logistic regression analysis amongst correlating factors.

RESULTS

In our cohort, the majority (83%) of the patients activated PCS during surgery under central neuraxial blocks at median time of 30 min and (17%) did not activate PCS. Female patients activated sedation earlier (median 15 min) than male patients (median 30 min). All patients were hemodynamically stable and without significant side effects. Multivariate analysis showed that sedative use significantly ( P < 0.05) correlated with female gender (odds ratio-3.54 [IR-2.64 to 4.73]) and prolonged surgery (>90 min). Majority (91%) of patients rated PCS technique excellent to good.

CONCLUSIONS

PCS was very well accepted by patients during central neuraxial block. Propofol regimen (2 ml in 2 min) in PCS was safe, as it caused neither apnea nor significant hypotension.

Tacrolimus (Pan Graf) in Live Related Renal Transplantation: An Initial Experience of 101 Recipients in India

BACKGROUND

Success of modern transplantation is in large part due to the successful development of effective immunosuppressive agents. The safety and efficacy of tacrolimus in transplantation is well established. However, tacrolimus (Pan Graf, Panacea Biotec Ltd, India) has only been available in India for the last 2 years. This study was conducted to assess the safety and efficacy of tacrolimus in live related kidney transplantation. We report an initial experience of tacrolimus as de novo therapy in a live related renal transplantation program.

MATERIALS AND METHODS

One hundred one consecutive recipients of a live renal allograft were commenced on triple immunosuppression consisting of tacrolimus, mycophenolate mofetil or azathioprine, and steroids. The dose of tacrolimus was adjusted to keep trough levels at 10-12 ng/mL in the first 3 months, 8-10 ng/mL in the next 3 months, and 5-8 ng/mL thereafter. All patients were followed up for a period ranging from 4 weeks to 24 months. The effect of this regimen on the incidence of graft rejection, graft survival, patient survival, and new-onset diabetes mellitus was evaluated. Any evidence of graft dysfunction was evaluated using a graft biopsy.

RESULTS

There were 89 male and 12 female patients with mean age of 32.08 years. The incidence of acute rejection was 3.96%; 21.05% developed new-onset diabetes mellitus. Six patients were diabetic prior to transplantation and 9 patients were hepatitis C virus (HCV)-positive; 77.7% of HCV-positive patients and 15.1% of HCV-negative patients developed posttransplantation diabetes mellitus. The patient survival rate at the current follow-up was 92.07%. No graft was lost due to rejection.

CONCLUSION

Tacrolimus is a safe and effective immunosuppressant in live related renal transplantation.

Current role of portosystemic shunt surgery in the management of hepatic venous outflow obstruction

BACKGROUND

Hepatic venous outflow obstruction (HVOO) is a rare disorder that occurs predominantly due to a hypercoagulable state. The syndrome may result from hepatic vein obstruction, inferior vena cava obstruction or a combination of both and manifests with post-sinusoidal portal hypertension. The presentation may be fulminant with poor prognosis or as either acute, subacute or chronic forms with relatively better prognosis. Portosystemic shunt surgery (PSS) has thus far been the mainstay of treatment for HVOO. However, over the last decade, transjugular intrahepatic portosystemic shunt (TIPS) and liver transplantation have emerged as viable options. This review aims to evaluate the available treatment options and the current relevance of PSS for the management of HVOO.

METHODS

A literature review on investigations and treatment was performed using Medline and additional library searches.

RESULTS

Portosystemic shunts form the mainstay of treatment for patients with subacute presentation (preserved liver function) with medically intractable ascites or recurrent variceal hemorrhage. Excellent results with 5-year survival of more than 90% have been reported from specialized centers. The main limitation for PSS is the reported perioperative mortality of 10-20% and a declining technical expertise for such surgery. Liver transplantation with disease-specific 5-year survival between 50 and 95% is presently the treatment of choice for patients with fulminant presentation, end-stage liver disease (ESLD), unshuntable anatomy or decompensation after PSS. TIPS may be preferable for sick patients with acute presentation with isolated hepatic vein thrombosis or as a temporizing measure for those with ESLD awaiting transplantation. The drawback of TIPS is late shunt dysfunction that occurs in more than 50% of patients at 1 year.

CONCLUSIONS

Due to rarity of the disorder there is a lack of trials comparing the different treatment modalities. Hence, the current treatment recommendations are based on retrospective studies. In a select group of HVOO patients (subacute presentation with preserved liver function), PSS remains the treatment of choice with excellent long-term results.

Dynamics of organic carbon and microbial biomass in alluvial soil with tillage and amendments in rice-wheat systems

Rice-wheat cropping systems of the Indo-Gangetic plains (IGP) occupying 12 million ha of productive land are important for the food security of South Asia. There are, however, concerns that yield and factor productivity trends in these systems are declining/stagnating in recent years. Decrease in soil organic carbon is often suggested as a reason for such trends. A field experiment was conducted to study the soil organic carbon (SOC) and soil microbial biomass carbon (MBC) dynamics in the rice-wheat systems. Use of organic amendments and puddling of soil before rice transplanting increased SOC and MBC contents. Microbial biomass carbon showed a seasonal pattern. It was low initially, reached its peak during the flowering stages in both rice and wheat and declined thereafter. Microbial biomass carbon was linearly related to SOC in both rice and wheat indicating that SOC could be used as a proxy for MBC.

Screening cascade and development of potential Positron Emission Tomography radiotracers for mGluR5: in vitro and in vivo characterization

PURPOSE

Use of mGluR5 receptor radiotracers to determine whether an in vitro binding assay is able to predict how good a radiotracer is likely to be in imaging receptor in the central nervous system (CNS) via positron emission tomography (PET).

PROCEDURES

Saturation and equilibrium competition studies in rat and rhesus membranes were used to determine receptor concentrations and tracer affinities. In addition, specific binding of metabotropic receptor subtype 5 (mGluR5) radioligands in rhesus and rat brain sections was determined using a "no-wash protocol," and the in vivo binding signal in rats was determined using micro-PET.

RESULTS

Affinity values were determined for a series of mGluR5 antagonists (1-5) and ranged from 0.1 to 11 nM in rat. A previously reported "no-wash protocol" was then employed to determine specific binding in tissue sections following a 20-min incubation, and the regional distribution of these mGluR5 radiotracers determined in rat brain via autoradiography. The analogs 1b, 2b, 3b, and 4b, but not 5b, displayed good signal-to-noise ratios under these conditions with high density of binding in caudate, cortex, and hippocampus and lower density in cerebellum. With this information it was predicted that 1c, 2c, 3b, and 4b would display measurable signal-to-noise ratios in vivo, and that the larger in vitro signals for 3b and 4b would translate to 3b and 4b yielding the best in vivo signals. These predictions were investigated using micro-PET imaging in rat. Compound 1c showed a rapid wash-in and rapid wash-out profile in rat brain. Compound 2c showed similar signal-to-noise ratio as 1b, but slower washout. Compounds 3b and 4b showed the best signal-to-noise ratio in vivo, while 5b did not provide a significant signal, as predicted. In vivo occupancy estimates for 2-methyl-6-(phenylethynyl)-pyridine (MPEP) following intravenous administration were determined using radiolabeled compounds 1c, 2c, and 3b; they were essentially the same and were on the order of 1 mg kg(-1) (ID(50)).

CONCLUSIONS

An in vitro screen of several mGluR5 tracers was used to rapidly predict whether radiolabeled mGluR5 analogs would be useful as PET radiotracers. Results provided an extension to previously reported data. Two of the four radiotracers with the best in vitro "no-wash" results also showed the best potential as measured noninvasively using micro-PET.

Disseminated Cryptococcus neoformans in a cirrhotic patient

Disseminated cryptococcal infection often occurs in the setting of an immuncompromised patient. We report a case of disseminated Cryptococcus neoformans in a cirrhotic patient, referred for Orthotopic Liver Transplantation evaluation due to acute hepatic decompensation.

Biliary complications of pancreatic necrosis

BACKGROUND

Involvement of the biliary tract in pancreatic necrosis is rare. The authors are presenting six patients with this unusual complication.

METHODS

Retrospective analysis of a case series.

RESULTS

The necrotic process involved the bile duct in four patients (bile duct alone in two and bile duct with duodenum in two) and the gall bladder in two patients. It was not possible to make a preoperative diagnosis of biliary tract involvement in any of these patients. The lesions in the biliary tract were caused by the direct erosion by the necrotic tissue in five patients, and in one patient with gangrene of the gall bladder, it was a "remote" complication of the necrotizing process. All patients underwent surgery. Necrosectomy and cholecystectomy were performed in patients with gall bladder lesions, and proximal biliary drainage was the method of choice in patients with erosion of the bile duct. One patient died postoperatively. During follow-up, another patient who had bile-duct involvement developed a stricture in the damaged part of the bile duct and needed hepaticojejunostomy

CONCLUSIONS

Necrotizing pancreatitis can involve the biliary tract, both by direct extension and by its secondary effects. Although cholecystectomy is the treatment of choice in the presence of gallbladder involvement, proximal biliary diversion may be indicated in patients with erosion of the bile duct.

Comparison of magnetic resonance cholangiography and percutaneous transhepatic cholangiography in the evaluation of bile duct strictures after cholecystectomy

BACKGROUND

Percutaneous transhepatic cholangiography (PTC) has been the preferred investigation to delineate the anatomy of the biliary tract in a patient with a bile duct stricture after cholecystectomy. Recently magnetic resonance cholangiography (MRC) has been described to evaluate the obstructed biliary tract. This paper reports a comparison of MRC with PTC in evaluating patients with an iatrogenic bile duct stricture.

METHODS

This was a prospective study of 26 patients who had surgery for a bile duct stricture after cholecystectomy. Before operation all patients underwent both MRC and PTC, the results of which were compared with the intraoperative findings.

RESULTS

Both PTC and MRC were comparable with regard to image quality, detection of intrahepatic bile duct dilatation, assessment of the level of injury and detection of abnormalities such as intraduct calculi, cholangitic liver abscesses and atrophy of liver lobes. MRC provided additional information in four patients, including detection of associated fluid collections (n = 3) and portal hypertension (n = 1). In eight patients more than one puncture had to be performed during PTC to delineate the complete anatomy.

CONCLUSION

MRC is an accurate and non-invasive imaging procedure for preoperative evaluation of patients with a bile duct injury after cholecystectomy, and is capable of providing additional information which may not be available with PTC.

Portal biliopathy

In patients with portal hypertension, particularly with extrahepatic portal vein obstruction, portal biliopathy producing biliary ductal and gallbladder wall abnormalities are common. Portal cavernoma formation, choledochal varices and ischemic injury of the bile duct have been implicated as causes of these morphological alterations. While a majority of the patients are asymptomatic, some present with a raised alkaline phosphatase level, abdominal pain, fever and cholangitis. Choledocholithiasis may develop as a complication and manifest as obstructive jaundice with or without cholangitis. Endoscopic sphincterotomy and stone extraction can effectively treat cholangitis when jaundice is associated with common bile duct stone(s). Definitive decompressive shunt surgery is sometimes required when biliary obstruction is recurrent and progressive.

How do bile duct injuries sustained during laparoscopic cholecystectomy differ from those during open cholecystectomy?

BACKGROUND AND PURPOSE

Bile duct injuries sustained during laparoscopic cholecystectomy differ from those of open cholecystectomy. The authors conducted a retrospective analysis of their experience with 124 major bile duct injuries to identify these differences.

PATIENTS AND METHODS

Biliary injury in 83 patients (67%) was sustained during open cholecystectomy, while in 41 patients (33%), it occurred during laparoscopic cholecystectomy. Intraoperative recognition was possible in 21 patients (25%) in the former group and in 14 patients (34%) in the latter (P < 0.05).

RESULTS

The median time of presentation after laparoscopic cholecystectomy was 37 days v 240 days after open cholecystectomy (P < 0.001). Twenty-eight patients presented with external biliary fistulae in both groups. Spontaneous closure of these fistulae occurred in 21 patients (75%) in the open cholecystectomy group and in only 10 patients (36%) in the laparoscopic group (P < 0.01). Bismuth type III or IV injuries were the commonest type in the laparoscopic cholecystectomy group (N = 25; 61%) while Bismuth type I or II were the usual injuries in open cholecystectomy (N = 57; 69%) (P < 0.01). After hepaticojejunostomy, over a mean follow-up period of 3.4 years, stenosis of the hepaticojejunostomy was seen in two patients in both groups.

CONCLUSION

Compared with open cholecystectomy, biliary injuries sustained during laparoscopic cholecystectomy are more likely to present earlier, are more often associated with persistent bile leaks, and are usually high injuries. However, the results of surgical repair do not appear to be different in these two groups.

Complicated choledochal cysts

Choledochal cysts have a potential for causing a variety of complications. This article presents the incidence, types, and presentation of complications in patients with choledochal cysts and the results of surgery in these patients. Prospectively collected data of 81 patients with choledochal cysts treated at a tertiary care center were retrospectively analyzed. Sixteen (20% of surgical patients; 100% of study group) patients were found to have a complicated choledochal cyst that either manifested as an atypical presentation or necessitated a change in the treatment planning. Eight (50%) of these patients had complications of infective nature, and another 8 (50%) had noninfective complications. Fifteen (94%) patients with complications were adults and 11 (63%) patients had Todani type-IVa cysts; a cystic type of intrahepatic component in 10 patients. Five (31%) patients had undergone prior cystenteric drainage operations. Excision of the choledochal cyst was possible in 14 (88%) patients under both emergency and elective situations; cyst excision was performed in the second stage after an initial external drainage procedure in two of these patients. There was no mortality and no major postoperative complications. Complications of choledochal cysts are more likely in adult patients and in those with both intra- and extrahepatic cysts (Todani type-IVa). Despite the presence of complications, the choledochal cyst can be safely excised in a majority of patients.

Long-Term outcome of mitral balloon valvotomy in pregnant women

BACKGROUND AND AIM OF THE STUDY

The study aim was to examine the long-term outcome (nine years) of mitral balloon valvotomy in pregnant patients with severe mitral stenosis.

METHODS

Twenty-three patients with severe, symptomatic (NYHA class III/IV) mitral stenosis underwent mitral balloon valvotomy using an Inoue balloon technique during the second trimester of their pregnancy; mean follow up in 19 patients was 5.1 +/- 2.8 years (range: 1 to 9 years).

RESULTS

The procedure was successful in all patients. Immediately after valvotomy, the Doppler-derived mitral valve area increased from 0.90 +/- 0.18 to 1.97 +/- 0.36 cm2 (p <0.0001), and the transmitral mean gradient decreased from 15.7 +/- 4.7 to 5.5 +/- 1.6 mmHg (p <0.0001). Four patients had mild worsening of mitral regurgitation, and six developed insignificant interatrial communication immediately after valvotomy. There was no other morbidity or mortality. Patients showed a significant improvement in mean NYHA class, from 3.0 +/- 0.1 to 1.0 +/- 0.02 (p <0.001). Twenty-two patients had normal deliveries; one cesarean section in week 36 resulted in stillbirth. No developmental abnormalities were seen in the babies. At long-term follow up of mothers, the mitral valve area was 1.8 +/- 0.52 cm2; restenosis developed in three patients (16%). One baby died at one week from sudden infant death syndrome, and one at eight months, from pneumonia. All other children showed normal growth, development and speech for their age.

CONCLUSION

Mitral balloon valvotomy using the Inoue balloon technique can provide satisfactory immediate relief and long-term outcome in pregnant patients with severe mitral stenosis.

Ultrasonographic evaluation of common duct diameter in pre and post cholecystectomy patients

Thirty four patients with gall bladder disease and normal common duct were investigated prospectively by ultrasonography just before cholecystectomy and at periodic intervals of 1 months, 2 months, 3 months and once in 4-6 months after cholecystectomy. The pre and post cholecystectomy common duct diameters were measured at each visit and compared with each other to determine the statistical significance. No significant change (p > 0.05) occurred in common duct diameter following cholecystectomy.

Phosphatidylinositol 3-kinase regulates Raf1 through Pak phosphorylation of serine 338

We have previously shown that inhibition of phosphatidylinositol (PI) 3-kinase severely attenuates the activation of extracellular signal-regulated kinase (Erk) following engagement of integrin/fibronectin receptors and that Raf is the critical target of PI 3-kinase regulation [1]. To investigate how PI 3-kinase regulates Raf, we examined sites on Raf1 required for regulation by PI 3-kinase and explored the mechanisms involved in this regulation. Serine 338 (Ser338), which was critical for fibronectin stimulation of Raf1, was phosphorylated in a PI 3-kinase-dependent manner following engagement of fibronectin receptors. In addition, fibronectin activation of a Raf1 mutant containing a phospho-mimic mutation (S338D) was independent of PI 3-kinase. Furthermore, integrin-induced activation of the serine/threonine kinase Pak-1, which has been shown to phosphorylate Raf1 Ser338, was also dependent on PI 3-kinase activity and expression of a kinase-inactive Pak-1 mutant blocked phosphorylation of Raf1 Ser338. These results indicate that PI 3-kinase regulates phosphorylation of Raf1 Ser338 through the serine/threonine kinase Pak. Thus, phosphorylation of Raf1 Ser338 through PI 3-kinase and Pak provides a co-stimulatory signal which together with Ras leads to strong activation of Raf1 kinase activity by integrins.

Function of the central domain of streptokinase in substrate plasminogen docking and processing revealed by site-directed mutagenesis

The possible role of the central beta-domain (residues 151-287) of streptokinase (SK) was probed by site-specifically altering two charged residues at a time to alanines in a region (residues 230-290) previously identified by Peptide Walking to play a key role in plasminogen (PG) activation. These mutants were then screened for altered ability to activate equimolar "partner" human PG, or altered interaction with substrate PG resulting in an overall compromised capability for substrate PG processing. Of the eight initial alanine-linker mutants of SK, one mutant, viz. SK(KK256.257AA) (SK-D1), showed a roughly 20-fold reduction in PG activator activity in comparison to wild-type SK expressed in Escherichia coli (nSK). Five other mutants were as active as nSK, with two [SK(RE248.249AA) and SK(EK281.282AA), referred to as SK(C) and SK(H), respectively] showing specific activities approximately one-half and two-thirds, respectively, that of nSK. Unlike SK(C) and SK(H), however, SK(D1) showed an extended initial delay in the kinetics of PG activation. These features were drastically accentuated when the charges on the two Lys residues at positions 256 and 257 of nSK were reversed, to obtain SK(KK256.257EE) [SK(D2)]. This mutant showed a PG activator activity approximately 10-fold less than that of SK(D1). Remarkably, inclusion of small amounts of human plasmin (PN) in the PG activation reactions of SK(D2) resulted in a dramatic, PN dose-dependent rejuvenation of its PG activation capability, indicating that it required pre-existing PN to form a functional activator since it could not effect active site exposure in partner PG on its own, a conclusion further confirmed by its inability to show a "burst" of p-nitrophenol release in the presence of equimolar human PG and p-nitrophenyl guanidino benzoate. The steady-state kinetic parameters for HPG activation of its 1:1 complex with human PN revealed that although it could form a highly functional activator once "supplied" with a mature active site, the Km for PG was increased nearly eightfold in comparison to that of nSK-PN. SK mutants carrying simultaneous two- and three-site charge-cluster alterations, viz., SK(RE24249AA:EK281.282AA) [SK(CH)], SK(EK272.273AA;EK281.282AA) [SK(FH)], and SK(RE248.249AA;EK272.273AA:EK281.282AA+ ++) [SK(CFH)], showed additive/synergistic influence of multiple charge-cluster mutations on HPG activation when compared to the respective "single-site" mutants, with the "triple-site" mutant [SK(CFH)] showing absolutely no detectable HPG activation ability. Nevertheless, like the other constructs, the double- and triple-charge cluster mutants retained a native like affinity for complexation with partner PG. Their overall structure also, as judged by far-ultraviolet circular dichroism, was closely similar to that of nSK. These results provide the first experimental evidence for a direct assistance by the SK beta-domain in the docking and processing of substrate PG by the activator complex, a facet not readily evident probably because of the flexibility of this domain in the recent X-ray crystal structure of the SK-plasmin light chain complex.

Evaluation of prochlorperazine buccal tablets (Bukatel) and metoclopramide oral tablets in the treatment of acute emesis

The dizziness associated with vertiginous disorders is often accompanied with nausea and/or vomiting. Antiemetic effect of prochlorperazine (PCZ) is diminished by its low bioavailability owing to a significant gastric and hepatic first pass effect. This effect could be further diminished by likelihood of regurgitation of nauseating patients further limiting the therapeutic effect of oral PCZ. A buccal preparation achieves higher plasma concentrations through direct systemic absorption. In this study buccal prochlorperazine (Bukatel) was compared for its efficacy and tolerability with commonly used metoclopramide. Bukatel was well tolerated and well rated by both patients and investigators with no adverse effects on buccal mucosa and causing less drowsiness and sedation. Results indicate that Bukatel is safe and effective for the treatment of nausea and/or vomiting in patients suffering from vertiginous disorders and could be safely and strongly recommended as an alternative to less bioavailable and indiscriminately used oral metoclopramide tablets.

Gastric outlet obstruction in carcinoma gall bladder

BACKGROUND

Gastric outlet obstruction is occasionally reported to occur in advanced gall bladder malignancy and may require palliative surgery. A review of 39 patients who required gastroenterostomy for symptomatic or incipient gastric outlet obstruction in carcinoma gall bladder is presented.

METHODS

This retrospective review included 24 women and 15 men over nine years who underwent gastrojejunostomy for locally advanced neoplasms of the gall bladder.

RESULTS

Twenty two patients with carcinoma gall bladder had symptomatic gastric outlet obstruction whereas in 17 patients gastrojejunostomy had been performed for intraoperatively assessed impending obstruction. Thirty-four patients had concomitant jaundice. In most cases, there was obstruction of the first two parts of the duodenum, mostly by direct tumoral infiltration (64%). All patients underwent anterior gastrojejunostomy, with billoenteric bypass in 15 patients. There were two postoperative deaths. Eight patients developed postoperative delayed gastric emptying; all settled on conservative management, though two patients had recurrent refractory vomiting. Thirty patients had no vomiting till a follow up ranging from 36 days to 11 months.

CONCLUSIONS

Gastric outlet obstruction may frequently complicate gall bladder cancer and a satisfactory palliation can be achieved in most patients by gastrojejunostomy.

Double blind, randomised, parallel, prospective, comparative, clinical evaluation of a combination of antispasmodic analgesic Diclofenac + Pitofenone + Fenpiverinium (Manyana vs Analgin + Pitofenone + Fenpiverinium (Baralgan) in biliary, ureteric and intestinal colic

In this double blind, prospective study, the relative efficacy of Diclofenac + Pitofenone + Fenpiverinium (Manyana) and Analgin + Pitofenone + Fenpiverinium (Baralgan) in 200 patients of biliary, ureteric and intestinal colic was evaluated. Patients were given these coded drugs thrice daily for five days starting from day 0 to day 5. The results of the present clinical evaluation demonstrated that Manyana appeared to be superior to Baralgan in biliary and ureteric colic while it was therapeutically equivalent to Baralgan in reducing the pain intensity in intestinal colic. Both the medications were tolerated well and there were no side-effects reported.

Possible genetic association between interleukin-1alpha gene polymorphism and the severity of chronic polyarthritis

Interleukin-1 (IL-1) has been implicated in the pathogenesis of rheumatoid arthritis (RA). IL-1alpha gene polymorphism was analysed for the exon V and promoter region in 51 patients with destructive and 47 with non-destructive RA, as well as in 94 controls. The two biallelic polymorphisms in the promoter region and the exon V were 100% linked. The rare IL-1A2 allele carriage rate was 45% in the control population. It was increased in destructive (54.4%) and decreased in non-destructive RA (26.8%, destructive versus non-destructive, p < 0.007). All indices of disease activity and joint destruction were significantly lower in the patients positive for IL-1A1, and higher in those positive for IL-1A2. The present findings suggest that this IL-1alpha gene polymorphism may contribute to the pathogenesis of chronic polyarthritis. The presence of the IL-1A2 allele could constitute a risk factor for the development of destructive arthritis and could be used early in the course of the disease as a prognostic marker.

Duodenal villous adenoma

Duodenal villous adenomas are extremely rare (1/5th of small bowel tumors). In view of their strategic position and risk of malignancy, they require definitive management in specialized care units. We report a case of a 35 year old female patient with a large duodenal (5 cm) villous adenoma causing intussusception of duodenum (a phenomenon rare because of its anatomic location & fixation).

Generalized umbilicated granuloma annulare

Generalised umbilicated granuloma annulare is reported in an elderly man. There was no association of diabetes or other systemic disease.

Probing the phosphoinositide binding site of the clathrin assembly protein AP-2 with photoaffinity labels

The relative binding specificities of the subunitsof bovine assembly protein AP-2 for the phosphatidylinositol polyphosphates (PtdInsPn) and inositol polyphosphates (InsPn) were determined by photoaffinitylabeling. Three types of benzophenone-containing photoprobes were employed: (i) the water-solubleP-1- or P-2-tethered p-benzoyldihydrocinnamoyl-InsPn (BZDC-InsPn) analogs, (ii) P-1-linked phosphotriester PtdInsPn analogs that sampled the interface between the water and lipid phases, and (iii) sn-1-O-acyl-linked PtdInsPn analogs that interacted with proteins penetrating the bilayer. The InsPn and PtdInsPn probes bind with highest selectivity and affinity to the two alpha subunit isoforms, with certain probes and conditions resulting in strong labeling of the 50-kDa mu subunit. Three main conclusions were reached: (i) head group recognition predominated over acyl chain recognition, (ii) the PtdInsPn binding site of alpha-AP-2 prefers more highly phosphorylated species, and (iii) the protein-acyl chain interactions showed high capacity but low selectivity.