Mucinous Carcinoma of The Breast: Report of Two Cases

Mucinous carcinoma of the breast is one of 16 rare varieties of malignant lesions of epithelial origin Inbreast. They account for 1-6% of all breast cancer. Variations Inpresentation, cllnlcal course and prognosis has been observed in these patients. In this communication we report two cases of pure mucinous carcinoma of the breast .Both the cases were unusual, first one of them having early presentation with pulmonary and bone metastasis less commonly seen In this type of breast carcinoma and the second case had lymph node involvement that is seen in less than one fifth of the cases of mucinous carcinoma of breast. A brief review about mucinous carcinoma is supplemented with the report. Journal of Surgical Sciences (2013) Vol. 17 (1) : 45-49

P5435Epigenetic modifications and gene expressions in Mybpc3 knockout mice

Background

DNA methylation and hydroxymethylation plays critical role in important biological processes, including differentiation of tissues in the embryo and cellular response to different diseases and diverse environmental factors. The epigenetic landscape in heart failure might be altered.

Purpose

Our objective was to determine how Mybpc3 deficiency, which produces hypertrophic cardiomyopathy, affects epigenetic landscape, gene expression, and regulation.

Methods

We generated and analysed genome-wide DNA methylomes and hydroxymethylomes from cardiac tissues of 12-week old Mybpc3−/− mice and littermate controls, and performed whole genome RNA sequencing (RNA-seq) for gene expression and validated the findings using qPCR.

Results

Single base resolution revealed overall lower 5-mC level in Mybpc3 deficient mice. In deficient mice, different genic regions including transcription start site, exons, and introns, had low levels of 5-mC. Although there was no overall difference in 5-hmC content, knockout mice had lower levels of 5-hmC in the distal part of the genes (last exon, transcription termination site, and 3'-flanking regions). The 5-hmC enrichment in the intronic regions was associated with higher gene expression, whereas, the presence of 5-mC in the 5'-flanking regions was associated with lower gene expression in both knockout and wildtype mice. Ingenuity pathway analysis (IPA) of differentially expressed genes revealed overrepresentation of genes involved in axonal-guidance pathway. Tet activity was downregulated in Mybpc3−/− mice, and it may explain the overall difference of 5-mC in deficient mice. We also observed that Mybpc3 ablation affected alternative splicing of Myh6 and Myh7.

Conclusion

This study establishes that knocking out of Mybpc3 changes epigenetic landscape in cardiac tissue, which is tightly linked to gene expression and regulation.

Acknowledgement/Funding

LeDucq 13CVD04, Hjärt och Lungfonden (Sweden)

3D-printed Franz type diffusion cells

OBJECTIVE

Franz cells are routinely used to measure in vitro skin permeation of actives and must be inert to the permeant under study. The aim of the present work was to develop and manufacture transparent Franz-type diffusion cells using 3D printing. Printouts were then tested using a range of model active compounds. The study also aims to identify the critical 3D-printing parameters necessary for the process, including object design, choice of printing resin, printout curing and post-curing settings and introduction of model coatings.

METHODS

Transparent Franz cells were constructed using an online computer aided design program and reproduced with different stereolithography 3D printers. The two acrylate-based resins used for the fabrication process were a commercially available product and a polymer synthesised in-house. Comparative studies between glass and 3D-printed Franz cells were conducted with selected model actives: terbinafine hydrochloride (TBF), niacinamide (NIA), diclofenac free acid (DFA) and n-methyl paraben (MPB). In preliminary studies, MPB showed the lowest recovery when exposed to the receptor compartment of 3D printed cells. Consequently, in vitro permeation studies were carried out using only MPB with polydimethylsiloxane (PDMS) membrane.

RESULTS

A decrease in the amounts of selected compounds was observed for transparent 3D-printed Franz cells compared to glass cells. MPB showed the lowest recovery (53.8 ± 13.1%) when compared with NIA (74.9 ± 4.0%), TBF (81.5 ± 12.0%) and DFA (90.2 ± 12.9%) after 72 h. Permeation studies conducted using 3D-printed transparent cells with PDMS membrane also showed a decrease in MPB recovery of 51.4 ± 3.7% for the commercial resin and 94.4 ± 3.5% for the polymer synthesised in-house, when compared to glass cells. Although hydrophobic coatings were subsequently applied to the 3D-printed cells, the same reduction in MPB concentration was observed in the receptor solution.

CONCLUSION

Transparent Franz cells were successfully prepared using 3D printing and were observed to be robust and leak-proof. There are few resins currently available for preparation of transparent materials and incompatibilities between the actives investigated and the 3D-printed cells were evident. Hydrophobic coatings applied as barriers to the printed materials did not prevent these interactions.

Microbial Contamination of Handmade Sauce Used by Street Food Vendors in Jashore, Bangladesh

Background: Contaminated handmade street foods are often claimed to occur food-borne diseases, especially in developing countries. Therefore, considering the public health issue, this study was conducted to assess the microbial contamination of handmade sauce used by street food vendors in Jashore, Bangladesh. Methods: A total of 30 samples of Plum Sauce (PS) and Tomato Sauce (TS) were collected from Jashore district, Bangladesh. The quantitative microbial tests were done by dilution plate technique. Identification of particular bacterial group or species was performed using selective media. All the data related to microbial count were subjected to ANOVA test using SPSS version 21.0. Results: All the sauce samples contained viable Enterobacteriaceae cells; whereas 80% and 83.33% of the total samples were found to be contaminated with Salmonella spp. and Escherichia coli, respectively. Total viable bacterial cells found in the samples ranged from 1.2×103 to 4.2×109 Colony Forming Unit (CFU)/g. In addition, total Enterobacteriaceae and E. coli counts ranged from 30 to 2.0×107 and from 0 to 7.0×105 CFU/g, respectively. Although PS samples contained a higher amount of Enterobacteriaceae and E. coli compared to TS, no significant difference (p>0.05) was found. Conclusion: The consumption of street foods is of great concern in Bangladesh. Making the vendors aware of sanitary practices is too crucial that could be achieved through training of the vendors at the root level of the country. Furthermore, it is necessary to monitor the street foods frequently by the national authorities.

Efficacy of Palonosetron as Antiemetic Prophylaxis for Post Operative Patients

Palonosetron is a new, potent and long-acting 5HT3-receptorsantagonist that had been approved by the FDA for use in postoperative nausea and vomiting (PONV) prophylaxis. The objective of this study was to investigate and compare the prophylactic effects of intravenously administered palonosetron, ondansetron and granisetron on prevention of postoperative nausea and vomiting after general anesthesia. This randomized double blind prospective clinical study was carried out in the Department of Anaesthesia, DMCH, Dhaka, Bangladesh from January 2014 to December 2015. A total of 102 patients who underwent laparoscopic cholecystectomy under general anesthesia, out of which patients who received Palonosetron were in Group A (n=34), patients who received Ondansetron were in group B (n=34) and patients who received Granisetron were in group C (n=34) and also the patients were selected randomly by lottery method. Statistical analyses of the results were obtained by using window based computer software devised with Statistical Packages for Social Sciences (SPSS-22). Nausea was found 3(8.8%) in group A, 8(23.5%) in group B and 6(17.6%) in group C. Vomiting was found 3(8.8%) in group A, 10(29.4%) in group B and 7(20.6%) in group C. Vomiting was significantly higher in group B compare with group A. For group B rescue anti-emetic injection motilon (metoclopramide hydrochloride) 5mg IV slowly was given. Palonosetron is effective prophylaxis against post operative nausea and vomiting.

What have we learned from the time trend of mass shootings in the U.S.?

Little is known regarding the time trend of mass shootings and associated risk factors. In the current study, we intended to explore the time trend and relevant risk factors for mass shootings in the U.S. We attempted to identify factors associated with incidence rates of mass shootings at the population level. We evaluated if state-level gun ownership rate, serious mental illness rate, poverty percentage, and gun law permissiveness could predict the state-level mass shooting rate, using the Bayesian zero-inflated Poisson regression model. We also tested if the nationwide incidence rate of mass shootings increased over the past three decades using the non-homogenous Poisson regression model. We further examined if the frequency of online media coverage and online search interest levels correlated with the interval between two consecutive incidents. The results suggest an increasing trend of mass shooting incidences over time (p < 0.001). However, none of the state-level variables could predict the mass shooting rate. Interestingly, we have found inverse correlations between the interval between consecutive shootings and the frequency of on-line related reports as well as on-line search interests, respectively (p < 0.001). Therefore, our findings suggest that online media might correlate with the increasing incidence rate of mass shootings. Future research is warranted to continue monitoring if the incidence rates of mass shootings change with any population-level factors in order to inform us of possible prevention strategies.

Changes of Peak Expiratory Flow Rate in Adult Asthmatic Patient

Asthma is a common pulmonary disorder characterizerized by airway inflammation, airway- hyper reactivity, and reversible airflow obstruction. The classic triad of symptoms is wheezing, chronic episodic dyspnea and chronic cough. The prevalence of asthma increased steadily over the latter part of the last century, first in the developed and then in the developing world. The number of people with asthma in the world may be as high as 334 million. Asthma in Bangladesh appears to be a substantial public health problem: an estimated 11.6 million people including 4.1 million children suffer from asthma-related symptoms. A cross sectional study was conducted from January 1999 to August 1999 on 5642 Bangladeshi people and another same study carried out from November 2009 to April 2010 on 8088 subjects. In 1999 the prevalence of asthma was 6.9% whereas in 2010 it is 6.96%. Airway resistance is always increased during the asthmatic attack. Airways obstruction, such as that caused by asthma, results in a reduced and variable Peak Expiratory Flow Rate (PEFR). PEFR is classically reduced in asthma. Recent asthma guidelines recommended the assessment of severity levels based on the most severe symptoms and peak expiratory flow rate. This descriptive type of cross-sectional study was done to find the changes of Peak expiratory flow rate in adult asthmatic patients and carried out in the Department of Physiology, Mymensingh Medical College, Mymensingh, Bangladesh from July 2014 to January 2016. Fifty (50) male and 50 (fifty) female adult asthmatic patients aged 18-60 years were included in the study group. They are enrolled from the Department of Medicine, Mymensingh Medical College, Mymensingh, Bangladesh and also from locality. For comparison age matched 50 male and 50 female apparently healthy persons were also studied as control. PEFR was estimated by Wright's Peak flow meter. For statistical analysis unpaired student's 't' test was used. Mean PEFR were significantly decreased in study group in comparison to control group and the result was statistically significant (p<0.001). From this study, it may be concluded that peak expiratory flow rate was decreased in asthmatic patient and there was a significant relation of decline lung function.

Rescue of an Axillary-Axillary Arteriovenous Graft not Amenable to Endovascular Intervention by Formation of an Axillary Loop: A Case Report

Central venous obstruction associated with a distal arteriovenous fistula can result in massive swelling of the affected extremity and venous hypertension. We present the surgical rescue of an axillary-axillary arterio-venous access ((necklace graft) between the left axillary artery to the contralateral axillary vein), compromised by central venous stenosis, by conversion into an arteriovenous axillary loop graft (AVALG) as an additional “exotic” grafting procedure in the anterior chest. This procedure resulted in the salvage of the patient's access and rapid resolution of the associated upper extremity swelling.

Current Trends of Using Systemic Antifungal Drugs and their Comparative Efficacy in Tinea Corporis and Tinea Cruris in Outpatient Department of Dermatology in a Tertiary Level Hospital

Tinea corporis & cruris are one of the earliest known fungal infection and are very common throughout the world. Although tinea corporis and tinea cruris does not cause mortality but causes morbidity and poses a major health problem. This study was conducted to evaluate the Comparative Efficacy of Terbinafine and Fluconazole in the Treatment of Tinea corporis and Tinea cruris. This cross sectional comparative type of analytical study was carried out at the department of Pharmacology & Therapeutics with collaboration of Dermatology and Venereology in Mymensingh Medical College Hospital, Mymensingh, Bangladesh from January 2016 to December 2016. In this study 168 newly diagnosed Tinea corporis and Tinea cruris patient was purposively selected where pattern of comparative efficacy of terbinafine and fluconazole were analyzed. Among 168 patients most of the patients presented with tinea corporis (58.33%). Most patients belong to 21-30 years age group. Male female ratio in this study was 1.15:1. In this study 143 patients were treated by fluconazole 50mg once daily for 4 weeks and 25 patients were treated by terbinafine 250 mg once daily for 4 weeks. After 4 weeks, improvement rate by fluconazole was 86.02% and terbinafine 96.00%. The clinical score of both groups after 4th week of treatment, there was slight more reduction of clinical score in terbinafine using group than fluconazole using group. The difference between these two clinical score was not statistically significant (p>0.05). Although no significant difference was observed between these two groups of patient in clinical aspect, but due to its lower price and availability in the hospital, it is suggested that fluconazole is more suitable for the treatment of tinea corporis and tinea cruris.

Interaction between Hypertension and Asthma in Adult

Asthma has been defined as a chronic inflammatory disorder of the airways that is associated with recruitment of inflammatory cells and the clinical development of wheezing, shortness of breath, chest tightness, and cough. The prevalence of asthma increased steadily over the latter part of the last century, first in the developed and then in the developing world. Current estimates suggest that asthma affects 300 million people worldwide, with a predicted additional 100 million people affected by 2025. This cross sectional study was conducted from January 1999 to August 1999 on 5642 Bangladeshi people and another same study carried out from November 2009 to April 2010 on 8088 subjects. In 1999 the prevalence of asthma was 6.9% whereas in 2010 it is 6.96%. Both asthma and hypertension are spastic disorders of smooth muscle, there is the similarities between these two diseases may predispose the individuals with one disease to the other. This descriptive type of cross-sectional study was done to find the Interaction between hypertension and asthma in adult and carried out in the Department of Physiology, Mymensingh Medical College, Mymensingh, Bangladesh from July 2014 to January 2016. Fifty (50) male and fifty (50) female adult asthmatic patients aged 18-60 years were included in the study group. They are enrolled from the Department of Medicine, Mymensingh Medical College, Mymensingh and also from locality. For comparison age matched 50 male and 50 female apparently healthy persons were also studied as control. Blood pressure was estimated by auscultatory method by sphygmomanometer. For statistical analysis unpaired student's 't' test was used. Mean blood pressure were significantly increased in study group in comparison to control group and the result was statistically significant (p<0.001). The study findings showed a high prevalence of hypertension among asthmatic patients than non asthmatic healthy persons. From this study, it may be concluded that hypertension and asthma are closely connected.

Venous thromboembolism in adult elective spinal surgery

Aims

To evaluate the incidence of primary venous thromboembolism (VTE), epidural haematoma, surgical site infection (SSI), and 90-day mortality after elective spinal surgery, and the effect of two protocols for prophylaxis.

Patients and Methods

A total of 2181 adults underwent 2366 elective spinal procedures between January 2007 and January 2012. All patients wore anti-embolic stockings, mobilised early and were kept adequately hydrated. In addition, 29% (689) of these were given low molecular weight heparin (LMWH) while in hospital. SSI surveillance was undertaken using the Centers for Disease Control and Prevention criteria.

Results

In patients who only received mechanical prophylaxis, the incidence of VTE was 0.59% and that of SSI 2.1%. In patients who were additionally given LMWH, the incidence of VTE was 0% and that of SSI 0.7%. The unadjusted p-value was 0.04 for VTE and 0.01 for SSI. There were no cases of epidural haematoma or 90-day mortality in either group. When adjusted for case-mix, LMWH remained a significant factor (p = 0.006) for VTE, but not for SSI.

Conclusion

A peri-operative protocol involving mechanical anti-embolism stockings, adequate hydration, and early post-operative mobilisation is effective in significantly reducing the incidence of VTE. The addition of LMWH is safe in patients at higher risk of developing VTE. Cite this article: Bone Joint J 2017;99-B:1204–9.

Induced membrane technique for treating tibial defects gives mixed results

Aims

This study describes the use of the Masquelet technique to treat segmental tibial bone loss in 12 patients.

Patients and Methods

This retrospective case series reviewed 12 patients treated between 2010 and 2015 to determine their clinical outcome. Patients were mostly male with a mean age of 36 years (16 to 62). The outcomes recorded included union, infection and amputation. The mean follow-up was 675 days (403 to 952).

Results

The mean tibial defect measured 5.8 cm (2 to 15) in length. Of the 12 patients, 11 had an open fracture. Eight underwent fixation with an intramedullary nail, three with plates and one with a Taylor Spatial Frame. The mean interval between stages was 57 days (35 to 89). Bony union was achieved in only five patients. Five patients experienced infective complications during treatment, with two requiring amputation because of severe infection.

Conclusion

The Masquelet technique was relatively ineffective in achieving union in this series, and was associated with a high rate of infection. Cite this article: Bone Joint J 2017;99-B:680–5.

Bites by the Monocled Cobra, Naja kaouthia, in Chittagong Division, Bangladesh: Epidemiology, Clinical Features of Envenoming and Management of 70 Identified Cases

AbstractWe describe 70 cases of monocled cobra (Naja kaouthia) bite admitted to Chittagong Medical College Hospital, Bangladesh. The biting snakes were identified by examining the dead snake and/or detecting N. kaouthia venom antigens in patients' serum. Bites were most common in the early morning and evening during the monsoon (May-July). Ligatures were routinely applied to the bitten limb before admission. Thirty-seven patients consulted traditional healers, most of whom made incisions around the bite site. Fifty-eight patients experienced severe neurotoxicity and most suffered swelling and pain of the bitten limb. The use of an Indian polyvalent antivenom in patients exhibiting severe neurotoxicity resulted in clinical improvement but most patients experienced moderate-to-severe adverse reactions. Antivenom did not influence local blistering and necrosis appearing in 19 patients; 12 required debridement. Edrophonium significantly improved the ability of patients to open the eyes, endurance of upward gaze, and peak expiratory flow rate suggesting that a longer-acting anticholinesterase drug (neostigmine) could be recommended for first aid. The study suggested that regionally appropriate antivenom should be raised against the venoms of the major envenoming species of Bangladesh and highlighted the need to improve the training of staff of local medical centers and to invest in the basic health infrastructure in rural communities.

Predicting the pain continuum after adolescent idiopathic scoliosis surgery: A prospective cohort study

BACKGROUND

Chronic postsurgical pain (CPSP) affects half a million children annually in the United States, with dire socioeconomic consequences, including long-term disability into adulthood. The few studies of CPSP in children are limited by sample size, follow-up duration, non-homogeneity of surgical procedure and factors evaluated.

METHODS

In a prospective study of 144 adolescents undergoing a single major surgery (spine fusion), we evaluated demographic, perioperative, surgical and psychosocial factors as predictors of a continuum of postsurgical pain: immediate, pain maintenance at 2-3 months (chronic pain/CP) and persistence of pain a year (persistent pain/PP) after surgery.

RESULTS

We found an incidence of 37.8% and 41.8% for CP and PP. CP and acute pain were both significant predictors for developing PP (p-value <0.001 and 0.003). Preoperative pain and higher postoperative opioid requirement was significantly associated with CP (p = 0.015, p = 0.002), while Childhood Anxiety Sensitivity Index (p = 0.002) and surgical duration (p = 0.014) predicted PP. The final regression models had reasonable predictive accuracy (c-statistic of 0.73 and 0.83 for CP and PP, respectively). Anxiety scores and catastrophizing for child and parent were found to be significantly correlated (p = 0.005, p = 0.013 respectively). Pain trajectories revealed that 65% of patients who developed PP reported CP and high pain trends; however, 33% of those who developed PP could not be identified using solely pain criteria.

CONCLUSION

Persistent postsurgical pain in children is a significant problem. It can be predicted in part by combinations of psychological and clinical variables, which may provide evidence-based measures to prevent development of CPSP in the future.

SIGNIFICANCE

In a homogeneous cohort of adolescents undergoing spine fusion, we report a high incidence of persistent postsurgical pain (41.8%) predicted by child anxiety, perioperative pain, and surgical duration. Our results stress timely preventive and therapeutic strategies.

Echocardiographic comparison of regional wall motion abnormality between patients with acute anteroseptal and acute extensive anteior ST segment elevation myocardial infarction

Post myocardial infarction (MI) short and long-term clinical outcome is largely determined by the size of the infarcted area. It is generally assumed that as the lead involvement in electrocardiography (ECG) is less in anteroseptal ST segment elevation myocardial infarction (AS-STEMI), where ST segment elevation (STE) is limited to leads V1 to V3, myocardial damage is likely to be less; and in extensive anterior STEMI (EA-STEMI), as the STE extends further upto V6, the myocardial damage is likely to be more. This study was intended to compare regional wall motion abnormality (RWMA) between acute anteroseptal STEMI and acute extensive anterior STEMI patients. 90 patients with AS-STEMI and 106 patients with EA-STEMI, admitted in between October 2012 and September 2013, were included. For each patient, a transthoracic echocardiogram (TTE) was performed within 24-48 hours of MI and was interpreted by an independent investigator blinded to the patient's ECG data. No differences were observed between the two groups in baseline characteristics; except AS-STEMI group had more patients with diabetes and EA-STEMI group had more patients with family history of coronary artery disease. Distribution, extent of wall motion abnormalities and mean number of total involved segments were similar between patients with AS-STEMI and those with EA-STEMI (p > 0.05). Regarding regional dysfunction, the apical septal (99.1% vs. 92.2%, p < 0.05) and apical (76.4% vs. 60.0%, p < 0.05) segments were the only two segments that were affected significantly more in patients with EA-STEMI than in patients with AS-STEMI. So, the term AS-STEMI may be a misnomer, as it implies that only the anteroseptal segments of the left ventricle are involved. This study shows that regional dysfunction in patients with AS-STEMI extends beyond the anteroseptal region. So, any patients with anterior wall involvement, either anteroseptal or extensive anterior STEMI, should be treated with equal importance.