An unexpected gangrenous duplication of ileum

Alimentary tract duplication is a rare congenital anomaly which may involve any part of the alimentary tract extending from stomach to rectum. Clinical presentation may mimic an inflamed appendix as described in this case. A 9-year-old boy with a clinical diagnosis of perforated appendix was noted to have a normal appendix intra-operatively. On further search for an underlying pathology, a gangrenous ileal duplication was discovered. En-bloc resection with primary bowel anastomosis was done. Histopathology report revealed a gangrenous small bowel duplication. We discuss the preoperative diagnostic dilemma and management options in approaching this rare entity.

Ellis-Van Creveld syndrome in siblings: A rare case report

Ellis-Van Creveld syndrome or chondroectodermal dysplasia is a rare autosomal recessive disorder presenting several skeletal manifestations and congenital heart malformations. Ellis-Van Creveld syndrome comprises of a tetrad of clinical manifestations of chondrodysplasia, polydactyly, ectodermal dysplasia, and cardiac defects. Here, we are presenting a very rare case of Ellis-Van Creveld syndrome in siblings.

Living donor liver transplantation in maple syrup urine disease - Case series and world's youngest domino liver donor and recipient

MSUD occurs due to deficiency of enzyme BCKAD required for metabolism of leucine, isoleucine, and valine leading to the accumulation of these and their ketoacids causing acute metabolic decompensation manifesting as encephalopathy or sudden death. The patient requires special protein-restricted diet to survive. As this enzyme is expressed in liver, liver transplantation has been successfully performed as a cure. We report two patients of MSUD who underwent LDLT while their livers were used as a domino graft for other biliary cirrhotic patients. A 22-month-old male child diagnosed as a case of classic MSUD underwent LDLT from an altruistic aunt as donor following which his serum leucine levels normalized on an unrestricted protein diet. His liver was used as a domino graft. A 38-month-old female child with diagnosed MSUD underwent LDLT from a swap donor, and her liver was used as a domino graft. Her DQ improved post-transplant. LDLT from non-heterozygous donors is a cure for classical MSUD. Their livers can be used as domino grafts for non-MSUD cases.

Oral manifestations of plummer-vinson syndrome: a classic report with literature review

Plummer-Vinson syndrome (PVS) is a triad of microcytic hypochromic anemia, atrophic glossitis, and esophageal webs or strictures. It is one of the syndromes associated with iron deficiency anemia. Symptoms resulting from anemia predominates the clinical picture, apart from the additional features such as glossitis, angular cheilitis, and dysphagia. Dysphagia is main clinical feature of PVS. PVS carries an increased risk of development of squamous cell carcinoma of esophagus and pharynx. A classic case report of PVS with clinical features, oral manifestations, malignant potential, differential diagnosis, investigation, dental implication, and treatment is discussed here with the literature review from the dentist's point of view. The article carries a message that dental surgeons have to be familiar with the oral manifestations of anemia and be able to suspect PVS to aid in early diagnosis and prompt treatment.

First Order Perturbation Theory in the Study of Molecular Vibrations: Isotopic Rules and Properties of the Different Approximations

The first order perturbation expressions for various molecular constants such as isotopic shifts (⊿λi, ⊿λi/λi), inverse isotopic shifts (⊿σi, ⊿σi/σi), Coriolis coupling constants (Δξij)and mean amplitudes of vibration (Δ∑ij) obtained using different equations and approximations are given in detail.

The mathematical and physical properties of the different approximations are discussed extensively. Incidentally some isotopic rules obtained using the first order perturbation theory are presented.

On the Ratio L12/L21 For n = 2 Eigenvalue Problems: An Empirical Constraint For The Calculation of Force Constants (Extended L Matrix Approximation)

The variation of the ratio L12/L21 (where Lij refers to the element of the L matrix) as a function of the mass coupling term T=G12/|G|1/2 has been studied for molecules of the type XY4(Td), XY3(D3h) and XY2C2v) using the exact force field data. In the case of the XY4 and XY3 type molecules, the ratio L12/L21 is nearly independent of the mass coupling and in the case of the XY2 type, it shows a nearly linear dependence on T. The force constants have been evaluated using an empirically determined constraint for L12/L21. The values are generally in good agreement with the exact ones. In all cases except VCl4 the exact interaction term of the F matrix is in agreement with the sign rule of Müller et al.

Factors influencing polymerase chain reaction outcomes in patients with clinically suspected ocular tuberculosis

Background

Polymerase chain reaction (PCR) assay can be a useful method for definitive diagnosis in paucibacillary infections such as ocular tuberculosis (TB). In this study, we have evaluated factors affecting PCR outcomes in patients with clinically suspected ocular TB. Patients with clinically suspected ocular TB were investigated by PCR of aqueous or vitreous samples. Three control groups were also tested: group 1 included culture-proven non-tuberculous endophthalmitis, group 2 culture-negative non-tuberculous endophthalmitis, and group 3 patients undergoing surgery for uncomplicated cataract. PCR targeted one or more of following targets: IS6110, MPB64, and protein b genes of Mycobacterium tuberculosis complex. Multiple regression analysis (5% level of significance) was done to evaluate the associations between positive PCR outcome and laterality of disease, tuberculin skin test (TST)/interferon-gamma release assay (IGRA), chest radiography, and type of sample (aqueous or vitreous). The main outcome measures were positive PCR by one or more gene targets, and factors influencing positive PCR outcomes.

Results

All 114 samples were tested for MPB64, 110 for protein b, and 88 for IS6110. MPB64 was positive in 70.2% (n = 80) of tested samples, protein b in 40.0% (n = 44), and IS6110 in only 9.1% (n = 8). DNA sequencing of amplicons from four randomly chosen PCR reactions showed homology for M. tuberculosis complex. Of the 80 PCR-positive patients, 71 completed a full course of antitubercular therapy, of which 65 patients (91.5%) had complete resolution of inflammation at final follow-up. Among controls, 12.5% (3 out of 24) in group 1 and 18.7% (6 out of 32) in group 2 also tested positive by PCR. No PCR-positive outcome was observed in control group 3 (n = 25). Multiple regression analysis revealed significant association of positive PCR outcome with bilateral presentation, but not with a positive TST/IGRA, chest radiography, or type of sample (aqueous/vitreous) used.

Conclusions

Careful selection of gene targets can yield high PCR positivity in clinically suspected ocular TB. Bilateral disease presentation but not any evidence of latent systemic TB influences PCR outcomes. False-positive results may be seen in ocular inflammation unrelated to ocular TB.

Outcomes of repeat descemetopexy in post-cataract surgery descemet membrane detachment

PURPOSE

To assess the outcomes of repeat descemetopexy in post-cataract surgery Descemet membrane detachment.

DESIGN

Retrospective interventional case series.

METHODS

This multicenter, institutional study done between January 2007 and July 2013 included 13 eyes of 13 patients who underwent repeat descemetopexy after a failed initial procedure in post-cataract surgery Descemet membrane detachment. Patients without a minimum follow-up of 1 month were excluded. They underwent repeat descemetopexy with either 100% air or isoexpansile mixture of 14% C3F8. At 1 month, final status of Descemet membrane, final best-corrected visual acuity (BCVA), and incidence of postsurgical complications were noted.

RESULTS

Mean age was 63.7 ± 6.6 years; male-to-female ratio, 8:5. Descemet membrane detachment involved the visual axis in all cases. Mean interval between 2 interventions was 5.1 ± 3.1 days. Same gas was used in 9 of 13 patients (air, 4; C3F8, 5). Air was used earlier and C3F8 later in 4 patients. At 1 month, 12 of 13 patients had an attached Descemet membrane and improved mean logMAR BCVA (P = .0036). One case developed postoperative pupillary block and 1 case required endothelial transplantation.

CONCLUSION

Repeat descemetopexy for post-cataract surgery Descemet membrane detachment gives good anatomic and visual results and is definitely a worthwhile attempt before a complex surgical procedure like keratoplasty is offered.

Degree, duration, and causes of visual impairment in eyes affected with ocular tuberculosis

Background

Ocular tuberculosis (TB) can affect nearly every ocular tissue, leading to a variety of vision-threatening clinical manifestations. The goal of this study is to estimate the degree, duration, and causes of visual impairment in eyes affected by ocular TB.

Results

This was a retrospective study of patients diagnosed as ocular TB based on polymerase chain reaction (PCR) for Mycobacterium tuberculosis complex. We applied the World Health Organization definition of visual impairment (VI) to affected eye(s), instead of better-seeing eye. Best-corrected visual acuity (BCVA) of <6/18 and ≥6/60 in the affected eye was classified as moderate VI and <6/60 and ≥3/60 as severe VI. Data collected included presenting and final BCVA of affected eyes and the worst BCVA during the study period. Sixty-one eyes of 40 patients were analyzed. Twenty-five patients (52.1%) had bilateral disease. The mean worst BCVA and mean final BCVA (logMAR) were 1.26 ± 0.87 and 0.61 ± 0.85, respectively, and their difference was highly significant (p < 0.0001, Friedman test). The median worst and final BCVA results were 1.30 (range 0.0 to 3.0) and 0.20 (range 0.0 to 3.0), respectively. The mean duration of follow-up was 98.34 ± 81.81 weeks. Moderate and severe VIs were seen in 14 (22.9%) and 12 (19.7%) eyes, respectively, during the course of follow up. Twenty eyes (32.8%) had BCVA of <3/60. Moderate VI or worse was most commonly seen in eyes with multifocal serpiginoid choroiditis (n = 6; 100%), retinal vasculitis (n = 25; 80.6%), and panuveitis (n = 12; 80%). The mean duration of visual loss was 25.2 ± 42.37 weeks (median 6.43 weeks, range 0 to 206.42 weeks). Vitreous hemorrhage, complicated cataract, and macular scarring were the common causes of VI.

Conclusion

Ocular TB can result in prolonged visual impairment, more commonly in patients with posterior uveitis or panuveitis.

Use of ABO-incompatible grafts in living donor liver transplantation--first report from India

ABO incompatibility is the commonest reason for rejection of donors in living donor liver transplantation (LDLT). The donor pool could be expanded by 25 % to 35 % if the ABO barrier is overcome. In the absence of pre-conditioning, transplantation across the blood groups is fraught with the almost universal risk of antibody-mediated rejection (AMR) that rapidly leads to graft loss. However, AMR can be prevented by removal of preformed antibodies and reducing their production by B cells. We describe our initial experience of three cases of ABO-incompatible (ABO-i) LDLT: a 42-year-old male, an 8-month-old male and a 28-month-old female, all of blood group O+ who received blood group B + right lobe, B + left lateral segment, and A + left lateral segment liver grafts, respectively. Pre-LDLT conditioning included administration of anti-CD20 antibody (Rituximab(®)) to the adult 4 weeks prior, and four to seven sessions of double-filtration plasmapheresis to all, to remove preformed antibodies and achieve anti-donor blood group antibody (ADA) titers of ≤ 1:16 IgG and ≤ 1:8 IgM, respectively. In addition, cases 1 and 3 received mycophenolate mofetil for 7 days prior to LDLT. After LDLT, all three patients achieved normal graft function over 8-17 days with no evidence of AMR and without the need for further plasmapheresis. Postoperative complications included portal vein thrombosis (one successfully re-explored), CMV (one), Pseudomonas and Klebsiella sepsis (one each), and abdominal collection (one treated with percutaneous drainage). All are currently well with normal graft function and low ADA titers at 8, 16, and 19 months after ABO-i LDLT.

Elevated ferric, calcium and magnesium ions in the brain induce protein aggregation in brain mitochondria

OBJECTIVE

Alzheimer's disease and Parkinson's disease are two of several neurodegenerative disorders that affect the elderly. Although their aetiology remains uncertain, studies suggest that elevated aluminium or other metal ions in the brain directly influence the development of the histological abnormalities normally associated with these diseases; other investigations suggest that metal-ion-induced-dysfunction of mitochondria might be a critical factor.

METHODS

In this study, the impact of elevated aluminum (Al3+), ferric (Fe3+), calcium (Ca2+) and magnesium (Mg2+) ions on brain histology and on the protein composition of brain mitochondria were evaluated. Rabbits were injected intra-cerebrally with 1.4% solutions of either aluminium chloride (AlCl3), ferric chloride (FeCl3), calcium chloride (CaCl2) or magnesium chloride (MgCl2) and sacrificed 10 days later

RESULTS

Histological analysis revealed that Al3+ but not the other ions induced neurofibrillary degeneration within the midbrain and medulla. Alternatively, SDS-PAGE revealed that Fe3+, Ca2+ and Mg2+ but not Al3+ induced alterations to the distribution of brain mitochondrial proteins. Both Fe3+ and Ca2+ triggered decreased concentration of three low molecular weight proteins (-7-14 kd) but Ca2+ precipitated their total absence. Both ions led to increased concentration of a high molecular weight protein (-110 kd). In contrast, Mg2 led to the total absence of the protein of lowest molecular weight (-7 kd) and increased concentration of a -36 kd protein.

CONCLUSION

These results suggest that elevation of some metal ions in the brain induces protein aggregation with the nature of the aggregation being highly ion dependent. The results also point toward major differences between the histopathological effect of Al3+ and other ions.

Extent of surgery in the management of phyllodes tumor of the breast: a retrospective multicenter study from India

INTRODUCTION

Phyllodes tumor (PT) is a rare tumor of the breast. Usually, difficulty in making preoperative diagnoses and unpredictable clinical outcome of this disease leads to inappropriate management. Till date, no definite conclusion regarding the appropriate surgical procedure can be drawn.

OBJECTIVES

The objective of this retrospective study is to study the clinicopathological correlation of phyllodes tumors in North-Central part of the India and also to evaluate efficacy of the various surgical options available for the management of phyllodes tumors of the breast.

MATERIALS AND METHODS

A retrospective study of 24 cases from the archives of department of surgery of three tertiary institutes of North-Central part of India. We reviewed the clinical, pathological features of this disease entity with a view to highlight relevant features. We also analyzed various surgical options done for primary as well as recurrent PT.

RESULTS

The breast masses in our study were particularly large. The mean size of the lump was 9.5 +/- 5.5 cm (range was 4.0-23 cm). Histopathological report was benign, borderline, and malignant PT in 62.4%, 20.8%, and 16.8% of the cases, respectively. Overall, 31 surgical procedures (24 in primary and 7 in recurrent) were performed. Simple lumpectomy, wide local excision and simple mastectomy were done in 25%, 27.4% and 27.4% of primary (non-recurrent) cases of PT, respectively. Modified radical mastectomy and simple mastectomy with LD flap reconstruction was done in 7.2% and 2.4% in primary cases, respectively in recurrent cases, simple mastectomy was done in four cases and modified radical mastectomy was done in one case. Overall, recurrence was seen in 29.2% of the cases. The median time for recurrence was 6 months (range 5.0-36 months). 90% (6/7) of recurrence occurred in lumpectomy patients.

CONCLUSION

The unpredictable behavior of histological types and the disputable results of particular surgical procedures have contributed to the controversies. The therapeutic issue is further compounded by an imprecise preoperative diagnosis. This study shows that wide local excision for benign and borderline and simple mastectomy with or without reconstruction for the malignant PT of the breast are acceptable best surgical options.