Adalimumab induced pulmonary sarcoid reaction

Sarcoidosis is a multisystem granulomatous inflammatory disease of unknown etiology. There is evidence that Tumor Necrosis Factor alpha (TNF-α) antagonists are useful in the treatment of advanced or refractory disease. However, sarcoidosis-like reaction has been reported with TNF-α blockade in other inflammatory conditions. Here we report a case of sarcoid-like reaction in a patient with psoriatic arthritis shortly after initiation of adalimumab therapy. Stopping adalimumab and systemic anti-inflammatory therapy with corticosteroids resulted in resolution of pulmonary symptoms and chest radiographic findings. Though TNF-α plays a critical role in pathogenesis of sarcoidosis, the development of sarcoid reaction with TNF-α blockade is paradoxical and the mechanism of this response remains unknown. TNF-α induced sarcoid-reaction could involve multiple organs. Its development with one agent does not preclude therapy with other TNF-α blockers.

DURABILITY TESTING OF SILICONE MATERIALS FOR PROTON EXCHANGE MEMBRANE FUEL CELL USE

Silicone resins are ideal candidates for proton exchange membrane fuel cells (PEMFC) sealing and gasketing. They have many advantages for PEMFC application, such as superior stability and longevity under harsh environments, low water absorption, and broad temperature range. However, as this work shows, silicone-based materials have one big drawback: low molecular weight siloxanes, oligomers, and/or degradation byproducts may readily migrate from the base material into the fuel cell membrane, forming glassy structures, reducing the mechanical durability, and ultimately fracturing the proton exchange membrane (PEM). A novel, in situ testing method has been developed to test the effect of siloxanes on PEMFCs. The mechanism for migration of cyclic siloxanes to the PEM interface, causing it to fail in a brittle fashion, is presented. A commercially available silicone gasket material was used as a case study to validate the mechanism. Optical microscopy, scanning electron microscopy, and inductively coupled plasma were used to perform failure analysis of the tested samples. Thermogravimetric analysis was used to measure the removal rate of low molecular weight cyclic siloxanes. Gas chromatography–mass spectrometry was used to separate the organic molecules off-gassing from the material at temperature and provide a mass spectrum of each component.

Rhabdomyosarcoma in middle ear of an adult: a rare presentation

Rhabdomyosarcoma of the middle ear is a rare tumor, even rarer in adults and has a very poor prognosis. We report here an unusual case of rhabdomyosarcoma in middle ear of an adult, mimicking chronic suppurative otitis media and facial nerve palsy.

Higher incidence of C677T polymorphism of the MTHFR gene in North Indian patients with vascular disease

Homocysteine is a sulfur-containing amino acid, which is derived from dietary methionine. Hyperhomocysteinemia has been implicated in vascular disease for over a decade now, and can be treated with B vitamins. Among its causes is polymorphism of the MTHFR gene, the most common being the cytidine to thymidine at position 677 (MTHFR C677T), which gives rise to three genotypes - normal homozygous CC, heterozygous CT and homozygous variant TT. An attempt was made to ascertain the prevalence of this MTHFR C677T in our population so that preventive measures may accordingly be instituted. Blood samples from 70 patients with vascular disease and 70 healthy controls were analyzed for plasma homocysteine levels (chemiluminescent immunoassay) and for the presence of MTHFR C677T (polymerase chain reaction analysis). Homocysteine was higher in the homozygous subjects (TT genotype) than in the heterozygous (CT genotype). In patients, the frequency of the C allele was significantly lower, and that of the T allele was significantly higher than the corresponding frequencies in controls. In conclusion, the North Indian urban population has higher homocysteine levels associated with the TT genotype. Hence, instituting measures towards reduction of homocysteine levels in the population would probably reduce the incidence and morbidity of vascular disease in our population.

Metastatic angiosarcoma presenting as diffuse alveolar hemorrhage

Angiosarcoma is a rare malignant neoplasm of the vascular or lymphatic endothelium. Diffuse alveolar hemorrhage is a rare presenting manifestation of angiosarcoma. We describe a case of pulmonary metastasis of angiosarcoma who presented with diffuse alveolar hemorrhage as initial manifestation.

Evidence for a sodium-dependent proline and glycine-betaine uptake in the cyanobacterium Nostoc muscorum

The cyanobacterium Nostoc muscorum is able to utilized proline and glycine-betaine as a nitrogen source under unstressed growth conditions. This cyanobacterium when grow in modified Chu No. 10 medium (without Na+) unable to utilized proline and glycine-betaine as a nitrogen source. Spontaneously occurring mutant clones defective in Na+ transport (Na+-R) were isolated and analyzed for proline and glycine-betaine utilization. The mutant phenotype showed normal heterocyst frequency and nitrogenase activity even in the medium containing 1 mM proline or 1 mM glycine-betaine, indicates the role of Na+ for proline/glycine-betaine uptake. The Na+-R mutant showed 100% survival at pH 11 and was simultaneously able to uptake and utilize proline/glycine-betaine at higher alkaline pH. This indicates that proline and glycine-betaine uptake systems are more efficient at higher alkaline pH. Since, the hypersaline environments are rich in Na+ contents and have alkaline pH, therefore it is suggested that the origin and evolution of specific compatible solutes may not depend only on the osmoregulatory role they play, but also on the other ecological factors operating simultaneously in the organism's niche.

Low insertion of a cystic duct into the common bile duct as a cause for a malpositioned biliary stent: demonstration with multidetector computed tomography

Anatomical variations of the extrahepatic biliary system are common. Adequate knowledge of such variations and an appropriate roadmap before any surgical, endoscopic or percutaneous procedure/intervention help in preventing associated complications. Multiple imaging modalities can depict the anatomy of the extrahepatic biliary tree. High resolution magnetic resonance imaging and magnetic resonance cholangiopancreatography are increasingly used to delineate the hepatobiliary system. Multidetector computed tomography allows for high-speed volume scanning with an excellent spatial and temporal resolution. It also allows for multiplanar reconstructions in virtually any plane, with isotropic resolution. We describe an unusual complication of biliary stenting in a 62-year-old man with low insertion of a cystic duct, resulting in the inadvertent placement of the common bile duct stent into the cystic duct. This was demonstrated well by multidetector computed tomography and confirmed thereafter, during surgery.

Preparation & characterization of solid inclusion complex of cefpodoxime proxetil with beta-cyclodextrin

Cefpodoxime proxetil (CPDX-PR) is an oral cephalosporin antibiotic with poor aqueous solubility and bioavailability. Effect of beta-cyclodextrin on aqueous solubility and dissolution rate of cefpodoxime proxetil was evaluated by the formation of solid inclusion complexes in 1:2 molar ratio of drug: cyclodextrin. Phase solubility study was carried out whereby a typical B's type curve was obtained thus, indicating a 1:2 stoichiometric ratio for optimum complex formation. Solid inclusion complexes in 1:2 molar ratios were prepared by using methods such as physical mixture, solvent evaporation and freeze drying. Prepared complexes were characterized by fourier transform infrared spectroscopy (FT-IR) differential scanning calorimetry (DSC), powder x-ray diffraction (PXRD) and scanning electron microscopy (SEM). Results of in vitro studies appraised of an increased solubility and dissolution rate of cefpodoxime proxetil on complexation with beta- cyclodextrin (P < 0.05) as compared to CPDX-PR alone. Amongst the complexes prepared by different methods, the complex prepared by freeze drying showed the highest dissolution rate (P< 0.01). The in vitro antimicrobial activity of cefpodoxime proxetil and its freeze dried complex (1:2) was studied against both antibiotic-susceptible and antibiotic-resistant clinical isolates of Neisseria gonorrhoeae. The freeze dried complex (1:2) inhibited all penicillin-susceptible strains and penicillinase-producing strains at 0.015 microg/ml concentration. Chromosomally resistant strains which were not responsive to penicillin were inhibited by the complex at 0.125 microg/ml concentration. The study revealed that complexation of cefpodoxime proxetil with beta-cyclodextrin effectively enhanced the aqueous solubility and in vitro antibacterial activity.

Buccal mucosal urethroplasty: is it the new gold standard?

Whilst techniques for urethral reconstruction have developed in the past few decades the quest for an ideal substitute continues. We critically review the literature on buccal mucosal grafts for substitution urethroplasty, to determine the efficacy and complications arising from its use. Buccal mucosal grafts have proved to be a versatile substitute for strictures attributable to a wide range of causes. Placing the graft dorsally appears to be more successful than ventrally and was successful in 96% of cases; after treating complex urethral strictures with two-stage procedures about a quarter of patients required a revision after the first stage with fewer complications then when skin was used as a substitute. Thus, buccal mucosa is most likely to become the new gold standard for substitution urethroplasty and longer term results with its use are eagerly awaited.

Tissue-engineered buccal mucosa for substitution urethroplasty

OBJECTIVE

To develop tissue-engineered buccal mucosa (TEBM) for use in substitution urethroplasty, as urethral reconstruction is limited by the amount and type of tissue that is available for grafting, and BM has become the favoured tissue for use as a urethral substitute in the last decade.

MATERIALS AND METHODS

After enzymatic treatment of a small (0.5 cm) BM biopsy the epidermis and dermis were mechanically separated. Oral keratinocytes were isolated from the epidermis and oral fibroblasts from the dermis. These cells were expanded and applied to sterilized de-epidermized dermis (DED) to obtain a full-thickness TE oral mucosa. Horizontal migration of keratinocytes on the DED was assessed using a tetrazolium-blue (MTT) assay. The TEBM was assessed histologically after mechanical stressing in vitro using catheterization and meshing.

RESULTS

Histologically the TEBM closely resembled the native oral mucosa after culturing at an air-liquid interface for 2 weeks. The MTT assay showed good horizontal migration of keratinocytes on the DED. Serial histology revealed a gradually increasing thickness of the epidermis and remodelling of the dermis by the fibroblasts from day 1 to day 14. Despite subjecting the TEBM to mechanical stress the integrity of the epidermal-dermal junction was maintained.

CONCLUSIONS

We report the successful culture of full-thickness TEBM for substitution urethroplasty, which is robust and suitable for clinical use.

Treatment of Allergic Bronchopulmonary Aspergillosis with Fluconazole and Itraconazole

Treatment of allergic bronchopulmonary aspergillosis (ABPA) has remained both problematic as well as controversial. Although the sheet anchor in treatment of ABPA still remains steroids, various workers have tried oral antifungals (fluconazole and itraconazole) with encouraging results. This study evaluates the effect of fluconazole or itraconazole in the treatment of ABPA patients and compares them with the patients who had received palliative therapy other than antifungals. Case records of 44 proven cases of ABPA treated at our referral service hospital during February 1998 to April 2001 were analyzed. In addition to oral and inhaled bronchodilators, 16 patients received fluconazole 150 mg OD and 13 patients itraconazole 200 mg OD for six months. Response to therapy was assessed clinically, radiologically and by spirometry every 3 months. Patients who did not receive antifungals had chronic course characterized by airway obstruction, recurrent pulmonary consolidation and obstructive defect on pulmonary function test (PFT). Patients treated with itraconazole had better control of asthma symptoms, less requirement of reliever inhalers, steroids and lesser exacerbations of asthma during follow-up even after stopping antifungal. Fluconazole group had better control of symptoms but improvement in other parameters was not statistically significant. From this study it was evident that itraconazole improved the symptoms of airway obstruction, pulmonary functions, pulmonary opacities and decreased exacerbations during follow up.

Yield of dual endoscopy for positive fecal occult blood test

OBJECTIVES

Dual endoscopy is frequently performed on the same day in patients whose stools are found to be positive on fecal occult blood testing (FOBT). This is often done to localize the potential sources of GI bleed. The diagnostic yield of same day dual upper endoscopy (EGD) and lower endoscopy (colonoscopy) for the detection of positive FOBT is uncertain. In the era of cost-efficient medical practice, we investigated whether a more evidence-based and structured approach could be used to guide physicians to the workup of patients who present with positive FOBT.

METHODS

We performed a retrospective analysis of 309 patients, and 260 patients from this population met our inclusion criteria. Inclusion criteria included FOBT without acute GI hemorrhage, hematochezia, or melena. Patients were required to have had EGD and colonoscopy within the same day (<24 h).

RESULTS

Of 260 patients, a total of 135 (52%) patients had positive findings on colonoscopy and a total of 42 (16.1%) patients had positive findings on EGD. Sixteen (6.1%) had positive EGD and negative colonoscopy; 109 (42%) had positive colonoscopy and negative EGD; and 26 (10%) had positive findings on both EGD and colonoscopy.

CONCLUSIONS

Colonoscopy should be chosen as the initial procedure of choice in the evaluation of patients who present with positive FOBT. Same day dual endoscopy does not seem to be cost-effective.

Angiokeratoma of tongue

An 8-year-old male child who presented with lesions of angiokeratoma on tongue is described.

Utility of coaxial technique for renal angioplasty in patients with a difficult-to-cross stenosis

The aim of this study was to evaluate the feasibility of coaxial approach in difficult-to-cross lesions in patients with failed percutaneous transluminal renal angioplasty by conventional over-the-wire exchange technique. Twelve stenoses in 10 patients (six women and four men; age range 19 +/- 7 years) with uncontrolled hypertension were treated by this method. The stenosis was caused by nonspecific aortoarteritis in 8 patients and fibromuscular dysplasia in 2 patients. It was ostial in seven and post-ostial in five vessels. Conventional exchange technique was unsuccessful in all of them. All procedures were done by femoral route. Technical success was seen in 11 (92%), without complication. The stenosis improved from 90 +/- 2.1% (range 80-100%) to 6 +/- 7% (range 0-20%), blood pressure decreased from 198 +/- 12.3 mm Hg (range 180-220 mm Hg)/130 +/- 6.7 mm Hg (range 120-140 mm Hg) to 119 +/- 5.7 mm Hg (range 110-130 mm Hg)/83 +/- 3.9 mm Hg (range 80-90 mm Hg), and number of drug treatments for hypertension fell from 3.6 +/- 0.52 (range 3-4) to 1 +/- 0.94 (range 0-3; p < 0.01). Percutaneous transluminal renal angioplasty resulted in "cure" in 3 patients and "improvement" in 7 patients. Follow-up period was 3-21 months (mean 6.4 months). No restenosis was detected. Coaxial approach is safe and effective in treating difficult-to-cross lesions in which renal angioplasty by conventional exchange technique is unsuccessful.

INVESTIGATION OF BREAST LUMPS: AN EVALUATION

70 patients with 72 palpable breast lumps were assessed by Physical Examination (PE), Mammography (MG), Ultrasound Scan (USS) and Fine Needle Aspiration Cytology (FNAC). The individual and collective value of these investigations have been assessed and a cost effective algorithm suggested.

Characteristics of osteoarthritis among Kuwaitis: a hospital-based study

Sixty-nine Kuwaiti patients with osteoarthritis (OA) were studied. Primary knee OA was seen in 65 (94.2%) patients. The mean age of this group was 53.18 years with a range of 39-97 years. The female to male ratio was 2.82:1. OA was bilateral in 84.62% and predominantly involved the medial tibiofemoral joint. According to Kellgren's grading of knee OA, grade 1 changes were present in 40.0%, grade 2 in 32.5%, grade 3 in 22.5% and grade 4 in 5.0%. Grade I obesity was seen in 13%, grade II in 64% and grade III in 23% of patients. Generalised primary nodular OA was seen in only four patients, all of whom were women. Primary OA of the hip joint and chondrocalcinosis were conspicuous by their absence.

Jaipur block in postherpetic neuralgia

BACKGROUND

Postherpetic neuralgia, a common sequele to herpes zoster infection, is a chronic debilitating problem. The available therapeutic modalities are usually ineffective.

METHODS

A total of 3960 patients (1326 women and 2634 men; age group, 21-84 years), with postherpetic neuralgia as the presenting complaint and with pain lasting from 2 months to 5 years, were treated with Jaipur block, consisting of local subcutaneous infiltration of 2% xylocaine, 0.5% bupivacaine, and 4 mg/mL dexamethasone solution. Patients were followed up at six-weekly intervals with subsequent injections given in non-responders.

RESULTS

Twenty-eight per cent of patients obtained complete relief from pain after a single injection, another 57% after a second injection, and 11% after a third injection; 4% of patients did not respond to treatment. The non-responders were either old (over 60 years) or had pain lasting for more than 2 years. The response to therapy was similar in both sexes. There were 31 left-handed patients in this study. Pain was less severe in left-handed patients and they obtained complete relief after a single injection. Side-effects including giddiness and sweating were seen, occasionally, in a few patients.

CONCLUSIONS

Ninety six per cent of patients obtained complete relief after the block with a follow-up of up to 19 years.

Malignant acanthosis nigricans in a 2 year old child with Wilm's Tumour

Case report of a 2-year-old male child who developed acanthosis nigricans lesions of sudden onset and rapid spread is described. The child was diagnosed as having Wilm's tumour and the lesions of acanthosis nigricans subsided with resection of the tumour.

Bulbar representation of the 'water-nose' during Xenopus ontogeny

Olfactory epithelium that is specialized for the detection of water-borne odors is located in different cranial cavities in larval and postmetamorphic Xenopus. Soybean agglutinin histochemistry reveals that both "water-noses' innervate only the ventral olfactory bulb (OB). This is evidence for a parcellation of the OB into a ventral portion mediating information on water-soluble odorants and a dorsal part that processes information on volatile substances.