ANCA-negative limited Wegener's granulomatosis

A 26-year-old man presented with epistaxis, nasal obstruction and a subcutaneous swelling over the left malar region with radiological evidence of a mass in the right nasal cavity. Histology of the lesions showed necrotizing granuloma with evidence of vasculitis. There was no other systemic involvement and the patient was ANCA-negative. Excellent response to systemic steroid and cyclophosphamide therapy was noted.

The effects of selective cytokine inhibitory drugs (CC-10004 and CC-1088) on VEGF and IL-6 expression and apoptosis in myeloma and endothelial cell co-cultures

Myeloma cells and human umbilical vein endothelial cells (HUVECs) were co-cultured to model in vitro the interactions between myeloma and endothelium, and treated with thalidomide and two selective cytokine inhibitory drugs (SelCIDs, phosphodiesterase-4 inhibitors). Flow cytometry and enzyme-linked immunosorbent assay were used to assess production of two key cytokines--vascular endothelial growth factor (VEGF) and interleukin-6 (IL-6)--and apoptosis in co-cultured HUVECs and myeloma cells. VEGF was produced by both myeloma cells and HUVECs, while IL-6 was almost exclusively produced by endothelial cells. In co-culture, there was significant up-regulation of VEGF and IL-6 production compared with the sum of separate myeloma and endothelial cell cultures. SelCIDs markedly inhibited production of both cytokines in co-cultures, with CC-10004 being more potent than CC-1088. In addition, SelCIDs induced myeloma cell apoptosis. Apoptosis in co-cultured myeloma cells was significantly lower than in those cultured separately, suggesting that co-culture partially protected myeloma cells from drug-induced apoptosis. This protective effect was probably due to IL-6 produced by endothelial cells in co-culture as addition of anti-IL-6 neutralizing antibody, but not anti-VEGF antibody, abrogated it. In conclusion, SelCIDs can exert their anti-myeloma activity through two mechanisms, i.e. inhibition of VEGF and IL-6 production by interacting myeloma and endothelium and induction of myeloma cell apoptosis.

Influence of steric factors on exciplex energy and magnetic field effect

With the advent of spin chemistry, magnetic field effect (MFE) on exciplex luminescence has emerged as an important domain of research. MFE is a diffusion controlled phenomenon and hence is solvent dielectric (epsilon) dependent. It maximizes at a particular epsilon (epsilon(max)) for a specific exciplex system. Various attempts have been made to explain the variation of this epsilon(max) from one exciplex to another. In our present work we have succeeded for the first time to enmark the energy of exciplex (E(ex)) as the prime factor in determining the epsilon(max). We have indicated a definite inverse correlation (1:1) between epsilon(max) and E(ex). We have also tried to correlate some parameters that are important in exciplex formation, e.g. Charton's steric constant (nu(c)), repulsive energy (R(e)) and E(ex).

An alternative method of wound pain control following hepatic resection: a preliminary study

BACKGROUND

Epidural analgesia is considered one of the optimal methods for provision of postoperative pain relief in patients recovering from major upper abdominal operations. Concerns regarding the potential risk of neurological complications prompted an evaluation of an alternative strategy using a continuous intermuscular bupivacaine (CIB) infusion combined with patient-controlled analgesia (PCA).

METHODS

Two fine-bore catheters are inserted in the deep intermuscular intercostal neuronal plane during abdominal wound closure, and a continuous infusion of bupivacaine 0.25% is commenced for 72 h postoperatively. Simultaneously, patient-controlled analgesia provided intravenous morphine on demand. The study comprised 10 consecutive patients undergoing liver resection in whom CIB infusion and PCA were employed. The feasibility, safety and efficacy of the technique were investigated, analysing postoperative pain scores, morphine requirements, spirometry and oxygen saturation.

RESULTS

There were no postoperative deaths. Postoperative morbidity included one urinary tract infection, one minor chest infection and acute confusional episodes in two patients. Median pain scores and morphine requirements at 12, 24, 48 and 72 h postoperatively were satisfactory. Spirometry and oxygen saturation values also remained within the normal range.

DISCUSSION

Preliminary experience with CIB infusion/PCA in the aftermath of major liver resection has demonstrated its simplicity and safety as an alternative method of postoperative pain control. Further study is required to investigate the role of CIB infusion/PCA as a practical alternative to epidural analgesia or PCA alone.

Unusual uptake of radioiodine in the chest in a patient with thyroid carcinoma

A wide spectrum of potentially misleading artefacts can arise in 131I whole body scans from various anatomical variants and physiological processes as well as several unrelated non-thyroidal disease processes. A proper understanding of the causes of false positive 131I scans is essential for accurate interpretation of the images and to obviate diagnostic errors which may lead to administration of unnecessary therapy doses. The authors, in this article, present a case which had 131I uptake in the mediastinum persisting after surgical excision of mediastinal nodes, which was subsequently found to be due to accumulation of radioiodine in a hugely dilated oesophagus in secondary to achalasia. A comprehensive and rational classification of the various false positive 131I scintigraphic patterns based on the knowledge of the existing literature is reviewed.

Unusual haematological alterations in rheumatoid arthritis

Three cases of rheumatoid arthritis (RA), presenting with refractory anaemia, thrombocytopenia and peripheral lymphocytosis respectively, were observed. In all the cases haematological manifestations were unrelated to disease activity or drug toxicity. These patients were detected to have pure red cell aplasia (PRCA) (normocytic normochromic anaemia, reticulocytopenia and absence of erythroid precursors in the bone marrow), immune thrombocytopenia (IT) (absence of splenomegaly and presence of increased megakaryocytes in the bone marrow) and multiple myeloma (MM) (lytic lesions on skull, paraproteinaemia and bone marrow plasmacytosis) respectively. PRCA and IT responded to glucocorticoids. Association with these three haematological alterations has rarely been reported. Our report highlights the need to regularly monitor blood counts in patients with RA.

Autoimmune hemolytic anemia associated with benign ovarian cyst: a case report and review of literature

A 28-years-old female presented with severe autoimmune hemolytic anemia (AIHA), warm antibody mediated, and right side tubo-ovarian (TO) mass. There was sub-optimal response to immunosuppressive therapy (IST). Eight months later she underwent ovarian cystectomy which resulted in complete remission of AIHA without the need for IST. Pathological examination of the TO mass revealed benign ovarian cyst. Our case highlights the need to search for ovarian cyst/mass in females presenting with AIHA. Since immunosuppressive therapy is usually ineffectual in AIHA associated with ovarian cyst, it may be appropriate to contemplate surgery before embarking on IST in such cases.

Differences in cerebral reperfusion and oxidative injury after cardiac arrest in pigs

BACKGROUND

An investigation of the free radical scavenger sodium 2-sulfophenyl-N-tert-butyl nitrone (S-PBN) and the weak vasodilatator Tris buffer mixture (TBM) on cerebral cortical blood flow (CCBF) and the jugular bulb concentration of two eicosanoids, indicators of oxidative stress and inflammation, was undertaken in 30 anaesthetized piglets during cardiopulmonary resuscitation (CPR) and after restoration of spontaneous circulation (ROSC).

METHODS

Thirty animals were subjected to 8 min of untreated circulatory arrest followed by 8 min of closed-chest CPR. During CPR, the animals were randomized to receive 60 mg/kg S-PBN, 1 mmol/kg TBM or 2 ml/kg normal saline (n = 10 in each group). Systemic haemodynamic variables, CCBF and jugular bulb plasma concentrations of 8-iso-PGF2alpha and 15-keto-dihydro-PGF2alpha were measured.

RESULTS

The CCBF during reperfusion after ROSC was greater in the TBM group than in the S-PBN group, the regression coefficient between CCBF and mean arterial blood pressure being lower in the S-PBN group than in the TBM group. The jugular bulb plasma concentration of 8-iso-PGF2alpha during the first 30 min after ROSC was greater in the TBM group than in the S-PBN group. Administration of TBM after vasopressin did not attenuate the pressor effect of vasopressin.

CONCLUSION

Administration of S-PBN during CPR results in less cerebral oxidative stress, possibly by promoting normal distribution of cerebral blood flow.

Bobble-head doll syndrome: some atypical features with a new lesion and review of the literature

Bobble-head doll syndrome is a rare and unique movement disorder encountered in children. It is characterized by continuous or episodic involuntary forward and backward and side to side movement of the head at the frequency of 2-3 Hz. Neuroimaging in most of the cases reveals third ventricular tumors, suprasellar arachnoid cysts, aqueductal stenosis and other lesions in the region of the third ventricle along with communicating hydrocephalus. In most of the circumstances, the problem starts in the first decade of life and diversion of cerebrospinal fluid by shunt operation is very often accompanied by dramatic improvement. We report one case where bobbing of the head started at around 12 years of age. Additionally, there was evidence of partial left abducens nerve palsy, tremor in the outstretched hands, difficulty in finger-nose test and tandem walking, hyperreflexia and extensor plantar response. He was unconscious on two occasions and there was evidence of gross hydrocephalus along with a thin membranous web, running transversely across the lower part of the aqueduct of Sylvius without any cerebrospinal fluid flow void. Ventriculo-peritoneal shunt abolished the abnormal movements. We propose that the aqueductal web was the offending agent for the pathogenesis of bobble-head doll syndrome in our case and this lesion has not been identified in the cases reported so far. Relevant literature in this regard has also been reviewed.

Oropharyngeal carriage of Candida species in HIV-infected patients in India

The present investigation represents the first study of oropharyngeal carriage of Candida and other yeasts in HIV-infected patients in India. One hundred and fifty HIV-positive patients were investigated by culturing their swish samples on plates of CHROMagar Candida. Ninety-eight patients (65.3%) were positive for Candida and four (2.7%) were positive for other yeasts. Among them, the first Indian C. dubliniensis isolate has been recovered. Molecular typing of selected C. albicans isolates by AP-PCR revealed two major genotypes based on the banding patterns. The susceptibilities of 30 Candida isolates to five antifungal agents including the new triazole voriconazole were determined in a micro-dilution test, according to the NCCLS protocol M 27. All the 22 C. albicans isolates were susceptible to five antimycotic agents (flucytosine, amphotericin B, fluconazole, voriconazole and itraconazole) except one isolate (VPCI-122), which was resistant to flucytosine (MIC > or = 64 mg l-1). The azole-resistant isolates reported here endorse the role of antifungal susceptibility testing whenever antifungal treatment with azoles is planned.

Application of tracer packet technique for multielemental uptake studies on the inorganic ion exchanger zirconium vanadate

The conception of tracer packet was first started with the irradiation of a thick cobalt target with 16O, 7Li and 12C beams, consecutively. This produced carrier-free radiotracers of Mn, Cu, Zn, Ga, Ge, As and Se. These elements are adjacent members in the periodic table and are of nutritional importance. Another 'tracer packet', which was subsequently designed, was of heavy and toxic metals. A gold target irradiated with medium energy 7Li and 12C produced 197Hg, 200Tl, 200Pb, 204Bi, 204Po. The uptake of these elements has been studied using two different ion exchangers, one of inorganic origin and the other of chelating type.

Syringomyelia in caudal dysplasia sequence

Caudal dysplasia sequence (CDS) comprises developmental anomalies of the caudal vertebrae, neural tube, urogenital and digestive organs, and hind limbs, the precursors of all of which are derived from the caudal eminence. Although the syndrome is well recognized, the etiology and pathogenetic mechanisms are poorly understood. We report syringomyelia in association with the CDS, which has not been described previously and recommends inclusion of this entity in the spectrum of abnormalities encountered in this syndrome.

Single megadose vitamin A supplementation of Indian mothers and morbidity in breastfed young infants

BACKGROUND AND OBJECTIVE

In developing countries low maternal vitamin A stores combined with increased demands of pregnancy and lactation may lead to its deficiency in breastfed infants. This study evaluates the effects of maternal supplementation with a high dose of vitamin A on the serum retinol levels of exclusively breastfed infants, and their morbidity in the first six months of life.

SETTING

Hospital based.

STUDY DESIGN

Randomised controlled trial.

SUBJECTS AND METHODS

Mothers of the test group (n=150) were orally supplemented with a single dose of retinol (209 micro mol) soon after delivery and were advised exclusive breastfeeding for six months. Before supplementation retinol levels were estimated in the mothers' and newborns' blood, and in colostrum. On follow up, breastmilk and infants' serum retinol contents were assessed monthly for six months. Retinol level <0.7 micro mol/l indicated vitamin A deficiency. Morbidity patterns like vitamin A deficiency, diarrhoea, febrile illnesses, acute respiratory infection, measles, and ear infection were also studied and compared between the two groups.

RESULTS

Presupplement mean maternal serum retinol levels were 0.98 and 0.92 micro mol/l and mean breastmilk levels were 3.85 and 3.92 micro mol/l in the test and control groups respectively (p>0.05). Mean cord blood retinol levels were also comparable (0.68 v 0.64 micro mol/l). After supplementation, the test group showed a rise in mean breastmilk retinol content (12.08 v 2.96 micro mol/l) which remained significantly higher for four months. The infants' mean serum retinol level, initially 322.06% of the baseline value, was significantly higher for five months. In the control group, significant numbers of mothers and infants showed deficient breastmilk and serum retinol throughout the follow up (p<0.01). Decreased incidence and duration of various diseases were also found in the test group suggesting lesser morbidity.

CONCLUSION

Maternal supplementation with single megadose vitamin A is an effective strategy for vitamin A prophylaxis of exclusively breastfed infants of 0-6 months.

A survey of filamentous organisms at the Deer Island treatment plant

The Deer Island Treatment Plant (DITP) treating both domestic and industrial wastewater, has a peak flow capacity of up to 1270 million gallons per day (MGD) (3342 m3 min(-1). The DITP contains a Pilot Plant, which consists of two identical pure oxygen activated sludge treatment trains, each with a maximum capacity of 1 MGD (2.63 m3 min(-1)) to simulate the maximum flow of the full size facility. This study documents the community of filamentous organisms living in the activatedsludge under various operational conditions in the Pilot Plant. Sixteen types of filamentous organisms were identified. The major filamentous organisms present in the Pilot Plant were Type 1701, Type 0041, Sphaerotilus natans, Microthrix parvicella, and Nocardia sp. Nocardia sp. was quite dominant in the early stages of the experimental period during high ambient temperatures (summer), indicating that temperature is one determining factor in the distribution of Nocardia sp. Thiothrix sp. was very sensitive to the dissolved oxygen (DO) level, with low DO values favoring the growth of the organisms. Microbiological observations made during the start-up and stable operation of the full-scale secondary treatment plant (maximum capacity 780 MGD) are also reported. No dominant filamentous species existed during the start-up period. Type 0803 and Type 1701, indicators of low oxygen level for the applied food to microorganism ratio, confirmed the low DO conditions of activated sludge tanks.

Microdialysis-evaluated myocardial cyclooxygenase-mediated inflammation and early circulatory depression in porcine endotoxemia

OBJECTIVE

To evaluate the early myocardial biochemical inflammatory response with the microdialysis technique during porcine endotoxemia and to simultaneously monitor systemic hemodynamics.

DESIGN

Prospective, randomized, placebo-controlled trial with parallel groups.

SETTING

Animal research laboratory at the University Hospital of Uppsala, Sweden.

SUBJECTS

Thirteen piglets aged 12-14 wks receiving general anesthesia.

INTERVENTIONS

After thoracotomy and the insertion of microdialysis probes in standardized locations in the left ventricle of the heart and in the quadriceps muscle, seven pigs received a continuous infusion of endotoxin, initiating a severe endotoxemic shock. Six pigs received saline instead of endotoxin.

MEASUREMENTS AND MAIN RESULTS

Endotoxemia caused a rapid and pronounced elevation of a metabolite obtained from prostaglandin degradation, 15-keto-dihydro-PGF(2alpha), in myocardial microdialysate fluid being specific of cyclooxygenase (COX)-mediated inflammation (p <.001 vs. saline-infused controls). Simultaneously, we observed a decrease in left ventricular stroke work index in the endotoxemic pigs (p <.01 vs. saline-infused controls). Endotoxemia did not alter 15-keto-dihydro-PGF(2alpha) levels in quadriceps muscle. Endotoxemia caused increases in taurine, hypoxanthine, and magnesium in myocardial microdialysate (p <.05 vs. saline-infused controls), whereas the contents of pyruvate, lactate, inosine, adenosine, and calcium were not significantly changed.

CONCLUSION

Endotoxemia induced a myocardial COX-mediated inflammation without signs of ischemia. In parallel, a depletion of myocardial energy substrates and a deterioration in myocardial performance were seen.

Aggressive behaviour of solid arrangement pattern in differentiated papillary carcinoma of thyroid

The prognosis and overall outcome of solid growth pattern in differentiated papillary carcinoma of thyroid is controversial. While general consensus suggest outcomes similar to typical papillary carcinomas others demonstrate a more aggressive biology. We present a case of differentiated papillary carcinoma of thyroid with solid growth pattern presenting with neck swelling and widespread skeletal metastases. The areas of bone lesions showed avid 131I concentration on a postoperative large dose 131I whole body scan and was treated with 131I subsequently. The present case suggest that the solid architecture in a papillary thyroid carcinoma may be indicative of an aggressive clinical course, contrary to the common opinion that it does not adversely influence its biologic behaviour and thus emphasize the need to reexplore the prognostic significance of histopathologic subclassification along with an assessment of histologic grade and expression of molecular risk factors in this particular tumour subtype.

Cardiopulmonary bypass as a cause of free radical-induced oxidative stress and enhanced blood-borne isoprostanes in humans

Free radicals are believed to be involved in postsurgery-related complications. We studied whether cardiopulmonary bypass (CPB) operation has any immediate impact on the initiation of oxidative stress and inflammatory response by measuring isoprostanes and prostaglandin F2alpha during and 24 h following CPB. The levels of 8-iso-PGF2alpha (a major F2-isoprostane and biomarker of oxidative stress) and 15-keto-dihydro-PGF2alpha (a major metabolite of PGF2alpha and biomarker of inflammatory response) were measured in frequently collected plasma samples before, during, and up to 24 h postsurgery in 21 patients. 8-Iso-PGF2alpha levels significantly increased within 3 min (p <.0001) and continued until 50 min (p <.0001) during CPB. On the contrary, no significant increase of inflammatory response indicator, 15-keto-dihydro-PGF2alpha was found during and up to 24 h postoperatively. These findings establish an increased free radical-induced oxidative stress activity rather than inflammatory response after CPB.