Cystathionine B-Synthase 844ins68 Gene Variant and Idiopathic Male Infertility

Male infertility is a multifactorial disorder that affects approximately 10% of couples at childbearing age, with substantial clinical and social impact. The main regulating enzymes in folate and homocysteine metabolism are methylenetetrahydrofolate reductase (MTHFR) and cystathionine beta-synthase (CBS). In our previous study, we showed that a mutation C677T in the gene, MTHFR is a risk factor for idiopathic male infertility in the Indian population. To assess that a common polymorphism in the cystathionine beta-synthase (CBS) gene (844ins68) is acting as susceptibility factor for male infertility or not, we investigated this variant in 120 idiopathic male infertile patients and 200 fertile male controls. No significant association was observed (OR = 0.8348, 95% CI: 0.1578 to 4.4164, chi(2) = 0.040, P > .05); therefore we conclude that this common 844ins68 variant is a neutral insertion variant for idiopathic male infertility in the Indian population.

Open tibial fractures. Are children small adults?

Open tibial fractures in adults have been extensively studied. In children, however, only a small number of case series provide data on management and outcome of these injuries. It is not clear whether open tibial fractures in children 'behave' in a similar fashion to those in adults, and clear guidelines regarding their management do not exist. Primary wound closure after irrigation does not increase infection rates in low grade open tibial fractures. Cast is an effective method for fracture stabilization in stable fractures. External fixation is usually used in patients with significant soft tissue injury, and elastic intramedullary nailing is an alternative. Age over 10 years and open fracture grade III appear to be significant prognostic factors. Complication rates are not unremarkable and long-term studies are required to investigate their consequences. Children over 10 years should probably be managed as adults. Further research is needed to evaluate the effectiveness of different fracture management methods.

Rare mode of dynamic hip screw failure

The sliding hip screw (SHS) has been the orthopaedic surgeon's implant of choice for repairing intertrochanteric femur fractures for nearly 30 years. Breakage of SHS is very rare and is seen mainly at the plate screw junction. Here we report a rare case of SHS failure; in this case the patient was asymptomatic after apparently uneventful fracture healing and the failure of SHS took place at the junction of barrel and screw.

CA 19–9 as a predictor of response and survival in patients with pancreatic cancer treated with gemcitabine and cisplatin based chemotherapy

15094

Background: Radiologic evaluation of the efficacy of chemotherapy (CT) regimens in pancreatic cancer is complicated by the retroperitoneal location and the desmoplastic nature of the tumor. The aim of this study was to evaluate the role of baseline CA 19–9 and the decrease in CA 19–9 after one cycle of CT as predictors of response, time to progression (TTP) , and overall survival (OS). Methods: We conducted 3 consecutive phase II trials evaluating gemcitabine and cisplatin based CT between 1997 and 2004. A retrospective chart review of the 111 patients yielded demographic data, best response status, TTP, OS, and CA19–9 levels. Response by CA 19–9 (R-CA19–9) was defined as a decrease of = 50% in CA 19–9 after the completion of the first cycle of chemotherapy. Results: The median age was 59 years with 60% males. Median performance status (PS) was 1. No significant difference was observed across the three trials with respect to age, sex, or PS. Baseline CA19–9 was known for 102 patients, and was dichotomized near the median as: < 1,000; and = 1,000 ng/mL. Lower baseline CA19–9 levels were not associated with higher radiologic response (RR) rate (p = 0.82): 22%, and 19%, respectively. Lower baseline CA19–9 was associated with longer OS, (p = 0.0057), as shown in a recent UK study. Median OS was 9.2, and 6.1 months, respectively. Similar results were observed for TTP, with p = 0.0146, and median TTP of 6.4 and 4.2 months, respectively. The change in CA19–9 from baseline to the end of treatment cycle 1 was available for 68 patients. The patients with R-CA19- 9 had a higher RR rate (29%) than did the other patients (24%), but not significantly so (p = 0.7495). The patients with R-CA19–9 had longer OS (median 8.7 vs 7.1 months) and longer TTP (median 7.1 vs 5.4 months), but not significantly so (p > 0.73 for each endpoint). Conclusions: Lower baseline CA19–9 (but not R-CA19–9 after treatment cycle 1) was positively associated with OS and TTP prognosis in our patient population. A 50% decrease in CA19–9 after the first cycle of chemotherapy was not a useful predictor of response, TTP, or OS.

No significant financial relationships to disclose.

Functional hepatocyte-like cells derived from mouse embryonic stem cells: A novel in vitro hepatotoxicity model for drug screening

The aim of the present study was to differentiate mouse embryonic stem (mES) cells into a high percentage of hepatocyte-like cells, and to demonstrate their utility as an in vitro hepatotoxicity model. We were able to differentiate 80-90% of mES cells using optimized hepatocyte differentiation medium. These differentiated cells showed typical hepatocyte morphology, expressed hepatic specific genes as shown by RT-PCR and displayed antibody detectable expression of markers specific for hepatic maturation. These hepatocyte-like cells also demonstrated evidence of glycogen storage. These cells when exposed to CCl4, a commonly used hepatotoxicant, showed an elevation of liver function enzymes, SGOT, SGPT and LDH, indicating hepatic damage. Further, this increase was prevented by pre-treatment with N-acetylcysteine, a known anti-oxidant. Thus we propose that the hepatocyte-like cells derived by the present method may prove to be useful as an in vitro model of hepatotoxicity, thereby providing a novel and promising alternative for obtaining large numbers of functional hepatocyte-like cells for in vitro drug metabolism and hepatotoxicity screening of potential drug candidates.

Comparison of cardiac MR and 99mtc Sestamibi Spect in the evaluation of myocardial perfusion and viability in coronary artery disease

Objective - The present study was designed to compare the role of 99mTc sestamibi sciintigraphy (SPECT) and cardiac MR (CMR) in the detection of viable myocardium and to delineate myocardial scar tissue in patients with established chronic ischemic heart disease. Methods - Thirty six patients with established chronic ischemic heart disease on coronary angiograms which was the gold standard underwent both stress CMR and 99mTc sestamibi studies. Out of these 11 patients who had reduced end diastolic thickness < 5.5mm alongwith wall motion abnormalities also underwent dobutamine MR (DMR) for determining the contractile myocardial reserve. Results- Both CMR and SPECT showed a good correlation in the detection of perfusion defects (r=0.89) with the diagnostic region of operating characteristics being 0.97. The sensitivity and specificity of SPECT to detect perfusion defects were 82.6% and 90.4% respectively. In comparison CMR had a sensitivity, specificity of 92.8% and 98.2% respectively in identifying such defects.It was also superior in defining transmural infarcts(TMI) with sensitivity being 100% vs 79.3% of SPECT (p=< 0.0001) and all the 10 segments with TMI showed irreversible myocardial dysfunction on DMR. This was the only imaging parameter that indicated myocardial non viability with a specificity of 100%. Conclusions - CMR is a useful diagnostic tool in the evaluation of patients with chronic myocardial ischemia and is superior to SPECT in the detection and quantification of myocardial infarctions. Demonstration of a TMI on CMR is a finding strongly associated with non viability of the myocardium and may preclude the need for doing a DMR in such cases.

Congenital bilateral calcinosis cutis of the hands

Calcinosis cutis is the cutaneous deposition of calcium phosphate. We present the first reported case of symmetrical calcium deposits being present in both hands at birth.

Metabolic alkalosis

Metabolic alkalosis is a primary pathophysiologic event characterized by the gain of bicarbonate or the loss of nonvolatile acid from extracellular fluid. The kidney preserves normal acid-base balance by two mechanisms: bicarbonate reclamation mainly in the proximal tubule and bicarbonate generation predominantly in the distal nephron. Bicarbonate reclamation is mediated mainly by a Na-H antiporter and to a smaller extent by the H-ATPase. The principal factors affecting HCO 3 reabsorption include effective arterial blood volume, glomerular filtration rate, chloride, and potassium. Bicarbonate regeneration is primarily affected by distal Na delivery and reabsorption, aldosterone, arterial pH, and arterial pCO2. To generate metabolic alkalosis, either a gain of base or a loss of acid, must occur. The loss of acid may be via the GI tract or by the kidney. Excess base may be gained by oral or parenteral HCO 3 administration or by lactate, acetate, or citrate administration. Factors that help maintain metabolic alkalosis include decreased glomerular filtration rate (GFR), volume contraction, hypokalemia, hypochloremia, and aldosterone excess. Clinical states associated with metabolic alkalosis are vomiting, mineralocorticoid excess, the adrenogenital syndrome, licorice ingestion, diuretic administration, and Bartter's and Gitelma's Syndromes. The effects of metabolic alkalosis on the body are varied and include effects on the central nervous system, myocardium, skeletal muscle, and the liver. Treatment of this disorder is simple, once the pathophysiology of the cause is delineated. Therapy consists of reversing the contributory factors promoting alkalosis and in severe cases, administration of carbonic anhydrase inhibitors, acid infusion, and low bicarbonate dialysis.

Can we rely on a general practitioner's referral letter to a skin lesion clinic to prioritize appointments and does it make a difference to the patient's prognosis?

INTRODUCTION

This study was designed to: (i) determine if the priority of referral letters by general practitioners to a plastic surgery skin lesion clinic adhered to the national guidelines, what happened to these patients, and what was the histological diagnosis; and (ii) analyse whether the prognosis at diagnosis of malignant melanoma had improved since the introduction of the 2-week wait for patients with suspected cancer.

MATERIALS AND METHODS

The study involved a prospective audit questionnaire, retrospective note review and histology report review in the Plastic Surgery Department in a district general hospital and their 'bespoke' out-patient clinics.

RESULTS

Of 202 referral letters, 58 (29%) were referred as 2-week cancer referrals of which 13 (22%) suggested diagnoses that did not fall within the guidelines, and 11 gave no diagnosis. In addition, 84 (42%) had no indication of priority, though the text may suggest the need for it, either explicitly or implied. The prognostic indices for malignant melanoma have not altered since the 2-week wait rule has been implemented.

CONCLUSIONS

The guidelines are not being adhered to, thus patients with benign lesions are being given undue priority. The history and examination of skin lesions given in the referral letters is insufficient to allow the consultant to prioritize. Since the 2-week rule has be implemented, malignant melanomas have not been diagnosed at an earlier stage.

Skeletal muscle metastasis from malignant melanoma

Malignant melanomas commonly metastasise to skin, subcutaneous tissue and lymph nodes. Skeletal muscle metastases from malignant neoplasms are uncommon. There have been very few reports of malignant melanoma metastasising to skeletal muscle. We report a case of malignant melanoma metastasis in the thigh musculature in a young female patient.

Idiopathic cases of male infertility from a region in India show low incidence of Y-chromosome microdeletion

Chromosomal and Y-chromosomal microdeletion analysis has been done in cases of idiopathic infertility with the objective of evaluating the frequency of chromosomal and molecular anomaly as the causal factor of infertility. Barring a few cases of Klinefelter syndrome (XXY or XY/XXY mosaics), no chromosomal anomaly was encountered. Y-microdeletion was analysed by PCR-screening of STSs from different regions of the AZF (AZFa, AZFb, AZFc) on the long arm of the Y, as well as by using DNA probes of the genes RBM, DAZ (Yq), DAZLA (an autosomal homologue of DAZ) and SRY (Yp; sex determining gene). Out of 177 cases examined, 9 (azoospermia - 8 and oligoasthenospermia - 1) showed partial deletion of AZF. The size of deletion varied among patients but AZFc was either totally or partially removed in all of them. In contrast, no deletion was detected in AZFa. Testis biopsy done on a limited number of cases (50) showed diverse stages of spermatogenic arrest with no specific correlation with the genotype. The frequency of Y-chromosome microdeletion in our samples (approximately 5%) is much lower than the frequency (approximately 10%) reported globally and the two previous reports from India. We contend that the frequency may be affected by population structures in different geographical regions.