Successful management of multi-focal hepatic infantile hemangioendothelioma using TACE/surgery followed by maintenance metronomic therapy

Infantile hepatic hemangioendothelioma (IHE) is a rare angiogenic tumour with diverse clinical presentations and varied course ranging from spontaneous regression to life-threatening complications. The authors report a 2-year boy who presented with respiratory distress and was identified as a case of inoperable multi-focal hepatic IHE. He showed a transient response to trans-arterial-chemo-embolisation and liver resection but had progressive disease despite chemotherapy (prednisolone/vicristine/ifosfamide/cisplatin). Thereafter, he was successfully managed with metronomic therapy using cyclophosphamide and tamoxifen.

American ginseng suppresses Western diet-promoted tumorigenesis in model of inflammation-associated colon cancer: role of EGFR

Background

Western diets increase colon cancer risk. Epidemiological evidence and experimental studies suggest that ginseng can inhibit colon cancer development. In this study we asked if ginseng could inhibit Western diet (20% fat) promoted colonic tumorigenesis and if compound K, a microbial metabolite of ginseng could suppress colon cancer xenograft growth.

Methods

Mice were initiated with azoxymethane (AOM) and, two weeks later fed a Western diet (WD, 20% fat) alone, or WD supplemented with 250-ppm ginseng. After 1 wk, mice received 2.5% dextran sulfate sodium (DSS) for 5 days and were sacrificed 12 wks after AOM. Tumors were harvested and cell proliferation measured by Ki67 staining and apoptosis by TUNEL assay. Levels of EGF-related signaling molecules and apoptosis regulators were determined by Western blotting. Anti-tumor effects of intraperitoneal compound K were examined using a tumor xenograft model and compound K absorption measured following oral ginseng gavage by UPLC-mass spectrometry. Effects of dietary ginseng on microbial diversity were measured by analysis of bacterial 16S rRNA.

Results

Ginseng significantly inhibited colonic inflammation and tumorigenesis and concomitantly reduced proliferation and increased apoptosis. The EGFR cascade was up-regulated in colonic tumors and ginseng significantly reduced EGFR and ErbB2 activation and Cox-2 expression. Dietary ginseng altered colonic microbial diversity, and bacterial suppression with metronidazole reduced serum compound K following ginseng gavage. Furthermore, compound K significantly inhibited tumor xenograft growth.

Conclusions

Ginseng inhibited colonic inflammation and tumorigenesis promoted by Western diet. We speculate that the ginseng metabolite compound K contributes to the chemopreventive effects of this agent in colonic tumorigenesis.

Changes in the levels of factor VIII and von Willebrand factor in the puerperium

To determine changes in Factor VIII (FVIII) and von Willebrand Factor (VWF) in the first 3 days of the puerperium. A prospective study assessing FVIII clotting activity, VWF activity and antigen levels in 95 women (with singleton uncomplicated pregnancies) during labour and on days 1, 2 and 3 of the puerperium. There were no significant differences in FVIII, VWF:Ag and VWF:CB on days 1 and 2 of the puerperium compared with levels during labour. There was a significant decrease in VWF:Ag (P = 0.009) and VWF:CB (P = 0.04) on day 3. Age, ethnicity, duration of labour and mode of delivery did not have any significant effect on the changes in FVIII and VWF levels. The pregnancy induced increase in FVIII and VWF is maintained in the first 48 h after delivery. VWF levels start to decline on day 3 postdelivery.

Quantitative nuclease protection assay (qNPA) for gene expression analysis on breast cancer core biopsies

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Background: qNPA employs in situ hybridization of detection probes to cross linked mRNA, making it ideal for formalin fixed paraffin embedded (FFPE) tissue. It has been shown to measure gene expression in archived lymphoid and lung cancer tissue. We assessed the feasibility of qNPA to measure differentially expressed genes in pretreatment FFPE core breast biopsies among pathologic responders (pR) and nonresponders (pNR) to preoperative chemotherapy.

Methods: We included preoperative breast cancer patients treated at our institution from 2003-09 with FFPE core biopsies. mRNA expression of 170 genes, representing oncogenic pathways or associated with anthracycline and taxane response was measured by qNPA (HTG, Tucson, AZ). Data was normalized to 3 housekeeper genes and average of 3 biologic replicates reported. Seven genes below detection in > 50% samples were excluded. Expression values of 163 unique genes were analyzed for pR vs pNR with dChip software. Empirical FDR was estimated using 1,000 permutations of sample labels.

Results: Treatment and response: Sample failure: 6/57 (10%). pR vs pNR did not separate on hierarchical clustering. FLJ12650 and IGFBP2 showed lower expression in pR vs pNR with fold changes of 4.09 and 2.40, respectively (p < 0.01; median FDR: 1/163). FLJ12650 was significant (p < 0.01, median FDR: 0/163) when patients receiving anthracycline ± taxane were analyzed (groups 1-3) and showed a trend (p < 0.05) in group 1 alone.

Conclusions: qNPA for limited available FFPE tissue from core biopsies is feasible with acceptable sample failure rates. Small sample size and number of analyzed genes limited definitive conclusion about informative genes in our study. Our FLJ12650 results, a gene coding for membrane Na+/K+ ATPase interacting protein, are consistent with previous findings of overexpression in pNR to anthracyclines + taxanes (Hess et al, JCO 2006, Vol 24; 4236) using fresh tissue. Future qNPA validation of predictive markers, identified by whole transcriptome analysis in a homogenous cohort may provide more definitive results.

[Table: see text]

Clear cell chondrosarcoma in association with niemann-pick disease

Purpose: The purpose of this case report is to bring to light this unusual combination of two rare diseases, namely Neimann-Pick disease Type B and clear cell chondrosarcoma occurring in the same patient. This has not previously been reported in the world literature.

Subject: Niemann-Pick disease (NPD) is a rare autosomal recessive inborn error of metabolism. Type B NPD is even rarer. It is a lysosomal storage disorder affecting children and adolescents often causing death in early childhood, although in milder form patients may survive up to adulthood, like our patient. Clear cell chondrosarcoma is a very rare type of chondrosarcoma affecting the epiphyseo-metaphyseal region of long bones. We present a patient suffering from a milder form of Neimann Pick disease who developed a clear cell chondrosarcoma. We investigated to find if there was likely to be any relationship between these two events.

Results: NPD type B is caused by a three-base deletion in chromosome 11. Chondrosarcoma and multiple exostoses occur due to loss of tumour suppressor gene EXT 2 from centromeric region on chromosome 11, though it is difficult to establish the link between the two, as the two together have not yet been reported in the literature. NPD may present diagnostic difficulties when it occurs with chondrosarcoma.

Discussion: We conclude that the two diseases have not been reported together in the world literature and there is some evidence to show that chromosome 11 is central to both diseases. More research is needed to see if one leads to the other.

Nanostructural and functional properties of Ag-TiO2 coatings prepared by co-sputtering deposition technique

Ag-TiO2 nanocomposite coatings with varying Ag content were prepared by co-sputtering from two separate sputter sources. This technique allows to prepare coatings not only with a large variation of Ag content and different gradient but also allows much better control of nanocomposite thickness and nanostructure compared with mostly used techniques based on wet chemical approaches. Various thicknesses of nanocomposite layers with different deposition parameters were studied to obtain a better understanding on the growth of Ag nanostructures in the TiO2 films. The metal-volume-fraction was varied between 15% and 47%. Structural and microstructural investigations of the nanocomposite films were carried out by transmission electron microscopy. Special attention was paid to surface segregation of Ag and its suppression. The observed segregation on TiO2 contrasts sharply with the well known embedding tendency of Ag clusters on polymers. Functionality of the Ag-TiO2 nanocomposites was demonstrated via UV-Vis spectroscopy and antibacterial tests. It was shown that a thin layer of TiO2 can be used as an effective barrier to tailor the release behaviour of Ag ions.

Does bariatric surgery prior to lower limb joint replacement reduce complications?

Obesity is an increasing health concern in developed world. Bariatric surgery is considered in super-obese patients. Many of these patients will also require lower limb arthroplasty. This study was performed to investigate the complications of hip and knee replacement in patients who had bariatric surgery either before or after their joint replacement. Hospital episode statistics data for English NHS patients undergoing lower limb arthroplasty and bariatric surgery between 2005 and 2009 were analysed. The joint replacement-specific and general medical complications were compared between those undergoing joint replacement prior to bariatric surgery and vice versa, and also with the general English arthroplasty patient. One hundred and forty-three patients underwent bariatric surgery and joint replacement. Bariatric surgery was performed first in 53 and arthroplasty first in 90 patients. The mean age of obese patients was 9 years younger than the general arthroplasty population. Mean in-hospital stay was similar but general medical complications in obese patients appear to be less, possibly because of the lower age at the time of the procedure. Hip dislocation rate at 18 months was higher. Within the two obese groups wound infection rate was 3.5 times lower and readmission to hospital at 30 days appeared to be 7-times lower in patients who had bariatric surgery prior to joint replacement (p = 0.06). In this patient group, the risk of complications following joint replacement appears to be lower if bariatric surgery is performed first.

A cystic hepatic lesion: when to worry?

A 16-year old female presented to hospital with abdominal pain. Features on computed tomography raised the possibility of biliary cystadenoma or cystadenocarcinoma. She underwent a liver resection, and histopathology confirmed a serous biliary cystadenoma. This case is presented to highlight the radiological features of this uncommon pre-malignant condition as well as to summarize a management algorithm for cystic liver lesions.

First-in-human study demonstrating pharmacological activation of heme oxygenase-1 in humans

Heme oxygenase (HO)-1 degrades heme and protects against oxidative stress, but it has not been pharmacologically induced in humans. In this randomized study of 10 healthy volunteers, hemin (3 mg/kg intravenously in 25% albumin) was shown to increase plasma HO-1 protein concentration four- to fivefold and HO-1 activity ~15-fold relative to baseline at 24 and 48 h (placebo -56.41 +/- 6.31 (baseline), 69.79 +/- 13.00 (24 h), 77.44 +/- 10.62 (48 h) vs. hemin -71.70 +/- 9.20 (baseline), 1,126.20 +/- 293.30 (24 h), 1,192.20 +/- 333.30 (48 h)) in four of five subjects as compared with albumin alone (P </= 0.03). This represents the overcoming of a fundamental hurdle to HO-1 research in humans.

Compendium of gene expression profiles comprising a baseline model of the human liver drug metabolism transcriptome

Oligonucleotide microarrays were used to study the variability of pharmacokinetics and drug metabolism (PKDM)-related gene expression in 75 normal human livers. The objective was to define and use absorption, distribution, metabolism and excretion (ADME) gene expression variability to discern co-regulated genes and potential surrogate biomarkers of inducible gene expression. RNA was prepared from donor tissue and hybridized on Agilent microarrays against an RNA mass balanced pool from all donors. Clustering of PKDM gene sets revealed donors with distinct patterns of gene expression that grouped genes known to be regulated by the nuclear receptor, pregnane X-receptor (PXR). Fold range metrics and frequency distributions from the heterogeneous human population were used to define the variability of individual PKDM genes in the 75 human livers and were placed in context by comparing expression data with basal ADME gene expression variability in an inbred and diet/environment controlled population of 27 Rhesus livers. The most variable genes in the hepatic transcriptome were mainly related to drug metabolism, intermediary metabolism, inflammation and cell cycle control. Unique patterns of expression across 75 individuals of inducible ADME gene expression allowed their expression to be correlated with the expression of many other genes. Correlated genes for AhR, CAR and PXR responsive genes (CYP1A2, CYP2B6 and CYP3A4) were identified that may be co-regulated and, therefore, provide clues to the identity of surrogate gene or protein markers for CYP induction. In conclusion, microarrays were used to define the variable expression of hepatic ADME genes in a diverse human population, the expression variability of ADME genes was compared with the expression variability in an inbred population of Rhesus monkeys, and genes were defined that may be co-regulated with important inducible CYP genes.

Three dimensional modelling of interaction between surface and Darcy flow regimes through soils

The present paper deals with the impact of surface flow on hydrodynamic conditions in saturated underground domains. A three dimensional finite element scheme has been used to simulate underground flow resulting from the flow of water over a saturated land. The results clearly show the effects of the surface flow on the hydrodynamic conditions of the subsurface porous regions. This analysis is an important prerequisite for the prediction of contaminant mobility in soils and hence provides a convenient tool for the prediction of interaction between surface and subsurface flow processes. For low permeability cases, considered here, the governing equations consist of water continuity and Darcy equations. These equations are solved using a robust and reliable finite element procedure.

Disc calibration for digital templating in hip replacement

Digital radiography is becoming widespread. Accurate pre-operative templating of digital images of the hip traditionally involves positioning a calibration object at its centre. This can be difficult and cause embarrassment. We have devised a method whereby a planar disc placed on the radiographic cassette accounts for the expected magnification. Initial examination of 50 pelvic CT scans showed a mean hip centre distance of 117 mm (79 to 142) above the gluteal skin. Further calculations predicted that a disc of 37.17 mm diameter, placed on the cassette, would appear identical to a 30 mm sphere placed at the level of the centre of the hip as requested by our templating software. We assessed accuracy and reproducibility by 'reverse calibration' of 20 radiographs taken three months after hip replacement using simultaneous sphere and disc methods, and a further 20 with a precision disc of accurate size. Even when variations in patient size were ignored, the disc proved more accurate and reliable than the sphere. The technique is reliable, robust, cost effective and acceptable to patients and radiographers. It can easily be used in any radiography department after a few simple calculations and manufacture of appropriately-sized discs.

Transrectal ultrasound-guided biopsy of recurrent cervical carcinoma

The objective of this study was to evaluate the feasibility, safety and diagnostic accuracy of transrectal ultrasound (TRUS)-guided core biopsy for recurrent carcinoma of the uterine cervix in patients with non-diagnostic vaginal cytology and transvaginal punch biopsy.17 patients with clinical and imaging suspicion of recurrent carcinoma of the cervix, and with negative cytology and punch biopsy, were referred for TRUS-guided biopsy of a recurrent mass. Data were collected with respect to demography, previous diagnosis, treatment received, size and location of the recurrent lesion, and biopsy results. Adequate samples were obtained for all patients. TRUS-guided biopsy was technically successful in all of the patients and provided histological diagnosis of recurrence in 16 patients. One of the patients had post-radiation fibrosis. There were no procedure-related complications. In conclusion, TRUS-guided biopsy for recurrent cervical cancer is a feasible, safe and accurate method for establishing a histopathological diagnosis. It should be considered in patients with non-diagnostic vaginal cytology and punch biopsy.

Endoprosthetic reconstruction for the treatment of musculoskeletal tumors of the appendicular skeleton and pelvis

BACKGROUND

Excision of a bone tumor requires reconstruction if limb salvage is a priority. Reconstruction with an endoprosthetic implant is preferred in our unit, as the patient typically can return rapidly to full weight-bearing and functional activities. Long-term complications, such as deep infection, aseptic loosening, and mechanical failure of the implants, have led to concerns about the efficacy of reconstruction and the ability to revise failed implants while maintaining limb salvage in the longer term. The purpose of this study was to investigate the survival of endoprosthetic reconstructions in the medium to long term in order to determine the factors associated with their failure.

METHODS

A consecutive series of 776 patients underwent endoprosthetic reconstruction following resection of a bone tumor at a minimum of ten years prior to this investigation. One hundred and nine children with a so-called growing endoprosthesis were excluded as they often require revision to an adult prosthesis near skeletal maturity. Six patients were excluded because of a lack of adequate follow-up data, leaving 661 patients for analysis. Kaplan-Meier survival analysis of the implant was performed, with implant revision for any cause (infection, local recurrence, and mechanical failure), mechanical failure alone, and amputation used as the end points.

RESULTS

The mean duration of follow-up was fifteen years for patients who survived the original disease. Two hundred and twenty-seven patients (34%) had revision surgery because of mechanical failure (116 patients), infection (seventy-five patients), and locally recurrent disease (thirty-six patients). Implant survival at ten years was 75% with mechanical failure as the end point and 58% with failure from any cause as the end point. The limb salvage rate was 84% at twenty years.

CONCLUSIONS

We believe these medium to long-term results with first-generation endoprostheses are encouraging and justify the continued use of endoprostheses for reconstruction following the excision of a bone tumor.

Selective enzymatic degradation of poly(ε-caprolactone) containing multiblock copolymers

The hydrolytic and Pseudomonas lipase catalysed enzymatic degradation was studied for PDC multiblock copolymers consisting of poly(epsilon-caprolactone) (PCL) segments and poly(p-dioxanone) (PPDO) segments with variable composition. The enzymatic degradation of these multiblock copolymers is significantly accelerated by Pseudomonas lipase in contrast to the hydrolytic degradation where the degradation behaviour is determined by the PPDO segments. Degradation time intervals up to 200h are selected, where the PPDO segments remain stable and do not contribute to the degradation process. A linear correlation between weight loss and increasing PCL content of the multiblock copolymers was found. X-ray diffraction data confirm that both crystalline and amorphous PCL are attacked by the enzymes. SEM cross-section images reveal that Pseudomonas lipase penetrates into the PDC polymers. The present study impressively demonstrates that selective enzymatic degradation of PCL containing multifunctional polymers is a beneficial tool for controlling their degradation properties.

Enzymatic chain scission kinetics of poly(epsilon-caprolactone) monolayers

The hydrolytic and enzymatic degradation behavior of poly(epsilon-caprolactone) (PCL) is investigated using the Langmuir monolayer technique, and an improved data acquisition and data reduction procedure is presented. Hydrolytic and enzymatic monolayer degradation experiments of PCL with various molecular weights by Pseudomonas cepacia lipase have been carried out to analyze the influence of subphase pH, subphase temperature, enzyme concentration, and the packing density of polymer chains on the degradation kinetics. The enzymatic monolayer degradation results in an exponential increase in the number of dissolved degradation fragments with increasing degradation time, which confirms random chain scission to be the dominant scission mechanism. The increase in the enzymatic scission rate constant with decreasing initial average molecular weight of the polymers is assigned to the influence of the area density of polar terminal groups on the substrate-enzyme complex formation.

Conditions mimicking coarctation of the aorta

Coarctation of the aorta is a cause of right arm hypertension in children and of heart failure in infants after ductal closure. We present two cases with these presentations that were initially thought to be coarctation of the aorta. They were subsequently diagnosed as Takayasu's arteritis in the older child and a large cerebral arteriovenous malformation in the infant. These conditions should be in the differential of right arm hypertension and of aortic flow reversal on echocardiography.

Simultaneous Ocular and Systemic Cysticercosis and Tuberculosis

Human cysticercosis and tuberculosis are endemic diseases in developing countries. Both these diseases have certain common factors of origin. We would like to present the co-existence of these infections in a 20-year-old female. She was a known case of pulmonary and ocular tuberculosis and she acquired cysticercosis of the eye and brain.

Disorders of menstruation and their effect on the quality of life in women with congenital factor VII deficiency

AIMS AND OBJECTIVES

To review menstrual problems in women with congenital FVII deficiency and to study their effect on the quality of life during menstruation in women with congenital FVII deficiency.

METHOD

14 women with congenital factor VII deficiency registered with the Haemophilia Centre at the Royal Free Hospital were interviewed and their case notes reviewed. All women completed Pictorial Blood assessment Chart (PBAC) for assessment of menstrual blood loss and a quality of life questionnaire during menstruation. Similar questionnaire and PBAC was completed by an age matched healthy control group of 23 women.

RESULTS

Median age of study group was 35 yrs and of control group 34 yrs. Median FVII level of the study group was 31.5 IU/dL Two women had severe FVII deficiency (FVII level < 10 IU/dL) and 12 women had mild-moderate FVII deficiency. 57% women (8/14) from study group had menorrhagia (PBAC score > 100) compared with 17% (4/23) women from the control group. Six women (43%) from the study group were diagnosed with anaemia due to heavy periods, compared to two (9%) in the control group. The quality of life scores during menstruation were significantly worse in the women with FVII deficiency, compared to controls.

CONCLUSION

Women with factor VII deficiency exhibit a spectrum of bleeding symptoms, menorrhagia being one of the commonest symptoms. This has adverse effect on their quality of life.

Risk of ventriculoperitoneal shunt infections due to gastrostomy feeding tube insertion in pediatric patients with brain tumors

OBJECTIVE

To determine the risk of ventriculoperitoneal (VP) shunt infections after percutaneous retrograde gastrostomy feeding tube (GT) placement in children with brain tumors.

PATIENTS AND METHODS

All children (age 0-18 years) with primary brain tumors diagnosed and treated at the Hospital for Sick Children, Toronto, Canada, were subjected to a retrospective analysis. Two groups were identified: the study group included children with a VP shunt and a GT; the control group included children with VP shunts only. Each study patient was matched with 2 controls to compare the rate of infections (cohort comparative study).

RESULTS

There were 1,167 children diagnosed and treated with primary brain tumors during the study period (1988-2003); 174 (15%) had a VP shunt and 23 (2%) children had both, a VP shunt and a GT. In the study group (n=17), GTs were inserted at a median time of 80 days (range 6-204 days) after VP shunts. VP shunt infection rate was 23.5% (4/17) compared to 8.8% (3/34) in the control group (OR 3.18; 95% CI 0.622-16.54, p=0.16). Three (75%) of the infection episodes in the study group presented with an ascending VP shunt infection directly related to the GT insertion or manipulation in the first 6 weeks. These GTs were inserted at 13, 47 and 49 days after VP shunt insertion.

CONCLUSION

Placement of percutaneous retrograde GTs, in the acute phase, in children with brain tumors and VP shunts may increase the risk of ascending meningitis especially if there are early GT-related complications.

Altered cytokine expression in tissues of mice subjected to simulated microgravity

Space flight is known to induce microgravity-associated immune dysfunction in humans, non-human primates and rodents. To understand the mechanism underlying these defects, several studies in rodents have been conducted in a ground-based antiorthostatic suspension (AOS) model that would mimic the effects of microgravity. In all these in vivo studies that showed the effects on cytokine profiles actually investigated the ex vivo production from culturing the cells isolated from whole organism that was exposed to space flight and/or microgravity. So, the purpose of the study was to examine the in vivo expression of cytokines in mice in immunologically important tissue environments of mice that were subjected to AOS. Cytokines such as Interleukin-1beta, (IL-1beta), IL-2, IL-3, IL-6, Interferon-gamma (IFN-gamma) and Tumor Necrosis Factor-alpha (TNF-alpha) were measured by Enzyme Linked Immunosorbent Assay (ELISA) in the homogenates of spleen tissue, lymph nodes and also in serum of AOS mice and compared with that of control mice. AOS induced no change in the IL-3 levels, but IL-1beta was increased significantly whereas IL-2 levels decreased in spleen, lymph nodes and serum. IL-6 levels did not differ in spleen but were significantly increased in lymph nodes and serum of AOS mice. IFN-gamma levels in spleen did not change but showed nonsignificant reduction in lymph nodes and significant reduction in serum in response to AOS. TNF-alpha levels in spleen and serum were unchanged and increased in lymph nodes. This in vivo cytokine study confirms the earlier findings that microgravity-simulated conditions induce tissue-specific immune response.

Is the lingual forming part of the incisor a structural entity? Evidences from the fragilitas ossium (fro/fro) mouse mutation and the TGFbeta1 overexpressing transgenic strain

Our objective was to study the teeth of a mutant mice fro/fro that display severe forms of osteogenesis imperfecta. One day and 8 week-old fro/fro and +/fro heterozygote mice (wild type, WT) were processed for light and scanning electron microscopy. The genetic defect, shown to be located on chromosome 8, induced alveolar bone and teeth hypomineralisation. Due to defective cell proliferation in the fro/fro, the distal growth of the mandibular incisors was impaired. Immunolabelling revealed an increase of chondroitin/dermatan sulphate, whereas no difference was detected in dental tissues for decorin and biglycan. Amelogenin expression was decreased in the incisor and enhanced in the molar. Dentin sialoprotein was below the level of detection in the fro/fro, whereas osteonectin and osteopontin were unchanged. The main target of the mutation was seen in the lingual part of the incisor near the apex where dentine formation was delayed. In the molars, bulbous roots with obliteration of the pulp chamber were seen. In the TGFbeta1 overexpressing mice, the lingual root-analogue part of the incisor was missing. In the molar, short roots, circumpulpal dentine of the osteodentine type and pulp obliteration were seen. It may be noted that, although the mutant and transgenic strains mutations are two different genetic alterations not related to the same defective gene, in both cases the expression of the dentin sialoprotein is altered. Altogether, the present data suggest that the lingual forming part of the incisor seems to be an anatomical entity bearing its own biological specificities.

Is bilateral knee arthroscopy suitable as a day-case procedure?

A retrospective analysis of 100 out of 108 cases has been audited for suitability of bilateral knee arthroscopy as a day-case procedure. Fifty-three female and 47 male patients with age range of 15-78 years underwent bilateral knee arthroscopy. All patients had general anaesthetic and were ASA grade 1 or 2. Eight patients had more than one diagnosis and procedures. Post-operatively 68% could walk without walking aids, 1% had 1 stick and 31% needed 2 sticks and were given elbow crutches. One patient stayed overnight due to poor pain control and 1 attended A&E due to effusion. There were 5 (2.5%) major and 62 (31%) minor complications in 200 knees. Mild post-operative pain was the commonest minor complication in 52 (26%) out of 62 knees and was attributed to high number of bilateral arthritis cases in this study. Complication rate of bilateral arthroscopy is similar to unilateral arthroscopy. It is concluded that bilateral arthroscopy is safe as a day-case procedure.

PENCIL-CORE GRANULOMA OF THE DISTAL RADIO-ULNAR JOINT: AN UNUSUAL PRESENTATION AS SOFT-TISSUE SARCOMA AFTER 45 YEARS

A case of pencil-gore granuloma occurring 45 years after the initial injury is described. The clinical and radiological presentation was suggestive of a soft-tissue sarcoma. The diagnosis was confirmed by biopsy, which also revealed foreign body fragments which, on spectometric analysis, had high concentrations of carbon and aluminium.

The results of endoprosthetic replacement for tumours of the distal humerus

Ten patients underwent endoprosthetic replacement of the distal humerus for bone tumours over a period of 30 years. There were eight primary and two secondary tumours in four men and six women with a mean age of 47.5 years (15 to 76). The mean follow-up was eight years (9 months to 31 years). Four patients required further surgery, three having revision for aseptic loosening; two of these and one other later needing a rebushing. There were no cases of postoperative nerve palsy, infection, local recurrence or mechanical failure of the implant. Four patients died from their disease, all with the prosthesis functioning satisfactorily. At follow-up the mean flexion deformity of the elbow was 15 degrees (0 to 35) and the mean range of lexion was 115 degrees (110 to 135). The functional results showed a mean Toronto extremity salvage score of 73% of normal. Endoprosthetic replacement of the distal humerus and elbow is a satisfactory method of treating these rare tumours.

Protective effects of amifostine and its analogues on sulfur mustard toxicity in vitro and in vivo

Sulfur mustard (bis(2-chloroethyl)sulfide, SM) is a highly reactive bifunctional alkylating agent that forms sulfonium ions in the body. SM alkylates DNA, leading to DNA strand breaks and cell death in a variety of cell types and tissues. Although several approaches have been proposed to challenge the toxic action(s) of SM, no satisfactory treatment regimen has evolved. The synthetic aminothiol amifostine, earlier known as WR-2721 (S-2-(3-aminopropylamino)ethyl phosphorothioate), has been extensively used as a chemical radioprotector for the normal tissues in cancer radiotherapy and chemotherapy. SM is known as a radiomimetic agent and this prompted us to evaluate the protective efficacy of amifostine (2.5 mM) and three of its analogues, DRDE-06 (S-2 (3-aminopropylamino) ethyl phenyl sulfide), DRDE-07 (S-2 (2-aminoethylamino) ethyl phenyl sulfide), and DRDE-08 (S-2 (4-aminobutylamino) ethyl phenyl sulfide), against SM toxicity in rat liver slices. Of the four agents tested, a 30-min pretreatment of amifostine and DRDE-07 enhanced the LC50 (a concentration producing 50% leakage of lactate dehydrogenase (LDH) or alanine aminotransferase (ALT)) of SM by 5.9- and 3.3-fold for LDH and 10.2- and 5.5-fold for ALT, respectively. Except DNA fragmentation, both these agents significantly attenuated the loss of intracellular K(+) and mitochondrial integrity (MTT assay), depletion of GSH levels, and histopathology produced by a toxic concentration (80 microM) of SM. However, when amifostine and DRDE-07 were introduced 2 h after SM, no significant protection was observed. SM (77.5 or 155 mg/kg) was also applied dermally on female albino mice and challenged by 0.20 LD50 (po) of amifostine, DRDE-06, DRDE-07, or DRDE-08 at -30 min, 0 min, or +6 h. Protection was observed only when the agents were administered at -30 min or 0 min; posttreatment (+6 h) did not offer any protection. The magnitude of in vivo protection was in the following order: DRDE-07 >or= amifostine > DRDE-08 > DRDE-06. Gas chromatographic analysis showed that there was no direct chemical interaction between SM and the antidotes. The po LD50s of amifostine, DRDE-06, DRDE-07, and DRDE-08 were 1049, 1345, 1248, and 951 mg/kg, respectively. Both in vitro and in vivo data indicate promising roles of amifostine and DRDE-07 as prophylactic agents against SM poisoning.

Necrotizing enterocolitis

Improvement in survival rates of low birth-weight infants particularly in the neonatal intensive care units of India appears to be accompanied by frequent recognition of Necrotizing enterocolitis (NEC) among early survivors. As the philosophy and practice of advanced care for tiny infants becomes more acceptable and affordable in the country, a steady increase in survival of such infants is predictable. However there is growing concern in India that NEC could become a significant contributor to morbidity and mortality in the future. NEC is currently regarded as the most common acquired gastrointestinal emergency in the newborn period, and the outcome of this disease is universally poor. Improved understanding of the pathophysiology and pathogenesis of this condition is required for formulating optimal principles of prevention and management.

Green fluorescent protein-Dal80p illuminates up to 16 distinct foci that colocalize with and exhibit the same behavior as chromosomal DNA proceeding through the cell cycle of Saccharomyces cerevisiae

Four GATA family DNA binding proteins mediate nitrogen catabolite repression-sensitive transcription in Saccharomyces cerevisiae. Gln3p and Gat1p are transcriptional activators, while Dal80p and Deh1p repress Gln3p- and Gat1p-mediated transcription by competing with these activators for binding to DNA. Strong Dal80p binding to DNA is thought to result from C-terminal leucine zipper-mediated dimerization. Many Dal80p binding site-homologous sequences are relatively evenly distributed across the S. cerevisiae genome, raising the possibility that Dal80p might be able to "stain" DNA. We demonstrate that cells containing enhanced green fluorescent protein-Dal80p (EGFP-Dal80p) exhibit up to 16 fluorescent foci that colocalize with DAPI (4',6'-diamidino-2-phenylindole)-positive material and follow DNA movement through the cell cycle, suggesting that EGFP-Dal80p may indeed be useful for monitoring yeast chromosomes in live cells and in real time.

Cardiomediastinal tamponade and shock following three-stage transthoracic oesophagectomy

Massive gastric tube dilatation causing cardiomediastinal tamponade is an unusual cause of obstructive shock after transthoracic oesophagectomy. A 55-year-old female was operated for total transthoracic oesophagectomy. Twelve hours after the surgery, she developed hypotension and raised central venous pressure unresponsive to fluid infusion and ionotropes. X-ray chest showed a massively dilated stomach, which was causing intrathoracic tamponade. Suction applied to the nasogastric tube led to aspiration of 150-200 ml of fluid and a large volume of air, which led to resolution of the haemodynamic instability. A simple manoeuvre like nasogastric suction in postoperative case of oesophagectomy can serve as a diagnostic as well as therapeutic tool. It must be performed before resorting to invasive and expensive examination or intervention.

Molecular-based strategies for assessment of CMV infection and disease in immunosuppressed transplant recipients

OBJECTIVES

Molecular assays are now considered to be the "gold standard" for assessment of human cytomegalovirus (CMV) infection and disease in those at risk from severe associated clinical manifestations. There is, however little consistency in the methods used in different centres. This study was undertaken to compare different qualitative molecular-based approaches for assessment of CMV activation from latency in samples from immunosuppressed transplant recipients.

METHODS

Nucleic acid amplification techniques based on the polymerase chain reaction (PCR) and nucleic acid sequence-based amplification (NASBA) were undertaken for the assessment of CMV replication and associated disease in immunosuppressed transplant recipients. Samples from 32 transplant recipients were tested during this study using three molecular-based strategies: (1) detection of CMV DNA in whole blood extracts (positive after a single round of PCR considered "high-level" positive, N = 55); (2) detection of cell-free CMV DNA in plasma (two methods, N = 55 for each); and (3) detection of late pp67 CMV mRNA after NASBA (N = 51). Results using a commercial pp65 antigenemia assay were available for comparison from 40 samples.

RESULTS

Seven samples were positive for CMV by all methods and 36 were negative by all methods undertaken. The other 12 samples gave discordant results using different molecular methods. The correlation between whole blood "high-level" PCR, NASBA for pp67 mRNA and antigenemia results was generally good. Results presented show that plasma PCR results do not always correlate with methods utilizing whole blood as the substrate and that inhibitors in these samples could be problematic. Whole blood PCR gave more positive results than the other assays but use of a nested assay on whole blood or plasma led to detection of CMV in individuals who had no other indicators of virus replication and who did not develop associated disease (low specificity). Although the number of confirmed CMV disease episodes was low in this study, the problems of low positive predictive value for sensitive, qualitative PCR assays was clearly demonstrated.

CONCLUSION

Assays based on qualitative detection of viral nucleic acid may provide information useful for management of CMV but caution is necessary when making comparisons between results using different molecular strategies. It remains to be proven in large, comparative clinical studies in which the approach and method give the best balance between sensitivity, specificity and clinical relevance for different patient groups.