Leiomyosarcoma of kidney: a case report with long term result after radiotherapy and chemotherapy

Leiomyosarcoma of the kidney is a rare entity with poor prognosis. Among renal sarcomas, it is the most common histologic subtype amounting to 50-60% of all cases. The tumors usually arise from either the renal capsule or smooth muscle tissue in the renal pelvic wall. We describe a case of renal leiomyosarcoma that presented with history of left flank pain. Physical examination was normal. Abdominal ultrasound showed a solid lesion of 38 x 36 mm arising from the left kidney. Intravenous urography showed cut off of both major and minor calyces of the left kidney from its pelvis with a normal right kidney. Exploratory laparotomy revealed a well-encapsulated mass confined to the renal parenchyma for which radical nephrectomy was performed. Histopathology showed a Grade I leiomyosarcoma arising from the renal capsule. Adjuvant chemotherapy and sandwich radiotherapy was given and he is disease free after six and half years of follow up. The rarity of this disease, its severity and poor prognosis, uncommon form of presentation, resulting delay in diagnosis and difficulty in management is highlighted and reported.

Microfilaria of Wuchereria bancrofti in bone marrow smear

Microfilariae of Wuchereria bancrofti were detected in seven cases of anemia in persons with asymptomatic filariasis. In three cases microfilariae could not be detected in the blood. Their presence in bone marrow may indicate the ability of microfilariae to cross the vessel wall.

Distinct CG and CNG DNA methyltransferases in Pisum sativum

DNA methyltransferase activity, present in low salt extracts of nuclei from young pea shoot apices, has been fractionated into two different species by assaying with model substrates. The CG methyltransferase (an unstable enzyme believed to be of 140 kDa) methylates cytosine only in oligonucleotides with CG and Cl dinucleotide targets while an enzyme of 110 kDa (the CNG methyltransferase) methylates the cytosines in 5'-CAG-3' and 5'-CTG-3' target sequences, especially when hemimethylated, but not in 5'-CCG-3' nor in 5'-CGG-3' target sequences present in oligonucleotides.

Intensified treatment of type 2 diabetes--positive effects on blood pressure, but not glycaemic control

BACKGROUND

Since publication of the UK Prospective Diabetes Study (UKPDS) in 1998, there has been a clear evidence base for tight glycaemic (HBA(1c) < 7.0%) and blood pressure (BP < 140/85 mmHg) control.

AIM

To determine the effect of UKPDS-based intensified glycaemic and BP targets on the care of type 2 diabetic patients attending a routine diabetes clinic.

DESIGN

Two surveys, each of 500 consecutively attending type 2 diabetic patients.

METHODS

The first survey was in a 3-month period in 1999, shortly after publication of the UKPDS study. The second was identical, but 2 years later. Glycaemic control (by DCCT-aligned HBA(1c)), BP and treatment details were recorded in both.

RESULTS

BP control was significantly improved in the second survey (mean +/- SD systolic BP from 151 +/- 25 to 146 +/- 26 mmHg, p = 0.001; diastolic from 77 +/- 13 to 72 +/- 12 mmHg, p < 0.0001) and the proportion of patients on anti-hypertensive treatment increased from 33% to 60% (p < 0.0001). Mean HbA(1c) however remained unchanged (8.7 +/- 1.8% in 1999 vs. 8.5 +/- 1.8% in 2001), although there was evidence of more intensive treatment patterns, with declining numbers on diet alone and more on oral agents and/or insulin.

DISCUSSION

Intensified BP control may be achievable within the confines of routine diabetes care, but achievement of optimal glycaemic targets remains problematic.

Proportion and pattern of dystrophin gene deletions in north Indian Duchenne and Becker muscular dystrophy patients

Population-based variations in frequency and distribution of dystrophin gene deletions have been recognized in Duchenne/Becker (DMD/BMD) muscular dystrophy patients. In the present study, DNA samples from 121 unrelated DMD/BMD patients from North India were analyzed for deletional studies with multiplex PCR and Southern hybridization. A total of 88 (73%) patients showed intragenic deletions in the dystrophin gene. The observed proportion of gene deletions is relatively high, particularly compared with that of Asian counterparts. However, the distribution of breakpoints across the gene does not show significant variations.

Hybrid mouse-prokaryotic DNA (cytosine-5) methyltransferases retain the specificity of the parental C-terminal domain

The mouse (cytosine-5) DNA methyltransferase (Dnmt1) consists of a regulatory N-terminal and a catalytic C-terminal domain, which are fused by a stretch of Gly-Lys dipeptide repeats. The C-terminal region contains all of the conserved motifs found in other cytosine-5 DNA methyltransferases including the relative position of the catalytic Pro-Cys dipeptide. In prokaryotes, the methyltransferases are simpler and lack the regulatory N-terminal domain. We constructed three hybrid methyltransferases, containing the intact N-terminus of the murine Dnmt1 and most of the coding sequences from M.HhaI (GCGC), M.HpaII (CCGG) or M.SssI (CG). These hybrids are biologically active when expressed in a baculovirus system and show the specificity of the parental C-terminal domain. Expression of these recombinant constructs leads to de novo methylation of both host and viral genomes in a sequence-specific manner. Steady-state kinetic analyses were performed on the murine Dnmt1-HhaI hybrid using poly(dG-dC).poly (dG-dC), unmethylated and hemimethylated oligonucleotides as substrates. The enzyme has a slow catalytic turnover number of 4.38 h(-1) for poly(dG-dC). poly(dG-dC), and exhibits 3-fold higher catalytic efficiency for hemimethylated substrates.

Measurement of magnetization transfer in different stages of neurocysticercosis

The purpose of this study was to establish magnetization transfer ratio (MTR) in different stages of neurocysticercosis. A total 2,532 cysticerci were studied prospectively in 15 cases. MTR from different regions of the lesions (ie, the cyst, the protoscolex or mural nodule, the granuloma wall) were calculated in different stages of evolution/degeneration in all cases. Of a total 2,532 lesions studied, 2,261 (89.29%) were seen on routine spin-echo (SE) imaging. The rest of the lesions were only seen on magnetization transfer (MT) SE imaging. Maximum MTR was calculated from healing lesions (mean + SD = 31.0+/-2.8) and from the core of SE invisible lesions (30.0+/-5.1). Innocuous cystic lesions, which were hyperintense on T2-weighted images, did not show any MT (MTR = 5.10+/-1.2), whereas degenerating T2 hyperintense lesions showed MTR of 26.40+/-2.7. Nondegenerating and degenerating scolices showed an intermediate MTR of 21.7+/-3.3 and 15.0+/-4.5, respectively. MT varies between different parts of the lesion and also from the same part in different stages of evolution/degeneration of the lesion. The visibility of a lesion on MT-SE sequence was dependent on its MTR and its location at a particular site (cortical gray matter, white matter, or deep gray matter). The difference in MTR of the lesion and the surrounding brain parenchyma decides the resulting contrast and visibility of the lesion.

Interpatient variability: genetic predisposition and other genetic factors

Polymorphisms and other genetic factors related to enzymes metabolizing drugs and xenobiotic chemicals are well known. This article focuses on selected molecular mechanisms and introduces some of the clinical implications arising from genetically determined interpatient variability or expression in some of these enzymes. Selected are the polymorphic enzymes of cytochromes P-450 (CYP) as examples of phase I enzymes and methyl transferases, n-acetyl transferases, and glutathione-s-transferases as examples of phase II enzymes. The polymorphism surrounding arylhydrocarbon hydroxylase induction is briefly described. Phase I enzymatic reactions are predominantly oxidative, whereas phase II reactions often couple with the byproducts of phase I. Overall, in poor metabolizers, whether phase I or phase II, there is limited metabolism in most patients unless another major metabolic pathway involving other enzymes exists. Drug metabolism also depends on whether the parent compound is a prodrug that forms an active metabolite, and poor metabolizers under this condition will form only trace amounts of an active compound. Therefore, the clinical significance of genetic polymorphisms and other genetic factors may be related to substrate, metabolite, or the major elimination pathway.

Intercostal nerve conduction study in man

A new surface technique for the conduction study of the lower intercostal nerves has been developed and applied to 30 normal subjects. The problem of the short available nerve segment of the intercostal nerves and the bizzare compound motor action potential (CMAP) of inconsistent latency while recording over the intercostal muscles, is overcome by applying recording electrodes over the rectus abdominis muscle and stimulating the nerves at two points at a fair distance away. With the use of multiple recording sites over the rectus abdominis, the motor points for different intercostal nerves were delineated. CMAP of reproducible latencies and waveforms with sharp take-off points were obtained. Conduction velocity of the intercostal nerves could be determined.

Parainfectious myelitis: three distinct clinico-imagiological patterns with prognostic implications

Seventeen parainfectious myelitis patients were studied for site, extent and severity of lesions. Three patterns were observed each having distinct clinical, electrophysiological and MRI features: 1) focal segmental myelitis--focal cord lesion with long tract signs and good prognosis; 2) ascending myelitis--continuous lesion from conus to mid-cord with upper and lower motor neuron signs (not necessarily spinal shock), dysautonomia and poor outcome; 3) disseminated myelitis--discrete lesions scattered throughout the cord with subtle signs in spinal segmental distribution, above and below the transverse level and moderate outcome. Severe autonomic dysfunction, denervation of paraspinal muscles, "dense" lesion on imaging and often (but not always) the absent somatosensory evoked potentials carried poor outcome. In conclusion "parainfectious myelitis" is a better term to describe transverse myelitis, as the lesion extends to a large vertical extent. Further classification into 3 subgroups may improve understanding of anatomical and physiological dysfunction and prediction of outcome.

Multiparametric quantitation of the perilesional region in patients with healed or healing solitary cysticercus granuloma

The purpose of this study was to compute T2 values and magnetization transfer (MT) ratios in the perilesional region of healing and healed cysticercus granulomas to determine if there are T2 abnormalities not apparent on conventional T2-weighted imaging and to determine the relationship between seizure control and the quantitative measures. Sixty-three patients were studied. T2 values and MT ratios were computed for the perilesional region and were compared with measurements from the contralateral normal-appearing region. A significantly increased T2 value was found for the perilesional region compared to the corresponding contralateral region despite the absence of qualitative abnormality on conventional T2-weighted magnetic resonance imaging. For patients showing normal-appearing perilesional regions on MT imaging, there was no significant difference in T2 and MT ratios between the perilesional and the normal contralateral regions. There was a statistically significant inverse correlation between perilesional T2 values and MT ratios, suggesting each was associated with perilesional gliosis. The study illustrates that quantitative evaluation of MT ratios and T2 augments the qualitative visual assessment of the perilesional region in healing or healed cysticercus granulomas.

Urinary tract infection in patients of gynecological malignancies undergoing external pelvic radiotherapy

A total of 216 midstream urine (MSU) samples from 36 patients with gynecological malignancies undergoing external pelvic radiotherapy (RT) were studied periodically every week for any evidence of urinary tract infection (UTI). UTI was detected in 33.3% patients of whom 8.3% had infection at the onset of RT and the rest developed UTI during the course of therapy. All three patients who had UTI at the onset of RT underwent cystoscopy as a part of routine pretreatment workup. A higher preponderance of UTI was observed in patients of stage III carcinoma cervix (33.3%) compared to stage II (16.7%) during the course of RT. Half of the patients with UTI had repeated episodes of infection despite appropriate antibiotic treatment. The study emphasizes the importance of conducting periodic MSU examination in patients with gynecological malignancies during RT and its treatment with appropriate antibiotics to minimize the risks of further injury to the already susceptible uroepithelium following radiotherapy.

Influence of age of onset on limbic and paralimbic structures in depression

AIM

Major depressive disorder (MDD) onset during childhood/adolescence is associated with a greater illness burden and distinct clinical profile. However, limited research exists on the effect of age of MDD onset on volumetric abnormalities in para/limbic structures during adulthood.

METHODS

Subgenual anterior cingulate cortex (sgACC), hippocampus and caudate nucleus volumes were measured by manual tracing in depressed individuals (n = 45) and healthy controls (HC; n = 19). Volumetric comparisons were carried out between HC and MDD patients divided into those with pediatric (≤ 18 years; n = 17) and adult onset (≥ 19 years; n = 28).

RESULTS

The adult MDD-onset group had smaller sgACC volumes than the pediatric-onset and HC groups (age, sex controlled). No differences in caudate and hippocampus volumes existed. sgACC and hippocampal volumes were inversely correlated with depression severity.

CONCLUSIONS

Surprisingly, pediatric MDD-onset was not associated with more pronounced sgACC, hippocampus and caudate volume reductions. Nevertheless, age of illness onset appears to be a meaningful dimension of study in efforts to understand the neurobiological heterogeneity of MDD.

"Extensor toe sign" by various methods in spastic children with cerebral palsy

Upper motor neuron lesion in adults is usually associated with spasticity and "extensor toe sign" on plantar stimulation (extensor plantar response). There are various methods of eliciting this sign including the classic method by Babinski. Other methods produce this response when the area of reflexogenic zone is increased due to upper motor neuron lesion. There are varying reports of Babinski positivity in spastic cerebral palsy. This study was undertaken to assess the sensitivity of different methods of eliciting "extensor toe sign." An attempt has also been made to correlate the severity of spasticity with the combined "extensor toe sign" positivity by various methods and with the increase in reflexogenic zone. Eighty-one children with spastic cerebral palsy were examined. Twelve had hemiplegia; therefore, a total of 150 limbs were tested. "Extensor toe sign" was elicited by 12 different methods in each patient. The sensitivity of each method was calculated and compared with each other one. The assessment of spasticity was done using the Ashworth Tone Scale. The severity of spasticity was correlated with "extensor toe sign" positivity using various methods. Classic Babinski reflex was positive in 75% of cases, whereas Gonda-Allen sign was positive in 90% of cases followed by Allen-Cleckley (82%), Chaddock (74%), and Cornell (54%). All other signs had sensitivity of less than 30%. There was no increase in sensitivity after combining them. There was significant negative correlation between the spasticity and the combined "extensor toe sign" positivity (by all the methods). This study, therefore, suggests that the majority of patients with spastic cerebral palsy have positive "extensor toe sign." The Gonda-Allen method is more sensitive than the classic Babinski method. A positive "extensor toe sign" is negatively correlated to the degree of spasticity.

Prevention of postischemic injury in immature intestine by deferoxamine

Free radical-mediated reperfusion injury has been demonstrated in ischemic neonatal bowel necrosis, but the mechanism of injury remains elusive. To determine whether such an injury can be prevented, 76 weaning rats were studied to test the effects of deferoxamine, an iron chelator, in postischemic injury. Group I (N = 20) had a sham laparotomy without vascular occlusion. Group II (N = 21) was subjected to 90 min of superior mesenteric artery occlusion prior to reperfusion. Group III (N = 35) received deferoxamine 15 mg/kg intravenous prereperfusion, in addition to ischemia and reperfusion as in group II. Survival profiles for each group were determined and a scale of pathologic severity was applied and compared. Group I had 100% long-term survival and group II, 14%. Group III had an overall survival of 28% and demonstrated a prolonged postreperfusion survival profile (P < 0.002) compared to group II. Histology was nearly identical to human necrotizing enterocolitis in degrees of bowel wall destruction and relative paucity of neutrophils. Group III showed a significant reduction in severity of injury compared to group II (P < 0.003). We conclude that neonatal bowel ischemia conditions such as necrotizing enterocolitis may be reperfusion injuries wherein free iron plays an important role in tissue injury. Administration of an iron chelating agent under such conditions has a beneficial effect on survival and histology.

Intermittent symptoms in neurocysticercosis: could they be epileptic?

OBJECTIVES

Some patients with neurocysticercosis (NCC) develop perilesional gliosis during the course of healing and carry poor prognosis for the seizure control. We evaluated the clinical status of these patients during complete control of their original seizures on anti-epileptic drugs (AED).

MATERIAL AND METHODS

We studied 172 patients with solitary NCC, 45 with perilesional gliosis as visible on magnetization transfer spin echo (MTSE) magnetic resonance imaging and 127 without gliosis, for any abnormal symptom during the course of their "seizure-free" period. All of them received optimum doses of AED to control the original seizures.

RESULTS

Patients with gliosis had high incidence of abnormal symptoms with or without corresponding abnormalities on surface electroencephalogram (EEG). These symptoms disappeared on increasing the dose or adding a new AED. The symptoms, which were transient episodic in nature, included heaviness, dystonic posturing, weightlessness, numbness and alien limb phenomenon on the side of the body contralateral to cerebral lesion, and headache.

CONCLUSION

Patients with NCC who develop perilesional gliosis during the process of healing tend to suffer from disturbing intermittent symptoms during their apparent control of seizures. The symptoms are controllable with increased dosage of previously prescribed or addition of another AED. As these symptoms could possibly be epileptic in nature, their identification and treatment may have a bearing on long-term seizure control after stopping AED therapy.