True epiphrenic diverticulum of esophagus secondary to tubercular adenitis

Ephiphrenic esophageal diverticulum is rare and usually is a pulsion-type pseudodiverticulum that occurs in association with motility disorders of the esophagus. We report a 35-year-old man with tubercular lymphadenitis causing true traction type of epiphrenic diverticulum. Esophageal diverticulectomy and esophagomyotomy was done; he is doing well on antitubercular drugs.

Surface dynamics of polymer films

The dynamics of supported polymer films were studied by probing the surface height fluctuations as a function of lateral length scale using x-ray photon correlation spectroscopy. Measurements were performed on polystyrene (PS) films of thicknesses varying from 84 to 333 nm at temperatures above the PS glass transition temperature. Within a range of wave vectors spanning 10(-3) to 10(-2) nm(-1), good agreement is found between the measured surface dynamics and the theory of overdamped thermal capillary waves on thin films. Quantitatively, the data can be accounted for using the viscosity of bulk PS.

Effect of external electrical field on mobile water fraction and physiological processes in wheat (Triticum aestivum) leaves

Experiments were conducted to study the effect of external electric field on physiological processes, moisture content and mobile water fraction in wheat leaves. Application of electric field increased the stomatal resistance immediately and it continued to increase upto 10 min. Photosynthesis and respiration of leaves decreased with the application of external electric field. Leaf moisture content and mobile fraction of water measured as relaxation times were marginally increased with electric field. Closure of stomata, in spite of maintaining higher leaf moisture content of the leaf with external electric field, suggested that electric field might have regulated stomatal movement through hormones or ion flux across the cells.

Momentum-resolved charge excitations in a prototype one-dimensional mott insulator

We report momentum-resolved charge excitations in a one-dimensional (1D) Mott insulator studied using high resolution inelastic x-ray scattering over the entire Brillouin zone for the first time. Excitations at the insulating gap edge are found to be highly dispersive (momentum dependent) compared to excitations observed in two-dimensional Mott insulators. The observed dispersion in 1D cuprates ( SrCuO2 and Sr2CuO3) is consistent with charge excitations involving holons which is unique to spin-1/2 quantum chain systems. These results point to the potential utility of momentum-resolved inelastic x-ray scattering in providing valuable information about electronic structure of strongly correlated insulators.

Study of primary amenorrhoea with special reference to cytogenetic evaluation

An attempt has been made to find out the proportion of genetic causes in cases of primary amenorrhoea and to analyse different chromosomal pattern. Cases were analysed according to clinical profile, X-ray, laparoscopy/pneumography, hormone profile, USG, Gonadal Biopsy and Cytogenetic study including Sex Chromatin (Barr body) and Karyotyping. Among the 72 cases studied, the aetiological factors were Mullerian duct abnormalities in 27 cases (37.5%) Gonadal agenesis in 13 cases (18.05%). Turner stigmata in 18 cases (25%), Y cell line in 6 cases (8.33%). Delayed menarche in 4 cases (5.55%), systemic disease like Tuberculosis and Idiopathic 2 cases (2.77%) each. Chromosomal aberration was seen in 24 cases (33.33%) and it comes second most common cause of primary amenorrhoea after mullerian duct abnormalities.

Minor salivary glands: causing major problems

Tumours arising in the parapharyngeal space (PPS) are rare and account for approximately 0.5% of all head and neck neoplasms. These neoplastic processes represent a wide variety of both benign (80%) and malignant lesions arising from the diverse range of structures within and surrounding the PPS. The PPS is typically conceptualized as a potential neck space in the shape of an inverted cone with its base at the skull base and apex at the greater cornu of the hyoid. Because of this unique structure, lesions must often grow to a considerable size before symptoms become apparent and clinical detection is possible. A rare case of mucoepidermoid tumour of the minor salivary glands arising in the prestyloid parapharyngeal space is described. The complex anatomical and pathological considerations within this region present a substantial challenge to the head and neck surgeon in the evaluation and management of these lesions.

Volume-controlled ventilation. Variations on a theme

Development of sophisticated transducers and microprocessor-based ventilators now enables the performance of volume-controlled ventilation of newborn infants. Volume-controlled modes include standard intermittent or synchronized intermittent mandatory ventilation; assist-control ventilation; and hybrid modes, such as pressure-support ventilation, pressure-regulated volume-control ventilation, volume-assured pressure support, and volume guarantee. This article describes the concepts and clinical applications of these ventilatory modes.

Newer modes of mechanical ventilation for the neonate

For decades, the overwhelming majority of infants requiring mechanical ventilation for respiratory failure were treated with standard time-cycled, pressure-limited intermittent mandatory ventilation. Technologic advances in the 1990s brought forth sophisticated transducers and microprocessor-based mechanical ventilators that enabled implementation of many newer modes of mechanical ventilation. Some of these are volume-targeted rather than pressure-targeted, and many allow an element of patient control of the ventilator, including initiation and termination of inspiration and control of flow. Some modes are even hybrids, combining the best features of both pressure-targeted and volume-targeted modes. This article reviews the principles and salient clinical features of the newer ventilatory modes for newborns with respiratory failure.

Poor agreement in recognition of abnormal mitoses: requirement for standardized and robust definitions

AIMS

The finding of abnormal mitoses is a helpful feature in differentiating between benign and malignant neoplasia and has prognostic significance for some tumours. As the use of a histopathological variable is limited by the reproducibility of its recognition, we tested the interobserver agreement in the classification of abnormal mitoses among histopathologists. METHODS adn

RESULTS

Ten practising histopathologists were shown 30 potential mitotic figures and were asked to classify these as 'normal mitoses', 'abnormal mitoses' or 'not mitoses' according to the criteria each pathologist used in their routine practice. The results were analysed using kappa statistics. Overall agreement was only fair with a combined kappa of 0.31 and there was unanimous categorization of only four of 30 test items, none of which was called abnormal. The poorest result was obtained for the category 'abnormal mitosis' with only slight agreement (kappa 0.19). Agreement for the other categories varied from moderate (kappa = 0.45) for 'not a mitosis' to fair (kappa = 0.26) for 'normal mitosis'. Comparison of the results for observer pairs showed that for 12 out of the 45 possible pairings, there was no more agreement than might be expected by chance alone.

CONCLUSION

Agreement is poor among practising histopathologists in the recognition of abnormal mitoses. A standardized and robust definition is needed if diagnostic and prognostic significance is accorded to the finding of an abnormal mitosis in the context of neoplasia.

Detection and correction of a migration anomaly on a 310 genetic analyzer

During STR analysis on the 310 Genetic Analyzer, retarded migration of GS500ROX size standards and alleles in some samples was observed. The contribution of reagents, capillary and performance optimized polymer POP 4 to the observed anomaly was experimentally eliminated. Variation in electrophoresis temperature between 55 degrees C and 65 degrees C did not alter the rate of migration of GX500ROX size standard and sample alleles. An eroded connector for the cathode mounted on the heat plate assembly caused the abnormal migration. Hence, it is important to verify the mobility of all fragments in the size standard for each sample to avoid any erroneous allele calls by the automated data analysis software.

Robinow syndrome

Robinow syndrome is a rare congenital abnormality. It is characterized by mesomelic brachymelia, hemivertebrae, dysmorphic facies, genital hypoplasia, micropenis, clinodactyly, camptodactly, hypoplastic nails and moderate short stature. We are documenting the case on the account of its rarity and additional features.

Endoscopic dilation for treatment of anastomotic leaks following transhiatal esophagectomy

BACKGROUND AND STUDY AIMS

Anastomotic leak is a known complication after transhiatal esophagectomy (THE) and cervical esophagogastric anastomosis. Conservative management takes a long time to heal such leaks. We assessed the role of endoscopic dilation in patients with anastomotic leak following THE.

PATIENTS AND METHODS

Eight consecutive patients (seven men, one woman; mean age 51) with anastomotic leak following THE were subjected to endoscopic dilation using Savary Gilliard dilators of 7-15 mm diameter. The mean interval between surgery and detection of leak was 9 days (range 5-22 days) and dilation was performed at a mean interval of 11.4 days (range 1-20 days) after detection of the leak.

RESULTS

Drainage from fistulas stopped completely after 1-8 days (mean 3 days). X-ray with water soluble contrast showed closure of the fistula in all cases. Duration of follow-up ranged from 2 to 12 months. Anastomotic strictures developed in three patients. These patients required three sessions each of repeat dilation, and were alive at follow-up periods of 2, 4, and 12 months, respectively. One patient developed recurrence of growth at an anastomotic site. Four patients died because of distant metastasis.

CONCLUSIONS

Bougie dilation of anastomotic sites is a safe and effective technique for the healing of anastomotic leaks following THE. However there is a need for a prospective randomized trial comparing endoscopic dilation with no dilation in patients with anastomotic leaks following THE.

Budd-Chiari syndrome: our experience of 71 patients

BACKGROUND

Hepatic venous outflow obstruction (Budd-Chiari syndrome) is frequently encountered as a cause of portal hypertension at our centre.

METHODS AND RESULTS

We studied the clinical presentation, therapeutic modalities and outcome of 71 patients with hepatic venous outflow obstruction between 1992 and 1997. Twenty-seven patients presented with acute disease, while 44 had chronic presentation. Abdominal pain, distension, jaundice and upper gastrointestinal bleeding were the commonest presenting symptoms. The majority of patients had distended veins, hepatomegaly, splenomegaly, ascites and ankle oedema. The diagnosis was made on the basis of inferior vena cavography/functional hepatography and pulsed Doppler ultrasonography and/or liver biopsy in 39 patients and pulsed Doppler ultrasonography and/or liver biopsy in 32 patients. Pulsed Doppler ultrasonography accurately detected the site of the block in 31 of 39 patients (79.4%). The obstruction was in the hepatic vein in 20 patients, in the inferior vena cava in 10, and in both in 41 patients. Aetiologically, four had pregnancy-related disease, four tumour-related, three hypercoagulable states, 18 inferior vena cava membranes and 42 were idiopathic. Of 30 patients in whom liver biopsy was carried out, eight had centrizonal congestion and necrosis, 13 had mixed features and nine had established cirrhosis. Seven patients underwent a shunt operation and surgical membranotomy was carried out in one. Three patients (4.2%) died in the hospital.

CONCLUSIONS

Hepatic venous outflow obstruction is a common problem; patients present with abdominal pain, distension, jaundice, distended veins, ascites and ankle oedema. Chronic presentation is more frequent. Pulsed Doppler ultrasound, venography and liver biopsy are very helpful in diagnosis.

Intestinal pseudo-obstruction due to neurofibromatosis responding to cisapride

Gastrointestinal involvement in neurofibromatosis presenting with mechanical obstruction, hemorrhage or intussusception is known. Small bowel dysmotility and intestinal pseudo-obstruction due to neurofibromatosis is rare. A 23-year-old man with classical neurofibromatosis presented with intermittent episodes of intestinal pseudo-obstruction, small bowel bacterial overgrowth and steatorrhea. The patient had good symptomatic improvement with cisapride.

Helicobacter pylori eradication: comparison of three treatment regimens in India

Conventional bismuth-based triple therapy has multiple problems, such as inadequate drug compliance, side effects, and drug resistance. Combination of omeprazole and clarithromycin with or without combination with antibiotics like amoxycillin has been shown to be effective in eradication of Helicobacter pylori. Reports from India are few on the efficacy of clarithromycin-based drug combinations. Therefore, we evaluated efficacy of omeprazole and clarithromycin with or without amoxycillin for treating H. pylori infection. Sixty-four consecutive patients with upper gastrointestinal symptoms and having H. pylori infection were included. In every patient, complete upper gastrointestinal endoscopy was done. H. pylori infection was diagnosed by identification of organism on antral biopsies and positive rapid urease test. Patients were treated with omeprazole 40 mg/day + clarithromycin 250 mg twice daily (group I, n = 22), or omeprazole 40 mg/day + clarithromycin 250 mg twice daily + amoxycillin 500 mg three times daily (group II, n = 20), or bismuth subcitrate 120 mg four times daily + amoxycillin 500 mg three times daily + metronidazole 400 mg three times daily (group III, n = 22) for 2 weeks. H. pylori status was reevaluated 1 month after completion of treatment. One patient in each group stopped drugs due to side effects. Eradication rate was not significantly different in group I (15/22, 68%), group II (14/20, 70%), and group III (13/22, 59%). Of those completing therapy, side effects were observed in three patients in group III (nausea, skin rash, metallic taste), whereas none of the patients in group I and group II had any side effects. Addition of amoxycillin did not appear to improve efficacy of dual omeprazole and clarithromycin therapy and appeared to be no different than bismuth, metronidazole, and amoxycillin triple therapy. Overall, none of regimens was particularly good.

[14C]-urea breath test to confirm eradication of Helicobacter pylori

BACKGROUND

Treatment for Helicobacter pylori reduces ulcer recurrence. Eradication rates of the organism vary with different drug regimens from 30% to 90%. There is a need to identify patients who have failed treatment. [14C]-Urea breath test (UBT) is non-invasive, sensitive, safe and highly reliable test for diagnosis of H. pylori infection. As there is a paucity of reports on the utility of [14C]-UBT in confirming H. pylori eradication, this study was undertaken.

METHODS

Thirty-eight patients (age 34 +/- 17 years, range 16-84 years, 27 men) with upper gastrointestinal symptoms underwent upper gastrointestinal endoscopy. Baseline H. pylori infection was diagnosed by identification of the organism on antral biopsies and positive rapid urease test (RUT). After 1 month of completion of treatment, repeat RUT and histological examination of antral endoscopic biopsies were performed. Eradication of H. pylori was defined as absence of the organism on histology, and negative RUT. The [14C]-UBT was performed using 185 kBq [14C]-urea dissolved in 300 mL water. Breath samples were collected once before ingestion of [14C]-urea, and subsequently at 5 and 15 min. Results were expressed as 14CO2/mmol CO2 exhaled as per cent of administered urea.

RESULTS

Endoscopy revealed antral gastritis (n = 14), duodenal ulcer (n = 8), duodenitis (n = 2), oesophagitis (n = 1), antral gastritis and duodenal ulcer (n = 3), antral gastritis and duodenitis (n = 7) and normal upper gastrointestinal endoscopy (n = 3). All the 20 patients who were negative for H. pylori on RUT and histology, tested negative for H. pylori on [14C]-UBT. However, of 18 patients shown to have H. pylori infection on RUT and histology, 16 were positive for H. pylori on [14C]-UBT. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of [14C]-UBT were 100, 89, 91, 100 and 95% respectively.

CONCLUSIONS

The [14C]-UBT is a reliable indicator of H. pylori eradication after treatment. It can obviate the need for antral biopsies to confirm eradication of H. pylori after completion of treatment.

Retroperitonial, teratoma as fetus in fetu--a case report

We report a rare case of Retroperitonial teratoma containing Axial Skeleton long bone. Jaw, pelvis & scapula in a 27 yrs old male. Aberration in monozygotic twinning may rarely present as Fetus in Fetu. Rarer is presentation in Adult.

Retained surgical sponge: an unusual cause of malabsorption

Retained surgical sponge is an unpleasant surprise in clinical practice. Intraluminal migration of the retained sponge, though rare, can lead to intestinal obstruction and other complications. We describe two cases of retained surgical sponge, both following gynaecological surgery, presenting several years after surgery with features of subacute intestinal obstruction, malabsorption and several years after surgery with features of subacute intestinal obstruction, malabsorption and sever hypoproteinemia which reverted after surgical removal.

Langerhan cell granulomatosis with unusual FNAC findings

An interesting case of a multifocal Langerhans cell granulomatosis in an 18-mo-old female child is described. The diagnosis was confirmed by fine-needle aspiration cytology. The unusual findings at the initial stage of the disease and its possible etiopathogenesis are discussed.

Cytomorphological features, AgNOR counts and c-erb B-2 in carcinoma breast

The present study was designed to evaluate the cytomorphological features (nuclear grade and smear pattern) and AgNOR counts in 60 cases of carcinoma breast. The smears were stained with May Gruenwald Giemsa (MGG) and Papanicolaou stains. Silver staining nucleolar organiser region (AgNOR) counts and c-erb B-2 immunostaining were also done in each case. The smear pattern was assessed and classified as 'typical', 'cluster predominant' or 'individual cell type', and the nuclei were graded as grade I, II or III. Smear pattern and nuclear grade were found to be related variables. A significant association was found between nuclear grade and AgNOR counts (p = 0.03). Also postmenopausal women had statistically significant higher nuclear grades and less cohesive cell clusters as compared to premenopausal women. Twenty-three carcinoma breast were positive for c-erb B-2, of these 14 were postmenopausal women.

Controversies in patient-triggered ventilation

Patient-triggered ventilation is a relatively recent development in neonatal mechanical ventilation. Advances in microprocessor-based technology, transducers, and monitoring have enabled patient-driven ventilator control and synchronization of mechanical ventilation with patient effort. The novelty of the newer ventilatory techniques has generated several controversies that remain to be resolved. Among these are signal detection and transduction, the optimal ventilatory modes, and weaning during patient-triggered ventilation.

Newer concepts and approaches to neonatal brain asphyxia

The asphyxial injury to neonate brain seems to be mediated through a cascade of biochemical events during ischaemia--reperfusion which includes excitatory amino acids, free radicals and accelerated programmed cell death (Apoptosis). The diagnosis of asphyxia requires rigorous approach based on background clinical information, certain diagnostic tests and exclusion of alternative diagnosis which may have similar clinical presentation. The treatment currently employed for the management of birth asphyxia controversial and requires critical appraisal. The future strategies for management include a number of approaches based on putative mechanism for asphyxial brain injury but they are still being evaluated as research and should not be used for clinical purposes in human newborns as yet.

Randomised trial of volume controlled versus time cycled, pressure limited ventilation in preterm infants with respiratory distress syndrome

Fifty preterm infants weighing 1200 g or more with clinical and radiographic evidence of respiratory distress syndrome, requiring both mechanical ventilation and exogenous surfactant replacement, were randomly allocated to receive either volume controlled ventilation or time cycled, pressure limited ventilation. Tidal volume delivery in each group was deliberately controlled at 5-8 ml/kg so that the only difference between the two groups was the ventilatory modality, the manner in which tidal volume was delivered. The rest of the ventilatory management and clinical care was done according to protocol. The two modes of ventilation were compared by determining the time required to achieve pre-determined success criteria, based on either the alveolar-arterial oxygen gradient or the mean airway pressure as a standard against which the speed of weaning could be objectively assessed. Infants randomised to volume controlled ventilation met success criteria sooner and had a shorter duration of mechanical ventilation. These babies also had a significantly lower incidence of intraventricular haemorrhages and abnormal periventricular echodensities on ultrasound scans. Volume controlled ventilation seems to be both safe and effective in this group of patients.

Cell mediated immune status in malignancy--pretherapy and post-therapy assessment

Twenty-eight cases of malignancies of different kinds were studied to assess T-cell activity and population before and after institution of therapy. Fifteen cases were diagnosed as non-metastasising squamous cell carcinoma of larynx, pharynx, laryngopharynx, hypopharynx and tonsils. Seven cases were non-metastasising infiltrating duct carcinoma of breast and 6 cases were non-Hodgkin's lymphoma (NHL). It was observed that 3 out of 15 cases (20%) of squamous cell carcinoma cases were Mantoux test (MT) negative with a T-cell population of less than 40%, 2 out of 7 cases (28.6%) of infiltrating duct carcinoma of breast were MT negative with a T-cell population of less than 40% and 3 out of 6 cases (50%) of NHL were MT negative with a T-cell population of less than 40%. The normal controls, consisting of apparently normal healthy adults, had a T-cell population of more than 40% and were all MT positive. The patients who showed a negative skin test and a T-cell population less than 40% were further subjected to assessment of T-cell population and activity after appropriate therapy, and clinical cure of the disease. It was observed that 2 out of 3 cases (66.66%) of squamous cell carcinomas, 2 out of 2 cases (100%) of adenocarcinomas and one out of 3 cases (33.33%) of NHL showed positive conversion with a T-cell population of more than 40%.

Response of higher plants to lead contaminated environment

Lead concentration is increasing rapidly in the environment due to increased use of its sources by human society. Alarming concentrations of the metal have been reported in dust of densely populated urban areas and, water and land of various areas near the industrial waste disposals. Plants absorb lead and accumulation of the metal have been reported in roots, stems, leaves, root nodules and seeds etc. which increases with the increase in the exogenous lead level. Lead affects plant growth and productivity and the magnitude of the effects depend upon the plant species. Photosynthesis has been found to be one of the most sensitive plant processes and the effect of the metal is multifacial. Nitrate reduction is inhibited drastically in roots by the metal but in the leaves a differential effect is observed in various cultivars. Lead also inhibits nodulation, N-fixation and ammonium assimilation in the root nodules. It appears that the toxic effect of the metal is primarily at physiological level and provision of certain inorganic salts can antagonize the toxic effects to some extent. Further responses of plants to the metal depend on various endogenous, environmental and nutritional factors. Some plants are able to tolerate excess of Pb+2 by involving processes like exclusion, compartmentalization or synthesizing metal detoxifying peptides-the phytochelatins.

Cytology. A valuable tool in prognostication of carcinoma breast

Sixty consecutive cases of carcinoma breast diagnosed on fine needle aspiration cytology (FNAC) between July 1993 to June 1994 were studied prospectively. Nuclear grading was done on all cytologic smears, histologic grading was possible in only 22 cases. A good correlation was seen between nuclear grading on cytology and histology. Silver staining for nucleolar organizer region, and immunocytochemical staining for Ki-67 and C-erbB-2 could be done with ease on cytologic smears, providing necessary additional information on which to base the theraputic decisions.

C-erb B2 oncoprotein expression. Correlation with the Ki-67 labeling index and AgNOR counts in breast carcinoma on fine needle aspiration cytology

OBJECTIVE

To evaluate the expression of C-erb B2 on-coprotein and study its correlation with the Ki-67 labeling index and silver-stained nucleolar organizer region (AgNOR) counts on fine needle aspiration cytology (FNAC) of breast carcinoma.

STUDY DESIGN

In a prospective study, FNAC was done on 60 cases of infiltrating ductal carcinoma of the breast. Smears from aspirates were either air dried and methanol fixed for May-Grüwald-Giemsa and silver staining for AgNORs or wet fixed for Papanicolaou and immunocytochemical staining for Ki-67 and C-erb B2.

RESULTS

Breast carcinoma showing overexpression of C-erb B2 had higher Ki-67 labeling indexes (mean, 21.43) and higher AgNOR counts (mean, 37.92). A statistically significant correlation (r = .8) was seen between AgNOR counts and the Ki-67 labeling index.

CONCLUSION

FNAC proved suitable for studying C-erb B2 oncoprotein expression and the Ki-67 labeling index by immunocytochemistry. These parameters supplement the cytologic diagnosis.

Bacteriology of necrotizing infections of soft tissues

BACKGROUND

Necrotizing infections of soft tissues (NIST) are being attributed to a large variety of organisms, besides the originally described beta-haemolytic Streptococcus. A detailed bacteriological study of these infections was thought worthwhile.

METHODS

A prospective study of 55 patients with NIST was carried out. Analysis of surface swabs and debrided tissue for aerobic and anaerobic bacteria and fungal infection was performed. A detailed bacteriological profile was obtained in 50 patients.

RESULTS

A total of 257 isolates (167 aerobic, 90 anaerobic) was obtained. One to nine strains of bacteria were isolated from each patient. Aerobic bacteria alone were isolated in 26 patients while the remaining patients grew both aerobic and anaerobic bacteria. Forty-two patients had at least one Gram-positive bacterium while 40 had at least one Gram-negative bacterium. Staphylococcus aureus was the organism isolated most frequently (52%), followed by Bacteroides fragilis (40%) and anaerobic cocci (38%). Group A beta-haemolytic streptococci were isolated in 16%. Blood cultures were positive in only eight patients. Fungal cultures were positive in six patients. Aspergillus fumigatus was the commonest pathogen.

CONCLUSIONS

Necrotizing infections of soft tissues are polymicrobial and no single bacterium is associated with a specific clinical entity. Importance should be placed on early recognition and treatment of the disease rather than on isolation of bacteria.