Atypical Presentation of Coarctation of Aorta Mimicking a Spinal Vascular Malformation

Coarctation of the aorta accounts for about 8% of all congenital heart diseases. It usually presents in infancy or later in the third decade depending on its severity. It has a wide spectrum varying from an asymptomatic presentation to cardiac and extracardiac manifestations with neurological complications. Coarctation presenting as a spinal complication is extremely rare. We describe a case of coarctation detected on magnetic resonance imaging (MRI) in a 40-year-old man with an uncommon presentation mimicking a spinal arteriovenous malformation (AVM). To our knowledge, coarctation presenting with a spinal manifestation, resembling an AVM is rare, and has not been reported to date.

Clomifene citrate and intrauterine insemination as first-line treatments for unexplained infertility: are they cost-effective?

BACKGROUND

First-line treatments for unexplained infertility traditionally include clomifene citrate (CC) or unstimulated intrauterine insemination (IUI). A recently published randomized controlled trial considered the effectiveness of CC and IUI in patients with unexplained infertility and found that neither treatment offered a superior live birth rate when compared with expectant management (EM). This paper reports the economic evaluation conducted alongside this trial in order to assess whether health care providers are gaining value for money in this clinical area.

METHODS

Five hundred and eighty women across five Scottish hospitals were randomized to either EM, CC or IUI for 6 months. The primary outcome measure was live births. Resource-use data were collected during the trial and costs were calculated from a UK National Health Service (NHS) perspective. Incremental cost-effectiveness ratios were calculated, expressed as cost per live birth, in order to compare the cost-effectiveness of CC and IUI with that of EM to treat unexplained infertility.

RESULTS

Live birth rates in the three randomized groups were: EM = 32/193 (17%), CC = 26/194 (13%) and IUI = 43/193 (22%). The mean (standard deviation) costs per treatment cycle were £0 for EM, £83 (£17) for CC and £98 (£31) for IUI. The mean treatment costs per patient for EM, CC and IUI were £12 (£117), £350 (£220) and £331 (£222), respectively. The cost per live birth for EM, CC and IUI was £72 (95% confidence interval £0-£206), £2611 (£1870-£4166) and £1487 (£1116-£2155), respectively. The incremental cost-effectiveness ratio for IUI versus EM was £5604 (-£12204 to £2227), with CC dominated by IUI.

CONCLUSIONS

Despite being more expensive, existing treatments such as empirical CC and unstimulated IUI do not offer superior live birth rates compared with EM of unexplained infertility. They are unlikely to be a cost-effective use of limited NHS resources. The study's main limitation is that it did not consider the psychological effects on couples. ISRCT Number: 71762042.

Detection of virulent Marek's disease virus in poultry in India

Marek's disease virus (MDV) isolated from poultry flocks in three states of India was monitored for the virus occurrence in the field. The MDV genome was isolated from feather follicles, spleen, and liver of the chicken (173 samples). Twenty two samples were positive for MDV genome in PCR and belonged to the serotype 1. The sequencing of MEQ gene of 11 samples revealed that nucleotide sequences of the isolate Ind-KA-01-06 was similar to the very virulent MDV, strain RB-1B. In situ hybridization studies also confirmed a presence of MDV serotype 1 in the infected liver tissues. Furthermore, the ability of the virus to induce apoptosis detected by flow cytometry showed that the virulent MDV induced apoptosis more efficiently than Turkey herpesvirus (HVT) vaccine virus. The present study showed the presence of virulent/very virulent MDV strains in the Indian poultry flocks.

Differential expression of toll-like receptor mRNA in selected tissues of goat (Capra hircus)

Pattern recognition receptors (PRRs) expressed by various immune cells and tissues have been shown to play a pivotal role in the recognition of pathogens by the host. The present study was carried out to identify toll-like receptors (TLRs) 1-10 mRNA in goat peripheral blood mononuclear cells (PBMCs) and selected tissues including jejunum, lung, lymph node, skin, spleen and uterus using reverse transcriptase polymerase chain reaction (RT-PCR). Our results confirm earlier reports regarding the evolutionarily conserved nature of these receptors as successful amplification of the goat TLR mRNAs could be obtained with bovine TLR mRNA-specific primers. The partial sequences of the purified TLR PCR amplicons had 93.8-99.7% nucleotide identity with sheep TLR cDNA sequences available in the GenBank. Semi-quantification of the expression levels of the TLR mRNAs was done using densitometric analysis of band intensities. All the TLR mRNAs (1-10) were expressed in high amounts in the lymph node while spleen showed lower expression of TLR 6 and 10 mRNAs. PBMC and lung expressed all TLR mRNAs in high amounts except TLR 10 mRNA. In uterus and jejunum, lower expression of TLR 3, 4 and 10 mRNAs was seen. Skin had the lowest repertoire of TLR mRNA expression with lower or no expression of TLR 2, 3, 4, 8, 9 and 10 mRNAs. Another interesting observation was that tissues such as uterus, lung and skin that exhibited lower levels of TLR 2 had higher levels of TLR 6 mRNAs.

Spontaneous transdural spread of glioblastoma with atypical presentation

The dura provides an excellent protection against infiltration by malignant tumours. It is extremely rare for glial tumour cells to infiltrate the dura and subsequently invade adjacent structures. We report an interesting case of glioblastoma of the temporal lobe with spontaneous transdural spread to the skull base and infratemporal fossa. This is the first radiologically documented case of transdural spread of glioblastoma before and after the spread without previous craniotomy.

High dose radiation induced meningioma

Radiation therapy has played an important integral part in the management of various intracranial rumours. However, radiation has been implicated in the development of intracranial tumours. We describe three cases of radiation-induced meningiomas following high dose cranial irradiation. All these patients developed tumours within the previous radiation field and satisfied the criteria used for the definition of radiation-induced neoplasm. The interval between the irradiation and the onset of meningioma was significantly less in the younger patient. All the cases had several unique features of radiation-induced meningioma including features of atypical meningioma. Two patients developed multiple site meningiomas and one patient developed early recurrence of the tumour. This report confirms that patients exposed to cranial irradiation are at lifelong risk of developing radiation-induced tumours such as meningiomas. Hence these patients require long-term clinical and radiological surveillance to detect occurrence as early as possible.

Factors contributing to the time taken to consult with symptoms of lung cancer: a cross-sectional study

OBJECTIVES

To determine what factors are associated with the time people take to consult with symptoms of lung cancer, with a focus on those from rural and socially deprived areas.

METHODS

A cross-sectional quantitative interview survey was performed of 360 patients with newly diagnosed primary lung cancer in three Scottish hospitals (two in Glasgow, one in NE Scotland). Supplementary data were obtained from medical case notes. The main outcome measures were the number of days from (1) the date participant defined first symptom until date of presentation to a medical practitioner; and (2) the date of earliest symptom from a symptom checklist (derived from clinical guidelines) until date of presentation to a medical practitioner.

RESULTS

179 participants (50%) had symptoms for more than 14 weeks before presenting to a medical practitioner (median 99 days; interquartile range 31-381). 270 participants (75%) had unrecognised symptoms of lung cancer. There were no significant differences in time taken to consult with symptoms of lung cancer between rural and/or deprived participants compared with urban and/or affluent participants. Factors independently associated with increased time before consulting about symptoms were living alone, a history of chronic obstructive pulmonary disease (COPD) and longer pack years of smoking. Haemoptysis, new onset of shortness of breath, cough and loss of appetite were significantly associated with earlier consulting, as were a history of chest infection and renal failure.

CONCLUSION

For many people with lung cancer, regardless of location and socioeconomic status, the time between symptom onset and consultation was long enough to plausibly affect prognosis. Long-term smokers, those with COPD and/or those living alone are at particular risk of taking longer to consult with symptoms of lung cancer and practitioners should be alert to this.

Clomifene citrate or unstimulated intrauterine insemination compared with expectant management for unexplained infertility: pragmatic randomised controlled trial

OBJECTIVE

To compare the effectiveness of clomifene citrate and unstimulated intrauterine insemination with expectant management for the treatment of unexplained infertility.

DESIGN

Three arm parallel group, pragmatic randomised controlled trial.

SETTING

Four teaching hospitals and a district general hospital in Scotland.

PARTICIPANTS

Couples with infertility for over two years, confirmed ovulation, patent fallopian tubes, and motile sperm.

INTERVENTION

Expectant management, oral clomifene citrate, and unstimulated intrauterine insemination.

MAIN OUTCOME MEASURES

The primary outcome was live birth. Secondary outcome measures included clinical pregnancy, multiple pregnancy, miscarriage, and acceptability.

RESULTS

580 women were randomised to expectant management (n=193), oral clomifene citrate (n=194), or unstimulated intrauterine insemination (n=193) for six months. The three randomised groups were comparable in terms of age, body mass index, duration of infertility, sperm concentration, and motility. Live birth rates were 32/193 (17%), 26/192 (14%), and 43/191 (23%), respectively. Compared with expectant management, the odds ratio for a live birth was 0.79 (95% confidence interval 0.45 to 1.38) after clomifene citrate and 1.46 (0.88 to 2.43) after unstimulated intrauterine insemination. More women randomised to clomifene citrate (159/170, 94%) and unstimulated intrauterine insemination (155/162, 96%) found the process of treatment acceptable than those randomised to expectant management (123/153, 80%) (P=0.001 and P<0.001, respectively).

CONCLUSION

In couples with unexplained infertility existing treatments such as empirical clomifene and unstimulated intrauterine insemination are unlikely to offer superior live birth rates compared with expectant management.

TRIAL REGISTRATION

ISRCT No: 71762042.

Effect of siRNA mediated suppression of signaling lymphocyte activation molecule on replication of peste des petits ruminants virus in vitro

Signaling lymphocyte activation molecule (SLAM) expression was inhibited in B95a cell line using siRNA and the effect of SLAM inhibition on peste des petits ruminants virus (PPRV) replication and infectivity titre was studied. SLAM suppression was assessed using real-time PCR and flow cytometry to confirm suppression at the m-RNA and protein levels, respectively. Three chemically synthesized siRNAs were transfected individually using oligofectamine into B95a cell line. This resulted in SLAM suppression from 48 to 454-folds, in comparison to the untransfected B95a cell line. When the SLAM suppressed B95a cell line was infected with PPRV, replication was reduced by 12-143-folds and virus titre was reduced from log10 1.09 to 2.28. siRNA 3 showed the most potent inhibition of SLAM expression both at m-RNA and protein levels. This also caused the maximum reduction of virus replication and virus titre. A 100-fold reduction in PPRV titres was seen in anti-SLAM antibody neutralized B95a cell line. This further confirms that SLAM is one of the (co) receptors for PPRV. However, the presence of other putative virus receptor(s) is/are not ruled out.