Primary tracheobronchial amyloidosis: coronal CT scan may provide clues for early diagnosis

Primary tracheobronchial amyloidosis (PTBA) is a localized form of amyloidosis. The clinical signs of this condition are non-specific and diagnosis before bronchoscopic examination with multiple biopsies is uncommon. We present three cases of PTBA and compare findings between the thoracic imaging and fiberoptic bronchoscopy. Radiographic findings often had uncharacteristic features. The relatively specific coronal section CT preceded findings in transverse sections, and showed an irregular mucosal surface with diffuse prominent nodes and/or calcification of the tracheobronchus, which we called the "wavy path sign". In conclusion, coronal CT scan can provide ample clues for the early diagnosis of PTBA.

Induction of Labor Using Misoprostol With or Without Mifepristone in Intrauterine Death

INTRODUCTION

Rapid expulsion of fetus in intrauterine fetal death is usually requested without any medical grounds for it. So an efficient, safe method for induction of labor is required. The objective of this study is to determine if pre-treatment with mifepristone followed by induction of labor with misoprostol in late intrauterine fetal death is more efficacious.

METHODS

We conducted a randomized controlled trial in 100 patients in B.P.Koirala Institute of Health Sciences, Nepal from June 2011 to May 2013. Group A women received single oral dose of 200 mg mifepristone, followed by induction with vaginal misoprostol after 24 hours. Group B women were induced only with vaginal misoprostol. In each group, five doses of misoprostol was used four hourly. If first cycle was unsuccessful, after break of 12 hour, second course of misoprostol was started. The primary outcome was a measure of induction to delivery time and vaginal delivery within 24 hours. Secondary outcome was to measure need of oxytocin and complications.

RESULTS

Maternal age, parity and period of gestation were comparable between groups. Number of misoprostol dose needed in group A was significantly less than group B. Mann Whitney U test showed, women in group A had significantly earlier onset of labor, however total induction to delivery interval was not significant. In group A, 85.7% delivered within 24 hours of first dose of misoprostol while in group B 70% delivered within 24 hours (p=0.07). More women in Group B required oxytocin.

CONCLUSIONS

Pretreatment with mifepristone before induction of labor following late intrauterine fetal death is an effective and safe regimen. It appears to shorten the duration of induction to onset of labor.

Multiple infusions of CD20-targeted T cells and low-dose IL-2 after SCT for high-risk non-Hodgkin's lymphoma: a pilot study

A pilot phase I clinical trial involving 15 infusions of anti-CD3 × anti-CD20 bispecific Ab (CD20Bi)-armed anti-CD3-activated T cells (aATC) and low-dose IL-2 was conducted in three non-Hodgkin's lymphoma (NHL) patients (two high-risk and one refractory) after autologous SCT. The feasibility of T-cell expansion, safety of aATC infusions, cytotoxic immune responses and trafficking of aATC were evaluated. Three NHL patients received 15 infusions of 5 × 10(9) aATC (three infusions/week for 3 weeks and one infusion/week for 6 weeks) between days 1 and 65 after SCT with IL-2. There were no dose-limiting toxicities. Chills, fever, hypotension and malaise were the common side effects. Engraftment was delayed in one patient with a low stem cell dose. CD20Bi aATC infusions induced specific cytotoxicity directed at lymphoma targets. Endogenous peripheral blood mononuclear cells from two patients mediated anti-lymphoma cytotoxicity above preSCT background (P<0.001). (111)In labeled aATC trafficked to the lungs at 1 h and accumulated in the liver and bone marrow after 24 h. aATC infusions given over 69 days in combination with IL-2 were safe, did not inhibit engraftment, and induced endogenous cytotoxic responses directed at lymphoma targets.

Serum C-reactive protein and leptin for assessment of nutritional status in patients on maintenance hemodialysis

Nutrition is one of the key parameters in predicting morbidity and mortality in patients with end-stage renal disease (ESRD) on hemodialysis. Body weight, body mass index, and visceral protein levels (serum protein, albumin, prealbumin, and transferrin) have traditionally been used as markers for nutritional status. Serum leptin and C-reactive protein (CRP), have been recently added to the list of markers for nutritional status. This study was a comparative assessment of serum leptin and CRP for nutritional status in patients with ESRD on maintenance hemodialysis. A total of 40 patients with ESRD on maintenance hemodialysis and a similar number of age-, gender-, and BMI-matched healthy individuals were studies. Complete medical history was obtained and relevant clinical examination including anthropometry was carried out. All the individuals were subjected to routine investigations and special investigations (serum leptin and CRP). Data were analyzed using Student's t-test and correlation was found using Pearson's correlation coefficient. Mean value of serum leptin for the study group (1.44 ± 0.72 ng/ml) was found to be significantly higher than that of the control group (0.68 ± 0.55 ng/ml). In addition, we also observed a positive correlation between serum leptin and BMI (r = 0.350, P<0.05). For CRP, we observed that the study group (3.93 ± 1.20 mg/ml) had a significantly higher value vis-à-vis the control group (0.28 ± 0.24 mg/ml). However, CRP and BMI did not show a significant correlation. Based on the above observations, we conclude that serum leptin is a better biomarker than CRP for assessing nutritional status in patients with ESRD on maintenance hemodialysis.

Ocular manifestations in herpes zoster ophthalmicus

BACKGROUND

Ocular complications of herpes zoster ophthalmicus (HZO) may lead to substantial visual disability, severe post-herpetic neuralgia and rarely fatal cerebral complications.

AIM

To identify the pattern of ocular manifestation in herpes zoster ophthalmicus.

MATERIALS AND METHODS

A cross-sectional descriptive study was under taken including the clinically diagnosed cases of HZO. All of them underwent a complete ophthalmological evaluation.

RESULTS

Sixty-eight cases of HZO were examined, of which 37 (54.4 %) were male and 31 (45.6%) female. The mean age was 48.7 ± 18.5 years. Most of the patients (64.7 %) were above the age of 40 years. 77.94 % of the patients had some form of ocular involvement. Pain (77.9 %) was the commonest ocular complaint. In young patients less than 35 years, HIV was the most common risk factor (19.3 %).Visual status was good in the majority (73.5 %) of patients at presentation. Lid and adnexal findings (45.8 %) were most common ocular involvement followed by conjunctivitis (41.1 %). Corneal complication was seen in 38.2 % of cases, uveitis in 19.1 % and post-herpetic neuralgia (PHN) and secondary glaucoma each in 5.8 %.

CONCLUSION

Eyelid and ocular adnexal involvement is most commonly found in patients with herpes zoster ophthalmicus followed by corneal complication and uveitis. There needs to be awareness of ocular involvement, which can be sight threatening, among the HZO patients and other medical departments and an increased emphasis on regular ophthalmic examination.

Assessment of medical and health institutions registered as research centres in Nepal

BACKGROUND

There were several reports in the various mass media regarding misuse of the word "research" by various organization and it has been argued that putting the word "Research" in any agency's name made easier to get the various medical from abroad without paying or paying minimum or discounted government tax than others. The objectives of the study was to find out the status Medical and Health institutions designated as Research Centres in Nepal.

METHODS

A cross sectional prospective study was carried in medical and health institutions of Nepal. Data regarding the registration of institutions/organizations having the word "research" in its name were collected from concerned registered organizations. Formative evaluation method was adopted in which information were added continuously, organized systematically and analysed periodically during the evaluation period.

RESULTS

There were altogether 370 health related research centers registered in MoI and CDO at the district level till 31 December 2010. These research centers were located in 33 districts of Nepal. Among these there were 65 (82%) health facilities and 305 (18%) NGOs designated as research centers. The region wise the range of number of research centers among five regions was 4 to 283. The highest number of research centers level. The highest number of research centers was found in Kathmandu district. Out of 370 research centers, 85 research centers (72 from among health facility related research centers and 13 from among NGO related research centers) were selected randomly for evaluation purpose, which represented 23 percent of sample selection. The sample selection was not less than 20 percent in each category of research centers. One fifth research centers were found to conduct health related research progam. Among which majority (more than 50%) of NGO related research centers was found to conduct health research. There were few (14%) health facility related research centers that actually conducted health related research program. The study also shows that majority 73 (86%) of the research centers didn't start the research yet.

CONCLUSIONS

Forty percent of the research centers in Nepal didn't know the actual reason for putting the word "research" into their signboard. A regulation has to be made to safeguard and maintain the integrity of research in Nepal.

Bilateral parotid tuberculosis

Tuberculosis of parotid is a rare clinical entity, and cases of bilateral tubercular parotitis are even rarer. We present a case of bilateral primary parotid tuberculosis in a 49-year-old female. The patient received anti-tuberculosis treatment for six months, resulting in complete resolution of the disease. We also review the theories related to the pathogenesis of tubercular parotitis, and propose a novel hypothesis about greater involvement of parotid gland as compared to other salivary glands in primary tuberculosis.

Biliary complications after laparoscopic cholecystectomy

BACKGROUND

The reported prevalence of biliary tract disruption following laparoscopic cholecystectomy has ranged from 0% to 7% in early reports. Bile leaks are the most common biliary complication of laparoscopic cholecystectomy.

METHODS

Total 530 patients who had undergone laparoscopic cholecystectomy from January 2004 to November 2006 at Kathmandu Medical College Teaching Hospital were studied for biliary complications after laparoscopic cholecystectomy.

RESULTS

We reviewed 500 laparoscopic cholecystectomies performed at our institution and found 13 cases of bile extravasation and/or biloma formation and/or bile duct injuries (prevalence, 2.6%). One bile duct transection was acutely recognized and treated with hepaticojejunostomy. Three lateral bile duct injuries were also acutely recognized, two of them were managed with primary repair of CBD without T tube and the other was managed with repair and T-tube drainage. Two patients had postoperative generalized biliary peritonitis, one of whom was undergone exploratory laparotomy and found to have lateral injury on CBD which was managed with repair and T-tube drainage, whereas the other was undergone diagnostic laparoscopy with clipping of duct of Lushka. Two patients presented within seven days with biloma, one was treated with percutaneous drainage alone, the other treated with percutanous drainage was found to be complete transection of CBD on subsequent ERCP and managed with late hepaticojejunostomy. One patient with continued bile leak from surgical drainage tube for more than one week was managed with ERCP, diagnosed to be bile leak from duct of Lushka, managed by sphincterotomy and bile duct stenting. One patient presented with obstructive jaundice 6 months after laparoscopic cholecystectomy was found to have Bismuth type II bile duct stricture and was undergone hepaticojejunostomy. The remaining three had bile leak from surgical drainage which resolved within one week without further complication.

CONCLUSIONS

Laparoscopic cholecystectomy appears to be associated with a higher incidence of bile duct injury than previous reports of open cholecystectomy. Possible explanations include variant anatomy plus failure to obtain an operative cholangiogram, inadequate dissection, injudicious use of cautery or clip placement, inherent limitations of the procedure, or the learning curve associated with a new technology.

Knowledge, behavior and attitude towards sexually transmitted infections and acquired immunodeficiency syndrome of adolescent students

BACKGROUND

Adolescence is a period of great physical, mental and emotional turmoil within teenagers. The objective of the study was to assess the knowledge of, attitude to and behaviour towards STI and AIDS among adolescence.

METHODS

Four randomly selected higher secondary school from students of class XI and XII were included after taking their verbal consent. A pre-designed and pre-tested questionnaire was given to all the participants of the school. In order to get correct answers, specific questions were explained to the students with the help of their class teachers.

RESULTS

The results were encouraging with the majority (94.16%) have heard about STIs and HIV/AIDS. Teachers (100%), Newspaper/magazine (90%) and Television (78.33%) were the main informational source about disease. Respondents correctly identified that unsafe sexual contact (86.66%) as major mode of transmission of AIDS and more than 90% of students regarded the use of condoms as the true preventive method for the disease. Among those respondents 6% were sexually active and their partners were either sex worker (71%) or friends (29%).

CONCLUSIONS

The student's attitude towards disease was positive and most of the adolescent wished inclusion of sex education in their text book from secondary level school's curriculum.

Studies on the pharmacokinetics and metabolism of a gamma-secretase inhibitor BMS-299897, and exploratory investigation of CYP enzyme induction

BMS-299897 is a gamma-secretase inhibitor that was effective in reducing amyloid beta-peptide (A beta) in transgenic mice and guinea pigs. Therefore, pharmacokinetic and drug metabolism studies were conducted in animals to support its clinical development. The compound appeared to have low to intermediate total body clearance and was orally bioavailable (24-100%). The oral absorption of BMS-299897 from solid dosage forms appeared to be dissolution rate-limited. BMS-299897 was distributed into extravascular space (V(ss) >or= 1.3 l kg(-1)), including brain (brain-to-plasma ratio = 0.13-0.50). BMS-299897 appeared to be a P-glycoprotein (P-gp) substrate as the brain-to-plasma ratio was two-fold higher in the mdr1a knockout mouse as compared with the wild-type. Apparent autoinduction by BMS-299897 was observed in murine and rat efficacy and toxicity studies. In vitro, BMS-299897 was a weaker inducer of cytochrome P450 3A4 (CYP3A4) and a weaker transactivator of human pregnane X receptor (hPXR) as compared with rifampicin. Induction of human UGT1A and UGT2B was evaluated in primary human hepatocytes, but the results were inconclusive. A low potential for autoinduction in humans was predicted at a clinical dose of 250 mg and the prediction was consistent with the findings from a clinical multiple-dose study with BMS-299897 in probable Alzheimer's patients.

Speckle reduction in ultrasound medical images using adaptive filter based on second order statistics

This article discusses an adaptive filtering technique for reducing speckle using second order statistics of the speckle pattern in ultrasound medical images. Several region-based adaptive filter techniques have been developed for speckle noise suppression, but there are no specific criteria for selecting the region growing size in the post processing of the filter. The size appropriate for one local region may not be appropriate for other regions. Selection of the correct region size involves a trade-off between speckle reduction and edge preservation. Generally, a large region size is used to smooth speckle and a small size to preserve the edges into an image. In this paper, a smoothing procedure combines the first order statistics of speckle for the homogeneity test and second order statistics for selection of filters and desired region growth. Grey level co-occurrence matrix (GLCM) is calculated for every region during the region contraction and region growing for second order statistics. Further, these GLCM features determine the appropriate filter for the region smoothing. The performance of this approach is compared with the aggressive region-growing filter (ARGF) using edge preservation and speckle reduction tests. The processed image results show that the proposed method effectively reduces speckle noise and preserves edge details.

Hydatid cyst of mediastinum

We report a case of hydatid cyst of the mediastinum in a 32-year-old female patient who was admitted with chest pain. CT scan reported posterior mediastinal mass towards the right side. Surgical exploration revealed a loculated cyst in posterior mediastinum on the right side, adherent to the overlying lung and underlying bone. Posterolateral thoracotomy was performed for cyst aspiration and excision. The patient was discharged on albendazole.