Endoscopic management of spontaneous perforation of a cystic duct in a 10-year-old child

A 10-year-old boy presented to us with acute abdominal pain and vomiting. The patient was stable on clinical examination. On ultrasound and computed tomography scan of the abdomen he had persistent peritoneal collection with edematous pancreas. Abdominal paracentesis revealed bile and 99m Tc HIDA (hepatobiliary iminodiacetic acid) scan showed a biliary leak. A percutaneous drain was inserted for collection, and endoscopic retrograde cholangiopancreatography (ERCP) was performed. A spontaneous cystic duct perforation was confirmed on ERCP and a biliary stent was inserted. The patient's general condition improved, his percutaneous drain was removed on day 6 post ERCP and the biliary stent removed after 3 months. The patient is asymptomatic and doing well at 6 months' follow up. Spontaneous perforation of a cystic duct is an extremely rare condition with very few reported cases in the literature. Radionuclide scanning and ERCP are reliable modes for diagnosis and localization of the site of the leak. ERCP and biliary stenting are successful in the management of these patients.

Magnetic properties of self-assembled Ni nanoparticles in two dimensional structures

A pulsed laser deposition technique has been used to synthesize a uniform distribution of Ni nanoparticles of controllable size in Al2O3 thin film matrix. The ability to control particle size in confined layers provides a very convenient means to tune the magnetic properties from superparamagnetic to ferromagnetic. The coercivity of these particles was measured at various temperatures as a function of particle size. The results indicate that the magnetic transition from single- to multi-domain region occurs at a larger particle size at higher temperature than at lower temperature. Stronger magnetic interaction among particles at lower temperatures is believed to lead to the formation of smaller sized domains for any given particle size in order to minimize the interaction energy.

Febrile neutropenia during acute myeloid leukemia therapy: Single institution experience from a developing country

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Background: Febrile neutropenia poses a major challenge during treatment of acute myeloid leukaemia (AML). Methods: Episodes of febrile neutropenia in 104 consecutive patients of AML admitted to the medical oncology ward between May 2001 and December 2006 were studied. There were 62 males and 42 females, median age 28 years (2–61 years). Results: 402 febrile episodes including 363 episodes of febrile neutropenia (180 in induction, 183 in consolidation) and 39 non-neutropenic episodes (18 in induction, 21 in consolidation) occurred. Clinical, microbiological and radiological foci could be detected in 51.1%, 22.2 %, and 31.1% episodes of febrile neutropenia during induction and 31.1%, 19.1% and 12.7% episodes during consolidation. Rates of documented infections during induction and consolidation were 74% and 52%. Respiratory (39.2%) and ear, nose, and throat ( 23.9%) were the commonest clinical sites during induction. Respiratory (21%) and central line infections (19.2%) were commonest during consolidation. Gram negative infections predominated (Pseudomonas aeruginosa, Klebsiella pneumoniae: major isolates). 32.5% of microbiologically proven infections during induction and 14.2% during consolidation were polymicrobial. Bronchopneumonia was the commonest radiological focus. There were 60 episodes of fungal infections (47 in induction, 13 in consolidation). There were: 1 definite: mucormycosis, 3 probable (1 case each: Candida krusei, Candida tropicalis in blood, 1 chronic disseminated hepatosplenic candidiasis), and 56 possible infections. Halo sign was seen in 18, sinusitis with bone erosion in 7. Infections accounted for 85% of the 20 deaths (induction: 18). Fungal infections and bronchopneumonia were major causes of mortality (p = 0.001). 3/4 enterococcal bacteremias were associated with mortality (p = 0.001). 6 cases of tuberculosis (5 pneumonias with necrotic mediastinal nodes, 1 Pott's spine) and 3 cases of malaria (1 cerebral malaria) were also detected. Conclusions: Induction was associated with greater morbidity and mortality. Prompt and proper institution of antibiotics and antifungals besides considering alternative diagnosis peculiar to the region (e.g. tuberculosis, malaria) may aid in better management.

No significant financial relationships to disclose.

Neoadjuvant versus concurrent chemotherapy in the management of carcinoma nasopharynx

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Background: Chemotherapy is added to radiotherapy in the treatment of nasopharyngeal carcinoma with advanced locoregional disease to enhance therapeutic gain. Thirty percent patients with locally advanced nasopharyngeal carcinoma (LA-NPC) still die of distant metastases despite concurrent chemoradiation being the standard of care. In this retrospective study we performed the pooled analysis of these patients to assess the impact of neoadjuvant chemotherapy versus the concurrent chemoradiation approach. Methods: Between January 2000 and December 2007, 45 patients of stage IIB- IVB nasopharyngeal were treated with 3 cycles of induction chemotherapy with cisplatin and 5FU (n = 23) followed by conventional radical radiotherapy, or concurrent chemoradiation with weekly cisplatin (n = 22). Results: Total numbers of patients eligible for analyses were 45. Median age of the patients was 52 years (range 19–76 years). Median follow up was 17 months (range 6–60 months). At the time of last follow up, 13 patients (out of 23, i.e. 56.53%) were alive and disease free in the neoadjuvant group and 13 patients (out of 22, i.e. 59.1%) were alive and disease free in the concurrent chemoradiation group. The 2-year failure free survival in the concurrent chemoradiation arm was 63% versus 35% in the neoadjuvant arm (p = 0.197). Survival analyses adjusted for the gender male revealed 2-year failure free survival as 81% in the concurrent chemoradiation versus 44% in the neoadjuvant chemotherapy group among male patients (p = 0.0143). On multivariate analysis age and stage were the two significant predictive factors for failure free survival. Conclusions: The neoadjuvant chemotherapy seems to be at least as effective as concurrent chemoradiation in this small cohort of patients.

No significant financial relationships to disclose.

Multiple myeloma: Autologous stem cell transplantation versus conventional chemotherapy—A retrospective age and stage matched analysis

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Background: We retrospectively analyzed results of MM patients who underwent high-dose chemotherapy and stem cell transplantation (ASCT). In age and stage matched analysis, we compared with those patients who received conventional chemotherapy. Methods: Between January 1995 and June 2007, 95 patients underwent ASCT (Tx Group). 149 age and stage matched patients received conventional chemotherapy (CC Group). High-dose melphalan (200 mg/m2) was used for conditioning in Tx group. Baseline characteristics were comparable in both groups: median age was 50 years (range, 26 to 68 years) in Tx group versus 52 years (range 24 to 68 years) in CC group, p < 0.05; M:F = Tx Group -68:27 versus CC Group 98:51, p = 0.34; stage 3A/3B = 76.8%/23.2% in Tx Group versus 62.4%/37.6%, p = 0.02; mean Hb (Gm/dl) 9.1(range, 3.3–14.3) versus 8.6 (3.3–14.8), p = 0.21; median serum albumin (Gm/dl) 3.5 (range, 1.8–5.2) versus 3.4 (1.6–6.2), p = 0.7, respectively in two groups. Results: Following treatment, the response rates (CR + VGPR + PR = 81%) were significantly higher in Tx group compared to CC group (55%), p = 0.001. CR rate was higher in Tx group, 34.7% versus 12.8%, p < 0.001. The median overall survival was significantly higher in Tx group (75 months, 95%CI [72–106 months]) versus (24 months, 95%CI [19–36months]), p = 0.001. The median progression free survival was 30 months in Tx group (95%CI [21–48 months]) compared to 6 months in CC group (95% CI 3–9 months), p < 0.0001. Estimated overall survival at 5 years in Tx group is 66.6% (95% CI [54.8%-75.9%]) compared to 20.7% (95% CI [13.5%-29%]) in CC group. Conclusions: High-dose chemotherapy followed by autologous stem cell transplantation results in higher overall and complete response rates in multiple myeloma patients. This is associated with improved progression free and overall survival. Low-dose maintenance therapy to sustain the survival benefit of transplant would be possible areas of research in future studies.

No significant financial relationships to disclose.

A novel selective therapeutic targeting heme oxygenase-1 revealed a potent antimetastatic activity in androgen-refractory human prostate cancer models

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Prostate cancer is a highly prevalent disease. Despite a significant improvement in the overall survival attributed in part to early detection and introduction of novel therapeutic modalities, many cancer patients at primary diagnosis present advanced disease or experience recurrence of the cancer. The progression of prostate cancer (PCA) to hormone-refractory phenotype (HRPCA) and to metastasis is an ominous event in patients with advanced PCA. Currently, clinically available drugs for hormone refractory PCA have only marginal efficacy. In this study, we identified heme oxygenase 1 (HO-1) to be significantly upregulated in epithelial PCA cells, but not in surrounding stromal cells, from hormone refractory prostate cancer cases compared to hormone-responsive prostate cancer and to benign tissues. We validated HO-1 as a novel therapeutic target for HRPCA. Specifically, inhibition of HO-1 gene in androgen-independent and highly invasive prostate cancer cells, PC3M, decreased HO-1 activity, oxidative stress, MAPKs activation, cell proliferation, and cell migration and invasion in vitro, as well as inhibition of prostate tumor growth and lymph nodes and lung metastases in vivo. The impact of HO-1 silencing on these oncogenic features was mimicked by exposure of cells to a novel selective small-molecule HO-1 inhibitor referred to as OB-24. OB-24 selectively downregulates HO-1 activity, oxidative stress, and significantly inhibits cell proliferation in vitro and tumor growth and lymph node/lung metastases in vivo. A potent synergistic activity in inhibiting HRPCA metastasis formation was observed when OB-24 was combined with the chemotherapy drug taxol. The molecular and potential clinical impact of OB-24 alone and in combination with taxanes on HRPCA will be discussed.

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Spontaneous transmural migration of retained surgical textile into both small and large bowel: a rare cause of intestinal obstruction

Retained surgical textile is an infrequent but serious complication of abdominal surgery. Diagnosis is often delayed owing to non-specific clinical symptoms and inconclusive imaging features. Medicolegal implications further complicate the issue. We report a case of a 30-year-old woman who had previously undergone caesarean section and who presented with pain and features of intestinal obstruction. Contrast-enhanced CT revealed a heterogeneous ill-defined mass with mottled air densities lying within both the large and the small bowel. Barium study beautifully demonstrated the intraluminal mass in the transverse colon extending into the jejunum, with a fistulous communication between the two loops. To the best of our knowledge, this is the first reported case in which the gauze migrated simultaneously into the large and small bowel, and where the exact site of migration was clearly mapped out on pre-operative imaging studies.

Two variants in Ankyrin 3 (ANK3) are independent genetic risk factors for bipolar disorder

Two recent reports have highlighted ANK3 as a susceptibility gene for bipolar disorder (BD). We first reported association between BD and the ANK3 marker rs9804190 in a genome-wide association study (GWAS) of two independent samples (Baum et al., 2008). Subsequently, a meta-analysis of GWAS data based on samples from the US and the UK reported association with a different ANK3 marker, rs10994336 (Ferreira et al., 2008). The markers lie about 340 kb apart in the gene. Here, we test both markers in additional samples and characterize the contribution of each marker to BD risk. Our previously reported findings at rs9804190, which had been based on DNA pooling, were confirmed by individual genotyping in the National Institute of Mental Health (NIMH) waves 1-4 (P=0.05; odds ratio (OR)=1.24) and German (P=0.0006; OR=1.34) samples. This association was replicated in an independent US sample known as NIMH wave 5 (466 cases, 212 controls; P=0.017; OR=1.38). A random-effects meta-analysis of all three samples was significant (P=3 x 10(-6); OR=1.32), with no heterogeneity. Individual genotyping of rs10994336 revealed a significant association in the German sample (P=0.0001; OR=1.70), and similar ORs in the NIMH 1-4 and NIMH 5 samples that were not significant at the P<0.05 level. Meta-analysis of all three samples supported an association with rs10994336 (P=1.7 x 10(-5); OR=1.54), again with no heterogeneity. There was little linkage disequilibrium between the two markers. Further analysis suggested that each marker contributed independently to BD, with no significant marker x marker interaction. Our findings strongly support ANK3 as a BD susceptibility gene and suggest true allelic heterogeneity.

Actions and comparative efficacy of phosphatidylcholine formulation and isolated sodium deoxycholate for different cell types

BACKGROUND

Phosphatidylcholine formulation has been used to dissolve local fat deposits. This study aimed to evaluate and compare the effects of phosphatidylcholine formulation and its vehicle sodium deoxycholate alone on different cell lines to understand better its mechanism of action.

METHODS

Cells and media including 3T3-L1 preadipocytes, normal foreskin fibroblasts, neonatal human dermal microvascular endothelial cells (CADMEC), and fetal human skeletal muscle cells (HSkMC) were used. After 24 h, cells were exposed in 3-4, 5-dimethylthiazol-2-yl-2, 3-diphenyl tetrazolium bromide reagent (MTT assays) to increasing dosages of phosphatidylcholine formulation (0.0156-0.5 mg/ml) or an equivalent vehicle, sodium deoxycholate solution, pH 9.0 (0.0066-0.210 mg/ml). Viability was assessed after 1, 2, and 3 days of treatment. Fat tissue (4 x 4 cm) obtained ex vivo from the dorsal fat pads of five rabbits was injected with 2 ml of phosphatidylcholine formulation (50 mg/ml), sodium deoxycholate (21 mg/ml), or normal saline and incubated for 24 h. These were examined histologically to identify cell lysis and morphologic changes.

RESULTS

At 0.125- and 0.25-mg/ml doses of phosphatidylcholine solution, CADMEC and HSkMC were more sensitive (P < 0.001, one-way ANOVA) than adipocytes at all time points examined. Phosphatidylcholine formulation at a dose of 0.5 mg/ml and the equivalent vehicle, sodium deoxycholate, at a dose of 0.21-mg/ml both induced nearly 100% fat cell lysis after 24 h, and evidence of cell lysis as early as 6 h after exposure. After incubation of fat tissue for 24 h with phosphatidylcholine formulation, loss of intracellular lipid staining with an increase in extracellular lipids was seen.

CONCLUSIONS

Isolated sodium deoxycholate was almost as effective as the phosphatidylcholine formulation, at clinical concentrations, in reducing the viability of mature adipocytes over time. Similar cytotoxic effects of phosphatidylcholine formulation on normal foreskin fibroblasts, endothelial cells, and human skeletal muscle cells also were observed. The data prove that the formulation acts in a nonspecific manner and that its unintentional administration to other tissues causes cell death.

Acute toxicity of endosulfan and malathion on Chironomus ramosus (Insecta: Diptera: Chironomidae) from north Cachar hills, Assam, India

Acute toxicity tests for the pesticides endosulfan and malathion on the larvae of Chironomus ramosus were conducted. Median Lethal Concentration (LC50) values of endosulfan were 0.55 x 10(-2), 0.16 x 10(-2), 0.089 x 10(-2) and 0.036 x 10(-2) ppb respectively, while those for malathion were 0.139 x 10(-2), 0.054 x 10(-2), 0.019 x 10(-2) and 0.0032 x 10(-2) ppb respectively, at 24, 48, 72 and 96 hr. Thus Chironomus ramosus larvae were more sensitive to malathion at all hours of toxicity tests than endosulfan.

Fixed-diameter scan protocol preferable for retinal nerve fibre layer measurement by optical coherence tomography in all sizes of optic discs

BACKGROUND

Retinal nerve fibre layer (RNFL) measurements using a fixed-diameter versus a user-defined scan-protocol of optical coherence tomography (Stratus OCT) were compared in 32 normal, 62 glaucoma suspects and 36 glaucomatous eyes.

METHODS

Peripapillary RNFL thickness was measured using the standard "fast" RNFL scan-protocol and proportional 2.27 x disc scan protocol. Disc size was measured using the "fast" optic disc protocol. The correlation between RNFL thickness for each scan-protocol and disc size was analysed.

RESULTS

In normal eyes, RNFL thickness was independent of the optic-disc area using the fixed-diameter protocol (p = 0.92) but was inversely proportional to disc size using the proportional protocol (p<0.001). In glaucoma suspects, the optic-disc area correlated with RNFL thickness using the fixed-diameter protocol (p<0.001). In the multivariate analysis in glaucomatous eyes, the RNFL thickness using the fixed-diameter protocol was significantly affected by the mean deviation on visual fields but not by disc area (p<0.001 and p = 0.64 respectively)

CONCLUSION

In normal subjects, disc size does not appear to affect RNFL measurements by OCT using the fixed-diameter protocol, thus indicating that RNFL thickness may be related to distance from the centre of the optic disc rather than the margin. The thicker RNFL observed in large glaucomatous discs in this study may be related to the earlier stage of glaucoma, though it may not apply to the general population.

Bifid mandibular condyle with associated temporomandibular joint ankylosis: a computed tomography study of the patterns and morphological variations

OBJECTIVES

Bifid mandibular condyle (BMC) with associated temporomandibular joint ankylosis (TMJA) is extremely rare with only four cases reported. We present the first case series of BMC with TMJA in an attempt to elucidate the morphological pattern in this rare condition.

METHODS

Retrospective examination of CTs over a period of 6 years revealed 37 patients with TMJA, of whom 10 had BMC. Clinical and CT features of these were analysed. Patients were grouped according to sides of involvement and orientation of condyles.

RESULTS

The male:female ratio was 1:1. Nine were post-traumatic and one post-infectious. The aetiology was sustained in childhood in all patients. Six patients had unilateral BMCs and four had bilateral. One patient had bilateral BMCs with bilateral TMJA. This was anteroposterior (AP) in orientation. Three patients had bilateral BMCs with unilateral TMJA, among which one was AP and two mediolateral (ML). Six patients had unilateral BMC with ipsilateral TMJA; all of the ML anterior condylar process was ankylosed in joints with AP BMC and TMJA. Lateral condylar process was ankylosed in post-traumatic ML BMC with TMJA, while the medial condylar process ankylosed in the post-infectious patient. In general, ankylosed heads were found to be larger, sclerotic and often mushroom shaped compared with non-ankylosed heads.

CONCLUSIONS

This series attempts to elucidate patterns of ankylosis and CT morphology in BMC with associated TMJA. Also included are hitherto unreported cases such as bilateral AP BMC with TMJA and post-infectious BMC with TMJA.

Bone Marrow Culture Vs Blood Culture in FUO

Introduction:Bone marrow culture is considered superior to blood culture in evaluation of FUO. The aim of this study was to compare the usefulness of these two cultures.Methods:A one year prospective cross sectional study was conducted to fi nd out the usefulness of bone marrow culture and blood culture in the diagnosis of FUO. Marrow aspirates in each case were sent for bacterial, myocbacterial and fungal culture. Simultaneously venous blood was sent forbacterial culture. The results of BMCs and BCs were compared. Results:Total 57 cases of FUO were included in the study. Male female ratio was 1.22:1. Age range was fi ve to 83 years (median 30). Duration of fever was 21 to 365 days. Bacterial growth was seen in nine cases (15.78%) of BMCs and in three cases (5.26%) of corresponding BCs. Fungal or myocbacterial growth was not seen. Salmonella typhi was the commonest organism isolated in BMCs (three cases) followed by Staphylococcus aureus (two cases), Escherichia coli, Non fermenting Gram negative bacilli, Enterococcus species and Salmonella paratyphi–A (one case each). Two cases of Salmonella typhi and one case of Salmonella paratyphi–A were isolated in BCs. Conclusions:BMCs are more useful than BCs in evaluation of patients with FUO, especially in cases of salmonella infection and are particularly important when the patient has already taken antibiotics. In immuno-competent patients presenting with FUO, BMCs for mycobacteria or fungi is unlikely to yield any growth. Key Words: blood culture, bone marrow culture, fever of unknown origin

Bone marrow culture vs. blood culture in FUO

INTRODUCTION

Bone marrow culture is considered superior to blood culture in evaluation of FUO. The aim of this study was to compare the usefulness of these two cultures.

METHODS

A one year prospective cross sectional study was conducted to find out the usefulness of bone marrow culture and blood culture in the diagnosis of FUO. Marrow aspirates in each case were sent for bacterial, myocbacterial and fungal culture. Simultaneously venous blood was sent for bacterial culture. The results of BMCs and BCs were compared.

RESULTS

Total 57 cases of FUO were included in the study. Male female ratio was 1.22:1. Age range was five to 83 years (median 30). Duration of fever was 21 to 365 days. Bacterial growth was seen in nine cases (15.78%) of BMCs and in three cases (5.26%) of corresponding BCs. Fungal or myocbacterial growth was not seen. Salmonella typhi was the commonest organism isolated in BMCs (three cases) followed by Staphylococcus aureus (two cases), Escherichia coli, Non fermenting Gram negative bacilli, Enterococcus species and Salmonella paratyphi-A (one case each). Two cases of Salmonella typhi and one case of Salmonella paratyphi-A were isolated in BCs.

CONCLUSION

BMCs are more useful than BCs in evaluation of patients with FUO, especially in cases of salmonella infection and are particularly important when the patient has already taken antibiotics. In immuno-competent patients presenting with FUO, BMCs for mycobacteria or fungi is unlikely to yield any growth.

The effectiveness and safety of single-use disposable instruments in cataract surgery--a clinical study using a surgeon-based survey

AIM

To compare ease of use, handling, defects and complication rates between single use and reusable instruments in cataract surgery.

METHODS

Prospective questionnaire-based study involving ophthalmic surgeons operating during a one-year period.

RESULTS

Results showed better scores in relation to questions regarding ease of use and handling for permanent instruments (p < 0.0001). Two complications out of 93 procedures were reported in the reusable group (2.2%) compared to six out of 157 in the disposable group (3.8%) (p = 0.4681).

CONCLUSIONS

Disposable instruments in cataract surgery are an acceptable and safe alternative to reusable ones.

Observation of two-source interference in the photoproduction reaction AuAu --> AuAurho0

In ultraperipheral relativistic heavy-ion collisions, a photon from the electromagnetic field of one nucleus can fluctuate to a quark-antiquark pair and scatter from the other nucleus, emerging as a rho{0}. The rho{0} production occurs in two well-separated (median impact parameters of 20 and 40 F for the cases considered here) nuclei, so the system forms a two-source interferometer. At low transverse momenta, the two amplitudes interfere destructively, suppressing rho{0} production. Since the rho{0} decays before the production amplitudes from the two sources can overlap, the two-pion system can only be described with an entangled nonlocal wave function, and is thus an example of the Einstein-Podolsky-Rosen paradox. We observe this suppression in 200 GeV per nucleon-pair gold-gold collisions. The interference is 87%+/-5%(stat.)+/-8%(syst.) of the expected level. This translates into a limit on decoherence due to wave function collapse or other factors of 23% at the 90% confidence level.

Vesicoscopic ureterotomy: novel technique for management of posttransplant ureteric stricture

Ureteral obstruction following renal transplantation is not an uncommon complication. Open surgery has been the traditional approach. In recent years, retrograde endourologic techniques have been used to manage this complication with good results. In cases of failure of retrograde catheterization of the neomeatus, a percutaneous approach is employed. We present a new technique of pneumovesicoscopic ureterotomy in case of posttransplant ureteric stricture, with failure of retrograde catheterization. This simple, minimally invasive approach for these patients avoids transplant kidney puncture.