Abducens (sixth) nerve palsy presenting as a rare case of isolated brainstem metastasis from a primary breast carcinoma

Most isolated abducens (sixth) nerve palsies are ischaemic in nature. However, there are other causes that can mimic an abducens nerve palsy, which requires aggressive diagnostic management. A 56-year-old hypertensive woman presented with a right abduction deficit. Her past history revealed that she had undergone a mastectomy and completed a course of chemo- and radiation therapy for breast carcinoma. She was well until she develped binocular diplopia five months later. Magnetic resonance imaging showed a right pontine mass. Stereotactic biopsy was performed, and histopathology revealed a metastatic carcinoma that was compatible with an origin from the breast primary. We conclude that identifying and managing patients with metastatic lesions involves a multidisciplinary approach. Thorough history-taking and neuro-ophthalmologic evaluation would help physicians in establishing the primary differentials, which could not only be sight-saving but life-saving as well.

Elastic properties of polycaprolactone at small strains are significantly affected by strain rate and temperature

Tensile tests were conducted on polycaprolactone at various strain rates and temperatures. Focusing on the mechanical properties within only the small-strain elastic region, i.e. up to the inflection point in the stress–strain diagram, it was found that strain rate and temperature had significant effects on the polymer. This finding implies that the effects of strain rate and temperature on the elastic properties of polycaprolactone should be considered in the design and manufacture of rigidity-sensitive, load-bearing applications, including use as biomaterial for scaffolds in tissue engineering applications.

Isolation of the first three cases of Clostridium difficile polymerase chain reaction ribotype 027 in Singapore

INTRODUCTION

The incidence of Clostridium (C.) difficile infection (CDI) was on the rise from 2001 to 2006 in Singapore. Recent unpublished data suggests that its incidence had remained stable or decreased in most local public hospitals between 2006 and 2010. It is, however, not known if the polymerase chain reaction (PCR) ribotype 027 strains have been circulating, although reports suggest that this strain is emerging in Asia, with the first cases reported from Japan in 2007, as well as in Hong Kong and Australia in 2009. We initiated a culture-based surveillance to detect this epidemic strain in Singapore.

METHODS

From September 2008 to December 2009, all non-duplicate toxin-positive stool samples from the three largest public hospitals in Singapore were collected for culture and further analysis.

RESULTS

Out of the 366 samples collected, 272 viable isolates were cultured. Of these, 240 tested toxin-positive and ten tested positive for the binary toxin gene; 35 different PCR ribotypes were found. Three isolates that tested positive for binary toxin contained the same PCR ribotyping pattern as the C. difficile 027 control strain. All three had the 18-bp deletion and single nucleotide tcdC deletion at position 117. Susceptibility testing was performed, demonstrating susceptibility to erythromycin and moxifloxacin.

CONCLUSION

We report the first three isolates of C. difficile 027 from Singapore. However, their susceptibility patterns are more consistent with the historical 027 strains. Rising CDI incidence may not be associated with the emergence of the epidemic 027 strain at this time.

Mesenteric desmoid tumour masquerading as a fat-containing cystic mass

Mesenteric desmoid tumour (MDT) is an uncommon neoplasm that typically presents as a solid soft-tissue mass on cross-sectional imaging. MDT manifesting as a fat-containing cystic mass on CT has not been described in the literature. We report such an unusual case with clinicopathological correlation.

A case of a giant mucocoele of the appendiceal stump presented with a palpable mass in the right thigh: pre-operative diagnosis based on characteristic multidetector CT findings

The pre-operative diagnosis of a mucocoele of the appendiceal stump (MAS) may be difficult owing to rarity and non-specific clinical presentation. However, a pre-operative diagnosis of a MAS is important to prevent widespread dissemination by inadvertent spillage of mucous contents. We describe a case of a MAS presenting with a palpable mass in the right thigh in which a pre-operative diagnosis was made by characteristic multidetector CT (MDCT) findings.

Incidence trends in invasive uterine cervix cancer and carcinoma in situ in Incheon, South Korea

INTRODUCTION

This study examined trends of invasive uterine cervix cancer and carcinoma in situ (CIS) in terms of the incidence and mortality in Incheon over a twelve year period.

METHODS

Uterine cervical cancer data were retrieved from the Incheon Cancer Registry (ICR) and Korea Central Cancer Registry (KCCR) from 1997 to 2008. The time trends in age-standardized incidence rates (ASR) of invasive uterine cervix cancer patients and CIS were calculated and compared with the nation-wide cancer registry data for each year. Mortality/incidence (M/I) ratios according to age and the incidence of the pathologic subtype in Incheon each year were also examined, along with an international comparison.

RESULTS

A total of 3,096 cases of invasive cervical cancer and 2,079 cases of carcinoma in situ were analyzed from 1997 to 2008. The time trend incidence of the total ASR in uterine cervical cancer decreased from 25.7 in 1997 to 13.4 in 2008, but the incidence of CIS increased from 7.6 to 15.8 in same period. In invasive cancers, the age-specific incidence rates were highest in those in their sixties while patients in their forties showed highest CIS values. The mortality rate in ICR was 3.7 from 1998 to 2002. Compared to the other countries which have high risk factors for cervix cancer, the peak incidence zone was different in Incheon.

CONCLUSION

The ICR showed a decrease in the incidence of invasive cervical cancer that was similar to the nation-wide data. An early increase zone is a characteristic pattern in the age specific incidence curve. Early screening and a vaccination program should be activated for prevention of young age cervical cancer.

Novel oxidative modifications in redox-active cysteine residues

Redox-active cysteine, a highly reactive sulfhydryl, is one of the major targets of ROS. Formation of disulfide bonds and other oxidative derivatives of cysteine including sulfenic, sulfinic, and sulfonic acids, regulates the biological function of various proteins. We identified novel low-abundant cysteine modifications in cellular GAPDH purified on 2-dimensional gel electrophoresis (2D-PAGE) by employing selectively excluded mass screening analysis for nano ultraperformance liquid chromatography-electrospray-quadrupole-time of flight tandem mass spectrometry, in conjunction with MODi and MODmap algorithm. We observed unexpected mass shifts (Δm=-16, -34, +64, +87, and +103 Da) at redox-active cysteine residue in cellular GAPDH purified on 2D-PAGE, in oxidized NDP kinase A, peroxiredoxin 6, and in various mitochondrial proteins. Mass differences of -16, -34, and +64 Da are presumed to reflect the conversion of cysteine to serine, dehydroalanine (DHA), and Cys-SO2-SH respectively. To determine the plausible pathways to the formation of these products, we prepared model compounds and examined the hydrolysis and hydration of thiosulfonate (Cys-S-SO2-Cys) either to DHA (Δm=-34 Da) or serine along with Cys-SO2-SH (Δm=+64 Da). We also detected acrylamide adducts of sulfenic and sulfinic acids (+87 and +103 Da). These findings suggest that oxidations take place at redox-active cysteine residues in cellular proteins, with the formation of thiosulfonate, Cys-SO2-SH, and DHA, and conversion of cysteine to serine, in addition to sulfenic, sulfinic and sulfonic acids of reactive cysteine.

Systemic lupus erythematosus presenting as Stevens-Johnson syndrome and toxic epidermal necrolysis: a report of three cases

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening dermatological conditions that are characterized by mucositis, epidermal detachment and erosions. The underlying etiology in SJS and TEN is almost invariably secondary to drugs. Rarely, other causes such as systemic lupus erythematosus (SLE), infections and vaccinations have been implicated. This report describes three patients with SLE who presented with manifestations of SJS/TEN without a clear drug causality. All three patients presented with photodistributed macular exanthema, which evolved to target lesions, bullae, erosions or sheet-like detachment. This was associated with oral mucositis and conjunctivitis. The onset of the rash was insidious with a protracted clinical course. Ultraviolet exposure and steroid tapering appear to be precipitating factors. In two of the patients, SJS and TEN were the initial presentation of lupus. Although SJS and TEN are almost invariably due to medications, they may, rarely, be an initial presentation of lupus, particularly when associated with an initial photodistribution, absence of genital involvement and a prolonged clinical course.

Vitamin C protects against ethanol and PTZ-induced apoptotic neurodegeneration in prenatal rat hippocampal neurons

Exposure to alcohol during brain development may cause a neurological syndrome called fetal alcohol syndrome, characterized by pre- and postnatal growth deficiencies, craniofacial anomalies, and evidence of CNS dysfunction. The objective of this study was to evaluate pentylenetetrazol (PTZ) and ethanol effects on Bax, Bcl-2 expression, which further induced activation of caspase-3, release of cytochrome-c from mitochondria, and to observe the protective effects of vitamin C (vit-C) against PTZ and ethanol-induced apoptotic neurodegeneration in primary-cultured neuronal cells at gestational day 17.5. Apoptotic neurodegeneration and neuroprotective effect of vit-C were measured by using 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl tetrazolium bromide assay, Western blot analysis, which further conformed by the measurement of mitochondrial membrane potential using JC-1 detection kit and immunofluorescence analysis. The results showed that PTZ and ethanol produced extensive Bax-dependent caspase-9 and caspase-3 activation and caused neuronal apoptosis. Furthermore, the cotreatment of vit-C along with ethanol and PTZ showed significantly decreased expression of Bax, caspase-9, caspase-3, cytochrome-c, and significantly increased expression of antiapoptotic Bcl-2 protein when compared with control group. Our findings indicate that PTZ and ethanol activate an intrinsic apoptotic death program in neurons that is likely to contribute to the neuropathologic effects in fetal alcohol exposure, and vit-C can prevent some of the deleterious effects of PTZ and ethanol on the developing brain. The available experimental evidence and the safety of vit-C in pregnancy suggest the experimental use of ascorbic acid as a new and effective protective agent ethanol and PTZ-induced apoptotic neurodegeneration.

Brain-derived neurotrophic factor gene polymorphisms and mirtazapine responses in Koreans with major depression

Brain-derived neurotrophic factor (BDNF) is a candidate molecule for influencing the clinical response to antidepressant treatment. The aims of this study were to determine the relationship between the Val66Met polymorphism in the BDNF gene and the response to mirtazapine in 243 Korean subjects with major depressive disorder (MDD). The reduction in the Hamilton Depression score over the 8-week treatment period was not influenced by BDNF V66M genotypes. A marginal effect of genotype on somatic anxiety score was observed at baseline (P = 0.047 in the dominant model). However, genotype-time interaction had no effect on somatic anxiety score after the 8-week a treatment period. Plasma BDNF levels tended to increase during mirtazapine treatment, although without statistical significance (P = 0.055). After 8 weeks of mirtazapine treatment, plasma BDNF levels were higher in Met allele homozygotes (1499.7 ± 370.6 ng/mL) than in Val allele carriers (649.7 ± 158.5 ng/mL, P = 0.049). Our results do not support the hypothesis that the Val66Met promoter polymorphism in the BDNF gene influences the therapeutic response to mirtazapine in Korean MDD patients. However, our data indicate that this polymorphism results in increased plasma BDNF after mirtazapine treatment.

Lysophosphatidic acid augments human hepatocellular carcinoma cell invasion through LPA1 receptor and MMP-9 expression

Lysophosphatidic acid (LPA), produced extracellularly by autotaxin (ATX), has diverse biological activities implicated in tumor initiation and progression, including increasing cell survival, angiogenesis, invasion and metastasis. ATX, LPA and the matrix metalloproteinase (MMP)-9 have all been implicated in hepatocellular carcinoma (HCC) invasion and metastasis. We, thus sought to determine whether ATX with subsequent LPA production and action, including induction of MMP-9 could provide a unifying mechanism. ATX transcripts and LPA receptor type 1 (LPA1) protein are elevated in HCC compared with normal tissues. Silencing or pharmacological inhibition of LPA1 significantly attenuated LPA-induced MMP-9 expression and HCC cell invasion. Further, reducing MMP-9 activity or expression significantly inhibits LPA-induced HCC cell invasion, demonstrating that MMP-9 is downstream of LPA1. Inhibition of phosphoinositide-3 kinase (PI3K) signaling or dominant-negative mutants of protein kinase Cδ and p38 mitogen-activated protein kinase (MAPK) abrogated LPA-induced MMP-9 expression and subsequent invasion. We thus demonstrate a mechanistic cascade of ATX-producing LPA with LPA activating LPA1 and inducing MMP-9 through coordinate activation of the PI3K and the p38 MPAK signaling cascades, providing novel biomarkers and potential therapeutic targets for HCC.

Intracranial stenting in patients with atherosclerotic stenosis associated with various aneurysms in the same diseased arterial segment

BACKGROUND AND PURPOSE

Aneurysms are rarely associated with symptomatic intracranial stenosis. We report the results of recanalization by stent placement in patients with symptomatic severe intracranial stenosis associated with adjacent aneurysms.

MATERIALS AND METHODS

Of 139 patients who underwent intracranial stent placement during a 5-year period, 10 (7%) had symptomatic severe intracranial stenosis associated with adjacent aneurysms. Five were in the VA, 3 in the BA, and 2 in M1. The types of aneurysm were atherosclerotic fusiform (n = 5), ulcerative (n = 4), and saccular (n = 1). We analyzed angiographic findings based on biplane and 3D angiograms and assessed patient outcomes and complications after stent placement. The results were compared with those of a control group without aneurysms who underwent stent placement during the same study period.

RESULTS

Aneurysm locations were post- (n = 6), in- (n = 2), and pre-stenotic (n = 2). After angioplasty with stent placement and/or aneurysm embolization, there were no lesion-related strokes or deaths during a median follow-up period of 25 months (range, 11-43 months). One patient had asymptomatic restenosis. The final mRS score was good (≤2) in all patients. There were no statistically significant differences in event or restenosis rates compared with the control group.

CONCLUSIONS

Adjacent aneurysms were rarely associated with severe intracranial stenosis but were more common in the posterior circulation. Intracranial stent placement may be performed without additional stroke risk, regardless of the type and location of the aneurysm.

Quality of life comparison between open and retroperitoneal video-assisted minilaparotomy surgery for kidney donors

This study compared open and video-assisted minilaparotomy surgery in live kidney donors for quality of life (QoL), pain, cosmesis, and recovery. Between January 2003 and March 2006, we reviewed data from 205 patients who underwent live-donor nephrectomy: 116 by video-assisted minilaparotomy and 89 by open surgery. Pain and satisfaction were evaluated using scales from 1 to 10, and QoL, with the 36-item Short Form questionnaire. Hospital stay was significantly shorter among the video-assisted (5.1 +/- 1.6 days) than the open group (6.9 +/- 1.3 days; P < .01). Time to resumption of walking without difficulty and normal activity was significantly shorter among the video-assisted than the open group (P<.01). The video-assisted group showed better QoL scores in 6 of 8 QoL categories, including physical role (P < .01), bodily pain (P < .01), general health (P < .01), vitality (P < .01), emotional health (P < .01), and mental health (P < .01). Patients in the video-assisted group (score, 7.3 +/- 2.4) were more satisfied with the cosmetic outcome than those in the open group (score, 5.1 +/- 3.0; P < .01). In conclusion, donors who underwent nephrectomy via video-assisted minilaparotomy showed better outcomes regarding pain, convalescence, cosmesis, and QoL than those who underwent open surgery.

Cutaneous adverse drug reactions in hospitalised patients

INTRODUCTION

Serious adverse drug reactions are common in hospitalised patients. There have been few studies examining the clinical presentation, implicated drugs and outcomes in Singapore.

METHODS

The clinical and laboratory data of all inpatient dermatology consultations with a diagnosis of cutaneous adverse drug reaction were retrospectively analysed over a one-year period.

RESULTS

A total of 97 patients were diagnosed with cutaneous adverse drug reactions. Eight different clinical reaction patterns were noted, namely drug exanthems (46.4 percent), drug rash with eosinophilia and systemic symptoms (18.6 percent), Stevens-Johnson syndrome/toxic epidermal necrolysis spectrum (14.4 percent), urticaria/angioedema (11.3 percent), acute generalised exanthematous pustulosis (3.1 percent), fixed drug eruptions (3.1 percent), generalised exfoliative dermatitis (2.1 percent) and drug-induced vasculitis (1.0 percent). The putative medications included antibiotics (50.5 percent), anticonvulsants (11.3 percent), allopurinol (8.2 percent), chemotherapeutic agents (7.2 percent), nonsteroidal anti-inflammatory agents (7.2 percent), intravenous contrasts (3.2 percent), complementary medications (2.1 percent) and various other medications (10.3 percent). 30 patients were admitted primarily for their adverse drug reaction, with an average length of hospital stay of nine days, while the remaining 67 patients developed these reactions as a complication of their inpatient stay. A total of five deaths were recorded.

CONCLUSION

The presentation of cutaneous adverse drug reactions in hospitalised patients is diverse, ranging from self-limiting and benign reaction patterns to those that are life-threatening. Early recognition, accurate diagnosis, withdrawal of putative medications and specific treatments when indicated may improve outcome.

Application of beam emission spectroscopy to NBI plasmas of Heliotron J

This paper describes the application of the beam emission spectroscopy (BES) to Heliotron J, having the nonsymmetrical helical-magnetic-axis configuration. The spectral and spatial profile of the beam emission has been estimated by the numerical calculation taking the collisional excitation processes between plasmas (electrons/ions) and beam atoms. Two sets of the sightlines with good spatial resolution are presented. One is the optimized viewing chords which have 20 sightlines and observe the whole plasma region with the spatial resolution Δρ less than ±0.055 using the newly designed viewing port. The other is 15 sightlines from the present viewing port of Heliotron J for the preliminary measurement to discuss the feasibility of the density fluctuation measurement by BES. The beam emission has been measured by a monochromator with a CCD camera. A good consistency has been obtained between the spectral profiles of the beam emission measured by the monochromator and the beam emission spectrum deduced by the model calculation. An avalanche photodiode with an interference filter system was also used to evaluate the signal-to-noise (S/N) ratio of the beam emission in the present experimental setup. The modification of the optical system is being planned to improve the S/N ratio, which will enable us to estimate the density fluctuation in Heliotron J.

¹⁵C(d,p)¹⁶C reaction and exotic behavior in ¹⁶C

We have studied the ¹⁵C(d,p)¹⁶C reaction in inverse kinematics using the Helical Orbit Spectrometer at Argonne National Laboratory. Prior studies of electromagnetic-transition rates in ¹⁶C suggested an exotic decoupling of the valence neutrons from the core in that nucleus. Neutron-adding spectroscopic factors give a different probe of the wave functions of the relevant states in ¹⁶C. Shell-model calculations reproduce both the present transfer data and the previously measured transition rates, suggesting that ¹⁶C may be described without invoking very exotic phenomena.

Decompression and interspinous dynamic stabilization using the locker for lumbar canal stenosis associated with low-grade degenerative spondylolisthesis

BACKGROUND

Decompression and spinal fusion have been generally recommended for spinal stenosis associated with low-grade degenerative spondylolisthesis (DS), although this is still controversial. The purpose of the present study is to analyze the clinical and radiological outcomes of interspinous dynamic stabilization using the Locker (WINNOVA co, Seoul, Korea) for lumbar canal stenosis with grade I DS.

METHODS

The authors performed a retrospective review of 23 consecutive patients who underwent single level decompression and the Locker application for lumbar canal stenosis with grade I DS and were followed up for at least 2 years. Excluded were those with DS grade II or higher and DS combined with foraminal disc herniation/stenosis. The mean age of patients at the time of surgery was 62.1 years (range: 45-81 years).

RESULTS

There were no complications in the perioperative period. At a mean follow-up duration of 28.3 months (range: 24-32 months), visual analogue scale scores for back pain, leg pain, and Oswestry disability index had decreased significantly; from 4.6, 7.2, and 38.5% to 2.4, 2.6, and 15.3%, respectively. Clinical success was achieved in 87% of the patients. The mean percentage of slippage did not change significantly. The mean sagittal rotation angle significantly decreased from 9.7 to 6.5 degrees (p=0.01). One patient (4.3%) underwent secondary fusion surgery due to persistent pain.

CONCLUSIONS

Decompression and interspinous dynamic stabilization using the Locker yielded favorable clinical and radiological outcomes for lumbar canal stenosis with grade I DS and could be an alternative for spinal fusion. However, further long-term follow-up studies are necessary.