Nasal chondromesynchymal hamartoma presenting in an adolescent

Nasal chondromesenchymal hamartoma (NCMH) is extremely uncommon primary benign cartilaginous growth of the nasal and paranasal sinuses. To date, it has been reported almost exclusively in infancy. We report a NCMH in a 16-year-old patient who presented with an asymptomatic, fixed swelling on the left side of the nose approximately 2x2 cm in size. Computed tomography (CT) and magnetic resonance imaging (MRI) of the nose, paranasal sinuses and neck confirmed a heterogeneous, calcified polypoidal mass protruding caudally into the left nasal cavity. After an initial inconclusive incisional biopsy, the patient underwent a complete radical resection, with staged reconstruction of the full nasal defect using septal mucosal flap, conchal cartilage graft and forehead skin flap. Histological examination of the resected specimen confirmed NCMH, which, we believe, had probably been present and undetected for many years. This report greatly extends the age at which NCMH may be entertained as part of the differential diagnosis of cartilaginous lesions of the nose and paranasal sinuses.

How much effort is required to isolate nuclear microsatellites from plants?

The attributes of codominance, reproducibility and high resolution have all contributed towards the current popularity of nuclear microsatellites as genetic markers in molecular ecological studies. One of their major drawbacks, however, is the development phase required to obtain working primers for a given study species. To facilitate project planning, we have reviewed the literature to quantify the workload involved in isolating nuclear microsatellites from plants. We highlight the attrition of loci at each stage in the process, and the average effort required to obtain 10 working microsatellite primer pairs.

Management of a large bronchial haemangioma in an infant

Haemangiomas are the most common soft tissue tumor of infancy. Despite the benign and trivial nature of most cutaneous haemangiomas, airway haemangiomas are rare but potentially life threatening. We report the case of a 9-week-old infant with a left main stem bronchial haemangioma. This was successfully treated with the oral corticosteroids. We discuss the current available treatments for haemangiomas and highlight that treatment should be specific to each individual case.

New skills for a new age: leading the introduction of public health concepts in healthcare curricula

Health policy in the UK is going through significant changes. At the heart of the transformation is a dedicated focus on public health. The new primary-care-based health system will not only be premised on a specialist public health workforce, but also on broader based public-health-oriented health professionals. Within primary care, widening the foundation of health professionals with public health competencies suggests that higher education bodies will need to adapt their curricula to an approach that highlights population-based health principles, preventive philosophy, and public health concepts and methods. The first part of this paper describes the mapping of the public health content of healthcare curricula at one university in England, based on the 10 public health standard areas of competencies of the Faculty of Public Health Medicine. The second part examines, through the findings of a strengths, weaknesses, opportunities, threats (SWOT) analysis, the factors that advocates for a public-health-oriented educational strategy must examine before embarking on the instigation and development of public health concepts in the healthcare curricula. The aspects that necessitate consideration include strengths such as the prevailing policy, market forces, commitment, and motivation to the effort, and the availability of resources, information and external contacts. Features such as political drive and advocacy, interest in the education debate, collaborative links through joint working and partnerships, and ongoing internal reforms and restructuring could all act as opportunities. However, resistance and anxiety are to be expected, the operationalization of the effort and empowerment of those leading it need to be thought about, and issues of control and interests are critical. The presence of conflicting priorities and competition or the lack of vision and directives, or uncertainty about change, could act as threats and barriers to the effort. If shifting the 'traditional' healthcare curricula to a more 'innovative' public-health-oriented one is to be a success, administrators of educational change will need to take into account a 'melange' of factors and stakeholders involved in a gradual and incremental process.

Anorexia nervosa (restrictive subtype) is associated with a polymorphism in the novel norepinephrine transporter gene promoter polymorphic region

Long-term weight-restored patients with anorexia nervosa (AN) have lower norepinephrine levels than controls. Since this may reflect altered reuptake by the norepinephrine transporter (NET), we hypothesised that the NET gene was involved in the genetic component of AN. PCR-amplification of an AAGG repeat island (AAGG1) in the NET gene promoter region revealed a novel 343-bp sequence with five additional AAGG repeat islands (AAGG2-AAGG6). We named the sequence from AAGG1 to AAGG6 inclusive, the NET gene promoter polymorphic region (NETpPR). A 4-bp deletion (S4) or insertion (L4) in AAGG4 resulted in the net loss or gain, respectively, of a putative Elk-1 transcription factor site. The transmission disequilibrium test(TDT) with 87 Australian trios (patient plus parents) demonstrated significant preferential transmission of L4 (McNemar's chi(2) = 7.806, df = 1, P = 0.0052, odds ratio: 2.1) from parent to child with restricting AN (AN-R), suggesting that L4 or a DNA variant in linkage disequilibrium with it, doubles the risk for developing AN-R.

Biological phosphorus removal from a phosphorus-rich dairy processing wastewater

Dairy industry processing wastewaters consist mainly of dilutions of milk, milk products and cleaning solutions and, depending on the processes used, may be rich in phosphorus. In New Zealand and internationally, chemical removal of phosphorus is typically the phosphorus removal method of choice from dairy processing wastewaters. The enhanced biological phosphorus removal (EBPR) process was investigated in this study as an alternative phosphorus removal option using a continuous activated sludge system. A synthetic dairy processing wastewater was firstly subjected to fermentation in an anaerobic reactor (HRT = 12 hrs, pH = 6.5, temperature = 35 degrees C) resulting in a fermented wastewater with an average volatile fatty acid (VFA) concentration of 1055 mg COD/L. The activated sludge reactor was operated in an AO configuration with an HRT of 2.5 days and an SRT of 15 days. Stable EBPR was exhibited with 42 mg P/L removed, resulting in a final sludge phosphorus content of 4.9% mg P/mg TSS. In the anaerobic zone (HRT = 2.85 hrs) the sludge had a phosphorus content of 3.16% mg P/mg TSS and a poly-beta-hydroxyalkanoate (PHA) concentration of 86 mg COD/g TS.

Possible benefits of high-dose chemotherapy and autologous stem cell transplantation for adults with recurrent medulloblastoma

In an attempt to improve the dismal prognosis of adults with recurrent medulloblastoma, six patients were treated with aggressive salvage therapy including high-dose chemotherapy (HDCT) and autologous stem cell transplantation (ASCT). At relapse, all patients underwent surgical debulking followed by HDCT/ASCT and then radiotherapy when possible. The treatment plan included two cycles of HDCT/ASCT; first with cyclophosphamide, etoposide and carboplatin (CECb) and then 2 months later with cyclophosphamide and thiotepa (CT). Three of the six patients received the planned therapy. One patient experienced severe toxicity requiring life-sustaining therapy. This patient developed multi-organ dysfunction including multiple enhancing lesions in both cerebral hemispheres that slowly resolved over several months. Two other patients did not mobilize sufficient stem cells for two ASCT procedures. They received one ASCT conditioned with cyclophosphamide, thiotepa and carboplatin (CTCb). Three of six patients had a complete response (CR); the other three had a partial response (PR). Following the first ASCT, median duration of response was 13.5 months (range 9-29 months) and median survival was 21.5 months (range 12-42 months). There was no treatment-related mortality. We conclude that HDCT/ASCT with CECb-CT or CTCb is active against recurrent medulloblastoma in adults and may be associated with prolonged remissions. Multiple enhancing cerebral lesions on brain MRI early post-HDCT/ASCT may be a consequence of the treatment rather than metastatic disease.

Linking deer browsing and terpene production among genetic identities in Chamaecyparis nootkatensis and Thuja plicata (Cupressaceae)

To investigate whether differential herbivore browsing reflects genetic variation in plant defense expression, variation in needle terpenes and damage caused by black-tailed deer (Odocoileus hemionus) was analyzed on yellow-cedar (Chamaecyparis nootkatensis) and western redcedar (Thuja plicata). In a 100-genet yellow-cedar population, three genets that were heavily browsed and had extremely low levels of monoterpenes (0-0.36% dry matter), sesquiterpenes, and diterpenes were compared to unbrowsed genets (0.85-3.83% monoterpenes in dry matter). These differences were maintained in individuals protected from browsing, suggesting genetically based variation in constitutive terpene production. In western redcedar, heavily browsed trees had significantly lower total monoterpene concentrations (1.69% dry matter) than lightly browsed trees (3.32% dry matter). One heavily browsed tree expressed no monoterpenes. No differences were found for diterpenes. In both species, the genotypes with extremely low monoterpene concentrations came from the same open-pollinated families.

Successful treatment of post-transplant lymphoproliferative disorder in autologous blood stem cell transplant recipients

We report three cases of post-transplant lymphoproliferative disorder (PTLD) in the context of autologous stem cell transplantation (ASCT) for multiple myeloma (MM) and non-Hodgkin's lymphoma. The first two cases received ASCT for MM, one with a CD34-selected autograft and the other with an unmanipulated autograft. Both these cases of PTLD achieved a complete response following treatment with IVIG, gancyclovir, solumedrol and interferon (IFN). The third case received ASCT with an unmanipulated autograft for relapsed angioimmunoblastic lymphoma. He also achieved a complete response but only after rituximab was added to IVIG, gancyclovir, solumedrol and IFN. None of these patients experienced a relapse of their PTLD with follow-up ranging from 1.5 to 5 years. These cases highlight the importance of considering PTLD in the differential diagnosis of lymphadenopathy and fever post ASCT. They also demonstrate the possibility of durable complete remission of post-ASCT PTLD following antiviral and immune modulating therapy.

Laser Acupuncture in the Management of Depression

Introduction

Traditional Chinese medicine (TCM) has long recognised the use of acupuncture in psychological medicine. Classically the acupuncture meridians or channels are each linked to particular emotions, for example, joy and sadness (heart channel), panic and anxiety (kidney channel), anger and frustration (liver channel). By correct diagnosis, acupuncture intervention can be useful in the restoration of emotional well-being. Today it is realised that this restoration of emotional health is due to neuromodulation at the higher centres. Results of the NIH funded depression study by Allen, Hitt and Schnyer (1998) were encouraging. The study demonstrated acupoint specificity (p < 0.05) for mood disorders. Unfortunately, the study was single blinded. This study is based on the NIH study. The research team hoped to reproduce the significant results achieved then. With laser as the modality, the advantages were obvious: non-invasive modality, randomised double blind control achievable, no infection risk and ease of training community-based doctors to utilise the technique.

Method

This pilot study utilised laser acupuncture in an outpatient population with mild to moderately severe depression with Beck Depression Inventory (BDI) scale of 12 to 30. Normal was less than or equal to BDI of 10. Recruitment was through family practices (called general practices in Australia) and newspapers. Recruits were each screened by a psychiatrist to confirm their suitability. They were then randomised into sham laser and true laser groups. Each patient received twice a week sessions for a month, followed by once a week sessions for another month. BDI scores were taken fortnightly to ensure none of the patients deteriorated. The acupuncturist was also blinded. BDIs were repeated at one month and three months post laser.

Results

Thirty patients were recruited and randomised into true and sham laser. Four patients were withdrawn, two from each arm of the study. The rest completed the laser sessions. Of those who completed the study, one patient did not respond to any of the post laser follow up BDI requests. Another patient did not complete the three-month follow up BDI. Results showed a markedly significant improvement in the active group (p< 0.001) at the end of the course of treatment with a sustained difference one month after treatment (p<0.05).

Discussion

The markedly significant results were unexpected. They do however make laser acupuncture a serious contender as a third standard management option in the treatment of depression in the community. Laser acupuncture could stand alone, or be used together with counselling, psychotherapy or drug therapy. These latter areas of mixed management need to be explored. In the National Institute of Mental Health Treatment of Depression Collaborative Research Programme over 30% of participants terminated treatment early due to adverse effects, lack of improvement or desire to change therapies. These were based on psychological and/or pharmacological treatments. Patients were obviously searching for more satisfactory treatments, non-chemical in nature and without adverse effects. An important point to note from this laser study is that the series of treatments maintained their significance for the month after completion. This suggested that follow-up or maintenance laser acupuncture sessions were important for patient well-being and the one month mark could be indicative of appropriate timing. The research team recommends larger and more specific studies to confirm these findings and explore the wider clinical implications. The team is keen to perform a multicentre study but is restricted by funding issues.

Critical airway compromise caused by neck haematoma

The recognition and treatment of the compromised airway needs to be quick and systematic. Airway obstruction, can rapidly progresses to anoxia irreversible cerebral damage and death, within four to five minutes. Management of the unstable airway has the highest treatment priority regardless of the presence of other medical conditions. We report the clinical course of minor anterior neck injury in two elderly patients taking oral anticoagulants. Both patients developed sudden airway obstruction, due to circumferential neck haematoma; six to eight hours post injury. The rapid neck swelling caused upper airway compression and rapid desaturation. Both patients required urgent orotracheal intubation in the emergency room. Patients with a history of blunt neck trauma may initially appear stable, then quickly decompensate and require an emergency airway.

Airway evaluation on placental support

BACKGROUND Prenatal ultrasonography predicting airway obstruction can facilitate intrapartum management, revolutionising the approach to potential airway difficulties at birth.

AIMS

This report presents the first case of this procedure attempted in Ireland.

RESULT AND CONCLUSION

This case was unsuccessful in securing an airway, but the potential for intubation or tracheostomy with an intact maternal-foetal circulation provides encouragement for the management of future cases.

Tardive dystonia of the larynx in a quadriplegic patient: an unusual cause of stridor

We describe a case of a quadriplegic brain-damaged man with severe upper airway obstruction. A diagnosis of tardive dystonia affecting the vocal folds was made and confirmed by flexible nasopharyngoscopy. Emergency tracheotomy was required. The tardive movement disorder resolved with discontinuation of thioridazine. This case serves to heighten awareness of potentially serious airway complications associated with the use of anti-psychotics and anti-emetics particularly in those with organic brain disease.