Laryngocele masquerading as a soft tissue neck mass

Laryngocele is a rare entity which can clinically present as a neck mass and requires Computed Tomography (CT) and laryngoscopy for diagnosis. We present an interesting case of bilateral laryngocele in a 45-year-old male presented clinically as hoarseness and left sided neck mass without any history of predisposing factors. Ultrasonography (USG) and CT features of laryngocele is also presented here.

Relationship of Age at First Live Birth, Parity and Duration of Breast Feeding with Non Familial Breast Cancer in Pakistani Women. A Study of the Cancer Research Group Pakistan

Background and objectives; This multicenter case control study is being conducted at seven different centers in Pakistan in order to find out the association and relationship of different hormonal and reproductive factors with breast cancer. These factors have been identified either as risk factors or protective factors for breast cancer in other communities but not in Pakistani women. Preliminary results from four centers are being reported here.Method; Patients attending these cancer treatment centers were interviewed by the trained medical personals and the findings were recorded in a proforma. Age and area matched unrelated controls were randomly selected and interviewed with same questions and findings were recorded in a corresponding proforma. SPSS version 11.5 was used for statistical analysis.Results; From June, 2008 to May, 2009 six hundred eighty eight cases were compared with an equal number of controls. Median age of cases was 47 years (26-70 years) and controls 47.5 years (25-71 years). One hundred ninety eight of cases (28.78%) and 208 of controls (30.23 %) gave first full term live birth before the age of 20. Sixty two cases (09.01%) and 38 controls (5.52%) gave first full term live birth after the age of 30. Seventy one cases and 65 controls were nulliparous.Fifty cases (07.27%) and 51 controls (07.41%) had only one child whereas 104 (15.12%) cases and 118 controls (17.15%) had more then 7 children.Breast feeding duration was more then 24 months in 410 (72.31%) of all women who had more then 1 child. Duration of breast feeding in cases Vs. control in women with 2-4 children, 5-7 children and more then 7 children was similar. Statistical analysis reveals that first live birth below the age of 20 and duration of breast feeding of greater then 24 months duration are not associated as protective factors in this patient population. Odds ratio of 1.35, 95% CI; 1.01-1.70 and 1.014, 95% CI; 0.80-1.22 respectively. Age at first live birth after 30 years of age seems to be positively associated with breast cancer. Odds ratio of 1.75, 95% CI; 1.15-2.65. These results do not support the young age at first full term pregnancy and prolonged duration of breast feeding as protective factors against the breast cancer.Key Words: Breast Cancer, Breast feeding, Parity, Risk Factor

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2071.

Modeling multisensory enhancement with self-organizing maps

Self-organization, a process by which the internal organization of a system changes without supervision, has been proposed as a possible basis for multisensory enhancement (MSE) in the superior colliculus (Anastasio and Patton, 2003). We simplify and extend these results by presenting a simulation using traditional self-organizing maps, intended to understand and simulate MSE as it may generally occur throughout the central nervous system. This simulation of MSE: (1) uses a standard unsupervised competitive learning algorithm, (2) learns from artificially generated activation levels corresponding to driven and spontaneous stimuli from separate and combined input channels, (3) uses a sigmoidal transfer function to generate quantifiable responses to separate inputs, (4) enhances the responses when those same inputs are combined, (5) obeys the inverse effectiveness principle of multisensory integration, and (6) can topographically congregate MSE in a manner similar to that seen in cortex. Thus, the model provides a useful method for evaluating and simulating the development of enhanced interactions between responses to different sensory modalities.

Frequency of tuberculous cervical lymphadenitis detection at a single laboratory in islamabad

OBJECTIVE

To determine the frequency of tuberculous cervical lymphadenitis and to evaluate the diagnostic efficacy of microscopy and conventional Lowenstein Jensen (LJ) culture technique in the diagnosis of cervical lymphadenitis caused by M. tuberculosis (MTB) Study Design: A descriptive, cross-sectional study. Place and Duration of the Study: Department of Mycobacteriology, Public Health Laboratories Division, National Institute of Health, Islamabad, from January 2003 to December 2004.

PATIENTS AND METHODS

A total of 220 patients from Pakistan Institute of Medical Sciences (PIMS), Islamabad, Federal Government Services Hospital (FGSH), Islamabad and Rawalpindi General Hospital (RGH), Rawalpindi, presenting with enlarged cervical lymph nodes (for at least six months), pain/ weight loss and low grade fever were studied for the presence of MTB from 142 lymph node biopsies, 60 FNA samples and 18 discharge fluids/swabs. All the samples were examined at NIH by ZN staining smear and culture on conventional LJ medium as well as on Bactec 12B medium using Bactec 460 TB system. The drug susceptibility testing of the isolates was performed on Bactec 460 TB system. NAP test on Bactec 460-TB system, Accuprobe and biochemical tests were employed to identify the mycobacterial isolates.

RESULTS

M. tuberculosis accounted for 173 out of 220 cases of cervical lymphadenopathy. Maximum incidence was found to be in the age group 10-30 years with male to female ratio of 1:1.7. Discharge sinuses and abscess formation were uncommon. Biopsy tissue samples gave the maximum yield of positive mycobacterial cultures as all 142 biopsy samples being positive while only 50% (30/60) of FNA and 5.5% (1/18) of discharge fluids/swabs were positive. All the isolates were identified as M. tuberculosis. No atypical mycobacteria were recovered from the samples examined. All isolates were found to be susceptible to first line anti-tuberculous drugs i.e. Streptomycin, Isoniazid, Rifampicin and Ethambutol (SIRE).

CONCLUSION

Tuberculosis was the major cause of cervical lymphadenopathy in the referral area. Culture of the biopsy tissue from the affected lymph nodes is a method of choice for laboratory diagnosis of tuberculous cervical lymphadenopathy.

Two years of experience with etanercept in recalcitrant psoriasis

BACKGROUND

The safety and efficacy of etanercept have been demonstrated in patients with rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis. Placebo-controlled trials have indicated the efficacy of etanercept in moderate to severe psoriasis.

OBJECTIVES

To observe the efficacy and safety profile of etanercept in patients with severe psoriasis resistant to other systemic agents over a 2-year period.

METHODS

In this retrospective study, 49 patients were treated with etanercept between March 2004 and March 2006. All patients were screened for tuberculosis with tuberculin test and a chest X-ray. Thirty-nine patients started on etanercept 25 mg twice weekly (BIW) and 10 started at 50 mg BIW when judged to be clinically indicated. In 19 of those on 25 mg BIW, the dose was increased to 50 mg BIW because of poor response and psoriasis flaring. Response to treatment was assessed by Psoriasis Area and Severity Index (PASI) and static Physician Global Assessment (PGA). Patients were reviewed at 8-week intervals, when clinical response and adverse effects were noted.

RESULTS

Forty-four patients (90%) had chronic plaque psoriasis, two (4%) were suberythrodermic, one (2%) had palmoplantar pustular psoriasis and two (4%) had acrodermatitis continua of Hallopeau. At least 75% reduction in PASI was achieved in 47% of patients at week 24 and 66% at week 48. At week 24, 44% had a PGA score of excellent, and at week 48, 58% scored excellent. In 12 who cleared, etanercept was stopped. Ten of these relapsed and etanercept was recommenced, while two remained in remission (mean 12.5 weeks). One patient developed extrapulmonary tuberculosis.

CONCLUSIONS

Etanercept was effective in severe psoriasis recalcitrant to other systemic medication. The drug was well tolerated. Development of tuberculosis in one patient underlines the need for rigorous tuberculosis screening.

Three years' experience with infliximab in recalcitrant psoriasis

BACKGROUND

In this retrospective study, we report our experience with infliximab for recalcitrant psoriasis.

METHODS

Twelve patients were treated between September 2001 and April 2005. Infliximab 5 mg/kg was given at 0, 2 and 6 weeks followed by 5 mg/kg at 8-week intervals. When two patients developed resistance to treatment, methotrexate was added at a dose of 5-7.5 mg weekly for all patients. Response to treatment was assessed with physician global assessment with a score of excellent, good, moderate, poor and failure. Ten patients had chronic plaque psoriasis, one had pustular palmoplantar psoriasis and one had acrodermatitis continua of Hallopeau.

RESULTS

Nine patients, including the patient with acrodermatitis continua, showed an excellent response. Two patients initially showed good response but became resistant to treatment. One patient failed to respond, and treatment was discontinued. With time, six patients with excellent response and two with good response developed side-effects that necessitated stopping treatment.

CONCLUSIONS

We have found infliximab to be very impressive, both in efficacy and speed of action, in severe psoriasis. Its use, however, is limited, as it requires hospital admission and by the need for concomitant methotrexate. Because of its powerful immunosuppressive action, the possibility of activating tuberculosis and inducing lymphoma remains a concern.

A competitive neural model of small number detection

The ability to represent numbers is a key attribute for both humans and animals. Recent developments in the understanding of numerical processing has led to the proposal that humans utilise two independent representations of number, one for real numbers and another for integers. We describe a computational model of small number detection to explore the relationship between these core systems of number. We use a combination of unsupervised and supervised neural networks to simulate the interaction between the real and integer representations. For real values we use a self-organised spatial representation of number. For integer values we use a supervised network motivated by linguistic processing. During training and testing, the networks exhibit behavioural characteristics such as the number size and numerical distance effects. Each representation is combined using the mixture-of-experts architecture that allows us to model the subitization limit (the maximum number of visual stimuli that can be accurately quantified almost immediately) as the competitive allocation of representations for number detection, where the crossover point between deploying the real and integer representations of number is obtained through a process of learning. Our results suggest that the existence of two core systems of number is at least computationally plausible and further suggests that the subitization limit emerges through the interaction of spatial and linguistic numerical processing. This provides computational evidence for one way in which small and large numbers are related in humans.

Popliteal-to-distal artery bypass for diabetic limb salvage

BACKGROUND

Poor long-term survival and significant co-morbidity among diabetic patients with limb ischaemia makes the shortest, simplest revascularisation procedure desirable.

AIM

Evaluate limb salvage, primary graft patency and peri-operative morbidity rates in diabetic patients undergoing popliteal-to-distal artery bypass for limb salvage.

METHODS

Patients undergoing popliteal-to-distal artery bypass for critical limb ischaemia over a seven-year period were retrospectively identified. Patients operative and follow-up data were entered into a database and limb salvage and patient survival determined using Kaplan Meier survival analysis.

RESULTS

During the study period 21 popliteal-to-distal artery bypasses were performed on 19 diabetic patients. Mortality rate after one year was 11%. Primary graft patency rates among surviving patients was 81%, 67% and 48% at 1, 2 and 6 years respectively. Amputation was required in three patients.

CONCLUSION

Popliteal-to-distal artery bypass produces favourable results in high-risk diabetic patients with critical limb ischaemia.

Cataract blindness and visual outcome of cataract surgery in a tribal area in Pakistan

AIM

To estimate the rates of cataract blindness and cataract surgical coverage and to assess the visual outcome of cataract surgery among individuals aged > or =50 years in Orakzai Agency, Pakistan.

METHODS

1600 individuals aged > or =50 years were selected using probability proportional to size sampling. The main outcome measure was bilateral cataract blindness which was defined as visual acuity of <3/60 in the better eye with best available correction and with obvious central lens opacities/absence of red reflex in both eyes.

RESULTS

A total of 1549 people were examined; the coverage rate was 96.8%. Of individuals who were examined, 958 (61.8%) were men. The overall prevalence of bilateral cataract blindness was 4.8% (95% CI: 3.8% to 5.9%). Women had a 2.1-fold greater prevalence of bilateral cataract blindness than men (7.1% (5.0% to 9.2%) v 3.4% (2.3% to 4.6%); p = <0.0001). However, cataract surgical coverage rates were lower for women than men. The overall quality of previous cataract surgery was poor: 43.1% eyes with cataract surgery had VA <6/60. 73.3% people with bilateral cataract blindness reported they could not undergo cataract surgery because they were too poor to afford its cost.

CONCLUSION

The unacceptably high rates of cataract blindness and poor affordability and visual outcome of cataract surgery calls for the establishment, in the agency, of static cataract surgical services that are high quality, affordable, and gender sensitive.

Bullying of junior doctors prevails in Irish health system: a bitter reality

Workplace bullying in health systems is a well known fact. It leads to not only breakdown in teamwork but also has significant affect on the individual's personal life. True prevalence of bullying in junior doctors working in Ireland is unknown. Our aim of study was to find out the prevalence of bullying in junior doctors working hospitals in south and western counties of Ireland and to assess its effects on the productivity of work and family life and to identify the common source of bullying. We carried out a questionnaire survey. A total of 950 questionnaires were sent. Response rate was 51%. Our sample is 15% of the target population of all the hospital junior doctors. 30% of the responders claimed to be subjected to one or more bullying behaviors. Doctors from European Union (EU) reported significantly less rate of bullying compares to non EU doctors. Our results are in line with the results of studies conducted in United Kingdom. This study shows the magnitude and source of the problem. We conclude that bullying is a common problem in Irish health system. Increased awareness and zero tolerance are required to eradicate bullying.

Cutaneous sarcoidal reaction in a patient with pulmonary tuberculosis

Sarcoidosis is a systemic disorder characterized by non-caseating epithelioid granulomas that may affect any organ system. The etiology of sarcoidosis is unknown, but several immune aberrations are thought to play a role in its pathogenesis. The possible role of mycobacterial infection in the pathogenesis of sarcoidosis has been suggested. In recent studies mycobacterial DNA was detected in lung tissues and bronchial lavage fluid of 30% to 50% of patients with sarcoidosis. We report a patient with pulmonary tuberculosis treated successfully three years earlier who developed cutaneous sarcoidosis with negative polymerase chain reaction (PCR) assay for mycobacterial DNA of the skin lesion.

Accuracy of admitting diagnosis in acute surgical patients by non consultant hospital doctors

The incidence of accurate diagnosis made by non-consultant hospital doctors (NCHDs) is unknown in acute surgical admissions. There is a common assumption that reliance is made on excessive and inappropriate investigations. The aim of study was to assess the accuracy of admitting diagnosis by the NCHDs and the appropriateness of radiological investigations ordered. Data were collected on 100 consecutive acute surgical admissions. A final diagnosis was made in all the patients. 79 patients had accurate initial diagnosis (NCHDs). 23 scans were performed which confirmed the initial diagnosis. Out of 21 initial inaccurate diagnoses, final diagnosis was made on repeated clinical examination in 10, on imaging alone in 5 and by endoscopy or surgery in the remaining 6 patients. 11 patients had scans and 7 were appropriate. We conclude that 79% of diagnoses made by NCHDs are the accurate final diagnoses. The utilization of diagnostic modalities especially radiological imaging is highly appropriate. Our study suggests that the physical presence of a consultant on site may not lead to significant improvement to the delivery of health care to the Irish population.