Schwann Cell Hamartoma Presenting as a Colonic Polyp: A Rare Case Report With a Literature Review

Mucosal Schwann cell hamartomas (MSCHs) are non-common noncancerous growths derived from Schwann cells in the peripheral nervous system, often found unexpectedly during routine colonoscopy examinations. These growths primarily occur in the colon, although they can also appear in the esophagus and are not linked to familial cancer syndromes. Diagnosis relies on specific histological characteristics and staining patterns. It is essential to distinguish MSCHs accurately since their appearance can closely resemble that of malignant tumors. Characteristically, these hamartomas test positive for S-100 protein but do not exhibit markers typical of other gastrointestinal growths, such as gastrointestinal stromal tumors (negative for KIT), leiomyomas (negative for smooth muscle actin), neurofibromas (negative for CD34), and perineuromas (negative for epithelial membrane antigen or claudin-1). This report discusses the case of a 48-year-old woman who was diagnosed with MSCH during a screening colonoscopy.

Metabolic-associated fatty liver disease and hepatocellular carcinoma: a prospective study of characteristics and response to therapy

BACKGROUND AND AIM

The rising incidence of hepatocellular carcinoma (HCC) in Australia is related to increasing rates of metabolic-associated fatty liver disease (MAFLD). This study aimed to prospectively characterize the metabolic profile, lifestyle, biometric features, and response to treatment of HCC patients in an Australian population.

METHOD

Multicenter prospective cohort analysis of newly diagnosed HCC patients at six multidisciplinary team meetings over a 2-year period.

RESULTS

Three hundred and thirteen (313) newly diagnosed HCC patients with MAFLD (n = 77), MAFLD plus other liver disease (n = 57) (the "mixed" group), and non-MAFLD (n = 179) were included in the study. Alcohol-associated liver disease (ALD) (43%) and MAFLD (43%) were the most common underlying liver diseases. MAFLD-HCC patients were older (73 years vs 67 years vs 63 years), more likely to be female (40% vs 14% vs 20%), less likely to have cirrhosis (69% vs 88% vs 85%), showed higher ECOG, and were less likely to be identified by screening (29% vs 53% vs 45%). Metabolic syndrome was more prevalent in the MAFLD and mixed groups. The severity of underlying liver disease and HCC characteristics were the same across groups. While the MAFLD population self-reported more sedentary lifestyles, reported dietary patterns were no different across the groups. Dyslipidemia was associated with tumor size, and those taking statins had a lower recurrence rate.

CONCLUSION

Equal to ALD, MAFLD is now the most common underlying liver disease seen in HCC patients in Australia. Future HCC prevention screening and treatment strategies need to take this important group of patients into consideration.

Extended-Spectrum Beta-Lactamase Escherichia coli-Associated Acute Cholangitis: Uncommon Patient Characteristics and Clinical Implications

Acute cholangitis is a potentially life-threatening condition caused by an infection of the biliary tract resulting from biliary obstruction. This case report highlights an unusual presentation of acute cholangitis in an elderly patient characterized by the presence of extended-spectrum beta-lactamase-producing Escherichia coli. We aim to emphasize the significance of recognizing diverse clinical manifestations in the elderly population to enhance timely diagnosis and appropriate management. The case highlights the importance of better understanding patient risk factors for potential causative organisms and their susceptibility to selecting proper antibiotics and improving clinical outcomes.

Emphysematous Gastritis: A Case Series on a Rare but Critical Gastrointestinal Condition

Emphysematous gastritis (EG) is a rare and life-threatening condition characterized by gas-forming microorganisms causing gas to accumulate within the stomach wall. It has a high mortality rate and is associated with risk factors like gastroenteritis, alcohol use disorder, diabetes mellitus, renal failure, recent abdominal surgery, long-term corticosteroid use, and ingestion of corrosive agents. Diagnosis is challenging due to its rarity and nonspecific symptoms, including severe abdominal pain, coffee-ground emesis, fever, and signs of systemic infection. We present two cases of patients with signs and symptoms of EG, where prompt diagnosis and treatment were achieved, avoiding further complications. Surgical intervention was avoided due to the successful response to conservative treatment. These cases highlight the importance of early detection and intervention in improving patient outcomes and preventing complications associated with EG.

Troponin I Elevation after Elective Percutaneous Coronary Interventions: Prevalence and Risk Factors

Percutaneous coronary intervention (PCI) is one of the most important modalities of treatment for coronary artery disease (CAD). Minor extents of injury to the myocardium have been observed even after successful PCI. This peri-procedural injury might therefore reduce some of the beneficial effects of coronary revascularization. The objective of this hospital based comparative observational study was to determine the prevalence of post procedural Cardiac troponin I (cTnI) elevation after elective PCI and also to find out the relation with risk factors such as age, sex, body mass index (BMI), smoking, anemia, diabetes mellitus, hypertension, dyslipidemia, family history, left ventricular dysfunction, renal insufficiency, type of stent, number of stent and length of stent. This was a hospital based comparative observational study carried out in the Department of Cardiology, Chattogram Medical College Hospital (CMCH), Chattogram, Bangladesh from July 2018 to June 2019. A total of 50 patients who underwent elective PCI were included as sampled by purposive sampling method. Serum cTnI was measured by FIA8000 quantitative immunoassay analyzer with an analytical measurement before and at 24 hours of PCI. Value >1.0ng/ml was considered elevated. Univariate and multivariate analysis were applied to assess predictors for the occurrence of post-procedural elevation of cTnI. The mean±SD age of the study population was 54.96±9.1 years (range 35-74 years) and 34(68.0%) patients were male. Regarding cardiovascular risk factors, 17(34.0%) patients had diabetes mellitus, 27(54.0%) had dyslipidemia, 30(60.0%) had hypertension, 32(64.0%) were current or ex-smokers and 20(40.0%) had a family history of CAD. Eighteen patients (36.0%) had post-procedural cTnI elevation but only 8(16.0%) had significant (>1.0ng/ml) elevation. Change of cTnI before and at 24 hours of PCI was not significant (p=0.057). Cardiac Troponin I increase was related to age, pre-procedural serum creatinine and multi-vessel stenting. Minor elevation of cTnI was common following elective PCI and associated with few risk factors such as elderly patient (more than 50 years), raised serum creatinine and multi-vessel stenting. So, early detection of these risk factors, as well as effective intervention may help to prevent injury to cardiac tissue hence stop elevation of cardiac TnI following elective PCI.

Comparison of Risk Factors and Angiographic Profile between Younger and Older Patients with Acute Myocardial Infarction

Acute myocardial infarction (AMI) in younger adults (≤40 years) is being increasingly encountered in recent years among the South Asian population. Data regarding the presentation, risk factors and angiographic findings on this important subset of patients is lacking in our country. The aim of this study was to compare the risk factors and pattern of Coronary artery involvement in younger patients presenting with AMI with that of the older age group. This was a cross-sectional observational study conducted during the period from October 2018 to June 2019. Seventy consecutive AMI patients age ≤40 years and another 70 consecutive AMI patients age >40 years undergoing Coronary Angiogram (CAG) were included in the study. After taking informed written consent; demographic, anthropometric, risk factors, CAG findings were recorded in a pre-designed case record form. The severity of Coronary Artery Disease (CAD) was calculated by using Gensini score. The mean age of the younger and older patient groups was 36.89±4.4 years and 57.00±8.4 years respectively. Among the risk factors, smoking (67.1% versus 45.7%, p=0.017), positive family history CAD (38.6% versus 22.9%, p=0.040) and obesity (34.3% versus 20.0%, p= 0.05) were more common in younger group. Whereas, Hypertension (41.4% versus 72.9%, p=0.010) and DM (28.6% versus 50.0%, p=0.024) were more common in older patients. Younger patients mainly presented with STEMI (60.0% versus 48.6%) and predominantly had single vessel disease (42.9%), whereas older patients readily presented with NSTEMI (51.4%) and had a higher incidence of double vessel disease (32.9%) and triple vessel disease (30.0%). The Median Gensini score was significantly higher among the older patients than in the younger age group. Patients in younger age group showed a different pattern of risk factors and coronary artery involvement in comparison to the older age group. Thus, offering younger individuals to make them aware of these risk factors and their early detection, as well as an effective intervention may help to prevent AMI in younger people.

Ansa Pancreatica, an Uncommon Cause of Acute, Recurrent Pancreatitis

The pancreatic duct is vulnerable to developmental anomalies which may produce variations in its course and/or its configuration. Ansa pancreatica is the least common anatomic variant. It is characterized by the formation of an “S-shaped loop” from the main pancreatic duct to the minor papilla. Ansa pancreatica has been implicated as a cause of recurrent acute pancreatitis. We review existing literature on pancreatitis secondary to the ansa deformity and present a case of recurrent acute pancreatitis in a patient who was ultimately found to have the ansa deformity on endoscopic ultrasound.

Hermansky-Pudlak Syndrome: A Rare Cause of Post-polypectomy Bleeding

A colonoscopy is an effective tool for colorectal cancer screening, which aims at identifying precancerous polyps and removing them. Post-polypectomy bleeding (PPB) is one of the most common complications of endoscopic polypectomy. Here, we report a rare and interesting case of a 68-year-old man known to have Hermansky-Pudlak syndrome (HPS) who presented with two days history of rectal bleeding one day after he had a screening colonoscopy with polypectomy. He had a drop in his hemoglobin count and was admitted to the medicine floor and given 1-desamino-8-D-arginine vasopressin (DDAVP). Later, his bleeding stopped and he reported improvement in his symptoms. This case illustrates the importance of considering platelet transfusion and/or administration during minor surgical procedures for patients with bleeding diathesis such as Hermansky-Pudlak syndrome.

An Unusual Case of Polymicrobial Bacteremia From Methicillin-Resistant Staphylococcus Aureus and Shigella

Bloodstream infections (BSIs) are a significant cause of morbidity and mortality worldwide. Patients with polymicrobial BSI have a two-fold risk of hospital mortality as compared with patients with monomicrobial BSI. We present a case of a 53-year-old African American male with a medical history significant for hyperlipidemia, coronary artery disease, hypertension, anxiety, depression, and human immunodeficiency virus non-adherent to antiretroviral therapy who presented to the hospital with complaints of shoulder pain and diarrhea. The physical exam was significant for multiple skin abscesses, the largest being 5x6 cm. Blood culture grew Shigella and methicillin-resistant Staphylococcus aureus (MRSA), stool culture grew Shigella, and wound culture after incision and drainage grew MRSA. Transthoracic echocardiogram showed no vegetations. He was treated with vancomycin and ceftriaxone. The patient's clinical condition improved, and diarrhea resolved. Patient repeat cultures showed no growth. As polymicrobial bacteremia is associated with higher morbidity and mortality, early initiation of antibiotics and appropriate antibiotic therapy are pivotal.

Clinical relevance of endoscopically identified extrinsic compression of the oesophagus and stomach

Background

Various degree of extrinsic compression of the oesophagus and stomach are experienced during upper endoscopy. However, its utility in clinical practice has not been studied.

Methods

Electronic chart review of all upper gastrointestinal endoscopies done at our hospital between 2005 and 2016 was performed. A total of 79 patients with documented extrinsic compression on upper gastrointestinal procedure report who had a preceding or subsequent abdomen/chest CT imaging performed within 6 months were included.

Results

30 (38%) out of 79 patients had abnormal finding on CT scan. 14 (47%) out of 30 patients had an associated malignant lesion, whereas remaining had a benign lesion. Overall, patients with associated gastrointestinal symptoms (60% vs 22%, p=0.001) or history of weight loss (50% vs 16%, p=0.001) had increased odds of having an abnormal finding on CT scan compared with the patients who lacked such symptoms. Pancreatic cancer was the most commonly diagnosed malignancy. On subgroup analysis of patients with extrinsic compression and malignant lesion on imaging study, the likelihood of a malignancy was higher in blacks as compared with Hispanics (71%:29% vs 39%:61%, p=0.031), and with presence of gastrointestinal symptoms (64% vs 22%, p=0.003), presence of weight loss (64% vs 16%, p=0.0001) and hypoalbuminaemia (p=0.001).

Conclusion

Finding an extrinsic compression of the oesophagus and stomach on an upper endoscopy may suggest malignancy, and hence should prompt further work-up. Posterior wall gastric body compression may signal the presence of pancreatic cancer.

Evaluation of the combined effect of factors influencing bowel preparation and adenoma detection rates in patients undergoing colonoscopy

Background

Colonoscopy is a commonly used modality for screening and surveillance of colorectal cancer (CRC). Therefore, it is essential to have adequate bowel preparation (prep) for the procedure which depends on type of bowel regimens, diet before colonoscopy and timing of the procedure.

Aims

The purpose of this study is to analyse the effect of multiple factors on adenoma detection rate (ADR) and prep quality of colonoscopy. This is the also the first study determining outcomes based on various combinations of diet, timing of the procedure and bowel prep regimens.

Methods

This is a retrospective single-centre observational study. Data about diet before procedure, bowel prepprep regimen and timing of the procedure was collected for patients coming for screening colonoscopy.

Results

Patients with split prep had higher good prep rates (73.8% vs 56.2%) and higher ADRs (34.2 % vs 29.9%) as compared with non-split prep. The good prep quality (65.8% vs 62.1%) and ADRs (31.9% vs 31.5%) were comparable in patients who received clear liquid diet as compared with low residue diet. The good results of bowel prep were obtained with split prep with either clear liquids or low residue diet irrespective of the timing of procedure. The poor prep was noticed in patients who underwent procedure in afternoon, with a low restrictive diet and non-split bowel regimen.

Conclusions

The current study adds to our knowledge about the combined effect of multiple variables affecting the bowel prep quality and ADR. It is imperative to opt for the best combination required for colonoscopy, as this will influence the effectiveness of colonoscopies regarding timely cancer detection and prevention.

A Rare Cause of Abdominal Pain in Adults: Meckel's Diverticulitis

A 42-year-old man presented to the emergency room with complaints of periumbilical abdominal pain. A contrast-enhanced computed tomography revealed mucosal thickening in the small bowel of the right abdomen. There was a fairly large small bowel diverticulum associated with this segment. Findings were suggestive of small bowel diverticulitis or possibly focal enteritis. A Meckel's diverticulum scan was diagnostic of Meckel's diverticulum. The patient was then immediately taken to the operating room for emergency laparotomy and was intra-operatively found to have a thickened Meckel's diverticulitis with adjacent small bowel obstruction. Meckel's diverticulectomy was performed in continuity with the adjacent inflamed small bowel. The patient had a stable postoperative course without any complications and was discharged within 10 days. At the 3-month follow-up, the patient was well and remained asymptomatic.

A Rare Cause of Abdominal Pain and Mass in an 18-Year-Old Patient: A Diagnostic Dilemma

We present a case of an 18-year-old male who presented with complains of abdominal pain, nausea and vomiting for 2 years. An esophagogastroduodenoscopy (EGD) revealed a 3 mm nodule on the lesser curvature of the stomach and prominent gastric folds. Biopsy of the nodule revealed a well-differentiated neuroendocrine tumor (NET) in lamina prop with focal extension into muscularis mucosa consistent with a gastric carcinoid. Tumor cells stained with neuron-specific enolase (NSE), chromogranin and synaptophysin only. The prominent gastric fold biopsy revealed gastric fundic mucosa with mucosal edema and focal mild chronic inflammation. Serum gastrin level was found to be 2,083 pg/mL. Abdomen CT and endoscopic ultrasound (EUS) revealed a mass near the pancreatic neck. These findings were consistent with a functional gastrin producing well-differentiated grade 1 neuroendocrine neoplasm (gastrinoma). The patient underwent exploratory laparotomy with resection of the mass and resulting in normalization of gastrin levels.

Anemia, intractable vomiting, chronic diarrhea, and syndrome of inappropriate antidiuretic secretion: a diagnostic dilemma: Disseminated strongyloidosis in a patient with newly diagnosed HTLV infection-case report and review of literature

RATIONALE

Strongyloidiasis hyperinfection and disseminated disease have high mortality rates due to several complications and early detection of Strongyloides infection is therefore prudent.

PATIENT CONCERNS

A 37-year-old male patient came with chronic diarrhea, intractable vomiting and was found to have hyponatremia, and anemia on the initial laboratory tests.

DIAGNOSES

Further work up revealed syndrome of inappropriate antidiuretic secretion to be the cause of the hyponatremia in addition to gastrointestinal loses. His hospital course was complicated by persistent hyponatremia and later development of partial small bowel obstruction.

INTERVENTIONS

Considering his symptoms we had a suspicion of small bowel pathology for which he underwent an esophagogastroduodenoscopywith biopsies that revealed strongyloidosis as the cause of his symptoms. He was also found to have human T-cell lymphotropic virus infection, likely contributing to the disseminated disease.

OUTCOMES

He was started on ivermectin with complete resolution of symptoms and improvement of hyponatremia.

LESSONS

It is very important to suspect Strongyloides infection in a patient presenting with syndrome ofinappropriate antidiuretic secretion as hyperinfection and disseminated disease can be life threatening without antihelmintic therapy.

Recombinant Factor VIIa Use for Endoscopic Retrograde Cholangiopancreatography With Sphincterotomy in a Patient With Choledocholithiasis and Unusual Coagulopathy

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that combines the use of endoscopy and fluoroscopy to diagnose and treat pancreaticobiliary disorders. The risks of ERCP include pancreatitis, infection, bleeding and perforation. Bleeding during ERCP typically develops after sphincterotomy, hence patients should be screened and tested for coagulopathy before undergoing ERCP. Coagulopathy is a major risk factor for ERCP-related bleeding. Inherited factor VII (FVII) deficiency is a rare autosomal recessive hemorrhagic disorder that can lead to significant coagulopathy and severe bleeding if not appropriately recognized and treated preoperatively. Clinically, the disease ranges between an asymptomatic state to lethal hemorrhage and the degree of FVII deficiency does not correlate with the severity of bleeding. The use of FVII replacement therapy has been reported to prevent bleeding during surgery. We present the first report of a patient with a rare cause of coagulopathy due to inherited FVII deficiency who successfully underwent ERCP with sphincterotomy without bleeding where we used recombinant factor VIIa before and after the procedure.

Factors associated with poor adherence to antiviral treatment for hepatitis B

Antiviral therapy for hepatitis B is effective and reduces the risk of progression to cirrhosis and liver cancer but is often required for an indefinite duration. Treatment adherence is important to prevent the development of resistance and optimize outcomes. Pharmacy adherence measures can be used to assess treatment adherence, with the medication possession ratio being less susceptible to bias than physician- or self-reported adherence. The aim of this study was to measure adherence in public hospital outpatients over a 3-year period and to examine factors associated with nonadherence. A retrospective study of pharmacy records of patients dispensed antiviral therapy for hepatitis B from four major hospitals in Melbourne between 2010 and 2013. Hospital record numbers were linked with and de-identified demographic information including age, sex, Indigenous status, country of birth, interpreter requirement, spoken language and postcode of residence. The medication possession ratio was the outcome measure with poor adherence defined <.90. Univariate logistic regression and multivariate logistic regression were performed to examine associations with nonadherence. Records of 1026 patients were included in the analysis. Twenty per cent of all participants met the definition of poor adherence. Significant factors affecting adherence included age <35 years (P=.002), hospital site and treatment by multiple doctors within shorter time periods. This is the largest study examining detailed factors associated with adherence to hepatitis B treatment. Understanding poor adherence in clinical settings, and the factors associated with lower adherence, is important to inform efforts towards promoting treatment adherence for hepatitis B.

Nano-curcumin influences blue light photodynamic therapy for restraining glioblastoma stem cells growth

Nano-curcumin based blue light photodynamic therapy has therapeutic potential in the arsenal of glioblastoma cancer stem cells recurrence.

Gallstone ileus with multiple stones: Where Rigler triad meets Bouveret’s syndrome

A 53-year-old man with multiple medical conditions presented to the emergency department with complaints of vomiting, anorexia and diffuse colicky abdominal pain for 3 d. A computed tomography scan of the abdomen and pelvis showed radiographic findings consistent with Rigler triad seen in small proportion of patients with small bowel obstruction secondary to gallstone impaction. In addition there was a gastric outlet obstruction, consistent with Bouveret’s syndrome. The patient underwent an exploratory laparotomy and enterotomy with multiple stones extracted. The patient had an uneventful post-surgical clinical course and was discharged home.

Influence of perception of colorectal cancer risk and patient bowel preparation behaviors: a study in minority populations

BACKGROUND

Large disparities exist in the utilization rates of screening modalities for colorectal cancer (CRC) in different socioeconomic areas. In this study, we evaluated whether the quality of bowel preparation differed significantly among populations with a high risk of CRC compared with that among the general population after matching for potential confounding factors.

METHODS

Hispanic and African American patients who underwent routine screening or surveillance colonoscopies in an outpatient setting between 2003 and 2013 were included in this retrospective study. Patients who underwent colonoscopies for emergent indications and repeat routine screening colonoscopies because of prior history of inadequate bowel preparation were excluded from this study. The patients were divided into three groups: patients having an average risk of being diagnosed with CRC (group 1); patients having a high risk of being diagnosed with CRC because of a personal history of adenomatous polyps (group 2); and patients having a high risk of being diagnosed with CRC because of a family history of CRC in first-degree relatives (group 3). All the patients were given preprocedural counseling and written instructions for bowel preparation. Data on demographic information, method of bowel preparation, quality of bowel preparation, comorbidities, and prescription medications were collected.

RESULTS

In all, 834 patients had a "high-risk for CRC" surveillance colonoscopy in view of their personal history of adenomatous polyps and were included in group 2. In total, 250 patients had a "high-risk for CRC" screening colonoscopy in view of their family history of CRC in first-degree relatives and were included in group 3. Further, 1,000 patients were selected to serve as controls (after matching for age, sex and ethnicity) and were included in group 1. Bowel preparation was graded as good, fair, or poor by the endoscopist performing the study. We observed a significantly higher number of good bowel preparations in group 2 and group 3 (P=0.0001) when compared with group 1 (controls) after adjusting for comorbidities and usage of prescription medication that could potentially cause colonic dysmotility. These differences were significant in both Hispanic and African American patients.

CONCLUSION

Our study showed that perception of CRC risk significantly influenced the bowel preparation behaviors of patients belonging to minority populations, with a significantly greater number of patients with a high risk of CRC having adequate bowel preparations.

Paraduodenal pancreatitis

Paraduodenal pancreatitis is a distinct clinicopathological entity involving the duodenum and the pancreatic tissue in the vicinity of the minor papilla. Most afflicted patients are young alcoholic males who present clinically with upper abdominal pain, weight loss, nausea, and vomiting. Pancreatic tissue elements in the duodenal wall and impedance to exocrine pancreatic secretions at the minor papilla are key factors in the pathogenesis of this condition. On imaging, the condition may manifest as a solid fibrotic mass around the minor papilla or as cysts in the duodenum and the pancreaticoduodenal groove. Duodenal stenosis, biliary strictures, chronic calcifying pancreatitis, and pancreatic ductal dilatation are also often observed.

Generation of substrate-free III-V nanodisks from user-defined multilayer nanopillar arrays for integration on Si

High material quality InP-based multilayer nanopillar (NP) arrays are fabricated using a combination of self-assembly of silica particles for mask generation and dry etching. In particular, the NP arrays are made from user-defined epitaxial multilayer stacks with specific materials and layer thicknesses. An additional degree of flexibility in the structures is obtained by changing the lateral diameters of the NP multilayer stacks. Pre-defined NP arrays made from InGaAsP/InP and InGaAs/InP NPs are then used to generate substrate-free nanodisks of a chosen material from the stack by selective etching. A soft-stamping method is demonstrated to transfer the generated nanodisks with arbitrary densities onto Si. The transferred nanodisks retain their smooth surface morphologies and their designed geometrical dimensions. Both InP and InGaAsP nanodisks display excellent photoluminescence properties, with line-widths comparable to unprocessed reference epitaxial layers of similar composition. The multilayer NP arrays are potentially attractive for broad-band absorption in third-generation solar cells. The high optical quality, substrate-free InP and InGaAsP nanodisks on Si offer a new path to explore alternative ways to integrate III-V on Si by bonding nanodisks to Si. The method also has the advantage of re-usable III-V substrates for subsequent layer growth.

A rare coexistence: drug induced hepatitis and meningitis in association with Ibuprofen

Ibuprofen, a commonly used NSAID is reported to be associated with drug induced liver injury. Ibuprofen is also known to be associated with drug-induced meningitis especially in patients with connective tissue disorders. However presentation of hepatitis and meningitis in association with Ibuprofen use in the same individual has never been reported. We present a case of young woman who developed abnormal liver chemistries and neurological symptoms while on Ibuprofen. Her liver biopsy findings were suggestive of drug induced liver injury and cerebrospinal fluid analysis was suggestive of aseptic meningitis. Clinical and biochemical improvement was noted on cessation of Ibuprofen.

Incidental finding of esophageal pneumatosis

Pneumatosis of the gastrointestinal tract is a rare condition characterized by the presence of air filled cavities in the gastrointestinal tract wall. Its occurrence has been described throughout the gastrointestinal tract from the esophagus to the rectum, however it is most commonly reported in the small intestine. Despite multiple case reports in literature, its pathogenesis still remains unclear. Pneumatosis may be idiopathic or associated with a variety of disorders namely peptic ulcer disease, jejunoileal bypass, intestinal obstruction and non-gastrointestinal disorders like asthma, chronic obstructive pulmonary disease, systemic lupus erythematosus, infectious enteritis, etc. We here present a rare case of pneumatosis of the esophagus diagnosed incidentally at an esophagogastroduodenoscopy (EGD). A 78-year-old asymptomatic woman underwent EGD and colonoscopy at our hospital for evaluation of anemia. Few months prior to EGD, she had undergone excision of laryngocele at our hospital. EGD revealed extensive submucosal blebs distributed throughout the esophagus, otherwise unremarkable stomach and duodenum. Colonoscopy showed a tubular adenomatous polyp. Since our patient was asymptomatic she did not require any surgical intervention. Management of pneumatosis depends on the underlying cause.

Rare endoscopic manifestation of pancreatic adenocarcinoma

Gastric ulcer secondary to direct invasion from pancreatic adenocarcinoma is rare. Metastases to the stomach have been commonly reported with melanoma and with primary tumors of the breast, lung, ovary, liver, colon and testis. We report a patient who presented with epigastric pain and in whom subsequently upper endoscopy showed a malignant gastric ulcer secondary to direct invasion from pancreatic adenocarcinoma of the body. An 81-year-old female presented to our hospital with epigastric pain and subsequently underwent endoscopy with endoscopic ultrasound for evaluation of a pancreatic body mass. She had a large gastric ulcer in the fundus which was in direct continuity with the pancreatic mass. Pathology from biopsy of the ulcer revealed invasive well-to-moderately-differentiated adenocarcinoma, and immunohistochemical stains were strongly positive for CA19-9, CK7, CK19 and carcinoembryonic antigen. These findings were consistent with a histopathological diagnosis of metastatic carcinoma of the pancreas. Patients with gastrointestinal metastases usually have advanced malignancy with poor prognosis. Endoscopic evaluation with adequate biopsies should be performed for symptomatic patients.

Hypertriglyceridemia Induced Pancreatitis in a Non-Diabetic Pregnant Patient Requiring the Use of Total Parenteral Nutrition

Hypertriglyceridemia induced pancreatitis in pregnancy is established and has been widely reported. However there are very scanty reports of cases involving the use of total parenteral nutrition. We report the case of a 37-year-old gravida 3, para 2 woman at 34 weeks of gestation who presented with one day of severe epigastric pain radiating to the back, nausea and bilious vomiting caused by pancreatitis induced by hypertriglyceridemia. Her initial serum triglyceride, amylase and lipase concentration were 6,552 mg/dl, 314 U/L and 537 U/L respectively. She initially received intravenous fluids and insulin with reduction of serum triglyceride levels to 583 mg/dl on the fifth day of admission. However attempts to refeed the patient with solid food resulted in induction of hypertriglyceridemia and relapse of pancreatitis. Lipid free total parenteral nutrition was commenced in the third week of admission and lead to a better control of triglyciderides and resolution of pancreatitis until delivery of a full term healthy neonate.

Staining for p53 and Ki-67 increases the sensitivity of EUS-FNA to detect pancreatic malignancy

AIM: To investigate whether tumor marker staining can improve the sensitivity of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) to diagnose pancreatic malignancy.

METHODS: Patients who underwent EUS-FNA were retrospectively identified. Each EUS-FNA specimen was evaluated by routine cytology and stained for tumor markers p53, Ki-67, carcinoembryonic antigen (CEA) and CA19-9. Sensitivity, specificity, positive and negative predictive values (PPV and NPV), and positive and negative likelihood ratios (PLR and NLR) were calculated in order to evaluate the performance of each test to detect malignancy.

RESULTS: Sixty-one specimens had complete sets of stains, yielding 49 and 12 specimens from pancreatic adenocarcinomas and benign pancreatic lesions due to pancreatitis, respectively. Cytology alone had sensitivity and specificity of 41% and 100% to detect malignancy, respectively. In 46% of the specimens, routine cytology alone was deemed indeterminate. The addition of either p53 or Ki-67 increased the sensitivity to 51% and 53%, respectively, with perfect specificity, PPV and PLR (100%, 100% and infinite). Both stains in combination increased the sensitivity to 57%. While additional staining with CEA and CA19-9 further increased the sensitivity to 86%, the specificity, PPV and PLR were significantly reduced (at minimum 42%, 84% and 1, respectively). Markers in all combinations performed poorly as a negative test (NPV 26% to 47%, and NLR 0.27 and 0.70).

CONCLUSION: Immunohistochemical staining for p53 and Ki-67 can improve the sensitivity of EUS-FNA to diagnose pancreatic adenocarcinoma.

Stable enhancement of near-band-edge emission of ZnO nanowires by hydrogen incorporation

We report on the photoluminescence properties of ZnO nanowires treated with a mild Ar plasma. The nanowires exhibited stable and strong enhancement of the near-band-edge emission and quenching of the deep level emission. The low temperature PL revealed a strong hydrogen donor-bound-exciton line in the plasma-treated samples indicating unintentional incorporation of hydrogen during the plasma treatment. To confirm the results, hydrogen was implanted into the ZnO nanowires with a low ion energy of 600 eV and different fluences. The observed result can be related to the passivation of deep centers by hydrogen. The absolute photoluminescence intensity measured by an integrating sphere showed stable and strong UV emission from the treated samples even after several weeks.

Interferon and ribavirin therapy does not select for resistance mutations in hepatitis C virus polymerase

Ribavirin has a minor and transient effect on hepatitis C virus (HCV) replication and has been suggested to select a novel mutation, F415Y, in the RNA-dependent RNA polymerase of subtype 1a viruses. Twenty-nine patients with chronic hepatitis C (subtyped by INNO LiPA as 1a, 17; 1b, 11; 1a/1b, 1) who were nonresponders to interferon-based therapies were identified retrospectively and screened at Baseline, week 24 of treatment, and 24 weeks post-treatment. Selection of resistance mutations, including at amino acid position 415 of the polymerase, was investigated. Using clonal sequencing and pyrosequencing of the NS5B gene, we screened for the F415Y resistance mutation among patients who received combination therapy with ribavirin and interferon α. Of the 15 subtype 1a patients treated with interferon plus ribavirin, only one had the F415Y change at week 24, and an F/Y mixture was still present 24 weeks after therapy. Four additional patients in this group had the F415Y change 24 weeks post-therapy. The NS5B genes were sequenced in order to identify amino acid changes associated with ribavirin therapy, but no evidence was found that ribavirin selects for particular amino acids in the RNA-dependent RNA polymerase. Ribavirin, a weak inhibitor of HCV replication, does not select for resistance mutations in the sequence of the HCV RNA polymerase.

Clinical significance of incidental colorectal wall thickening on computed tomography scan in African-American and Hispanic patients

We sought to assess the significance of an incidental finding of colorectal wall thickening (CRWT) on computed tomography (CT) scan in African-American and Hispanic patients. We retrospectively reviewed charts of African-American and Hispanic patients from January 1994 to December 2005. Those patients were included in whom the colonoscopy was performed due to incidental CRWT on CT scan. Patients with a history or a family history of colorectal malignancy, inflammatory bowel disease, or colorectal surgery, with an incomplete colonoscopic examination, or <18 years of age were excluded. Endoscopic and pathological findings were abstracted. Thirty-two patients met the criteria. Endoscopic examination was abnormal in 21 (65.6%). The positive predictive value of CRWT for abnormal endoscopic examination was 65.6%. Abnormal endoscopic examination revealed diverticulosis in 9 (43%), erythematous mucosa in 8 (38%), polyps in 6 (29%), mass in 2 (9%), thickened folds in 1 (5%), and diverticulitis in 1 (5%). Histopathological findings revealed colitis in 7 (33%), adenoma in 4 (19%), hyperplastic polyps in 4 (19%), adenocarcinoma in 2 (9%), lymphoid aggregates in 2 (9%), melanosis coli in 1 (5%), and normal in 1 (5%) in the abnormal examination group. Abnormal endoscopic examination was found in 65.6% of patients. The prevalence of colitis, adenomas, and malignancy was high, therefore abnormal CRWT warrants further endoscopic evaluation.

Asthenoteratozoospermia in mice lacking testis expressed gene 18 (Tex18)

Testis expressed gene 18 (Tex18) is a small gene with one exon of 240 bp, which is specifically expressed in male germ cells. The gene encodes for a protein of 80 amino acids with unknown domain. To investigate the function of (Tex18) gene, we generated mice with targeted disruption of the (Tex18) gene by homologous recombination. Homozygous mutant males on a mixed genetic background (C57BL/6J x 129/Sv) are fertile, while they are subfertile on the 129/Sv background, although mating is normal. We showed that Tex18(-/-) males are subfertile because of abnormal sperm morphology and reduced motility, which is called asthenoteratozoospermia, suggesting that (Tex18) affects sperm characteristics. Maturation of spermatids is unsynchronized and partially impaired in seminiferous tubules of Tex18(-/-) mice. Electron microscopical examination demonstrated abnormal structures of sperm head. In vivo experiments with sperm of Tex18(-/-) 129/Sv mice revealed that the migration of spermatozoa from the uterus into the oviduct is reduced. This result is supported by the observation that sperm motility, as determined by the computer-assisted semen analysis system, is significantly affected, compared to wild-type spermatozoa. Generation of transgenic mice containing Tex18-EGFP fusion construct revealed a high transcriptional activity of (Tex18) during spermiogenesis, a process with morphological changes of haploid germ cells and development to mature spermatozoa. These results indicate that (Tex18) is expressed predominantly during spermatid differentiation and subfertility of the male Tex18(-/-) mice on the 129/Sv background is due to the differentiation arrest, abnormal sperm morphology and reduced sperm motility.

The neuroleptic malignant syndrome: A report of 14 cases from North India

Neuroleptic malignant syndrome (NMS) is a rare, life-threatening but potentially treatable condition. This study was performed to investigate the clinical spectrum, antecedent events and outcome of NMS patients admitted in the Neurology department of a large teaching hospital of North India. Fourteen cases of NMS were taken after a thorough search during a three-year period (May 2000 to April 2003). The Incidence of NMS was 1.40/ 1000 patients treated with neuroleptics and mortality rate was 14.28%. Amongst the neuroleptics Haloperidol (parenteral) was implicated as a most common drug for NMS in 57% of patients. An association with coexisting precipitating illness was clearly recorded in 71.4% patients. All the recorded patients of NMS received 500-700 mg CPZ equivalent/day of neuroleptics. NMS as an indiosyncratic phenomenon was noticed in 28% patients. 85.7% responded to dopaminergic drugs along with supportive treatment and showed partial or complete recovery within 7-14 days. In those with partial recovery residual deficits included Parkinsonian features, depression and diaphoresis in a small percentage of patients.

Zileuton, a 5-lipoxygenase inhibitor, increases production of thromboxane A2 and platelet aggregation in patients with asthma

Leukotrienes, generated from arachidonic acid via the lipoxygenase pathway, play an important role in the pathophysiology of asthma. Therefore, leukotriene inhibitors, such as Zileuton, are used in the treatment of asthma. However, thromboxanes, generated from arachidonic acid via the cyclooxygenase pathway, play an important role in platelet aggregation and thrombosis. Therefore, we studied whether Zileuton, by shifting arachidonic acid to the cyclooxygenase pathway, enhances thromboxane production and, hence, platelet aggregation. Blood samples were collected from 10 asthmatic patients before and 2 weeks after standard Zileuton treatment. Spontaneous platelet aggregation was measured in platelet-rich plasma. Platelet-rich plasma was also used to determine thromboxane B(2), a stable metabolite of thromboxane A(2), as the indirect measure of thromboxane A(2) because thromboxane A(2) is too unstable for assay. Baseline thromboxane B(2) and platelet aggregation values in the 10 asthmatic patients were normal. Treatment with Zileuton for 2 weeks significantly increased thromboxane B(2) levels from baseline levels of 267 +/- 54 microg/l to 389 +/- 62 microg/l after 2 weeks of treatment (P < 0.0002). Spontaneous platelet aggregation also increased significantly from baseline values of 4.2 +/- 2.4% to 6.8 +/- 2.8% after 2 weeks of treatment (P < 0.0001). These results establish that Zileuton, an effective drug for asthma, adversely affects in vitro platelet function. The findings suggest that this drug, and perhaps related agents also, may pose a thrombotic risk; clinical attention will be needed to address this possibility.

Co-existence of dual intracranial pathology clinical relevance of proton MRS

The co-existence of neuro-cysticercosis (NCC) and intracranial neoplasm in an individual is a rare entity. Atypical presentation of cerebral cysticercosis may mimic glioma, metastasis, cerebral abscess or vice versa. The dual existence of these two lesions have led to several postulates which may have clinical impact in due course of time i.e. NCC as an oncogenetic factor for glioma or similarity of antigen found in glioma and NCC etc. An adequate management of such cases poses a challenge to both imageologists as well as clinicians. Thus, a proper diagnostic evaluation is essential for successful management of such cases. MR spectroscopy (MRS), although still a clinical research tool, may be extremely useful for exclusion or confirmation of neoplastic lesions in such a clinical scenario. The findings of MRS in collaboration with imaging parameters may increase the diagnostic yield of a MR investigation. The authors encountered five cases of dual intracranial pathologies i.e. neurocysticercosis and glioma. MR spectroscopy was useful to arrive at a definitive diagnosis in such a situation.

Detection of moving objects in video using a robust motion similarity measure

This correspondence deals with the segmentation of a video clip into independently moving visual objects. This is an important step in structuring video data for storage in digital libraries. The method follows a bottom-up approach. The major contribution is a new well-founded measure for motion similarity leading to a robust method for merging regions. The improvements with respect to existing methods have been confirmed by experimental results.

Acquired tracheo-oesophageal fistula (a case report)

A case of acquired tracheo-oesophageal fistula in a 16-year-old boy, caused by a bullet wound, is presented. The fistula was located just below the cricoid cartilage and was successfully treated by excision of the fistula followed by interposition of the sternomastoid muscle.