Total Parathyroidectomy Without Autotransplantation for ESRD Patients With Secondary Hyperparathyroidism; an Effective Alternative

BACKGROUND

The most common operations performed for secondary hyperparathyroidism include subtotal parathyroidectomy (STPX) and total parathyroidectomy with autotransplantation (TPX + AT). We present a series of ESRD patients treated with total parathyroidectomy without autotransplantation (TPX).

METHODS

This is a retrospective cohort analysis of ESRD patients, age 18 years or older, with three or more glands resected on final pathology and follow-up parathyroid hormone levels obtained up to 1.5 years postoperatively. The primary endpoint was recurrence of hyperparathyroidism (defined as PTH > 500 pg/mL).

RESULTS

The incidence of recurrent hyperparathyroidism at 1.5 years was 5.9% (2/34). The incidence of persistent hyperparathyroidism at 1.5 years was 11.8% (4/34). In this series, no patients were hospitalized for symptomatic hypocalcemia or experienced pathologic bone fractures.

CONCLUSIONS

Recurrence rates are low with TPX. The most common cause of recurrent and persistent disease is resection of three rather than four glands. The known complications of TPX, pathologic fractures, and severe hypocalcemia, were not seen in this study.

Evaluation of Neck Pain and Posture of Cervical Spine among Helmet Users Riding Motor Bike

Background: Helmet use is become mandatory by the Indian govt. in the year of 2016. After the helmet law the prevalence of helmet users increased up to 80%. Other 20% populations refused to wear helmet while riding due their own reasons such as some founds wearing of helmet causing suffocating, heaviness over neck muscles or some feels headache too. Among various postural disorders, forward head posture (FHP) has found to be commonest. It occurs when position of the head is forward to a plumb line passing over the centre of gravity. The good posture could be present, as the external auditory meatus allied with the plumb line. FHP can be assessed by using various assessment methods and Cranio-vertebral angle (CVA) method is highly reliable method to measure FHP, which indicates smaller the angle greater the FHP. The aim of the study was to evaluate the postural changes in cervical spine and presence of neck pain among helmet users riding motor bike. Method Total 300 subjects participated in the study and were assessed by self- made questionnaire, out of which 260(Male= 189, Female= 71) subjects were taken in the study as they were fulfilling the inclusion criteria. Then dividing them into two groups based on complaining of pain on neck (with neck pain and without neck pain) using Numeric pain rating scale (NPRS). CVA was measured using MB-Ruler software for both the groups. Result The results shows CVA has a significant correlation with helmet weight (p value=0.000), BMI (p value=0.04), years of riding (p value=0.037) and days of riding per week (p value=0.031). NPRS showed to have significant correlation with helmet weight (p value=0.046) and weight of the bag (p value=0.012). 45% of study populations were having FHP and 66% populations were having neck pain. Conclusion The study concludes that helmet weight has significant impact on both neck pain and forward head posture. The incidence rate of forward head posture was greater among with neck pain populations.

A rare case of posttraumatic meningitis presenting with acute hydrocephalus

Posttraumatic meningitis is a severe complication of traumatic brain injury (TBI) that dramatically increases its mortality. Skull-base fractures increase the risk of posttraumatic meningitis. Posttraumatic hydrocephalus was encountered in 0.7 %–29 % of the patients with severe head injury. Posttraumatic hydrocephalus should be differentiated from ventriculomegaly due to brain atrophy.

We present a clinical case of a 52-year-old patient after a mild TBI and a linear skull base fracture who developed acute hydrocephalus in the context of a posttraumatic meningitis within the first week after the injury. The occurrence of hydrocephalus in patients with posttraumatic meningitis is not well studied but could lead to rapid deterioration of the patient. It results from injury-induced disturbance of CSF flow either through obstruction or lack of CSF reabsorption. Factors increasing the risk of posttraumatic meningitis are - operative interventions, skull base fractures and CSF leakage. Patients with meningitis usually present with lower GCS score. The lower GCS is a harbinger of worse prognosis. Therefore, aggressive medical treatment is warranted.

With this case study we show that meningitis presenting with PTH can develop rapidly over 24 h within the first week post mild head injury with basilar skull fracture. A swift response in providing timely ventricular drainage, together with an appropriate antimicrobial coverage, can greatly reduce any lasting neurological deficits and produce a good clinical outcome.

The importance of targeting signalling mechanisms of the SLC39A family of zinc transporters to inhibit endocrine resistant breast cancer

Aim:

Zinc is a key secondary messenger that can regulate multiple signalling pathways within cancer cells, thus its levels need to be strictly controlled. The Zrt, Irt-like protein (ZIP, SLC39A) family of zinc transporters increase cytosolic zinc from either extracellular or intracellular stores. This study examines the relevance of zinc transporters ZIP7 and ZIP6 as therapeutic targets in tamoxifen resistant (TAMR) breast cancer.

Methods:

A series of in vitro assays, including immunohistochemistry, immunofluorescence, flow cytometry, and western blotting were used to evaluate levels and activity of ZIP7 and ZIP6 in models of TAMR and sensitive (MCF-7) breast cancer. Analyses of these transporters in the clinical setting were performed using publicly available online resources: Gene Expression Profiling Interactive Analysis (GEPIA)2 and Kaplan-Meier Plotter (KmPlot).

Results:

Both total and activated levels of ZIP7 were significantly elevated in TAMR cells versus responsive MCF-7 cells. This was accompanied by an associated increase in free cytoplasmic zinc leading to amplification of downstream signals. Consistent with our proposed model, activated ZIP6 levels correlated with mitotic cells, which could be efficiently inhibited through use of our anti-ZIP6 monoclonal antibody. Mitotic inhibition translated to impaired proliferation in both models, with TAMR cells displaying increased sensitivity. Analysis of matched tumour and normal breast samples from patients revealed significant increases in both ZIP7 and ZIP6 in tumours, as well as family member ZIP4. Kaplan-Meier analysis revealed that high ZIP7 levels correlated with decreased overall and relapse-free survival (RFS) of patients, including patient groups who had received systemic endocrine therapy or tamoxifen only. In contrast, high ZIP6 levels were significantly linked to improved overall and RFS in all patients, as well as RFS in patients that received systemic endocrine therapy.

Conclusions:

TAMR cells displayed increased activity of both ZIP7 and ZIP6 transporters compared to anti-hormone responsive cells, suggesting their potential as novel therapeutic targets following development of resistant disease.

Suspected Interaction of Cranberry Juice Extracts and Tacrolimus Serum Levels: A Case Report

Cytochrome P450 inhibition through fruit supplement interactions often results in increased serum levels of calcineurin inhibitors, including tacrolimus. Cranberry extract is a supplement often used for the prevention of recurrent urinary tract infections (UTIs), which are common in renal allograft recipients. To our knowledge, a decrease in serum levels of tacrolimus as a result of cranberry extract interaction is unreported. A 40-year-old renal transplant patient taking cranberry extract capsules for her recurrent cystitis presented asymptomatically with low serum levels of tacrolimus. Dose increase had little effect on the level, and cessation of the cranberry extract returned levels to desired range. Cranberry extracts are an adjunctive therapy used in the management of recurrent UTIs. Tacrolimus, an immunosuppressive agent, is metabolized intestinally by isoenzymes of the P450 cytochrome. Cranberry extracts may alter this metabolism and lead to sub-therapeutic serum levels of tacrolimus. This interaction is heretofore unreported. Cranberry extracts should be carefully monitored in allograft recipients due to interactions with serum tacrolimus levels.

Kinetic analysis for non-isothermal decomposition of un-irradiated and gamma-irradiated anhydrous cadmium nitrate

The thermal decomposition of untreated and γ-irradiated samples of anhydrous cadmium nitrate was performed under non-isothermal conditions at different heating rates (5, 10, 15 and 20 ℃ min –1). The results showed that the decomposition proceeds in one major step with the formation of cadmium oxide as solid residue. The data were analysed by using both isoconversional and non-isoconversional methods. The activation energy was calculated by various model-free isoconversional methods: Flynn-Wall-Ozawa (FWO), Kissinger-Akahira-Sunose (KAS) and Friedman (FR) methods. Irradiation enhances the decomposition and the effect increases with the irradiation dose. The activation energy decreases on irradiation. The appropriate conversion model for the thermal decomposition process selected by means of the master-plot method agrees with phase boundary reaction with spherical symmetry (R3 mechanism) for both untreated and irradiated salts at all heating rates.

Chicken or the leg: Sigmoid colon perforation by ingested poultry fibula proximal to an occult malignancy

INTRODUCTION

Colonic perforation by ingested foreign bodies is exceedingly rare, with the diagnosis made more challenging by patients infrequently recalling any inadvertent ingestion and the poor sensitivity of plain radiography.

PRESENTATION OF CASE

The presented case demonstrates that bony perforation of the large bowel might occur immediately proximal to an otherwise occult colonic malignancy.

DISCUSSION

Ingestion of foreign bodies is common and rarely results in colonic perforation. However, bony ingestion is not usually remembered and can be missed even with cross-sectional imaging. If present, consideration should be given to the presence of an adjacent concealed colon cancer.

CONCLUSION

The co-existence of separate pathology should be carefully assessed in these patients, since this has important implications for relevant investigations and appropriate surgical management.

Recent Developments in Organically Doped Sol-Gel Sensors: A Microns-Scale Probe; Successful Trapping of Purified Polyclonal Antibodies; Solutions to the Dopant-Leaching Problem

We describe recent advances made in our laboratories in the general field of organically and bio-organically doped sol-gel sensors. The developments described are: (a) The first miniaturization of a sol-gel sensor down to the microns scale, with potential applications to near-field optical microscopy, using a fluorescent pH-indicator. (b) The first successful sol-gel encapsulation of purified polyclonal antibodies, and in particular an anti-nitroaromatics immunoglobulin, with which selective sensing of nitroaromatics, an important class of environmental pollutants, was demonstrated, (c) The leaching problem, occasionally encountered in doping procedures, is solved by two methodologies: First, TMOS polymerization at high acidity and low water content was found to result in non-leachable yet reactive matrices, as demonstrated with O2 sensing by excited state pyrene and with H+ sensing by excited state pyranine; and second, doping with molecules capable of forming a covalent bond within the encapsulating cage results in the permanent anchoring of the dopant. Thus, Methyl-Red, a pH indicator, was derivatized with a silylating residue, and a polymerizing TMOS was doped with it forming a pH-shifted indicator. With both methodologies, leachability was practically zero.

Hazardous alcohol use in rural southern India: nature, prevalence and risk factors

BACKGROUND

There is a dearth of data on the hazardous use of alcohol in rural India.

METHODS

We examined the nature, prevalence and factors associated with hazardous use of alcohol among men in a rural community in southern India. We used stratified sampling to select subjects from the Kaniyambadi block and employed 'AUDIT', a standard instrument, to assess the use of alcohol.

RESULTS

The prevalence of life-time use, use in the past year and hazardous use of alcohol was 46.7%, 34.8% and 14.2%, respectively. Using Indian made foreign liquor (OR 20.51; 95% CI 8.81-47.75) and living in a village which brewed illicit alcohol (OR 2.82; 95% CI 1.39-5.72) were risk factors for hazardous use while education (OR 0.39; 95% CI 0.21-0.72) was protective. These factors remained significantly associated with hazardous use after adjusting for age and education using logistic regression.

CONCLUSION

The relationship between the availability of illicit and commercial alcohol and its hazardous use suggests the need for an alcohol policy which takes into account health and economic issues and also implements the law to prevent the negative impact of problem drinking.

Mycobacterium mucogenicum from the Hickman line of an immunocompromised patient

Gram stain of a positive blood culture is the clinician's first indication of a possible causative infective organism and a guide to suitable antimicrobial therapy prior to cultural and phenotypic identification with susceptibility test results. Occasionally interpretation of a Gram stain can be difficult; if there is a low bacterial load, no organisms may be seen. Such a case is reported, where a positive blood culture taken from the Hickman line of an immunocompromised patient flagged as positive at 5 days' incubation, but no organisms were seen on Gram film. On subculture, a slow growing Gram-positive bacillus was isolated which was initially misidentified and reported as a "diphtheroid" species. The actual identity of this organism and further isolates was later elucidated as Mycobacterium mucogenicum, a rapidly growing non-tuberculous mycobacterium.

CDKN2B methylation status and isolated chromosome 7 abnormalities predict responses to treatment with 5-azacytidine

5-Azacytidine, a DNA methyl transferase inhibitor, is effective in patients with myelodysplastic syndromes (MDS). Whether responses to 5-Azacytidine are achieved by demethylation of key genes or by cytotoxicity is unclear. Of 34 patients with MDS or acute myeloid leukaemia (AML) treated with 5-Azacytidine, 7 achieved complete remissions (CR) (21%) and 6 achieved haematological improvement. All six had less than 5% bone marrow (BM) blasts at the time of haematological improvements (HI) (2 had pre-existing refractory anaemia (RA), 4 had refractory anaemia with excess blasts (RAEB)). A further patient with RAEB had blast reduction to less than 5% without HI. Five of the seven (71%) complete responders had chromosome 7 abnormalities. BM CR predicted longer overall survival (OS) (median 23 versus 9 months, P=0.015). Bisulphite genomic sequencing (BGS) of the CDKN2B (p15(INK4b)) promoter showed low level, heterogeneous pretreatment methylation (mean 12.2%) in 14/17 (82%) patients analysed. Lower baseline methylation occurred in responders (9.8% versus 16.2% in non-responders P=0.07). No response was seen in patients with >24% methylation, in whom p15(INK4b) mRNA was not expressed. 5-Azacytidine reduced CDKN2B methylation by mean 6.8% in 8/17 (47%) patients, but this did not correlate with response. At 75 mg/m(2), cell death (reduced BM cellularity (P=0.001) and increased apoptosis (P=0.02)) rather than demethylation of CDKN2B correlates with response. Patients with >24% methylation may benefit from alternative dosing or combination strategies.

Prognostic factors of concurrent chemo-radiotherapy in head and neck cancers

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Background: Concurrent chemo-radiotherapy either as primary or adjuvant treatment is now the standard of care in high- risk head and neck squamous cell carcinomas. This has improved survival rates and chances of organ preservation. Advanced stage, extra- capsular extension, perineural and lympho-vascular invasion and positive surgical margins were considered as poor prognostic factors with radiotherapy alone. Herein we report the significance of these clinical and pathological factors, with concurrent chemo-radiotherapy regimens. Methods:A retrospective analysis of 54 patients with squamous cell carcinoma of head and neck who underwent either primary (21,39 %) or adjuvant (33,61%) concurrent chemoradiation at Amrita Institute of Medical Sciences, Kochi, India, during January 2004 to May 2005 and followed up to Dec 2006. 6 (11%) patients had stage III and 48 (89 %) had stage IV disease. Prognostic significance of clinical and pathological factors was evaluated. Kaplan-Meir curves for survival analysis, log rank test for univariate and Cox proportional method for multivariate analysis were employed. Results: The median follow up was 22 months. Two-year overall (OS) and disease free survival (DFS) rates were 66 % and 52 % respectively. Univariate and multivariate analysis of T stage, nodal stage, radiotherapy interruptions, completion of chemotherapy, schedule of chemotherapy (week 1,4,7 vs weekly), perineural invasion, extra-capsular extension and positive margins showed no significant difference in OS and DFS. However both univariate (p = 0.019 for OS and p = 0.012 for DFS) and multivariate analysis (p = 0.029, HR 0.16,95 %CI - 0.03 to 0.8 for OS and p = 0.017,HR 0.188,95% CI - 0.04 to 0.74 for DFS) revealed lympho-vascular invasion as a significant prognostic factor. Conclusions: Advanced stage, extra capsular invasion and positive margins were conventionally thought to be poor prognostic markers in head and neck cancer. However in our series of patients treated with concurrent chemo radiation lymphovascular invasion was the only significant poor prognostic factor. Other factors were found to be not significant.

No significant financial relationships to disclose.

Single institutional experience with rituximab in the treatment of B cell lymphoproliferative malignancies and autoimmune disorders

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Background: This is a retrospective analysis of usage of rituximab( Rituxan) a monoclonal antibodies against CD20 expressing B lymphocytes.The duration of period studied is from December first,2004 to July first,2006.This involved one single institution, John Stroger hospital of Cook County,chicago. Methods: A total of two hundred and thirty 230 treatment courses recorded.This involved a total of 208 patients.Some patients treated with more than one course in combination with different chemotheraputic agents. Results: . A total of 208 patients received Rituxan. Median number of doses is 8 (range 1–18). This include 92 patients with Diffuse large B-cell NHL, six patients with Burkitt’s lymphoma, thirty six patients with low grade NHL, three patients with mantle cell lymphoma, three patients with orbital lymphoma, three patient with AIDS related NHL, twenty seven patients with chronic lymphocytic leukemia CLL, ten patients with MALT/Gastric lymphoma, ten patients with ITP and 7 patient with warm autoimmune hemolysis, 7 patients given Rituxan as part of Rheumatoid Arthritis treatment. The complete response rate CR, near CR, partial response improved with adding Rituxan to 85% in Diffuse large grade Bcell lymphoma, one third high IPI score. Only 15% were refractory or relapsed after response. In low grade Bcell NHL 1/3 of patients received multiple prior treatments and the response rate were improved and disease progression was delayed. Most patients are of younger mean age 55 range (19–80).One third of patients recieved maintenace rituxan .Transfusion reaction occurred in less than 10%, severe leucopenia 3%, GI perforation in one patient, focal leukoencephalopathy PML in one with CNS involvement, tumor lysis syndrome occured in three patients, severe mucocutaneous reaction occured in one patient.One patient with RA and warm immune hemolysis died with sever pancytopenia after two months from recieving four doses. . Conclusions: This is a single institution experience where 60 percents are african american. This also show that Rituxan usage has became a standard therapy in Bcell lymphoproliferative malignancies.The improvement in response rate and progression free survival match other published phase III multicentered studies.

No significant financial relationships to disclose.