Cleavage and Polyadenylation-Specific Factor 4 (CPSF4) Expression Is Associated with Enhanced Prostate Cancer Cell Migration and Cell Cycle Dysregulation, In Vitro

Potential oncogene cleavage and polyadenylation specific factor 4 (CPSF4) has been linked to several cancer types. However, little research has been conducted on its function in prostate cancer (PCa). In benign, incidental, advanced, and castrate resistant PCa (CRPCa) patient samples, protein expression of CPSF4 was examined on tissue microarray (TMAs) of 353 PCa patients using immunohistochemistry. Using the 'The Cancer Genome Atlas' Prostate Adenocarcinoma (TCGA PRAD) database, significant correlations were found between high CPSF4 expression and high-risk genomic abnormalities such as ERG-fusion, ETV1-fusion, and SPOP mutations. Gene Set Enrichment Analysis (GSEA) of CPSF4 revealed evidence for the increase in biological processes such as cellular proliferation and metastasis. We further examined the function of CPSF4 in vitro and confirmed CPSF4 clinical outcomes and its underlying mechanism. Our findings showed a substantial correlation between Gleason groups and CPSF4 protein expression. In vitro, CPSF4 knockdown reduced cell invasion and migration while also causing G1 and G2 arrest in PC3 cell lines. Our findings demonstrate that CPSF4 may be used as a possible biomarker in PCa and support its oncogenic function in cellular proliferation and metastasis.

Serrate RNA Effector Molecule (SRRT) Is Associated with Prostate Cancer Progression and Is a Predictor of Poor Prognosis in Lethal Prostate Cancer

Arsenite-resistance protein 2, also known as serrate RNA effector molecule (ARS2/SRRT), is known to be involved in cellular proliferation and tumorigenicity. However, its role in prostate cancer (PCa) has not yet been established. We investigated the potential role of SRRT in 496 prostate samples including benign, incidental, advanced, and castrate-resistant patients treated by androgen deprivation therapy (ADT). We also explored the association of SRRT with common genetic aberrations in lethal PCa using immunohistochemistry (IHC) and performed a detailed analysis of SRRT expression using The Cancer Genome Atlas (TCGA PRAD) by utilizing RNA-seq, clinical information (pathological T category and pathological Gleason score). Our findings indicated that high SRRT expression was significantly associated with poor overall survival (OS) and cause-specific survival (CSS). SRRT expression was also significantly associated with common genomic aberrations in lethal PCa such as PTEN loss, ERG gain, mutant TP53, or ATM. Furthermore, TCGA PRAD data revealed that high SRRT mRNA expression was significantly associated with higher Gleason scores, PSA levels, and T pathological categories. Gene set enrichment analysis (GSEA) of RNAseq data from the TCGA PRAD cohort indicated that SRRT may play a potential role in regulating the expression of genes involved in prostate cancer aggressiveness. Conclusion: The current data identify the SRRT's potential role as a prognostic for lethal PCa, and further research is required to investigate its potential as a therapeutic target.

Downregulation of BUD31 Promotes Prostate Cancer Cell Proliferation and Migration via Activation of p-AKT and Vimentin In Vitro

Among men, prostate cancer (PCa) is the second most frequently diagnosed cancer subtype and has demonstrated a high degree of prevalence globally. BUD31, also known as Functional Spliceosome-Associated Protein 17, is a protein that works at the level of the spliceosome; it is functionally implicated in pre-mRNA splicing as well as processing, while also acting as a transcriptional regulator of androgen receptor (AR) target genes. Clinically, the expression of BUD31 and its functions in the development and progression of PCa is yet to be elucidated. The BUD31 expression was assessed using IHC in a tissue microarray (TMA) constructed from a cohort of 284 patient samples. In addition, we analyzed the prostate adenocarcinoma (TCGAPRAD-) database. Finally, we used PCa cell lines to knockdown BUD31 to study the underlying mechanisms in vitro.Assesment of BUD31 protein expression revealed lower expression in incidental and advanced PCa, and significantly lower expression was observed in patients diagnosed with castrate-resistant prostate cancer. Additionally, bioinformatic analysis and GSEA revealed that BUD31 increased processes related to cancer cell migration and proliferation. In vitro results made evident that BUD31 knockdown in PC3 cells led to an increase in the G2 cell population, indicating a more active and proliferative state. Additionally, an investigation of metastatic processes revealed that knockdown of BUD31 significantly enhanced the ability of PC3 cells to migrate and invade. Our in vitro results showed BUD31 knockdown promotes cell proliferation and migration of prostate cancer cells via activation of p-AKT and vimentin. These results support the clinical data, where low expression of BUD31 was correlated to more advanced stages of PCa.

A randomized clinical trial of glenohumeral joint steroid injection versus suprascapular nerve block in patients with frozen shoulder: a protocol for the Therapeutic Injections For Frozen Shoulder (TIFFS) study

Frozen shoulder is a common, painful condition that results in impairment of function. Corticosteroid injections are commonly used for frozen shoulder and can be given as glenohumeral joint (GHJ) injection or suprascapular nerve block (SSNB). Both injection types have been shown to significantly improve shoulder pain and range of motion. It is not currently known which is superior in terms of relieving patients' symptoms. This is the protocol for a randomized clinical trial to investigate the clinical effectiveness of corticosteroid injection given as either a GHJ injection or SSNB. The Therapeutic Injections For Frozen Shoulder (TIFFS) study is a single centre, parallel, two-arm, randomized clinical trial. Participants will be allocated on a 1:1 basis to either a GHJ corticosteroid injection or SSNB. Participants in both trial arms will then receive physiotherapy as normal for frozen shoulder. The primary analysis will compare the Oxford Shoulder Score (OSS) at three months after injection. Secondary outcomes include OSS at six and 12 months, range of shoulder movement at three months, and Numeric Pain Rating Scale, abbreviated Disabilities of Arm, Shoulder and Hand score, and EuroQol five-level five-dimension health index at three months, six months, and one year after injection. A minimum of 40 patients will be recruited to obtain 80% power to detect a minimally important difference of ten points on the OSS between the groups at three months after injection. The study is registered under ClinicalTrials.gov with the identifier NCT04965376. The results of this trial will demonstrate if there is a difference in shoulder pain and function after GHJ injection or SSNB in patients with frozen shoulder. This will help provide effective treatment to patients with frozen shoulder.

Late Diagnosis of Hirschsprung's Disease: Definition and Implication on Core Outcomes

INTRODUCTION

 Late diagnosis of Hirschsprung's disease (LDHD) may carry a poor prognosis. Its definition remains unclear and its implication on HD-related core outcomes has not been fully reported.

METHODS

 A single-center 20-year series was reviewed to include HD with follow-up of 1 year or more post pull-through (PT) and aged 5 years or older. We investigated six core outcomes derived from NETS^1HD study by comparing the groups dichotomized by four time points using age at diagnosis (44-week gestation, 6 months, 1 year, and 3 years). Following establishment of definition of LDHD, the outcomes and complications were compared with timely diagnosis of HD (TDHD).

RESULTS

 Forty-nine out of eighty-six HD were included. The definition of LDHD was found to be HD diagnosed at 1 year of age or later because 3/6 core outcomes were significantly worse than TDHD. Nine patients (18%) had LDHD-median age at diagnosis 42 months (12-89) and PT performed at 57 months (12-103), mostly Soave (73%); a covering stoma was performed in 7/9, significantly higher than TDHD in 10/40 (p = 0.001). LDHD was associated with increased unplanned surgery (78% vs. 30%, p = 0.019), fecal incontinence (100% vs. 62%, p = 0.01), and permanent stoma (33% vs. 5%, p = 0.037). Major complications (56% vs. 20%, p = 0.043) and redo PT (33% vs. 5%, p = 0.037) were also higher in LDHD.

CONCLUSION

 LDHD could be defined as HD diagnosis at or over 1 year of age. LDHD was associated with more preoperative stoma, major postoperative complications, unplanned reoperation, and worse HD-related core outcomes.

The Association between Cyclin Dependent Kinase 2 Associated Protein 1 (CDK2AP1) and Molecular Subtypes of Lethal Prostate Cancer

Prostate cancer (PCa) is one of the most commonly diagnosed types of malignancy and is the second leading cause of cancer-related death in men in developed countries. Cyclin dependent kinase 2 associate protein 1(CDK2AP1) is an epigenetic and cell cycle regulator gene which has been downregulated in several malignancies, but its involvement in PCa has not yet been investigated in a clinical setting. We assessed the prognostic value of CDK2AP1 expression in a cohort of men diagnosed with PCa (n = 275) treated non-surgically by transurethral resection of the prostate (TURP) and studied the relationship between CDK2AP1 expression to various PCa molecular subtypes (ERG, PTEN, p53 and AR) and evaluated the association with clinical outcome. Further, we used bioinformatic tools to analyze the available TCGA PRAD transcriptomic data to explore the underlying mechanism. Our data confirmed increased expression of CDK2AP1 with higher Gleason Grade Group (GG) and metastatic PCa (p <0.0001). High CDK2AP1 expression was associated with worse overall survival (OS) (HR: 1.62, CI: 1.19−2.21, p = 0.002) and cause-specific survival (CSS) (HR: 2.012, CI 1.29−3.13, p = 0.002) using univariate analysis. When compared to each sub-molecular type. High CDK2AP1/PTEN-loss, abnormal AR or p53 expression showed even worse association to poorer OS and CCS and remained significant when adjusted for GG. Our data indicates that CDK2AP1 directly binds to p53 using the Co-Immunoprecipitation (Co-IP) technique, which was validated using molecular docking tools. This suggests that these two proteins have a significant association through several binding features and correlates with our observed clinical data. In conclusion, our results indicated that the CDK2AP1 overexpression is associate with worse OS and CSS when combined with certain PCa molecular subtypes; interaction between p53 stands out as the most prominent candidate which directly interacts with CDK2AP1.

A Multi-Layer Data-Driven Security Constrained Unit Commitment Approach with Feasibility Compliance

Security constrained unit commitment is an essential part of the day-ahead energy markets. The presence of discrete and continuous variables makes it a complex, mixed-integer, and time-hungry optimization problem. Grid operators solve unit commitment problems multiple times daily with only minor changes in the operating conditions. Solving a large-scale unit commitment problem requires considerable computational effort and a reasonable time. However, the solution time can be improved by exploiting the fact that the operating conditions do not change significantly in the day-ahead market clearing. Therefore, in this paper, a novel multi-layer data-driven approach is proposed, which significantly improves the solution time (90% time-reduction on average for the three studied systems). The proposed approach not only provides a near-optimal solution (<1% optimality gap) but also ensures that it is feasible for the stable operation of the system (0% infeasible predicted solutions). The efficacy of the developed algorithm is demonstrated through numerical simulations on three test systems, namely a 4-bus system and the IEEE 39-bus and 118-bus systems, and promising results are obtained.

The Expression of Proto-Oncogene ETS-Related Gene (ERG) Plays a Central Role in the Oncogenic Mechanism Involved in the Development and Progression of Prostate Cancer

The ETS-related gene (ERG) is proto-oncogene that is classified as a member of the ETS transcription factor family, which has been found to be consistently overexpressed in about half of the patients with clinically significant prostate cancer (PCa). The overexpression of ERG can mostly be attributed to the fusion of the ERG and transmembrane serine protease 2 (TMPRSS2) genes, and this fusion is estimated to represent about 85% of all gene fusions observed in prostate cancer. Clinically, individuals with ERG gene fusion are mostly documented to have advanced tumor stages, increased mortality, and higher rates of metastasis in non-surgical cohorts. In the current review, we elucidate ERG’s molecular interaction with downstream genes and the pathways associated with PCa. Studies have documented that ERG plays a central role in PCa progression due to its ability to enhance tumor growth by promoting inflammatory and angiogenic responses. ERG has also been implicated in the epithelial–mesenchymal transition (EMT) in PCa cells, which increases the ability of cancer cells to metastasize. In vivo, research has demonstrated that higher levels of ERG expression are involved with nuclear pleomorphism that prompts hyperplasia and the loss of cell polarity.

A Critical Analysis of Rectal Biopsy to Exclude Hirschsprung's Disease

INTRODUCTION

 Most Hirschsprung's disease (HD) are diagnosed in young children with increased risk ("red flag"). Older children (>6 months) require open rectal biopsy (ORB) with its own impact on risk and resources. We investigated if "red flag", age, and sex used in combination could exclude HD.

MATERIALS AND METHODS

 "Red flags" are risk factors associated with HD, including neonatal bowel obstruction, genetic association, failure of passage of meconium in <48 hours, infantile constipation, distension with vomiting, or family history. All rectal biopsies (2015-2018) were reviewed for indications, methods, and histopathological findings. Logistic regression analysis was adopted to assess predictive value of "red flag," age, and sex (p < 0.05* was significant).

RESULTS

 A total of 187 children underwent 84 suction rectal biopsies and 113 ORBs (n = 197 in total). Final histopathological diagnoses were non-HD (n = 154) and HD (n = 43). Total 78% of rectal biopsies were non-HD, of which 63% by ORB. Non-HD was associated with absence of "red flag" (49 vs. 16%*), increased age at biopsy (22 months vs. 28 days*), >6 months old (62 vs. 30%*), and female gender (54 vs. 16%*), compared with HD. In the absence of "red flag," 7/82 (9%) had HD (negative predictive value = 91%). Logistic regression analysis found absent "red flag" predicted non-HD biopsy with odds ratio 4.77 (1.38, 16.47), corrected for age and sex.

CONCLUSION

 Negative rectal biopsy rate for HD is very high. The majority required ORB. Although "red flag" and gender, but not age, have strong predictive values, it is inadequate for excluding HD. This study supports the need for alternative strategies in excluding HD.

Therapeutic strategies for stricturing Crohn’s disease in childhood: a systematic review

PURPOSE

Childhood stricturing Crohn's disease (CD) has significant morbidity. Interventions including resection, stricturoplasty and endoscopic balloon dilatation (EBD) are often required. Optimal intervention modality and timing, and use of adjuvant medical therapies, remains unclear. We aim to review the therapies used in paediatric stricturing CD.

METHODS

A systematic review in accordance with PRISMA was performed (PROSPERO: CRD42020164464). Demographics, stricture features, interventions and outcomes were extracted.

RESULTS

Fourteen studies were selected, including 177 patients (183 strictures). Strictures presented at 40.6 months (range 14-108) following CD diagnosis. Medical therapy was used in 142 patients for an average of 20.4 months (2-36), with a complete response in 11 (8%). Interventions were undertaken in 138 patients: 53 (38%) resections, 39 (28%) stricturoplasties, and 17 (12%) EBD. Complications occurred in 11% of resections, versus 15% stricturoplasties, versus 6% EBD (p = 0.223). At a median follow-up of 1.9 years (interquartile range 1.2-2.4) pooled stricture recurrence was 22%. Resection had 9% recurrence, versus 38% stricturoplasty, versus 47% EBD (p < 0.001).

CONCLUSIONS

Resection is associated with a low incidence of recurrence and complications. There remains a paucity of evidence regarding adjuvant medical therapy and the role of EBD. We propose a minimum reported dataset for interventions in paediatric stricturing CD.

Thoracoscopic Repair of Congenital Diaphragmatic Hernia in Preterm Neonate at 1 Kilogram

We report the first successful primary thoracoscopic repair of congenital diaphragmatic hernia (CDH) in a preterm infant born at 28 weeks of gestation weighing 1,043 g. Left-sided CDH was incidentally diagnosed on postnatal chest X-ray on day 1. The neonate subsequently underwent thoracoscopic repair with primary closure of the defect on day 8 weighing 1,150 g. Intraoperative arterial blood gas monitoring including end tidal carbon-dioxide remained within normal range throughout. Postoperative recovery was uneventful. One year neurodevelopmental outcome was normal for age with no CDH recurrence.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

The Sustained Induction of c-MYC Drives Nab-Paclitaxel Resistance in Primary Pancreatic Ductal Carcinoma Cells

Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive disease with limited and, very often, ineffective medical and surgical therapeutic options. The treatment of patients with advanced unresectable PDAC is restricted to systemic chemotherapy, a therapeutic intervention to which most eventually develop resistance. Recently, nab-paclitaxel (n-PTX) has been added to the arsenal of first-line therapies, and the combination of gemcitabine and n-PTX has modestly prolonged median overall survival. However, patients almost invariably succumb to the disease, and little is known about the mechanisms underlying n-PTX resistance. Using the conditionally reprogrammed (CR) cell approach, we established and verified continuously growing cell cultures from treatment-naïve patients with PDAC. To study the mechanisms of primary drug resistance, nab-paclitaxel-resistant (n-PTX-R) cells were generated from primary cultures and drug resistance was verified in vivo, both in zebrafish and in athymic nude mouse xenograft models. Molecular analyses identified the sustained induction of c-MYC in the n-PTX-R cells. Depletion of c-MYC restored n-PTX sensitivity, as did treatment with either the MEK inhibitor, trametinib, or a small-molecule activator of protein phosphatase 2a. IMPLICATIONS: The strategies we have devised, including the patient-derived primary cells and the unique, drug-resistant isogenic cells, are rapid and easily applied in vitro and in vivo platforms to better understand the mechanisms of drug resistance and for defining effective therapeutic options on a patient by patient basis.

Fetal abdominal cysts: antenatal course and postnatal outcomes

Background There is little information on which to base the prognostic counselling as to whether an antenatally diagnosed fetal abdominal cyst will grow or shrink, or need surgery. This study aims to provide contemporary data on prenatally diagnosed fetal abdominal cysts in relation to their course and postnatal outcomes. Methods Fetal abdominal cysts diagnosed over 11 years in a single centre were identified. The gestational age at diagnosis and cyst characteristics at each examination were recorded (size, location, echogenity, septation and vascularity) and follow-up data from postnatal visits were collected. Results Eighty abdominal cysts were identified antenatally at 28+4 weeks (range 11+0-38+3). Most (87%) were isolated and the majority were pelvic (52%), simple (87.5%) and avascular (100%). Antenatally, 29% resolved spontaneously; 29% reduced in size; 9% were stable and 33% increased in size. Forty-one percent of cysts under 20 mm diameter increased in size, while only 20% of cysts with a diameter of over 40 mm increased in size. The majority of cysts were ovarian in origin (n=45, 56%), followed by intestinal (n=15, 18%), choledochal (n=3, 4%), liver (n=2, 3%) and renal/adrenal origins (n=2, 3%), respectively. In 16% (n=13), the antenatal diagnosis was not obvious. Seventy-five percent of the cysts that persisted postnatally required surgical intervention. Conclusion Most antenatally diagnosed fetal abdominal cysts were ovarian in origin. Though most disappeared antenatally, nearly three quarters required surgical intervention when present after birth. Cysts of intestinal origin are more difficult to diagnose antenatally and often require surgery.

Feeding Jejunostomy: Is It a Safe Route in Pediatric Patients? Single Institution Experience

INTRODUCTION

 Impossibility to place a gastrostomy and failed gastroesophageal reflux surgery with unsafe swallow are the main indications to Feeding Jejunostomy (FJ) in children. The aim of this study is to quantify the incidence of complications associated with FJ.

MATERIALS AND METHODS

 A retrospective review of patients who had surgically inserted FJ between January 2009 and August 2013 at our institution was conducted. Data were obtained from medical records, operative notes, and radiology database, focusing on complications.

RESULTS

 A total of 19 patients, average age 39.6 months (3-168 months), were treated during the study period. Indications to FJ were gastroesophageal reflux disease (GERD) associated with unsafe swallow in 12, esophageal atresia in 5, and foregut dysmotility in 2. Seventeen FJ were inserted via laparotomy and 2 were laparoscopically assisted. In all cases, a serosal tunnel on the antimesenteric border was fashioned. No intraoperative complications were recorded. Tube dislodgement/blockage occurred on an average of 0.48 times per month in 18 out of 19 patients. The average radiation dose received for tube reinsertion/manipulation was 3.316 mSv/year/patient (0-10.66). Major postoperative complications occurred in 7 out of 19. After an average follow-up of 21 months, two have abandoned the use of FJ due to poor tolerance and three have fully weaned off. Two patients died due to unrelated causes.

CONCLUSION

 FJ, as an alternative means for enteral feeding, may require multiple readmissions and exposure to radiological procedures. The high risk of severe complications should be considered when offering this procedure.

Antenatally diagnosed lung malformations: a plea for long-term outcome studies

There is a wide variation in the management of infants with antenatally diagnosed lung malformations, with many paediatric surgeons and respiratory paediatricians recommending early investigations for all infants and a surgical excision for the majority of lesions, while others favour a conservative management for all asymptomatic infants. The benefits and risks of a surgical intervention have to be compared with the natural history of the untreated malformation and cohort studies from foetal diagnosis to adult life are required to provide the relevant evidence. Careful and repeated surveillance of identified foetuses is essential as recent advances in foetal medicine and surgery have improved the outcomes for the small minority, who are at risk of developing hydrops.

Diaphragmatic hernia: a postnatal complication of anomalous drainage of the umbilical vein

The ductus venosus (DV) connects the portal venous system to the inferior vena cava. Rarely, the umbilical venous drainage is anomalous, either connecting to the portal sinus within the liver or having an extrahepatic connection, bypassing the liver and draining to one of a variety of sites, including to the heart directly. Prenatally, there is a recognized association of anomalous umbilical venous drainage with aneuploidy and other structural malformations. The fetus may also develop right heart failure because of unregulated volume loading. We report the postnatal development of diaphragmatic hernia in three fetuses with absent DV and umbilical venous drainage to the right atrium directly in two cases and to the coronary sinus in the third. In all fetuses, the abnormality was well-tolerated in pregnancy, with only a modest degree of right heart dilatation. All three neonates underwent repair of the diaphragmatic hernia and made a good recovery.

A case report describing a suspected rivaroxaban hypersensitivity reaction in a surgical patient

WHAT IS KNOWN AND OBJECTIVE

Rivaroxaban is an oral anticoagulant, currently licensed for use as a venous thromboembolism (VTE) prophylaxis, and recommended by the National Institute for Clinical Excellence (NICE) for all patients undergoing elective hip and knee replacement surgery in the UK. We present the first case of a suspected hypersensitivity to rivaroxaban.

CASE SUMMARY

A 57-year-old man with no previous allergies underwent an uncomplicated, elective partial knee replacement, after which he was prescribed a routine 2-week course of rivaroxaban 10 mg. He developed an allergic response requiring readmission for assessment and treatment 7 days post-operatively.

WHAT IS NEW AND CONCLUSION

We believe this to be the first published case of hypersensitivity associated with rivaroxaban. More research is needed to determine this association. At the same time, given the growing range and increasing use of anticoagulants, particular vigilance is required regarding potential side effects so that these may be managed quickly and effectively in the early stages.

Successful treatment of cryoglobulinaemia with rituximab

Cryoglobulinaemia is a systemic inflammatory condition characterised by immune complex-mediated small-to-medium-sized vasculitis. It has a wide variety of presentations ranging from bruising, neuropathy, and hepatosplenomegaly to acute renal failure. Mixed cryoglobulinaemia is the most common type and is strongly associated with hepatitis C. Management approaches include use of cyclophosphamide, prednisolone, and plasmapheresis, with differing views on alternative treatments in resistant cases. Rituximab has emerged as an attractive option in resistant cases on account of its potent immunosuppressive effects on B cells. We describe a case of type 2 mixed cryoglobulinaemia in association with non-Hodgkin's lymphoma resistant to standard treatments which responded well to rituximab. This case is remarkable as mixed cryoglobulinaemia associated with non-Hodgkin's lymphoma presenting with nephritis is unusual, and, contrary to the high rate of recurrence in lymphoma-related cryoglobulinaemia, our patient has not shown any recurrence over 24 months. This highlights an alternative treatment modality which can be used in patients not responsive to existing managements for this condition with benefits of minimal side effects and no oncogenetic potential.

Successful treatment of calcific uremic arteriolopathy with sodium thiosulfate in a renal transplant recipient

Abstract Calcific uremic arteriolopathy (CUA) is a rare but life-threatening disorder of arteriolar calcification. It frequently leads to severe ischemia, intense pain, and tissue necrosis with non-healing skin ulcerations. CUA usually occurs in patients with chronic kidney disease (CKD), especially those on dialysis, and its occurrence is rare in kidney transplant recipients. The treatment of this disorder is not clearly defined, and no randomized prospective trials are available. Treatment has focused on optimizing dialysis treatment, control of bone mineral parameters, wound care, experimental anticalcification therapies-using bisphosphonates, cinacalcet, parathyroidectomy, and hyperbaric oxygen. Such treatments are based on the pathophysiological considerations and evidences from case reports or series. Recently, several cases have reported about the emerging benefits of intravenous sodium thiosulfate (STS) in the treatment of CUA. STS has resulted in rapid pain relief, wound healing, and prevention of death. We report a case of CUA in a 63-year-old Caucasian man with a functioning renal allograft. In this patient, intravenous STS was administered for 8 months, which was the principal therapy, which resulted in complete resolution of the CUA and skin healing.

Isolated gallbladder perforation following blunt abdominal trauma in a six-year-old child

Isolated perforation of the gallbladder secondary to blunt trauma is rare. Furthermore, only a few cases exist in the infant age group. It has vague symptoms and interpretation of the radiology imaging is challenging. Diagnosis is usually made at operation. We report the case of a six-year-old boy who fell on to the handlebars of his scooter, sustaining an isolated gallbladder perforation. The authors highlight the importance of interpreting the volume of intraperitoneal fluid and early diagnostic laparoscopy.

The diagnostic dilemma of a multilocular renal cyst: a case report

Introduction

Renal cysts presenting in childhood are rare. Historically, renal cysts have been subject to variable nomenclature which has contributed to diagnostic difficulties. They can occur as solitary, unilateral or multiple lesions. Cysts can be further classified according to loculation, communications within the structure and tissue types present.

Case presentation

We report the case of a 15-month-old Caucasian boy presenting with abdominal distension as the only clinical symptom. On examination, an ill-defined abdominal mass was found. This was confirmed on ultrasound to be a multiseptated cystic mass with a solid element, arising from the right side of the abdomen. Despite further imaging, the origin of the mass could not be identified. The mass was suspected of malignancy but all blood tests and tumour markers were normal. The mass proved to be a diagnostic challenge. The renal origin of the mass was only confirmed at surgery.

Conclusion

Imaging appears to be unreliable in differentiating benign cysts from malignant renal tumours, raising a diagnostic dilemma where surgery seems the only way to reliably establish aetiology of the mass.

Prenatal diagnosis of tracheo-oesophageal fistula and oesophageal atresia

OBJECTIVES

To assess the accuracy of the prenatal ultrasound finding of subjectively small/absent stomach bubble in the prenatal diagnosis of tracheo-oesophageal fistula and oesophageal atresia (TOF/OA).

METHODS

A retrospective study of prenatal ultrasound scans showing small/absent stomach bubble was carried out between 1st January 1994 and 31st December 2003.

RESULTS

There were 62 cases with prenatally suspected (n = 40) and/or post-natally diagnosed (n = 22) TOF/OA. Among the 40 cases of prenatally suspected TOF/OA 15 were thought to be isolated and 25 non-isolated. Of the 15 suspected isolated cases, 7 were normal and 8 had TOF/OA (5 isolated + 3 TOF/OA with another anomaly) at delivery. Among the 25 cases of prenatally suspected non-isolated TOF/OA, there was confirmation in only two cases, in the remaining 23 cases other anomalies were confirmed but TOF/OA was not present.Twenty-two babies with TOF/OA were identified in whom there had been no prenatal ultrasound suspicion on ultrasound scanning. Six had isolated TOF/OA and 16 had non-isolated TOF/OA.

CONCLUSION

Of the 32 cases of confirmed TOF/OA,10 (31%) were suspected prenatally. If the TOF/OA was an isolated anomaly (11 cases), the prenatal detection rate was 45%. Interpretation of ultrasound findings suspicious of TOF/OA requires caution, particularly, when there are associated multiple anomalies on scan.

Infantile hypertrophic pyloric stenosis: an infectious cause?

The aetiology of infantile hypertrophic pyloric stenosis (IHPS) remains unclear. The aim of this study was to test the hypothesis that a common bacterium, Helicobacter pylori (HP) may be implicated in the pathogenesis of IHPS. Thirty-nine consecutive infants with confirmed IHPS had their stool analysed with an enzyme immunoassay for the presence of HP. An age/sex-matched group of infants with unrelated surgical conditions were also tested. No positive results for the presence of HP stool antigen were obtained in the study nor the control group. The results of this study demonstrate no causative link between HP and IHPS. A genetic basis has been implicated for IHPS. However, evidence does exist that IHPS is a condition acquired after birth and that an infective agent may be involved in the pathogenesis. Further studies are required to elucidate perinatal factors that may induce the expression of this condition in a genetically sensitive individual.

Assessment of iodine deficiency disorders in urban areas of Udaipur District, Rajasthan

The present study was conducted on 6-12 years school going children of urban areas of Udaipur to assess the prevalence of iodine deficiency disorders. The study revealed a goiter prevalence of 8.4 percent and biochemical deficiency of nearly 8 per cent but the median iodine levels of the study population was 20 mcg/dL. Iodometric titration of salt samples collected from the beneficiaries revealed that more than 85 per cent of the salt samples had within or more than the stipulated levels of iodine 15 ppm. It appears that the population is in the transition phase from iodine deficiency to iodine sufficiency due to successful implementation of salt iodisation program.

Effects of burn with and without Escherichia coli infection in rats on intestinal vs. splenic T-cell responses

OBJECTIVE

To evaluate the effect of burn injury with and without an Escherichia coliseptic complication on T-cell proliferation, interleukin-2 production, and Ca(2+) signaling responses in intestinal Peyer's patch and splenic T cells.

DESIGN

Prospective, randomized, sham-controlled animal study.

SETTING

University medical center research laboratory.

SUBJECTS

Adult male Sprague-Dawley rats.

INTERVENTIONS

Rats were subjected to a 30% total body surface area, full skin thickness burn. Infection in rats was induced via intraperitoneal inoculation of E. coli, 10(9) colony forming units/kg, with or without a prior burn.

MEASUREMENTS AND MAIN RESULTS

Rat Peyer's patch and splenic T lymphocytes were isolated by using a nylon wool cell purification protocol. T-cell proliferation, interleukin-2 production, and Ca(2+) signaling responses were measured after stimulation of cells with the mitogen, concanavalin A. T-cell proliferation was determined by measuring incorporation of (3)H-thymidine into T-cell cultures. Interleukin-2 production by T-cell cultures was measured by using enzyme-linked immunosorbent assay. Intracellular T-cell Ca2(+ )concentration, [Ca(2+)](i), was measured by the use of Ca(2+)-specific fluorescent label, fura-2, and its fluorometric quantification. [Ca(2+)](i) was also evaluated by the use of digital video imaging of fura-2 loaded individual T cells. T-cell proliferation and interleukin-2 production were suppressed substantially in both Peyer's patch and splenic T cells 3 days after either the initial burn alone or burn followed by the E. coli inoculation at 24 hrs after the initial burn. There seemed to be no demonstrable additive effects of E. coli infection on the effects produced by burn injury alone. The T-cell proliferation and interleukin-2 production suppressions with burn or burn-plus-infection insults were correlated with attenuated Ca(2+) signaling. E. coli infection alone suppressed T-cell proliferation in Peyer's patch but not in splenic T cells at 2 days postbacterial inoculation; E. coli infection had no effect on Peyer's patch or splenic T cells at 1 day postinjury. On the other hand, burn injury alone caused a substantial T-cell proliferative suppression at 2 days postburn in both Peyer's patch and splenic cells and a significant suppression in T-cell proliferation on day 1 postburn in Peyer's patch but not in the spleen.

CONCLUSION

An initial burn injury suppressed T-cell proliferation at a level that it would not be further affected by a subsequent infection even if the infection by itself has the potential of suppressing T-cell proliferation. An earlier onset of T-cell suppression in Peyer's patch cells than in the spleen with burn could be attributable to an initial hypoperfusion-related intestinal mucosal tissue injury. Overall, our study supports the concept that burn injury per se can significantly suppress T-cell mediated immunity and that the intestine is an early tissue site of such suppression.

Cutaneous expression of CRH and CRH-R. Is there a "skin stress response system?"

The classical neuroendocrine pathway for response to systemic stress is by hypothalamic release of corticotropin releasing hormone (CRH), subsequent activation of pituitary CRH receptors (CRH-R), and production and release of proopiomelanocortin (POMC) derived peptides. It has been proposed that an equivalent to the hypothalamic-pituitary-adrenal axis functions in mammalian skin, in response to local stress (see Reference 1). To further define such system we used immunocytochemistry, RP-HPLC separation, and RIA techniques, in rodent and human skin, and in cultured normal and malignant melanocytes and keratinocytes. Production of mRNA for CRH-R1 was documented in mouse and human skin using RT-PCR and Northern blot techniques; CRH binding sites and CRH-R1 protein were also identified. Addition of CRH to immortalized human keratinocytes, and to rodent and human melanoma cells induced rapid, specific, and dose-dependent increases in intracellular Ca2+. The latter were inhibited by the CRH antagonist alpha-helical-CRH(9-41) and by the depletion of extracellular calcium with EGTA. CRH production was enhanced by ultraviolet light radiation and forskolin (a stimulator for intracellular cAMP production), and inhibited by dexamethasone. Thus, evidence that skin cells, both produce CRH and express functional CRH-R1, supports the existence of a local CRH/CRH-R neuroendocrine pathway that may be activated within the context of a skin stress response system.

Characterization of local inflammatory response in an isolated lung perfusion model

BACKGROUND

Current phase I trials of isolated lung perfusion for treatment of pulmonary metastases have an arbitrarily determined length of perfusion. Our objective was to examine the temporal course of the local and distant inflammatory response as a function of the length of perfusion (ischemia) and subsequent reperfusion in an equivalent animal model.

METHODS

Sixty male Fischer 344 rats were randomized into four groups (n = 15). Each group underwent left isolated lung perfusion with buffered Hespan for 10, 30, 60, or 90 minutes. Subsequently, two subgroups of five animals within each group were allowed to reperfuse for 1 or 3 hours, respectively. Non-perfused right lung was used as control. At each time point, lung specimens were assayed for TNF-alpha by ELISA and histologic sections were examined.

RESULTS

There was no significant difference between the left and right lung tissue levels of TNF-alpha at the termination of the ischemic period. However, on reperfusion, the left lung TNF-alpha levels increased significantly above the ischemia baseline in all groups, with a greater magnitude of rise in the groups with 60 and 90 minutes of preceding ischemia (12,757 +/- 1985 vs. 3524 +/- 494 pg/g, and 16,914 +/- 1657 vs. 6530 +/- 1104 pg/g, respectively; p < 0.05). There was no significant elevation in tissue levels of TNF-alpha in the right lung. Histologic changes consistent with early pulmonary edema were first detected at 12 hours following onset of reperfusion.

CONCLUSIONS

Reperfusion following prolonged pulmonary ischemia during isolated lung perfusion results in a significant elevation of local tissue levels of TNF-alpha and may render the perfused lung vulnerable to the adverse effects of the inflammatory cascade.

A longitudinal study of changes in body composition and basal metabolism in physically active elderly men

Ageing in the elderly is usually characterised by loss of fat-free mass (FFM) and reduction in basal metabolic rate (BMR). These age-related changes probably vary in rate, timing and extent between subjects in response to differences in leisure or occupational physical activity, disease and several other factors. Information on rates of change in BMR and FFM is limited by study design (most published work is cross-sectional rather than longitudinal), and possibly by methodology (use of imprecise and/or biased methods for assessment of changes in body composition). In the present study BMR and body composition were first measured in 22 physically active elderly men (mean age 62) in good health and measurements were repeated 6.5 years later. Changes in BMR, FFM and percentage body fat were small and not statistically significant over the time period (paired t, P > 0.05). The study suggests that physically active elderly men in good health in this age range can show very small age-related declines in BMR and FFM.

Mother surrogate and nutritional status of preschool children

The study was conducted on 200 preschool children to find out the effect of mother surrogate on the nutritional status. The nutritional status of children was found to be affected by the time devoted by mother on child care activities, working status of mother and type of family independently and jointly. The children cared by mother had better nutritional status than those children who were cared by servants and any other family member in the absence of mother. It shows that no one can substitute the care provided by the mother.

Pattern of preventable diseases in Afghanistan: suggestions to reduce the morbidity and mortality at IGICH

Over nine years period (1354-1362), 1,39,436 children were admitted in Indira Gandhi Institute of Child Health (IGICH), Kabul. Of these 51,212 (46.8%) children were hospitalised with preventable diseases. Seventy four per cent of patients were under five years of age. Among the infectious diseases, gastroenteritis accounted for nearly 70% of admissions. Tuberculosis, measles, diphtheria and typhoid fever were other common infectious diseases. Malnutrition of varying degree was the core problem among the hospitalised children and was seen in nearly two thirds of admissions. Twenty per cent of them had severe protein energy malnutrition which contributed for higher mortality. Gastroenteritis contributed for half (51.5%) of the mortality. Septicemia, tetanus neonatorum and central nervous system infections were associated with high mortality especially among the neonates. Deaths following 6-target preventable diseases accounted for nearly 1/4th of deaths (20.4-24.6%) over these years.

Extra AV nodal Wenckebach periodicity

Extra AV nodal Wenckebach periodicity was diagnosed in seven patients. The most frequent form of this conduction abnormality was an exit block. The underlying block was localized in the sinoatrial junction and in the atria in two patients; the AV junction and the ventricle were the site of the Wenckebach periodicity in one case each. In extra AV nodal exit block, the actual conduction delay is not seen on the ECG and the diagnosis is based on the progressive shortening of the P-P or R-R intervals followed by a pause which is less than twice the shortest P-P (R-R) interval depending on the level of the block. A Wenckebach periodicity in the bundle branches or within the reentry pathway each occurred in one patient. In these forms of Wenckebach periodicity, the diagnosis is established more readily because the conduction delay can be demonstrated on the surface ECG. The clinical significance of extra AV nodal Wenckebach periodicity is discussed.