A contemporary analysis of the pre- and intraoperative recognition of multigland parathyroid disease

BACKGROUND

Despite advances in biochemical and radiological identification of parathyroid gland enlargement, primary hyperparathyroidism (PHPT) due to sporadic multigland parathyroid disease (MGPD) remains a perioperative diagnostic dilemma. Failure to recognise MGPD pre- or intraoperatively may negatively impact surgical cure rates and result in persistent PHPT and ongoing patient morbidity.

METHODS

We have conducted a comprehensive review of published literature in attempt to determine factors that could aid in reliably diagnosing sporadic MGPD pre- or intraoperatively. We discuss preoperative clinical features and examine pre- and intraoperative biochemical and imaging findings concentrating on those areas that give practicing surgeons and the wider multi-disciplinary endocrine team indications that a patient has MGDP. This could alter surgical strategy.

CONCLUSION

Biochemistry can provide diagnosis of PHPT but cannot reliably discriminate parathyroid pathology. Histopathology can aid diagnosis between MGPD and adenoma, but histological appearance can overlap. Multiple negative imaging modalities indicate that MGPD may be more likely than a single parathyroid adenoma, but the gold standard for diagnosis is still intraoperative identification during BNE. MGPD remains a difficult disease to both diagnose and treat.

Management strategies and outcomes in renal transplant recipients recovering from COVID-19: A retrospective, multicentre, cohort study

Background

There is an enormous knowledge gap on management strategies, clinical outcomes, and follow-up after kidney transplantation (KT) in recipients that have recovered from coronavirus disease (COVID-19).

Methods

We conducted a multi-center, retrospective analysis in 23 Indian transplant centres between June 26, 2020 to December 1, 2021 on KT recipients who recovered after COVID-19 infections. We analyzed clinical and biopsy-confirmed acute rejection (AR) incidence and used cox-proportional modeling to estimate multivariate-adjusted hazard ratios (HR) for predictors of AR. We also performed competing risk analysis. Additional outcome measures included graft loss, all-cause mortality, waiting time from a positive real-time polymerase test (RT-PCR) to KT, laboratory parameters, and quality of life in follow-up.

Findings

Among 372 KT which included 38(10·21%) ABO-incompatible, 12(3·22%) sensitized, 64(17·20%) coexisting donors with COVID-19 history and 20 (5·37%) recipients with residual radiographic abnormalities, the incidence of AR was 34 (9·1%) with 1(0·26%) death censored graft loss, and 4(1·07%) all-cause mortality over a median (interquartile range) follow-up of 241 (106-350) days. In our cox hazard proportional analysis, absence of oxygen requirement during COVID-19 compared to oxygen need [HR = 0·14(0·03-0·59); p-value = 0·0071], and use of thymoglobulin use compared to other induction strategies [HR = 0·17(0·03-0.95); p-value = 0·044] had a lower risk for AR. Degree of Human leukocyte antigen (HLA) DR mismatch had the highest risk of AR [HR = 10.2(1·74-65·83); p-value = 0·011]. With competing risk analysis, with death as a competing event, HLA DR mismatch, and oxygen requirement continued to be associated with AR. Age, gender, obesity, inflammatory markers, dialysis vintage, steroid use, sensitization and ABO-incompatibility have not been associated with a higher risk of AR. The median duration between COVID-19 real time polymerase test negativity to transplant was 88(40-145) days (overall), and ranged from 88(40-137), 65(42-120), 110(49-190), and 127(64-161) days in World Health Organization ordinal scale ≤ 3, 4, 5, and 6-7, respectively. There was no difference in quality of life, tacrolimus levels, blood counts, and mean serum creatinine assessed in patients with a past COVID-19 infection independent of severity.

Interpretation

Our findings support that the outcomes of KT after COVID-19 recovery are excellent with absence of COVID-19 sequelae during follow-up. Additionally, there does not seem to be a need for changes in the induction/immunosuppression regimen based on the severity of COVID-19.

Funding

Sanofi.

Assessing the impact of a gynaecomastia assessment and treatment infographic in primary care in Greater Manchester

INTRODUCTION

Men with gynaecomastia are routinely referred to breast clinics, yet most do not require breast surgical intervention. The aim of this study was to assess the impact of a novel point-of-care gynaecomastia decision infographic in primary care on the assessment, management and referral practices to tertiary breast surgical services.

METHODS

A study was carried out of male patient referrals from primary care in Greater Manchester to a tertiary breast centre between January and March in 2018-2020. Referral patterns were compared before and after the infographic went live in general practices in Greater Manchester in January 2020. Data were collected for gynaecomastia referrals, including aetiology, investigation and management.

RESULTS

In total, 394 men were referred to a tertiary breast centre from 163 general practices, of which 271 (68.8%) had a diagnosis of gynaecomastia. Use of the decision infographic by primary healthcare providers was associated with a decrease in male breast referrals with gynaecomastia (79.6% to 62.0%). Fewer gynaecomastia patients were referred with a benign physiological or drug-related cause after implementation of the infographic (52.2% vs 41.8%). Only 10 (3.7%) patients with gynaecomastia underwent breast surgery during the study period.

CONCLUSION

Implementation of a gynaecomastia infographic in primary care in Manchester was associated with a reduction in gynaecomastia referrals to secondary care. We hypothesise that implementation of the infographic into primary care nationally may potentially translate to hundreds of patients receiving more specialty-appropriate referrals, improving overall management of gynaecomastia. Further study is warranted to test this hypothesis.

Impact of COVID-19-associated Mucormycosis in Kidney Transplant Recipients: A Multicenter Cohort Study

BACKGROUND

COVID-19-associated mucormycosis (CAM) is a recently emerging entity. There is a lack of reports of CAM in organ transplant recipients.

METHODS

We conducted a multicenter (n = 18) retrospective research in India during November 2020 to July 2021. The purpose of this study was to explore the clinical spectrum, outcome and risk factors for mortality of CAM in kidney transplant recipients (KTRs).

RESULTS

The incidence of CAM was 4.4% (61/1382 COVID-19-positive KTRs) with 26.2% mortality. The median age of the cohort was 45 (38-54) y. Twenty (32%) were not hospitalized and 14 (22.9%) were on room air during COVID-19. The proportion of postdischarge CAM was 59.1%, while concurrent CAM was reported in 40.9%. The presentation of CAM was 91.8% rhino-orbital-cerebral mucormycosis and 8.2% pulmonary with 19.6% and 100% mortality, respectively. In the univariable analysis, older age, obesity, difficulty of breathing, high-flow oxygen requirement, and delay in starting therapy were significantly associated with mortality. In the multivariable logistic regression analysis, patients requiring high-flow oxygen therapy [odds ratio (95% confidence interval) = 9.3 (1.6-51); P = 0.01] and obesity [odds ratio (95% confidence interval) = 5.2 (1-28); P = 0.05] was associated with mortality. The median follow-up of the study was 60 (35-60) d.

CONCLUSIONS

We describe the largest case series of CAM in KTRs. Morality in pulmonary CAM is extremely high. Severe COVID-19 pose extra risk for the development of CAM and associated mortality. Our report will help in better understanding the conundrum and management of CAM.

126 White-Eyed Blowout Fracture in The Paediatric Patient Thought to Be A Head Injury – A Missed Diagnosis

White eyed blowout fracture or ‘trapdoor fracture’ is an orbital floor injury caused by blunt force trauma directly to the orbit causing ocular muscle entrapment between fractured bones of the floor of the orbit. It is most commonly encountered in the paediatric patient population and presents acutely with little to no periorbital signs of injury. This serious diagnosis is frequently missed at initial presentation due to a lack of obvious soft tissue pathology, termed “White Eyed” blow out fracture. It is frequently misdiagnosed as a head injury due to presenting nausea and vomiting and failure to examine eye movements.

The authors present a case of a 15-year-old male who suffered blunt force trauma to the orbit and a white eyed blowout fracture ensued. This was not identified in the emergency department and the patient consequently suffered permanent motility deficit of the globe. We outline recommendations for emergency department practitioners to help identify such presentations and see their timely surgical management.

COVID-19 vaccination and low cervical lymphadenopathy in the two week neck lump clinic - a follow up audit

The UK COVID vaccination programme has progressed at an astonishing rate since the first patients received their doses in December 2020. It is well known that other vaccines including influenza and human papilloma virus (HPV) can result in reactive lymphadenopathy in the axilla and/or neck. Patients are now presenting via the two week wait neck lump clinic with supraclavicular fossa and low neck lymphadenopathy related to COVID vaccination, and to similar one stop breast clinics with axillary lymph nodes. In an audit of 80 patients seen over a period of one month, we found COVID vaccine-related low neck lymphadenopathy in four cases (5%), with an additional rectal cancer patient thought to have metastatic disease who presented with a Virchow type node. COVID vaccine-related lymphadenopathy should be considered in the differential diagnosis of low-neck nodes if they occurred shortly after vaccination, but it is important to exclude sinister disease using ultrasound and other investigations as necessary.

Dialysis Vascular Access: Where do Tunneled Catheters Stand? - A Single-Center Experience

Introduction

Tunneled cuffed catheters (TCC) provides a short and intermediate-term access solution for dialysis patients who fail to get an arteriovenous fistula (AVF). They are associated with high morbidity and mortality along with high rates of infectious complications.

Methods

We present a single-center prospective cohort of 159 TCCs inserted over one year. Patients were dialyzed in-hospital and in various peripheral dialysis units attached to the institute. The primary endpoint was catheter drop-out.

Results

The mean age of patients was 41.8 ± 16.9 years. The right internal jugular vein was the commonest site of TCC insertion (66%). The absence of suitable veins was the predominant reason for TCC insertion. The mean time to catheter drop-out was 134.4 ± 83.3 days (5-399 days). Death with a working catheter was the most common cause of catheter drop-out (22.6%). About 25% of catheters were lost to catheter-related bloodstream infections (CRBSI), either alone or as overlap with poor flow. CRBSI rates were 3.74 episodes per 1000 catheter-days. No difference in survival between the staggered tip and split-tip catheters was found.

Conclusions

With the advent of the "hub and spoke" model for dialysis in the public sector healthcare, TCCs are suboptimal with regards to patient and catheter survival, with high infection rates. It must be regarded as a temporary solution and AVF creation should be prioritized.

Supraclavicular lymphadenopathy following COVID-19 vaccination: an increasing presentation to the two-week wait neck lump clinic?

The first COVID-19 vaccination was given in December 2020 and there is an effort to vaccinate the international population on a massive scale. Common side effects from the vaccine include headache and tiredness. Regional lymphadenopathy has been described in relation to other vaccines. We describe two cases of supraclavicular reactive lymphadenopathy presenting in patients who had the COVID vaccination in the ipsilateral arm. Awareness of this diagnosis is important for patients presenting to the neck lump clinic.

Therapeutic mammaplasty is a safe and effective alternative to mastectomy with or without immediate breast reconstruction

BACKGROUND

Therapeutic mammaplasty (TM) may be an alternative to mastectomy, but few well designed studies have evaluated the success of this approach or compared the short-term outcomes of TM with mastectomy with or without immediate breast reconstruction (IBR). Data from the national iBRA-2 and TeaM studies were combined to compare the safety and short-term outcomes of TM and mastectomy with or without IBR.

METHODS

The subgroup of patients in the TeaM study who underwent TM to avoid mastectomy were identified, and data on demographics, complications, oncology and adjuvant treatment were compared with those of patients undergoing mastectomy with or without IBR in the iBRA-2 study. The primary outcome was the percentage of successful breast-conserving procedures in the TM group. Secondary outcomes included postoperative complications and time to adjuvant therapy.

RESULTS

A total of 2916 patients (TM 376; mastectomy 1532; mastectomy and IBR 1008) were included in the analysis. Patients undergoing TM were more likely to be obese and to have undergone bilateral surgery than those having IBR. However, patients undergoing mastectomy with or without IBR were more likely to experience complications than the TM group (TM: 79, 21·0 per cent; mastectomy: 570, 37·2 per cent; mastectomy and IBR: 359, 35·6 per cent; P < 0·001). Breast conservation was possible in 87·0 per cent of patients who had TM, and TM did not delay adjuvant treatment.

CONCLUSION

TM may allow high-risk patients who would not be candidates for IBR to avoid mastectomy safely. Further work is needed to explore the comparative patient-reported and cosmetic outcomes of the different approaches, and to establish long-term oncological safety.

Is the current training pathway for oncoplastic breast surgeons fit for purpose?

We take a look at the results of a Mammary Fold members' survey to find out.

Standardised extract of safed musli (Chlorophytum borivilianum) increases aphrodisiac potential besides being safe in male Wistar rats

The standardised extract of root of safed musli (Chlorophytum borivilianum) was evaluated for its aphrodisiac potential and safety profile on reproductive system. Wistar albino rats were trained to provide sexual experience under a dim red light (10 W) in a glass tank. Male and female rats were placed periodically in the glass tank in a particular order, that is male followed by introduction of the receptive female. Dosing of extract was carried out for 54 days at 125 and 250 mg kg^-1 p.o to male rats. On 14th and 28th days, the animals were observed from the cage side for sexual behaviours. Safed musli at both dose levels enhanced sexual vigour and libido which might be useful for treatment of sexual dysfunction in male till 28th day. Safety profile was assessed after 54 days of drug treatment, where both doses showed an increase in sperm count and increase in sperm motility. Thus, it can be stated that both doses possessed the spermatogenic potential, which would be highly beneficial in treating oligospermia or low sperm count. After 54 days of study, there was increase in sperm abnormality (%) at both doses, but not more than 10%, which indicated that this formulation will not induce infertility.

Abstract P4-02-09: Can MRI be used to determine pathological complete response following neo-adjuvant chemotherapy for breast cancer?

Intro

Neo-adjuvant chemotherapy (NACT) is increasingly offered to patients with breast cancer, and it understood that patients with pathological complete response (PCR) have improved survival. It has been suggested that patients with radiological complete response may be spared surgery. We aimed to determine whether MRI findings can predict PCR following NACT.

Methods

This was a retrospective analysis of a prospectively maintained database. Most patients had NACT with 6 cycles of EC/DC+/-Traztuzumab and response was monitored using MRI. For univariate analysis χ2 and Fisher's exact test was used for categorical data. Log rank test by Kaplan Meier method was used for survival analysis.

Results

310 patients had NACT from December 2007 to December 2014. Baseline MRI prior to embarking on NACT was achieved in 251 patients. MRI concorded with size on mammography/USS in the majority of cases (83%) and upgraded the overall size of the lesion in 16% (50% of unifocal lesions on USS upgraded to multifocal).

In the 247 patients who had baseline MRI, a radiological response seen on the 2nd MRI (early responders, n=138), was predictive of eventual PCR (p=0.000, sensitivity = 77%). Patients with Her2+ve non-luminal (65%), triple negative (TNBC) (64%) and Luminal B Her2-ve (65%) tumours were more likely to be early responders on MRI. The non-early responders with Her2+ve tumours all had late radiological response, however, the TNBC tumours had low rates of late radiological response. Complete radiological response on the final MRI correlated strongly with PCR; p=0.000, specificity=98%. Tumour vascularity correlated positively and significantly with PCR. There was no difference in survival between those with early and late radiological response (median survival 66.2 months and 66.9 months), but those with no radiological response had significantly poorer survival 53.2 months, p=0.012).

Conclusion

Response on MRI is predictive of PCR, particularly within the non-luminal Her2+ve and TNBC molecular subtypes. Early response has high sensitivity, and complete response on final MRI has high specificity. Further work on larger data-sets is required before we confidently spare patient from surgery in the event of complete response on MRI.

Citation Format: Sharma N, Dave R, Millican-slater R, Dodwell D, Horgan K. Can MRI be used to determine pathological complete response following neo-adjuvant chemotherapy for breast cancer?. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-02-09.

Controlled infection with a therapeutic virus defines the activation kinetics of human natural killer cells in vivo

Human natural killer (NK) cells play an important role in anti-viral immunity. However, studying their activation kinetics during infection is highly problematic. A clinical trial of a therapeutic virus provided an opportunity to study human NK cell activation in vivo in a controlled manner. Ten colorectal cancer patients with liver metastases received between one and five doses of oncolytic reovirus prior to surgical resection of their tumour. NK cell surface expression of the interferon-inducible molecules CD69 and tetherin peaked 24-48 h post-infection, coincident with a peak of interferon-induced gene expression. The interferon response and NK cell activation were transient, declining by 96 h post-infection. Furthermore, neither NK cell activation nor the interferon response were sustained in patients undergoing multiple rounds of virus treatment. These results show that reovirus modulates human NK cell activity in vivo and suggest that this may contribute to any therapeutic effect of this oncolytic virus. Detection of a single, transient peak of activation, despite multiple treatment rounds, has implications for the design of reovirus-based therapy. Furthermore, our results suggest the existence of a post-infection refractory period when the interferon response and NK cell activation are blunted. This refractory period has been observed previously in animal models and may underlie the enhanced susceptibility to secondary infections that is seen following viral infection.

Multiphasic changes in systemic VEGF following intravitreal injections of ranibizumab in a child

PURPOSE

To investigate whether intravitreal ranibizumab injections administered to a child alter systemic plasma levels of total and free VEGF 165.

METHODS

A 9-year-old child sustained a choroidal rupture from blunt trauma. He subsequently developed a secondary choroidal neovascular membrane, which was treated with five ranibizumab injections over a period of 8 months. Peripheral venous blood samples were taken at each visit over a period of 12 months and plasma was extracted. Plasma VEGF 165 levels were determined using enzyme-linked immunosorbent assay and were assayed both pre- and post-immunodepletion to remove complexed VEGF.

RESULTS

Plasma VEGF 165 levels proved labile following intravitreal injection of ranibizumab. Levels increased by 30% above baseline following the first intravitreal ranibizumab injection, but then returned to baseline despite two subsequent injections. There was then a rebound increase of 67% in total plasma VEGF levels following a further injection, which remained above baseline for 12 weeks despite two further intravitreal ranibizumab injections. Baseline levels were re-attained 26 weeks after the final injection.

CONCLUSIONS

These results suggest intravitreal ranibizumab injections can cause significant, multiphasic changes in systemic VEGF levels. This may be of particular clinical significance in children as VEGF is known to be vital in the development of major organs, in addition to its role in the maintenance of normal organ function in adults.

Arsenate exposure affects amino acids, mineral nutrient status and antioxidants in rice (Oryza sativa L.) genotypes

Simulated pot experiments were conducted on four rice (Oryza sativa L.) genotypes (Triguna, IR-36, PNR-519, and IET-4786) to examine the effects of As(V) on amino acids and mineral nutrient status in grain along with antioxidant response to arsenic exposure. Rice genotypes responded differentially to As(V) exposure in terms of amino acids and antioxidant profiles. Total amino acid content in grains of all rice genotypes was positively correlated with arsenic accumulation. While, most of the essential amino acids increased in all cultivars except IR-36, glutamic acid and glycine increased in IET-4786 and PNR-519. The level of nonprotein thiols (NPTs) and the activities of superoxide dismutase (SOD; EC 1.15.1.1), glutathione reductase (GR; EC 1.6.4.2) and ascorbate peroxidase (APX; EC 1.11.1.11) increased in all rice cultivars except IET-4786. A significant genotypic variation was also observed in specific arsenic uptake (SAU; mg kg(-1)dw), which was in the order of Triguna (134) > IR-36 (71) > PNR-519 (53) > IET-4786 (29). Further, application of As(V) at lower doses (4 and 8 mg L(-1) As) enhanced the accumulation of selenium (Se) and other nutrients (Fe, P, Zn, and S), however, higher dose (12 mg L(-1) As) limits the nutrient uptake in rice. In conclusion, low As accumulating genotype, IET-4786, which also had significantly induced level of essential amino acids, seems suitable for cultivation in moderately As contaminated soil and would be safe for human consumption.

Characterization of native microalgal strains for their chromium bioaccumulation potential: phytoplankton response in polluted habitats

Due to its various uses, Cr contamination has become widespread in a diverse array of environments. The present study was carried out during 2007-2008 to investigate the accumulation potential of metals (Cr, Cu, Fe, Mn, Ni and Zn) and metalloid (As) by green (GA) and blue green (BGA) microalgae growing naturally in selected Cr-contaminated sites in districts Unnao and Kanpur (Uttar Pradesh, India). This investigation is a preliminary work to identify suitable native microalgae for biomonitoring and phytoremediation purposes. A total of 22 GA and 11 BGA were encountered in three seasons (summer, rainy and winter). Among these, the accumulation potential was evaluated in high biomass producing strains of BGA (three) and GA (nine). The maximum accumulation of Cr was shown by Phormedium bohneri (8550 microg g(-1)dw) followed by Oscillatoria tenuis (7354 microg g(-1)dw), Chlamydomonas angulosa (5325 microg g(-1)dw), Ulothrix tenuissima (4564 microg g(-1)dw), and Oscillatoria nigra (1862 microg g(-1)dw); all of which demonstrated a transfer factor of >10% for Cr. The results also indicate that the phytoplankton diversity was modified by Cr pollution. BGA represented the dominant community where Cr concentration was higher (11.84 and 2.27 mg L(-1)) (r=0.695), whereas GA showed negative correlation with respect to Cr concentration (r=-0.567). In conclusion, different algal species were able to grow in Cr-contaminated sites and to accumulate significant amounts of Cr with a high transfer factor.

Development in modeling submicron particle formation in two phases flow of solvent-supercritical antisolvent emulsion

The use of a supercritical Solvent (S)-Antisolvent (AS) process (SAS) for fine particle production is finding widespread industrial applications. The perfection of this technology requires insight into many basic laws of interface and colloid science. In SAS the solute is dissolved in an organic solvent and the solution is sprayed into a near critical AS stream. SAS is a complex process involving the interaction of jet hydrodynamics, droplet formation, mass transfer, phase equilibrium, intra-droplet nucleation, and microcrystal growth. A complete description would have to take into account all of these processes; however, such a model is not currently available. In the two-phase flow of an S/AS emulsion, S diffuses from droplets into AS, while AS dissolves inside the S droplets. S replacement by AS (Supercritical CO2) causes solute supersaturation in the droplets. When it occurs near the critical point of the S/AS emulsion (80 bar, 32 degrees C), intra-droplet nucleation and precipitation of the solute occurs. The possibility of solute particle production and the particle size is controlled by the droplet size and by the interrelationship between three time scales. These are the droplet mass transfer time tau N, the nucleation time tau N, i.e., the time necessary for one particle nucleus to form in one droplet, and the droplet residence in the supersaturated stream tau res. An approximate analytical theory for intra-droplet nucleation is developed and the conditions necessary for nanoparticle production are established. The smaller the droplet dimension and the lower the solute concentration, the smaller the particle dimension that is obtained. The recent success in membrane emulsifying may be used for the production of micron-sized droplets. After the AS stream is saturated with S due to partial dissolution of the droplets, a quasi-equilibrium between the droplets and AS stream occurs and a steady and uniform zone with intra-droplet supersaturation is formed downstream. But tau res>tau N is necessary for one nucleus formation per droplet, i.e., tau res has to be much longer than that reported in the literature (10(-3) s), because tau N increases with decreasing droplet dimension. Accordingly, a long residence time version of the SAS process (tau res approximately 1 s) is necessary. However, a long tau res is problematic because of micro-droplet turbulent coagulation. Since an increase in tau res is difficult, a decrease in tau N by means of an increase in S becomes significant. This is achieved by using a phenomenon which we call supersaturation of the second kind S2 In the literature attention is paid only to a decrease in the equilibrium solute concentration, when solvent and antisolvent are mixed. However, S2 occurs due to an actual increase in concentration of solute within the droplets as they shrink due to S dissolution. The smaller the ratio of solvent to antisolvent flow rate, the larger the droplet shrinkage and the higher the S2 achieved. Due to large S2, nanoparticle production becomes possible even for solutes with high surface tension sigma and large molecular volume V o, while earlier it was impossible because of the exponential increase of tau N with increasing V o and sigma. Combining a long tau res and variable and precisely controllable supersaturation, which is uniform in space and enhanced due to S2, creates an opportunity for standardization of characterizing different solutes through their tau N, which is the key solute property affecting nanoparticle production by SAS.

Major Advances in Concentrated and Dry Milk Products, Cheese, and Milk Fat-Based Spreads

Advances in dairy foods and dairy foods processing since 1981 have influenced consumers and processors of dairy products. Consumer benefits include dairy products with enhanced nutrition and product functionality for specific applications. Processors convert raw milk to finished product with improved efficiencies and have developed processing technologies to improve traditional products and to introduce new products for expanding the dairy foods market. Membrane processing evolved from a laboratory technique to a major industrial process for milk and whey processing. Ultra-filtration and reverse osmosis have been used extensively in fractionation of milk and whey components. Advances in cheese manufacturing methods have included mechanization of the making process. Membrane processing has allowed uniform composition of the cheese milk and starter cultures have become more predictable. Cheese vats have become larger and enclosed as well as computer controlled. Researchers have learned to control many of the functional properties of cheese by understanding the role of fat and calcium distribution, as bound or unbound, in the cheese matrix. Processed cheese (cheese, foods, spreads, and products) maintain their importance in the industry as many product types can be produced to meet market needs and provide stable products for an extended shelf life. Cheese delivers concentrated nutrients of milk and bio-active peptides to consumers. The technologies for the production of concentrated and dried milk and whey products have not changed greatly in the last 25 yr. The size and efficiencies of the equipment have increased. Use of reverse osmosis in place of vacuum condensing has been proposed. Modifying the fatty acid composition of milkfat to alter the nutritional and functional properties of dairy spread has been a focus of research in the last 2 decades. Conjugated linoleic acid, which can be increased in milkfat by alteration of the cow's diet, has been reported to have anticancer, anti-atherogenic, antidiabetic, and antiobesity effects for human health. Separating milk fat into fractions has been accomplished to provide specific fractions to improve butter spreadability, modulate chocolate meltability, and provide texture for low-fat cheeses.

Combined early treatment of congenital melanocytic naevus with carbon dioxide and NdYag lasers

Three cases of extensive congenital melanocytic naevi were treated with a combined approach using a ultrapulse carbon dioxide laser and a Nd Yag laser within 1 year of birth. The naevi were substantially depigmented and this result has been maintained for up to 36 months following treatment. The condition, treatment and the relevant literature are discussed.

Gamma-fluorinated analogues of glutamic acid and glutamine

Gamma-fluorinated analogues of glutamic acid and glutamine are compounds of biological interest. Syntheses of such compounds are extensively reviewed in this article. 4-fluoroglutamic acid was prepared as a mixture of racemic diastereomers by Michael reaction, inverse-Michael reaction or by electrophilic / nucleophilic fluorination. Optically enriched 4-fluoroglutamic acids were obtained by several resolution techniques as well as by asymmetric methodologies using the chiral pool. 4-fluoroglutamine was prepared as a mixture of stereoisomers as well as in racemic erythro and threo forms from the corresponding 4-fluoroglutamic acids using aminolysis and conventional protection and deprotection strategies. Racemic 4,4-difluoroglutamic acid was synthesized by a nitroaldol reaction and its L-enantiomer obtained via three different asymmetric routes. Racemic 4,4-difluoroglutamic acid was converted into the corresponding 4,4-difluoroglutamine using a protection / aminolysis / deprotection sequence while N-Boc-L-4,4-difluoroglutamine was prepared directly from (R)-Garner's aldehyde using a Reformatsky reaction as the key step.

Spontaneous disappearance of refractory viral warts at distant sites following carbon-dioxide laser treatment

We report the spontaneous disappearance of distant viral skin lesions following carbon-dioxide laser treatment of refractory viral warts.

The control of fire hazard during cutaneous laser therapy

This article reviews the literature on fire hazard relating to the laser treatment of cutaneous conditions and collates recommended precautions. Further suggestions are added.

Isolation of primary HIV-1 that target CD8+ T lymphocytes using CD8 as a receptor

HIV-1 use CD4 receptors to infect their primary targets, CD4+ cells, whereas CD8+ cells have a protective role against HIV-1. We recently isolated HIV-1-producing CD8+ clones from two AIDS patients. Here we show that although HIV-1 produced by CD8+ cells maintained the ability to infect CD4+ cells, these viruses were able to infect CD8+ cells independent of CD4. Evidence indicates that these viruses used CD8 as a receptor to infect CD8+ cells. First, expression of CD8 was downmodulated after infection. Second, anti-CD8 antibodies blocked viral entry and replication in CD8+ cells. Finally, resistant cells became susceptible after expression of CD8. Although these viruses used CXCR4 to enter CD4+ cells, it seems that infection of CD8+ cells was independent of CXCR4 or CCR5 co-receptors. Novel changes were observed in envelope sequences of CD8-tropic viruses. These results provide initial evidence that HIV-1 can mutate to infect CD8+ cells using CD8 as a receptor.

Dermatomycosis in and around Aurangabad

A total of 175 cases of dermatophytoses were studied. Out of all the clinical types, Tinea corporis (T. corporis) was found to be the predominant clinical type (24.57%) followed by tinea cruris (T. cruris) (22.28%). Incidence of Tinea barbae (T. barbae) and Tinea imbricata (T. imbricata) was the least (2.85%) and 0.57% respectively. Out of 175 cases of dermatophytoses, 66 (37.71%) cases were positive on microscopic examination, out of which 27 (40.90%) cases were positive by culture also. Out of the 175 cases of dermatophytoses, 109 (62.28%) were engative on microscopic examination, out of which 13 (11.92%) were culture positive. In this study, Trichophyton was the commonest genus of dermatophyte isolated, with Trichophyton rubrum (T. rubrum) being the commonest species (28.12%), followed by Trichophyton mentagrophyte. (T. mentagrophyte) (25.0%) Trichophyton soudanense (T. soundanense), which is a rare species (not reported from any studies) was isolated from cases of T. corporis and T. cruris.

Prospective study of outcome in antenatally diagnosed renal pelvis dilatation

AIMS

To ascertain the outcome associated with antenatal renal pelvis dilatation; to recommend guidelines for postnatal investigation and determine an upper limit of normal for the anterioposterior dimensions of the fetal renal pelvis.

METHODS

Infants whose antenatal ultrasound scan showed a fetal renal pelvis of 5 mm or greater were investigated using postnatal renal tract ultrasound and a micturating cystogram. Isotope studies were also performed, where appropriate.

RESULTS

Vesicoureteric reflux (VUR), the most common diagnosis, was evident in 23/104 (22%). In 14 infants with VUR the postnatal ultrasound scan was normal. There was no evidence of renal scarring or dysplasia in any of the refluxing kidneys. Other diagnoses were pelviureteric junction obstruction, renal dysplasia, and idiopathic dilatation. Antenatal counselling and parental information facilitated postnatal assessment.

CONCLUSIONS

Infants with antenatal renal pelvis measurements of 5 mm or greater should be investigated postnatally, as a significant percentage will have VUR. A normal postnatal ultrasound scan does not preclude the presence of VUR.

Arterial injury by cholesterol oxidation products causes endothelial dysfunction and arterial wall cholesterol accumulation

Cholesterol oxidation products (ChOx) have been reported to cause acute vascular injury in vivo; however, the pharmacokinetics of ChOx after administration and the mechanisms by which they cause chronic vascular injury are not well understood. To further study the pharmacokinetics and atherogenic properties of ChOx, New Zealand White rabbits were injected intravenously (70 mg per injection, 20 injections per animal) with a ChOx mixture having a composition similar to that found in vivo during a 70-day period. Total ChOx concentrations in plasma peaked almost immediately after a single injection, declined rapidly, and returned to preinjection levels in 2 hours. After multiple injections, the ChOx concentrations rose gradually to levels 2- to 3-fold above baseline levels, increasing mostly in the cholesteryl ester fraction of LDL and VLDL. Rabbit serum and the isolated LDL/VLDL fraction containing elevated ChOx concentrations were cytotoxic to V79 fibroblasts and rabbit aortic endothelial cells. At the time of killing, cholesterol levels in the aortas from ChOx-injected rabbits were significantly elevated despite the fact that plasma cholesterol levels remained in the normal range. In addition, aortas from the ChOx-injected rabbits retained more 125I-labeled horseradish peroxidase, measured 20 minutes after intravenous injection. Transmural concentration profiles across the arterial wall also showed increased horseradish peroxidase accumulation in the inner half of the media from the thoracic aorta in ChOx-injected rabbits. In conclusion, ChOx injection resulted in accumulation of circulating ChOx and induced increased vascular permeability and accumulation of lipids and macromolecules. This study reveals that even under normocholesterolemic conditions, ChOx can cause endothelial dysfunction, increased macromolecular permeability, and increased cholesterol accumulation, parameters believed to be involved in the development of early atherosclerotic lesions.

Prolonged survival after massive pulmonary embolism in a patient with atrial septal defect and mass in the right ventricle

Unless thrombolytic or surgical therapy is rapidly available, massive pulmonary embolism in both pulmonary arteries invariably results in instantaneous death. A patient is presented with congenital atrial septal defect and right ventricular thrombus who developed extensive bilateral pulmonary embolism with an apparently prolonged survival. The ante- and postmortem findings represent the unusual and interesting aspects of this particular case.