Detecting goals of care conversations in clinical notes with active learning

OBJECTIVE

Goals of care (GOC) discussions are an increasingly used quality metric in serious illness care and research. Wide variation in documentation practices within the Electronic Health Record (EHR) presents challenges for reliable measurement of GOC discussions. Novel natural language processing approaches are needed to capture GOC discussions documented in real-world samples of seriously ill hospitalized patients' EHR notes, a corpus with a very low event prevalence.

METHODS

To automatically detect sentences documenting GOC discussions outside of dedicated GOC note types, we proposed an ensemble of classifiers aggregating the predictions of rule-based, feature-based, and three transformers-based classifiers. We trained our classifier on 600 manually annotated EHR notes among patients with serious illnesses. Our corpus exhibited an extremely imbalanced ratio between sentences discussing GOC and sentences that do not. This ratio challenges standard supervision methods to train a classifier. Therefore, we trained our classifier with active learning.

RESULTS

Using active learning, we reduced the annotation cost to fine-tune our ensemble by 70% while improving its performance in our test set of 176 EHR notes, with 0.557 F1-score for sentence classification and 0.629 for note classification.

CONCLUSION

When classifying notes, with a true positive rate of 72% (13/18) and false positive rate of 8% (13/158), our performance may be sufficient for deploying our classifier in the EHR to facilitate bedside clinicians' access to GOC conversations documented outside of dedicated notes types, without overburdening clinicians with false positives. Improvements are needed before using it to enrich trial populations or as an outcome measure.

PhenoID, a language model normalizer of physical examinations from genetics clinical notes

Background

Phenotypes identified during dysmorphology physical examinations are critical to genetic diagnosis and nearly universally documented as free-text in the electronic health record (EHR). Variation in how phenotypes are recorded in free-text makes large-scale computational analysis extremely challenging. Existing natural language processing (NLP) approaches to address phenotype extraction are trained largely on the biomedical literature or on case vignettes rather than actual EHR data.

Methods

We implemented a tailored system at the Children's Hospital of Philadelpia that allows clinicians to document dysmorphology physical exam findings. From the underlying data, we manually annotated a corpus of 3136 organ system observations using the Human Phenotype Ontology (HPO). We provide this corpus publicly. We trained a transformer based NLP system to identify HPO terms from exam observations. The pipeline includes an extractor, which identifies tokens in the sentence expected to contain an HPO term, and a normalizer, which uses those tokens together with the original observation to determine the specific term mentioned.

Findings

We find that our labeler and normalizer NLP pipeline, which we call PhenoID, achieves state-of-the-art performance for the dysmorphology physical exam phenotype extraction task. PhenoID's performance on the test set was 0.717, compared to the nearest baseline system (Pheno-Tagger) performance of 0.633. An analysis of our system's normalization errors shows possible imperfections in the HPO terminology itself but also reveals a lack of semantic understanding by our transformer models.

Interpretation

Transformers-based NLP models are a promising approach to genetic phenotype extraction and, with recent development of larger pre-trained causal language models, may improve semantic understanding in the future. We believe our results also have direct applicability to more general extraction of medical signs and symptoms.

Funding

US National Institutes of Health.

Automatic Extraction of Medication Mentions from Tweets-Overview of the BioCreative VII Shared Task 3 Competition

This study presents the outcomes of the shared task competition BioCreative VII (Task 3) focusing on the extraction of medication names from a Twitter user's publicly available tweets (the user's 'timeline'). In general, detecting health-related tweets is notoriously challenging for natural language processing tools. The main challenge, aside from the informality of the language used, is that people tweet about any and all topics, and most of their tweets are not related to health. Thus, finding those tweets in a user's timeline that mention specific health-related concepts such as medications requires addressing extreme imbalance. Task 3 called for detecting tweets in a user's timeline that mentions a medication name and, for each detected mention, extracting its span. The organizers made available a corpus consisting of 182 049 tweets publicly posted by 212 Twitter users with all medication mentions manually annotated. The corpus exhibits the natural distribution of positive tweets, with only 442 tweets (0.2%) mentioning a medication. This task was an opportunity for participants to evaluate methods that are robust to class imbalance beyond the simple lexical match. A total of 65 teams registered, and 16 teams submitted a system run. This study summarizes the corpus created by the organizers and the approaches taken by the participating teams for this challenge. The corpus is freely available at https://biocreative.bioinformatics.udel.edu/tasks/biocreative-vii/track-3/. The methods and the results of the competing systems are analyzed with a focus on the approaches taken for learning from class-imbalanced data.

Isolated lymph node recurrence in epithelial ovarian cancer - management and outcome

INTRODUCTION

The aim of our study was to assess the clinical outcome of isolated lymph node recurrence in patients with epithelial ovarian cancer treated by surgery and to analyze the impact of various clinico-pathological factors on prognosis.

MATERIAL AND METHODS

We conducted a retrospective analysis of all the epithelial ovarian cancer patients who underwent secondary lymphadenectomy surgery for isolated lymph node recurrence at our institute from 2013 to 2020. Univariate analysis of various factors influencing the post-recurrence disease free survival and post-recurrence survival was done using Kaplan-Meier for categorical variables and cox-proportional hazard progression for continuous variables.

RESULTS

A total of 21 patients of isolated lymph node recurrence were treated surgically during the study period. The median disease free interval to develop lymph nodal recurrence was 13 months. All the patients achieved complete resection to no gross residual disease without any significant morbidity associated with the procedure. The median post-recurrence disease free survival after treatment of lymph node recurrence was 25 months with 3-year post-recurrence survival of 72% and 3-year overall survival of 85%. Amongst the factors influencing post-recurrence disease free survival, young age (< 50 years), para-aortic lymph node dissection at initial surgery and single site of lymph node recurrence were significantly associated with better prognosis. A single site of lymph node recurrence was associated with significantly better post-recurrence survival.

CONCLUSIONS

Complete resection is feasible for epithelial ovarian cancer patients presenting with isolated lymph node recurrence, without any significant perioperative morbidity. When combined with postoperative adjuvant chemotherapy, complete resection is associated with favourable survival outcomes. Young age, para-aortic lymph node dissection during primary surgery and single site of lymph node recurrence are associated with better prognosis.

Automatic Cohort Determination from Twitter for HIV Prevention amongst Black and Hispanic Men

Recruiting people from diverse backgrounds to participate in health research requires intentional and culture-driven strategic efforts. In this study, we utilize publicly available Twitter posts to identify targeted populations to recruit for our HIV prevention study. Natural language processing and machine learning classification methods were used to find self-declarations of ethnicity, gender, age group, and sexually-explicit language. Using the official Twitter API we collected 47.4 million tweets posted over 8 months from two areas geo-centered around Los Angeles. Using available tools (Demographer and M3), we identified the age and race of 5,392 users as likely young Black or Hispanic men living in Los Angeles. We then collected and analyzed their timelines to automatically find sex-related tweets, yielding 2,166 users. Despite a limited precision, our results suggest that it is possible to automatically identify users based on their demographic attributes and Twitter language characteristics for enrollment into epidemiological studies.

Lipid Profile and Ultrasonographic Grading in Alcoholic and Non Alcoholic Fatty Liver Patients

Background Fatty liver disease (FLD) is a common and major chronic liver disease. It has been implicated that patients have disorders of lipid metabolism and are involved in the pathogenesis of fatty liver. Hence, it was designed to observe the association between lipid profile and fatty liver disease. Objective This study was undertaken to evaluate the association of lipid profile status, hemoglobin and albumin levels with fatty liver disease patients diagnosed based on ultrasonography (USG). Method This Cross-sectional study was undertaken in the Department of Internal Medicine with the collaboration of the Department of Radiology and Department of Biochemistry, Universal College of Medical Sciences-Teaching Hospital (UCMS-TH), Bhairahawa, Nepal from March 2019 to February 2020 in a total of 100 patients diagnosed with fatty liver disease by ultrasonography. The fasting blood was collected for lipid profile and carried out in the automated analyzer following standard protocol. Result In 100 cases, the male to female ratio was 1.8:1. Fifty six percent of the total cases presented with alcoholic fatty liver disease (AFLD) while the remaining 44% with nonalcoholic fatty liver disease (NAFLD). The spectrum of lipid abnormality was observed with increased total cholesterol (TC), Low Density Lipoprotein (LDL), increased triglycerides (TG), Very Low Density Lipoprotein (VLDL) in alcoholic fatty liver disease cases as compared to nonalcoholic fatty liver disease cases. However, it has been observed that TG/HDL and Non-HDL/HDL were higher in nonalcoholic fatty liver disease as compared to alcoholic fatty liver disease. Moreover, a statistically significant difference was observed in HDL between AFLG2 and NAFLG2 (p-value: 0.012). Conclusion Dyslipidemia and decreased HDL have been implicated in fatty liver diseases. USG in conjunction with Non-HDL/HDL, TG/HDL, hemoglobin, and albumin can be useful in early screening and monitoring of dyslipidemia in fatty liver patients.

Focal Leptomeningeal Disease with Perivascular Invasion in EGFR-Mutant Non-Small-Cell Lung Cancer

We report a previously undescribed pattern of brain metastases in patients with epidermal growth factor receptor-mutated non-small-cell lung cancer treated with tyrosine kinase inhibitors and radiation therapy. These highly distinct lesions appear to spread focally within the leptomeninges, with invasion along the perivascular spaces (FLIP). The survival of patients with FLIP was significantly better compared with patients with classic leptomeningeal disease (median survival, 21 versus 3 months; P = .003). It is unclear whether this pattern of growth is unique to epidermal growth factor receptor-mutated non-small-cell lung cancer.

Diagnostic Impact of Intracranial Vessel Wall MRI in 205 Patients with Ischemic Stroke or TIA

BACKGROUND AND PURPOSE

Secondary prevention of ischemic stroke depends on determining the cause of the initial ischemic event, but standard investigations often fail to identify a cause or identify multiple potential causes. The purpose of this study was to characterize the impact of intracranial vessel wall MR imaging on the etiologic classification of ischemic stroke.

MATERIALS AND METHODS

This was a single-center, retrospective study of 205 consecutive patients who were referred for vessel wall MR imaging to clarify the etiology of an ischemic stroke or TIA. An expert panel classified stroke etiology before and after incorporating vessel wall MR imaging results using a modified Trial of Org 10172 in Acute Stroke Treatment system. We measured the proportion of patients with an altered etiologic classification after vessel wall MR imaging.

RESULTS

The median age was 56 years (interquartile range = 44-67 years), and 51% (106/205) of patients were men. Vessel wall MR imaging altered the etiologic classification in 55% (112/205) of patients. The proportion of patients classified as having intracranial arteriopathy not otherwise specified decreased from 31% to 4% (64/205 versus 9/205; P < .001) and the proportion classified as having intracranial atherosclerotic disease increased from 23% to 57% (48/205 versus 116/205; P < .001). Conventional work-up classification as intracranial arteriopathy not otherwise specified was an independent predictor of vessel wall MR imaging impact (OR = 8.9; 95% CI, 3.0-27.2). The time between symptom onset and vessel wall MR imaging was not a predictor of impact.

CONCLUSIONS

When vessel wall MR imaging is performed to clarify the etiology of a stroke or TIA, it frequently alters the etiologic classification. This is important because the etiologic classification is the basis for therapeutic decision-making.

Diagnostic Accuracy of Intraoperative Frozen Section in Ovarian Neoplasms: Experience in a Tertiary Oncology Centre

Background Ovarian cancer is the second most common type of female genital tract malignancy. Treatment planning differs for benign, borderline and malignant subtypes of surface epithelial tumours and depends on accurate histopathological diagnosis. A pre-operative diagnosis of the nature of ovarian tumors is not always reliable. Frozen section is a valuable diagnostic tool in rapid intraoperative categorization of ovarian masses and thereby helps in planning the surgical management. Adequate management and treatment of ovarian carcinoma requires a complete surgical staging supported by frozen-section examination. To achieve this goal it is necessary to have a high level of accuracy. Objective To assess the accuracy of intra-operative frozen section in the diagnosis of various categories of ovarian neoplasm conducted in Rajiv Gandhi Cancer Institute and Research Centre. Method Intra-operative frozen sections for suspected ovarian neoplasm that underwent surgery as primary line of therapy at this institution were analyzed retrospectively from Jan. 2014 - Dec. 2015. The results of frozen section were compared with the final histopathology diagnosis on paraffin sections and the overall accuracy, sensitivity, specificity, positive and negative predictive values were determined. Result The study included 159 cases and the mean age of patients was 44.72±14.28 years (Range 19-75 years). The mean size of tumor was 12.5±5.9 cm. Sensitivity of frozen section for benign, borderline and malignant tumors was 98.53%, 73.33% and 94.74% respectively and the related specificities were 95.60%, 96.53% and 100% respectively. There were 150 concordant cases and 9 discordant cases. Overall diagnostic accuracy of frozen section was 94.33%. Conclusion Intra-operative frozen section diagnosis appeared to be an accurate and comparable technique for the histopathology diagnosis of ovarian tumors.

Comparison of Sagittal FSE T2, STIR, and T1-Weighted Phase-Sensitive Inversion Recovery in the Detection of Spinal Cord Lesions in MS at 3T

BACKGROUND AND PURPOSE

Determining the diagnostic accuracy of different MR sequences is essential to design MR imaging protocols. The purpose of the study was to compare 3T sagittal FSE T2, STIR, and T1-weighted phase-sensitive inversion recovery in the detection of spinal cord lesions in patients with suspected or definite MS.

MATERIALS AND METHODS

We performed a retrospective analysis of 38 patients with suspected or definite MS. Involvement of the cervical and thoracic cord segments was recorded on sagittal FSE T2, STIR, and T1-weighted phase-sensitive inversion recovery sequences independently by 2 readers. A consensus criterion standard read was performed with all sequences available. Sensitivity, specificity, and interobserver agreement were calculated for each sequence.

RESULTS

In the cervical cord, the sensitivity of T1-weighted phase-sensitive inversion recovery (96.2%) and STIR (89.6%) was significantly higher (P < .05) than that of FSE T2 (50.9%), but no significant difference was found between T1-weighted phase-sensitive inversion recovery and STIR. In the thoracic cord, sensitivity values were 93.8% for STIR, 71.9% for FSE T2, and 50.8% for T1-weighted phase-sensitive inversion recovery. Significant differences were found for all comparisons (P < .05). No differences were detected in specificity. Poor image quality and lower sensitivity of thoracic T1-weighted phase-sensitive inversion recovery compared with the other 2 sequences were associated with a thicker back fat pad.

CONCLUSIONS

The use of an additional sagittal sequence other than FSE T2 significantly increases the detection of cervical and thoracic spinal cord lesions in patients with MS at 3T. In the cervical segment, both STIR and T1-weighted phase-sensitive inversion recovery offer high sensitivity and specificity, whereas in the thoracic spine, STIR performs better than T1-weighted phase-sensitive inversion recovery, particularly in patients with a thick dorsal fat pad.

Pregnancy Related Acute Kidney Injury at a Tertiary Care Center in Nepal

Aims: This was performed to study the characteristics of Pregnancy Related Acute Kidney Injury (PRAKI), its management and outcome in patients at a tertiary level referral centre. Methods: A hospital based prospective observational study was conducted in Tribhuvan University Teaching Hospital (TUTH) over a period of 18 months. All patients diagnosed with PRAKI were included in the study. Patient profiles in terms of age, parity, gestational age were studied along with time of occurrence of PRAKI, preceding event, etiology, management and maternal outcome. Descriptive and univariate analyses were conducted and qualitative variables were expressed as percentages while quantitative variables as means. Results: There were fifteen cases of PRAKI during the study period with incidence of 2.1 per 1000 deliveries. The average age was 25.23± 3.8 years and 9(60%) were primipara. Fourteen (93.3%) developed PRAKI in the postpartum period with 10(66.6%) cases following Lower Segment Caesarian Section (LSCS). The commonest etiology of PRAKI was severe preeclampsia/ Hemolysis, Elevated Liver enzymes, Low Platelet (HELLP) syndrome and pregnancy hemorrhages each consisting 4(26.6%) cases. The stage of Acute Kidney Injury (AKI) according to RIFLE (Risk, Injury, Failure, Loss, ESRD-End Stage Renal Disease) criteria was as follows: risk in 1(6.6%), injury in 3(20%) and failure in 11(73.3%) cases. Hemodialysis was necessary in 12(80%) cases while 3 cases (20%) improved with medical management only. The average duration of hospital stay was 25.2±14.7 days and 7(46.6%) needed ICU admission. Twelve (80%) cases recovered completely while two patients were dialysis dependent at the time of evaluation. There was one death. Conclusions: PRAKI occurred mainly in the postpartum period with severe preeclampsia/HELLP syndrome and hemorrhages as the most common causes. It is associated with high maternal morbidity, prolonged hospital stay and even mortality. Multidisciplinary team management is essential. 

Targeted Therapy for Renal Cell Carcinoma

INTRODUCTION

Our study aims to evaluate the use of targeted therapy in metastatic renal cell carcinoma Methods: This is a prospective study done over three years from December 2010 to December, 2013.Out of Forty seven patients of metastatic renal cell carcinoma 8(neo-adjuvant cases) were excluded and 39 were included in this study. All patients received Tyrosine kinase inhibitor, sunitinib therapy (50 mg OD, 4/2 scheme). All 39 patients underwent radical nephrectomy prior to sunitinib therapy. Patients were followed up every cycle for their clinical symptoms following sunitinib therapy and every 3 months with chest X-ray, ultra-sonography and bone scan. CT scan was done if needed. A RECIST criterion was used to evaluate the complete, partial and no tumor response.

RESULTS

The median survival was 28.5 months (CI 9.253-47.7) and progression free survival (PFS) was 9.16 months(CI 6.08-12.23).According to RECIST, stable disease was found in 6 patients till date and a complete response in two patients. Clear cell histology was found in 30(76.9%) patients, papillary variety in 6(15.39%) patients, chromophobe type was seen in one patient and rest had mixed sarcomatoid papillary and rhabdoid clear cell variety. Twenty four patients (61.5%) had multiple metastases. Most frequent metastasis was seen in lungs in 14 patients (36%) and bone in 12 patients (31%).Metastases were also seen in draining lymph nodes, adrenals, omentum,skin, liver, and brain.

CONCLUSIONS

In our cohort, use of sunitinib showed similar outcome to previously published articles. Our study supports the use of sunitinib in metastatic renal cell carcinoma.

Subcortical cystic lesions within the anterior superior temporal gyrus: a newly recognized characteristic location for dilated perivascular spaces

SUMMARY

Cystic parenchymal lesions may pose an important diagnostic challenge, particularly when encountered in unexpected locations. Dilated perivascular spaces, which may mimic cystic neoplasms, are known to occur in the inferior basal ganglia and mesencephalothalamic regions; a focal preference within the subcortical white matter has not been reported. This series describes 15 cases of patients with cystic lesions within the subcortical white matter of the anterior superior temporal lobe, which followed a CSF signal; were located adjacent to a subarachnoid space; demonstrated variable surrounding signal change; and, in those that were followed up, showed stability. Pathology study results obtained in 1 patient demonstrated chronic gliosis surrounding innumerable dilated perivascular spaces. These findings suggest that dilated perivascular spaces may exhibit a regional preference for the subcortical white matter of the anterior superior temporal lobe. Other features-lack of clinical symptoms, proximity to the subarachnoid space, identification of an adjacent vessel, and stability with time-may help in confidently making the prospective diagnosis of a dilated perivascular space, thereby preventing unnecessary invasive management.

A Randomized Trial to Determine the Efficacy of Dry Versus Wet Misoprostol for Termination of First Trimester Pregnancy

NJOG 2011 Nov-Dec; 6 (2): 20-23 DOI: http://dx.doi.org/10.3126/njog.v6i2.6751

Detection of meticillin-resistant staphylococcus aureus (MRSA) colonization in newborn infants using real-time polymerase chain reaction (PCR)

OBJECTIVE

Meticillin-resistant staphylococcus aureus (MRSA) colonization on neonatal units is a common and important clinical problem. Effectiveness of polymerase chain reaction (PCR) for detecting MRSA nasal colonization of infants was evaluated and compared to culture-based methods. The effect of skin decolonization in affected infants was studied.

METHODS

Paired nasal swabs were collected from infants in our neonatal unit over a 12-month period (September 2007-2008). Colonization with MRSA was determined with a commercially available PCR method and compared to culture.

RESULTS

A total of 696 paired nasal swabs were taken. Three infants were colonized at the beginning and were included. There were positive PCRs in 12 infants. Five infants cultured MRSA from a nasal swab at the same time. No infants were culture-positive when PCR was negative (sensitivity 100%, specificity 99% compared to culture). PCR results were available within 24 h. Five infants were PCR+ and isolated meticillin-sensitive Staphylococcus aureus. This organism gave a false-positive PCR result. Two infants transferred in on broad-spectrum antibiotics were PCR+ and negative by culture. Decolonization led to negative nasal PCR and culture in 4/5 infants to discharge.

CONCLUSIONS

PCR methods are sensitive and specific for detection of MRSA colonization in newborn infants of all gestations with results 1-2 days before culture.

Ovarian Pregnancy- A Rare Ectopic Pregnancy

Primary ovarian pregnancy is a rare entity, the incidence being 1 in 25,000 to 40,000 pregnancies. The diagnosis is difficult and still continues to challenge the clinicians. A case of ovarian pregnancy is reported here. The patient underwent laparotomy with right sided oophorectomy. Histopathological examination confirmed it to be an ovarian pregnancy. Keywords: ectopia pregnancy, oophorectomy, ovarian pregnancy.

Ovarian pregnancy: a rare ectopic pregnancy

Primary ovarian pregnancy is a rare entity, the incidence being 1 in 25,000 to 40,000 pregnancies. The diagnosis is difficult and still continues to challenge the clinicians. A case of ovarian pregnancy is reported here. The patient underwent laparotomy with right sided oophorectomy. Histopathological examination confirmed it to be an ovarian pregnancy.

Structure, genetic mapping, and function of the cytochrome P450 3A37 gene in the turkey (Meleagris gallopavo)

Cytochromes P450 (P450 for protein; CYP for gene) are a superfamily of membrane-bound hemoproteins that oxidize a large number of endogenous and exogenous compounds. Through oxidation reactions, these enzymes are often responsible for the toxic and carcinogenic effects of natural food-borne toxicants, such as the mycotoxin aflatoxin B1 (AFB1). Previous studies in our laboratory have shown that the extreme sensitivity of turkeys to AFB1 is in part explained by efficient hepatic P450-mediated epoxidation to the toxic and reactive metabolite the exo-AFB1-8,9-epoxide (AFBO). Using 3'-5'-rapid amplification of cDNA ends (RACE), we amplified CYP3A37 from turkey liver RNA, the E. coli-expressed protein which efficiently epoxidates AFB(1). Turkey CYP3A37 has an ORF of 1512 bp, and the protein is predicted to be 504 amino acids with 97% homology to chicken CYP3A37. The turkey gene is organized into 13 exons and 12 introns. A single nucleotide polymorphism in the 11th intron was used to assign CYP3A37 to turkey linkage group 10 (corresponding to chicken chromosome 14, GGA14). Because of the important role of P450s in the extreme sensitivity of turkeys to the toxic effects of AFB(1), this study will contribute to the identifying allelic variants of this important gene in poultry.

Predicting relapse in Crohn's disease: a biopsychosocial model

BACKGROUND

Crohn's disease (CD) is a chronic relapsing inflammatory bowel disorder. Both biological and psychosocial factors may modulate the illness experience.

AIM

The aim of this study was to identify clinical, biological and psychosocial parameters as predictors of clinical relapse in quiescent CD.

METHODS

Patients in medically induced remission were followed prospectively for 1 year, or less if they relapsed. Disease characteristics were determined at baseline. Serum cytokines, anti-Saccharomyces cerevisiae antibodies, C-reactive protein (CRP), erythrocyte sedimentation rate and intestinal permeability were measured every 3 months. Psychological distress, perceived stress, minor life stressors and coping strategies were measured monthly. A time-dependent multivariate Cox regression model determined predictors of time to relapse.

RESULTS

101 patients (60 females, 41 males) were recruited. Fourteen withdrew and 37 relapsed. CRP (HR = 1.5 per 10 mg/l, 95% CI 1.1 to 1.9, p = 0.007), fistulising disease (HR = 3.2, 95% CI, 1.1 to 9.4, p = 0.04), colitis (HR = 3.5 95% CI 1.2 to 9.9, p = 0.02) and the interaction between perceived stress and avoidance coping (HR = 7.0 per 5 unit increase for both scales, 95% CI 2.3 to 21.8, p = 0.003) were predictors of earlier relapse.

CONCLUSIONS

In quiescent CD, a higher CRP, fistulising disease behaviour and disease confined to the colon were independent predictors of relapse. Moreover, patients under conditions of low stress and who scored low on avoidance coping (ie, did not engage in social diversion or distraction) were least likely to relapse. This study supports a biopsychosocial model of CD exacerbation.

Heterotopic pregnancy with spontaneous intrauterine conception: a rare clinical entity with diagnostic dilemma

Twenty-one years old primigravida presented to emergency with amenorrhoea for 2 months and complaints of severe abdominal pain for few hours. The pain was associated with 2 episodes of fainting attacks in emergency during the period of observation. Viable intrauterine pregnancy of 8-9 weeks along with collection of fluid in the Pouch of Douglas was detected by ultrasound examination and on laparotomy ectopic pregnancy was confirmed with haemoperitoneum of 2 litres with 500gms of clots. Histopathology report confirmed the tubal ectopic pregnancy and postlaparotomy, transvaginal sonography confirmed the salvage of the intrauterine pregnancy. Despite massive haemoperitoneum, the pregnancy continued till 40+6 weeks with uneventful antenatal period. She underwent emergency caesarean section for meconium stained liquor with foetal distress and delivered of an alive healthy female of 2.5 kg with good Apgar score.

Pure choriocarcinoma of testis with rare gingival and skin metastases

A 22-year-old man presented with complaints of gingival and skin lesions. Physical examination revealed the presence of two nodular lesions, one over the sternum, 3 cm in size, and another, on the right side of chin, 1 cm in size. There was another fleshy soft tissue deposit over the left lower gingiva, in the oral cavity. He had noticed these lesions ten days prior to his visit to the hospital. In addition, there was left testicular non-tender swelling which had been present for two months, but was not investigated. Fine-needle aspiration cytology from skin and gingival lesions was suggestive of metastatic deposits. Patient underwent left high orchidectomy, and histopathological examination was consistent with the diagnosis of pure choriocarcinoma. Although rare, cases of testicular neoplasms and especially choriocarcinoma of the testis leading to skin metastases have been reported, but case reports of choriocarcinoma of testis metastatic to gingiva have been reported exceptionally in the English literature. We report this unique case of a young man with pure choricarcinoma of testis with unusual gingival and skin metastases.

Early Experience with Pancreatic, Periampullary malignancies: Case Reviews, Management Guidelines and Discussion

Early Experience with Pancreatic, Periampullary malignancies: Case Reviews, Management Guidelines and Discussion

A Rare Abdominal Mass, A Case Presentation

A Rare Abdominal Mass, A Case Presentation

Parametrial invasion in carcinoma of cervix: role of MRI measured tumour volume

The aim of the study was to determine the correlation between MRI measured tumour volume and parametrial invasion on histology in the evaluation of carcinoma of the cervix showing full thickness stromal invasion (FTSI). Original MR images of 159 surgical cases of carcinoma of the cervix retrieved from the MR image bank of the department were analysed retrospectively. Tumour volume from the maximum tumour diameters in each case was computed using the standard formula for an ellipse and correlated with parametrial invasion on histology. Of 105 cases showing FTSI on axial T(2) weighted MRI, tumour volume between the two groups of cases, with parametrial invasion (n=27) and without parametrial invasion (n=78), shows a statistically significant difference (p=0.006). Best accuracy of 60.95%, sensitivity 59.26% and specificity 61.54% was found for tumour volume of 36.39 cm(3). The study concludes that MRI measured tumour volume is associated with low accuracy in the evaluation of parametrial invasion in carcinoma of cervix showing FTSI in axial T(2) weighted MR images and may not help as an additional diagnostic criterion to predict parametrial invasion pre-operatively.

Damage Control Surgery: Management of Critically Injured Patients

Damage Control Surgery: Management of Critically Injured Patients

Entamoeba histolytica Gal/GalNAc lectin depletes antioxidant defences of target epithelial cells

Among the variety of virulence factors of Entamoeba histolytica, an adherence lectin (Gal/GalNAc, 260 kDa) is known to mediate colonization and subsequent host responses. Gal/GalNAc lectin is universally recognized by the immune sera of patients with amoebic liver abscess. It plays a crucial role in cytolysis and phagocytosis of human and rat colonic mucin glycoproteins. The objective of the present study was to elucidate the role of antioxidants in E. histolytica Gal/GalNAc lectin-induced signals in the target epithelial cells. We have attempted to define a pathway in target cells, Henle-407 cells (human intestinal epithelial cell line), that could link this immunodominant antigen to a known biological pathway for target cell activation and triggering of subsequent disease pathology/parasite survival. Since several workers have demonstrated that cAMP and cGMP may act as important cellular signals for altering ion transport, so in the present study, cAMP and cGMP levels were measured in Henle-407 cells which showed significant increase at 15 min after stimulation. Elevated cAMP and cGMP levels are implicated in altered electrolyte transport and conductance. Results showed that there were increased levels of ROS and RNI which led to reduced activities of antioxidant enzymes--catalase, superoxide dismutase and glutathione peroxidase. Despite the increased glutathione (reduced) levels, the enzymes were not able to combat the damage caused by ROS and RNI. Thus, there was an increased local concentration of the free radicals and reduced activities of all the three enzymes which could damage the target cell in terms of cytoskeleton and permeability changes.

Outbreaks of cholera in Kathmandu Valley in Nepal

An analysis of the seasonal outbreak of diarrhoea in children in Kathmandu, Nepal, is reported. Vibrio cholera, 01 biotype El Tor Ogawa was the major cause of this epidemic. The pattern of spread suggested a waterborne infection related to contaminated river water and this was confirmed by a field survey. Although the mortality rate was low, younger children were more susceptible. Enteropathogenic E. coli seems to be a major cause for diarrhoea after cholera amongst children in this study.

Serological study of Japanese encephalitis in Nepal

Antibodies against Japanese encephalitis virus (JEV) were examined in 356 serum samples from individuals visiting Tribhuvan University Teaching Hospital using neutralization test. A total of 13.2% (47/356) seropositivity was observed. Antibody positivity against both Nakayama-NIH and Beijing-1 strains was seen in 7.9% subjects. Infection by Nakayama-NIH strain alone was seen to be 4.2% while 1.1% of study populations were found to be infected only by Beijing-1 strain. High antibody titer was observed in the 20-40 years age-group and did not increase with age. Seropositivity was more common in zone-A (Tarai) area compared to zone-B (Hills) and zone-C (Mountains). Spectrum of antigenicity of JEV in zone-A as shown by neutralization test was identical to Indian isolates (strains). Difference in seropositivity was observed against Nakayama-NIH and Beijing-1 strain in zone-B and C indicating recent spread of JEV in these areas.

Guanine nucleotides can activate the insulin-stimulated phosphodiesterase in liver plasma membranes

The insulin-stimulated cyclic AMP phosphodiesterase from liver plasma membranes is shown to be activated upon incubation with guanine nucleotides in the presence of ATP. The non-hydrolysable analogue of ATP, adenylyl imidodiphosphate failed to substitute for ATP in achieving activation. GTP, its non-hydrolysable analogues p[NH]ppG and GTP-gamma-S, as well as GDP, all elicited activation. It is suggested that guanine nucleotides, and probably insulin, exert their effect on this enzyme through a distinct species of guanine nucleotide regulatory protein.

Perturbations of liver plasma membranes induced by Ca2+ are detected using a fatty acid spin label and adenylate cyclase as membrane probes

Ca2+ decreased the lipid fluidity of rat liver plasma membranes labeled with 5-nitroxide stearate, I(12,3), as indicated by the order parameter (S). These effects form a reversible, saturable process with an association constant of 1 x 10(3) M-1. Arrhenius-type plots of S indicated that the lipid phase separation, present in the external leaflet of native membranes between 28 and 19 degrees C, is perturbed by mM Ca2+ such that the high temperature onset is elevated to 32-34 degrees C. Fluoride-stimulated adenylate cyclase was similarly inhibited by Ca2+ (ID50 = 1 mM) for the enzyme in membrane-bound or solubilized states. The glucagon-stimulated activity was more sensitive to Ca2+ inhibition with an ID50 of 0.2 mM. These inhibitory effects are due neither to perturbations of glucagon binding to its receptor nor to fluidity changes, but are instead attributed to direct Ca2+-enzyme interactions. Such binding desensitizes the enzyme to fluidity alterations induced by temperature elevation or benzyl alcohol addition. With Ca2+, Arrhenius plots of glucagon-stimulated activity indicated breaks at 32 and 16 degrees C, whereas those of fluoride-stimulated activity showed one break at 17 degrees C. Without Ca2+, Arrhenius plots exhibited one break at 28 degrees C for glucagon-stimulated activity, whereas fluoride-stimulated plots were linear. We propose that Ca2+ achieves these effects through asymmetric perturbations of the membrane lipid structure.

Glucagon-stimulated adenylate cyclase detects a selective perturbation of the inner half of the liver plasma-membrane bilayer achieved by the local anaesthetic prilocaine

Prilocaine can increase the fluidity of rat liver plasma membranes, as indicated by a fatty acid spin-probe. This led to the activation of the membrane-bound fluoride-stimulated adenylate cyclase activity, but not the Lubrol-solubilized activity, suggesting that increased lipid fluidity can activate the enzyme. With increasing prilocaine concentrations above 10 mM, the membrane-bound fluoride-stimulated activity was progressively inhibited, even though bilayer fluidity continued to increase and the activity of the solubilized enzyme remained unaffected. Glucagon-stimulated adenylate cyclase was progressively inhibited by increasing prilocaine concentrations. Prilocaine (10 mM) had no effect on the lipid phase separation occurring at 28 degrees C and attributed to those lipids in the external half of the bilayer, as indicated by Arrhenius plots of both glucagon-stimulated adenylate cyclase activity and the order parameter of a fatty acid spin-probe. However, 10 mM-prilocaine induced a lipid phase separation at around 11 degrees C that was attributed to the lipids of the internal (cytosol-facing) half of the bilayer. It is suggested that prilocaine (10 mM) can selectively perturb the inner half of the bilayer of rat liver plasma membranes owing to its preferential interaction with the acidic phospholipids residing there.

Chorioangioma of Placenta

We report a case of Chrioangima of placenta resulting to hydropsfetalis. A 24 yrs old primigravida with polyhydramnios and large placental chorioangioma at 24 wks of gestation expelled a nonimmune hydropic male baby weighing 900gms. The baby expired after 5 minutes of expulsion. Keywords: Placental chorioangioma; Hydropsfetalis; Polyhydraamnios DOI: http://dx.doi.org/10.3126/mjsbh.v9i2.5026 Medical Journal of Shree Birendra Hospital Vol.9(2) 2010: 44-46