Radiological impact of oral bisphosphonate use on polyostotic Paget's disease of bone over a 2 year period

Paget's disease of bone is a disorder of osteoclasts which hampers the physiological process of bone remodeling. It is the most common metabolic orthopedic disease in the Caucasian populace; we report the diagnosis of Paget's disease of bone in a South-Asian male in his early 50s with a history of gastrointestinal symptoms, weight loss and back pain. An alkaline phosphatase level of 1104 IU/L was noted. A 3-phase bone scan showed noncontiguous heterogenous nuclear uptake. After exhaustive evaluation, the patient was diagnosed with Paget's disease of bone. Despite the disease activity being mitigated by alendronate and monitored by ALP levels within normal range per protocol, the patient had compression fractures of the vertebrae requiring early reinitiation of oral bisphosphonates. This raised doubts about the efficacy of metabolic marker-based management in Paget's disease of bone.

Use of Polyurethane-Covered Stents for Exclusion of Pulmonary Arteriovenous Malformations

PURPOSE

To evaluate the safety, technical success and short-term effectiveness of polyurethane-covered stent (PK Papyrus, BioTronik, Berlin) in the treatment of pulmonary arteriovenous malformations (PAVMs) that are not amenable to embolotherapy.

MATERIALS AND METHODS

In this IRB-approved, retrospective study, data from patients who received polyurethane-covered stents for exclusion of PAVMs were analyzed. The study included 5 patients (all women) with a median age of 40 years (range 25-60). Patients presented with hypoxemia, TIAs, and/or epistaxis; 4 were confirmed to have HHT. All had multiple PAVMs diagnosed on chest CT and underwent embolization with other devices in addition to the polyurethane-covered stent. The indication for stent placement in all cases was a short and/or tortuous feeding artery. Safety was assessed by immediate or short-term complications, e.g., migration, stent thrombosis, and fracture. Technical success was defined as the ability to accurately place the stent at the intended location. Effectiveness was defined as successful exclusion of PAVM with no perfusion across the AVM.

RESULTS

Technical success of stent placement was 100%. AVM exclusion rate was 80% after single stent deployment; in the case of incomplete exclusion, success was achieved using an overlapping stent to completely cover a second feeding artery. During the median follow-up period of 5 months (range 2-10), all stents remained patent, and AVMs were excluded without other complications.

CONCLUSION

Exclusion of PAVMs with polyurethane-covered stents is technically feasible, safe, and shows short-term effectiveness for PAVMs with a short/tortuous feeding artery when traditional embolization techniques are not possible.

Cough Sounds in Screening and Diagnostics: A Scoping Review

OBJECTIVE

The aim of the study was to examine applications of cough sounds towards screening tools and diagnostics in the biomedical and engineering literature, with particular focus on disease types, acoustic data collection protocols, data processing and analytics, accuracy, and limitations.

DATA SOURCES

PubMed, EMBASE, Web of Science, Scopus, Cochrane Library, IEEE Xplore, Engineering Village, and ACM Digital Library were searched from inception to August 2021.

REVIEW METHODS

A scoping review was conducted on screening and diagnostic uses of cough sounds in adults, children, and animals, in English peer-reviewed and gray literature of any design.

RESULTS

From a total of 438 abstracts screened, 108 articles met inclusion criteria. Human studies were most common (77.8%); the majority focused on adults (57.3%). Single-modality acoustic data collection was most common (71.2%), with few multimodal studies, including plethysmography (15.7%) and clinico-demographic data (7.4%). Data analytics methods were highly variable, with 61.1% using machine learning, the majority of which (78.8%) were published after 2010. Studies commonly focused on cough detection (41.7%) and screening of COVID-19 (11.1%); among pediatric studies, the most common focus was diagnosis of asthma (52.6%).

CONCLUSION

Though the use of cough sounds in diagnostics is not new, academic interest has accelerated in the past decade. Cough sound offers the possibility of an accessible, noninvasive, and low-cost disease biomarker, particularly in the era of rapid development of machine learning capabilities in combination with the ubiquity of cellular technology with high-quality recording capability. However, most cough sound literature hinges on nonstandardized data collection protocols and small, nondiverse, single-modality datasets, with limited external validity. Laryngoscope, 134:1023-1031, 2024.

Uncommon Presentation of Craniopharyngioma: A Case Report of Post-traumatic Intratumoral Hemorrhage Leading to Cerebral Infarct

Craniopharyngiomas emanate from squamous cell remnants in the hypophyseal/pharyngeal duct region. This report details the unprecedented case of a 29-year-old male with adamantinomatous craniopharyngioma, who, following a motor vehicle collision (MVC), presented with post-traumatic intratumoral hemorrhage leading to acute basal ganglia infarct. The patient, previously subjected to subtotal resection, exhibited focal neurological deficits attributed to compression of lenticulostriate arteries due to the sudden increase in tumor volume. The patient, ineligible for thrombolysis or thrombectomy, was conservatively managed post-MVC. Subtotal resection occurred four months later. After one year, persistent right-sided weakness (2/5 motor power) remained, and the recommended stereotactic radiotherapy was declined by the patient. Notably, this instance represents the first documented case of post-traumatic intratumoral hemorrhage in adamantinomatous craniopharyngioma. This report distinguishes between adamantinomatous and papillary subtypes, noting their prevalence in different age groups. While these tumors commonly present with gradual vision changes, fatigue, and endocrine dysfunction, complications such as intra-tumoral hemorrhage remain rare. This report serves as an educational tool, shedding light on potential complications and urging increased vigilance in managing craniopharyngiomas.

Endobronchial Migration of a POD Packing Coil Following Embolization of a Pulmonary Artery Pseudoaneurysm

The authors report a case of endobronchial migration of a POD packing coil following embolization of a pulmonary artery pseudoaneurysm in a patient with cavitary tuberculosis and its successful management by bronchoscopy-assisted removal of the coil. Coil migration may be secondary to continued cough and persistence of a bronchial to pulmonary artery fistula from tuberculous infection and inflammation.

Provocative mesenteric angiography for occult gastrointestinal bleeding: a systematic review

Occult gastrointestinal bleeding (GIB) is a challenge for physicians to diagnose and treat. A systematic literature search of the PubMed and Embase databases was conducted up to January 1, 2023. Eligible studies included primary research studies with patients undergoing provocative mesenteric angiography (PMA) for diagnosis or localization of occult GIB. Twenty-seven articles (230 patients) were included in the review. Most patients (64.8%) presented with lower GIB. The average positivity rate for provocative angiography was 48.7% (58% with heparin and 46.7% in thrombolytics). Embolization was performed in 46.4% of patients, and surgical management was performed in 37.5%. Complications were rare. PMA can be an important diagnostic and treatment tool but studies with high-level evidence and standardized protocols are needed to establish its safety and optimal use.

Dirofilariasis mouse models for heartworm preclinical research

Introduction

Dirofilariasis, including heartworm disease, is a major emergent veterinary parasitic infection and a human zoonosis. Currently, experimental infections of cats and dogs are used in veterinary heartworm preclinical drug research.

Methods

As a refined alternative in vivo heartworm preventative drug screen, we assessed lymphopenic mouse strains with ablation of the interleukin-2/7 common gamma chain (γc) as susceptible to the larval development phase of Dirofilaria immitis.

Results

Non-obese diabetic (NOD) severe combined immunodeficiency (SCID)γc^-/- (NSG and NXG) and recombination-activating gene (RAG)2^-/-γc^-/- mouse strains yielded viable D. immitis larvae at 2-4 weeks post-infection, including the use of different batches of D. immitis infectious larvae, different D. immitis isolates, and at different laboratories. Mice did not display any clinical signs associated with infection for up to 4 weeks. Developing larvae were found in subcutaneous and muscle fascia tissues, which is the natural site of this stage of heartworm in dogs. Compared with in vitro-propagated larvae at day 14, in vivo-derived larvae had completed the L4 molt, were significantly larger, and contained expanded Wolbachia endobacteria titres. We established an ex vivo L4 paralytic screening system whereby assays with moxidectin or levamisole highlighted discrepancies in relative drug sensitivities in comparison with in vitro-reared L4 D. immitis. We demonstrated effective depletion of Wolbachia by 70%-90% in D. immitis L4 following 2- to 7-day oral in vivo exposures of NSG- or NXG-infected mice with doxycycline or the rapid-acting investigational drug, AWZ1066S. We validated NSG and NXG D. immitis mouse models as a filaricide screen by in vivo treatments with single injections of moxidectin, which mediated a 60%-88% reduction in L4 larvae at 14-28 days.

Discussion

Future adoption of these mouse models will benefit end-user laboratories conducting research and development of novel heartworm preventatives via increased access, rapid turnaround, and reduced costs and may simultaneously decrease the need for experimental cat or dog use.

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

Clinical Outcomes of Percutaneous Biliary Endoscopy: A 7-Year Single-Institution Experience

PURPOSE

To evaluate safety and effectiveness of percutaneous biliary endoscopy (PBE) performed on patients ineligible for surgery or endoscopic retrograde cholangiopancreatography.

MATERIALS AND METHODS

Retrospective review was conducted for all patients who underwent PBE at a single academic institution between June 2013 and February 2020; 39 patients underwent 58 choledochoscopy sessions, and 21 patients underwent 48 cholecystoscopy sessions. Choledochoscopy indications included stone removal (23 of 39 patients) or biliary stenosis evaluation (19 of 39 patients). Cholecystoscopy indications included calculous cholecystitis (18 of 21 patients) and symptomatic cholelithiasis (3 of 21 patients). Technical success, procedural and fluoroscopy times, and tube-free survival were assessed.

RESULTS

For all PBEs performed for stone clearance, using disposable endoscopes led to shorter mean ± SD procedural (128.7 minutes ± 56.2 vs 240.2 minutes ± 184.6; P < .01) and fluoroscopy times (10.7 minutes ± 7.9 vs 16.5 minutes ± 12.0; P = .01) than using reusable endoscopes. Increasing institutional experience was associated with reduced procedural time (β = -56.73; P < .001). Choledochoscopy technical success was 94.8% with 1 adverse event of bile duct perforation with bile leak requiring drainage. For patients with choledocholithiasis, biliary drains were removed in 14 (60.9%) patients, with a mean tube-free survival of 22.1 months ± 23.8. For cholecystoscopy, technical success was 93.8% with no adverse events. Cholecystostomy tubes were removed in 15 (71.4%) patients, with a mean tube-free survival of 7.5 months ± 8.8.

CONCLUSIONS

This study supports PBE as a safe and feasible option for nonsurgical patients or those with altered anatomy precluding endoscopic retrograde cholangiopancreatography. Moreover, PBE may result in tube-free survival.

Evaluation of post-COVID health status using the EuroQol-5D-5L scale

SARS-CoV-2 has had a lasting effect on the overall health of recovered patients, called 'long COVID'. Currently, there is a lack of a validated standard questionnaire to assess post-COVID health status. A retrospective observational study involving the recovered COVID patients admitted to a secondary care hospital in India between June to December 2020 (n = 123), was conducted using the EuroQol-5D-5L scale at discharge, 4 weeks and 8 weeks post-discharge. A significant difference in anxiety/depression scores was found (χ² = 65.6, p < 0.000) among the 3 categories of time (discharge, 4 weeks and 8 weeks). The anxiety/depression dimension scores showed a significant change (p < 0.0001) between discharge and 8 weeks, using paired t-test. Age had a significant relationship with the anxiety/depression dimension at 4 weeks (OR = 5.617, 95% CI = 1.0320-30.5746, p < 0.05). A significant difference was found using Kruskal-Wallis rank-sum test on mean index scores (χ² = 60.0, p < 0.000) among the three categories of time (discharge, 4 weeks and 8 weeks). There was a statistically significant difference of time on EQ Index scores as determined by one-way repeated measures ANOVA (F(2,375) = 18.941, p = <0.00001). Our study found time to have a statistically significant impact on the mean index scores, level sum scores and dimension scores. Smoking was found to be significantly associated with usual activity scores at 4 weeks. The most remarkable changes occurred in the anxiety/depression dimension. Overall, there was a general trend of health improvement.

Spontaneous Transvaginal Small Bowel Evisceration With Uterine Procidentia: A Report of a Rare Case

Spontaneous transvaginal small bowel evisceration is an extremely rare condition with a few more than 100 documented cases to date. The complications of such a rare entity revolve around its preoperative presentation as well as its operative and postoperative complications. The complications seen are intestinal incarcerations and perforations with an increased risk of post-surgical ileus and peritonitis in a time-dependent fashion. In our case, a postmenopausal female presented with sudden onset bowel evisceration through a defect in the posterior vaginal apex during straining for defecation. Past medical history was significant for intermittent abdominal pain, bloating, and chronic constipation. The patient had no signs of trauma, signs of sexual assault, preceding events, or prior urinary disturbances. The patient was treated surgically with laparotomy and bowel-packing followed by Ward-Mayo's repair with added on anterior and posterior colporrhaphy, and site-specific repair. Postoperatively, following a period of prolonged ileus, the patient made a full recovery. This case report aims to provide a better understanding of the mechanism and occurrence of such an event and also intends to raise awareness of this rare presentation as an emergency condition requiring prompt surgical management.

Ethnic disparities in adverse events of chemotherapy for breast cancer: A scoping review

e18524

Background: Ethnic disparities may contribute to a higher symptom burden of adverse events following chemotherapy and poorer response to treatment for breast cancer. The objective was to examine the intra-group and inter-group ethnic differences in adverse effects experienced by Asian breast cancer patients undergoing chemotherapy with aromatase inhibitors or tamoxifen. Methods: A scoping review involving the Pubmed database was conducted. The search strategy included a combination of keywords and index terms related to Asians, breast cancer, CTCAE and treatment. Title, abstract and then full-text screening was performed by two reviewers. Primary research studies and systematic review articles involving female adults in peer-reviewed articles or grey literature records, of any design or date and published in English, were included. Descriptive statistics and charting was used to summarize the results. Results: Of 1765 abstracts retrieved and screened, 56 articles were ultimately included for analysis. Most articles (58.9%) studied the adverse events of tamoxifen. The majority of the studies involved Japanese patients (35.7%) followed by Chinese patients (19.6%) with an average of 8515 patients being studied per study. Only 2 studies were conducted in the US. Half the studies (50%) involved patients with TNM stage I breast cancer, postoperatively enrolled after BCS or mastectomy (71.4%). ER/PR status was reported in 58.9% of studies with an average of 494 patients being positive for either hormone receptor. HER-2 status was reported in 10 studies with an average of 53 positive HER-2 patients. 28.5% of studies involved patients with musculoskeletal adverse events following chemotherapy with aromatase inhibitors, commonly grade 3 or above (31.2%). These adverse events were arthralgia, fractures, osteoporosis or myalgia, affecting an average of 33.9% of patients in each study. 35.7% of studies involved patients with endocrinological adverse events following chemotherapy with tamoxifen. These adverse events involved menopausal symptoms, gynecological complications or endometrial cancer, affecting an average of 36.1% of patients in each study. Conclusions: Multi-level differences may contribute to the adverse events affecting Asian breast cancer patients undergoing chemotherapy with aromatase inhibitors or tamoxifen. Improving physician knowledge of ethnic disparities in adverse events occurring in Asian ethnic subgroups can help improve overall outcomes and patient adherence through a patient-centered approach.

Ethnic disparities in adverse events of radiotherapy for breast cancer: A scoping review

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Background: Ethnic disparities have been well-documented in the US as a contributor to poor outcomes following radiotherapy in ethnic minorities. The objective was to examine the intra-group and inter-group ethnic differences in adverse effects experienced by Asian breast cancer patients undergoing radiotherapy. Methods: A scoping review involving the Pubmed database was conducted. The search strategy included a combination of keywords and index terms related to Asians, breast cancer, CTCAE and treatment. Title, abstract and then full-text screening was performed by two reviewers. Primary research studies and systematic review articles involving female adults in peer-reviewed articles or grey literature records, of any design or date and published in English, were included. Descriptive statistics and charting was used to summarize the results. Results: Of 1765 abstracts retrieved and screened, 37 articles were ultimately included for analysis. The majority of the studies involved Japanese patients (40.5%) followed by Chinese patients (24.3%) with an average of 468 patients being studied per study (ranging from 1-4,869 patients). Only a single study was conducted in the US. 35.1% of studies reported ethnicity and 64.8% of studies reported Asian ethnic subgroups. Most patients underwent whole-breast irradiation (62.1%). 37.5% of studies involved patients with TNM stages I-III breast cancer. Most patients were postoperatively enrolled after BCS (59.4%).ER/PR status was reported in most studies (54.1%) with an average of 553 patients being positive for either hormone receptor and averages of 210 and 905 patients each in studies where numbers were reported individually. HER-2 status was reported in 48.7% of studies with an average of 28 positive HER-2 patients in each study. Most studies reported skin toxicity following radiotherapy (81.1%), commonly grade 1 or 2 (40.5% each) affecting an average of 46% of patients in each study. These dermatological adverse events were radiation dermatitis, hyperpigmentation, fibrosis, hypertrophic scarring or erythema. Conclusions: Ethnicity was under-reported in the studied literature involving breast cancer treatment. Strategies to improve reporting of ethnic subgroups in literature and to reduce psychosocial barriers to access and treatment with a specific focus on mitigating dermatological adverse events of radiotherapy in Asian breast cancer patients may improve overall outcomes in this group.

Gastric teratoma presenting as melena in the newborn: A case report

Melena is reported in 1 of 350 to 400 new-borns. Significant upper gastrointestinal bleeding in a neonate with an antenatally diagnosed abdominal mass has not been reported before. This case highlights an unusual presentation of a gastric teratoma and proposes a probable embryological explanation for the site of occurrence.

Impella versus intra-aortic balloon pump in cardiogenic shock: a meta-analysis assessing 30-days mortality

Introduction

Cardiogenic shock is linked with eminent morbidity and mortality despite advances in treatment modality. Adjuvant treatment modalities to provide mechanical haemodynamic support in the form of intra-aortic balloon pump (IABP) or Impella are being used among patients with cardiogenic shock. The Impella prunes left ventricular preload, whereas, IABP persuades after load reduction and both contribute to improved cardiac output. A few underpowered randomised control trials (RCTs) and observational studies compared short term mortality benefit of Impella juxtaposed to IABP among patients with cardiogenic shock.

Purpose

A meta-analysis of RCTs and observational studies researching the short-term mortality in cardiogenic shock comparing Impella to IABP was executed.

Methods

The databases PubMed, EMBASE and Cochrane were searched systematically to identify relevant RCTs and observational studies contrasting Impella to IABP and reporting 30-days mortality as outcomes. The search terms used were “Impella”, “IAPB”, “intra-aortic balloon pump” and all word variations were utilised. The search was conducted from the debut of the databases up to January 2020. Two reviewers independently and in tandem performed data screening and extraction from identified articles. Inverse variance method with Paule-Mandel estimator for tau2 and Hartung-Knapp adjustment was used to calculate Risk Ratio with 95% confidence interval. Heterogeneity was assessed using I2 statistics. Furthermore, we calculated the 95% predictive interval for the pooled estimate. All statistical analysis for this meta-analysis was carried out using R statistical software version 3.6.2 using the package meta ( ). Additionally, Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria were used to assess the certainty of evidence.

Results

Five studies constituting 728 patients were included in the final analysis. Two were RCTs (ISAR-SHOCK trial and IMPRESS in Severe Shock trial), one study was a propensity score matched observational study and two were unmatched observational studies. There was no difference in the risk of 30-days mortality in patients treated with Impella as compared to IABP [Risk Ratio: 0.97, 95% confidence interval: 0.66–1.41, I2: 32%]. To account for the heterogeneity, we calculated 95% predictive interval: 0.46–2.02. Thus, very low certainty of evidence concluded no difference in the risk of 30-days mortality among cardiogenic shock patients treated with Impella in opposition to IABP.

Conclusion

This meta-analysis comparing Impella juxtaposed with IABP demonstrated no difference in the risk of 30-days mortality among patients with cardiogenic shock.

30-days Mortality

Funding Acknowledgement

Type of funding source: None

The applicability of the Demirjian, Willems and Chaillet standards to age estimation of 5-15 year old Indian children

BACKGROUND

Demirjian's method of age estimation has been reported to overestimate age and Willems' method to give consistently more accurate results. Not enough, however, is known about the applicability of Chaillet's standards.

AIM

The present study aimed to compare the accuracy of Demirjian's, Willems' and Chaillet's standards in age estimation of 5 to 15 year-old Indian children.

DESIGN

In this cross-sectional observational study, three methods were compared for accuracy in estimating the age of 1200 Indian children aged 5-15 years.

RESULTS

Demirjian's method overestimated age by +0.24 ± 0.80 years, +0.11 ± 0.81years and +0.19 ± 0.80 years in boys, girls and the total sample, respectively. With Willems' method, overestimations of +0.09 ± 0.80 years, +0.08 ± 0.80 years and +0.09 ± 0.80 years were obtained in boys, girls and the total sample, respectively. Chaillet's method underestimated age by -0.12 ± 0.69 years, -0.45 ± 0.88 years and -0.25 ± 0.83 years in boys, girls and the total sample, respectively. Statistically significant differences were observed between dental and chronological ages with all methods (p < 0.001). Significant sex-based differences were observed only with Demirjian's and Chaillet's methods (p < 0.05).

CONCLUSION

Willems' method was the most accurate in age estimation, followed by Demirjian's and Chaillet's methods. While Demirjian's method was more accurate than Chaillet's in females, Chaillet's method better predicted the age of males.

The signaling axis atypical protein kinase C λ/ι-Satb2 mediates leukemic transformation of B-cell progenitors

Epigenetically regulated transcriptional plasticity has been proposed as a mechanism of differentiation arrest and resistance to therapy. BCR-ABL leukemias result from leukemic stem cell/progenitor transformation and represent an opportunity to identify epigenetic progress contributing to lineage leukemogenesis. Primary human and murine BCR-ABL⁺ leukemic progenitors have increased activation of Cdc42 and the downstream atypical protein kinase C (aPKC). While the isoform aPKCζ behaves as a leukemic suppressor, aPKCλ/ι is critically required for oncogenic progenitor proliferation, survival, and B-cell differentiation arrest, but not for normal B-cell lineage differentiation. In vitro and in vivo B-cell transformation by BCR-ABL requires the downregulation of key genes in the B-cell differentiation program through an aPKC λ/ι-Erk dependent Etv5/Satb2 chromatin repressive signaling complex. Genetic or pharmacological targeting of aPKC impairs human oncogenic addicted leukemias. Therefore, the aPKCλ/ι-SATB2 signaling cascade is required for leukemic BCR-ABL⁺ B-cell progenitor transformation and is amenable to non-tyrosine kinase inhibition.

The upstream pathways regulating leukemic transcriptional plasticity for differentiation arrest and resistance to therapy are unclear. Here the authors show that aPKC λ/ι-controls leukemic B-cell precursor differentiation arrest trough RAC/MEK/ERK/SATB2 epigenetic repression

Erb's palsy complicating a case of annular pancreas

We report an unusual presentation of annular pancreas with pneumoperitoneum in a newborn with an associated left sided Erb's palsy. The neurological deficit caused considerable confusion in the diagnosis and unexpected complications after surgery. We highlight the importance of clinical examination and the complications that an Erb's palsy can cause. This unusual triad of Erb's palsy, eventration of diaphragm and annular pancreas has hitherto not been described in literature.

PDE11A negatively regulates lithium responsivity

Lithium responsivity in patients with bipolar disorder has been genetically associated with Phosphodiesterase 11A (PDE11A), and lithium decreases PDE11A mRNA in induced pluripotent stem cell-derived hippocampal neurons originating from lithium-responsive patients. PDE11 is an enzyme uniquely enriched in the hippocampus that breaks down cyclic AMP and cyclic GMP. Here we determined whether decreasing PDE11A expression is sufficient to increase lithium responsivity in mice. In dorsal hippocampus and ventral hippocampus (VHIPP), lithium-responsive C57BL/6J and 129S6/SvEvTac mice show decreased PDE11A4 protein expression relative to lithium-unresponsive BALB/cJ mice. In VHIPP, C57BL/6J mice also show differences in PDE11A4 compartmentalization relative to BALB/cJ mice. In contrast, neither PDE2A nor PDE10A expression differ among the strains. The compartment-specific differences in PDE11A4 protein expression are explained by a coding single-nucleotide polymorphism (SNP) at amino acid 499, which falls within the GAF-B homodimerization domain. Relative to the BALB/cJ 499T, the C57BL/6J 499A decreases PDE11A4 homodimerization, which removes PDE11A4 from the membrane. Consistent with the observation that lower PDE11A4 expression correlates with better lithium responsiveness, we found that Pde11a knockout mice (KO) given 0.4% lithium chow for 3+ weeks exhibit greater lithium responsivity relative to wild-type (WT) littermates in tail suspension, an antidepressant-predictive assay, and amphetamine hyperlocomotion, an anti-manic predictive assay. Reduced PDE11A4 expression may represent a lithium-sensitive pathophysiology, because both C57BL/6J and Pde11a KO mice show increased expression of the pro-inflammatory cytokine interleukin-6 (IL-6) relative to BALB/cJ and PDE11A WT mice, respectively. Our finding that PDE11A4 negatively regulates lithium responsivity in mice suggests that the PDE11A SNPs identified in patients may be functionally relevant.

Bat Hunting and Bat-Human Interactions in Bangladeshi Villages: Implications for Zoonotic Disease Transmission and Bat Conservation

Bats are an important reservoir for emerging zoonotic pathogens. Close human–bat interactions, including the sharing of living spaces and hunting and butchering of bats for food and medicines, may lead to spillover of zoonotic disease into human populations. We used bat exposure and environmental data gathered from 207 Bangladeshi villages to characterize bat exposures and hunting in Bangladesh. Eleven percent of households reported having a bat roost near their homes, 65% reported seeing bats flying over their households at dusk, and 31% reported seeing bats inside their compounds or courtyard areas. Twenty percent of households reported that members had at least daily exposure to bats. Bat hunting occurred in 49% of the villages surveyed and was more likely to occur in households that reported nearby bat roosts (adjusted prevalence ratio [aPR] 2.3, 95% CI 1.1–4.9) and villages located in north‐west (aPR 7.5, 95% CI 2.5–23.0) and south‐west (aPR 6.8, 95% CI 2.1–21.6) regions. Our results suggest high exposure to bats and widespread hunting throughout Bangladesh. This has implications for both zoonotic disease spillover and bat conservation.

A Rare Bilateral Presentation of Multiple Dens Invaginatus, Shovel-Shaped Incisor and Talon Cusp With Mesiodens

The aim of this paper is to describe a unique and unusual case of concomitant appearance of morphological dental anomalies in the maxillary anterior region, along with its management in a patient with no systemic abnormality. This case report describes the clinical and radiographic features of talon cusp, dens invaginatus, shovel-shaped incisors and a supernumerary tooth occurring in a single patient, which is a rare presentation. All 4 permanent maxillary incisors had dens invaginatus, the permanent maxillary canines showed the presence of talon cusps, the permanent maxillary central incisors were shovel-shaped and an erupted mesiodens was also observed. Treatment included restorative, surgical and orthodontic approaches.Kathmandu University Medical Journal Vol.12(4) 2014; 292-295

Differential requirement for P2X7R function in IL-17 dependent vs. IL-17 independent cellular immune responses

IL17-dependent autoimmunity to collagen type V (Col V) has been associated with lung transplant obliterative bronchiolitis. Unlike the T helper 1 (Th1)-dependent immune responses to Tetanus Toxoid (TT), the Th17 response to Col V in lung transplant patients and its Th1/17 variant observed in coronary artery disease patients requires IL-1β, tumor necrosis factor α and CD14(+) cells. Given the involvement of the P2X7 receptor (P2X7R) in monocyte IL-1β responses, we investigated its role in Th17-, Th1/17- and Th1-mediated proinflammatory responses. Transfer of antigen-pulsed peripheral blood mononucleated cells (PBMCs) from Col V-reactive patients into SCID mouse footpads along with P2X7R antagonists revealed a selective inhibition of Col V-, but not TT-specific swelling responses. P2X7R inhibitors blocked IL-1β induction from monocytes, including both Col V-α1 peptide-induced (T-dependent), as well as native Col V-induced (T-independent) responses. Significantly higher P2X7R expression was found on CXCR3(neg) CCR4(+)/6(+) CD4(+) [Th17] versus CXCR3(+)CCR4/6(neg) CD4(+) [Th1] subsets in PBMCs, suggesting that the paradigm of selective dependence on P2X7R might extend beyond Col V autoimmunity. Indeed, P2X7R inhibitors suppressed not only anti-Col V, but also Th1/17-mediated alloimmunity, in a heart transplant patient without affecting anti-viral Epstein-Barr virus responses. These results suggest that agents targeting the P2X7R might effectively treat Th17-related transplant pathologies, while maintaining Th1-immunity to infection.

Nonfatal congenital alveolar dysplasia due to abnormalities of NO synthase isoforms

Congenital alveolar dysplasia (CAD) is a rare disorder thought to represent alveolar growth arrest at the canalicular stage of development. An infant with CAD diagnosed on lung biopsy is reported, her respiratory problems resolved spontaneously and she was doing well at follow-up. The infant additionally suffered from systemic hypertension and hypertrophic pyloric stenosis. In conclusion, we speculate that the association of CAD with systemic hypertension and hypertrophic pyloric stenosis might be explained by abnormalities of isoforms of nitric oxide synthase (NOS) resulting in congenital deformities involving smooth muscles.

Using combined x-ray and MR imaging for prostate I-125 post-implant dosimetry: phantom validation and preliminary patient work

Post-implantation dosimetry is an important element of permanent prostate brachytherapy. This process relies on accurate localization of implanted seeds relative to the surrounding organs. Localization is commonly achieved using CT images, which provide suboptimal prostate delineation. On MR images, conversely, prostate visualization is excellent but seed localization is imprecise due to distortion and susceptibility artefacts. This paper presents a method based on fused MR and x-ray images acquired consecutively in a combined x-ray and MRI interventional suite. The method does not rely on any explicit registration step but on a combination of system calibration and tracking. A purpose-built phantom was imaged using MRI and x-rays, and the images were successfully registered. The same protocol was applied to three patients where combining soft tissue information from MRI with stereoscopic seed identification from x-ray imaging facilitated post-implant dosimetry. This technique has the potential to improve on dosimetry using either CT or MR alone.

Simulation of cardiac pathologies using an electromechanical biventricular model and XMR interventional imaging

Simulating cardiac electromechanical activity is of great interest for a better understanding of pathologies and for therapy planning. Design and validation of such models is difficult due to the lack of clinical data. XMR systems are a new type of interventional facility in which patients can be rapidly transferred between X-ray and MR systems. Our goal is to design and validate an electromechanical model of the myocardium using XMR imaging. The proposed model is computationally fast and uses clinically observable parameters. We present the integration of anatomy, electrophysiology, and motion from patient data. Pathologies are introduced in the model and simulations are compared to measured data. Initial qualitative comparison on the two clinical cases presented is encouraging. Once fully validated, these models will make it possible to simulate different interventional strategies.

End stage renal disease due to bilateral renal malakoplakia

Malakoplakia typically affects the bladders of immunocompromised adults who have defective intracellular killing of Escherichia coli. Renal malakoplakia is rare in children and generally has a good outcome. In the case presented, however, it caused end stage renal failure in a 5 year old girl. The management dilemmas surrounding renal transplantation are highlighted.

What can structure tell us about in vivo function? The case of aminoglycoside-resistance genes

Resistance to antibiotics used in the treatment of bacterial infections is an expanding clinical problem. Aminoglycosides, one of the oldest classes of natural product antibiotics, exert their bactericidal effect as the result of inhibiting bacterial protein synthesis by binding to the acceptor site of the 30 S ribosomal subunit. The most common mechanism of clinical resistance to aminoglycosides results from the expression of enzymes that covalently modify the aminoglycoside. We will discuss the enzymology and structure of two representative chromosomally encoded aminoglycoside N-acetyltransferases, Mycobacterium tuberculosis AAC(2')-Ic and Salmonella enterica AAC(6')-Iy, and speculate about their possible physiological function and substrates.

Mapping of electrostatic potential in deep submicron CMOS devices by electron holography

Quantitative two-dimensional maps of electrostatic potential in device structures are obtained using off-axis electron holography with a spatial resolution of 6 nm and a sensitivity of 0.17 V. Estimates of junction depth and variation in electrostatic potential obtained by electron holography, process simulation, and secondary ion mass spectroscopy show close agreement. Measurement artifacts due to sample charging and surface "dead layers" do not need to be considered provided that proper care is taken with sample preparation. The results demonstrate that electron holography could become an effective method for quantitative 2D analysis of dopant diffusion in deep-submicron devices.

Beta-endorphin infusion during exercise in rats does not alter hepatic or muscle glycogen

The aim of this study was to determine whether beta-endorphin infusion influences liver or muscle glycogen concentration during exercise. Thirty-two rats (Harlan Co., IN, USA) with a body mass of 265-290 g were assigned at random to four groups, each of eight rats: (1) beta-endorphin infusion for 90 min at rest; (2) beta-endorphin infusion for 90 min while running on a rodent treadmill at 22 m x min(-1) and 0% grade; (3) saline infusion (0.9% NaCl) for 90 min at rest; and (4) saline infusion for 90 min while running on a rodent treadmill at 22 m x min(-1) and 0% grade. Beta-endorphin infusion elevated plasma beta-endorphin concentration by 2.5-fold at rest compared with saline infusion at rest, and by two-fold after exercise compared with saline infusion after exercise. Beta-endorphin infusion attenuated exercise-induced glucose concentration but did not alter the fasting hepatic glycogen concentration at rest or after exercise compared with saline infusion. Fasting hepatic glycogen decreased significantly as a result of 90 min of exercise independent of treatment. Deep intermedius muscle glycogen concentration at rest was similar after 90 min of both beta-endorphin and saline infusion and decreased significantly as a result of 90 min of exercise independent of treatment. Our results suggest that liver and muscle glycogenolysis is not responsible for the differences in plasma glucose with beta-endorphin infusion during exercise.