Core needle biopsy causing a pseudoaneurysm in the breast

Core needle biopsy (CNB) is the first-choice method of sampling suspicious, focal breast lesions for histological analysis. Here we present the case of a 65-year-old woman who was recalled for evaluation of the left breast following a screening mammogram. An ultrasound-guided biopsy was performed using a disposable core biopsy needle and 3 weeks later a magnetic resonance imaging scan showed a distended vessel with adjacent sac measuring 17 × 15mm². A Doppler ultrasound scan confirmed pseudoaneurysm. A review of the literature was made on breast pseudoaneurysm following CNB, and over the past 20 years there were few other reports. Pseudoaneurysms in the breast are a rare but serious complication of CNBs. They may spontaneously thrombose, but often require intervention, so it is essential that clinicians are aware of the risk.

Schizophyllum commune sinusitis in an immunocompetent host

Schizophyllum commune is widely distributed in the nature, but it rarely causes human infection. We have isolated this mould in a 46-year-old immunocompetent, non-diabetic patient with chronic sinusitis, previously treated with multiple antibiotics and topical steroid nasal drops with no response. Materials obtained from the nasal sinus during the endoscopic surgery, on KOH mount and histopathological study revealed broad septed hyaline hyphae. Growth on the Sabouraud's dextrose agar and potato dextrose agar produced white moulds with microscopic and macroscopic characters of S. commune. Till date there are few reports of S. commune sinusitis in immunocompetent individuals Worldwide. This is the first reported case in India to the best of our knowledge.

Inductive expression of toll-like receptor 5 (TLR5) and associated downstream signaling molecules following ligand exposure and bacterial infection in the Indian major carp, mrigal (Cirrhinus mrigala)

Toll-like receptors (TLRs) are one of the key components of innate immunity. Among various types of TLRs, TLR5 is involved in recognizing bacterial flagellin and after binding, it triggers myeloid differentiation primary response gene 88 (MyD88)-dependent signaling pathway to induce pro-inflammatory cytokines. In this report, we analyzed the expression profile of TLR5 and its associated downstream signaling molecules like MyD88 and tumor necrosis factor (TNF) receptor-associated factor (TRAF) 6 in the Indian major carp (IMC), mrigal (Cirrhinus mrigala) which is highly commercially important fish species in the Indian subcontinent. Ontogeny analysis of TLR5, MyD88 and TRAF6 revealed constitutive expression of these genes in all embryonic developmental stages, and highlighted the importance of embryonic innate immune defense system in fish. Tissue specific expression analysis of these genes by quantitative real-time PCR (qRT-PCR) revealed their wide distribution in various organs and tissues; highest expression of TLR5 and MyD88 was in liver and TRAF6 was in kidney. Modulation of TLR5, MyD88 and TRAF6 gene expression, and the induction of interleukin (IL)-8 and TNF-α were analyzed in various organs by qRT-PCR following flagellin stimulation, and Aeromonas hydrophila and Edwardsiella tarda infection. In the treated fish, majority of the tested tissues exhibited significant induction of these genes, although with varied intensity among the tissues and with the types of treatments. Among the examined tissues, a significant relationship of TLR5 induction, MyD88 and TRAF6 up-regulation, and enhanced expression of IL-8 and TNF-α gene transcripts was observed in the blood and intestine of both flagellin stimulated and bacteria infected fish. These findings may indicate the involvement of TLR5 in inducing IL-8 and TNF-α, and suggest the important role of TLR5 in augmenting innate immunity in fish in response to pathogenic invasion. This study will enrich the information in understanding the innate immune mechanism in fish and may be helpful in developing preventive measures against infectious diseases in fish.

Molecular characterization of nucleotide binding and oligomerization domain (NOD)-2, analysis of its inductive expression and down-stream signaling following ligands exposure and bacterial infection in rohu (Labeo rohita)

Nucleotide-binding and oligomerization domain (NOD)-2 is a cytoplasmic pattern recognition receptor (PRR) and is a member of NOD like receptor (NLR) family. It senses a wide range of bacteria and viruses or their products and is involved in innate immune responses. In this report, NOD-2 gene was cloned and characterized from rohu (Labeo rohita) which is highly commercially important fish species in the Indian subcontinent. The full length rohu NOD-2 (rNOD-2) cDNA comprised of 3176 bp with a single open reading frame (ORF) of 2949 bp encoding a polypeptide of 982 amino acids (aa) with an estimated molecular mass of 109.65 kDa. The rNOD-2 comprised two N-terminal CARD domains (at 4-91 aa and 111-200 aa), one NACHT domain (at 271-441 aa) and seven C-terminal leucine rich repeat (LRR) regions. Phylogenetically, rNOD-2 was closely related to grass carp NOD-2 (gcNOD2) and exhibited significant similarity (94.2%) and identity (88.6%) in their amino acids. Ontogeny analysis of rNOD-2 showed its constitutive expression across the developmental stages, and highlighted the embryonic innate defense system in fish. Tissue specific analysis of rNOD-2 by quantitative real-time PCR (qRT-PCR) revealed its wide distribution; highest expression was in liver followed by blood. In response to PGN and LTA stimulation, Aeromonas hydrophila and Edwardsiella tarda infection, and poly I:C treatment, expression of rNOD-2 and its associated downstream molecules RICK and IFN-γ were significantly enhanced in the treated fish compared to control. These findings suggested the key role of NOD-2 in augmenting innate immunity in fish in response to bacterial and viral infection. This study may be helpful for the development of preventive measures against infectious diseases in fish.

Pleural empyema due to S. typhi: a case report

In a 35 year old immunocompetent male, clinically diagnosed as a case of hydropneumothorax of left side, Salmonella typhi was isolated as the causative agent of pleural empyema.

Fast track recovery of elderly coronary bypass surgery patients

BACKGROUND

To ascertain whether early extubation and fast-track treatment protocols are feasible in elderly patients, we analyzed 487 consecutive patients who had isolated coronary artery bypass grafting between January 1995 and June 1997, constituting the experience of a single surgeon.

METHODS

Management consistently applied to all patients emphasized early extubation protocol, tepid cardioplegia and normothermic bypass to reduce pump times, early mobilization and chest tube removal, and protocol treatment of atrial fibrillation. Elderly patients at least 70 years old (n = 176, mean age 75 years) were compared with younger patients (n = 311, mean age 58 years).

RESULTS

The hospital mortality rate was 0.8% (4 of 487 patients), and there was no difference in the operative mortality rate of the older cohort versus the younger cohort (0.6% versus 0.9%; p > 0.05). Older patients had a higher incidence of peripheral vascular disease, congestive heart failure, prior strokes, renal failure, and cerebrovascular disease (p < 0.05). Early extubation was achieved in 71% of younger patients versus 57% of older cohort (95% confidence interval, 14%+/-9%; p = 0.002). Older patients had significantly higher incidence of postoperative atrial fibrillation (27% versus 14%; 95% CI, 13%+/-7%; p < 0.001), a factor responsible for shorter length of stay among younger patients (5.6+/-2.8 days versus 7.2+/-3.7 days; 95% CI, 1.6+/-0.3 days; p < 0.001). Nonetheless discharge before the fifth postoperative day was achieved in 34% of the elderly patients.

CONCLUSIONS

Although elderly patients have a higher acuity of illness, critical pathways for accelerated discharge are safe and feasible in most elderly patients.

In a managed care setting, are there sex differences in the use of coronary angiography after acute myocardial infarction?

OBJECTIVES

The goal of this study was to examine sex differences in the use of coronary angiography after acute myocardial infarction in managed care facilities by using the American College of Cardiology/American Heart Association (ACC/AHA) practice guidelines (which incorporate clinical information on infarct complications, severity of illness, and comorbidity).

BACKGROUND

Although sex differences in the use of coronary angiography after acute myocardial infarction have been previously explored, the effects of indications for coronary angiography and common health insurance coverage on the sex and coronary angiography use relation have not been previously examined.

METHODS

This historical prospective study analyzed data collected from a random sample of 1133 patients (377 women, 756 men) from among 2740 patients hospitalized with validated acute myocardial infarction between Jan. 1, 1990, and Dec. 31, 1992, from seven of 16 Northern California Kaiser Facilities (three with high procedure rates for coronary angiography, four with low rates relative to the average region-wide utilization rate). In accordance with the guidelines, use of coronary angiography was determined for the in-hospital and "0 to 8 weeks" postdischarge periods. Patients were assigned time specific ACC/AHA classes for coronary angiography indications (I = highly indicated, IIA = probably indicated, IIB = not harmful, III = not indicated). The independent impact of ACC/AHA class, age, race, and facility on the sex and use of coronary angiography relation was examined by the Cox proportional hazard model.

RESULTS

Accounting only for ACC/AHA class, fewer women underwent coronary angiography compared with men among the "highly indicated" class I patients during the in-hospital period (43% vs 35%; p < 0.05), but not after discharge. Use of coronary angiography between the sexes was not statistically different among classes IIA, IIB, and III for both periods. After adjusting for differences in age, race, facility, and ACC/AHA class, we found no sex difference in in-hospital use of coronary angiography (hazard ratio (HR) = 1.02; 95% confidence interval [CI], 0.82 to 1.26), but among those discharged without receiving coronary angiography, women probably received fewer angiograms than did men (HR = 0.61; 95% CI, 0.37 to 1.00). For both periods, no significant sex difference in use of coronary angiography was found within ACC/AHA classes after adjustments.

CONCLUSION

In a setting where health insurance is prepaid and after controlling for ACC/AHA classification for coronary angiography indications, age, race, and facility, use of coronary angiography after myocardial infarction was similar among men and women during hospitalization, but was lower among women after discharge. Likely explanations for these differences in use of coronary angiography may include effects of physician judgment, patient decision, other social factors, or clinical information not captured in the practice guidelines.

Influence of gender on cardiovascular mortality in acute myocardial infarction patients with high indication for coronary angiography

BACKGROUND

This study was undertaken to study gender differences in the use of coronary angiography (CA), revascularization (RV), and cardiovascular disease (CVD) mortality in patient with acute myocardial infarction (AMI) who were assigned to "High Indication for CA" per the American College of Cardiology/American Heart Association (ACC/ AHA) practice guidelines.

METHODS AND RESULTS

This is a historical prospective study based on a stratified random sample of 1165 AMI patients from January 1990 to December 1992 at seven health maintenance organization hospitals. CA was highly indicated in 286 women and 564 men. In a Cox hazard ratio (HR), women received significantly (P<.05) fewer CAs (HR, .78) and RVs (HR, .62) than men after adjusting for age, Charlson index, and congestive heart failure. Crude CVD mortality for women was higher than men (HR, 1.7). After adjustments for age, Charlson index, and congestive heart failure, the HR was reduced to 1.19 for women. Further adjustment for CA and RV lowered CVD mortality in women slightly (HR, 1.14). RV is associated with lowered CVD (HR, .41).

CONCLUSIONS

In patients with high indication for CA, use of CA and RV was significantly lower in women. After adjustments were made for risk profile and treatment modalities, women did not have a significantly increased risk for CVD compared with men. However, the apparent protective effect of RV in patients with a high indication for CA suggests that practices in line with ACC/AHA guidelines may reduce CVD in both women and men.

Phagocytosis and oxidative-burst response of planktonic Staphylococcus epidermidis RP62A and its non-slime-producing variant in human neutrophils

The ability of bacterial organisms to produce an extracellular polysaccharide matrix known as slime has been associated with increased virulence and delayed infections in various prosthetic implants. Within a biofilm, this slime may protect the embedded bacteria from host defense mechanisms, especially phagocytosis by polymorphonuclear leukocytes. To determine whether planktonic Staphylococcus epidermidis is protected in a similar way, a novel flow cytometric assay was performed, measuring ingestion and adherence during phagocytosis and the production of superoxide during oxidative burst. Hydrophobicity was determined by hydrophobic interaction chromatography. Slime-producing S. epidermidis RP62A and its phenotypic variant, non-slime-producing RP62A-NA, were compared. The results showed increased phagocytosis of RP62A at 2, 5, 10, and 30 min; increased adherence of RP62A at 30 s and 30 min; and increased superoxide production of RP62A after 2 min. Decreased hydrophobicity of RP62A over RP62A-NA was correlated with a hydrophilic slime coat. The data argue that the host aggressively combats slime-producing S. epidermidis. This biological phenomenon is potentially important during bacteremia to prevent further adhesion, accumulation, and the genesis of a bacterial biofilm on implants or tissue surfaces.

Clinical features of eating disorders and individual psychological functioning

Relationships between the clinical features of eating disorders and individual psychological functioning were investigated in a population of 114 eating-disordered females, which consisted of 63 bulimics, 9 anorexics, 7 bulimic anorexics, 23 with eating disorders not otherwise specified, and 12 with indications of an eating disorder, but without sufficient data for further differential diagnosis. No significant differences in psychological functioning were found when diagnosis was used to classify the subjects into groups, but significant differences did emerge when subjects were classified by specific clinical features. Among the clinical features associated with greater psychopathology were: low body weight, frequent weight fluctuations, amenorrhea of longer duration, purging via laxatives, frequent exercising, and more frequent binges of longer duration.