16 Horner Syndrome: Can it be Familial? Case series in a family and review of literature

Ophthalmic literature reveals vague and rare references to Horner syndrome on a hereditary basis. We present a case series of mother and son with Horner syndrome, which was confirmed pharmacologically. They noticed symptoms on the same side at a similar age and no serious pathology was found.Retrospective case review of notes:Case 1: An 11-year-old male presented with 6 week history of anisocoria, mild right ptosis, no heterochromia and no history of trauma or previous surgeries. The anisocoria was more noticeable in the dark, Horner syndrome was confirmed with apraclonidine test.Case 2: Mother of case 1, 50-year-old female diagnosed with right Horner syndrome at the age of 14 in Austria. The presenting features were anisocoria, a lack of sweating on the right side of her face. Diagnosis was reconfirmed pharmacologically.Case 1 was referred to paediatrics for a systemic examination which was normal. He was investigated with urinary catecholamines, MRI head and CT neck and thorax which were all normal. Case 2 was investigated in the past with a normal CT head.Horner syndrome results in the interruption of the oculo-sympathetic pathway and can indicate serious pathology in the head, chest or neck. Our cases demonstrate that familial presentation could indicate an idiopathic aetiology as it is unlikely to have pathological Horner syndrome in two first degree relatives.Our case series highlights the importance of eliciting a family history of Horner syndrome and examining the family members. Positive family history can reassure patients while awaiting results of investigations.

A GIS-Based Methodology to Determine Effect of Vehicular Pollution at Ward Level: Case Study of Jaipur City

To determine appropriate measures to reduce air pollution in any urban city, the first essential requirement is to estimate the spatial distribution of air pollution parameters in that area. In absence of air monitoring stations, alternative methods are required for the same. In the present work, a GIS-based methodology is presented to estimate the level of NO2 based on the road density of the road network of different categories of roads. Road network GIS layer and measured levels of the average value of NO2 for the year 2019 at 12 air pollution monitoring stations of Jaipur city are used to develop a large number of possible linear regression models for estimation of NO2 values based on road density values. Akaike Information Criterion (AIC) and adjusted r2 values are used to evaluate and arrive at the best-fitted model. Values from the cities of Jodhpur and Kota are used to validate the model. Using this model, NO2 levels are determined at 91 wards of Jaipur city and the output is compared with the similar map derived based on interpolation of NO2 values at the 12 monitoring stations. It is concluded that the methodology developed in this study generates better estimates of NO2 at the ward levels.

Need for Changes in the Practical Physiology Curriculum of Medical Undergraduates

INTRODUCTION

Physiology is one of the foundation sciences for the medical curriculum. It forms the basis of all life sciences. Physiology practical classes in India are divided into three sections: exercises in haematology, exercises on humans and experiments on amphibians. Faculty and students of medical schools in India are of the opinion that animal experiments should be discontinued, that the curriculum in experimental physiology and pharmacology needs to be updated, that the same understanding of topics could be obtained by using alternative methods and that there is an urgent need to introduce alternatives of animal experiments.

AIM

To assess the need for changes in the practical physiology curriculum of medical undergraduates.

MATERIALS AND METHODS

The study was conducted among 300 MBBS, second and third professional students using a semi-structured questionnaire. The questionnaire consisted of two sections: the first section was based on the current experimental physiology curriculum regarding the relevance of topics taught in haematology, amphibian and human practical classes. In the second section, the opinion was also sought regarding introduction of new topics related to recent advances in clinical physiology and basic clinical skills.

RESULTS

More than 60% of the students marked most of the haematology experiments useful. All the amphibian practicals were considered irrelevant/not useful by more than 75% of the students. Regarding the human experiments, more than 70% of the students marked useful. More than 65% students were of the opinion that basic clinical skills should be introduced at undergraduate level. More than 50% students favoured introduction of topics from recent advances in physiology.

CONCLUSION

The present study concludes that there is an imperative need to implement radical changes in the experimental physiology curriculum which should be in consonance with patient care for the doctors of tomorrow to render better health service.

Effect of Menstrual Cycle Phases on Plasma Lipid and Lipoprotein Levels in Regularly Menstruating Women

INTRODUCTION

Physiological cyclic variability in levels of sex hormones during a menstrual cycle may possibly have an impact on lipids, lipoprotein levels and therefore on cardiovascular health status of females.

AIM

To ascertain the effect of menstrual cycle phases on the levels of cardiovascular risk predictors i.e., plasma lipids and lipoproteins in healthy menstruating women.

MATERIALS AND METHODS

In the present study, 111 healthy regularly menstruating females aged 15-45 years were examined at two points of a menstrual cycle i.e., in the follicular phase (10th day) and in the luteal phase (22nd day) to find out the plasma levels of lipids and lipoproteins. The data were statistically analysed using paired t-test.

RESULTS

A significant decrease in the mean levels of Total Cholesterol (TC) (p=0.006), Low Density Lipoprotein Cholesterol (LDL-C) (p=0.004), TC/High Density Lipoprotein Cholesterol (HDL-C) (p=0.006), Low Density Lipoprotein Cholesterol (LDL)/HDL (p=0.01), and Triglyceride (TG)/HDL (p=0.02) was observed in the luteal phase compared to the follicular phase while TG (p=0.18), HDL-C (p=0.16). VLDL-C (p=0.17) did not show a significant difference although lower levels were observed in the luteal phase of TG and VLDL-C and higher levels for HDL-C.

CONCLUSION

The present findings reveal high levels of oestrogen in the luteal phase compared to follicular phase of menstrual cycle. Clinicians should take menstrual cycle phase in account when inferring a women biomarker measurement in the analysis of cardiovascular diseases, particularly females possessing marginal levels. Moreover research studies should take the menstrual cycle phase in consideration which may be a confounding factor in framing and concluding studies on reproductive age group women.

Zollinger-Ellison syndrome: an unusual case of chronic diarrhoea in a child

Most cases of Zollinger-Ellison syndrome (ZES) are described in adults. It is a rare disorder in childhood. Most cases present with abdominal pain due to peptic ulceration and chronic diarrhoea not responding to general measures. The symptom complex is initially confused with other more common diseases, which lead to a delay in diagnosis. We present a rare case of a-12-year boy who initially presented with abdominal pain, diarrhoea, vomiting and progressive weight loss for over a two-year period before he was finally diagnosed as a case of ZES with the primary tumour in the pancreatic head and with multiple metastasis in both the liver and lymph nodes.

EspR-dependent ESAT-6 Protein Secretion of Mycobacterium tuberculosis Requires the Presence of Virulence Regulator PhoP

Attenuation of Mycobacterium bovis BCG strain is related to the loss of the RD1-encoded ESX-1 secretion system. The ESX-1 system secretes virulence factor ESAT-6 that plays a critical role in modulation of the host immune system, which is essential for establishment of a productive infection. Previous studies suggest that among the reasons for attenuation of Mycobacterium tuberculosis H37Ra is a mutation in the phoP gene that interferes with the ESX-1 secretion system and inhibits secretion of ESAT-6. Here, we identify a totally different and distinct regulatory mechanism involving PhoP and transcription regulator EspR on transcriptional control of the espACD operon, which is required for ESX-1-dependent ESAT-6 secretion. Although both of these regulators are capable of influencing espACD expression, we show that activation of espACD requires direct recruitment of both PhoP and EspR at the espACD promoter. The most fundamental insights are derived from the inhibition of EspR binding at the espACD regulatory region of the phoP mutant strain because of PhoP-EspR protein-protein interactions. Based on these results, a model is proposed suggesting how PhoP and EspR protein-protein interactions contribute to activation of espACD expression and, in turn, control ESAT-6 secretion, an essential pathogenic determinant of M. tuberculosis Together, these results have significant implications on the mechanism of virulence regulation of M. tuberculosis.

Histological and immunohistochemical study of estrogen and progesterone receptors in normal human breast tissue in adult age groups vulnerable to malignancy

Analysis of receptor status has become standard procedure for assessing breast cancer patients. Estrogen causes epithelial proliferation in breast tissue via the estrogen receptor (ER). The progesterone receptor (PR) is also regulated by the estrogen gene. Analyzing ER and PR together gives information regarding the likely response of carcinoma patients to hormonal therapy. The aim of the present study was to record the expression patterns of ER and PR in normal mammary tissue in different age groups to provide reference data to facilitate histological diagnosis. Breast tissues from the upper outer quadrant of each side of 27 adult female cadavers were examined after H & E staining. ER and PR were identified and examined by immunohistochemistry. The percentage area occupied by parenchyma relative to stromal tissue was calculated in different age groups and was about 4:6, 3.5:6.5, 3:7, 2:8, and 1.5:8.5 in the 3rd, 4th and 5th, 6th, 7th, 8th and 9th, and 10th decades of life, respectively. Both ER and PR were present in all age groups and the numbers of both receptors were maximal during the 4th decade. The distribution and staining patterns for both ER and PR were recorded in different age groups. The contiguous pattern of ER, which is considered pathognomonic of breast carcinoma, was not seen except in one case in the 6th decade. Moderately stained ER and PR receptor sites predominated throughout. The study of normal breast tissue of similar age might provide comparisons that will help histopathologists to make clinical diagnoses from breast biopsies. Clin. Anat. 29:729-737, 2016. © 2016 Wiley Periodicals, Inc.

Flow Cytometric Analysis of Mononuclear Phagocytes in Nondiseased Human Lung and Lung-Draining Lymph Nodes

RATIONALE

The pulmonary mononuclear phagocyte system is a critical host defense mechanism composed of macrophages, monocytes, monocyte-derived cells, and dendritic cells. However, our current characterization of these cells is limited because it is derived largely from animal studies and analysis of human mononuclear phagocytes from blood and small tissue resections around tumors.

OBJECTIVES

Phenotypic and morphologic characterization of mononuclear phagocytes that potentially access inhaled antigens in human lungs.

METHODS

We acquired and analyzed pulmonary mononuclear phagocytes from fully intact nondiseased human lungs (including the major blood vessels and draining lymph nodes) obtained en bloc from 72 individual donors. Differential labeling of hematopoietic cells via intrabronchial and intravenous administration of antibodies within the same lobe was used to identify extravascular tissue-resident mononuclear phagocytes and exclude cells within the vascular lumen. Multiparameter flow cytometry was used to identify mononuclear phagocyte populations among cells labeled by each route of antibody delivery.

MEASUREMENTS AND MAIN RESULTS

We performed a phenotypic analysis of pulmonary mononuclear phagocytes isolated from whole nondiseased human lungs and lung-draining lymph nodes. Five pulmonary mononuclear phagocytes were observed, including macrophages, monocyte-derived cells, and dendritic cells that were phenotypically distinct from cell populations found in blood.

CONCLUSIONS

Different mononuclear phagocytes, particularly dendritic cells, were labeled by intravascular and intrabronchial antibody delivery, countering the notion that tissue and blood mononuclear phagocytes are equivalent systems. Phenotypic descriptions of the mononuclear phagocytes in nondiseased lungs provide a precedent for comparative studies in diseased lungs and potential targets for therapeutics.

Renal Transplantation in the Setting of Prior Urinary Diversion: A Case of Poorly Differentiated Adenocarcinoma in an Ileal Conduit

Though rare, renal transplantation into a bowel containing urinary diversion is necessary in select clinical situations. Compared to renal transplant patients with functional native bladders, patients with urinary diversion have comparable long-term graft and patient survival rates. However, compounding the increased risk of malignancy in those on chronic immunosuppression are the inherent risks of urinary diversion. We present a case report of a high grade adenocarcinoma with neuroendocrine differentiation arising in an ileal conduit and discussion on the pathophysiology, management, and screening of this highly select population.

Effect of pranayama on rate pressure product in mild hypertensives

Context:

The modern living life-style is known to produce various physical and psychological stresses resulting in increased blood pressure (BP) and heart rate (HR). This can lead to increased myocardial oxygen demand (MVO₂). MVO₂ correlated best with rate pressure product (RPP). RPP is a product of HR and systolic BP.

Objective:

The present study was conducted to evaluate the effect of relaxation in the form of pranayama on RPP in mild hypertensives.

Materials and Methods:

Mild hypertensive patients were divided into two groups. Group A received antihypertensive drugs for 6 weeks and Group B received antihypertensive drugs along with pranayama training for 6 weeks.

Results:

BP decreased significantly in Group B (148 ± 8.09-127 ± 12.10 mm of Hg) where pranayama was added. The decrease was significant as compared to Group A. HR decreased significantly in both the groups as compared to baseline, however the decrease was similar in both groups. RPP decreased significantly in both groups as compared to baseline, however the decrease was significantly more (P < 0.01) when pranayama was added to antihypertensive drugs (96.73 ± 20.53) when compared to antihypertensive drugs alone (114.66 ± 26.30).

Conclusion:

The pranayama produces relaxed state and in this state parasympathetic activity overrides sympathetic activity. Hence, addition of pranayama can be a useful addition to antihypertensive drugs for better control of hypertension in mild hypertensives.

Is limitation of hip abduction a useful clinical sign in the diagnosis of developmental dysplasia of the hip?

AIM

The relationship between the presence and severity of sonographically diagnosed developmental dysplasia of the hip (DDH) and the clinical abnormality of limitation of hip abduction (LHA) was investigated.

METHODS

A prospective, longitudinal, selective 'at risk' and neonatal instability hip ultrasound programme between 1 January 1996 and 31 December 2005. 2876 neonates/infants were initially screened for DDH by clinical examination and by hip ultrasound imaging. Pathological sonographically evaluated DDH was considered to be Graf Type III, IV and irreducible hip dislocation. Inclusion criteria were cases of unilateral or bilateral limitation of hip abduction hip.

EXCLUSION CRITERIA

syndromal, neuromuscular and skeletal dysplasia cases.

RESULTS

492 children presented with LHA (55 unilateral LHA). The mean age of neonates/infants with either unilateral or bilateral LHA was significantly higher than those without (p<0.001). In the sonographic diagnosis of Graf Type III and IV dysplasias, unilateral LHA had a PPV of 40% compared with only 0.3% for bilateral LHA. The sensitivity of unilateral LHA increased to 78.3% and a PPV 54.7% after the age of 8 weeks for Graf Types III, IV and irreducible hip dislocation.

CONCLUSIONS

This study identifies a time-dependent association with unilateral LHA in the diagnosis of 'pathological' DDH after the age of 8 weeks. The presence of bilateral LHA in the young infant may be a normal variant and is an inaccurate clinical sign in the diagnosis of pathological DDH. LHA should be actively sought after 8 weeks of age and if present should be followed by a formal ultrasound or radiographic examination to confirm whether or not the hip is developing in a satisfactory manner.

Frontal sinus mucopyelocele with intracranial and intraorbital extension

This case is related to a 52-year-old lady with proptosis, diplopia and diminution of vision due to a mass lesion in upper medial quadrant of the orbit. CT scan revealed a well defined mass in basi-frontal area with intra-orbital and intracranial extension. On exploring it was found to be mucopyocele of the frontal sinus. Surgical excision was done by external approach. The symptoms and signs resolved completely within a week. Frontal sinus mucopyoceles are benign and curable. Early recognition and management of them is of paramount importance because they can expand and cause local, orbital or intracranial complications.

Effectiveness of etoposide chemomobilization in lymphoma patients undergoing auto-SCT

The effectiveness of stem cell mobilization with G-CSF in lymphoma patients is suboptimal. We reviewed our institutional experience using chemomobilization with etoposide (VP-16; 375 mg/m(2) on days +1 and +2) and G-CSF (5 μg/kg twice daily from day +3 through the final day of collection) in 159 patients with lymphoma. This approach resulted in successful mobilization (>2 × 10(6) CD34+ cells collected) in 94% of patients (83% within 4 apheresis sessions). Fifty-seven percent of patients yielded at least 5 × 10(6) cells in 2 days and were defined as good mobilizers. The regimen was safe with a low rate of rehospitalization. Average costs were $14 923 for good mobilizers and $27 044 for poor mobilizers (P<0.05). Using our data, we performed a 'break-even' analysis that demonstrated that adding two doses of Plerixafor to predicted poor mobilizers at the time of first CD34+ cell count would achieve cost neutrality if the frequency of good mobilizers were to increase by 21%, while the frequency of good mobilizers would need to increase by 25% if three doses of Plerixafor were used. We conclude that chemomobilization with etoposide and G-CSF in patients with lymphoma is effective, with future opportunities for cost-neutral improvement using novel agents.

Efficacy of barley based probiotic food mixture in treatment of pathogenic E.coli induced diarrhoea in mice

An indigenous food mixture was developed by mixing barley flour (raw and germinated), whey powder and tomato pulp in the ratio of 2:1:1:1 (w/w). The developed food (100 g) was mixed with water (500 ml) and autoclaved at 1.5 kg/cm(2) for 15 min. It was then cooled and inoculated with Lactobacillus acidophilus curd (5%) and incubated at 37°C for 12 h containing 10(6) cfu/ml broth. Fermented food mixture formulated from germinated barley flour maintained adequate cell viability (8.88 cfu/ml) as compared to non-germinated food mixture. To study the therapeutic effect of the food mixture, diarrhoea was induced in mice using 0.5 ml of aqueous suspension orally with the help of sterilized syringe to each of the overnight fasted mice and the mice were examined till onset of diarrhoea. The aqueous suspension was prepared by using 10 ml of six h old culture of E. coli cells (5 × 10(11) cfu/ml) and 6 ml alkaline solution (powdered chalk (40%), colloidal kaolin (43%) and magnesium trisilicate (17%) and both were mixed in 10:6 (v/v) proportions. After induction of diarrhoea, the mice were divided in two groups, control and experimental. The control group was fed on unfermented food mixture whereas experimental group was fed on fermented food mixture. Faecal ash, nitrogen, moisture and coliform count increased while faecal lactobacilli count decreased in mice having diarrhoea. In the experimental group, which was fed on fermented food mixture, normal values were reached within 7 days of feeding but no such changes were observed in control group which was fed on unfermented food mixture. Liver and kidney showed lesions due to E. coli infection were significantly alleviated on feeding of probiotic food mixture.

Teratoma of the tongue

Teratomas are the benign tumours, which may occur anywhere in the body. Development of these lesions in the oral cavity is extremely rare. In the oral cavity, they usually arise in the midline, in the floor of mouth. Infrequently, they may be seen in the tongue proper. We hereby, present a case of swelling tongue in 56 years female diagnosed as teratoma.

Bronchoscopic management of benign bronchial stenosis by electrocautery and balloon dilatation

Benign bronchial stenosis is managed by surgical or bronchoscopic methods. Although surgical approach is definitive, it is technically demanding and is costlier than bronchoscopic treatment. Here, we report the case of a 27-year-old female patient with symptomatic benign bronchial stenosis of the left main bronchus. The stenosis was dilated successfully through a fibreoptic bronchoscope by electrocautery followed by balloon bronchoplasty and application of mitomycin-C. On follow up, there was no evidence of re-stenosis.

Phosphorylation of PhoP protein plays direct regulatory role in lipid biosynthesis of Mycobacterium tuberculosis

Mycobacterium tuberculosis PhoP is essential for virulence and intracellular growth of the tubercle bacilli. Genetic evidence suggests that PhoP regulates complex lipid biosynthesis, and absence of some of these lipid molecules in a phoP mutant partly accounts for its attenuated growth in macrophages and/or mice. To investigate the mechanism of regulation, here we demonstrate the essentiality of phosphorylation of PhoP in the regulation of complex lipid biosynthesis. We show that phosphorylated PhoP activates transcription of pks2 and msl3, gene(s) encoding polyketide β-ketoacyl synthases through direct DNA binding at the upstream regulatory region(s) of the target genes. Our results identify the genetic determinants recognized by PhoP and show that activation of target genes requires interaction(s) of the phosphorylated regulator at the cognate binding sites. The fact that these sites within the regulatory region of respective genes do not bind in vitro with either unphosphorylated or phosphorylation-deficient PhoP protein is consistent with phosphorylation-dependent assembly of the transcription initiation complex leading to in vivo transcriptional activation. Together, these results reveal so far unknown molecular mechanisms of how PhoP contributes to M. tuberculosis cell wall composition by regulating complex lipid biosynthesis.

Endotracheal Tube Cuff Pressure Monitoring in Peripheral Hospitals

BACKGROUND

An improvised monitor was designed in a peripheral hospital to measure the tracheal tube cuff pressures in patients intubated under anaesthesia. The aim of the study was to assess the efficacy of assessment of cuff pressure by the traditional palpatory method and to compare the improvised monitor with the standard monitor commercially available. The effect of nitrous oxide on the cuff-pressure was also studied.

METHODS

The tracheal tube cuff pressure of 80 patients undergoing general anaesthesia was assessed by palpation and measured with an improvised and standard monitor.

RESULTS

The study showed that the tracheal cuff pressure recorded were higher than normal tracheal perfusion pressure in 40% of the cases with satisfactory palpatory assessment. The pressures recorded by the improvised monitor were comparable to that of the standard monitor. The use of nitrous oxide resulted in increase in cuff pressures over a period of time.

CONCLUSION

An objective measurement by any equipment is superior to assessment of cuff pressure by palpation. The improvised monitor can be used to give a fair idea of the cuff pressures, in places where a standard monitor is not available.

Antenatal maternal hypoxic stress: adaptations of the placental renin-angiotensin system in the mouse

The stress of Antenatal Maternal Hypoxia (AMH) can lead to a number of physiological and pathological changes in both mother and fetus, changes which can be linked to alterations in placental morphology and gene regulation. Recently, in the Brown Norway rat "model" of placental insufficiency, we reported alterations in placental renin-angiotensin system (RAS) genes. Moreover, AMH can lead to reduced oxygen availability to the fetus, similar to a state of placental insufficiency. Thus, in pregnant mice dams we tested the hypothesis that antenatal maternal hypoxic stress leads to alterations in the placental RAS. These alterations may, in part, account for the phenotypic changes in both pregnant mice dams as well as fetus and adult offspring.

METHODS

Pregnant FVB/NJ mice dams were either maintained as controls, or exposed to 10.5% O(2) for 48 h from 15.5 to 17.5 day post coitum. We then measured placental mRNA and protein expression of several RAS genes (n = 4 to 5; P < 0.05 was considered significant).

RESULT

In murine placenta: (1) angiotensinogen (AGT) mRNA was undetectable; however, AGT protein was detectable and increased significantly with AMH. (2) In AMH, although renin mRNA was reduced protein expression increased, in association with decreased microRNA (miRNA) 199b, which can lead to increased renin translation. (3) Also in AMH placenta, angiotensin converting enzyme (ACE) -1 mRNA was unaltered; however, protein expression increased significantly, in association with decreased miRNA 27a, which can result in increased ACE-1 translation. (4) In AMH placenta, ACE-2 mRNA was reduced significantly, whereas protein expression was significantly greater, in association with reduced miRNA 429. (5) In AMH placenta, angiotensin II type (AT) -1a receptor mRNA expression was unaltered while AT-1b receptor mRNA was undetectable in both groups. Moreover, AT-1 receptor protein expression was unchanged in response to AMH. (6) AT-2 receptor mRNA and proteins were undetectable in both groups.

CONCLUSION

The normal murine placenta possesses several components of RAS, and in response to AMH several of these elements undergo important changes. In addition, differential expression of RAS mRNA, miRNA and protein, indicate post-transcriptional regulatory mechanisms involved with hypoxic stress, and necessitate further investigation.

Domain structure of virulence-associated response regulator PhoP of Mycobacterium tuberculosis: role of the linker region in regulator-promoter interaction(s)

The PhoP and PhoR proteins from Mycobacterium tuberculosis form a highly specific two-component system that controls expression of genes involved in complex lipid biosynthesis and regulation of unknown virulence determinants. The several functions of PhoP are apportioned between a C-terminal effector domain (PhoPC) and an N-terminal receiver domain (PhoPN), phosphorylation of which regulates activation of the effector domain. Here we show that PhoPN, on its own, demonstrates PhoR-dependent phosphorylation. PhoPC, the truncated variant bearing the DNA binding domain, binds in vitro to the target site with affinity similar to that of the full-length protein. To complement the finding that residues spanning Met(1) to Arg(138) of PhoP constitute the minimal functional PhoPN, we identified Arg(150) as the first residue of the distal PhoPC domain capable of DNA binding on its own, thereby identifying an interdomain linker. However, coupling of two functional domains together in a single polypeptide chain is essential for phosphorylation-coupled DNA binding by PhoP. We discuss consequences of tethering of two domains on DNA binding and demonstrate that linker length and not individual residues of the newly identified linker plays a critical role in regulating interdomain interactions. Together, these results have implications for the molecular mechanism of transmission of conformation change associated with phosphorylation of PhoP that results in the altered DNA recognition by the C-terminal domain.