Valproate, risperidone, and paliperidone: A case of valproate-induced hyperammonemic encephalopathy

Hyperammonemia is a well-known adverse effect of valproate that can progress to a potentially fatal condition known as valproate-induced hyperammonemic encephalopathy (VHE). VHE is more common when valproate is used in combination therapy with other antiepileptic medications. A growing number of case reports have pointed to a possible interaction with the antipsychotic risperidone leading to an increased risk of VHE. We present a case of VHE in which a 20-year-old male patient with bipolar affective disorder developed VHE when on concomitant valproate, risperidone, and paliperidone palmitate. On the seventh day of treatment with oral risperidone, oral divalproex sodium was added. Intramuscular paliperidone palmitate was initiated on day 13, and oral risperidone was discontinued after the second loading dose on day 16. The following day, the patient displayed worsening psychomotor retardation, swaying gait, drowsiness, and vomiting. The patient was found to have hyperammonemia and transferred to the emergency department for treatment of suspected VHE.

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.

Development of CNT reinforced Al2O3-TiO2 coatings for boiler tubes to improve hot corrosion resistance

This study examines the hot corrosion behaviour of plasma-coated T12 steel for 10 cycles of 100 h each in an industrial boiler. The coating contains CNT (carbon nanotubes) reinforced alumina-titania powders. The substrates were exposed to the boiler at 750 °C. A thermogravimetric examination was conducted to evaluate the kinetics of corrosion. Corroded samples were examined with scanning electron microscopy and x-ray diffraction analysis after the end of the corrosion cycle. This research study concludes that CNT-reinforced coatings provide better corrosion resistance than conventional alumina coatings in the boiler environment.

Preventable iatrogenic cause of foot-drop in knee injuries with literature review

PURPOSE

Common peroneal nerve palsy is quite disabling and every effort should be made to prevent its injury during the treatment.

METHODS

We retrospectively reviewed the prospectively collected data of 7 cases of tibial plateau fractures in association with proximal fibula fracture from January 2019 to September 2019 who presented to emergency room of our hospital.

RESULTS

In addition to fibular neck fracture, the first case had type 6 tibial plateau displaced fracture and the second case had displaced acetabular fracture with instability of knee with tibial tuberosity avulsion. common peroneal nerve palsy developed following application of distal tibial skeletal traction in both the cases. Other 6 such cases remained neurologically intact as traction was not applied to them.

CONCLUSION

Such iatrogenic complication could have been prevented if the injury pattern of "concomitant medial and lateral columns" of the proximal leg is kept in mind by the treating surgeon before applying skeletal traction.

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.

548 Phase 2 study of FLX475 in combination with ipilimumab in advanced melanoma

Background

Regulatory T cells (Treg) can dampen antitumor immune responses in the tumor microenvironment (TME) and have been shown to correlate with poor clinical outcome. Translational studies have demonstrated an accumulation of Treg in tumors after treatment with immunotherapies including CAR-T cells and anti-CTLA-4, which could potentially reflect a mechanism of adaptive immune resistance.1–2 CCR4, the receptor for the chemokines CCL17 and CCL22, is the predominant chemokine receptor on human Treg and is responsible for the migration and accumulation of Treg in the TME. Preclinical studies with orally available CCR4 antagonists have demonstrated potent inhibition of Treg migration into tumors, an increase in the intratumoral Teff/Treg ratio, and antitumor efficacy as a single agent and in combination with checkpoint inhibitors, including anti-CTLA-4.3 In a first-in-human trial conducted in healthy volunteers, the oral CCR4 antagonist FLX475 was demonstrated to be well tolerated with outstanding pharmacokinetic and pharmacodynamic properties.4 An ongoing Phase 1/2 clinical trial of FLX475 is examining the safety and preliminary antitumor activity of FLX475 as monotherapy and in combination with pembrolizumab in subjects with several types of advanced cancer.5 Given the preclinical data demonstrating a significant enhancement of the antitumor activity of anti-CTLA-4 when combined with FLX475, a Phase 2 study investigating the combination of FLX475 and ipilimumab is now being conducted in subjects with advanced melanoma.

Methods

This clinical trial is a Phase 2, multicenter, open-label, single-arm study to determine the antitumor activity of FLX475 in combination with ipilimumab in subjects with advanced melanoma previously treated with an anti-PD-1 or anti-PD-L1 agent. The primary objectives of the study are to evaluate objective response rate, and the safety and tolerability of this combination. The study will first examine the safety of the combination of the 100 mg PO QD recommended Phase 2 dose of FLX475 and the approved 3 mg/kg IV Q3W dose of ipilimumab as part of a safety run-in phase, prior to examining the degree of antitumor activity in approximately 20 subjects. Evidence of an overall response rate (ORR) notably greater than the expected ORR of ipilimumab monotherapy alone in such subjects, which has been shown to be approximately 14%,6 would provide preliminary clinical evidence in support of the clinical hypothesis that CCR4 blockade by FLX475 can significantly enhance the antitumor activity of an anti-CTLA-4 checkpoint inhibitor.

Trial Registration

ClinicalTrials.

gov Identifier: NCT04894994

References

O’Rourke D, Nasrallah M, Desai A, Melenhorst J, Mansfield K, Morrissette J, Martinez-Lage M, Brem S, Maloney E, Shen A, Isaacs R, Mohan S, Plesa G, Lacey S, Navenot J, Zheng Z, Levine B, Okada H, June C, Brogdon J, Maus M. A single dose of peripherally infused EGFRvIII-directed CAR T cells mediates antigen loss and induces adaptive resistance in patients with recurrent glioblastoma. Sci Transl Med 2017;9:eaaa0984. doi: 10.1126/scitranslmed.aaa0984.

Sharma A, Subudhi S, Blando J, Vence L, Wargo J, Allison JP, Ribas A, Sharma P. Anti-CTLA-4 immunotherapy does not deplete FOXP3+ regulatory T cells (Tregs) in human cancers-Response. Clin Cancer Res 2019;25:1233–1238.

Marshall L, Marubayashi S, Jorapur A, Jacobson S, Zibinsky M, Robles O, Hu D, Jackson J, Pookot D, Sanchez J, Brovarney M, Wadsworth A, Chian D, Wustrow D, Kassner P, Cutler G, Wong B, Brockstedt D, Talay O. Tumors establish resistance to immunotherapy by regulating Treg recruitment via CCR4. J Immunother Cancer 2020;8:e000764.

van Marle S, van Hoogdalem E, Johnson D, Okal A, Kassner P, Wustrow D, Ho W, Smith S. Pharmacokinetics, pharmacodynamics, and safety of FLX475, an orally-available, potent, and selective small-molecule antagonist of CCR4, in healthy volunteers. J Immunother Cancer 2018; 6(Suppl 1):P484(SITC 2018).

Powderly J, Chmielowski B, Brahmer J, Piha-Paul S, Bowyer S, LoRusso P, Catenacci D, Wu C, Barve M, Chisamore M, Nasrah N, Johnson D, Ho W. Phase I/II dose-escalation and expansion study of FLX475 alone and in combination with pembrolizumab in advanced cancer. Journal of Clinical Oncology 2020;38(15_suppl): TPS3163 (ASCO 2020).

Long G, Mortier L, Schachter J, Middleton M, Neyns B, Sznol M, Zhou H, Ebbinghaus S, Ibrahim N, Arance A, Ribas A, Blank C and Robert C. Society for Melanoma Research 2016 Congress. Pigment Cell & Melanoma Research 2017;30:76–156.

Ethics Approval

This study has been approved by the Institutional Review Board at each investigational site.

Decreased motion with normal strength after Latarjet procedure has minimal impact on return to activity

PURPOSE

The Latarjet procedure can affect the range of motion (ROM) and strength of the shoulder, which determine the time to return to the preinjury level of activity. This study prospectively assessed whether the Latarjet procedure leads to a decrease in range of motion and muscle strength, affecting the time to return to the previous level of activity.

METHODS

Fifty-one consecutive patients who underwent the Latarjet procedure for recurrent dislocation of the shoulder were included prospectively. The ROM, strength, Walch-Duplay score, and Rowe score were measured every 3 months for 1 year and then every 6 months for 2 years. Radiological assessments were performed to confirm the graft location, union, and the humeral head position in abduction and external rotation (ER).

RESULTS

Out of 51 patients, 49 completed all follow-ups. The median age was 27 years (17-45 years), and the dominant side was involved in 36 patients. The median number of dislocations was 11 (5-50). Twelve patients were sleep dislocators. There was a significant loss (p < 0.0001) of abduction, forward flexion (FF), ER, and internal rotation (IR) in the affected shoulder compared to the contralateral shoulder. Recovery plateaued at 12 months. There was near complete recovery of muscle strength after the Latarjet procedure, and the difference between the affected and contralateral shoulders was not significant (n.s.). The modified Rowe score was excellent in 44 (90%) patients, and the Walch-Duplay score was excellent in 43 patients (88%) at 24 months. Suboptimal results were associated with non-compliance with rehabilitation in two (4%) patients and neglected unreduced dislocation in one (2%) patient. The coracoid graft position was below the equator in 44 patients (90%). Forty-six patients (94%) could return to the previous level of activity.

CONCLUSION

The Latarjet procedure results in a restricted ROM of the shoulder, but there is no loss of muscle strength.

LEVEL OF EVIDENCE

III.

Determination of outcomes of complex upper end tibial fractures in squatting and cross leg sitting South Asian population

INTRODUCTION

Treatment of complex upper end tibial fractures has always been a challenge to orthopaedic surgeons. Though the roentgenogram results are satisfactory, the clinical and functional outcomes especially in terms of squatting/cross-leg sitting after long term follow-up are little known. Hence, we have done this study with a primary aim to assess the clinico-radiological and functional outcomes after operative fixation (mostly by locking plates) in complex upper end tibial fractures and a secondary aim to analyze correlation between functional outcome scores/range of motion (ROM) and the ability to squat & sit cross-legged in post-operative period.

MATERIALS AND METHODS

This prospective study included a total of 33 patients who were mainly treated with locking plates. In the follow-up, patients were assessed clinico-radiologically and outcome measurements were determined using the Tegner-Lysholm (T-L) Knee Score. Patients were categorized according to their ability to squat/sit cross-legged and a subgroup analysis was performed by comparing mean ROM and T-L score in each group.

RESULTS

Majority of patients were in young and adult age group with a male to female ratio of 4.5:1. The average age was 42.39 ±14.64 years. Road traffic accident was the most common mode of injury. Average time interval between injury and surgery was 5.8±4.4 days. All the fractures united by 5-9 months. Mean ROM and T-L score at last follow-up were 120.94°±13.63° and 88.12±7.24 respectively. Average shortening, varus and valgus deformity were 0.43±0.09 cm, 2.12°±0.62° and 1.06°±0.45° respectively. 14 patients (42.42%) were able to squat and 15 (45.45%) were able to sit cross-legged postoperatively. Upon subgroup analysis, difference of mean ROM in those who could squat/sit cross-legged was found statistically significant (p≤0.05), however the difference in mean functional scores was not significant (p≥0.05).

CONCLUSION

Complex upper tibial fractures are a difficult entity to deal with. Anatomical locking plates take care of the alignment, articular congruity as well as ligamentous balancing thus giving good mid-term outcomes after ORIF/MIPO. However, applicability of the present functional outcome scores in assessing squatting/cross leg sitting remains doubtful. More weightage needs to be given to these activities to evaluate the outcome in South Asian population.

Is Revision Bankart Repair with Remplissage a Viable Option for Failed Bankart Repair in Non-contact Sports Person Aiming to Return to Sports?

PURPOSE

Failure of a well-executed Bankart repair in non-contact athletes is difficult to predict and its management is a lesser investigated area with uncertain outcome in terms of return to sports (RTS). This study analyses effectiveness of revision Bankart repair with remplissage for failed Bankart repair in non-contact athletes, focusing on time and level of RTS.

MATERIALS AND METHODS

Fifty-five consecutive non-contact athletes with evidence of instability after primary arthroscopic Bankart repair having glenoid loss < 25% and off-track Hill-Sachs lesion were included in the study according to algorithm mentioned. All cases underwent revision arthroscopic Bankart repair with remplissage and followed-up for 24 months. Rowe, UCLA, WOSI and Quick-DASH scores were recorded preoperative and at 24 months. RTS was allowed after unilateral seated shot-put test.

RESULTS

Out of 55 cases, 6 were excluded because of poor tissue quality, 7 were lost to follow-up. Forty-two cases with a mean age of 28.2 ± 5.2 years were included. Mean duration between primary surgery and failure was 7.3 ± 1.4 months with a mean 1.9 redislocations. The mean Rowe, WOSI, UCLA, Quick-DASH scores improved from 37 to 89, 39.3 to 83.7%, 18.4 to 30.5, 45.3 to 18.7 at 24 months. Thirty-five cases could RTS in a mean time 15.4 ± 1.4 months. Out of seven cases who could not RTS, four had instability, one had pain and two voluntarily quit sports.

CONCLUSION

Revision Bankart repair with remplissage is a feasible option for failed primary Bankart repair in non-contact athletes who have glenoid bone loss < 25% with off-track Hill-Sachs.

LEVEL OF EVIDENCE

Level IV.

Sensitive and Enzyme-Free Glucose Sensor Based on Copper Nanowires/Polyaniline/Reduced Graphene Oxide Nanocomposite Ink

In this paper, we report the preparation and characterization of a sensitive and reusable nonenzymatic glucose (NEG) sensor based on copper nanowires (CuNWs)/polyaniline (PANI)/reduced graphene oxide (rGO) nanocomposite ink. The CuNWs/PANI/rGO nanocomposite ink was prepared by solvothermal mixing of CuNWs, PANI, rGO and binders. The X-ray diffraction (XRD), field emission scanning electron microscopy (FESEM), Fourier Transform Infra-Red (FT-IR) spectroscopy techniques were used to assess the structural and morphological parameters of prepared nanocomposite ink. The cyclic voltammetry (CV) technique was used to estimate the electrochemical behavior of prepared NEG sensor. The structural, morphological and spectroscopy results confirmed the change in morphological and oxidation state of CuNWs to CuO nanostructures as a constituent of nanocomposite ink. The CuO nanostructures supported on PANI/rGO demonstrated good electrochemical stability and great electrocatalytic activity toward glucose oxidation. At a glucose oxidation potential of 0.64V, the prepared NEG sensor exhibited great electrocatalytic ability by offering a high sensitivity of 843.06[Formula: see text]AmM[Formula: see text]cm[Formula: see text] in the linear glucose range 0–4mM with a lower detection limit of 1.6mM. In addition to these outstanding performance characteristics, CuNWs/PANI/rGO nanocomposite ink-based NEG sensor has the advantages of ease of fabrication, low cost and reusability.

Giant Cell Tumor of the Ring Finger Distal Phalanx

Giant cell tumor (GCT) is a benign but locally aggressive neoplasm generally located in the epiphysis and metaphysis of the long bones. Its occurrence in the bones of the hand is rare. Giant cell tumors occurring in the hand account for only 2% of all the GCTs reported. The epimetaphyseal region of short long bones is a common site of GCTs in the hand; however, a phalangeal GCT originating in the distal phalanx is extremely rare. We present the clinical, radiological and histopathological findings of a case of GCT of the distal phalanx of the left ring finger presenting with a fungating mass and treated with en bloc resection by disarticulation of the distal interphalangeal joint.

Unusual Occurrence of Tenosynovial Giant Cell Tumor in Hoffa's Fat Pad: A Potential Differential Diagnosis for Nontraumatic Knee Swelling and Pain

A tenosynovial giant cell tumor (TGCT) is a benign lesion whose presence in Hoffa's pad has rarely been reported. This unique case report discusses a 33-year-old female patient who presented with swelling and pain in her left knee. Clinical and MRI findings were used to make the diagnosis, which was confirmed on a histopathological basis. The patient had a large tumor (5 × 3 × 3 cm) in Hoffa's fat pad, which was diagnosed as TGCT and managed with open resection due to its size. At follow-up after 20 months, the patient was asymptomatic, and there was no local recurrence of the tumor.

2759. Immunogenicity of Inactivated Influenza Vaccines Given Early vs. Late After Pediatric Allogeneic Hematopoietic Cell Transplantation

Background

Pediatric hematopoietic cell transplant (HCT) recipients often fail to have robust responses to influenza (flu) vaccine. We conducted a blinded phase II trial comparing high-dose (HD) trivalent inactivated vaccine (TIV) vs. standard dose (SD) quadrivalent inactivated vaccine (QIV).

Methods

Children 3–17 years old and 3–35 months post-allogeneic HCT were enrolled at 9 centers and randomized to either 2 doses of HD-TIV or SD-QIV during the 2016–2017 flu season. We compared immune responses by hemagglutination inhibition (HAI) from children 3–11 (early) vs. 12–35 (late) months (m) post-HCT to 3 common flu vaccine antigens, irrespective of vaccine type. HAI responses were evaluated at baseline (visit 1), 1 m post dose 1 (visit 2) and dose 2 (visit 3), and 7 m post dose 2 (visit 4). Geometric mean titers (GMT) were adjusted for baseline log-titer values.

Results

Thirty-one children, median age 11 (7–15) years, were enrolled; 17 (55%) were immunized early and 14 (45%) late. Over 50% of patients had a potentially seroprotective (≥1:40) HAI titer at baseline, with no significant difference post-vaccination between early and late subjects. Table 1 compares early vs late subjects with HAI seroconversion (4-fold HAI titer rise). Post dose 1, late subjects, compared with early, had higher rates of seroconversion to all influenza strains. Post dose 2, early subjects, compared with late, had increased seroconversion. Late subjects had higher GMTs for H1N1 post dose 1 and 2, H3N2 after dose 1, and strain B/VIC post dose 1 and 2 (Figure 1). Although immunogenicity waned throughout flu season, higher seroconversion rates and GMT to H3N2 and strain B/VIC were retained in late subjects.

Conclusion

Compared with subjects in early post-HCT group, late post-HCT subjects had better flu vaccine immune responses as noted by higher GMT and HAI seroconversion. However, 2 doses seemed more beneficial in the early post-HCT group. Future analyses are underway, including comparing immunogenicity of HD vs. SD flu vaccine.

Disclosures

Jennifer E. Schuster, MD, Satchel Health: Shareholder Flor M. Munoz, M.D, Biocryst: Grant/Research Support; CDC: Research Grant; Moderna: Other Financial or Material Support, Safety Monitoring Board Member/Chair; NIH: Research Grant; Novavax: Research Grant; UP to Date: Author and Editor - Royalties, Other Financial or Material Support.

Ganglion cyst of Hoffa's fat pad of knee-a rare cause of knee pain and swelling-a case report and literature review

Ganglion cysts around knee joint are uncommon and that from Hoffa's fat pad are even rarer. We present a case of 30 year old male patient with complaint of pain and swelling in left knee joint. Radiograph did not show any bony abnormality. MRI showed large tubulocystic lesion within Hoffa's fat pad which showed low signal intensity on T1-weighted images and high signal intensity on T2-STIR images. Open excision of the lesion was done. Histopathology of the specimen confirmed the diagnosis of the ganglion cyst. In follow-up, patient had asymptomatic left knee with full range of motion and did not show any sign of recurrence. Ganglion cysts from fat pad though very rare but should be considered in differential diagnosis to have an early diagnosis and management. Symptomatic ganglion cyst should be excised by open procedure or arthroscopically depending upon the size and extent of the lesion.

Outcome of children with rhinovirus detection prior to allogeneic hematopoietic cell transplant

Rhinoviruses are commonly detected in symptomatic and asymptomatic children prior to HCT. Unlike pre-HCT detection of other respiratory viruses, it is not known whether RV detection, with or without clinical symptoms, is associated with worse outcomes in children post-HCT. In a retrospective study of children undergoing allogeneic HCT from January 2009 to February 2015, 91 children underwent allogeneic HCT, and 62 children had RPP testing within 30 days pre-HCT. Fifty-six (90%) children had either no pathogen (n = 34, 55%) or single RV detection (n = 22, 35%), which was the most common pathogen identified. Compared with virus negative children, children with pre-HCT RV detection were not more likely to require ventilated support and did not have longer length of stay, higher mortality, or less days alive and out of the hospital within the first 100 days post-HCT. In a secondary analysis of all 56 patients with RPP testing and no pathogen or RV alone detected, the seven children with LRTI had less days alive and out of the hospital within the first 100 days post-HCT compared with the 49 children who were either asymptomatic or had URTI (10 vs 60 days, P = 0.002). In a bootstrapped regression model, presence of LRTI, not RV detection, was significantly associated with decreased days alive and out of the hospital within the first 100 days post-HCT. Thus, pre-HCT detection of RV, without associated LRTI, does not always warrant HCT delay.

Treatment of pediatric plasma cell myeloma type post-transplant lymphoproliferative disorder with modern risk-directed therapy

Post-transplant lymphoproliferative disorder (PTLD) related plasma cell neoplasms are rare in pediatric patients. We report a pediatric liver transplant recipient with plasma cell myeloma type PTLD. Cytogenetics included 1q duplication, associated with poor prognosis in adult multiple myeloma, and t(8;14). High-risk cytogenetics has not been reported in pediatric plasma cell myeloma type PTLD. The patient was treated with bortezomib, dexamethasone, and lenalidomide with subsequent autologous stem cell transplant. He achieved a 6-year remission, demonstrating tolerance to and efficacy of this modern myeloma regimen in a pediatric patient. Unfortunately, he subsequently died from complications of repeat liver transplant.

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.

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.

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.

A case of aripiprazole induced tardive dyskinesia in a neuroleptic-naïve patient with two years of follow up

Tardive dyskinesia (TD) is arguably the most serious and potential irreversible side effect of antipsychotic medication. Traditionally first generation antipsychotics are the neuroleptics considered to have higher risk of TD as compared to second and third generation antipsychotics. Aripiprazole is a third-generation antipsychotic with a novel mechanism of action. Risk of developing TD with use of aripiprazole has been unknown. Recently many cases of aripiprazole associated TD have been reported. A case of 52 year old Caucasian woman is discussed who presented to us with first manic episode. Patient had never been treated with any antipsychotic medication in her life before. During current episode, she was treated with aripiprazole 30 mg/day. During follow up, patient was found to have developed dyskinetic oro-facial movements within 2 months of starting aripiprazole. She was not taking any other antipsychotic/anti-dopaminergic medication at that time. Patient's abnormal oro-facial movements could not be reversed in spite of immediate discontinuation of aripiprazole. Multiple medications are tried over the next 2 years but her movement disorder never remitted. Above case (along with other recent reports) suggest that risk of movement disorder with aripiprazole use could be higher than previously thought. Further studies are required to find out incidence of movement disorder with aripiprazole. Aripiprazole use should be preferably restricted to FDA approved indications. Clinician needs to be very vigilant about emergence of any movement disorder while using aripiprazole, especially in patients with risk factors for TD.

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.