An objective way to predict remission and relapse in Cushing disease using Bayes' theorem of probability

OBJECTIVE

In this study on patients with Cushing disease, post-transsphenoidal surgery (TSS), we attempt to predict the probability of remaining in remission, at least for a year and relapse after that, using Bayes' theorem and the equation of conditional probability. The number of parameters, as well as the weightage of each, is incorporated in this equation.

DESIGN AND METHODS

The study design was a single-centre ambispective study. Ten clinical, biochemical, radiological and histopathological parameters capable of predicting Cushing disease remission were identified. The presence or absence of each parameter was entered as binary numbers. Bayes' theorem was applied, and each patient's probability of remission and relapse was calculated.

RESULTS

A total of 145 patients were included in the study. ROC plot showed a cut-off value of the probability of 0.68, with a sensitivity of 82% (range 73-89%) and a specificity of 94% (range 83-99%) to predict the probability of remission. Eighty-one patients who were in remission at 1 year were followed up for relapse and 23 patients developed relapse of the disease. The Bayes' equation was able to predict relapse in only 3 out of 23 patients.

CONCLUSIONS

Using various parameters, remission of Cushing disease can be predicted by applying Bayes' theorem of conditional probability with a sensitivity and a specificity of 82% and 94%, respectively. This study provided an objective way of predicting remission after TSS and relapse in patients with Cushing disease giving a weightage advantage to every parameter.

Detection of Pre-clinical Involvement of the Second Eye in Viral Acute Retinal Necrosis Using Optical Coherence Tomography

PURPOSE

To report the detection of retinitis in the second eye of a patient with viral acute retinal necrosis (ARN), before the appearance of clinical change, using swept-source optical coherence tomography.

RESULTS

A 63 year-old male developed right-sided varicella-zoster virus (VZV) ARN, confirmed with aqueous sampling. High-dose intravenous aciclovir caused renal impairment and was suspended for two-days. One day later, left eye macular SS-OCT revealed focal retinal thickening and disruption of retinal architecture without clinically detectable retinitis. The patient was asymptomatic. Aqueous sampling was VZV PCR positive. He received bilateral foscarnet injections and renal adjusted dose of aciclovir. The left OCT signs improved with full restoration of retinal layers.

CONCLUSIONS

We report for the first time the use of OCT to detect pre-clinical second eye retinitis during ARN. Prompt diagnosis and combined systemic and intensive local antiviral therapy resulted in a favourable structural and functional outcome.

Effectiveness of Interventional Strategies in Modulating Knowledge and Attitude of Health Care Professionals for Promoting Organ Donation: A Study in Tertiary Care Public Hospital of North India

Objective:

To evaluate the impact of interventional “educational module” on knowledge and attitude regarding organ donation amongst resident doctors and nurses in the Institute of National Importance.

Study Design:

Interventional and prospective.

Methods:

We devised an interactive educational module covering various aspects of organ donation through a series of audiovisual lectures and information booklets. Resident doctors and nurses posted in those areas of the 1948-bedded Postgraduate Institute of Medical Education and Research (PGIMER), where head injury patients were treated and were subject to intervention using this module. The pre and postinterventional scores of their knowledge and attitude regarding organ donation were compared to find out impact of the intervention.

Results:

A total of 242 nurses and 87 resident doctors participated in this research. Higher knowledge score was observed preintervention amongst doctors as compared to nurses. Significant improvement was seen in total knowledge scores of both groups postintervention. Doctors had better scores for the “concept of organ donation,” while nurses were more familiar with “procedures and protocols.” Both had low knowledge about “clinical criteria for brain death” and “legal issues” preintervention which improved significantly postintervention. The positive impact of intervention was also observed on attitude in both categories. A significant impact of intervention was observed on overall propensity of doctors and nurses to promote organ donation, for pledging their own organs and for counseling of the patient/attendants on this cause.

Conclusion:

Scientifically designed educational modules have a promising role in improving awareness and attitude of health care professionals regarding organ donation and their propensity to be prospective donors, effective counselors, and advocates of organ donation.

The Collaborative Ocular Tuberculosis Study (COTS) Consensus (CON) Group Meeting Proceedings

An international, expert led consensus initiative was set up by the Collaborative Ocular Tuberculosis Study (COTS) group to develop systematic, evidence, and experience-based recommendations for the treatment of ocular TB using a modified Delphi technique process. In the first round of Delphi, the group identified clinical scenarios pertinent to ocular TB based on five clinical phenotypes (anterior uveitis, intermediate uveitis, choroiditis, retinal vasculitis, and panuveitis). Using an interactive online questionnaires, guided by background knowledge from published literature, 486 consensus statements for initiating ATT were generated and deliberated amongst 81 global uveitis experts. The median score of five was considered reaching consensus for initiating ATT. The median score of four was tabled for deliberation through Delphi round 2 in a face-to-face meeting. This report describes the methodology adopted and followed through the consensus process, which help elucidate the guidelines for initiating ATT in patients with choroidal TB.

Posterior midline approach for large anterior/anterolateral foramen magnum tumours

The standard surgical approaches described for excision of anterior or anterolaterally placed foramen magnum (FM) tumours are the far lateral approach, the extreme lateral approach and the transoral approach. In general the posterior midline approach is considered not suitable for these lesions. We have operated on 27 patients with benign anterior/anterolaterally placed FM tumours in the last 8 years. Thirteen of these were operated via the posterior midline approach. All these 13 patients had large or giant tumours displacing the cervicomedullary region posteriorly and laterally. This allowed adequate access through this approach with minimal handling of neural tissue. For small lesions, the far lateral approach was used. Most of the patients improved significantly neurologically. We recommend the standard midline posterior approach for large/giant FM tumours as the tumour size itself provides enough working space for the surgeon. For small lesions, the far lateral approach is preferred.

Orbital roof growing fractures: a report of four cases and literature review

Trivial injuries among paediatric patients are usually underestimated. Such injuries may account for delayed problems such as growing fractures of skull vault. Growing fracture of the orbital roof is rarely reported. Four cases of paediatric cranial trauma with growing orbital roof fractures are presented. Three cases required only dural repair, while the fourth patient underwent both duraplasty and cranioplasty, due to a large orbital roof defect. At follow-up, all had satisfactory outcome. Trivial injuries among children should be evaluated with caution. The development of orbital symptomatology should ask for a complete radiological survey. The orbital roof growing fractures are potentially important cause of orbital problems. The dural repair alone, usually provides satisfactory outcome, while calvarial bone graft may be of help in cases with large bony defects. Early diagnosis and management of such cases may prevent permanent neurological deficits.

Decompressive surgery for acute subdural haematoma leading to contralateral extradural haematoma: a report of two casesand review of literature

Development of a contralateral epidural haematoma during or immediately after cranial surgery is a well-described entity. However, in a case of acute subdural haematoma where the brain is usually tense, postoperative development of contralateral extradural haematoma is uncommon. We report two cases of contralateral extradural haematoma after decompressive surgery for acute subdural haematoma. We recommend routine postoperative CT immediately after cranial surgery for head trauma. This would help in timely detection and treatment of such a complication.

Brainstem abscess: the nonsurgical management

The brainstem is an unusual location for a pyogenic abscess. Stereotactic aspiration or microsurgical drainage may be required in antibiotic refractory cases. Prolonged antibiotic therapy, along with symptomatic treatment may provide successful outcome. We report a case of cerebellar and brainstem abscess, managed successfully with prolonged antibiotic administration.

Subgaleal suction drain leading to fatal sagittal sinus haemorrhage

The use of wound drains in surgical practice, very often falls into the realm of habit, rather than science. The utility of a prophylactic drain in surgical wounds may be questionable, but this practice is not uncommon, despite complications. We report a case of fatal haemorrhage from the superior sagittal sinus, due to a closed negative suction drain of the craniotomy wound in an infant operated upon for a growing fracture skull.

Calvarial malignant fibrous histiocytoma

Primary malignant fibrous histiocytoma (MFH) of the central nervous system (CNS) is uncommon. We report cases of two young patients of MFH arising from the cranial meninges and involving the adjacent skull and scalp. There was infiltration of the brain in one case. Both the lesions were excised and primary scalp repair was performed.

Vertebral cryptococcosis simulating tuberculosis

Infection with the fungus Cryptococcus neoformans is seen predominantly in two forms: (a) pulmonary and (b) cerebromeningeal. Skeletal cryptococcosis is uncommon. There have been only occasional case reports of thoracic vertebral cryptococcosis presenting as cord compression. A young female had cervical lymphadenopathy diagnosed as tuberculosis by fine needle aspiration cytology (FNAC) and was on antitubercular therapy (ATT) for 5 months. She developed rapidly progressive paraparesis and imaging demonstrated a destructive vertebral body lesion involving T2-3 with a paraspinal abscess producing cord compression. A costotransversectomy with excision of the diseased bone and bone grafting was done. Histopathological examination revealed cryptococcosis. The patient was put on antifungal medication, but expired 2 weeks after surgery. Radiological, magnetic resonance imaging and surgical finding of vertebral cryptococcosis can mimic tuberculosis. The definite diagnosis of cryptococcosis depends upon microscopic identification of the organism. A high index of suspicion leading to early surgical confirmation and institution of anti fungal therapy is necessary to reduce the mortality and morbidity.

Raised intracranial pressure in hepatic encephalopathy

Intracranial hypertension secondary to cerebral edema is the cause of death in 50%-80% of patients with fulminant hepatic failure (FHF). This is rarely seen in chronic hepatic failure. The genesis of cerebral edema in FHF is poorly understood. The grade of encephalopathy and coagulopathy are the most important predictors of outcome in FHF. However, it is important to emphasize that intracranial pressure (ICP) may not reflect clinical course. Decerebrate posturing may be seen with ICP recording of 16 mmHg, while a quarter of the patients may have brain damage without clinical signs of raised ICP. ICP monitoring is therefore vital. The gold standard for ICP monitoring is the intraventricular method. Non-invasive methods like computerized tomography scan and magnetic resonance imaging have poor correlation with ICP. Other methods like transcranial Doppler and jugular venous oximetry measurement of brain metabolites need evaluation. The main indications for ICP monitoring in FHF are (a) patients in grade III or IV encephalopathy and (b) patients undergoing liver transplantation. Generally, patients with an ICP >40 mmHg with cerebral perfusion pressure <50 mmHg for over 2 hours are poor subjects for liver transplant.

Recurrent intramedullary cervical ependymal cyst

We report a rare case of high cervical intramedullary ependymal cyst in a young boy. This was associated with atlantoaxial dislocation. After partial removal and marsupialization, the cyst recurred and needed radical total resection.

Traumatic subarachnoid haemorrhage: a clinicoradiological and TCD correlation

Twenty five consecutive patients with CT proven pure traumatic subarachnoid haemorrhage (tSAH) were studied, prospectively over a 6 month period. They constituted 2% of all head injuries. Most of the patients (88%) had a mild or moderate head injury at the time of admission, with a mean glasgow comma scale (GCS) of 10.68. The CT scan findings were divided into 3 grades. Grade 1 - blood in hemispheric region only (n=4), grade 2 - blood in basal region only (n=11), grade 3 - blood in both hemispheric as well as basal region (n=10). Transcranial doppler ultrasound (TCD) velocities were recorded in all patients by insonating the middle cerebral artery, internal carotid artery and anterior cerebral artery on both sides. All patients were also subjected to digital substraction angiography (DSA). All patients with mild head injury had normal TCD velocity (<100 cm/sec), while TCD velocities of more than 150 cm/sec were seen only in one patient with severe head injury. Patients with severe head injury were found to have grade 3 tSAH on CT. No statistically significant correlation was found between the CT grade and TCD velocities. Angiographic vasospasm was found in 2 patients with severe head injury only. 90.2% of patients had good outcome at discharge.

Fatal posterior fossa pneumocephalus due to hydrogen peroxide irrigation of lumbar wound

Fatal brain stem failure developed suddenly in a 40-year-old male undergoing irrigation of an infected wound consequent to lumbar disc space infection. CT of head revealed posterior fossa pneumacephalus compressing the brain stem, which most likely developed from ingress of nascent oxygen under pressure through a defect in the thecal sac.

Housing status and health care service utilization among low-income persons with HIV/AIDS

OBJECTIVE

To examine the impact of housing status on health service utilization patterns in low-income HIV-infected adults.

DESIGN

A survey of 1,445 HIV-infected Medicaid recipients in New York State between April 1996 and March 1997.

MAIN RESULTS

Six percent of study participants were homeless, 24.5% were "doubled-up," and 69.5% were stably housed. Compared with the stably housed, doubled-up and homeless participants were less likely to be seeing a physician regularly (P = .0001), and if seeing a physician, they were likely to have been doing so for a significantly shorter time (P = .02). The homeless were also less likely than either stably housed or doubled-up individuals to see the same physician or group of physicians at each ambulatory visit (P = .007). In addition, a higher proportion of the homeless had made one or more hospital visits over the prior 3 months than the nonhomeless. After multivariate adjustment, doubled-up participants were found to make more emergency room visits, the homeless were less likely to be taking prophylaxis for Pneumocystis carinii pneumonia, and both the doubled-up and the homeless were shown to use slightly more outpatient care than the stably housed.

CONCLUSION

Our study documents differences in health care utilization patterns across stably housed, doubled-up, and homeless HIV-infected persons after controlling for health insurance coverage. These differences, especially those pertaining to outpatient services, suggest that the unstably housed may be receiving less adequate health care than the stably housed, and hence may be more likely to experience adverse clinical outcomes.

Use of midline catheters in low birth weight infants

Prolonged intravenous access is an important consideration in the treatment of premature neonates. Because peripheral intravenous catheters have short dwell times, centrally positioned percutaneous catheters have been used increasingly in neonatal intensive care. Midline catheters are peripherally inserted long catheters advanced only to the proximal portion of a limb or to the neck, with the tip remaining outside the thoracic and abdominal cavities. Midline catheters were placed with use of an innovative technique via a 24-gauge Angiocath catheter (Becton Dickinson, Sandy, Utah). This study compared dwell time and reason for removal of midline catheters with respective data for peripheral intravenous catheters. Dwell time was found to be 9.0 +/- 1.4 days for the midline catheters versus 3.1 +/- 0.5 days for peripheral intravenous catheters placed in the same patients (p < 0.05). No significant complications occurred with the use of midline catheters. These data suggest that midline catheters may be useful in neonates who require a limited duration of intravenous therapy.

Tumors of the bladder, kidney, and intestine of F344 rats and liver of B6C3F1 mice administered o-nitroanisole in feed

o-Nitroanisole, a mutagenic intermediate used in the manufacture of azo dyes, was administered in feed for 2 years at concentrations of 0, 222, 666, or 2000 ppm to groups of 60 male and 60 female F344 rats. No significant increase in neoplasms occurred in these groups of rats. Additional (stop exposure) groups of 60 male and 60 female F344 rats received diets containing 0, 6000, or 18,000 ppm for 27 weeks followed by maintenance on control diets for up to an additional 77 weeks. Survival of the stop exposure groups was reduced because of the development of chemical related neoplasms of the urinary bladder. After 13, 28, 40, and 65 weeks on study, 10 rats per group were necropsied and evaluated for the presence of chemical associated lesions. Hyperplasia of the epithelium of the urinary bladder was significantly increased at all interim evaluations. A transitional cell carcinoma was observed at the 13-week evaluation in one male rat that received 18,000 ppm and thereafter transitional cell neoplasms of the bladder were present in male and female rats at each interim evaluation. Adenomatous polyps of the large intestine were significantly increased in groups that received 6000 or 18,000 ppm. In addition carcinomas of the large intestine were present in four males and two females that received 18,000 ppm. Hyperplasia of the transitional epithelium of the renal pelvis was significantly increased in groups of rats that received 6000 or 18,000 ppm and transitional cell papillomas were observed in three males and one female that received 18,000 ppm. Transitional cell carcinomas of the kidney occurred in one male that received 6000 ppm and six males and one female that received 18,000. Groups of 60 male and 60 female B6C3F1 mice received dietary concentrations of 0, 666, 2000, or 6000 ppm o-nitroanisole for 2 years. No stop exposure study was conducted with mice. The only neoplastic response observed in mice was in the liver of males; hepatocellular adenomas or carcinomas were increased in groups of male mice that received 2000 or 6000 ppm. No increase in neoplasms associated with chemical exposure occurred in female mice.

Respiratory burst in peritoneal exudate cells in response to a modified tuftsin

Intraperitoneal administration of tuftsin-M [Thr-Lys-Pro-Arg-NH-(CH2)2-NH-CO-C15H31] to Balb/C mice has been shown to induce a respiratory burst in the peritoneal exudate cells. The macrophages exhibited enhanced levels of O2-, H2O2, NADPH oxidase and myeloperoxidase, but the activities of superoxide dismutase, catalase and glutathione peroxidase remained virtually unchanged. The magnitude of the oxidative burst depended directly on the dose of tuftsin-M; higher activity was observed at higher doses of the peptide. Tuftsin-M enhanced the generation of both O2- and H2O2 under in vitro conditions, as did phorbol myristate acetate. These results suggest that tuftsin-M could enhance non-specific defence against infections by activating the macrophages.

Duodenal atresia presenting as hematemesis in a premature infant with Down syndrome. Case report and review of the literature

Congenital duodenal obstruction, a common complication of Down syndrome, most often presents as neonatal bilious vomiting. We report the first premature infant with Down syndrome whose duodenal atresia presented with a massive hematemesis secondary to duodenitis. Since a plain radiograph of the abdomen is diagnostic in the case of duodenal obstruction, it should be included in the diagnostic workup of hematemesis in newborn infants.

Characterization of specific insulin binding sites in rat testis following induced diabetes and experimental starvation

The presence of insulin-saturable binding sites in the rat testis have been demonstrated. Employing radioreceptor assay (RRA), the characteristics of insulin binding in both liver and testis of the normal (control) rats have been studied. Crude receptor binding at 37 degrees C after 18-20 hrs of incubation in Tris-HCl buffer at pH-7.5. The binding of 125I-insulin to liver and testis of the experimental rats, rendered diabetic for two months with single parenteral streptozotocin (STZ) administration (65 mg/Kg, BW, ip) was also studied. In the diabetic rats, the insulin binding in liver as compared to the control increased by over 92% (P 0.001); the increase in the binding of 125I-insulin to the testis of the diabetic rats however was not statistically significant. Similarly, insulin binding to the testis did not vary much after 3 days of starvation as against 84% (P 0.001) increase in the insulin binding to the liver of the fasted rats. These results suggest that testicular insulin receptors are similar to those of liver but may have a different physiological control.

Nonenzymatic synthesis of delta-aminolevulinate (ALA) by cobalt (Co++)

Cobalt, a metal known to modulate the heme biosynthetic enzymes, is shown to be capable of catalysing the formation of ALA through a transamination reaction. The transamination reaction follows a double-displacement reaction kinetics. Further, it has also been shown that the product of the reaction catalysed by cobalt can be used by the enzyme ALA dehydratase as the substrate in the formation of porphobilinogen. The formation of ALA by cobalt can be inhibited by the intermediates of the heme biosynthetic pathway, mainly protoporphyrin. Heme, on the other hand, does not have any effect on the reaction at all concentrations tested.

Induction of L-alanine:4,5-dioxovalerate transaminase by phenylhydrazine is associated with depletion of heme level

The hemin regulation of L-alanine:4,5-dioxovalerate transaminase, the enzyme proposed for an alternate route of delta-aminolevulinic acid (ALA) biosynthesis in mammalian system was studied in different conditions: phenylhydrazine induced anemia, polycythemia by erythropoietin to anemic rats, treatment with cobalt chloride, a porphyrogenic drug. The activity of L- alanine:4,5-dioxovalerate transaminase in liver and kidney is stimulated in phenylhydrazine, whereas, erythropoietin injection to anemic rats prevents such stimulation. Further treatment with cobalt chloride to erythropoietin treated anemic rats stimulates the enzyme activity. Actinomycin D, however, inhibits the stimulation of L-alanine:4,5-dioxovalerate transaminase by phenylhydrazine suggesting that induction is at the level of transcription. Induced level of this enzyme in anemic condition was estimated quantitatively by radial immunodiffusion using antibody raised against L-alanine:4,5-dioxovalerate transaminase. Moreover, our studies reveal that stimulation of L-alanine:4,5-dioxovalerate transaminase in anemic condition is dependent on depletion of heme level. The regulatory role of intracellular heme pool on the induction of this enzyme suggests its physiological importance in heme biosynthesis.