Goblet Cell Adenocarcinoma With Heterotopic Ossification: A Rare Case Report and Review of Literature

Heterotopic bone formation is a rare phenomenon when associated with gastrointestinal neoplasms. Here we present a rare case of heterotopic ossification associated with goblet cell adenocarcinoma of the appendix, and a literature review of such cases associated with neoplasms within and out of the gastrointestinal tracts. We reviewed the clinical data and when available, immunohistochemical markers of osteoblastic differentiation. Our review shows similar findings to prior reports of apparent high association of heterotopic bone formation with neoplasms with mucinous features. Two, previously proposed main hypotheses of the mechanisms are reviewed. The unique feature about this case is that goblet cell adenocarcinoma was not reported previously in the setting of bone formation.

Early clinical exposure through a vertical integration programme in physiology

Background

Early clinical exposure is likely to be beneficial during the preclinical year. This pilot programme aimed to define a learning framework of introducing first year medical students to early clinical exposure through a vertical integration programme in the physiology course. The intent was to enhance the understanding of theoretical concepts and practical applications of physiology. Student and faculty perceptions were evaluated.

Methods

First year MBBS students (n = 60) had bedside clinics conducted by 5 clinical departments, where the clinical context and applied physiological concepts were emphasized. Clinical sessions were synchronized with pedagogic highlights on related physiological concepts. The student's perceptions were recorded through a semi-structured questionnaire, while qualitative feedback was obtained from the faculty.

Results

All students ( 100%) reported that the programme was relevant and did not interfere with their physiology course. Most (91%) appreciated the synchronization of classroom knowledge with clinical exposures, and thought that integrated teaching helped in better understanding of practical applications of physiology (94%) with adequate discussions during the sessions (91 %). Fifty-nine (98%) students preferred integrated teaching over the isolated traditional classroom teaching. The clinicians involved also felt that the early clinical exposure was relevant. The students achieved a mean (SD) score of 13 (2.98) of 25 in the quiz consisting of multiple-choice questions that attempted to test their learning through early clinical exposures.

Conclusion

This pilot exercise showed the utility of early clinical exposure integrated into the physiology course. It will be worthwhile to replicate this exercise at other institutions and among a larger student strength.

Bis(arylmethyl)-substituted unsymmetrical phosphites for the synthesis of lipidated peptides via Staudinger-phosphite reactions

With this study we introduce new unsymmetrical phosphites to obtain lipidated peptide-conjugates starting from easily accessible azide-modified amino acid or peptide precursors.

Post-exposure prophylaxis against rabies at two newly designated intradermal rabies vaccination clinics in Kerala, India

BACKGROUND

The two-site intradermal rabies vaccination (IDRV) regimen was recently introduced in Kerala. We aimed to determine factors associated with exposure of category III severity among patients seeking prophylaxis against rabies at IDRV clinics.

METHODS

This hospital-based, cross-sectional study was done at two clinics in Thiruvananthapuram district, Kerala. Data were collected using a semi-structured questionnaire by direct interview and 320 patients were included. Bivariate analysis of quantitative variables was done using t-test and that of qualitative variables using chi-square test.

RESULTS

The mean (standard deviation) age of patients was 32.4 (19.6) years. Among the 320 cases, 202 (63.1%) had category III exposure. Lower extremities were the most frequent site of exposure (146, 45.6%). The most frequent mode of exposure was being bitten by an animal (214, 66.9%), often a dog. Residence in rural areas, exposure to dogs and wounds on the extremities had a significant association with severity of exposure.

CONCLUSION

Animal exposures were more among people from rural areas. About two-thirds of exposures which necessitated post-exposure prophylaxis were category III.

Patients accessing HIV treatment via sexual health services: what are the risks of the dual case-note system?

In many British hospitals, HIV-positive patients access care via genitourinary (GU) medicine services. As a result of National Health Service (NHS) legislation, such patients may have information concerning HIV treatment filed separately from their general clinical records. We sought to evaluate accuracy of medication records of patients with both GU medicine and general hospital case-notes, and to assess clinical risk arising from incorrect or incomplete recording. In this retrospective review, 156 episodes of care from 100 HIV-positive patients with separate HIV case-notes were evaluated for accuracy of medication recording, when paired with clinical notes from attendances in other hospital departments. Discrepancies were observed in 52.6% of care episodes; significant discrepancies were apparent in 7.8%. The dual case-note system represents significant risk to patient care. We recommend that hospitals that continue to operate this system urgently consider amalgamation of HIV care records into hospital case sheets, in line with current national standards.

Search for a vectorlike quark with charge 2/3 in t+Z events from pp collisions at √s=7 TeV

A search for pair-produced heavy vectorlike charge-2/3 quarks, T, in pp collisions at a center-of-mass energy of 7 TeV, is performed with the CMS detector at the LHC. Events consistent with the flavor-changing-neutral-current decay of a T quark to a top quark and a Z boson are selected by requiring two leptons from the Z-boson decay, as well as an additional isolated charged lepton. In a data sample corresponding to an integrated luminosity of 1.14  fb(-1), the number of observed events is found to be consistent with the standard model background prediction. Assuming a branching fraction of 100% for the decay T→tZ, a T quark with a mass less than 475  GeV/c(2) is excluded at the 95% confidence level.

Search for supersymmetry at the LHC in events with jets and missing transverse energy

A search for events with jets and missing transverse energy is performed in a data sample of pp collisions collected at √s=7 TeV by the CMS experiment at the LHC. The analyzed data sample corresponds to an integrated luminosity of 1.14 fb(-1). In this search, a kinematic variable α(T) is used as the main discriminator between events with genuine and misreconstructed missing transverse energy. No excess of events over the standard model expectation is found. Exclusion limits in the parameter space of the constrained minimal supersymmetric extension of the standard model are set. In this model, squark masses below 1.1 TeV are excluded at 95% C.L. Gluino masses below 1.1 TeV are also ruled out at 95% C.L. for values of the universal scalar mass parameter below 500 GeV.

Shortening the voiding interval for men having chlamydia nucleic acid amplification tests

Male patients are assessed for a sexually transmitted infection provided a considerable length of time has elapsed since last micturition. The current availability of highly sensitive nucleic acid amplification tests (NAATs) for Chlamydia trachomatis (CT) and Neisseria gonorrhoea such as APTIMA Combo2 (AC2) led us to investigate the impact of voiding interval on the positivity of urine tests for CT. Male patients attending a genitourinary medicine clinic at high clinical risk for CT infection and known CT positives returning for treatment were included. Two first-void urine (FVU) specimens were collected: the first sample in the standard manner and the second sample was collected 20 minutes later or as soon as possible thereafter. Fifty-two CT-positive males were included in the analysis. All of the second samples were also CT positive and none were in the equivocal range. Paired t-test analysis did not show a significant difference between relative light unit readings of the first and second urine samples (P = 0.127). Even in male patients who have recently passed urine, FVU tested by AC2 can still reliably detect CT. This provides us opportunity for more flexible and effective patient management.

Cryptococcal meningitis: clinical, diagnostic and therapeutic overviews

Cryptococcal meningitis has emerged as a leading cause of infectious morbidity and mortality in patients with AIDS. Among the human immunodeficiency virus (HIV)-seropositive subjects, cryptococcal meningitis is the second most common cause of opportunistic neuro-infection. Current trends are changing due to the marked improvement of quality and length of life produced by highly active antiretroviral therapy (HAART). The introduction of generic HAART in India has resulted in an increase in the number of individuals getting treatment for HIV infection, as the cost of highly active antiretroviral therapy (HAART) has decreased 20- fold. Cryptococcal meningitis occurs in non-HIV patients who are immunodeficient due to diabetes, cancer, solid organ transplants, chemotherapeutic drugs, hematological malignancies etc and rarely in healthy individuals with no obvious predisposing factors. Diagnosis of cryptococcal meningitis is fairly straightforward once the diagnosis is considered in the differential diagnosis of chronic meningitis. Treatment of a patient with cryptococcal infection is a challenge for both the physician and the patient, but rewarding, as many would recover with timely and adequate antifungal therapy.

A Comparative Investigation of Surface Modification of Carbon Black and Silica by Plasma Polymerization

Carbon black and silica are widely used active fillers in the rubber industry to improve the physical and dynamic properties of rubbers. The surface energy difference between rubbers and these active fillers is large, which has a negative influence on the stability of their dispersion in the rubber matrix and on the distribution in blends of different rubbers. Reduction of the surface energy of carbon black and silica is aimed for by modifying their surfaces. Plasma polymerization is utilized to modify the surface of carbon black and silica by depositing a thin film over its surface. The modified fillers are characterized using thermogravimetric analysis (TGA), x-ray photoelectron spectroscopy (XPS) and time of flight secondary ion mass spectroscopy (ToF-SIMS). The studies show that carbon black and silica behave differently towards surface modification by plasma polymerization. The difference in behavior of carbon black and silica is related to the availability of active sites on their surface during exposure to the plasma atmosphere. In this paper the mechanistic aspects of surface modification by plasma polymerization are also discussed.

Subclinical hypothyroidism, arterial stiffness, and myocardial reserve

CONTEXT

Subclinical hypothyroidism (SCH) is associated with increased risk of cardiac disease; its impact on arterial function is less clear.

OBJECTIVE

The objective of the study was the assessment of arterial and cardiac function.

DESIGN

The study was a 6-month controlled observational study using pulse wave analysis and tissue Doppler dobutamine stress echocardiography.

SETTING

The study was conducted at a thyroid clinic.

PATIENTS

Nineteen female SCH patients with raised TSH, normal free T(4), and no cardiovascular disease [aged 49.2 +/- 3.8 yr; body mass index (BMI) 29.9 +/- 6.7 kg/m(2)] were recruited from the thyroid clinic, and 10 female controls (aged 50.2 +/- 3.4 yr; BMI 29.7 +/- 7.2 kg/m(2)) also participated in the study.

INTERVENTIONS

Incremental doses of l-thyroxine were used.

MAIN OUTCOME MEASURES

Indices of vascular stiffness and left ventricular echocardiographic function were measured.

RESULTS

Baseline augmentation gradient was elevated in SCH, compared with controls [10.3 +/- 5.1 (sd) mm Hg vs. 8.0 +/- 4.2, P < 0.05]; when euthyroid (mean T(4) dose 114 mug/d), it fell to 8.8 +/- 5.3 mm Hg (P < 0.05). Heart rate-corrected augmentation index was 26.7 +/- 9.9 vs. 18.8 +/- 9.9% (P < 0.02), falling to 19.7 +/- 9.6% (P < 0.001) after treatment. Time of travel of the reflected wave was 139.3 +/- 11.7 msec, compared with 141.5 +/- 8.8 msec in controls (P < 0.05), increasing to 144.9 +/- 11.9 msec (P < 0.05). There were no differences in resting global, regional left ventricular function, or regional myocardial velocities during maximal dobutamine stress between SCH patients and controls, or in treated patients, compared with baseline.

CONCLUSIONS

Arterial stiffness was increased in SCH and improved with l-thyroxine, which may be beneficial, whereas myocardial functional reserve was similar to controls and remained unaltered after treatment.

Spontaneous tumour lysis syndrome associated with non-Hodgkin's lymphoma--a case report

Spontaneous tumour lysis syndrome is characterized by hyperuricemia, hyperkalemia, hyperphosphatemia, metabolic acidosis and hypocalcemia, that occur even prior to the treatment of a neoplasm. This rare occurrence was encountered in a patient with non-Hodgkin's lymphoma (NHL), of follicular cell type. Conservative but intensive treatment led to complete resolution. Subsequent chemotherapy was well tolerated.

Candida tropicalis causing Prosthetic Valve Endocarditis

The incidence of endocarditis produced by the so-called "opportunists" as a complication of prosthetic valve surgery is progressively increasing in frequency and gradually transforming the clinical picture habitually associated with this disease. Candida endocarditis is an unusual but severe complication caused by Candida albicans or other fungal species. This case and a review of the literature indicate that Candida endocarditis treated with amphotericin B and prosthetic valve replacement may recur months after treatment, and that late recurrent Candida endocarditis, which is difficult to diagnose and treat, may be best prevented by lifelong antifungal suppressive therapy.

Neurological manifestations of Ehlers-Danlos syndrome

Ehlers-Danlos Syndrome (EDS) is more identified for its cutaneous features but its neurological manifestations have not received the focused attention. Four patients of Ehlers-Danlos Syndrome (EDS) with neurological manifestations were evaluated for phenotypic data. These four men were from three families and two had consanguineous parentage. The mean age at onset and presentation of neurological symptoms were 10.5 years and 19 years respectively. Patient 1 presented with bilateral optic atrophy, sensorineural deafness, cerebellar ataxia and neuropathy. Patient 2 had marfanoid habitus, chorea and cerebellar ataxia. Patient 3 had action and percussion myotonia, wasting and weakness of sternocleidomastoid and distal limb muscles. Patient 4 had action myotonia, mirror movements of both hands and neuropathy. MRI of brain showed right parietal polymicrogyria. Neuroaxis involvement at multiple levels in EDS may have prognostic significance.

Protocol core needle biopsy and histological chronic allograft damage index as surrogate endpoint for Long-Term graft survival

Following encouraging results from several single-center studies showing that early histological manifestations of chronic rejection are seen in the graft before a decline in transplant function, we tested this concept in a multicenter study and investigated whether protocol needle biopsy may be used as a surrogate to late graft survival in multicenter renal transplantation trials. During two mycophenolate mofetil trials, 621 representative protocol biopsies were obtained at baseline, 1 year, and 3 years. The samples were coded and evaluated blindly by two pathologists and a Chronic Allograft Damage Index (CADI) score was constructed. At 1 year only 20% of patients had elevated (>1.5 mg/100 mL) serum creatinine, whereas 60% of the biopsies demonstrated an elevated (>2.0) CADI score. The mean CADI score at baseline, 1.3 +/- 1.1, increased to 3.3 +/- 1.8 at 1 year and to 4.1 +/- 2.2 at 3 years. The patients at 1 year were divided into 3 groups, those with CADI <2, between 2 and 3.9, and >4.0, the first two groups having normal (1.4 +/- 0.3 and 1.5 +/- 0.6 mg/dL) and the third group pathological (1.9 +/- 0.8 mg/dL) levels of serum creatinine. At 3 years there were no lost grafts in the "low" CADI group, six lost grafts (4.6%) in the "elevated" CADI group, and 17 lost grafts (16.7%) in the "high" CADI group (P <.001). One-year histological CADI score predicts graft survival even when the graft function is still normal. This observation makes it possible to use CADI as a surrogate endpoint in prevention trials and to identify the patients at risk for intervention trials.

Unexpected presentations--four cases of lead poisoning

OBJECTIVE

To describe the clinical presentation and response to treatment of four patients who presented with abdominal pain and were diagnosed to have lead poisoning.

METHODS

After ruling out the more obvious causes of abdominal pain by barium studies, gastrointestinal endoscopies, and biochemical studies, blood lead levels were estimated by atomic absorption spectrophotometry. The patients were treated with oral d-penicillamine.

RESULTS

The four patients had blood lead levels from 79 microg/dL to 365 microg/dL. All four of them showed marked improvement in their clinical condition and lowering of blood lead levels on follow up.

CONCLUSIONS

Clinicians need to develop a high index of suspicion of lead poisoning as a possible cause of unexplained abdominal pain or altered sensorium, especially against a background of environmental lead contamination in India.

A comparative study of the intestinal parasites prevalent among children living in rural and urban settings in and around Chennai

A comparative analysis of the various intestinal parasites detected among children attending schools was carried out in a rural and urban location in and around Chennai. A total of 324 stool samples were examined by routine microscopy using normal saline and Lugol's iodine preparation as well as by saturated sodium chloride flotation technique. All suspicious samples were subjected to zinc sulphate concentration technique as well as modified Ziehl Neelson stain and Trichrome stains to identify the other uncommon intestinal parasites. Out of 125 specimens tested from the rural location, the overall prevalence of intestinal parasites was 91%. Ascaris lumbricoides was the most common helminthic parasite detected (52.8%) followed by Trichuris trichura (45.6%), Ancylostoma duodenale (37.6%), Strongyloides stercoralis (3.2%) and Hymenolepis nana (1.6%). Giardia lamblia was the most common protozoan parasite detected (16%), followed by Entamoeba histolytica (4%). In contrast under urban settings, out of the 199 stool specimens tested the positivity rate was 33%. Giardia was the most common parasite detected (22.6%) followed by Entamoeba histolytica (10.6%). All other intestinal parasites such as T. trichura (2.01%), H. nana (1.01%) and A. lumbricoides (0.50%) were found to have much lower prevalence in comparison to the rural area tested. Enterobius vermicularis (0.50%) was also detected. Ancylostoma duodenale and Strongyloides stercoralis were not encountered at all in the urban setting studied.

Acid-catalyzed isomerization of pivalaldehyde to methyl isopropyl ketone via a reactive protosolvated carboxonium ion intermediate

Quantitative rearrangement of pivalaldehyde to methyl isopropyl ketone is observed in acids such as trifluoromethanesulfonic acid, anhydrous HF, and trifluoroethyl alcohol-BF3 but not in trifluoroacetic acid. Studies in a mixture of trifluoroacetic acid and trifluoromethanesulfonic acid show that acids with H(o) < or = -11 are able to carry out complete isomerization. These results and density functional theory calculations at the B3LYP/6-31G level suggest that protonated pivalaldehyde undergoes further protosolvation at higher acidities to a reactive superelectrophilic species resulting in rearrangement. A mechanism for the pivalaldehyde rearrangement to methyl isopropyl ketone in strong protic acids involving a reactive protosolvated superelectrophilic intermediate is suggested. Aspects of the related mechanism of the reaction with isobutane with CO in HF/BF3 medium leading to methyl isopropyl ketone are also discussed.

Streptococcus agalactiae endocarditis

Streptococcus agalactiae (S. agalactiae) is a rare cause of infective endocarditis, which is associated with a high mortality rate. Endocarditis in adults is generally related to immunocompromised states. We hereby report the case of a 35 year old man who presented with fever and delirium in whom aortic valve endocarditis due to S. agalactiae was detected. Though most patients with S. agalactiae endocarditis need surgical intervention along with antibiotics, our patient improved with medical therapy alone.

Nafion-H catalysed sulfonylation of aromatics with arene/alkenesulfonic acids for the preparation of sulfones1a

Synthesis of both symmetric and unsymmetric diaryl/aryl alkyl sulfones is easily achieved by Friedel-Crafts type sulfonylation of aromatics with suitable arene- or alkane-sulfonic acids in the presence of Nafion-H, a perfluorinated resinsulfonic acid catalyst.

Rapid identification of fluconazole resistance using Chrom agar Candida

All though extremely rare 10 years ago, antifungal drug resistance is becoming a major problem in certain populations, especially in those infected with HIV. This study was undertaken to study the resistance of Candida species isolated in our hospital to Fluconazole using Chrom agar Candida. The Candida strains which were routinely isolated from clinical specimens like blood, urine, sputum, pus, fluid and homograft isolates were included in the study. 142 Candida isolates were tested by using Chrom agar Candida incorporated with Fluconazole. 16 strains were found to be resistant to Fluconazole and 126 strains sensitive to Fluconazole. Nine were C. tropicalis, 3 C. krusei, 2 C. guillermondii, 1 Geotrichum candidum and one was an unidentified strain of Candida. The MIC of the 16 strains were done using RPMI 1640 medium by macro broth dilution method. MIC of 9 strains was 64 & > 64 ug/ml of 6 strains 32 ug/ml and 1 strain 16 ug/ml.