Cardiac involvement in Wilson's disease--an electrocardiographic observation

BACKGROUND

Wilson's disease is known for its protean manifestations; however electrocardiographic abnormalities have not received much attention.

AIM

To evaluate the various electrocardiographic (ECG) changes in patients with Wilson's disease.

METHOD

The resting ECGs of 50 patients with Wilson's disease were systematically analyzed independently by three observers after excluding other causes that could induce ECG abnormalities.

RESULT

Fifteen patients had at least one abnormality in the ECG. Sinus tachycardia was seen in eight and sinus bradycardia in six. Other abnormalities included: bifid P wave (1), ST elevation (2), ST depression (2), T inversion (4), ventricular premature contraction - VPC (1) and prominent U waves (1). QRS axis, PR interval, QRS complex, R/S amplitude ratio and QT interval were normal in all. Ventricular premature beats were not recorded in any. None had features of ventricular hypertrophy. There was no statistically significant difference in ECG abnormalities with reference to age, gender, duration of illness or treatment, serum copper or ceruloplasmin, and severity of neurological impairment.

CONCLUSION

ECG abnormalities are not uncommon in Wilson's disease and are presumably related to an underlying cardiomyopathy due to deposition of copper in heart.

Liver metastasis in renal chondrosarcoma

A 39-year-old woman who had a left radical nephrectomy for a renal chondrosarcoma presented 18 years later with a large epigastric mass and deep jaundice. The patient was very dyspnoeic and had a feeling of continuous pressure on her chest. Computed tomography arterioportography of the abdomen showed that the mass involved both lobes of the liver. Multiple non-anatomical resections of tumour masses were performed, including a mass arising from the falciform ligament, left lateral segment, and segments VII and VIII. The largest resected mass weighed 2.5kg and had a diameter of 15cm. Histopathology of the hepatic metastasis was similar to the original renal chondrosarcoma. The patient was followed up for 24 months postoperatively and had symptomatic relief. Our case demonstrates the slow-growing nature of this tumour and the usefulness of palliative surgery despite large tumour load.

Myxopapillary ependymoma of the temporal lobe--report of a rare case of temporal lobe epilepsy

Myxopapillary ependymomas are a benign variant of ependymomas, occurring almost exclusively in the cauda equina region. We report an extremely rare case of myxopapillary ependymoma located in the left anterior temporal lobe. A 22-year-old man is presented with intractable seizures of 2 years duration with no focal neurologic deficits. Imaging of the brain revealed a well-circumscribed heterogeneous mass in the left anterior temporal pole with no connection to the ventricles. Imaging of the spine was normal. The patient underwent surgical removal of the tumor and at follow-up 4 months after surgery, there was improvement in his memory and speech along with complete cessation of seizures. Microscopic examination revealed the tumor to be a myxopapillary ependymoma, further confirmed by histochemical and immunohistochemical stains. To the best of our knowledge, this is the first documentation of myxopapillary ependymoma at this location and consequently, the first case to clinically present as intractable temporal lobe epilepsy.

Paradoxical cerebral embolisation

Fat embolism occurs following fractures of a long bone or arthroplasty. We investigated whether paradoxical embolisation through a venous-to-arterial circulation shunt (v-a) could lead to cerebral embolisation during elective hip or knee arthroplasty.

Transcranial Doppler ultrasound (TCD), following the intravenous injection of microbubble contrast, identified the presence of a shunt in 41 patients undergoing hip (n=20) or knee (n=21) arthroplasty. Intra-operative cerebral embolism was detected during continuous TCD monitoring. Of the 41 patients, 34 had a v-a shunt of whom 18 had an embolism and embolism only occurred in patients with a shunt (p = 0.012). Spontaneous and larger shunts were associated with a greater number of emboli (rs = 0.67 and rs = 0.71 respectively, p < 0.01). Observations in two patients with large spontaneous shunts revealed 368 and 203 emboli and unexplained post-operative confusion and pancreatitis.

Paradoxical cerebral embolisation only occurred in patients with a shunt and may explain both postoperative confusion and fat embolism syndrome following surgery.

Paradoxical cerebral embolisation. An explanation for fat embolism syndrome

Fat embolism occurs following fractures of a long bone or arthroplasty. We investigated whether paradoxical embolisation through a venous-to-arterial circulation shunt (v-a) could lead to cerebral embolisation during elective hip or knee arthroplasty. Transcranial Doppler ultrasound (TCD), following the intravenous injection of microbubble contrast, identified the presence of a shunt in 41 patients undergoing hip (n = 20) or knee (n = 21) arthroplasty. Intra-operative cerebral embolism was detected during continuous TCD monitoring. Of the 41 patients, 34 had a v-a shunt of whom 18 had an embolism and embolism only occurred in patients with a shunt (p = 0.012). Spontaneous and larger shunts were associated with a greater number of emboli (rs = 0.67 and rs = 0.71 respectively, p < 0.01). Observations in two patients with large spontaneous shunts revealed 368 and 203 emboli and unexplained post-operative confusion and pancreatitis. Paradoxical cerebral embolisation only occurred in patients with a shunt and may explain both postoperative confusion and fat embolism syndrome following surgery.

Cost of Illness Associated with Metastatic Breast Cancer

This study assesses cost of illness of metastatic breast cancer (MBC) patients over a specific period of time as observed in Medicare program expenditure data. Incident cases of MBC from 1997 to 1999 were included. Direct care cost data were obtained from Medicare claims from a 5% national sample of program beneficiaries. Costs to the health care system were determined from the date of first diagnosis of MBC to the end of follow-up. A matched case-control study provided comparison of Medicare payments in cancer and non-cancer patients. A total of 397 MBC patients were identified and followed for an average of 16.2 months. The mean total cost was US$ 35,164 per MBC patient and US$ 4176 per person for the control group. Over the follow-up period, the MBC patients averaged 1.7 inpatient admissions per patient and 14.4 inpatient days per admission. The control group averaged 0.3 inpatient admissions per patient and 1.6 inpatient days per admission. Home health aide for MBC averaged one visit every 2 weeks. The direct costs for the older MBC patients were less than the direct costs of the younger MBC group. Multivariate regression analysis showed that as the age increased, the Medicare costs decreased within the MBC cohorts. Less combination treatments were provided for older MBC patients. Cost of illness was inversely proportional to age.

Discovery of novel modulators of metabotropic glutamate receptor subtype-5

A series of potent and selective mGluR5 antagonists were synthesized and evaluated in vitro and in vivo. It was found that a pyridyl functionality is a potential replacement for acetonitrile in the lead structure, with 2-pyridyl being most favored. Additionally, the benzoxazole moiety could also be replaced by other heterobicyclic rings such as imidazothiazole.

Immunoreactivity to MIB-1 in breast cancer: methodological assessment and comparison with other proliferation indices

The recent availability of the monoclonal antibody MIB-1 (which is able to detect the human nuclear cell proliferation-associated antigen Ki-67 even on formalin-fixed, paraffin-embedded sections, microwave-treated and routinely processed for immunohistochemistry) could open new avenues for validation of the clinical role of tumour cell proliferation on large, consecutive and unselected series of human tumours. However, the routine use of such a marker requires a methodological standardization as well as the comparative assessment of some technical and biological aspects. The MIB-1 index was determined in parallel samples from 50 consecutive invasive breast carcinomas processed with different fixatives for different times. The median values of MIB-1 indices following 2, 6 and 24 h of formalin fixation were similar (29.4%, 30.6% and 29.7%, respectively) and consistent with those reported in the literature; squared linear regression coefficients were 0.99. The median values of MIB-1 indices were markedly lower in Bouin-fixed, paraffin embedded, and in frozen samples (20.0% and 19.8%, respectively), with a poor correlation coefficient with the values detected following formalin fixation (R2 = 0.456). Moderate and poor correlations were observed between Ki-67 index and MIB-1 detected on frozen (rs, 0.78) or formalin-fixed, paraffin-embedded samples (rs, 0.47) and a minimal concordance was observed between TLI and MIB-1 or Ki-67 (rs, 0.25 and 0.22, respectively). Our results indicate interference of the fixative type on immunoreactivity to MIB-1 and also suggest that Ki-67 and MIB-1 reacted with different epitopes of the same antigen.

First-trimester uterine artery blood flow and birth weight

OBJECTIVES

To determine reference values for first-trimester uterine artery resistance index (RI) in healthy pregnant women with uncomplicated pregnancies and to investigate the relationship between uterine artery Doppler indices and birth weight.

METHODS

This was a cross-sectional study of 265 consecutive pregnant women attending routine ultrasound examination at 11-14 weeks' gestation. Both uterine arteries were identified using color Doppler ultrasound and the RI was measured. The presence or absence of an early diastolic notch was also noted. Pregnancy outcomes were obtained from the delivery suite database and birth weight was expressed as Z-scores.

RESULTS

The 5(th), 50(th) and 95(th) centiles for uterine artery RI between 11 and 14 weeks' gestation were 0.53, 0.71 and 0.85, respectively. Complete pregnancy outcome data were available for 246 fetuses. There was a significant negative correlation between birth-weight Z-scores and first-trimester uterine artery mean RI (r = - 0.219, P = 0.001). The difference in birth weight between fetuses with absent and those with bilateral diastolic notches was also significant (P < 0.001). Multiple regression analysis demonstrated that both mean RI (standardized regression coefficient = - 0.14, P = 0.039) and uterine artery notching (standardized regression coefficient = - 0.17, P = 0.017) contributed independently towards the prediction of birth-weight Z-score.

CONCLUSIONS

A significant negative correlation exists between birth weight and first-trimester uterine artery Doppler parameters, a reliable and non-invasive method of examining uteroplacental perfusion. The value of first-trimester uterine artery Doppler as a prognostic screening tool, either in isolation or in conjunction with maternal biochemistry, remains to be determined.

Bloody diarrhea caused by a needle in the pancreatic head

Bloody diarrhea in adolescents is not uncommon polyposis, inflammatory bowel disease, and infections are the usual causes. A 13-year-old boy with a metallic foreign body in the head of the pancreas presented with bloody diarrhea. The clinical problems and surgical approach are discussed.

PathMiner: predicting metabolic pathways by heuristic search

MOTIVATION

Automated methods for biochemical pathway inference are becoming increasingly important for understanding biological processes in living and synthetic systems. With the availability of data on complete genomes and increasing information about enzyme-catalyzed biochemistry it is becoming feasible to approach this problem computationally. In this paper we present PathMiner, a system for automatic metabolic pathway inference. PathMiner predicts metabolic routes by reasoning over transformations using chemical and biological information.

RESULTS

We build a biochemical state-space using data from known enzyme-catalyzed transformations in Ligand, including, 2917 unique transformations between 3890 different compounds. To predict metabolic pathways we explore this state-space by developing an informed search algorithm. For this purpose we develop a chemically motivated heuristic to guide the search. Since the algorithm does not depend on predefined pathways, it can efficiently identify plausible routes using known biochemical transformations.

Adjuvant therapy for colon cancer in the new millenium

A significant proportion of patients with colon cancer who undergo curative surgical resection develop metastatic disease. Over the last 20 years large prospective randomised studies have demonstrated a clear survival benefit for patients with stage III colon cancer who are treated with adjuvant 5FU based chemotherapy. At the present time 6 months of 5FU and leucovorin is generally considered the standard adjuvant therapy. For stage II disease the routine use of adjuvant treatment remains controversial. Newer drugs such as oxaliplatin, irinotecan, and the oral fluoropyrimidines have proven active in advanced colorectal cancer and are currently being evaluated in the adjuvant setting. Molecular markers for this disease are being identified and may help define those patients who would benefit from therapy. The integration of adjuvant immunotherapy with conventional chemotherapy offers the potential to improve the long-term outcome for surgically resected colon cancer.

Plasma antioxidant vitamins in brain tumors

Plasma levels of vitamins A, E and C were analyzed in 102 patients with different types of brain tumors. A follow-up study was done with 27 postoperative patients. On comparison with plasma from normal individuals, vitamin A and E were decreased, but the decrease was statistically insignificant. Vitamin C levels remained in the normal range. In a comparative study of preoperative and postoperative cases, plasma vitamin A levels in postoperative glioma patients were significantly higher than those in the pre-operative state. There was no significant difference in the plasma level of vitamins C and E. The results of the present study suggest that the plasma antioxidant vitamins are not altered effectively in brain tumor cases.

Maternal activity in relation to birth size in rural India. The Pune Maternal Nutrition Study

OBJECTIVE

To describe the relationship of the mother's physical activity to the birth size of her baby in a rural Indian population.

DESIGN

: Prospective observational study.

SETTING

Six villages near Pune, Maharashtra, India.

SUBJECTS

: A total of 797 women were studied after excluding abortions and termination of pregnancies (112), foetal anomalies (8), multiple pregnancies (3), incomplete pre-pregnancy anthropometry (14) and pregnancies detected later than 21 weeks of gestation (168).

METHOD

An activity questionnaire was developed after focus group discussions and incorporated community-specific activities. It was validated against an observer-maintained diary. Activity scores were derived using published data on energy costs to weight the contributions of various activities. It was then administered to assess physical activity at 18 (+/-2) and 28 (+/-2) weeks of gestation.

OUTCOME MEASURES

Birth outcome, maternal weight gain and neonatal anthropometry.

RESULTS

The activity questionnaire was used to classify women into light, moderate and heavy activity categories. Maternal activity did not influence the incidence of prematurity or stillbirth, or the duration of gestation. It was inversely related to maternal weight gain up to 28 weeks of gestation (P=0.002). Higher maternal activity in early, as well as mid gestation, was associated with lower mean birth weight (P=0.05 and 0.02, respectively ), and smaller neonatal head circumference (P=0.005 and 0.009) and mid-arm circumference (P=0.03 and 0.01) after adjusting for the effect of major confounding factors.

CONCLUSIONS

The Findings suggest that excessive maternal activity during pregnancy is associated with smaller foetal size in rural India, The approach described for developing an activity questionnaire has potential for adoption in other settings.

Autoimmune sensorineural hearing loss: is it still a clinical diagnosis?

Inner ear involvement with sensorineural hearing loss (SNHL) has been reported in many autoimmune disorders including ulcerative colitis. The pathogenetic mechanism of hearing loss in ulcerative colitis is thought to be immune mediated. Diagnostic tests are being developed to identify inner ear autoantibodies, that may be the cause of such hearing loss. The only test that is currently available for clinical use is the Otoblot test. This, however, tests only for antibodies against bovine heat shock protein 70 which is only one of the many cross-reacting proteins against the inner ear in suspected immune-mediated hearing loss. The clinical response to steroid therapy is thus the mainstay in the diagnosis of immune-mediated hearing loss. This paper presents a series of patients with clinically suspected autoimmune hearing loss. Diagnostic assays for this condition are discussed along with a review of the recent advances in the pathogenesis and laboratory diagnosis of immune-mediated sensorineural hearing loss.

Free radical toxicity and antioxidants in Parkinson's disease

Erythrocyte lipid peroxidation, oxidative hemolysis, erythrocyte antioxidant enzymes, viz. superoxide dismutase, glutathione reductase, glutathione peroxidase, catalase and plasma antioxidants, viz. vitamin A, vitamin E, vitamin C and ceruloplasmin have been determined by spectrophotometric methods in 15 patients with Parkinson's disease (PD) and in 50 controls. Lipid peroxidation, oxidative hemolysis and plasma ceruloplasmin were significantly higher in PD patients as compared to normals. Erythrocyte antioxidants in PD patients were not significantly different from the controls. However, plasma vitamin C in PD patients was significantly lower than the controls. It is concluded that these patients are under oxidative stress which points to a possible involvement of free radicals in PD.