The efficacy of electrosurgery and excision in treating patients with multiple apocrine hidrocystomas

BACKGROUND

Apocrine hidrocystomas are adenomatous cystic proliferations of the apocrine glands. They typically occur as solitary lesions, though rarely may occur as multiple lesions. Management of multiple hidrocystomas can be difficult, particularly if they are large. Surgical modalities may be required for effective therapy.

OBJECTIVE

To compare the results of electrosurgery and excision in treating multiple apocrine hidrocystomas.

METHODS

A 50-year-old man presented with multiple apocrine hidrocystomas ranging in size from 1 to 12 mm. The lesions were located over the periorbital skin, cheeks, and pinnae. Excision and electrodessication were utilized for therapy. At a 1-year follow-up, the patient was evaluated for recurrences and cosmetic result.

RESULTS

There were no recurrences until 1 year after surgery. In the areas treated with electrodessication, no visible scars were identified. In the areas treated with excision, localized scars were observed.

CONCLUSIONS

Both electrodessiation and excision are effective therapies for multiple apocrine hidrocystomas. We suggest that tumors less than 1 cm be treated with electrodessication and lesions greater than 1 cm with excision.

Redefining 'self': the role of microflora (commensals) mismatch in the development of GvHD after allogeneic stem cell transplantation and some possible remedies

The discovery of human leukocyte antigen (HLA) molecules and their role in allorecognition has facilitated the initiation of allogeneic stem cell transplantation in human beings. HLA mismatch to a large extent explains the phenomenon of graft rejection and graft versus host disease (GvHD). Incidence of GvHD even in syngeneic transplants suggests a role for extra genetic factors in the causation of GvHD. We hereby propose a hypothesis that the definition of 'self' (in the immunological sense) should be broadened to include both genetically determined molecules (e.g. HLA) and the microbial flora that colonize an individual. This hypothesis explains several observations about GvHD which can not fully be accounted for by the HLA mismatch theory and gives some clues towards circumventing GvHD.

Repopulation of mouse liver with human hepatocytes and in vivo infection with hepatitis B virus

Mice containing livers repopulated with human hepatocytes would provide excellent in vivo models for studies on human liver diseases and hepatotropic viruses, for which no permissive cell lines exist. Here, we report partial repopulation of the liver of immunodeficient urokinase-type plasminogen activator (uPA)/recombinant activation gene-2 (RAG-2) mice with normal human hepatocytes isolated from the adult liver. In the transplanted mice, the production of human albumin was demonstrated, indicating that human hepatocytes remained functional in the mouse liver for at least 2 months after transplantation. Inoculation of transplanted mice with human hepatitis B virus (HBV) led to the establishment of productive HBV infection. According to human-specific genomic DNA analysis and immunostaining of cryostat liver sections, human hepatocytes were estimated to constitute up to 15% of the uPA/RAG-2 mouse liver. This is proof that normal human hepatocytes can integrate into the mouse hepatic parenchyma, undergo multiple cell divisions, and remain permissive for a human hepatotropic virus in a xenogenic liver. This system will provide new opportunities for studies on etiology and therapy of viral and nonviral human liver diseases, as well as on hepatocyte biology and hepatocellular transplantation.

A comparative study of cardiovascular stress during different swimming strokes

The study was aimed: (i) to compare maximum heart rate during exhaustive running (HRmasr) and swimming (HRmaxs), (ii) to compare heart rate (HR) in various modes of swimming-front crawl (FC), butterfly (BF), breast stroke (BRS) and back stroke (BS). HRmaxr (192.3 +/- 4.9 beats/min) of the swimmers (N = 7) was higher, although not significantly (P < 0.05), than their HRmaxs (183.7 +/- 3.8). Peak HR of the swimmers in FC, BF, BRS and BS (each of 100 m distance) were 179.9 +/- 7.2, 180.3 +/- 7, 178.6 +/- 6.2 and 177.3 +/- 5.4 beats/min respectively. Average HR in the respective events were 167.3 +/- 15.8, 166.6 +/- 14.1, 163.3 +/- 13.5 and 165.8 +/- 14.6 beats/min. Differences were not significant between any two modes, either in peak HR or mean HR. The results conclude that: (i) maximum HR in swimming is approximately 8 beats/min lower than maximal running and (ii) when the effort is maximum, cardiovascular stress remains unaltered in different swimming modes.

Mandibular metastasis from renal cell carcinoma. A case report

Renal cell carcinoma (RCC) metastasizing to the mandible and subsequently spreading to oropharynx in a 62 year old man is reported. The patient presented with solitary mandibular lesion with hematuria, which on further investigation was diagnosed to be RCC with no other systemic involvement. Clinical manifestation of the mandibular metastasis from RCC is rarely seen. A case is reported and literature regarding extracranial head and neck metastasis by RCC is reviewed.

A population-based eye survey of older adults in a rural district of Rajasthan: I. Central vision impairment, blindness, and cataract surgery

PURPOSE

To assess the prevalence of central vision blindness and cataract surgery in older adults in rural northwest India.

DESIGN

Population-based, cross-sectional study.

PARTICIPANTS

A total of 4284 examined persons 50 years of age or older.

METHODS

A random selection of village-based clusters was used to identify a population sample in the predominantly rural Bharatpur district of Rajasthan. Eligible subjects in the 25 selected clusters were enumerated through a door-to-door household survey and invited to village sites for visual acuity testing and eye examination early in 1999. The principal cause of reduced central vision was identified for eyes that had visual acuity worse than 6/18. Independent replicate testing for quality assurance monitoring took place in participants with reduced vision and in a sample of those with normal vision in five of the study clusters.

MAIN OUTCOME MEASURES

Presenting and best-corrected visual acuity and lens status.

RESULTS

A total of 4728 eligible persons in 2821 households were enumerated, and 4284 (90.6%) were examined. The prevalence of presenting and best-corrected visual acuity worse than 6/60 in both eyes was 11.9% (95% confidence interval: 10.0%-13.9%) and 6.1% (95% CI: 4.7%-7.4%), respectively. Presenting blindness was associated with increasing age, female gender, lack of schooling, and rural residence. Cataract was the principal cause of blindness in one or both eyes in 67.5% of blind persons, with uncorrected aphakia and other refractive error affecting 18.4% in at least one eye. The prevalence of cataract surgery was 12.8% (95% CI: 11.6%-14.0%), with an estimated 65.7% of the cataract blind operated on; low surgical coverage was associated with lack of schooling.

CONCLUSIONS

Blindness, particularly blindness because of cataract, continues to be a significant problem among the elderly living in remote areas of rural northwest India. Increased attention should be given to reaching women and the illiterate.

Microfilariae in association with neoplastic lesions: report of five cases

Microfilariae and adult filarial worms have occasionally been detected in association with neoplastic lesions in cytological smears. The presence of microfilariae along with neoplasms is generally regarded as a chance association, yet some authors suggest that such parasitic infestations may be a causative factor for tumourigenesis. There are only a few reported cases in cytology literature documenting this association. We report the presence of microfilariae in routine cytology smears from one benign and four malignant tumours. Microfilariae could not be identified on histopathology available in four of these cases.

Clinical, hematological and histomorphological profile of myelodysplastic syndrome

AIM

The present study was designed to analyse clinical, haematological and histomorphogical features in 37 cases of myelodysplasic syndrome (MDS).

MATERIAL AND METHODS

FAB criteria was used to diagnose MDS in 37 patients. Clinical details, peripheral blood findings, bone marrow aspirate and biopsy were reviewed.

RESULTS

Of 37 cases, there were 25 females and 12 males in age range of 2 years to 75 years. There were three children. There were nine cases of refractory anaemia (RA), 18 of refractory anaemia with excess blasts (RAEB), nine of refractory anaemia with excess blasts in transformation (RAEB-t) and one of chronic myelomonocytic leukemia (CMML). All were denovo MDS. All patients had pallor. Hepato and/or splenomegaly was seen in 15 cases. Anemia, leukopenia and thrombocytopenia was seen in 37, 6 and 23 cases respectively. Bone marrow aspiration (BMA) was hyper to normo cellular in 35 cases. Dyshemopoiesis was seen in one or more cell lines in all cases. Bone marrow biopsy (BMB) was available in 16 cases. Abnormal localisation of immature precursors (ALIP) was seen in 11/12 biopsies of RAEB and 3/4 of RAEB-t. BMB was helpful in diagnosis of 3 doubtful cases (one RAEB and two RAEB-t), and upgrading of 2 cases of RAEB to RAEB-t. On follow up, 1 case of RA, 3 of RAEB, 1 of RAEB-t developed AML. One case of RAEB developed ALL and 2 progressed to RAEB-t.

CONCLUSION

Primary MDS is seen in all age groups. Pallor is commonest presentation. RAEB was commonest subgroup seen. BMB is helpful in diagnosis of doubtful cases. ALIP is a reliable diagnostic feature of MDS. BMB is a diagnostic as well as prognostic tool in MDS cases which should be taken as a mandatory investigation.

Exploring the evolution of diversity in pathogen populations

Pathogen biodiversity is an under-exploited source of inference regarding disease processes and the evolution of pathogens and pathogenesis. In addition, the structure of pathogen populations, especially for diverse organisms such as the meningococcus, has implications for public health interventions including vaccination and antibiotic use. The predominant paradigm for interpreting bacterial diversity has been the clonal population structure, which has been modified by the incorporation of the effects of horizontal genetic exchange. Multilocus models of variable antigens, which explore the effects of immune selection, provide alternative explanations for structured diversity in pathogen populations.

Single chain Fv: a ligand in receptor-mediated gene delivery

We have used an anti-human polymeric immunoglobulin receptor (pIgR) single chain Fv (scFv) to deliver reporter genes to epithelial cells in vitro. The scFv was constructed from a monoclonal antibody directed against pIgR and a cysteine residue was added at the carboxyl end to facilitate its conjugation to polylysine (polyK) via the heterobifunctional cross-linker SPDP. ScFv-cys was expressed in Drosophila S2 cells and purified to homogeneity using conventional column chromatography. ScFv-polyK, and polyK as control, were condensed with a DNA expression plasmid containing the luciferase reporter gene driven by the CMV promoter into unimolecular (with respect to DNA) complexes under high salt conditions. Target cells were MDCK cells transfected with human pIgR and repeatedly sorted for high-level receptor expression, with untransfected MDCK cells as control. Receptor-bearing MDCK cells were readily transfected by scFv-cys containing, pIgR directed complexes, and expression could be blocked by addition of excess human secretory component (SC), the extracellular portion of pIgR. In contrast, MDCK cells that did not express pIgR were not transfected. Nontargeted complexes were not effective in transfecting MDCK cells with or without pIgR. Targeted complexes also transfected human tracheal epithelial cells in primary culture, corroborating the pIgR-mediated gene delivery. These data indicate that a scFv directed against human pIgR can direct foreign genes specifically into receptor-bearing cells in vitro. We have expressed and purified a ligand that is efficient and specific in pIgR-mediated gene delivery.

Inflammation, infection and antimicrobial therapy in coronary heart disease--where do we currently stand?

Traditional atherosclerotic risk factors such as hypertension, smoking, hyperlipidaemia and diabetes mellitus, account for only about 50% of the clinical occurrence of coronary heart disease (CHD). The infectious hypothesis proposes that various microorganisms, in particular, Chlamydia pneumoniae, may serve as potential etiological factors, linking inflammation and atherosclerosis (or its clinical manifestations). Evidence from seroepidemiology, pathology, animal models, molecular biology and immunology, and human antibiotic intervention studies, collectively have suggested a largely positive association between C. pneumoniae infection and CHD. As CHD is a multifactorial disease, it is possible that C. pneumoniae may interact with conventional cardiovascular risk factors and predispose certain genetically susceptible people to atherosclerotic disease. However, the precise nature of a causal or coincidental link between C. pneumoniae and CHD remains to be determined. The results of ongoing antibiotic intervention studies may help to further clarify the role of infection and inflammation in CHD, but until such a role is proven beyond reasonable doubt, antimicrobial therapy cannot yet be justified in the treatment or prevention of CHD. A current perspective is presented in this review.

Blood lactate concentration at selected of olympic modes weightlifting

This study highlights the blood lactate response of weightlifters (N = 5) in two modes of olympic lifts: Snatch (SN) and Clean & Jerk (CJ), during three types of training namely (1) one repetition lift (ORL), (2) Multiple set session (MSS) and (3) one set session (OSS). In ORL, 30, 40, 50, and 60 kg, each of one repetition only, were lifted with an interval of 5 min between two consecutive loads. Both MSS and OSS consisted of 6 sets of lift: 50% x 6 (i.e. 50% of 1 Repetition Maximum x 6 repetitions), 60% x 5, 70% x 4, 80% x 3, 90% x 2, and 100% x 1. In MSS, 3 to 3.5 min interval was given between two successive sets whereas in OSS the interval was approximately 24 hours. Lactate levels were very low (< 3.5 mM) in ORL. In MSS, lactate reached peak at an intermediate set, but, it was maximum at the first set and then declined gradually in OSS. In most of the cases, however, lactate were significantly higher in CJ than SN. The study concludes that: (a) anaerobic glycolysis is not stimulated considerably when the lifting time is only 4-5 sec, (b) repetition of lift plays more important role, than intensity, in lactate production, (c) CJ is more strenuous than SN for a given %RM.

The effect of CD28/B7 blockade on alloreactive T and B cells after liver cell transplantation

BACKGROUND

Hepatocyte cell lines are beginning to be developed as universal donors for isolated liver cell transplantation, which is a less invasive method than orthotopic liver transplantation for treatment of metabolic liver disease. The immune response to isolated liver cell transplantation and its modification by costimulatory blockade are as yet not well delineated.

METHODS

Adenovirus expressing CTLA4Ig was used to study blockade of the costimulatory CD28/B7 pathway in murine models of hepatocyte transplantation, and the effects on alloreactive T and B cells were studied.

RESULTS

CTLA4Ig delayed rejection of subcutaneously administered C57L-derived murine hepatoma cells in CBA/J recipients for >50 days. Activation and cytokine secretion by allospecific CD4+ and CD8+ T cells were initially blocked by CTLA4Ig; delayed rejection was associated with tumor infiltration by CD8+ T cells that did not secrete interferon-gamma. CTLA4Ig failed to block transplant rejection in primed mice, indicating that memory effector T cells were resistant to its action. In contrast, CTLA4Ig suppressed both naive and memory alloreactive B cells. High levels of CTLA4Ig mediated acceptance of hepatoma cells delivered directly into the spleen. However, isolated primary C57BL/6 mouse hepatocytes delivered into the spleen were rejected with only moderately delayed kinetics.

CONCLUSIONS

Transplant antigenicity, transplant site, and CTLA4Ig dose all affected the survival of transplanted liver cells. CD8+ T cells are significant mediators of hepatocyte transplant rejection and are relatively resistant to costimulatory blockade with CTLA4Ig. Strategies to specifically antagonize CD8+ T cells or to modulate MHC class I expression in association with costimulatory blockade by CTLA4Ig may enhance the clinical feasibility of transplanting allogeneic hepatocytes.

TNF-alpha-induced apoptosis in neonatal lymphocytes: TNFRp55 expression and downstream pathways of apoptosis

Previously we have shown decreased Fas-mediated apoptosis in cord blood lymphocyte subsets. In this study, we compared tumor necrosis factor (TNF)-alpha-induced apoptosis in T lymphocytes and their subsets between cord blood and peripheral blood from healthy young controls. The expression of TNF receptor I (TNFR-I) was assessed by flow cytometry and quantitative RT-PCR. The expression of adapter molecules TNF receptor-associated death domain (TRADD), Fas-associated death domain (FADD) and TNF-associated factor-2 (TRAF-2) and caspase 3 was analyzed by Western blotting. The activity of caspase 3 and caspase 8 was measured by colorimetric assay. The susceptibility of CD4+ and CD8+ T cells to TNF-alpha-induced apoptosis was measured by terminal deoxytidyl transferase-mediated dUTP nick end labelling (TUNEL) assay. Both CD4+ and CD8+ T cell subsets from cord blood demonstrated decreased susceptibility to TNF-alpha-induced apoptosis that was associated with decreased activation of both caspase 8 and caspase 3 as compared to T cell subsets in peripheral blood. Furthermore, expression of TNFR-I, TRADD and caspase 3 was decreased in cord blood lymphocytes as compared to peripheral blood lymphocytes. The significance of these observations is discussed.

Infiltration of differentiated thyroid carcinoma by proliferating lymphocytes is associated with improved disease-free survival for children and young adults

An immune response directed against thyroid cancer might be important in preventing metastasis and recurrence. This idea is supported by previous observations showing that adults with autoimmune thyroiditis or lymphocytic infiltration surrounding papillary thyroid carcinoma (PTC) have improved disease-free survival. The long-term outcome for differentiated thyroid cancer is even more favorable for children and young adults. If the immune response is important, we hypothesized that tumor-associated lymphocytes with a high proliferation index would be found in thyroid cancers from children and young adults and would be associated with improved disease-free survival. Using immunohistochemistry, we examined 39 childhood PTC, 9 follicular thyroid carcinomas, 2 medullary thyroid carcinomas, 11 benign thyroid lesions, and 2 normal thyroid glands for the presence of lymphocytes (leukocyte common antigen) and lymphocyte proliferation (proliferating cell nuclear antigen, Ki-67). The majority of PTC (65%) and follicular thyroid carcinomas (75%) from children and young adults contained lymphocytes in the immediate vicinity of thyroid cancers, but only 7 (18%) patients with PTC also had a diagnosis of autoimmune thyroiditis. Disease-free survival did not correlate with the presence or number of lymphocytes per high power field. In contrast, disease-free survival was significantly improved (P = 0.01) for thyroid cancers with the greatest number of Ki-67-positive lymphocytes per high power field. The number of lymphocytes per high powered field was greater for multifocal PTC (P: = 0.023), and the number of proliferating lymphocytes was greatest for PTC with regional lymph node involvement (30.5 +/- 12.3 vs. 6.8 +/- 5.0; P = 0.047). We conclude that proliferation of tumor-associated lymphocytes is associated with improved disease-free survival for children and young adults with thyroid cancer.

Negative pressure pulmonary oedema after cryotherapy for tracheal obstruction

We report a patient who suffered negative pressure pulmonary oedema because of tracheal obstruction after cryotherapy to granulation tissue in the trachea. The pathophysiology and clinical course of negative pressure pulmonary oedema is described. Though there are reports of negative pressure pulmonary oedema after airway obstruction, to our knowledge this is the first case reported after cryotherapy.

Pharmacokinetic and safety profile of desloratadine and fexofenadine when coadministered with azithromycin: a randomized, placebo-controlled, parallel-group study

BACKGROUND

Significant cardiac toxicity has been associated with some older antihistamines (eg, terfenadine and astemizole) when their plasma concentrations are increased. There is thus a need for a thorough assessment of the cardiac safety of newer antihistamine compounds.

OBJECTIVE

This study was undertaken to assess the effects of coadministration of desloratadine or fexofenadine with azithromycin on pharmacokinetic parameters, tolerability, and electrocardiographic (ECG) findings.

METHODS

Healthy volunteers aged 19 to 46 years participated in this randomized, placebo-controlled, parallel-group, third-party-blind, multiple-dose study. Subjects received desloratadine 5 mg once daily, fexofenadine 60 mg twice daily, or placebo for 7 days. An azithromycin loading dose (500 mg) followed by azithromycin 250 mg once daily for 4 days was administered concomitantly starting on day 3. Group 1 received desloratadine and azithromycin, group 2 received desloratadine and placebo, group 3 received placebo and azithromycin, group 4 received fexofenadine and azithromycin, and group 5 received fexofenadine and placebo.

RESULTS

The results of the pharmacokinetic analysis revealed little change in mean maximum concentration (Cmax) and area under the concentration-time curve (AUC) values for desloratadine with concomitant administration of azithromycin: Cmax ratio, 115% (90% CI, 92-144); AUC, ratio 105% (90% CI, 82-134). The corresponding ratios for 3-hydroxydesloratadine were 115% (90% CI, 98-136) and 104% (90% CI, 88-122), respectively. A substantial increase was observed in mean Cmax and AUC values for fexofenadine when administered with azithromycin: Cmax, ratio, 169% (90% CI, 120-237); AUC ratio, 167% (90% CI, 122-229). Compared with the group receiving desloratadine and azithromycin, subjects receiving fexofenadine and azithromycin also displayed greater variability in pharmacokinetic parameters for the antihistamine. Mean Cmax and AUC values of azithromycin were slightly higher when administered with desloratadine (Cmax ratio, 131% [90% CI, 92-187]; AUC ratio, 112% [90% CI, 83-153]) but were lower when given in combination with fexofenadine (Cmax ratio, 87% [90% CI, 61-124]; AUC ratio, 88% [90% CI, 65-1201). The most common adverse event for all regimens was headache, reported in 20 (22%) subjects. All combinations of desloratadine or fexofenadine with and without azithromycin were well tolerated, and no statistically significant changes in PR, QT, or QT, interval, QRS complex, or ventricular rate were observed.

CONCLUSIONS

Small increases (<15%) in mean pharmacokinetics of desloratadine were observed with coadministration of azithromycin. By contrast, peak fexofenadine concentrations were increased by 69% and the AUC was increased by 67% in the presence of the azalide antibiotic. Based on the reported adverse-events profile and the absence of changes in ECG parameters, the combination of desloratadine and azithromycin was well tolerated. This study suggests that desloratadine has a more favorable drug-interaction potential than does fexofenadine.

The superior and inferior components of Whitnall's ligament

During an orbital dissection in a 60-year-old white male, we came across a very well defined superior and inferior component of Whitnall's ligament (Figure 1). The superior component of Whitnall's ligament is well described and well known to ophthalmologists performing eyelid surgery. The inferior component, however, is not well recognized or described. This cadaver dissection illustrates both Whitnall's components well.

Experience of the first pelvic examination

OBJECTIVES

To analyze women's experiences of the first pelvic examination and identify positive and negative components. To learn lessons, and build on and incorporate the positive components into a model of good clinical practice.

METHOD

The open, cross-sectional study was carried out in community family planning and young persons clinics. A self-administered questionnaire was offered to all women under 25 years of age who attended a family planning or young persons clinic during the study period. The questionnaire was constructed to determine how experience compared with expectations and which components showed a significant trend towards a positive or negative effect. It also aimed to find what women considered to be important aspects of an internal examination.

RESULTS

A total of 167 evaluable questionnaires were completed in which experience of the first pelvic examination was reported from family planning clinics (41%), general practice (39%) and hospital/genitourinary medicine faculties (20%). These first pelvic examinations occurred at a mean age of 17.3 years (range 11-23 years). Significant trends of a positive experience were found when the examination was conducted by a female doctor (p = 0.02), when it was conducted in a family planning clinic as opposed to general practice (p = 0.04), after permission was sought (p = 0.001) and with increasing age at first examination (Mann-Whitney, p = 0.003). There were no significant differences in outcome with offer of, or presence of, a chaperone.

CONCLUSIONS

A friendly, female doctor who seeks permission before the examination, which should be uninterrupted, were considered to be important aspects for an internal examination.

Multiple linear eccrine spiradenomas with eyelid involvement

Eccrine spiradenoma is an uncommon tumour of the sweat gland and usually occurs as a solitary small painful nodule. Very rarely, it may present as multiple tumours arranged in a linear/zosteriform fashion. We present the case of a 23-year-old female who had multiple spiradenomas arranged linearly from the midline of forehead to the left corner of the mouth and a few lesions also on the margin of the left eyelid. The lesions were probably along the Blaschko's lines. Tumours were excised surgically in stages. Literature search revealed only 13 reported cases of linear/zosteriform/naevoid multiple spiradenomas and only four cases of solitary spiradenoma of the eyelid. The review of reported cases suggests that arrangement of tumours in a linear/zosteriform pattern is an important diagnostic clue for multiple (naevoid) spiradenomas.

Facio-cervical transfixion by a metallic rod: a case report

Foreign bodies penetrating into the neck may cause extensive neurovascular and aerodigestive tract injuries. Facio-cervical transfixion by a metallic rod without such injuries is very rare. The patient presented in this article reported to our center 5 hours after the road traffic accident with impacted hollow metallic rod traversing through the tongue, pharynx, and neck after causing fracture to maxilla. Exploration under general anesthesia after tracheostomy resulted in an uneventful extraction of the metallic rod. Postoperatively, the patient recovered completely and had no neurologic deficits. [Editorial comment: This case report demonstrates an approach to an extremely difficult and potentially dangerous clinical problem. The authors decision to forego angiography is based on physical examination with evidence of palpable flow in the superficial temporal artery.]