Idiopathic Bilateral Pulmonary Vein Thrombosis

A 52-year-old female with a history of chronic lymphoedema and untreated deep vein thrombosis, presented with non-specific right-sided chest pain. A CT angiogram confirmed bilateral inferior pulmonary vein thromboses (PVT). A comprehensive hypercoagulable workup and age-appropriate cancer screening were unremarkable; the lack of associated risk factors confirmed idiopathic PVT. The management strategy of systemic anticoagulation with apixaban and multidisciplinary follow-up underscores the treatment challenges of rare presentations. This case accentuates the importance of considering PVT in differential diagnoses of atypical chest pain and contributes valuable insights into the diagnosis, understanding and management of this uncommon condition.

LEARNING POINTS

Pulmonary vein thrombosis (PVT) may present as chest pain, especially in patients with a history of prior blood clots and can occur without an underlying malignancy or coagulation disorder.Utilising a chest CT angiogram with delayed contrast timing is effective in detecting pulmonary vein thrombus.Systemic anticoagulation proves effective in managing pulmonary vein thrombus; however, further data on dosage and duration are required for better guidance.

Infectious Diseases Specific to Women

Female patients are at a greater risk for infections such as urinary tract infections and mastitis, as well as complications from abortions/miscarriages, and sexually transmitted infections. This review highlights risk factors, pathogenesis, complications, diagnostic, and treatment modalities associated with the following infections: mastitis, sexually transmitted diseases, postpartum/abortion-related infections, and urinary tract infections.

Is surface roughness of direct resin composite restorations material and polisher-dependent? A systematic review

STATEMENT OF PROBLEM

Direct resin composite bonding offers a highly esthetic, minimally invasive option for the treatment of anterior teeth however the challenge to improve their longevity remains. Direct resin composite restorations are limited by the risk of staining which may be influenced by the final surface roughness (Ra) of composite achieved.

PURPOSE

The purpose of this review is to investigate, using a systematic approach, whether the final surface roughness of anterior composite restorations is affected by the interaction between resin composite and polishing systems.

MATERIALS AND METHODS

The review was conducted by 3 independent reviewers and included articles published up to January 21, 2021. Three electronic databases were searched: Medline, Embase, and Web of Science. Studies assessing a quantitative effect of polishing methods on the Ra of direct composite resin materials published after the year 2000 and restricted to the English language were included.

RESULTS

The database search for the effect of polishing systems on composite materials retrieved 125 eligible studies. Twelve duplicate records were removed. The resulting records were screened using title and abstract leading to 38 reports which were sought for retrieval. Application of eligibility criteria led to 11 studies included in the review. Hand searching of these studies yielded no additional papers.

CONCLUSIONS

There is insufficient evidence to determine whether combination of composite and polisher influences final Ra. More research is required to determine if there is an optimum combination of polisher and composite.

CLINICAL IMPLICATIONS

Polishing should be completed following planned finishing procedures. The approximation to the final surface and which finishing burs to use, if any, should be considered when planning a restoration. Durafill VS predictably achieves an acceptable Ra by different polishers.

The level and distribution of selected organochlorine pesticides in water of River Satluj Pakistan

The study was aimed to identify different environmental factors (selected organochlorine pesticides) affecting the river water of Satluj. River Sutlej is about 1400 kilometers long and its water is extensively used for irrigation in Punjab, located both in India and Pakistan, which was also a reason of dispute between both countries for its water share. The study area was divided into four zones, Sulemanki Zone, Islam Zone, Mailsi Syphone Zone and Panjnad Zone. Liquid Liquid Extraction (LLE) technique was used for the collected water samples followed by high performance liquid chromatography (HPLC) UV-Visible detector The current finding revealed that aldrin was not detected during summer period in water samples of SZ-1 (Sulemanki Barrage), SZ-2 and SZ-3 (Maisli Siphon) of the study area. Lindane and DDE were found more in the samples of sediments from the study area at SZ-4 ranging from 2.238-8.226 ppb and 4.234-6.876 ppb, respectively. Heaptachlor (in sediments) was found to be0.032-234 ppb only at SZ-4.Endosulfan concentrations in water (winter) at SZ-3 was 0.06 ppb and at SZ-4,it was 0.05 ppb; dieldrin in water (winter) at SZ-4 was 0.0314 ppb and heptachlor was detected at SZ-1 (0.0315 ppb) and SZ-2 (0.0310 ppb) in water during winter season, were reaching to the Maximum Concentrations Limits (MCL), while all other residues investigated were found below the MCLin all the compartments of the study area set by various agencies like WHO/FAO- Codex Alimenterious. Present findings revealed that although the organochlorine pesticides are banned for agricultural use in many countries, including Pakistan, their presence in various samples might be due to illegal use of these pesticides in the study area and its neighboring regions. The overall study area comprises of mainly urban, suburban and agricultural land being the largest cotton growing area of the country. There is a need to take serious steps to minimize water pollution caused by pesticides to achieve a healthy lifestyle.

Presence of selected organochlorine pesticides (OCPs) in sediments and biota of River Satluj, Pakistan: first report

Abstract In the developed countries, the use of OCPs (organochlorine pesticides) has been banned. However, in South Asia several of them are still in use. In Pakistan and India a constant addition of OCPs into the atmosphere has been indicated by various researchers. In this study levels of selected organochlorine pesticide residues were assessed in sediment and biota collected from four (4) water reservoirs (3 Barrages & 1 Siphon) on the River Satluj Pakistan, along 231 miles (372 km) of River stretch which was further divided into 12 sampling sites. It was aimed to find out the levels of organochlorine pesticide (OCPs) residues in sediments and from selected fish species (Labeo rohita, Wallagu attu, Cyprinus carpio) of the River Satluj Pakistan. The Organochlorine residues (seven pesticides) present in samples of sediments and biota were investigated through multi residue method, using Gas Chromatograph (GC-ECD).In the current study, the concentration of DDT, was investigated in Wallago attu (0.786-3.987 ppb), Labeo rohita (0.779-4.355 ppb) and Cyprinus carpio (1.234-5.654 ppb). DDE was also found in Cyprinus carpio (1.244-6.322 ppb), Wallag attu (0.877-4.221 ppb) and Labeo rohita (2.112-5.897 ppb). Aldrin was not observed in Labeo rohita and Wallago attu. Currently, lindane and DDE was found predominately high in the sediments of study area at SZ-4 (Panjnad Barrage) ranging (2.238-8.226 ppb) and (4.234-6.876 ppb), respectively. Heaptachlor was found only at SZ-4 (Panjnad Barrage) from the sediments with concentration ranging (0.032-234 ppb). In short all other residues investigated were found below the MCL (maximum concentration level) in all the compartments of the study area set by various agencies like WHO/FAO- Codex Alimenterious.

Neurological Emergencies in the Intensive Care Unit

Neurological emergencies carry significant morbidity and mortality, and it is necessary to have a multidisciplinary approach involving the emergency physician, the neurologist, the intensivist, and the critical care nursing staff. These disorders can be broadly divided into noninfectious and infectious etiologies. In this article, we review a few of the neurological emergencies that present to the neurological intensive unit, with emphasis on convulsive status epileptics, myasthenia gravis, Guillain-Barré syndrome, meningitis, encephalitis, and brain abscess.

Toward Grading Subarachnoid Hemorrhage Risk Prediction: A Machine Learning-Based Aneurysm Rupture Score

OBJECTIVE

Existing approaches neither provide an accurate prediction of subarachnoid hemorrhage (SAH) nor offer a quantitative comparison among a group of its risk factors. To evaluate the population, hypertension, age, size, earlier subarachnoid hemorrhage, and location (PHASES) and unruptured intracranial aneurysm treatment score (UIATS) scores and develop an Artificial Intelligence-based 5-year and lifetime aneurysmal rupture criticality prediction (ARCP) score for a set of risk factors.

METHODS

We design various location-specific and ensemble learning models to develop lifetime rupture risk, employ the longitudinal data to develop a linear regression-based model to predict an aneurysm's growth score, and use the Apriori algorithm to identify risk factors strongly associated with SAH. We develop ARCP by integrating output of Apriori algorithm and ML models and compare with PHASES and UIATS scores along with the scores of a multidisciplinary team of neurosurgeons.

RESULTS

The PHASES and UIATS scores show sensitivities of 22% and 35% and specificities of 76% and 79%, respectively. Location-specific models show precision and recall of 93% and 90% for the middle cerebral artery, 83% and 80% for the anterior communicating artery, and 80% and 80% for the supraclinoid internal carotid artery, respectively. The ensemble method shows both precision and recall of 80%. The validation of the models shows that ARCP performs better than our control group of neurosurgeons. Data-driven knowledge produces comparisons among 61 risk factor combinations, 11 ranked minor, 8 moderate, and 41 severe, and 1 of which is a critical factor.

CONCLUSIONS

The PHASES and UIATS are weak predictors, and the ARCP score can identify, and grade, risk factors associated with SAH.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

EP-415 The use of gastrografin in the management of adhesive small bowel obstruction

Background

Adhesive small bowel obstruction (aSBO) is a common surgical emergency causing high morbidity and even some mortality. The adhesions causing such small bowel obstructions (SBO) are typically the footprints of previous abdominal surgeries. The National Audit of Small bowel Obstruction (NASBO) recommended that in patients not needing emergency surgery for aSBO, gastrografin should be embedded in clinical management. An audit was undertaken to see our adherence to best practice in the management of aSBO.

Methods

Data of all patients who were admitted with SBO between April and October 2020 were obtained. This list was filtered carefully to extract patients who had aSBO. Data was collected on signs of intestinal ischaemia, administration of gastrografin and progression, need for surgery and length of stay.

Results

26 patients were admitted with aSBO in the above period. Half of all patients needed an emergency operation. Only 30% (8) received gastrografin. Conservative management was successful in 62% (5/8) of patients who received gastrografin. 38% (3/8) needed surgery as they either had signs of intestinal ischaemia or gastrografin failed to pass through. More than half of all patients (55%) who did not receive gastrografin (10/18) required surgery. The average length of stay was significantly higher in patients who did not receive gastrografin.

Conclusion

From the limited data it is evident that the use of gastrografin in patients with aSBO reduces the duration of stay and need for surgery. We have now developed and implemented a local protocol for managing such patients and we aim to re-audit in 6 months.

Human Granulocytic Anaplasmosis as a COVID-19 Mimicker

Introduction

Human granulocytic anaplasmosis (HGA) is a tick-borne illness caused by the bacterium Anaplasma phagocytophilum. HGA has a widely variable clinical presentation and can be life-threatening.

Case description

A 77-year-old man was transferred from an outside facility with altered mental status, a fever of up to 40.5°C, and shortness of breath. Laboratory analysis revealed a progressively worsening pro-inflammatory state and abnormalities in the patient’s coagulation studies. With clinical and laboratory evidence concerning for potential COVID-19 infection, the patient was placed in isolation as a precaution. The results of two COVID-19 tests, given approximately 24 hours apart, were negative. The patient’s spouse confirmed a bug bite to his upper extremity while working outdoors. His symptoms resolved completely after a 10-day course of empiric doxycycline.

Discussion

The diverse clinical presentations of HGA necessitate a broad differential diagnosis, including viral, bacterial and non-infectious aetiologies. In severe cases, a cytokine-mediated immune cascade can occur (namely, cytokine storm) leading to devastating downstream effects. This cytokine storm can be seen in many other diseases, but most recently it has been demonstrated in the novel coronavirus disease 2019 (COVID-19).

Conclusion

Here we present a case of HGA in which diagnosis was delayed due to mimicry of COVID-19 infection. This case highlights the importance of taking clinical and social histories, seasonality and geography into account during diagnosis, and maintaining a broad differential with non-specific symptoms. Despite the current COVID-19 pandemic, we recommend that HGA remains in the differential diagnosis of a pro-inflammatory state with an atypical respiratory presentation.

LEARNING POINTS

Antibacterial and antifungal activity of methanolic extracts of Salix alba L. against various disease causing pathogens

The present study was aimed to manifest the antibacterial and antifungal activity of methanolic extracts of Salix alba L. against seven Gram-positive and Gram-negative bacterial pathogens e.g. Streptococcus pyogenes, Staphylococcus aureus (1), S. aureus (2), Shigella sonnei, Escherichia coli (1), E. coli (2) and Neisseria gonorrhoeae and three fungal isolates from the air such as Aspergillus terreus, A. ornatus, and Rhizopus stolonifer. Two different serotypes of S. aureus and E. coli were used. The agar well-diffusion method results showed the dose-dependent response of plant extracts against bacterial and fungal strains while some organisms were found resistant e.g. E. coli (1), S. sonnei, A. terreus and R. stolonifer. The highest antibacterial activity was recorded at 17.000±1.732 mm from 100 mg/mL of leaves methanolic extracts against S. pyogenes while the activity of most of the pathogens decreased after 24 h of incubation. The highest antifungal activity was reported at 11.833±1.0 mm against A. ornatus at 50 mg/mL after 48 h of the incubation period. These experimental findings endorse the use of S. alba in ethnopharmacological formulations and suggest the use of methanolic extracts of the said plant to develop drugs to control the proliferation of resistant disease causing pathogenic microbes.

Comorbidities Associated With Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease or COPD is characterized by airflow obstruction, causing respiratory symptoms. There are treatments available for COPD; however, COPD has significant extrapulmonary effects, including well-recognized ones as cardiovascular disease and often underdiagnosed ones as osteoporosis. It is imperative to be aware of these comorbidities to optimize COPD patient care.

Is Preexisting Cervical Degeneration a Risk Factor for Poor Prognosis in Whiplash-Associated Disorder?

BACKGROUND

The term whiplash describes the acceleration-deceleration mechanism of injury to the cervical spine. Whiplash injuries present with a variety of clinical and psychological manifestations, collectively termed as whiplash-associated disorders (WADs). Although largely self-limiting, some patients may experience long-lasting symptoms. This review aimed to summarize the current literature regarding the predictive value of cervical degeneration in the prognosis of patients with WAD.

METHODS

A comprehensive search of the literature was performed. Nine studies were identified, including 894 patients, with an age range between 16 and 76 years.

RESULTS

A statistically significant association was found between moderate facet joint degeneration and nonrecovery. Although no association was established between isolated disc degeneration and nonrecovery, total cervical degeneration (facet joint + disc degeneration) was shown to correlate with nonrecovery.All included studies demonstrated the lack of correlation between preexisting disc degeneration and clinical outcomes. Four studies showed a significant correlation between cervical degeneration and poor prognosis following whiplash injury. A significantly higher proportion of patients who remained symptomatic at 2 years following a whiplash injury had preexisting degenerative changes.

CONCLUSIONS

This review highlights the presence of significant variability in the existing literature concerning WAD in terms of study methodology, definitions of cervical degeneration, and outcome measures. Degenerative changes of the facet joint lead to alterations in its biomechanics. Several cadaveric, biomechanical, and clinical studies have demonstrated facet joints as a source of pain in patients with chronic WAD. We present moderate evidence to suggest that preexisting facet joint degeneration is a negative prognostic indicator for long-lasting symptoms in WAD. Conversely, preexisting disc degeneration is not associated with chronicity of WAD symptoms. We propose facet joint instability due to facet joint capsule rupture as a potential mechanism for nonrecovery. Further studies are needed to inform our knowledge of the long-term sequelae of WAD among patients with preexisting cervicalspine degeneration.

IgG4 related lung disease- a rare and novel mimic of malignancy and infections-a case series of three patients with a brief review of updated literature

IgG4-related lung disease is an extremely rare and novel entity which is still poorly understood. We reviewed the 16 patients diagnosed with IgG4-related disease from October 2014 through December 2019 at our institution. The three cases that showed pulmonary involvement are included in this series. Of these, two patients had cavitary lung disease and developed aspergilloma and chronic cavitating aspergillosis after a prolonged course of steroid therapy, and one had isolated pulmonary nodule and ground glass opacity. We reviewed the updated literature and briefly described disease epidemiology, clinical characteristics, diagnostic approaches, and management strategies for IgG4-related lung disease.

Coincidence or connection? A patient with concurrent Lane Hamilton Syndrome and idiopathic membranous nephropathy

Lane Hamilton Syndrome is the rare association of idiopathic pulmonary hemosiderosis and Celiac Disease. The definitive pathophysiologic link is unknown, but the syndrome has been described as co-occurring along with other diseases. We describe the first reported case of Lane Hamilton Syndrome and idiopathic membranous nephropathy. We also hypothesize the possibility of an immune-mediated connection between the pathologies and propose a potential link of the phospholipase A2 receptor.

Possible role of COVID-19 in the relapse of Klein-Levin Syndrome

Klein-Levin Syndrome (KLS) is an extremely rare neurological disorder which can manifest as recurring spells of sleepiness, cognitive disturbances and behavioral changes. We present a novel case of KLS relapse in the setting of Coronavirus disease-19 (COVID-19). A 36-year-old male who had a known history of KLS since adolescence was admitted with sleepiness and behavioral disturbances. Brain imaging and autoimmune encephalitis work was unremarkable. The patient was diagnosed with a relapse of KLS secondary to COVID-19 based on symptomology and lack of any other precipitating factor. The patient required 8 days of hospitalization and was treated with benzodiazepines due to a history of robust response to lorazepam during a prior episode. The patient progressively improved and was discharged home on lorazepam taper. We report that similar to other neurotropic viruses, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) could be the culprit in instigating KLS relapse.

28 Shifting to Virtual MDT in the COVID-19 Era and Beyond

Aim

The COVID19 pandemic has accelerated the need for staff to work remotely. Our aim was to demonstrate how a next-generation digital platform could be used to create a virtual MDT ecosystem in order to manipulate holographic 2D and 3D images in real-time.

Method

This study involved setting up a mock virtual MDT using de-identified DICOM files from a patient who had been treated for colorectal cancer and then subsequently found to have a liver metastasis. The image file was segmented and converted into a 2D and 3D format for visualisation within Microsoft HoloLens 2 ® (smart glasses) using Holocare Solutions ® (Mixed Reality software).

Results

A seamless cross-border pipeline was developed that involved "clinician" training, DICOM segmentation and virtual connection. We successfully performed a virtual MDT with participants able to visualise and manipulate a virtual 3D organ in real-time. The digital network remotely connected sites in England and Norway. The streaming quality was stable and HIPAA compliant. Each participant could observe others as "avatars" interacting with images within the virtual ecosystem allowing image characteristics to be highlighted.

Conclusions

We successfully conducted a virtual MDT using novel hardware and software. Our intention is to conduct a large-scale study to assess the platform's effectiveness in “Real World" MDTs.

A Rare Case of Methamphetamine-Induced Lung Injury During the Ongoing COVID-19 Pandemic

Methamphetamine-induced lung injury is a very rare entity and is poorly understood due to the paucity of available literature. It can present with respiratory failure, often requiring immediate ventilatory support and conservative management. Secondary bacterial infection can result from smoking contaminated crystalline methamphetamine. Although there is growing evidence for the use of steroids in acute respiratory distress syndrome (ARDS), the literature is limited regarding cases of non-cardiogenic pulmonary edema due to meth use. We present a case of ARDS due to methamphetamine use, which dramatically resolved with ventilatory support. A low threshold to investigate drug-induced lung injury in suspicious cases can limit unnecessary utilization of resources during the ongoing coronavirus disease 2019 (COVID-19) pandemic.

Coronavirus Disease-Associated Pulmonary Aspergillosis: A Devastating Complication of COVID-19

Coronavirus disease-19 (COVID-19) has affected more than ninety-three million people worldwide till January 2021. COVID-19 can cause a destructive dysregulated immune response which can result in numerous complications such as kidney failure, myocarditis, and strokes. A new entity called coronavirus disease-associated pulmonary aspergillosis (CAPA) has emerged in recent times. The literature on CAPA is limited. We present a case of CAPA in an immunocompetent patient who was placed on veno-venous extra-corporeal membranous oxygen (VV-ECMO). We briefly explained pathophysiology, clinical presentations, and management of CAPA in this report.

A comparison of patient-reported outcome measures (PROMs) between short and conventional stem hip replacements: a systematic review and meta-analysis

INTRODUCTION

Short stem hip replacements may allow preservation of proximal bone stock and minimise soft tissue disruption, easing future revision surgery. However patient satisfaction with these implants must be determined before widespread use. We aimed to compare patient reported outcome measures (PROMs) between short and conventional stem hip replacements.

METHODS

A systematic review was conducted according to PRISMA guidelines for studies comparing short and conventional stem hip replacements with validated PROMs. Meta-analyses were performed for studies reporting Harris Hip and WOMAC scores. Study bias was assessed with the Cochrane Risk of Bias tool and Newcastle-Ottawa Scale.

RESULTS

24 studies, incorporating 2593 total hip replacements were included for qualitative analysis. 17 studies were included in the meta-analyses. Of the 7 excluded, 1 study reported the Japanese Orthopaedic Association score and 2 others reported the Oxford Hip score. All three showed no difference between the stems. A meta-analysis of 17 studies reporting Harris hip scores showed no statistically significant difference between short and conventional stems (standard mean difference (SMD) -0.06, 95% CI -0.20-0.07, p = 0.35). 6 studies reported WOMAC scores with higher scores indicating worse outcome. No difference was seen between the two groups (SMD 0.21, 95%CI, -0.01-0.42, p = 0.06). 4 studies reported higher WOMAC scores as better. Once again, a meta-analysis showed no statistically significant difference between the stems (SMD 0.28, 95% CI -0.07-0.63, p = 0.12).

CONCLUSIONS

Our systematic review showed no difference in PROMs between short and conventional stem total hip replacements. This is in keeping with previous evidence but is a more comprehensive analysis. Short stems may have an important role in younger individuals as they allow preservation of proximal femoral bone, minimal access surgery and are amenable to abnormal anatomy. The current literature is hindered by non-uniform methodologies and outcome assessments across studies. Further, standardised, high quality evidence is required before widespread changes in practice.

OVERVIEW OF NEUTRON MEASUREMENTS IN JET FUSION DEVICE

The design and operation of ITER experimental fusion reactor requires the development of neutron measurement techniques and numerical tools to derive the fusion power and the radiation field in the device and in the surrounding areas. Nuclear analyses provide essential input to the conceptual design, optimisation, engineering and safety case in ITER and power plant studies. The required radiation transport calculations are extremely challenging because of the large physical extent of the reactor plant, the complexity of the geometry, and the combination of deep penetration and streaming paths. This article reports the experimental activities which are carried-out at JET to validate the neutronics measurements methods and numerical tools used in ITER and power plant design. A new deuterium-tritium campaign is proposed in 2019 at JET: the unique 14 MeV neutron yields produced will be exploited as much as possible to validate measurement techniques, codes, procedures and data currently used in ITER design thus reducing the related uncertainties and the associated risks in the machine operation.

Alopecia areata is characterized by expansion of circulating Th2/Tc2/Th22, within the skin-homing and systemic T-cell populations

BACKGROUND

Characterizing blood profile of alopecia areata (AA) is important not only for treatment advancements, but also for possibly identifying peripheral biomarkers that will eliminate the need for scalp biopsies. We aimed to compare frequencies of skin homing (CLA⁺ ) vs systemic (CLA^- ) "polar" CD4⁺ and CD8⁺ and activated T-cell subsets in AA vs atopic dermatitis (AD) and control blood.

METHODS

Flow cytometry was used to measure IFN-γ, IL-13, IL-9, IL-17, and IL-22 cytokines in CD4⁺ and CD8⁺ T cells. Inducible co-stimulator molecule (ICOS) and HLA-DR were used to define mid- and long-term T-cell activation. We compared peripheral blood from 32 moderate-to-severe AA adults with 43 moderate-to-severe AD patients and 30 age-matched controls.

RESULTS

AA patients had increased CLA⁺ /CLA^- Th2 (P < .007), CLA⁺ Tc2 (P = .04), and CLA⁺ Th22 (P < .05) frequencies than controls. Except of CLA^- Tc1 cells (P = .03), IFN-γ levels were mostly similar between AA, AD, and controls (P > .1). ICOS and HLA-DR activation were significantly higher in AA than controls (P < .05). T regulatory cells were significantly decreased in AA patients than controls (P < .01) and were correlated with activated CD8⁺ T cells and with multiple cytokine subsets (P < .05). While Th2 and Tc2 clustered with disease severity, IFN-γ producing cells were linked with AA duration.

CONCLUSIONS

Alopecia areata is accompanied by Th2/Tc2 activation in skin-homing and systemic subsets, correlating with disease severity, while IFN-γ is linked to disease chronicity. These data hint for a possible role of diverse T-cells subsets in disease pathogenesis and emphasize the systemic nature of AA supporting the need for systemic therapeutic strategies in severe patients.

Pneumatic Balloon Dilatation for Achalasia Cardia; Early & late results, a single center study

Objective:

Achalasia Cardia is treated by Pneumatic balloon dilatation, Heller’s Myotomy and recently, by Peroral Esophagaeal Myotomy. This study reports the efficacy of pneumatic balloon dilatation as a non-surgical motility in achieving relief of dysphagia, clinical improvement and recurrence. Long-term complications were reported.

Methods:

Eight hundred ninety two adult achalasia patients of both genders were treated from January 1988 till December 2011, with pneumatic balloon (Rigiflex Microvasive^®) dilatation, under fluoroscopy Barium swallow was obtained prior to and five minutes after dilatation to evaluate for efficacy of dilatation as well as for complications. Patients not responding to 30 mm balloon had repeat dilatation with 35 mm balloon after 8 weeks. All patients were enrolled in regular follow up at one, six months and yearly intervals up to a period of five years. Recurrence was defined as an increase in symptom score at 8 weeks greater than 50% of their baseline value. These patients were treated with 35 mm balloon or referred for surgical intervention.

Results:

Of 892 patients, follow up was obtained in 50% for 5 years, 9.2% for 4-years), 9.3% for 3-years, 10% for 2-years and 21.5% for 1-year of patients. One patient died after repeat dilatation. Eighty-eight patients were excluded from this analysis (20 died due to non-procedure related causes and another 68 were lost during follow up). Statistically significant improvement was noted in reduction in height and width of barium column and symptom score coupled with weight gain during follow up. Forty-eight patients were subjected to repeat dilatation with 35 mm balloon, two of these developed post-procedure perforations with one mortality. Three non-responsive patients required surgical laparoscopic myotomy. No carcinoma of esophagus was reported during follow up. One patient post dilatation, developed esophageal bezoar. A single pneumatic dilatation achieved a remission rate of 93% at four years, 90% at three years, 95% at two years and 92% at one year post dilatation.

Conclusion:

Achalasia of esophagus can be effectively and safely treated with balloon dilatation to achieve adequate short and long-term symptomatic relief with a low complication rate.

AAA Syndrome, Case Report of a Rare Disease

Triple A (Allgrove) syndrome, an autosomal recessive disease is characterized by achalasia, alacrimia and ACTH-resistant adrenal failure with progressive neurological syndrome including central, peripheral and autonomic nervous system impairment, and mild mental retardation. The triple A syndrome gene, designated AAAS, localized on chromosome 12q 13 encodes for a 546 amino acid protein called ALADIN (Alacrimia-Achlasia-Adrenal Insufficiency and Neurologic disorder). This report relates to two sisters, aged 8 and 12 years, who had vomiting, muscle weakness, alacrimia, excessive fatigue and dysphagia. Abdominal sonography, esophago-gastroduodenoscopy, barium swallow, esophageal manometry, CT scan abdomen and brain, biochemical profiles, as well as neurologic and ophthalmic evaluations were consistent with Allgrove's syndrome. Management consisted of pneumatic balloon dilatation for achalasia and initiation of cortisone therapy with successful resolution of dysphagia and other symptoms.

A case of atrio-esophageal fistula masquerading as upper GI bleed

We represent a fatal case of atrio esophageal fistula that presented as upper GI bleed. The case was complicated by rapidly progressing multi organ dysfunction syndrome and eventual death. This was an iatrogenic complication of an elective procedure.

Metastatic renal carcinoid: To skin, lungs, and pancreas

Carcinoid tumors rarely originate in the urogenital system. We represent a unique case of primary renal carcinoid tumor which was initially diagnosed as renal cell cancer and 10 years later correctly diagnosed as metastatic renal carcinoid.

Epidural steroid injections: update on efficacy, safety, and newer medications for injection

The best evidence for epidural injection appears to be in the setting of radicular pain with epidural steroid and non-steroid injections more efficacious than non-epidural injections. Studies showed the efficacy of non-particulate steroid to approach the efficacy of particulate steroid and very limited comparisons demonstrated no significant difference between epidural steroid and epidural non-steroid (local anesthetic) injection. Preliminary studies evaluating epidural injection of disease modifying anti-rheumatic drugs such etanercept and tocilizumab showed conflicting results and had significant limitations. Randomized studies support better efficacy of transforaminal injection due to greater incidence of ventral epidural spread of injectate when compared to interlaminar injection. Thus, the transforaminal approach is recommended when unilateral radicular pain is limited to one nerve root. However, the transforaminal approach is associated with greater incidence of central nervous system injury, including paraplegia, attributed to embolization of the particulate steroid. Recent studies showed that non-particulate steroids potentially last as long as particulate steroids. Therefore non-particulate steroid should be used in initial transforaminal epidural injection. Future studies should look into the role of adjunct diagnostic aids, including digital subtraction angiography, in detecting intravascular injection and the ideal site of needle placement, whether it is the safe triangle or the triangle of Kambin. Finally, the role of epidural disease -modifying antirheumatic drugs in the management of back pain needs to be better elucidated.

Steroid-resistant nephrotic syndrome: impact of genetic testing

BACKGROUND AND OBJECTIVES

Mutations in several genes are known to cause steroid-resistant nephrotic syndome (SRNS), most commonly in NPHS1, NPHS2, and WT1. Our aims were to determine the frequency of mutations in these genes in children with SRNS, the response of patients with SRNS to various immunosuppressants, and the disease outcome, and to review the predictive value of genetic testing and renal biopsy result.

DESIGN AND SETTINGS

A retrospective review was performed of the medical records for all children with SRNS who were treated and followed-up in the Pediatric Nephrology Unit of King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia from 2002-2012.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of children above 1 year of age, who presented with SRNS to KAUH, Jeddah, Saudi Arabia, in the 10-year interval from 2002-2012 and for whom the results of genetic testing for NPHS1, NPHS2, and WT1 were available. We compared the clinical phenotype, including response to treatment and renal outcome to genotype data.

RESULTS

We identified 44 children with a clinical diagnosis of SRNS in whom results of genetic testing were available. Presumably disease-causing mutations were detected in 5 children (11.4%) of which 3 (6.8%) had NPHS2 mutation and 2 (4.5%) had NPHS1 mutation. Renal biopsy revealed minimal change disease (MCD) or variants in 17 children, focal segmental glomerulosclerosis (FSGS) in 23 children, membranoproliferative changes (MPGN) in 2 children, and IgA nephropathy in another 2 children. Children with MCD on biopsy were more likely to respond to treatment than those with FSGS. None of those with an identified genetic cause showed any response to treatment.

CONCLUSION

The frequency of identified disease-causing mutations in children older than 1 year with SRNS presented to KAUH was 11.4%, and these patients showed no response to treatment. Initial testing for gene mutation in children with SRNS may obviate the need for biopsy, and the use of immunosuppressive treatment in children with disease due to NPHS1 or NPHS2 mutations. Renal biopsy was useful in predicting response in those without genetic mutations.

Amelogenesis imperfecta: an introduction

Amelogenesis imperfecta (AI) is an inherited disorder that is associated with mutations in five genes (AMEL; ENAM; MMP20; KLK4 and FAM83H) with a wide range of clinical presentations (phenotypes). It affects the structure and appearance of enamel of all teeth, both in the primary and secondary dentition. In this review paper, we look at the epidemiology, classification, aetiology, clinical description and diagnosis of AI. In the following three papers of this series, we aim to describe the role of paediatric dentists, orthodontists and restorative dentists in the clinical management of patients with AI.

Long-range epigenetic silencing of chromosome 5q31 protocadherins is involved in early and late stages of colorectal tumorigenesis through modulation of oncogenic pathways

Loss of tumour suppressor gene function can occur as a result of epigenetic silencing of large chromosomal regions, referred to as long-range epigenetic silencing (LRES), and genome-wide analyses have revealed that LRES is present in many cancer types. Here we utilize Illumina Beadchip methylation array analysis to identify LRES across 800 kb of chromosome 5q31 in colorectal adenomas and carcinomas (n=34) relative to normal colonic epithelial DNA (n=6). This region encompasses 53 individual protocadherin (PCDH) genes divided among three gene clusters. Hypermethylation within these gene clusters is asynchronous; while most PCDH hypermethylation occurs early, and is apparent in adenomas, PCDHGC3 promoter methylation occurs later in the adenoma-carcinoma transition. PCDHGC3 was hypermethylated in 17/28 carcinomas (60.7%) according to methylation array analysis. Quantitative real-time reverse transcription-polymerase chain reaction showed that PCDHGC3 is the highest expressed PCDH in normal colonic epithelium, and that there was a strong reciprocal relationship between PCDHGC3 methylation and expression in carcinomas (R=-0.84). PCDH LRES patterns are reflected in colorectal tumour cell lines; adenoma cell lines are not methylated at PCDHGC3 and show abundant expression at the mRNA and protein level, while the expression is suppressed in hypermethylated carcinoma cell lines (R=-0.73). Short-interfering RNA-mediated reduction of PCDHGC3 led to a decrease of apoptosis in RG/C2 adenoma cells, and overexpression of PCDHGC3 in HCT116 cells resulted in the reduction of colony formation, consistent with tumour suppressor capabilities for PCDHGC3. Further functional analysis showed that PCDHGC3 can suppress Wnt and mammalian target of rapamycin signalling in colorectal cancer cell lines. Taken together, our data suggest that the PCDH LRES is an important tumour suppressor locus in colorectal cancer, and that PCDHGC3 may be a strong marker and driver for the adenoma-carcinoma transition.