A Case Report of a Metastatic Papillary Carcinoma of the Thyroid

Neck lumps can be a symptom of thyroid and parathyroid gland metabolic diseases, and papillary thyroid carcinoma is reported in some cases. It is commonly observed in middle-aged people with a female predominance. Papillary carcinoma of the thyroid is the most common type of thyroid cancer, originating from the thyroid gland cells. It is slow-growing and less aggressive, but it has been reported to have the ability to affect nearby lymph nodes and other organs. It is associated with the RET protooncogene, NTRK1, and MET genes. Early detection is crucial, especially for middle-aged patients. Treatment typically involves thyroidectomy and radioactive iodine therapy, with the need for hormone replacement therapy. Fine-needle aspiration cytology (FNAC) is an efficient and cost-effective tool for diagnosing neck swellings, leading to a conclusive diagnosis of the mass. We present a case of a 60-year-old Indian female with swelling over the neck for the past six years, which was recently accompanied by dyspnea, hand tremors, and palpitations. The ignored neck mass was found to be a hyper-echoic mass with macro calcifications and cystic degeneration on ultrasonography, confirmed as papillary thyroid carcinoma by FNAC, followed by a complete thyroidectomy and uneventful follow-up.

A Case of Neurofibroma in the Supraumbilical Region Undergoing Cystic Myxomatous Degeneration: An Unusual Presentation

Primary umbilical neoplasms are exceptionally rare. Neurofibromas histologic findings vary from collagenous to myxoid matrix according to the neoplastic elements differentiation. We present a case of neurofibroma in the supraumbilical region undergoing cystic myxomatous degeneration. A 75-year-old female presented to the department with a complaint of swelling above the umbilicus for the last three years. The swelling was excised and grossly was a single, irregular, reddish-yellow cystic mass measuring 4.5 × 4 x 3 cm. On the cut section, cystic jelly-like areas were identified, and histopathological features were suggestive of neurofibroma undergoing cystic myxomatous degeneration. The diagnosis needed to be combined with pathological examination, and careful consideration during the surgical intervention was important to confirm there was no residue.

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

BACKGROUND

Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks.

METHODS

The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned.

RESULTS

A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31).

CONCLUSION

Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov).

Surgical Excision of Lipomas in Bilateral Upper Limbs and Right Thigh: A Case Report

Lipomas are common benign soft tissue tumors composed primarily of mature adipose tissue. They are often encountered clinically due to their characteristic slow growth, typically as soft, painless, subcutaneous nodules. While lipomas are generally asymptomatic, surgical intervention is sought by patients when they lead to discomfort, cosmetic concerns, or functional impairment. In this case report, we present the successful surgical excision of 25 lipomas in the bilateral upper limbs and right thigh of a 43-year-old male. Pre-operative assessment, precise surgical technique, and post-operative care are highlighted as essential management components. The case emphasizes the importance of individualized treatment, ensuring symptomatic lipomas' diagnosis and effective management. This report serves as a valuable reference for healthcare professionals caring for patients with lipomatous lesions, contributing to understanding soft tissue tumor management.

Toxic Megacolon: A Sequelae of Clostridioides difficile Infection in a Case of Necrotizing Fasciitis

Necrotizing fasciitis is an illness that ascends quickly and affects the fascia, subcutaneous tissues, and deeper skin layers. To combat this infection, strong antibiotics are used along with prompt debridement. Frequent usage of such drugs is connected to antibiotic-associated diarrhea and colonic illnesses like colitis. High-spectrum antibiotic usage over an extended period of time can alter the gut microbiota, which promotes the growth of commensal bacteria including Staphylococcus aureus and Clostridioides difficile (previously known as Clostridium difficile) resulting in complications such as toxic megacolon. C. difficile infection can result in extreme inflammation and colon dilatation leading to toxic megacolon. In order to effectively treat necrotizing fasciitis, a timely diagnosis and vigorous management are essential; failing of which may have fatal consequences such as sepsis and even mortality. We present a case of a 56-year-old male, suffering from necrotizing fasciitis of the left lower limb which further complicated to toxic megacolon and caused mortality of the patient. Timely presentation and early diagnosis can be helpful in better prognosis, which in the context of this case was delayed; had the patient presented to the hospital earlier, there were chances of preventing mortality.

Navigating Parotid Lymphoepithelial Cysts in HIV Patients: A Tale of Two Distinct Scenarios

A rare occurrence in HIV-infected individuals is the development of diffuse infiltrative lymphocytic syndrome (DILS), which is marked by a widespread infiltration of CD8+ lymphocytes in body tissues, persistent elevation of CD8+ lymphocyte levels, as well as bilateral parotid swellings and cervical lymphadenopathy. It is distinct due to its suspected autoimmune origin and is found in about 5-10% of people living with HIV. This retrospective analysis involves two patients admitted to our tertiary care rural hospital with complaints of bilateral parotid swellings, a provisional diagnosis of DILS associated with HIV-positive status and lymphoepithelial cysts, their subsequent management, including conservative treatment and surgical excision of one of our patients. Our goal is to contribute to and advance the knowledge of this rare condition.

Understanding Gangrene in the Context of Peripheral Vascular Disease: Prevalence, Etiology, and Considerations for Amputation-Level Determination

Gangrene is a grave complication of peripheral vascular disease (PVD), characterised by tissue necrosis due to inadequate blood supply. This review article comprehensively explores gangrene in PVD, encompassing its prevalence, aetiology, clinical presentation, diagnostic modalities, management strategies, prognosis, and future directions. Key factors influencing outcomes, including the timeliness of intervention and the choice between limb salvage and amputation, are identified. Moreover, this review underscores the importance of early detection and multidisciplinary care, emphasising the significance of patient-centred approaches. It also calls for increased awareness, continued research, and innovative solutions to improve the lives of individuals grappling with gangrene in the context of PVD.

A Comprehensive Review of the Vascular Consequences of Diabetes in the Lower Extremities: Current Approaches to Management and Evaluation of Clinical Outcomes

Diabetes mellitus is a global health concern characterized by chronic hyperglycemia, and its vascular consequences in the lower extremities pose significant challenges for individuals living with the condition. This comprehensive review delves into the multifaceted landscape of diabetes-related vascular complications in the lower limbs, with a primary focus on current strategies for management and the evaluation of clinical outcomes. This review achieves several critical objectives by synthesizing existing knowledge and research findings. It elucidates the intricate pathophysiological mechanisms underpinning these complications, shedding light on the cellular and molecular processes involved. Additionally, it outlines clinical assessment and diagnostic strategies used to identify and stratify risk, ranging from cutting-edge imaging techniques to clinical examinations. The review comprehensively examines current management strategies, encompassing lifestyle modifications, pharmacological interventions, surgical procedures, and wound care practices. Moreover, it assesses and analyzes clinical outcomes, including limb salvage rates, amputation rates, and overall quality of life for individuals undergoing treatment. In addressing the challenges faced in managing these complications, this review aims to contribute to improved patient care. It proposes future research directions to enhance the management and outcomes of diabetes-related vascular consequences in the lower extremities.

Antibiotic Prophylaxis in Surgery: Current Insights and Future Directions for Surgical Site Infection Prevention

Surgical site infections (SSIs) remain a significant concern in the field of surgery, contributing to patient morbidity, prolonged hospital stays, and increased healthcare costs. Antibiotic prophylaxis, the administration of antibiotics before surgery, has been a cornerstone in preventing SSIs for decades. This review explores the current state of antibiotic prophylaxis in surgery, offering insights into its effectiveness, challenges, and emerging trends. In this comprehensive analysis, we delve into the historical development of antibiotic prophylaxis, examining its evolution from early practices to modern guidelines. We explore the various classes of antibiotics commonly used, their dosing regimens, and the importance of timing in optimizing prophylactic interventions. Additionally, we investigate the role of patient-specific factors, such as comorbidities and allergies, in tailoring antibiotic prophylaxis to individual needs. While antibiotic prophylaxis has undeniably reduced the incidence of SSIs, concerns about antimicrobial resistance and adverse effects necessitate a reevaluation of current practices. This review presents a critical assessment of the challenges posed by the overuse and misuse of antibiotics in surgery and highlights the urgent need for judicious antibiotic stewardship. Moreover, the future of antibiotic prophylaxis holds promise with the emergence of innovative strategies such as antimicrobial coatings, probiotics, and immunomodulatory agents. We discuss these novel approaches and their potential to enhance SSI prevention while minimizing antibiotic-related risks. In conclusion, antibiotic prophylaxis in surgery has been instrumental in reducing SSIs, but its continued effectiveness requires a multifaceted approach. By addressing current challenges, promoting antibiotic stewardship, and embracing innovative strategies, we can advance the field of SSI prevention and improve patient outcomes in the years to come. This review provides valuable insights and direction for clinicians, researchers, and policymakers as they navigate the evolving landscape of surgical prophylaxis.

Process intensification of atorvastatin calcium crystallization for target polymorph development via continuous combined cooling and antisolvent crystallization using an oscillatory baffled crystallizer

In this paper, continuous crystallization of Atorvastatin calcium (ASC) using a continuous oscillatory baffled crystallizer (COBC) has been investigated. Like most API manufacturing, ASC is manufactured batchwise and the pure API is recovered via batch combined cooling and antisolvent crystallization (CCAC) process, which has the challenges of low productivity, wide crystal size distribution (CSD) and sometimes polymorphic form contamination. To overcome the limitations of the batch crystallization, continuous crystallization of ASC was studied in a NiTech (United Kingdom) DN15 COBC, manufactured by Alconbury Weston Ltd. (AWL, United Kingdom), with the aim to improve productivity and CSD of the desired polymorph. The COBC has the advantage of high heat transfer rates and improved mixing that significantly reduces the crystallization time. It also has the advantage of spatial temperature distribution and multiple addition ports to control supersaturation and hence the crystallization process. This work uses an array of process analytical technology (PAT) tools to assess key process parameters that affect the polymorphic outcome and CSD. Two parameters were found to have significant impact on the polymorph, they are ratio of solvent to antisolvent at the point of mixing of the two streams and presence of seeds. The splitting of antisolvent into two addition ports in the COBC was found to give the desired form. The CCAC of ASC in COBC was found to be -30-fold more productive than the batch CCAC process. The cycle time for generating 100 g of desired polymorphic form of ASC also significantly reduced from 22 h in batch process to 12 min in the COBC. The crystals obtained using a CCAC process in a COBC had a narrower CSD compared to that from a batch crystallization process.

Pharmacological Characterization of ZYAN1, a Novel Prolyl Hydroxylase Inhibitor for the Treatment of Anemia

Prolyl hydroxylase (PHD) inhibitors stabilize hypoxia inducible factor (HIF), and exert antianemic effect by potentiating erythropoietin (EPO) expression and down-regulation of hepcidin. ZYAN1 is a novel PHD inhibitor under clinical development for the treatment of anemia. The pharmacodynamic effects of acute and chronic dosing of ZYAN1 were assessed in normal and 5/6 nephrectomized Wistar rats. The effect of ZYAN1 was also investigated in cisplatin-induced anemia using C57 mice. Acute treatment with ZYAN1 increased circulating EPO levels (10.3 ± 3.7 and 40.0 ± 8.5 fold rise at 15 and 30 mg/kg, respectively), reticulocyte count (4.2 ± 0.5 and 6.0 ± 0.2 fold rise at 15 and 30 mg/kg, respectively) and stabilized HIF (28% increase at 45 mg/kg) in normal rats. Nephrectomized rats showed similar dose-related pharmacodynamic effects. In a 28-day study in nephrectomized rats, ZYAN1 administered every alternate day, caused increase in hemoglobin (1.9 ± 0.3 and 2.5 ± 0.4 g/dL) and RBC count (10.7 ± 4.0 and 14.0 ± 4.1%) at 15 and 30 mg/kg respectively. In cisplatin-treated mice also an increase in hemoglobin (3.4 ± 0.2 and 5.9 ± 0.2 g/dL) and RBC count (22.5 ± 2.2 and 37.3 ± 1.7%) at 15 and 30 mg/kg respectively was observed. ZYAN1's effects on hemoglobin and RBC count were distinct from darbepoietin. ZYAN1 demonstrated hematinic potential by combined effects on EPO release and efficient iron utilization. The efficacy of ZYAN1 in disease models of different etiologies suggests that it will be useful in treating wide spectrum of anemia patients.

Preclinical to clinical translation of CNS transporter occupancy of TD-9855, a novel norepinephrine and serotonin reuptake inhibitor

BACKGROUND

Monoamine reuptake inhibitors exhibit unique clinical profiles that reflect distinct engagement of the central nervous system (CNS) transporters.

METHODS

We used a translational strategy, including rodent pharmacokinetic/pharmacodynamic modeling and positron emission tomography (PET) imaging in humans, to establish the transporter profile of TD-9855, a novel norepinephrine and serotonin reuptake inhibitor.

RESULTS

TD-9855 was a potent inhibitor of norepinephrine (NE) and serotonin 5-HT uptake in vitro with an inhibitory selectivity of 4- to 10-fold for NE at human and rat transporters. TD-9855 engaged norepinephrine transporters (NET) and serotonin transporters (SERT) in rat spinal cord, with a plasma EC50 of 11.7 ng/mL and 50.8 ng/mL, respectively, consistent with modest selectivity for NET in vivo. Accounting for species differences in protein binding, the projected human NET and SERT plasma EC50 values were 5.5 ng/mL and 23.9 ng/mL, respectively. A single-dose, open-label PET study (4-20mg TD-9855, oral) was conducted in eight healthy males using the radiotracers [(11)C]-3-amino-4- [2-[(di(methyl)amino)methyl]phenyl]sulfanylbenzonitrile for SERT and [(11)C]-(S,S)-methylreboxetine for NET. The long pharmacokinetic half-life (30-40 h) of TD-9855 allowed for sequential assessment of SERT and NET occupancy in the same subject. The plasma EC50 for NET was estimated to be 1.21 ng/mL, and at doses of greater than 4 mg the projected steady-state NET occupancy is high (>75%). After a single oral dose of 20mg, SERT occupancy was 25 (±8)% at a plasma level of 6.35 ng/mL.

CONCLUSIONS

These data establish the CNS penetration and transporter profile of TD-9855 and inform the selection of potential doses for future clinical evaluation.

Thyroid hormone modulates food intake and glycemia via ghrelin secretion in Zucker fatty rats

Hyperthyroidism is known to increase food intake and central administration of thyroid hormone shows acute orexigenic effects in rodents. We investigated whether T3 influences appetite and glucose homeostasis by modulating circulating ghrelin, an important orexigenic hormone, in Zucker fatty rats. The acute anorectic effects of T3 and ghrelin mimetic MK-0677 were studied in rats trained for fasting induced food intake. The serum concentration of T3, ghrelin, glucose, triglycerides, and liver glycogen were estimated. The involvement of sympathetic nervous system was evaluated by conducting similar experiments in vagotomized rats. T3 increased food intake and glucose in rats over 4 h, with increase in serum T3 and decrease in liver glycogen. T3 treatment was associated with increase in serum ghrelin. An additive effect on appetite and glucose was observed when T3 (oral) was administered with central (intracerebroventricular) administration of a ghrelin mimetic, MK-0677. Ghrelin antagonist, compound 8a, antagonized the hyperglycemic and hyperphagic effects of T3. In vagotomized rats, T3 did not show increase in appetite as well as glucose. Serum ghrelin levels were unchanged in these animals after T3 treatment. However, T3 showed increase in serum triglyceride levels indicating its peripheral lipolytic effect, in vagotomized as well as sham treated animals. To conclude, acute orexigenic and hyperglycemic effects of T3 are associated with ghrelin secretion and activity. This effect seems to be mediated via vagus nerves, and is independent of glucoregulatory hormones.

VEGF prevents apoptosis of human microvascular endothelial cells via opposing effects on MAPK/ERK and SAPK/JNK signaling

Vascular endothelial growth factor (VEGF), an endothelial cell-specific mitogen, promotes endothelial cell survival and angiogenesis. We recently showed that VEGF can support the growth of human dermal microvascular endothelial cells (HDMEC) and human umbilical vein endothelial cells in serum-free medium. Reasoning that VEGF might be modulating apoptotic signal transduction pathways, we examined mechanisms involved in the anti-apoptotic effect of VEGF on starvation- and ceramide-induced apoptosis in HDMEC. We observed that VEGF ameliorated the time-dependent increase in apoptosis, as demonstrated by morphologic observations, TUNEL assay, and DNA fragmentation. On the other hand, basic fibroblast growth factor only partially prevented apoptosis in serum-starved HDMEC; platelet-derived growth factor-BB was completely ineffective. VEGF activated the phosphorylation of extracellular signal regulated kinase (ERK)1 (p44 mitogen-activated protein kinase; MAPK) and ERK2 (p42 MAPK) in a time- and concentration-dependent manner. Both the VEGF-induced activation and its anti-apoptotic effect were prevented by the specific MAPK/ERK inhibitor PD98059. The presence of VEGF also inhibited the sustained activation of stress-activated protein kinase/c-jun-NH2-kinase (SAPK/JNK) caused by serum starvation and ceramide treatment. Activation of the MAPK pathway together with inhibition of SAPK/JNK activity by VEGF appears to be a key event in determining whether an endothelial cell survives or undergoes programmed cell death.

The occurrence of squamous carcinoma and osteosarcoma in young rabbits injected with 90Sr (50-100 mu-c--kg.)

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