Massive Subcutaneous Emphysema and Pneumothorax in a Case of Attacked by a Domesticated Bull - An Autopsy Based Diagnosis

Subcutaneous emphysema is a condition when air or gas gets trapped within the subcutaneous layer. It is characterised by crackling feeling on palpation of the skin known as subcutaneous crepitation which is described as touching rice krispies. A 70 years male from hilly region of Nepal with agricultural background suffered multiple injuries sustained due to an attack by domesticated bull in his house. Upon the incident the injured male was taken to hospital, where he was declared "Brought Dead" by the Emergency Department of Dhulikhel Hospital, Kathmandu University Hospital. His body was brought for autopsy in Department of Forensic Medicine and Toxicology of Kathmandu University School of Medical Sciences. On complete autopsy, massive subcutaneous emphysema and pneumothorax was demonstrated. The details of finding are discussed in detail as follows.

Sexual Dimorphism of Greater Sciatic Notch among Nepalese Population by Three Dimensional CT Images of Pelvis

Background Sex identification from the skeletal remains, is the first and the foremost step encountered by forensic experts. Hip bone being comparatively robust is resistant to damage and scores even in improperly preserved skeletons. It is also widely agreed that the greater sciatic notch (GSN) holds the greatest degree of sexual dimorphism. Objective To study the role of greater Sciatic Notch parameters in sex determination among Nepalese population by means of reconstructed Multi Slice Three-Dimensional Computed Tomography (MDCT) images. Method The CT images of individuals who underwent pelvic CT in the Department of Radiology, Dhulikhel Hospital were included in the study. Measurements of width, depth, angles and indices of greater sciatic notch were measured and calculated. Data were entered and analyzed using SPSS (Statistical Package for Social Sciences) version 25.0. Result There was a significant difference between means of all greater sciatic notch parameters (p > 0.001) between sex showing sexual dimorphism except depth (p=0.65). By using limiting point, 78.18% male and 83.64% female were correctly classified by using total width. Total angle, Posterior segment and Total width had sensitivity and specificity exceeding 80% and overall accuracy of 87% to 92% in all parameters except depth by receiver-operator characteristic curve analysis. Conclusion Application of 3D-CT virtual images in the present study helped us to easily quantify greater sciatic notch parameters. The important greater sciatic notch predictors for sex determination in Nepalese population were determined which would help forensic experts in ascertaining the sex of an unknown individual.

Age-related changes in amplitude, latency and specialization of ERP responses to faces and watches

Healthy aging is associated with impairments in face recognition. While earlier research suggests that these impairments arise during memory retrieval, more recent findings suggest that earlier mechanisms, at the perceptual stage, may also be at play. However, results are often inconsistent and very few studies have included a non-face control stimulus to facilitate interpretation of results with respect to the implication of specialized face mechanisms vs. general cognitive factors. To address these issues, P100, N170 and P200 event-related potentials (ERPs) were measured during processing of faces and watches. For faces, age-related differences were found for P100, N170 and P200 ERPs. For watches, age-related differences were found for N170 and P200 ERPs. Older adults showed less selective and less lateralized N170 responses to faces, suggesting that ERPs can detect age-related de-differentiation of specialized face networks. We conclude that age-related impairments in face recognition arise in part from difficulties in the earliest perceptual stages of visual information processing. A working model is presented based on coarse-to-fine analysis of visually similar exemplars.

Risk for and consequences of endometriosis: A critical epidemiologic review

Endometriosis affects approximately 10% of women of reproductive age. Characteristics robustly associated with a greater risk for endometriosis include early age at menarche, short menstrual cycle length, and lean body size, whereas greater parity has been associated with a lower risk. Relationships with other potential characteristics including physical activity, dietary factors, and lactation have been less consistent, partially because of the need for rigorous data collection and a longitudinal study design. Critical methodologic complexities include the need for a clear case definition; valid selection of comparison/control groups; and consideration of diagnostic bias and reverse causation when exploring demographic characteristics, medical history, and lifestyle factors. Reviewers and editors must demand a detailed description of rigorous methods to facilitate comparison and replication to advance our understanding of endometriosis.

Meckel's Diverticulum: a Systematic Review

Meckel's diverticulum is the most common congenital malformation of gastrointestinal tract. It can cause complications in the form of ulceration, haemorrhage, intussusception, intestinal obstruction, perforation and, very rarely, vesicodiverticular fistulae and tumours. These complications, especially bleeding, are more common in the paediatric age group than in adults; however it is not uncommon to miss the diagnosis of Meckel's diverticulum in adults. Here, we reviewed the literature regarding the complications of this forgotten clinical entity in adults with potential diagnostic difficulties and management strategies.

A study of Eagle’s syndrome in CMS-TH Bharatpur

Objective To study the common symptoms and outcome of surgical treatment of Eagle’s syndromeMethods A total of 22 cases were studied prospectively in both sexes from January 2008 to December 2010, in Department of ENT-HNS College Of Medical Sciences-Teaching Hospital, Bharatpur, Nepal. Patients with symptomatic styloid process were clinically palpated at tonsillar fossa and finally sent for X-ray styloid process. Patients underwent intra-oral tonsillectomy with styloidectomy. Post-operative improvement was analysed by follow up at one three and six months interval.Results Most common age group was 30-40 years (63.63%) with female dominance (M:F=1:4.5). The most frequent symptoms were pain in throat (29.62%), referred pain in ear (20.37%), pain in anterior triangle in neck (24.07%), foreign body sensation in throat (14.81%) and difficulty in swallowing (11.11%). Fifty nine percent of patients were having symptoms for last two to four years and 50% were on medication for last one to two years. All the patients underwent styloidectomy through intra-oral route. (63.63%) patients became symptom free and 13.63% didn’t show improvement even after operation.Conclusion Eagle’s syndrome is common in young females with various atypical presentations. Dull/throbbing or radiationg throat pain and pain in anterior triangle of the neck are common presentations. Diagnosis is done simply by palpating the tonsillar fossa.Journal of College of Medical Sciences-Nepal, 2014, Vol.10(1); 5-10

Development of maternal and neonatal composite outcomes for trials evaluating management of late-onset pre-eclampsia

OBJECTIVE

Pre-eclampsia is associated with significant maternal and neonatal complications, and delivery is often expedited to minimise complications. For randomised trials evaluating interventions in women with late-onset (>34 weeks) mild to moderate pre-eclampsia, no single outcome has been identified to be the most clinically important. Existing composite outcomes with more than one clinically relevant endpoint to evaluate interventions in pre-eclampsia provide limited justification for selection of the components. Our objective was to develop robust, valid composite maternal and neonatal outcome measures for clinical trials evaluating interventions in women with late-onset mild and moderate pre-eclampsia.

STUDY DESIGN

A two-generational Delphi method was used to identify these clinically important maternal and neonatal outcomes. Composite outcomes were developed based on biological plausibility, independence from each other, frequency of occurrence and level of importance.

RESULTS

The final maternal composite outcome included maternal death, eclampsia, stroke or reversible ischaemic neurological deficit, pulmonary oedema, major obstetric haemorrhage, need for positive inotropic support, haemolysis, elevated liver enzymes and low platelets syndrome and placental abruption; and the neonatal composite outcome included neonatal death, respiratory distress syndrome needing ventilator support and neurological outcomes as cystic periventricular leukomalacia and grade III/IV intraventricular haemorrhage.

CONCLUSION

The composite outcomes developed will enable clinical trials to provide robust estimates on the effectiveness of the interventions in women with mild to moderate late onset pre-eclampsia to inform clinical practice. Caution is needed in the interpretation of composite outcomes due to variation in the importance of individual components.

Meckel's diverticulum: a systematic review

Meckel's diverticulum is the most common congenital malformation of gastrointestinal tract. It can cause complications in the form of ulceration, haemorrhage, intussusception, intestinal obstruction, perforation and, very rarely, vesicodiverticular fistulae and tumours. These complications, especially bleeding, are more common in the paediatric age group than in adults; however it is not uncommon to miss the diagnosis of Meckel's diverticulum in adults. Here, we reviewed the literature regarding the complications of this forgotten clinical entity in adults with potential diagnostic difficulties and management strategies.

Idiopathic infected hydrocele in a toddler: a case report with review

Idiopathic infected hydrocele in infants is a rare, but well-documented, entity in English literature; however, occurrence of such a condition in a toddler is not yet documented. Here we report the case of an idiopathic infected hydrocele in a toddler for the first time in English literature. We also discuss a review of literature and demonstrate management of infected hydrocele by antibiotics without any surgical intervention, also for the first time in English literature.

Spontaneous penile (cavernosal) abscess: case report with discussion of aetiology, diagnosis, and management with review of literature

The rare presentation of spontaneous, corpus cavernosal abscess with evident pus discharge is reported. The 19-year-old English man was successfully treated with surgical drainage and antibiotics with long-term sequelae in form of mild, left-sided penile deviation, but normal erectile function. Though he did not require any further surgical intervention for correction of chordee at that time, there remains a possibility of it getting worse over time, which may ultimately need surgery for correction. The possible aetiology, diagnosis, and treatment of this rare condition are briefly discussed.

Neuroendocrine factors affecting the steady-state levels of early trypsin mRNA in Aedes aegypti

Transcription of the early trypsin gene occurs in the midgut after adult emergence under control of juvenile hormone (JH). We tested the hypothesis that factors that affect the steady-state levels of early trypsin mRNA do so by influencing the levels of JH. We investigated the effect of ingesting different meals on early trypsin mRNA levels as well as on JH levels. We also studied how early trypsin mRNA levels changed when the midgut was isolated from different components of the neuroendocrine system by abdominal ligation and decapitation. Early trypsin transcripts levels are high in unfed females; feeding different meals had three distinct effects on the changes of steady-state levels of early trypsin mRNA: (1) blood and protein meals caused the level to decrease drastically and remained low for at least 24 h; (2) amino acid meals caused a transient decrease in the mRNA level, but it returned to high levels after 12-18 h; and (3) sugar, latex and saline meals had no effect on the early trypsin mRNA steady-state levels. The changes in JH levels after ingesting blood and amino acid meals show profiles resembling the changes in early trypsin mRNA levels for the corresponding meal. Decapitation at 1, 2 and 3 days after emergence does not affect the steady-state levels of early trypsin in unfed females. In contrast, 24 h after feeding, transcript levels were significantly higher in decapitated females when compared with non-decapitated fed females. We propose that the changes in the steady-state levels of early trypsin mRNA observed after the ingestion of different meals, ligations and decapitations are generated by changes in the levels of juvenile hormone.

Endolymphatic sac surgery in Meniere's disease

Despite the controversy that surrounds sac surgery for Meniere's disease, it remains in the forefront of surgical intervention for the refractory patient. This article reviews the literature for all types of sac surgery, with emphasis on wide sac-vein decompression as performed at the Michigan Ear Institute.

Juvenile hormone controls early trypsin gene transcription in the midgut of Aedes aegypti

Early trypsin is a female-specific protease present in the Aedes aegypti midgut during the first few hours after ingestion of a blood meal. The enzymatic activity of early trypsin plays an essential role in the transcriptional activation of the late trypsin gene, which encodes the major midgut endoprotease involved in blood meal protein digestion. Transcription of the early trypsin gene is part of the normal post-emergence maturation of the midgut in the adult female. Abdominal ligation within 1 h of emergence completely prevented the transcription of the early trypsin gene. Topically applied JH III or methoprene induced transcription of the early trypsin gene in ligated abdomens to levels similar to those observed in non-ligated females. The induction of early trypsin transcription by JH is dose-dependent and 'head-independent', suggesting that factors coming from the neuro-secretory axis are not required.

Combination therapy for salvaging a failing, experimental skin flap

The failing free flap remains a major problem for the reconstructive surgeon. Many and varied pharmacologic agents have been utilized to reverse the effects of ischemia in these flaps. Treatments have been aimed at inhibiting presumed causative factors in the no-reflow phenomenon. Therapy has generally been single in nature and designed to affect only one of these presumed factors. In this study, several pharmacologic agents were utilized individually or in combination therapy as postischemic washouts, in an effort to attack the multiple causative factors in the no-reflow phenomenon and to improve flap survival in a rat abdominal skin flap model. The treatment agents included lactated Ringer's, superoxide dismutase, and urokinase, with each used independently as a postischemic perfusion washout. Combination therapy utilized an initial postischemic perfusion with urokinase, followed by a second perfusion washout with superoxide dismutase. After 18 hr of primary ischemia, there was increased flap survival in the animals undergoing perfusion washout with either superoxide dismutase alone or with combined urokinase and superoxide dismutase washouts, compared to all other treatments (p < 0.001). It was found that flaps undergoing combined urokinase and superoxide dismutase postischemic perfusion washouts demonstrated significantly improved survival after 20 hr of primary ischemia, compared to all other therapies (p < 0.05). By demonstrating improved survival when a thrombolytic agent is used in conjunction with an oxygen free radical scavenger, these findings may have implications in the treatment of clinically failing free flaps.

Sinonasal hemangiopericytomas: a clinicopathologic and immunohistochemical study of seven cases

BACKGROUND

Sinonasal hemangiopericytoma (SNHPC) is a rare lesion usually of low-grade malignant potential. Aggressive and metastatic cases are uncommon, and experience using adjuvant therapy on these cases has been limited. Tumor-induced osteomalacia has a very rare association with SNHPC. Further, the diagnosis of SNHPC remains one of histologic-pattern recognition. Traditionally, immunohistochemistry has aided in excluding other diagnoses; only vimentin has been consistently expressed by the tumor spindle cells of HPC. Recent studies have shown that Factor XIIIa is also expressed by HPC, (as well as tumors of fibrohistiocytic differentiation) and hence may be yet another helpful positive marker in establishing an immunohistochemical profile.

METHODS

We identified 7 patients at this institution with SNHPC from 1990 to 1994. Immunohistochemistry was performed on seven formalin-fixed paraffin-embedded tumors utilizing antibodies to factor XIIIa as well as antibodies to vimentin, factor VIII, muscle-specific antigen, cytokeratin, and S-100.

RESULTS

All 7 patients were initially seen with nasal obstruction or epistaxis and underwent surgical resection. The period of follow-up was from 3 months to 14 years (mean 54 months) for 7 patients. Three patients had recurrent disease after 3, 5, and 10 years. The first 2 were known to have been originally treated by polypectomy. One patient required adjuvant radiotherapy for metastatic disease and local extension. One patient was initially seen with tumor-induced osteomalacia which dramatically improved following resection of the lesion. The immunohistochemical profile revealed strong expression of vimentin in 7/7 cases, and of factor XIIIa in 4/7 cases; tumor cells did not express the other markers studied.

CONCLUSIONS

Adequate surgical resection with negative margins appears to be the appropriate therapy for SNHPC. Our 1 case associated with tumor-induced osteomalacia was reversible after surgical excision of the tumor. The immunohistochemical results suggest that the pattern of vimentin and factor XIIIa positivity, as well as lack of expression of other markers, is consistent with the diagnosis of HPC, which still remains in the domain of histopathology.

Evaluation of a continuous systemic infusion of iloprost, a stable PGI-2 analog, on the survival of experimental skin flaps

Numerous investigators have attempted to enhance the survival of ischemic experimental skin flaps using various pharmacologic manipulations. Recently, the authors' laboratory demonstrated the beneficial effect of iloprost, a stable PGI2 analogue, as a post-ischemic perfusion washout, in improving the survival of ischemic skin flaps. The rat unilateral abdominal skin flap, based on the superficial epigastric vessels, was utilized in this study involving 30 animals. The animals were divided into three different treatment groups, with ischemic periods of 16 and 18 hr. Perfusion washouts were performed at the completion of the various ischemic periods. Alzet osmotic pumps were used to deliver a continuous systemic infusion of iloprost for 7 days postoperatively. The groups consisted of the following: Group 1 (single ILO)--perfusion washout with iloprost only; Group 2 (continuous LD ILO)--low-dose systemic iloprost infusion (0.066 mcg/kg/min) and perfusion washout with iloprost; and Group 3 (continuous HD ILO)--high-dose systemic iloprost infusion (0.1 mcg/kg/min) and perfusion washout with iloprost. The percentage of flap survival was assessed on postoperative day 7. Skin flaps of the animals receiving the continuous systemic infusion of iloprost were noted to have varying percentages of survival, while skin flaps undergoing perfusion washout only were found to have either complete survival using a continuous systemic infusion of iloprost, compared to iloprost perfusion washout alone. In addition, the hypotensive side effects of systemic iloprost infusion limit its use in the rat skin-flap model.

Cerebrospinal fluid rhinorrhea with bilateral intradiploic epidermoid tumors: a case report

Bilateral large intradiploic epidermoid tumors of the occipital bone presented clinically with CSF rhinorrhea are presented.

The cardiac inotropic responses to insulin in the rat heart

Insulin (5 to 40 I.U.) produced dose-dependent positive inotropic effect in the isolated rat heart. The responses to insulin were markedly inhibited in the presence of propranolol (1 . 1X10(-6) M). Insulin responses were markedly reduced in reserpine pretreated (5 mg/kg, i.p.) rats. Theophylline (4.4 mM), the phosphodiesterase inhibitor, potentiated the responses to insulin, whereas imidazole (20 mM), the phosphodiesterase stimulator inhibited the responses to insulin. The data suggest that the positive inotropic effects of insulin in rat heart is mediated through the release of cardiac catecholamines which stimulates beta-adrenoceptors. The final mediator of cardiac action seems to be cyclic-AMP.