Benign Mullerian Glandular Inclusions in Men: A Metastatic Carcinoma Mimic

Introduction/Objective

Benign mullerian glandular inclusions (MGI) in lymph nodes is a well documented finding in women. However, it can also very rarely occur in men and mimic metastatic carcinoma. To our knowledge, only seven cases of benign MGI in men have been reported in the literature.

Methods/Case Report

We here-in present a case of a 62-year-old male with a three-year history of prostatic adenocarcinoma Gleason score 6, initially diagnosed on needle core biopsies. Subsequently, the patient underwent a radical prostatectomy with bilateral pelvic lymph node dissection. Histological evaluation of the right pelvic lymph node demonstrated cystically dilated glands beneath the capsule composed of cuboidal to columnar cells with minimal atypia raising concern for metastatic carcinoma to the lymph node. Immunohistochemical (IHC) stains showed the glandular cells to be positive for estrogen, progesterone, PAX-8 and WT-1; while negative for calretinin and PSA immunostains. This IHC profile in conjunction with the morphological findings are consistent with the diagnosis of benign mullerian-type glandular inclusions within the lymph node.

Results (if a Case Study enter NA)

NA.

Conclusion

As benign MGI is a rare finding in men and can easily be mistaken for metastatic carcinoma, this case demonstrates that clinical awareness of this entity is essential to avoid wrongful diagnosis of metastatic carcinoma and unnecessary therapeutic treatment. Utilizing immunohistochemical stains to further characterize the glands is critical to obtain the correct diagnosis.

Colonic Large Cell Neuroendocrine Carcinoma with Extensive Carcinomatosis: A Highly Aggressive Tumor

Introduction/Objective

Large cell neuroendocrine carcinoma (LCNEC) of the colon is an exceedingly rare and aggressive neuroendocrine carcinoma. These tumors are associated with a poor prognosis, as they are commonly diagnosed in advanced stages with distant metastases. We present a case of a patient with colonic LCNEC with carcinomatosis peritonei who underwent surgical resection and hyperthermic intraperitoneal chemotherapy.

Methods/Case Report

The patient is a 49-year-old Caucasian male who presented with several months history of occasional hematochezia, constipation, 40-pound unintentional weight loss, and reflux. An initial diagnosis of adenocarcinoma of colorectal origin was rendered. Subsequently, the patient underwent a low-anterior resection with hyperthermic intraperitoneal chemotherapy (HIPEC). Histological evaluation of the rectosigmoid lesion demonstrated sheets of malignant epithelial cells with scant amphophilic cytoplasm, large pleomorphic vesicular nuclei, prominent nucleoli, and numerous mitotic figures. The tumor invaded the entire colonic wall and extended to the visceral peritoneum with extensive small vessel lymphovascular and perineural invasion with widespread involvement of the diaphragm, spleen, falciform ligament, and omentum. Immunohistochemical stains showed the tumor to be diffusely positive for CK20, CDX2, and synaptophysin; while negative for CK7, PAP, PSA, chromogranin, and p40. These findings are consistent with the diagnosis of a large cell neuroendocrine carcinoma. In addition, CD31 highlighted lymphatic spaces that were extensively filled with tumor cells. One-month post-operative, the patient remains in critical but stable condition with features of acute hypoxic respiratory failure and possible metastatic disease to the lung associated with pleural effusion.

Results (if a Case Study enter NA)

NA

Conclusion

Colonic large cell neuroendocrine carcinoma (LCNEC) is a rare, highly aggressive neuroendocrine carcinoma that frequently presents with distant metastases. Clinical awareness of the entity with early diagnosis and surgical resection remains the essential initial step. Utilizing immunohistochemistry stains to further characterize the tumor is critical to reach the correct diagnosis. Accumulating appropriate clinical data will aid in the establishment of future treatment protocols.

Plastid-mediated singlet oxygen in regulated cell death

Reactive oxygen species (ROS) generation within a cell is a natural process of specific subcellular components involved in redox reactions. Within a plant cell, chloroplasts are one of the major sources of ROS generation. Plastid-generated ROS molecules include singlet oxygen (¹ O₂ ), superoxide radical (O₂ ^- ), hydroxyl radical (OH^• ) and hydrogen peroxide (H₂ O₂ ), which are produced mainly during photochemical reactions of photosynthesis and chlorophyll biosynthetic process. Under normal growth and developmental, generated ROS molecules act as a secondary messenger controlling several metabolic reactions; however, perturbed environmental conditions lead to multi-fold amplification of cellular ROS that eventually kill the target cell. To maintain homeostasis between production and scavenging of ROS, the cell has instituted several enzymatic and non-enzymatic antioxidant machineries to maintain ROS at a physiological level. Among chloroplastic ROS molecules, excess generation of singlet oxygen (¹ O₂ ) is highly deleterious to the cell metabolic functions and survival. Interestingly, within cellular antioxidant machinery, enzymes involved in detoxification of ¹ O₂ are lacking. Recent studies suggest that under optimal concentrations, ¹ O₂ acts as a signalling molecule and drives the cell to either the acclimation pathway or regulated cell death (RCD). Stress-induced RCD is a survival mechanism for the whole plant, while the involvement of chloroplasts and chloroplast-localized molecules that execute RCD are not well understood. In this review, we advocate for participation of chloroplasts-generated ¹ O₂ in signalling and RCD in plants.

Changing demographics and risk factors for cryptococcosis: A 12-year review at a tertiary care centre

BACKGROUND

Cryptococcosis is classically associated with the immunocompromised patients but there is a rising appreciation for its impact on the immunocompetent hosts. We sought to analyse the trends, diagnosis, treatment of different hosts and the effect of immunodeficiency and chronic liver disease on relapse and in-house mortality.

METHODS

This is a retrospective study of 12 years of patients with cryptococcosis, divided into three different groups: HIV-infected, transplant and non-HIV non-transplant (NHNT). Data were analysed with Chi-square, unpaired parametric t test, simple and multivariate logistic regression analysis.

RESULTS

Of 114 identified patients, 23 (20.2%) had HIV infection, 11 (9.6%) had transplant, 80 (70.2%) were NHNT patients. Overall, mortality was 28.1% (32/114) and relapse occurred in 10.5% (12/114) of patients. The mortality trend was higher (OR = 2.346, p = .287) in the transplant group (45.5%, 5/11) than in HIV (26.1%, 6/23) and NHNT groups (26.3%, 21/80). HIV was associated with relapse; 30.4% (7/23) for HIV-positive patients and 5.5% (5/91) for HIV-negative patients (OR = 7.525, p = .002). Chronic liver disease had a large and statistically significant association with mortality on multivariate analysis (OR = 3.583, p = .013) which was more pronounced than the HIV or transplant groups. It was independently associated with mortality by chi-square analysis (OR 3.137, p = .012).

CONCLUSION

Chronic liver disease represented 30.7% (35/114) of all studied patients. It was a risk factor for in-hospital mortality. HIV infection and transplant were not statistically significant for mortality. Relapse was highest in the HIV-infected patients at 30.4% (7/23). These data highlight the effect of type and degree of immunocompromise on cryptococcosis.

Clinical decision-making and importance of the AAE/AAOMR position statement for CBCT examination in endodontic cases

AIM

To compare conventional radiographic and cone beam computed tomography (CBCT) findings with reference to the American Association of Endodontics and American Academy of Oral and Maxillofacial Radiology (AAE/AAOMR) joint position statement and to determine the effect of the CBCT on the initial diagnoses and treatment plans in a single-centre Postgraduate Endodontic Programme.

METHODOLOGY

The clinical CBCT scans of patients, treated at the Endodontic Department of the University of British Columbia, were reviewed for CBCT referrals by comparing them with corresponding radiographs. The features considered were periapical lesions, missed/extra canals, root fractures, complex anatomy, calcified canals and root resorption of tooth/teeth in question. Reasons for the CBCT prescriptions were assigned to 3 groups: to formulate the primary diagnosis, to confirm the diagnosis achieved by clinical examination and conventional radiographs, and to assist in treatment planning. Variables were compared statistically using chi-square and McNemar tests.

RESULTS

A total of 128 CBCT examinations were performed on 110 patients. No CBCT examination was performed more than once on the same tooth. Overall, 76% of CBCT examinations were performed on previously root filled teeth. CBCT images revealed a significantly higher incidence of periapical lesions (P = 0.002), missed canals (P < 0.001), vertical root fractures (P = 0.004) and complex anatomy (P = 0.008) than periapical radiographs. CBCT was prescribed most frequently to assist surgical treatment planning (62%) rather than for generating a diagnosis (9%) or confirming diagnoses (29%). Both the diagnosis (P = 0.001) and the treatment plan (P = 0.005) initially made by examining periapical radiographs were altered significantly by the subsequent CBCT examination by revealing information such as new periapical lesions, missed canals or involvement of buccal or lingual cortical bone.

CONCLUSION

CBCT examinations were prescribed mainly to assist treatment planning rather than for diagnosis. The majority of CBCT examinations were performed on previously root filled teeth. The additional information obtained from CBCT scans resulted in the alteration of the initial diagnoses as well as subsequent treatment plans in 59 out of 128 cases.

Training of the spiritual dimension of health in India – an innovative ‘thought model’ approach

Background

The complexities in defining Spirituality, its association with religions, and misfit in modern scientific healthcare settings are the reasons behind the neglected attitude in training of spiritual dimension of health in religiously diverse and secular India.

Objectives

To define spirituality independent from religious views and scientifically sound for modern healthcare practices in a diverse society of India. For this, a 'Thought Model' developed with spirituality as the most evolved thought in the form of humanity and human values with transcendence, connectedness, and purpose of human life, which works as a controlling, communicating, and correcting thought in the ecosystem of human thought processes. Review and testing with healthcare professionals (completed in Nov 2019), leading to few pilot projects (in progress till Sept 2020), and finally working with academia to finetune it for training curricula for health systems.

Results

The 'thought model' presented to health experts from July to October 2019. 98% [80 out of 82(N)] considered this simple, comfortable to belief systems, and practice. 96% found it helpful in solving the issues where the physician and patient or the members of the medical team are from different religions. 99% considered this model scientific and useful in responding to the spiritual needs of all, including atheists. So, we planned to start a pilot project in two selected medical institutions for medical interns with the new session; results are awaiting.

Conclusions

Review results by health experts indicated that the 'thought model' can address the complexities and ambiguities in defining spirituality on religious grounds by simplifying its definition and independent of religious beliefs for the training of the spiritual dimension of health and healthcare in diverse and secular societies makes it easy to discuss spiritual aspects of health in communities with various religions and belief systems.

Key messages

Religiosity makes spirituality complex, communal, and unscientific in religiously diverse societies leading to reluctance in public health practices and training. Simplifying spirituality as an evolved thought can change the perspective by abolishing religiosity; it becomes comfortable with belief systems and science and suitable for training and research.

1713. Impact of False-Positive Low-Titer Cryptococcal Antigen Testing

Background

At University of Kentucky (UK) HealthCare, the transition from latex agglutination testing (Remel, Lenexa, KS) to IMMY Cryptococcal Antigen Lateral Flow Assay (CrAg LFA) occurred in September 2016. A few months later, it was noticed that several cryptococcal cases were diagnosed with weak positive test results where the diagnosis could not be confirmed by additional testing. The purpose of this study was to analyze the characteristics of these patients, and to assess the interventions they received based on positive results.

Methods

This was a retrospective study of the patients with positive CrAg LFA treated at UK HealthCare from November to December 2016. Low antigen titers (≤ 1:20) were considered to be false positive if repeat testing with the Remel Cryptococcal Latex assay, IMMY latex and IMMY microwell EIA were negative, cultures and histopathology were negative and there was no clear clinical evidence of infection.

Results

During this 2-month period, CrAg LFA was positive in 12 patients. The diagnosis of cryptococcosis could not be confirmed by additional testing in 9 (75%) individuals. Cirrhosis/liver disease was present in 3 (33.3%) patients, 5 (55.6%) underwent lumber puncture and antifungal therapy was administered in 8 (88.9%) patients (Table 1). CrAg LFA was false positive in 1/2 (50%) HIV, 3/3 (100%) transplant, and 5/7 (71.4%) non-HIV/non-transplant patients (Figure 1). Among the false positives, 4 (44.4%) patients had titer of 1:5, two (22.2%) had 1:20, and the original positive screen was not detected upon titration in 3 (33.3%) other patients. One HIV patient received a complete treatment course for unconfirmed cryptococcal meningitis because an LP could not be performed.

Conclusion

False-positive low CrAg LFA titers led to unnecessary tests, antifungal treatments and prolonged hospitalization in some patients. One-third of these individuals had cirrhosis/liver disease. Other institutions also reported false-positive low CrAg LFA titers. As a result, the company staged a recall of the specific lot and corrected the problem in reagent manufacturing. Low-positive titers using CrAg LFA should be interpreted carefully and further testing should be considered as determined by the clinical situation.

Disclosures

All authors: No reported disclosures.

1705. Clinical Characteristics and Outcomes of Cryptococcosis in a Tertiary Care Center in Kentucky, 2005 to 2017

Background

Cryptococcosis is an invasive fungal infection that causes pneumonia and extrapulmonary infection. This study explores its presentations, diagnostic tests, and outcome in different groups over a 12-year period at an academic medical center.

Methods

This was a retrospective study of the patients treated at University of Kentucky HealthCare from October 16, 2005 to October 15, 2017. Inclusion criteria were positive cryptococcal antigen (Ag), positive culture, or presence of yeast morphologically consistent with Cryptococcus on cyto- or histopathology. Patients were divided into HIV-infected, solid-organ transplant (SOT) recipients, and non-HIV/non-transplant groups. Cryptococcal meningitis comprised of either positive CSF Ag, culture, cytology or histopathology.

Results

A total of 114 patients were identified; 23 HIV-infected, 11 SOT recipients and 80 non-HIV/non-transplant patients (Table 1). Cryptococcus neoformans was the most common yeast isolated (91.8%). Cryptococcal meningitis was seen in 56% of total patients whereas 27% had isolated cryptococcal pneumonia (P < 0.01). Blood cultures and serum Ag were positive in 34% and 70%, respectively. Only 8.7% of HIV-infected patients had isolated pulmonary cryptococcosis compared with 36.4% in SOT recipients (P < 0.01). In patients with cryptococcal meningitis, abnormal CSF cell count, protein, or glucose was noted in 85.3%; India ink was positive in 61.3% and CSF culture was positive in 73.4% (Table 2, Figure 1). CSF cryptococcal Ag was detected in 95.6% cases if CSF cultures were positive, whereas serum Ag was positive in only 85.1% of meningitis cases. Mortality was seen in 48.6% (17/35) of patients with cirrhosis/liver disease, compared with 21.5% (17/79) of non-cirrhosis/liver disease (P = 0.003). Transplant group had 54.5% mortality compared with 26.1% in HIV group (P = 0.016).

Conclusion

Cryptococcal meningitis was the most common presentation for cryptococcal disease in all three groups. Isolated pulmonary disease was least common in the HIV-infected group. Inpatient mortality rate was higher in patients with cirrhosis/liver disease and transplant group compared with those without cirrhosis/liver disease and HIV group, respectively. It is imperative to rule out meningitis in immunosuppressed patients with cryptococcal pneumonia.

Disclosures

All authors: No reported disclosures.

Central Nervous System Blastomycosis With Multiple Brain Abscesses Presenting as Right Upper Extremity Weakness

Blastomycosis is a mycotic infection that typically affects the lung, but that can have dermatologic, orthopedic, genitourinary, and central nervous system manifestations. Blastomyces dermatitidis is a true human pathogen, which can produce disease in immunocompetent hosts. Risk factors for infection include residence in or travel to endemic areas and outdoor occupation, particularly those activities near open bodies of water and that disrupt soil. Immunosuppressed patients are also at increased risk for severe and disseminated disease. We present a case of a 79-year-old male who presented with a 2-week history of progressive right upper extremity weakness and severe odontogenic disease. He was found to have multiple brain abscesses with positive cultures from a cerebral abscess incision and drainage for B dermatitidis. He underwent an incision and drainage of the largest cerebral abscess and was treated with intravenous liposomal amphotericin B, which he tolerated poorly. He was subsequently switched to voriconazole, which was well tolerated, and his neurological deficits improved throughout his hospitalization.

Changing trend in bacterial etiology and antibiotic resistance in sepsis of intramural neonates at a tertiary care hospital

Background:

Septicemia is an important cause of neonatal morbidity and mortality. However, organized data on causative organisms and their resistant pattern are scanty from developing countries. The changing trend in causative organisms and their antibiotic resistance is yet to be documented in India. The present study examines the trends in bacterial profile and antibiotic resistance of the organisms causing sepsis in hospitalized neonates.

Materials and Methods:

A retrospective laboratory-based analysis of blood cultures obtained from Neonatal Intensive Care Unit of a tertiary care hospital in New Delhi was done for the period of 1999–2014, divided into five phases.

Results:

A total of 4700 isolates were considered. Over time, Gram-negative organisms have replaced Gram-positives as frequent isolates. Initially, there was predominance of Klebsiella pneumoniae, then of Staphylococcus aureus which recently has been changed with coagulase negative-Staphylococcus and Acinetobacter. Growing resistance against the first and second line of drugs has been noted, including methicillin-resistant S. aureus and vancomycin-resistant Enterococcus.

Conclusion:

The etiological profile of neonatal sepsis has changed tremendously in the past 15 years. High resistance against common drugs necessitates continued surveillance and review of empirical antibiotic policy for neonatal sepsis. These steps are important to effectively curtail the surge of further antibiotic resistance.

Phylogenetic analysis of haemagglutinin gene deciphering a new genetically distinct lineage of canine distemper virus circulating among domestic dogs in India

Canine distemper (CD) is one of the highly contagious and invariably fatal viral diseases of dogs and other carnivores. Despite the widespread use of modified live vaccines to control CD, the prevalence of disease has increased at an alarming rate in recent years. Although a number of factors may be ascribed for vaccine failure, antigenic differences among the vaccine and wild-type strains have gained the interest of researchers. Considering the high genetic variability of haemagglutinin gene (H gene) and its role in eliciting the immune response to canine distemper virus (CDV), we have generated nine full-length CDV H gene sequences from infected dogs including three vaccinated cases. Bayesian analysis was performed using 102 full-length H gene nucleotide sequences over a time frame of 76 years (1940-2016) from 18 countries. The time to the most recent common ancestor (tMRCA) of CDV was estimated to be 1696 AD. Phylogenetic reconstruction clustered Indian wild-type viruses into a distinct monophyletic group clearly separated from the previously established CDV lineages. This signifies the presence of a novel genetic variant (proposed as "Lineage India-1/Asia-5") circulating among dog population in India. To investigate the importance of substitutions at amino acid residues 530 and 549 of CDV H protein in determining the host switches from canid to non-canid hosts, we analysed 125 H gene sequences including nine sequences generated in this study. Selection pressure analysis and analysis of amino acid sequences revealed a trend towards adaptation of 549H variants in non-canid hosts although no role of G/E530R/D/N substitution could be identified. This is the first comprehensive study about the nature and ecology of CDV circulating among dog population in India. Outbreaks in vaccinated animals as observed in this study have raised a concern towards the effectiveness of current vaccine strains warranting detailed investigation.

1804. Impact of Susceptibility Testing Method on Antibiotic Selection for Methicillin-Resistant Staphylococcus Aureus (MRSA) Bacteremia

Background

The selection of intravenous (IV) antibiotics for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia can be influenced by the vancomycin minimum inhibitory concentration (MIC). This study explores the changes in antibiotic use and inpatient mortality for patients with MRSA bacteremia after switching the MIC testing methods.

Methods

At University of Kentucky Medical Center, Etest™ was implemented in November 2013 for all Staphylococcus aureus blood isolates. In April 2016, this was changed to Phoenix™ automated system. Data regarding antibiotic usage for patients with MRSA bacteremia were collected from July 2014 to December 2015 (Etest™) and September 2016 to March 2017 (Phoenix™). Only patients started on IV vancomycin were included. Daptomycin and ceftaroline use was monitored by the antimicrobial stewardship team with focus on guideline adherence.

Results

A total of 119 and 62 patients were identified before and after switching to Phoenix™. MICs of 2 μg/mL were significantly decreased (P < 0.001) after changing to Phoenix™ (Table 1). Daptomycin use (alone or in combination) decreased from 37% (44/119) to 21% (13/62) (P = 0.013). Ceftaroline use (alone or in combination) decreased from 32% (38/119) to 19% (12/62) (P = 0.036). The reason for escalation in 13 of 44 (30%) patients with daptomycin and 6 of 38 (16%) patients with ceftaroline was an MIC of 2 μg/mL. Overall, IV vancomycin use (alone or in combination) increased from 50% (60/119) to 69% (43/62) (P = 0.007). All-cause inpatient mortality was 16% (19/119) before and 10% (6/62) (P = 0.24) after switching to Phoenix.

Conclusion

A switch in vancomycin susceptibility testing from Etest™ to Phoenix™ automated system was associated with a significant decrease in daptomycin and ceftaroline use and an increase in IV vancomycin use without any change in all-cause inpatient mortality.

Disclosures

All authors: No reported disclosures.

Effect of non-genetic factors on the prevalence of Stilesia globipunctata in the goat

Despite its high prevalence and pathogenicity, Stilesia globipunctata is a neglected cestode infection of ruminants in the tropics and sub-tropics. The present study reports the effect of sex, age, year and month on the prevalence of S. globipunctata in the goat. A total of 5208 eviscerated intestines of the goat carcasses were screened for a period of seven years, from January 2001 to December 2007. The overall prevalence of 36.6 % was significantly affected by the factors studied (P<0.05). Male goats were more susceptible to the S. globipunctata infection than that of female (P<0.05). Goat aged between 6 months and 1 year were found to be significantly more susceptible (P<0.05) which was followed by animals between 1 and 4 years of age and then more than 4 years of age. Morbidity was high (59 to 86 %) in animals of less than one year of age. The striking observation was that the prevalence peaked during monsoon and at nadir in May.

Computational Fluid Dynamic Simulations of Maternal Circulation: Wall Shear Stress in the Human Placenta and Its Biological Implications

Introduction

In the human placenta the maternal blood circulates in the intervillous space (IVS). The syncytiotrophoblast (STB) is in direct contact with maternal blood. The wall shear stress (WSS) exerted by the maternal blood flow on the STB has not been evaluated. Our objective was to determine the physiological WSS exerted on the surface of the STB during the third trimester of pregnancy.

Material and Methods

To gain insight into the shear stress levels that the STB is expected to experience in vivo, we have formulated three different computational models of varying levels of complexity that reflect different physical representations of the IVS. Computations of the flow fields in all models were performed using the CFD module of the finite element code COMSOL Multiphysics 4.4. The mean velocity of maternal blood in the IVS during the third trimester was measured in vivo with dynamic MRI (0.94±0.14 mm.s^-1). To investigate if the in silico results are consistent with physiological observations, we studied the cytoadhesion of human parasitized (Plasmodium falciparum) erythrocytes to primary human STB cultures, in flow conditions with different WSS values.

Results

The WSS applied to the STB is highly heterogeneous in the IVS. The estimated average values are relatively low (0.5±0.2 to 2.3±1.1 dyn.cm^-2). The increase of WSS from 0.15 to 5 dyn.cm^-2 was associated with a significant decrease of infected erythrocyte cytoadhesion. No cytoadhesion of infected erythrocytes was observed above 5 dyn.cm^-2 applied for one hour.

Conclusion

Our study provides for the first time a WSS estimation in the maternal placental circulation. In spite of high maternal blood flow rates, the average WSS applied at the surface of the chorionic villi is low (<5 dyn.cm^-2). These results provide the basis for future physiologically-relevant in vitro studies of the biological effects of WSS on the STB.

Biofilm as a virulence marker in Candida species in Nosocomial blood stream infection and its correlation with antifungal resistance

Nosocomial blood stream infections (BSI) due to fungi especially Candida is increasing steadily. A two year prospective study was conducted in the S.C.B. Medical College with an aim to evaluate the species distribution, antifungal susceptibility and biofilm formation of Candida spp. isolated from nosocomial BSIs. 34 Candida spp. were isolated from 359 blood cultures. Antifungal susceptibility was performed by microbroth dilution technique and both visual and spectrophotometric method were used for biofilm detection. C. tropicalis was the common spp. isolated followed by C. parapsilosis and others. Most (92%) of the isolates were susceptible to Amphoterecin-B and highest resistance was observed against Flucytosine (37%) and Fluconazole(35%). Biofilm production and antifungal resistance was observed more in nonalbicans Candida spp.

Spontaneous coronary artery dissection with multiple coronary artery aneurysms in a patient with diabetic ketoacidosis

Spontaneous coronary artery dissection (SCAD) is a very rare and commonly fatal condition that typically presents with signs and symptoms of an acute myocardial infarction and cardiogenic shock. We herein present a case of a 54-year-old woman who was diagnosed with diabetic ketoacidosis (DKA) as the first manifestation of her underlying diabetes mellitus, while being hospitalized for treatment, she was found to have a non ST-elevation myocardial infarction (NSTEMI), an urgent cardiac catheterization revealed a complete dissection of the right coronary artery (RCA) with an intraluminal thrombus formation and multiple aneurismal dilatations in the left anterior descending (LAD) and left circumflex (LC) arteries. The patient underwent coronary artery bypass grafting with a favorable outcome.

Randomized trial of safinamide add-on to levodopa in Parkinson's disease with motor fluctuations

Levodopa is effective for the motor symptoms of Parkinson's disease (PD), but is associated with motor fluctuations and dyskinesia. Many patients require add-on therapy to improve motor fluctuations without exacerbating dyskinesia. The objective of this Phase III, multicenter, double-blind, placebo-controlled, parallel-group study was to evaluate the efficacy and safety of safinamide, an α-aminoamide with dopaminergic and nondopaminergic mechanisms, as add-on to l-dopa in the treatment of patients with PD and motor fluctuations. Patients were randomized to oral safinamide 100 mg/day (n = 224), 50 mg/day (n = 223), or placebo (n = 222) for 24 weeks. The primary endpoint was total on time with no or nontroublesome dyskinesia (assessed using the Hauser patient diaries). Secondary endpoints included off time, Unified Parkinson's Disease Rating Scale (UPDRS) Part III (motor) scores, and Clinical Global Impression-Change (CGI-C). At week 24, mean ± SD increases in total on time with no or nontroublesome dyskinesia were 1.36 ± 2.625 hours for safinamide 100 mg/day, 1.37 ± 2.745 hours for safinamide 50 mg/day, and 0.97 ± 2.375 hours for placebo. Least squares means differences in both safinamide groups were significantly higher versus placebo. Improvements in off time, UPDRS Part III, and CGI-C were significantly greater in both safinamide groups versus placebo. There were no significant between-group differences for incidences of treatment-emergent adverse events (TEAEs) or TEAEs leading to discontinuation. The addition of safinamide 50 mg/day or 100 mg/day to l-dopa in patients with PD and motor fluctuations significantly increased total on time with no or nontroublesome dyskinesia, decreased off time, and improved parkinsonism, indicating that safinamide improves motor symptoms and parkinsonism without worsening dyskinesia.

Long-term efficacy and safety of safinamide as add-on therapy in early Parkinson's disease

BACKGROUND AND PURPOSE

Safinamide is an α-aminoamide with both dopaminergic and non-dopaminergic mechanisms of action in Phase III clinical development as a once-daily add-on to dopamine agonist (DA) therapy for early Parkinson's disease (PD).

METHODS

Study 017 was a 12-month, randomized, double-blind, placebo-controlled pre-planned extension study to the previously reported Study 015. Patients received safinamide 100 or 200 mg/day or placebo added to a single DA in early PD. The primary efficacy endpoint was the time from baseline (Study 015 randomization) to 'intervention', defined as increase in DA dose; addition of another DA, levodopa or other PD treatment; or discontinuation due to lack of efficacy. Safinamide groups were pooled for the primary efficacy endpoint analysis; post hoc analyses were performed on each separate dose group.

RESULTS

Of the 269 patients randomized in Study 015, 227 (84%) enrolled in Study 017 and 187/227 (82%) patients completed the extension study. Median time to intervention was 559 and 466 days in the pooled safinamide and placebo groups, respectively (log-rank test; P = 0.3342). In post hoc analyses, patients receiving safinamide 100 mg/day experienced a significantly lower rate of intervention compared with placebo (25% vs. 51%, respectively) and a delay in median time to intervention of 9 days (P < 0.05; 240- to 540-day analysis).

CONCLUSIONS

The pooled data from the safinamide groups failed to reach statistical significance for the primary endpoint of median time from baseline to additional drug intervention. Post hoc analyses indicate that safinamide 100 mg/day may be effective as add-on treatment to DA in PD.

Posterior antebrachial cutaneous nerve conduction study technique

PURPOSE

This paper describes an improved electrodiagnostic methodology for posterior antebrachial cutaneous nerve (PABC) neuropathy based on retrospective analysis.

METHODS

Results of PABC nerve conduction studies in 14 control patients and 3 patients with left PABC neuropathy are included. Stimulation was performed 0.5 to 2.0 cm above the lateral epicondyle, and the recordings were acquired at 12 cm, 15 cm and 20 cm distally. Data was evaluated using the mean A+/- standard deviation, calculated for descriptive analysis of continuous variables whereas frequencies and percentages were determined for categorical variables. Abnormal cutoff values including side-side comparison values were established so that all normal control values would fall within the normal range.

RESULTS

PABC conduction studies with 20 cm recording distance demonstrated abnormal electrodiagnostic findings in all 3 patients, while more proximal recordings failed to document the neuropathy.

CONCLUSION

The recording of PABC responses at 12 cm, 15 cm and 20 cm distal to the stimulating electrode offers a more comprehensive evaluation and may be a more sensitive test for evaluation of suspected PABC neuropathy, in comparison to traditional 12 cm recording.

Severe tongue protrusion dystonia: Clinical syndromes and possible treatment

We describe intermittent or sustained severe involuntary tongue protrusion in patients with a dystonic syndrome. Speech, swallowing, and breathing difficulties can be severe enough to be life threatening. Causes include neuroacanthocytosis, pantothenate kinase-associated neurodegeneration, Lesch-Nyhan syndrome, and postanoxic and tardive dystonia. The pathophysiology of intermittent severe tongue protrusion remains unknown. Tongue protrusion dystonia is often unresponsive to oral drugs but may benefit from botulinum toxin injections into the genioglossus muscle. Bilateral deep brain pallidal stimulation was beneficial in two cases.

Perceptions of Indian women regarding menstruation

Although menstruation is still considered a natural event by women in India, perceptions about menstruation are changing. We report on our study of 1150 urban and 850 rural women. The urban women included high school and college students, professional women, and housewives. A 10-point questionnaire was pretested in a clinic setting and then administered to the study group. The responses show that 80% of high school and college students and professional women wish to have infrequent menses or no menses at all. In contrast, 70% of rural women prefer to have monthly menses. The authors wish to initiate a debate on this issue among health care providers and women's groups.

Management of infants with large, unrepaired ventricular septal defects and respiratory infection requiring mechanical ventilation

OBJECTIVES

We sought to describe the hospital management and early outcome of critically ill infants presenting with large ventricular septal defects and pneumonia requiring mechanical ventilation at a referral center in a developing country. Infants with large ventricular septal defects who have pneumonia might present with respiratory failure requiring mechanical ventilation. In the developing world this presentation is relatively common, but few data exist describing patient management strategies.

METHODS

Hospital data of consecutive infants admitted with large ventricular septal defects and pneumonia requiring mechanical ventilation were reviewed and analyzed.

RESULTS

We identified 18 infants (mean age, 3.6 +/- 3.0 months). On admission, all the infants were significantly malnourished, and echocardiography showed bidirectional shunting (predominantly right-to-left shunting) in 6 infants. Thirteen (72%) patients improved with intensive medical management that included mechanical ventilation for 1 to 16 days (median, 6.5 days); unequivocal left-to-right shunting was subsequently documented by means of echocardiography in all 13 patients. Twelve patients underwent surgical repair, and 11 (91.6%) were discharged after median mechanical ventilation of 100 hours (range, 42-240 hours) and intensive care unit stay of 8 days (range, 4-15 days). Five of 6 unoperated patients died, 4 of them within a few hours of admission. One child with multiple ventricular septal defects was discharged and subsequently underwent pulmonary artery banding.

CONCLUSION

Corrective cardiac surgery for selected critically ill infants with large ventricular septal defects, severe malnutrition, and pneumonia requiring mechanical ventilation is feasible and should be considered a viable management strategy.

Neonatal Kawasaki disease

The authors report a case of Kawasaki disease that manifested in a newborn and presented at the age of 6 weeks of age with coronary artery aneurysms.

An observational study to detect leptospirosis in Mumbai, India, 2000

BACKGROUND

Leptospirosis is relatively uncommon in children. Following torrential rains and flooding an outbreak of leptospirosis was suspected in Mumbai.

AIMS

To investigate the possibility of an outbreak of leptospirosis and describe the clinical illness.

METHODS

From 24 July to 14 September 2000, children with a history of abrupt onset of high fever (>39 degrees C), who presented to our hospital, were admitted and tested serologically for anti-Leptospira antibodies by a quantitative enzyme linked immunosorbent assay (ELISA) test. An IgM titre of more than 20U/ml confirmed the diagnosis of leptospirosis. Clinical features in the confirmed leptospirosis and leptospirosis negative groups were analysed.

RESULTS

Of 53 children screened, 18 (34%) had leptospirosis. In all 18, the disease was anicteric and responded well to intravenous penicillin. Four clinical features present at the time of admission were significantly associated with leptospirosis: a history of contact with flood water (18/18 v 16/35), conjunctival suffusion (5/18 v 1/35), abdominal pain (9/18 v 5/35), and skin rash (5/18 v 1/35). As the number of these four features concomitantly present increased, the chances of the child having leptospirosis also increased significantly. A history of contact with flood water had a sensitivity of 100%, and the presence of conjunctival suffusion, abdominal pain, and skin rash had a specificity of 97%, 86%, and 97%, respectively, for identifying children with leptospirosis.

CONCLUSION

Leptospirosis should be suspected in febrile children with contact with flood water.

Compost-mediated removal of polycyclic aromatic hydrocarbons from contaminated soil

Compost-assisted remediation of a manufactured-gas plant soil contaminated with polycyclic aromatic hydrocarbons (PAHs) was performed in thermally insulated composting chamber using mushroom compost consisting wheat straw, chicken manure, and gypsum. The degradation of individual PAHs was in range of 20-60% at the end of 54 days of composting followed by further increase of PAH removal (37-80%) after another 100 days of maturation. Both chemical analysis of the contaminated soil for PAHs and ecotoxicity tests on bioluminescent bacteria, earthworms, and plant seeds were performed before and after the composting. After the composting, inhibition of bioluminescence decreased, whereas no significant change in toxicity was observed for earthworm survival and seed germination. Using bacterial culture of Escherichia coli K12 genotoxicity tests were performed on samples taken from different parts of the composting pile; after the composting the decrease in genotoxicity was observed only in the sample taken from upper part of the composted pile.

Bioremediation of PAH-contaminated soil by composting: a case study

Composting technique was used for bioremediation of industrial soil originating from a former tar-contaminated site. The composting process was regulated by aeration to keep optimal temperature gradient and concentrations of O2 and CO2 inside the composting pile. The efficiency of bioremediation was evaluated by performing analysis of 11 individual three- to six-ring unsubstituted aromatic hydrocarbons (PAH) and estimating of changes in ecotoxicity of the contaminated soil. After 42 d of composting, PAH with 3-4 rings were removed from 42 to 68%, other higher-molar mass PAH from 35 to 57%. Additional 100 d of compost maturation in open-air field did not result in a further decrease of PAH. Ecotoxicity tests performed with bioluminescent bacteria Vibrio fischerii showed a decrease in toxicity both after composting and maturation phases. However, toxicity tests on mustard-seed germination did not reveal any significant changes during composting and maturation phases.

Mycoremediation of PAH-contaminated soil

Out of a number of white-rot fungal cultures, strains of Irpex lacteus and Pleurotus ostreatus were selected for degradation of 7 three- and four-ring unsubstituted aromatic hydrocarbons (PAH) in two contaminated industrial soils. Respective data for removal of PAH in the two industrial soils by I. lacteus were: fluorene (41 and 67%), phenanthrene (20 and 56%), anthracene (29 and 49%), fluoranthene (29 and 57%), pyrene (24 and 42%), chrysene (16 and 32%) and benzo[a]anthracene (13 and 20%). In the same two industrial soils P. ostreatus degraded the PAH with respective removal figures of fluorene (26 and 35%), phenanthrene (0 and 20%), anthracene (19 and 53%), fluoranthene (29 and 31%), pyrene (22 and 42%), chrysene (0 and 42%) and benzo[a]anthracene (0 and 13%). The degradation of PAH was determined against concentration of PAH in non-treated contaminated soils after 14 weeks of incubation. The fungal degradation of PAH in soil was studied simultaneously with ecotoxicity evaluation of fungal treated and non-treated contaminated soils. Compared to non-treated contaminated soil, fungus-treated soil samples indicated decrease in inhibition of bioluminescence in luminescent bacteria (Vibrio fischerii) and increase in germinated mustard (Brassica alba) seeds.

Capacity of Irpex lacteus and Pleurotus ostreatus for decolorization of chemically different dyes

The rate and efficiency of decolorization of poly R-478- or Remazol Brilliant Blue R (RBBR)-containing agar plates (200 microg x g(-1)) were tested to evaluate the dye degradation activity in a total of 103 wood-rotting fungal strains. Best strains were able to completely decolorize plates within 10 days at 28 degrees C. Irpex lacteus and Pleurotus ostreatus were selected and used for degradation of six different groups of dyes (azo, diazo, anthraquinone-based, heterocyclic, triphenylmethane, phthalocyanine) on agar plates. Both fungi efficiently degraded dyes from all groups. Removal of RBBR, Bromophenol blue, Cu-phthalocyanine, Methyl red and Congo red was studied with I. lacteus also in liquid medium. Within 14 days, the following color reductions were attained: RBBR 93%, Bromophenol blue 100%, Cu-phthalocyanine 98%, Methyl red 56%, Congo red 58%. The ability of I. lacteus to degrade RBBR spiked into sterile soil was checked, the removal being 77% of the dye added within 6 weeks. The capacity of selected white rot fungal species to remove efficiently diverse synthetic dyes from water and soil environments is documented.

Posttraumatic akinetic-rigid syndrome resembling Parkinson's disease: a report on three patients

We describe three patients who developed a rapidly evolving posttraumatic akinetic-rigid syndrome (ARS), the clinical manifestations of which were similar to Parkinson's disease, including response to levodopa. Despite initial imaging studies showing traumatic damage to the substantia nigra, the ARS appeared after a delay of 1-5 months after the injury. We stress the importance of magnetic resonance imaging to illustrate nigral damage in all patients in whom head trauma precedes an ARS.

P300 correlates of simulated malingered amnesia in a matching-to-sample task: topographic analyses of deception versus truthtelling responses

Two experiments using a P300-enhanced Forced Choice Procedure (P3FCP) investigated simulated amnesia in a matching-to-sample task. In Experiment 1, successful manipulation of subjects towards different behavioral hit rates (75-80% vs. 85-90%) did not adversely affect the diagnostic sensitivity of match-mismatch Pz-P300 amplitude analyses, allowing detection of 69% of simulators. P300 amplitudes of simulators (Malinger group) were as large as those of truth-tellers (truth group, a control), indicating no dual task-related (Malingering) reduction across different behavioral hit rates. Experiment 2 found no main effect of oddball type, match vs. mismatch, on P300 (P3) amplitude with a mismatch-rare variant of the P3FCP. This study also revealed larger Pz-P3s in the Malingering (vs. Truth-telling) condition. Subsequent topographic analyses suggested different Truth and Malinger scaled P3 amplitude topographies in both these sets of P3FCP data and in those from a previous autobiographical memory paradigm. Further analysis yielded preliminary evidence for a common deception-related P3 amplitude topography across different paradigms/conditions.