'There's a frog in my throat': bilateral prolapsing lung apices presenting as a neck lump

This case report discusses an unusual presentation of a voluntarily produced neck mass, caused by the rare case of lung herniation. Lung herniation is associated with increased intrathoracic pressure that can be caused by chronic chough, straining and continuous positive airway pressure ventilation. An association with Ehlers-Danlos syndrome 1 also exists. We present a case of lung herniation that was multifactorial in nature and was identified at a head and neck clinic. The female patient presented with a voluntarily expandable anterior neck mass on Valsalva manoeuvre. Computed tomography imaging with and without Valsalva manoeuvre demonstrated bilateral anterior lung herniation and findings of spinal spondylosis.

Long-term outcome after endoscopic ligation of acute esophageal variceal bleeding in patients with liver cirrhosis

Endoscopic variceal ligation (EVL) has been the standard treatment for acute variceal bleeding (AVB). However, reports of long-term prognosis after EVL are scarce. Therefore, the current work aimed to investigate the long-term outcome and prognostic modifiers of cirrhotic cases presented with acute esophageal variceal bleeding and managed with EVL. The current prospective work comprised primarily 276 consecutive grown-up cirrhotic cases presenting with AVB and managed with EVL. Two-hundred patients who completed the study till death or 3-year follow-up were enrolled in final analysis. The primary outcome measure was occurrence of rebleeding and all-cause mortality. By the end of follow up 56 patients (28%) developed rebleeding and 78 (39%) died. The independent factors associated with rebleeding were lacking follow up EVL (OR: 4.8, 95%CI: 1.9-12.2), BMI > 30 kg/m2 (OR: 0.-, 95%CI: 0.2-0.9), Child class C (OR: 3.8, 95%CI: 1.8-7.8), and grade IV varices (OR: 2.6, 95%CI: 1.3-5.3). The independent factors associated with mortality were: Age > 65 years (OR: 32.4, 95%CI: 8.7-120.3), rebleeding (OR: 98.4, 95%CI: 27.9-347.0), coexistence of HCC (OR: 7.4, 95%CI: 2.0-27.4), and lacking follow up EVL (OR: 6.1, 95%CI: 1.2-31.1). Recurrent bleeding after emergency endoscopic ligation of acute esophageal variceal bleeding in cirrhotic cases is a rather common complication that significantly increases the mortality rate. The liver condition, lack of follow up endoscopy, old age, and severity of esophageal varices are independent prognostic indicator of rebleeding and morality.

Expression levels of β-catenin and galectin-3 in meningioma and their effect on brain invasion and recurrence: a tissue microarray study

Objective:

Meningiomas are neoplasms that arise from the meninges of the central nervous system (CNS). They constitute about 25.6% of CNS tumors diagnosed in Egypt. Some morphological variants of meningiomas display aggressive behavior, leading to brain-invasive growth pattern. Although meningiomas are usually treated by complete surgical excision, the risk of postoperative recurrence remains. Hence, additional biomarkers for predicting aggressive behavior must be discovered. This study aims to explore the clinical and biological relevance of the protein expression levels of β-catenin and galectine-3 in meningioma and to understand the pathobiology of this neoplasm.

Methods:

This retrospective study was carried out on 153 cases of meningioma by using tissue microarrays and immunohistochemistry for β-catenin and galectine-3.

Results:

High β-catenin expression was significantly associated with transitional and meningiotheliomatous meningiomas, low tumor grade, low recurrence rate, and low incidence of brain invasion. Meanwhile, high galectin-3 expression was associated with brain invasion, recurrence, high tumor grade, and tumor type. Logistic regression analysis indicated that among all variables included in the model, β-catenin and galactin-3 expression levels were significant predictors of tumor recurrence (P<0.001).

Conclusions:

Galectin-3 and β-catenin are involved in meningioma recurrencebut not in brain invasion. These molecules could be important potential therapeutic targets and predictors for meningiomas.

γ-Tocotrienol reversal of epithelial-to-mesenchymal transition in human breast cancer cells is associated with inhibition of canonical Wnt signalling

OBJECTIVES

Frizzled-7 (FZD7) receptor-dependent activation of the canonical Wnt/β-catenin pathway plays a crucial role in epithelial-to-mesenchymal transition (EMT) and breast cancer metastasis. FZD7 and its co-receptor, low-density lipoprotein receptor-related protein 6 (LRP6), are highly expressed in MDA-MB-231 and T-47D breast cancer cells, and endogenous ligands for FZD7 include Wnt3a and Wnt5a/b. γ-Tocotrienol, a natural isoform of vitamin E, inhibits human breast cancer cell proliferation and EMT. Here, studies have been conducted to investigate the role of the canonical Wnt pathway in mediating inhibitory effects of γ-tocotrienol on EMT in human breast cancer cells.

MATERIALS AND METHODS

MDA-MB-231, T-47D and MCF-10A cells were maintained in serum-free defined media containing selected doses of γ-tocotrienol. Cell viability was determined using the MTT colorimetric assay, Western blot analysis was used to measure protein expression and the wound-healing assay was employed to study cell mobility and migration. Immunohistochemical fluorescence staining visualized expression and localization of EMT cell markers.

RESULTS

γ-Tocotrienol was found to induce dose-responsive inhibition of MDA-MB-231 and T-47D cell growth at doses that had no effect on immortalized normal MCF-10A mammary epithelial cells. These growth inhibitory effects were associated with suppression in canonical Wnt signalling, reversal of EMT and significant reduction in breast cancer cell motility.

CONCLUSIONS

γ-Tocotrienol suppression of metastatic breast cancer cell proliferation and EMT was associated with suppression of the canonical Wnt/β-catenin signalling pathway.

Difference between papillary and follicular thyroid carcinoma outcomes: an experience from Egyptian institution

Objective

Differentiated thyroid carcinomas (DTCs) are classified into papillary thyroid carcinoma (PTC) and follicular thyroid carcinoma (FTC). DTCs are analyzed as a single group in clinical studies that investigated the prognostic factors and prognosis of these malignancies. However, the biological behaviors of these carcinomas significantly differ. In the present study, we aimed to detect differences in the outcomes between PTC and FTC in Mansoura University Hospital in Egypt.

Methods

A total of 558 patients with histologically proven thyroid carcinomas from January 2003 to December 2012 were retrospectively enrolled. The clinical and pathological data of patients were reviewed.

Results

Large primary tumor size, lymph node involvement, extrathyroid extension, and distant metastasis were significant poor prognostic factors for overall survival (OS) in old PTC patients. Cox hazard analysis showed that the patient’s age, extra thyroid extension, and distant metastasis were the only independent prognostic factors. In FTC patients, only the distant metastasis and degree of tumor invasion were significant poor prognostic factors in OS univariate analysis. However, these factors were nonsignificant in multivariate analysis. The 10-year OS rates were 97% and 89% for PTC and FTC, respectively (P=0.003). The 10-year disease-free survival (DFS) rates were 77.2% in PTC vs. 65% in FTC (P=0.179).

Conclusion

The significant prognostic factors vary between the two types of DTCs. Therefore, PTC and FTC patients need to be analyzed and reported independently. PTC survival is widely and significantly affected by age, extrathyroid extension, and distant metastasis. By contrast, these factors were nonsignificant in FTC, which showed poorer survival than PTC.

Transfusion trigger--how precise are we? Intraoperative blood transfusion practices in a tertiary centre in Nigeria

SUMMARY

To determine how well anaesthetists in Nigeria determine the need for transfusion based solely on physiological variables and estimated blood loss. To determine the incidence of inappropriate blood transfusion. Anaesthetists in our hospital determine when to transfuse patients based solely on clinical acumen. This may result in inappropriate transfusion especially in this subregion where blood donors are scarce and risk of transmission of infection high. All surgical patients requiring blood transfusion were prospectively studied over 3 months. Transfusion was based solely on the discretion of the attending anaesthetist. Haemoglobin (Hb) concentration was measured prior to transfusion and 24 h postoperatively. Appropriate transfusion was defined as blood transfusion at Hb < 8 g dL(-1) or 10 g dL(-1) in the elderly and those with medical comorbidities. The trigger for transfusion was documented as well as estimated blood loss. Thirty-four patients were studied. The mean pretransfusion Hb was 8.09 +/- 2.45 g dL(-1) (range 4.6-14.2). Twenty-one patients (61.8%) had appropriate blood transfusion. The commonest transfusion triggers were clinical pallor (82.4%), excessive blood loss (76.4%), delayed capillary refill (55.9%) and severe hypotension (50%). The use of near patient monitoring devices might further improve blood transfusion practice in this setting where donor blood is scarce.

Influence of intravenous immunoglobulin therapy on serum levels of anti-beta 4 antibodies in ocular cicatricial pemphigoid. A correlation with disease activity. A preliminary study

PURPOSE

To determine any correlation between activity of ocular cicatricial pemphigoid and titer of anti-beta 4 antibodies, and any effect of intravenous immunoglobulin (IVIg) therapy on serum levels of anti-beta 4 antibodies followed over a 12 month period, using the specific immunoblot assay (IBA).

PATIENTS AND METHODS

Eight patients diagnosed with OCP and treated with IVIg as monotherapy were included in the study. Each patient was treated with at least two immunosuppressive agents prior to the institution of IVIg. The presence of anti-beta 4 antibodies in the patients' sera was detected by IBA using bovine gingival lysate (BGL) or tumor cell line lysate (TCL) as substrates. The activity of OCP was graded based on the conjunctival injection using a scale of zero to four in increments of 0.5 at monthly intervals. To determine the correlation between serum levels of circulating autoantibody and the patients' conjunctival disease activity, the titer of anti-beta 4 antibodies was determined at monthly intervals during the course of IVIg therapy. Blood samples were drawn prior to administration of IVIg infusion. The titer was determined by IBA, using serial dilutions of the patients' sera. The highest dilution at which the binding was visible was considered the titer. The dose of IVIg administered was approximately 2-3 g/kg/cycle. The infusion cycles were initially given at monthly intervals, approximately 70 grams daily over four hours for three consecutive days. As clinical improvement was observed, the interval between the cycles was increased, but the dose of IVIg remained the same for each cycle. To study whether the IVIg has an effect on other antibodies, monthly serum levels of antibodies to tetanus toxoid were measured by ELISA.

RESULTS

We observed a continuous decrease in mean monthly titer of circulating anti-beta 4 antibodies in the patients' sera during IVIg therapy. A decrease in conjunctival inflammation during the course of IVIg was documented by monthly examination in every patient and paralleled the decrease in titer of anti-beta 4 antibodies. Since the fifth month of IVIg therapy, the mean conjunctival inflammation remained less than 0.5, suggesting a clinical remission of OCP. Titers of antibodies to tetanus toxoid remained unchanged during the study period.

CONCLUSIONS

This preliminary study demonstrates a correlation between serum titers of anti-beta 4 antibodies and clinical disease activity in patients with OCP. In addition, the study shows that the use of IVIg is associated with a decrease in the serum titer of anti-beta 4 antibodies.

Fistula between a branch of left anterior descending coronary artery and pulmonary artery with spontaneous closure

Communication between a branch of left anterior descending coronary artery and main pulmonary artery is rare and has been previously described. However, spontaneous closure has not been described previously. We report such a case in a 41-year-old man with exertional angina and coronary artery disease.

Time resolved backscattering to monitor different stages of eye cataract

We show that measurement of the temporal profile of the backscattered pulse has the potential to monitor the extent of cataract development in the eye.