bluuebunny/crossref_metadata_2025 huggingface dataset:
Three Prevacuolar Compartment Rab GTPases Impact Candida albicans Hyphal Growth
Authors: Johnston Douglas A. , Tapia Arturo Luna , Eberle Karen E. , Palmer Glen E.
Published: May 2013

Disruption of vacuolar biogenesis in the pathogenic yeast
Candida albicans
causes profound defects in polarized hyphal growth. However, the precise vacuolar pathways involved in yeast-hypha differentiation have not been determined. Previously we focused on Vps21p, a Rab GTPase involved in directing vacuolar trafficking through the late endosomal
p
re
v
acuolar
c
ompartment (PVC). Herein, we identify two additional Vps21p-related GTPases, Ypt52p and Ypt53p, that colocalize with Vps21p and can suppress the hyphal defects of the
vps21
Δ/Δ mutant. Phenotypic analysis of gene deletion strains revealed that loss of both
VPS21
and
YPT52
causes synthetic defects in endocytic trafficking to the vacuole, as well as delivery of the virulence-associated vacuolar membrane protein Mlt1p from the Golgi compartment. Transcription of all three GTPase-encoding genes is increased under hyphal growth conditions, and overexpression of the transcription factor Ume6p is sufficient to increase the transcription of these genes. While only the
vps21
Δ/Δ single mutant has hyphal growth defects, these were greatly exacerbated in a
vps21
Δ/Δ
ypt52
Δ/Δ double mutant. On the basis of relative expression levels and phenotypic analysis of gene deletion strains, Vps21p is the most important of the three GTPases, followed by Ypt52p, while Ypt53p has an only marginal impact on
C. albicans
physiology. Finally, disruption of a nonendosomal AP-3-dependent vacuolar trafficking pathway in the
vps21
Δ/Δ
ypt52
Δ/Δ mutant, further exacerbated the stress and hyphal growth defects. These findings underscore the importance of membrane trafficking through the PVC in sustaining the invasive hyphal growth form of
C. albicans
.
Global Control of GacA in Secondary Metabolism, Primary Metabolism, Secretion Systems, and Motility in the Rhizobacterium Pseudomonas aeruginosa M18
Authors: Wei Xue , Huang Xianqing , Tang Lulu , Wu Daqiang , Xu Yuquan
Published: May 2013

The rhizobacterium
Pseudomonas aeruginosa
M18 can produce a broad spectrum of secondary metabolites, including the antibiotics pyoluteorin (Plt) and phenazine-1-carboxylic acid (PCA), hydrogen cyanide, and the siderophores pyoverdine and pyochelin. The antibiotic biosynthesis of M18 is coordinately controlled by multiple distinct regulatory pathways, of which the GacS/GacA system activates Plt biosynthesis but strongly downregulates PCA biosynthesis. Here, we investigated the global influence of a
gacA
mutation on the M18 transcriptome and related metabolic and physiological processes. Transcriptome profiling revealed that the transcript levels of 839 genes, which account for approximately 15% of the annotated genes in the M18 genome, were significantly influenced by the
gacA
mutation during the early stationary growth phase of M18. Most secondary metabolic gene clusters, such as
pvd
,
pch
,
plt
,
amb
, and
hcn
, were activated by GacA. The GacA regulon also included genes encoding extracellular enzymes and cytochrome oxidases. Interestingly, the primary metabolism involved in the assimilation and metabolism of phosphorus, sulfur, and nitrogen sources was also notably regulated by GacA. Another important category of the GacA regulon was secretion systems, including H1, H2, and H3 (type VI secretion systems [T6SSs]), Hxc (T2SS), and Has and Apr (T1SSs), and CupE and Tad pili. More remarkably, GacA inhibited swimming, swarming, and twitching motilities. Taken together, the Gac-initiated global regulation, which was mostly mediated through multiple regulatory systems or factors, was mainly involved in secondary and primary metabolism, secretion systems, motility, etc., contributing to ecological or nutritional competence, ion homeostasis, and biocontrol in M18.
Carbohydrate Kinase (RhaK)-Dependent ABC Transport of Rhamnose in Rhizobium leguminosarum Demonstrates Genetic Separation of Kinase and Transport Activities
Authors: Rivers Damien , Oresnik Ivan J.
Published: May 2013

In
Rhizobium leguminosarum
the ABC transporter responsible for rhamnose transport is dependent on RhaK, a sugar kinase that is necessary for the catabolism of rhamnose. This has led to a working hypothesis that RhaK has two biochemical functions: phosphorylation of its substrate and affecting the activity of the rhamnose ABC transporter. To address this hypothesis, a linker-scanning random mutagenesis of
rhaK
was carried out. Thirty-nine linker-scanning mutations were generated and mapped. Alleles were then systematically tested for their ability to physiologically complement kinase and transport activity in a strain carrying an
rhaK
mutation. The
rhaK
alleles generated could be divided into three classes: mutations that did not affect either kinase or transport activity, mutations that eliminated both transport and kinase activity, and mutations that affected transport activity but not kinase activity. Two genes of the last class (
rhaK72
and
rhaK73
) were found to have similar biochemical phenotypes but manifested different physiological phenotypes. Whereas
rhaK72
conferred a slow-growth phenotype when used to complement
rhaK
mutants, the
rhaK73
allele did not complement the inability to use rhamnose as a sole carbon source. To provide insight to how these insertional variants might be affecting rhamnose transport and catabolism, structural models of RhaK were generated based on the crystal structure of related sugar kinases. Structural modeling suggests that both
rhaK72
and
rhaK73
affect surface-exposed residues in two distinct regions that are found on one face of the protein, suggesting that this protein's face may play a role in protein-protein interaction that affects rhamnose transport.
The Essential Function of Genes for a Hydratase and an Aldehyde Dehydrogenase for Growth of Pseudomonas sp. Strain Chol1 with the Steroid Compound Cholate Indicates an Aldolytic Reaction Step for Deacetylation of the Side Chain
Authors: Holert Johannes , Jagmann Nina , Philipp Bodo
Published: May 2013

In the bacterial degradation of steroid compounds, the enzymes initiating the breakdown of the steroid rings are well known, while the reactions for degrading steroid side chains attached to C-17 are largely unknown. A recent
in vitro
analysis with
Pseudomonas
sp. strain Chol1 has shown that the degradation of the C
5
acyl side chain of the C
24
steroid compound cholate involves the C
22
intermediate 7α,12α-dihydroxy-3-oxopregna-1,4-diene-20
S
-carbaldehyde (DHOPDCA) with a terminal aldehyde group. In the present study, candidate genes with plausible functions in the formation and degradation of this aldehyde were identified. All deletion mutants were defective in growth with cholate but could transform it into dead-end metabolites. A mutant with a deletion of the
shy
gene, encoding a putative enoyl coenzyme A (CoA) hydratase, accumulated the C
24
steroid (22
E
)-7α,12α-dihydroxy-3-oxochola-1,4,22-triene-24-oate (DHOCTO). Deletion of the
sal
gene, formerly annotated as the steroid ketothiolase gene
skt
, resulted in the accumulation of 7α,12α,22-trihydroxy-3-oxochola-1,4-diene-24-oate (THOCDO). In cell extracts of strain Chol1, THOCDO was converted into DHOPDCA in a coenzyme A- and ATP-dependent reaction. A
sad
deletion mutant accumulated DHOPDCA, and expression in
Escherichia coli
revealed that
sad
encodes an aldehyde dehydrogenase for oxidizing DHOPDCA to the corresponding acid 7α,12α-dihydroxy-3-oxopregna-1,4-diene-20-carboxylate (DHOPDC) with NAD
+
as the electron acceptor. These results clearly show that the degradation of the acyl side chain of cholate proceeds via an aldolytic cleavage of an acetyl residue; they exclude a thiolytic cleavage for this reaction step. Based on these results and on sequence alignments with predicted aldolases from other bacteria, we conclude that the enzyme encoded by
sal
catalyzes this aldolytic cleavage.
Chlamydia trachomatis Transports NAD via the Npt1 ATP/ADP Translocase
Authors: Fisher Derek J. , Fernández Reinaldo E. , Maurelli Anthony T.
Published: May 2013

Obligate intracellular bacteria comprising the order
Chlamydiales
lack the ability to synthesize nucleotides
de novo
and must acquire these essential compounds from the cytosol of the host cell. The environmental protozoan endosymbiont
Protochlamydia amoebophila
UWE25 encodes five nucleotide transporters with specificities for different nucleotide substrates, including ATP, GTP, CTP, UTP, and NAD. In contrast, the human pathogen
Chlamydia trachomatis
encodes only two nucleotide transporters, the ATP/ADP translocase
C. trachomatis
Npt1 (Npt1
Ct
) and the nucleotide uniporter Npt2
Ct
, which transports GTP, UTP, CTP, and ATP. The notable absence of a NAD transporter, coupled with the lack of alternative nucleotide transporters on the basis of bioinformatic analysis of multiple
C. trachomatis
genomes, led us to re-evaluate the previously characterized transport properties of Npt1
Ct
. Using [adenylate-
32
P]NAD, we demonstrate that Npt1
Ct
expressed in
Escherichia coli
enables the transport of NAD with an apparent

K
m

and
V
max
of 1.7 μM and 5.8 nM mg
−1
h
−1
, respectively. The

K
m

for NAD transport is comparable to the

K
m

for ATP transport of 2.2 μM, as evaluated in this study. Efflux and substrate competition assays demonstrate that NAD is a preferred substrate of Npt1
Ct
compared to ATP. These results suggest that during reductive evolution, the pathogenic chlamydiae lost individual nucleotide transporters, in contrast to their environmental endosymbiont relatives, without compromising their ability to obtain nucleotides from the host cytosol through relaxation of transport specificity. The novel properties of Npt1
Ct
and its conservation in chlamydiae make it a potential target for the development of antimicrobial compounds and a model for studying the evolution of transport specificity.
QapR (PA5506) Represses an Operon That Negatively Affects the Pseudomonas Quinolone Signal in Pseudomonas aeruginosa
Authors: Tipton Kyle A. , Coleman James P. , Pesci Everett C.
Published: May 2013

Pseudomonas aeruginosa
is a Gram-negative, opportunistic pathogen that can cause disease in varied sites within the human body and is a significant source of morbidity and mortality in those afflicted with cystic fibrosis.
P. aeruginosa
is able to coordinate group behaviors, such as virulence factor production, through the process of cell-to-cell signaling. There are three intercellular signaling systems employed by
P. aeruginosa
, and one of these systems utilizes the small molecule 2-heptyl-3-hydroxy-4-quinolone (
Pseudomonas
quinolone signal [PQS]). PQS is required for virulence in multiple infection models and has been found in the lungs of cystic fibrosis patients colonized by
P. aeruginosa
. In this study, we have identified an RpiR family transcriptional regulator, QapR, which is an autoregulatory repressor. We found that mutation of
qapR
caused overexpression of the
qapR
operon. We characterized the
qapR
operon to show that it contains genes
qapR
, PA5507, PA5508, and PA5509 and that QapR directly controls the transcription of these genes in a negative manner. We also show that derepression of this operon greatly reduces PQS concentration in
P. aeruginosa
. Our results suggest that
qapR
affects PQS concentration by repressing an enzymatic pathway that acts on PQS or a PQS precursor to lower the PQS concentration. We believe that this operon comprises a novel mechanism to regulate PQS concentration in
P. aeruginosa
.
Role of
cis
-Acting Sites in Stimulation of the Phage λ
P
RM
Promoter by CI-Mediated Looping
Authors: Michalowski Christine B. , Little John W.
Published: May 2013

The lysogenic state of phage λ is maintained by the CI repressor. CI binds to three operators each in the right operator (
O
R
) and left operator (
O
L
) regions, which lie 2.4 kb apart. At moderate CI levels, the predominant binding pattern is two dimers of CI bound cooperatively at each regulatory region. The resulting tetramers can then interact, forming an octamer and a loop of the intervening DNA. CI is expressed from the
P
RM
promoter, which lies in the
O
R
region and is subjected to multiple regulatory controls. Of these, the most recently discovered is stimulation by loop formation. In this work, we have investigated the mechanism by which looping stimulates
P
RM
. We find that two
cis
-acting sites lying in the
O
L
region are involved. One site, an UP element, is required for stimulation. Based on the behavior of other promoters with UP elements located upstream of the −35 region, we suggest that a subunit of RNA polymerase (RNAP) bound at
P
RM
binds to the UP element located in the
O
L
region. In addition, adjacent to the UP element lies a binding site for integration host factor (IHF); this site plays a less critical role but is required for stimulation of the weak
prm240
allele. A loop with CI at the
O
L
2 and
O
L
3 operators does not stimulate
P
RM
, while one with CI only at
O
L
2 provides some stimulation. We discuss possible mechanisms for stimulation.
Expression of the Rhizobium leguminosarum bv. trifolii
pssA
Gene, Involved in Exopolysaccharide Synthesis, Is Regulated by RosR, Phosphate, and the Carbon Source
Authors: Janczarek Monika , Urbanik-Sypniewska Teresa
Published: May 2013

Rhizobium leguminosarum
bv. trifolii
pssA
encodes a glucosyl-isoprenylphosphate (IP)-transferase involved in the first step of exopolysaccharide (EPS) synthesis. It was found that the
pssA
gene is an important target for regulation of this biosynthetic pathway. The data of this study indicate that
pssA
transcription is a very complex and mainly positively regulated process. A detailed analysis of a 767-bp-long
pssA
upstream region revealed the presence of several sequence motifs recognized by regulatory proteins that are associated with phosphate-, carbon-, and iron-dependent regulation. In addition, numerous inverted repeats of different lengths have been identified in this region.
pssA
transcription is directed from two distal P1 and proximal P3 promoters whose sequences demonstrate a significant identity to promoters recognized by RNA polymerase sigma factor σ
70
. Among rhizobial proteins, RosR seems to be a primary regulator that positively affects
pssA
expression. This protein binds to RosR box 1 located downstream of the P1 promoter. In addition, phosphate and the carbon source strongly affect
pssA
transcription. A significantly lower level of
pssA
expression was observed in both the wild-type strain growing under phosphate-rich conditions and the
phoB
mutant. In this regulation, the PhoB protein and Pho box 2 located upstream of the P3 promoter were engaged.
pssA
transcription is also significantly affected by glucose. Transcriptional analysis of a set of
pssA-lacZ
fusions expressed in
Escherichia coli
wild-type and
cyaA
and
crp
mutants confirmed that cyclic AMP (cAMP) receptor protein (CRP) and two cAMP-CRP boxes located upstream of the P1 are required for this upregulation. Moreover, the production of EPS was totally abolished in
R. leguminosarum
bv. trifolii mutant strains 4440 and 1012 containing a Tn
5
insertion downstream of the P3 promoter and downstream of the P3 −35 hexamer, respectively.
Juvenile cellular pleomorphic adenoma
Authors: Ananthaneni Anuradha , Undavalli Suresh Babu
Published: May 2013

Salivary gland tumours are rare in children and when they do arise, they preferentially affect major salivary glands with sporadic incidence in minor salivary glands. The mucosa of the cheek is an uncommon site of occurrence for intraoral pleomorphic adenoma and most of these cases have been reported in adults. Histologically, it shows a highly variable morphology because of interplay between epithelial and mesenchymal (myxoid, hyaline, chondroid, osseous) elements which arise from same cell clone, which may be a myoepithelial or ductal reserve cell. Here we report a rare case of juvenile pleomorphic adenoma of the cheek in a 12-year-old girl with a predominant epithelial component histologically. Relevant studies are discussed with a focus on its cytology and cytogenetics.
When a colonoscopy becomes a duodenoscopy: a palliative treatment of a malignant sigmoidoduodenal fistula
Authors: Huber Xaver , Droeser Raoul A , Bernsmeier Christine , Kirchhoff Philipp
Published: May 2013

We report a case of a 63-year-old female patient suffering from cachexy, anaemia and intractable chronic diarrhoea. As an underlying disease, we found a malignant sigmoidoduodenal fistula of a primary adenocarcinoma of the sigma which represents a rare complication of a frequent disease. Despite the theoretical need for a pancreaticoduodenectomy, only a multivisceral en-bloc resection of the small intestine and left adnexa was performed because of bad general and nutritional condition; this case illustrates a successful multimodal treatment with a palliative intention of a locally advanced colon cancer to alleviate clinical symptoms. The further decourse with the fast development of hepatic metastases confirmed this decision.
Spontaneous coronary artery dissection: a rare cause of acute coronary syndrome
Authors: Laghari Abid Hussain , Khan Aamir Hameed , Kazmi Khawar Abbas
Published: May 2013

We present a case of a 71-year-old man, with a history of hypertension and dyslipidaemia, who presented with typical cardiac chest pain and palpitations of 2 h duration. The examination revealed irregular pulse of 138 bpm, blood pressure 115/75 mm Hg, variable first and normal second heart sounds. The lungs were clear to auscultation. The ECG showed atrial fibrillation with a rapid ventricular rate. His heart rate was controlled with β blockers and the acute coronary syndrome treatment protocol was initiated. His baseline blood reports were within normal limits and two serial troponin I tests were negative. Coronary angiogram showed dissection in the left coronary system extending into the branch vessels and 30–40% stenosis in the right coronary artery. The patient underwent coronary artery bypass graft as an emergent case. He suffered a mild stroke postsurgery with complete functional recovery. He is being followed up in the clinic and has performed well.
NSAID-induced diaphragmatic disease of the colon
Authors: Munipalle P C , Little M , Garud T , Henderson D
Published: May 2013

One of the rare side effects of chronic usage of non-steroidal anti-inflammatory drugs is colopathy, which is characterised by colonic inflammation, ulceration and formation of diaphragms in late stages. We treated a case of colonic diaphragm disease with similar findings in our unit recently. We present the case herewith, followed by a discussion of the management of this interesting rare but benign condition.
Uncommon presentation of a common condition: an easily missed cause of hip pain
Authors: Dhruva Rao Pawan Kumar , Sharpe Helen , Sherlock Rebecca , Muralikrishnan Vummiti
Published: May 2013

Conventionally, patients presenting with hip pain and restricted mobility to accident and emergency (A&E) department are thought to have musculoskeletal pain. Occasionally, patients with significant abdominal pathology can present with hip pain. Such atypical presentation causes the delayed diagnosis leading to significant morbidity and possible mortality. We report a 63-year-old man who had been treated in A&E on numerous occasions with left hip pain for over 6 weeks. On this occasion, he had been brought in septic shock. On examination, he had subcutaneous emphysema of left lower limb. A CT scan showed a large psoas abscess resulting from retroperitoneal perforation of sigmoid diverticulitis tracking into his left lower limb. He underwent a Hartmann's procedure and drainage of his intra-abdominal sepsis. The thigh was not drained with separate incisions at the index operation. Residual thigh abscess was managed by image-guided drainage.
Post-transfusion purpura: a rare and life-threatening aetiology of thrombocytopenia
Authors: Padhi Parikshit , Parihar Gulam Sadiq , Stepp Jason , Kaplan Robert
Published: May 2013

We present a middle-aged man with history of lung adenocarcinoma, who was admitted with massive haemoptysis secondary to severe thrombocytopenia. Two weeks prior he was started on enoxaparin for a newly diagnosed pulmonary embolus and at that time required blood transfusions for anaemia. Our initial diagnosis was heparin-induced thrombocytopenia. His platelet count, however, did not improve despite receiving argatroban and platelet transfusions. Hence, we suspected post-transfusion purpura (PTP) and started him on intravenous immunoglobulin which brought his platelet count to normal levels. The serotonin-release assay was negative and platelet-antibody test was positive confirming PTP as our diagnosis. The patient eventually was transferred to hospice care because of the advanced stage lung cancer and died of respiratory failure.
Streptococcal toxic shock syndrome secondary to a deep neck space infection presenting with no throat or neck symptoms
Authors: Rahman Habib , Illing Elizabeth , Webb Christopher , Banhegyi Gyorgy
Published: May 2013

A previously fit and well 44-year-old gentleman was admitted with a 3-week history of parotid swelling, malaise and feeling generally unwell. His only medical history was α-thalassaemia trait. Initial ear, nose and throat examination was unremarkable. Routine observations highlighted tachycardia, hypotension and a raised respiratory rate. Despite fluid resuscitation, his hypotension failed to resolve and he was admitted to intensive care for inotropic support. He was started on broad spectrum antibiotics and blood cultures isolated Lancefield group AStreptococcus. No obvious source of sepsis was identified. A CT scan from neck to pelvis highlighted a collection around the right tonsil, splenomegaly and widespread small volume lymphadenopathy. A right tonsillectomy, intraoral drainage of parapharyngeal and retropharyngeal abscesses and excision of an axillary lymph node were performed. With continued intravenous antibiotics and supportive measures, he recovered fully. Histology showed reactive lymphadenitis, but no cause of immunocompromise.
A ‘medical’ diagnosis in the trauma clinic
Authors: Hussain Kosar , AlNajjar Firas Jafar Kareem , Ahmad Mohammad Javad , Hussain Sahar
Published: May 2013

A previously healthy 27-year-old Nepalese man presented with a history of direct low-impact direct trauma to the left leg. An x-ray was performed in a private hospital and he was referred to our emergency department for the management of a possible foreign body in the left leg. X-ray of the left leg showed a single, small, ‘cigar-shaped’ calcified lesion in the posterior aspect of the left leg. There was an inconsistency between the injury and x-ray finding. As the patient originated from a region endemic inTaenia solium, a clinical suspicion for cysticercosis was raised. The patient was then sent for a skeletal survey which subsequently confirmed our diagnosis.
Corrective osteotomy through fracture site and internal fixation with headless screws for type I (Hahn-Steinthal) capitellar malunion
Authors: Jeevannavar Santosh Somayya , Shenoy Keshav Someshwar , Daddimani Ravi M
Published: May 2013

A 20-year-old woman presented 6 months after an initial injury to her left elbow with pain and restricted movements. She was diagnosed with a type I malunited (Hahn-Steinthal) type of capitellum fracture through radiographic studies. Classically, the treatment has been excision of the fragment, which carries a risk of valgus instability of the elbow and late osteoarthrosis. We report a case of malunited type I capitellum fracture, for which corrective osteotomy through fracture site, open reduction and internal fixation was done 6 months following missed trauma. At 24 months follow-up the capitellum fracture had united and the patient has a stable elbow and excellent range of motion. Our case demonstrates that for type I malunited capitellum fractures corrective osteotomy through fracture site and internal fixation rather than excision of the fragment in young can result in successful union and stable elbow.
Treacher Collins syndrome: a case report
Authors: Mohan Ravi Prakash Sasankoti , Verma Sankalp , Agarwal Neha , Singh Udita
Published: May 2013

Treacher Collins syndrome is a rare autosomal dominant disorder of craniofacial development. The fully expressed phenotype exhibits characteristic dysmorphic features involving the face, eyes, mandible and ears. We report a case of a 17-year-old woman presenting with the typical orofacial implications of this syndrome.
Amelogenesis imperfecta with bilateral nephrocalcinosis
Authors: Poornima P , Katkade Shashikant , Mohamed Roshan Noor , Mallikarjuna Rachappa
Published: May 2013

A 12-year-old patient presented with a severe delay of eruption in permanent maxillary and mandibular incisors. On examination, there was over-retained primary teeth and delayed eruption of permanent teeth. Retained primary teeth showed light yellow discolouration whereas permanent teeth were distinct yellow with thin or little enamel. Subsequent imaging revealed all the premolars except maxillary left first premolar showed signs of intra-alveolar coronal resorption, nephrocalcinosis with bilateral multiple calculi and small papillary tip calcifications, marked increase in alkaline phosphatase. Subsequent dental treatment for restoring the functional and aesthetic requirement followed by appropriate treatment for renal problem was undertaken.
Chryseobacterium indologenesperitonitis in peritoneal dialysis
Authors: Afshar Mehdi , Nobakht Ehsan , Lew Susie Q
Published: May 2013

Peritoneal dialysis-related peritonitis remains a major complication of peritoneal dialysis in patients with end-stage renal disease.Chryseobacterium indologenesis a rare organism that has been reported to cause infections mostly in hospitalised patients with severe underlying diseases. We report the first case ofC indologenesperitonitis in a patient on peritoneal dialysis outside of Asia. Our patient with end-stage renal disease on peritoneal dialysis grewC indologenesfrom peritoneal fluid when he presented with abdominal pain and cloudy effluent. The patient responded well to intraperitoneal antibiotic therapy. Tenckhoff catheter did not require removal. This case demonstrates the importance of considering rare causes of peritonitis, such asC indologenes, in patients on peritoneal dialysis. Given the resistance of such organisms to commonly used broad-spectrum antibiotics, antimicrobial susceptibility testing must be assessed as early as possible to assure appropriate antibiotic coverage to avoid untreated peritonitis leading to peritoneal dialysis failure.
Rehabilitation of anterior teeth with customised incisal guide table
Authors: Mall Priyanka , Singh Kamleshwar , Rao Jitendra , Kumar Lakshya
Published: May 2013

Restoration of anterior guidance is a major challenge to the clinician in planning of all restorative treatments. An accurate anterior guidance is important for proper function, aesthetics, comfort and phonetics. This article describes anterior rehabilitation of a patient who met with a road traffic accident and lost his anterior teeth. Anterior guidance developed in the provisional restorations was accurately recorded in the customised incisal guide table and permanent restorations were fabricated accordingly.
Tricky brucellosis
Authors: Hedayat Yaghoobi Mojtaba , Siroos Bahaoddin , Foroumandi Morteza , Asadi Gharabaghi Mehrnaz
Published: May 2013

We present a 23-year-old woman who was admitted due to fever, palpitation, musculoskeletal pain and a transient bout of sudden-onset left-sided hemiparesis. She had also myopericarditis according to echocardiography findings. After comprehensive diagnostic work-up for infectious and immunologic disorders, brucellosis was confirmed by bone marrow aspiration culture. She received doxycycline, rifampin and trimethoprim-sulfamethoxazole for 3 months. The treatment was continued with doxycycline and rifampin for another 6 months. By the end of treatment, she recovered completely with no evidence of persistent neurological or cardiac complications.
Rehabilitation following intracerebral haemorrhage secondary to extracorporeal membrane oxygenation (ECMO)
Authors: Kilsby Amanda , Buddha Sandeep
Published: May 2013

Extracorporeal membrane oxygenation (ECMO) was first used in adults with severe respiratory failure in the 1970s. Its use has been steadily increasing since the 1990s after a trial demonstrated improved survival. There are currently seven centres in the UK offering ECMO to adults. Neurological complications are often picked up within the first few days of initiating ECMO. Intracerebral haemorrhage is a well recognised complication and it is the leading cause of death in infants on ECMO and rates of 9–18.9% in adults have been reported. We report a 52-year-old woman admitted in severe type 1 respiratory failure in January 2012. She was transferred to a tertiary centre and suffered bitemporal and right parietal haemorrhages on ECMO in late February. She was repatriated to our unit for rehabilitation in April 2012. Her rehabilitation needs represent the complexity of this patient group with multiple medical, behavioural and physical challenges.
An under-diagnosed cause of leg swelling
Authors: Goodliffe James M , Ormerod Julian O M , Beale Andrew , Ramcharitar Steve
Published: May 2013

A grossly obese woman was wrongly diagnosed throughout her adult life of having lymphoedema. Her condition was subsequently confirmed as lipoedema, an entirely different condition, which is noted in medical text books but is seldom taught to medical students or to general practitioners. The condition is caused by abnormal deposition of adipose tissue in the extremities (usually the lower limbs) and almost exclusively affects women. It often starts at puberty or may occur after pregnancy. The exact aetiology is not yet understood but genetic and hormonal factors may be implicated. The problem is that misdiagnosis leads to inappropriate tests and improper treatment to the patient. When recognised it is often too late to do anything for the patient and they become highly dependent on social care. This case describes how the diagnosis can be confirmed through an ultrasound image and illustrates the need for early recognition to facilitate specialist care.
An unusual cause of recurrent chest pain in an adult woman: a case of recurrent stress-induced (Takotsubo) cardiomyopathy
Authors: Mainali Naba Raj , Aryal Madan Raj , Pradhan Rajesh , Hope Earl J
Published: May 2013

Recurrent Takotsubo cardiomyopathy is a relatively uncommon condition seen in patients with severe physical or emotional stress. We report a case of a 51-year-old woman who had recurrent Takotsubo cardiomyopathy with involvement of apical left ventricular (LV) segments, induced by intense emotional stress. On two occasions she presented with symptoms of acute coronary syndrome accompanied by LV regional wall motion abnormalities without a culprit coronary stenosis, and exhibited complete resolution of symptoms and restoration of normal LV wall motion.
Septo-optic dysplasia: fitting the pieces together
Authors: Ferraria Nélia , Castro Sofia , Amaral Daniela , Lopes Lurdes
Published: May 2013

A 7-year-old boy was admitted for a general tonic-clonic seizure with severe hypoglycaemia (1.39 mmol/l). His medical history was remarkable for a congenital left eye strabismus, unilateral cryptorchidism and three previous episodes of hypoglycaemic seizures with inconclusive metabolical and neurological investigations. Physical examination revealed a hoarse tone voice, dry skin, cold extremities and height in the third percentile (target height between 50th and 85th percentile). Left wrist radiography revealed a bone age of 4.5 years ±6 months Laboratory studies confirmed growth hormone deficiency and central hypothyroidism. The brain MRI showed an ectopic neurohypophysis. Neuroophthalmology investigation revealed left optic nerve hypoplasia and septo-optic dysplasia was then diagnosed. Thyroid and recombinant growth hormone replacement were started showing clinical improvement. A detailed clinical history and a careful physical examination in children presenting with multiple clinical signs of hypopituitarism may lead to a timely diagnosis, avoiding clinical morbidity associated to untreated hormonal abnormalities.
Primary squamous cell carcinoma of the stomach: a rare entity
Authors: Little Mhairi , Munipalle P C , Viswanath Y K S
Published: May 2013

A 73-year-old man presented acutely with upper gastrointestinal (GI) haemorrhage. Upper GI endoscopy was suggestive of a pancreatic or submucosal duodenal neoplasm invading the stomach. He underwent laparoscopically assisted distal gastrectomy. Histopathological examination showed the rare entity of primary gastric squamous cell carcinoma. He underwent adjuvant chemotherapy and remains disease free at 6 months.
Evidence for hypohydrosis as clinical clue to diagnosis of Horner's syndrome
Authors: Higaki Manabu , Kurai Daisuke , Ito Anri , Saraya Takeshi
Published: May 2013

A 59-year-old man presented with hypohydrosis in his left upper extremity and left hand, and experienced difficulty in gripping the steering wheel while driving. One year prior to admission, he had felt pain and/or paresthesias in his left anterior chest, left shoulder area and left periaxillar area, which corresponded to involvement of dermatomes in T1–T3. He was diagnosed with Horner's syndrome caused by lung tumour, which was located at the apical posterior wall along with the second to fourth ribs. The tumour interrupted sympathetic neurons at the T1–T4 level. The degree of hypohydrosis was successfully evaluated by the starch–iodine technique, dermal thermography and a skin surface hygrometer. After radiation therapy, hypohydrosis and pain or paresthesias improved partially, and he was discharged uneventfully.
Rupture of splenic angiosarcoma: a rare cause of spontaneous haemoperitoneum
Authors: Alexandrino Henrique , Julião Maria José , Tralhão José Guilherme , Castro Sousa Francisco
Published: May 2013

Primary splenic angiosarcoma, a very rare mesenchymal tumour of endothelial cell origin, comprises 2.6% of all cases of angiosarcoma and 10% of all primitive splenic tumours. Clinical presentation is usually unspecific, with abdominal pain and anaemia. Rupture is a rare complication and should prompt emergency splenectomy. Prognosis is usually poor because of liver, lung or bone metastases. We describe the case of an 80-year-old woman admitted to the emergency room with syncope, hypotension and vomiting. She stabilised after fluid resuscitation. Investigations showed anaemia, a large, heterogeneous spleen and free fluid in the abdominal cavity. She underwent emergency splenectomy. Pathology revealed primary splenic angiosarcoma. The postoperative period was complicated by respiratory failure but the patient made an otherwise uneventful course and was discharged 2 weeks after surgery. Six months after the operation she remains free of disease with no adjuvant treatment.
Management of fractured implant case using loop connector fixed partial denture
Authors: Yadav Ashish , Gupta Aratee , Tandan Amrit , Kumar Sulabh
Published: May 2013

Dental implants treatment have become a common modality of treatment nowadays for the replacement of missing tooth/teeth, but there have been failures due to a number of reasons; one of the rare problems is the fracture of the dental implants fixture. It is of prime importance to understand the type/system of the implant to be placed in a site and the amount and direction of occlusal forces incurred after the loading of prosthesis.
Striking temporally dynamic ECG changes associated with recurrent chest pain in a case of myopericarditis
Authors: Elmahy Hossam , Abdelbar Abdelrahman , Schmitt Matthias
Published: May 2013

A 33-year-old man without medical history or cardiovascular disease risk factors presented with recurrent progressively worsening chest pain that had been preceded by few days of flu like illness. His initial ECG and troponin rise supported the diagnosis of myopericarditis for which he was treated with aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) with good response initially. He later on developed severe recurrent chest pain and became tachycardic and hypotensive. Serial ECGs revealed a pattern of significant dynamic ST elevation in several leads, a pattern that is not usually seen in pericarditis. Subsequently, features of bedside echo did not support the diagnosis of acute ST-elevation myocardial infarction. The patient did well on conservative management with NSAIDs. He did not undergo urgent coronary angiography which would not have offered the patient any clinical benefit at the time and would have put him at procedural risk unnecessarily. The diagnosis of myopericarditis was confirmed retrospectively with typical features on cardiovascular magnetic resonance.
e-Prescribing: characterisation of patient safety hazards in community pharmacies using a sociotechnical systems approach
Authors: Odukoya Olufunmilola K , Chui Michelle A
Published: May 2013

Objective

To characterise the safety hazards related to e-prescribing in community pharmacies.

Methods

The sociotechnical systems framework was used to investigate the e-prescribing technology interface in community pharmacies by taking into consideration the social, technical and environmental work elements of a user's interaction with technology. This study focused specifically on aspects of the social subsystem.

Study design and setting

The study employed a cross-sectional qualitative design and was conducted in seven community pharmacies in Wisconsin. Direct observations, think aloud protocols and group interviews were conducted with 14 pharmacists and 16 technicians, and audio recorded. Recordings were transcribed and subjected to thematic content analysis guided by the sociotechnical systems’ theoretical framework.

Results

Three major themes that may increase the potential for medication errors with e-prescribing were identified and described. The three themes included: (1) increased cognitive burden on pharmacy staff, such as having to memorise parts of e-prescriptions or having to perform dosage calculations mentally; (2) interruptions during the e-prescription dispensing process; and (3) communication issues with prescribers, patients and among pharmacy staff. Pharmacy staff reported these consequences of e-prescribing increased the likelihood of medication errors.

Conclusions

This study is the first of its kind to identify patient safety risks related to e-prescribing in community pharmacies using a sociotechnical systems framework. The findings shed light on potential interventions that may enhance patient safety in pharmacies and facilitate improved e-prescribing use. Future studies should confirm patient safety hazards reported and identify ways to use e-prescribing effectively and safely in community pharmacies.
Effective prevention of thromboembolic complications in emergency surgery patients using a quality improvement approach
Authors: Kreckler Simon , Morgan Robert D , Catchpole Ken , New Steve , Handa Ashok , Collins Gary , McCulloch Peter
Published: May 2013

Objective

To assess the effectiveness of a multifaceted intervention based on industrial process improvement to identify and sustainably correct deficiencies in thromboprophylaxis delivery.

Summary background data

Deep vein thrombosis and pulmonary embolism are major causes of morbidity and mortality in surgical patients, but effective prophylactic treatments are available. Ensuring reliable delivery of the intended thromboprophylaxis is, however, a long-standing problem.

Methods

Delivery of thromboprophylactic treatment on an emergency general surgery admissions ward was targeted during a multidisciplinary intervention to improve process reliability using industrial quality improvement approaches. Delivery was audited against guidelines before and after 3- month intervention. Clinical outcome was evaluated by reviewing all radiological investigations for suspected Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE) from patients admitted to the unit in the 1 year immediately before and that immediately after intervention.

Results

Delivery of thromboprophylaxis according to guidelines was improved from 35% before to 87% 3 months after intervention (χ2=87.412, p<0.0001) and sustained at 86% 10 months after intervention. Radiologically identified thromboembolic events occurring up to 60 days after admission in patients admitted for over 48 h fell from 23/3075 (0.75%) before to 9/3080 (0.29%) after intervention (HR 0.39, CI 0.29 to 0.53, χ2=6.18, p=0.01292). The risk of thromboembolism in the two groups diverged during follow-up to 60 days, before converging again.

Conclusions

A quality improvement process resulted in major sustainable improvements in the delivery of thromboprophylaxis associated with a 61% reduction in radiologically detected clinical episodes of thromboembolism 2 months after admission. Further study of this approach to improving care quality is warranted.
Extrahepatic manifestations of hepatitis C virus (HCV)
Authors: Samuel David G , Rees Ian W
Published: May 2013

Hepatitis C virus (HCV) is an infectious disease that often remains asymptotic and unrecognised until complications of the virus arise. These often include extrahepatic manifestations of the virus, which first bring patients into contact with the medical profession. First recognised in the 1990s several syndromes and conditions have now been linked to hepatitis C, while others are still emerging. In some patients, extrahepatic manifestations can be the dominant feature, while hepatic disease is mild. Some conditions have an established association with the virus with a proven pathophysiological and epidemiology, such as cryoglobulinaemia. Others have consistently been found to be seen in patients with HCV, but the underlying cause of these conditions is not clearly understood. These include porphyria cutanea tarda. Many other autoimmune conditions are commonly seen in the patients with HCV as well as nephropathies, but the exact interplay between virus and resulting clinical condition is not clear. Clinicians have to have a high index of suspicion and a knowledge of the extrahepatic manifestations of HCV in order to not only treat the manifestation but also in initiated timely therapies for the underlying HCV.
Walking and child pedestrian injury: a systematic review of built environment correlates of safe walking
Authors: Rothman Linda , Buliung Ron , Macarthur Colin , To Teresa , Howard Andrew
Published: May 2013

Background

The child active transportation literature has focused on walking, with little attention to risk associated with increased traffic exposure. This paper reviews the literature related to built environment correlates of walking and pedestrian injury in children together, to broaden the current conceptualization of walkability to include injury prevention.

Methods

Two independent searches were conducted focused on walking in children and child pedestrian injury within nine electronic databases until March, 2012. Studies were included which: 1) were quantitative 2) set in motorized countries 3) were either urban or suburban 4) investigated specific built environment risk factors 5) had outcomes of either walking in children and/or child pedestrian roadway collisions (ages 0-12). Built environment features were categorized according to those related to density, land use diversity or roadway design. Results were cross-tabulated to identify how built environment features associate with walking and injury.

Results

Fifty walking and 35 child pedestrian injury studies were identified. Only traffic calming and presence of playgrounds/recreation areas were consistently associated with more walking and less pedestrian injury. Several built environment features were associated with more walking, but with increased injury. Many features had inconsistent results or had not been investigated for either outcome.

Conclusions

The findings emphasise the importance of incorporating safety into the conversation about creating more walkable cities.
The use of cost–benefit analysis in road assessments: a methodological inquiry
Authors: Vecino-Ortiz Andres I , Hyder Adnan A
Published: May 2013

Background

Cost–benefit analysis is a useful tool for priority setting in road safety. The value of statistical life (VOSL) is a metric used to estimate the benefits of road interventions in cost–benefit analyses. The International Road Assessment Program (iRAP), for example, created a rule-of-thumb to calculate VOSL benefits of road infrastructure when performing cost–benefit assessments in countries where data on VOSL are sparse.

Aim

To evaluate the rapid assessment metric developed by iRAP and provide suggestions for improvement in these methods.

Methods

We replicated iRAP calculations in order to make a critical assessment of the sources, results and conclusions.

Conclusions

We found the iRAP metric a good example for highlighting some relevant aspects that should be considered in any VOSL estimation in order to enhance its use as a guiding principle for assessing road interventions. Specifically, we recommend the explicit disclosure of the assumptions, the use of sensitivity analysis and the avoidance of omitted variables bias.
Unintentional alcohol and drug poisoning in association with substance use disorders and mood and anxiety disorders: results from the 2010 Nationwide Inpatient Sample
Authors: Yoon Young-Hee , Chen Chiung M , Yi Hsiao-Ye
Published: May 2013

Objective

To examine unintentional alcohol and drug poisoning in association with substance use disorders (SUDs) and mood and anxiety disorders.

Method

International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) external-cause-of-injury codes on discharge records of patients ages 12+ years from the 2010 Nationwide Inpatient Sample were examined to identify cases with unintentional alcohol poisoning (E860) and/or drug poisoning (E850–E858). ICD-9-CM diagnosis codes were examined to identify comorbid alcohol dependence, drug dependence, tobacco use disorder, and mood/anxiety disorders. Poisson regression was used to derive risk ratios to assess the associations between these comorbid conditions and alcohol/drug poisoning.

Results

Estimated numbers of hospitalisations related to unintentional alcohol and drug poisoning were, respectively, 5623 and 60 423 in men, and 3147 and 68 568 in women. For both sexes, the proportion with SUDs or mood/anxiety disorders was significantly higher among inpatients with alcohol and drug poisoning than among all inpatients. Estimated risk ratios indicated strong relationships of SUDs and mood/ anxiety disorders with unintentional poisoning from alcohol and drugs. The strongest association was between alcohol dependence and alcohol poisoning for both sexes. Significant associations also existed between drug dependence and drug poisoning, and mood/anxiety disorders and poisoning from alcohol and drugs.

Conclusions

SUDs and mood/anxiety disorders are key risk factors for unintentional poisoning by alcohol and drugs among inpatients in the USA. Effective treatments of these disorders should be targeted as poisoning prevention efforts. Future studies are needed to clarify a potential bias in the data due to differential inpatient mental condition screening practices.
Using media to promote suicide prevention hotlines to Veteran households
Authors: Karras Elizabeth , Stephens Brady , Kemp Janet E , Bossarte Robert M
Published: May 2013

This article presents preliminary evidence that media campaigns are valuable in promoting suicide prevention hotlines to Veteran households by reporting data from 2526 telephone surveys. Findings from this study underscore the need for further investigation of the use of media campaigns to support suicide prevention initiatives aimed at Veteran populations.