bluuebunny/crossref_metadata_2025 huggingface dataset:
The Calcineurin Pathway Inhibitor Tacrolimus Enhances the
In Vitro
Activity of Azoles against Mucorales via Apoptosis
Authors: Shirazi F. , Kontoyiannis D. P.
Published: July 2013

The calcineurin pathway regulates antifungal drug resistance and the virulence of several major human-pathogenic fungi, including the recalcitrant
Mucorales
. We hypothesized that the fungistatic triazoles posaconazole (PCZ) and itraconazole (ICZ) become fungicidal in the setting of the calcineurin inhibitor tacrolimus (TCR) and that such an effect is mediated through apoptosis. Fungicidal activity and apoptosis were studied using standard microbiological techniques and hyphal metabolic and vital dye reduction assays at 37°C in RPMI 1640. Apoptosis was characterized by detecting intracellular Ca
2+
, phosphatidylserine (PS) externalization, DNA fragmentation, plasma membrane integrity, chromatin condensation, reactive oxygen species (ROS) generation, caspase-like activity, ATP, and cytochrome
c
release. MICs for PCZ and ICZ alone were significantly higher (8 to 128 μg/ml) than those of PCZ or ICZ plus TCR (0.25 to 4 μg/ml) for
Rhizopus oryzae
,
Cunninghamella bertholletiae
, and
Mucor circinelloides
. Both PCZ and ICZ in combination with TCR became fungicidal, and their activity was mediated through increased apoptotic cell death of
R. oryzae
(10 to 50%),
C. bertholletiae
(5 to 50%), and
M. circinelloides
(5 to 55%) germlings, with morphological apoptotic changes characterized by externalization of PS, nuclear condensation, and DNA fragmentation. Moreover, activation of the caspase-like activity was correlated with cell death induced by TCR plus PCZ or ICZ. These changes correlated with elevated intracellular Ca
2+
and ROS levels and disturbance of mitochondrial potential. We found that PCZ or ICZ in combination with TCR renders
Mucorales
sensitive to triazoles via apoptotic death. These observations could serve as a new paradigm for the development of new therapeutic strategies.
Unraveling the Molecular Basis of Temperature-Dependent Genetic Regulation in Penicillium marneffei
Authors: Yang Ence , Wang Gang , Woo Patrick C. Y. , Lau Susanna K. P. , Chow Wang-Ngai , Chong Ken T. K. , Tse Herman , Kao Richard Y. T. , Chan Che-Man , Che Xiaoyan , Yuen Kwok-Yung , Cai James J.
Published: July 2013

Penicillium marneffei
is an opportunistic fungal pathogen endemic in Southeast Asia, causing lethal systemic infections in immunocompromised patients.
P. marneffei
grows in a mycelial form at the ambient temperature of 25°C and transitions to a yeast form at 37°C. The ability to alternate between the mycelial and yeast forms at different temperatures, namely, thermal dimorphism, has long been considered critical for the pathogenicity of
P. marneffei
, yet the underlying genetic mechanisms remain elusive. Here we employed high-throughput sequencing to unravel global transcriptional profiles of
P. marneffei
PM1 grown at 25 and 37°C. Among ∼11,000 protein-coding genes, 1,447 were overexpressed and 1,414 were underexpressed at 37°C. Counterintuitively, heat-responsive genes, predicted in
P. marneffei
through sequence comparison, did not tend to be overexpressed at 37°C. These results suggest that
P. marneffei
may take a distinct strategy of genetic regulation at the elevated temperature; the current knowledge concerning fungal heat response, based on studies of model fungal organisms, may not be applicable to
P. marneffei
. Our results further showed that the tandem repeat sequences (TRSs) are overrepresented in coding regions of
P. marneffei
genes, and TRS-containing genes tend to be overexpressed at 37°C. Furthermore, genomic sequences and expression data were integrated to characterize gene clusters, multigene families, and species-specific genes of
P. marneffei
. In sum, we present an integrated analysis and a comprehensive resource toward a better understanding of temperature-dependent genetic regulation in
P. marneffei
.
Mutations in
hemG
Mediate Resistance to Salicylidene Acylhydrazides, Demonstrating a Novel Link between Protoporphyrinogen Oxidase (HemG) and Chlamydia trachomatis Infectivity
Authors: Engström Patrik , Nguyen Bidong D. , Normark Johan , Nilsson Ingela , Bastidas Robert J. , Gylfe Åsa , Elofsson Mikael , Fields Kenneth A. , Valdivia Raphael H. , Wolf-Watz Hans , Bergström Sven
Published: July 2013

Salicylidene acylhydrazides (SAHs) inhibit the type III secretion system (T3S) of
Yersinia
and other Gram-negative bacteria. In addition, SAHs restrict the growth and development of
Chlamydia
species. However, since the inhibition of
Chlamydia
growth by SAH is suppressed by the addition of excess iron and since SAHs have an iron-chelating capacity, their role as specific T3S inhibitors is unclear. We investigated here whether SAHs exhibit a function on
C. trachomatis
that goes beyond iron chelation. We found that the iron-saturated SAH INP0341 (IS-INP0341) specifically affects
C. trachomatis
infectivity with reduced generation of infectious elementary body (EB) progeny. Selection and isolation of spontaneous SAH-resistant mutant strains revealed that mutations in
hemG
suppressed the reduced infectivity caused by IS-INP0341 treatment. Structural modeling of
C. trachomatis
HemG predicts that the acquired mutations are located in the active site of the enzyme, suggesting that IS-INP0341 inhibits this domain of HemG and that protoporphyrinogen oxidase (HemG) and heme metabolism are important for
C. trachomatis
infectivity.
Duplex Molecular Assay Intended for Point-of-Care Diagnosis of Influenza A/B Virus Infection
Authors: Wu Liang-Ta , Thomas Isabelle , Curran Martin D. , Ellis Joanna S. , Parmar Surendra , Goel Neha , Sharma Pia I. , Allain Jean-Pierre , Lee Helen H.
Published: July 2013

Early diagnosis and management of influenza virus infection directly correlates with the effectiveness in disease control. Current molecular influenza virus tests were designed for use in diagnostic testing facilities, where sophisticated equipment and highly trained technicians are available. A longer turnaround time for the centralized testing than when testing near the sample source could delay the initiation of medical intervention, thereby reducing the efficacy of antiviral treatment. The new assay, the SAMBA (
s
imple
am
plification-
b
ased
a
ssay) Flu duplex test, is a dipstick-based molecular assay developed to provide a simple, accurate, and cost-effective solution for the diagnosis of influenza A/B viruses intended for near-patient testing. The test presents an alternative format of influenza virus molecular testing that utilizes isothermal amplification and visual detection of nucleic acid on a test strip. The entire test procedure (extraction, amplification, and detection) is integrated into an enclosed semiautomated system. Analytically, the SAMBA Flu duplex test detects 95 and 85 copies of viral genomes for influenza A and B viruses, respectively, with no cross-reactivity observed against other common respiratory pathogens. The clinical performance was established by blind testing of 328 nasal/throat and nasopharyngeal swab specimens from the United Kingdom and Belgium and comparing the results with the quantitative reverse transcription-PCR method routinely used in two public health laboratories. The SAMBA Flu duplex test showed a clinical sensitivity and specificity of 100% and 97.9% for influenza virus A and 100% and 100% for influenza virus B. The test provides a new technology that could facilitate simple and timely identification of influenza virus infection, potentially resulting in more efficient control measures.
Evaluation of Luminex xTAG Gastrointestinal Pathogen Analyte-Specific Reagents for High-Throughput, Simultaneous Detection of Bacteria, Viruses, and Parasites of Clinical and Public Health Importance
Authors: Navidad Jose F. , Griswold David J. , Gradus M. Stephen , Bhattacharyya Sanjib
Published: July 2013

Acute diarrheal disease (ADD) can be caused by a range of pathogens, including bacteria, viruses, and parasites. Conventional diagnostic methods, such as culture, microscopy, biochemical assays, and enzyme-linked immunosorbent assays (ELISA), are laborious and time-consuming and lack sensitivity. Combined, the array of tests performed on a single specimen can increase the turnaround time (TAT) significantly. We validated a 19plex laboratory-developed gastrointestinal pathogen panel (GPP) using Luminex xTAG analyte-specific reagents (ASRs) to simultaneously screen directly in fecal specimens for diarrhea-causing pathogens, including bacteria (Campylobacter jejuni,Salmonellaspp.,Shigellaspp., enterotoxigenicEscherichia coli[ETEC], Shiga toxin-producingE. coli[STEC],E. coliO157:H7,Vibrio cholerae,Yersinia enterocolitica, and toxigenicClostridium difficile), parasites (Giardia lamblia,Cryptosporidiumspp., andEntamoeba histolytica), and viruses (norovirus GI and GII, adenovirus 40/41, and rotavirus A). Performance characteristics of GPP ASRs were determined using 48 reference isolates and 254 clinical specimens. Stool specimens from individuals with diarrhea were tested for pathogens using conventional and molecular methods. Using the predictive methods as standards, the sensitivities of the GPP ASRs were 100% for adenovirus 40/41, norovirus, rotavirus A,Vibrio cholerae,Yersinia enterocolitica,Entamoeba histolytica,Cryptosporidiumspp., andE. coliO157:H7; 95% forGiardia lamblia; 94% for ETEC and STEC; 93% forShigellaspp.; 92% forSalmonellaspp.; 91% forC. difficileA/B toxins; and 90% forCampylobacter jejuni. The overall comparative performance of the GPP ASRs with conventional methods in clinical samples was 94.5% (range, 90% to 97%), with 99% (99.0% to 99.9%) specificity. Implementation of the GPP ASRs enables our public health laboratory to offer highly sensitive and specific screening and identification of the major ADD-causing pathogens.
High Incidence but Low Burden of Coronaviruses and Preferential Associations between Respiratory Viruses
Authors: Lepiller Q. , Barth H. , Lefebvre F. , Herbrecht R. , Lutz P. , Kessler R. , Fafi-Kremer S. , Stoll-Keller F.
Published: July 2013

Respiratory viruses are the leading cause of acute infections in humans. However, the burden of certain respiratory viruses, such as coronaviruses, and the relevance of viral coinfections remain unclear. In this study, we investigated the distribution and seasonal occurrences of respiratory viruses detected by multiplex molecular assay in 6,014 samples from 2008 to 2011 in a French hospital. We assessed the detection frequencies of 14 respiratory viruses and their clinical impact in immunosuppressed and nonimmunosuppressed patients. Furthermore, we explored the preferential association patterns between respiratory viruses in multiple infections. Our results indicated that human rhinovirus/enterovirus (HRV/EV) and coronavirus (HCoV) were frequently detected in respiratory samples (48.81% and 11.74% of infected samples, respectively), and the detection frequencies of these viruses were further increased in immunosuppressed patients. The most common subtypes of HCoV were HCoV-229E (33.80%) and HCoV-HKU1 (32.39%). A sharp increase in the detection frequencies of HCoV-229E and HCoV-HKU1 over several months suggested that these subtypes were epidemic in our population. In immunosuppressed patients, HCoV contributed to upper respiratory tract infections (52%). Evidence did not support lower respiratory tract infections exclusive to a unique HCoV infection. In multiply infected individuals, determined in 6.3% of samples, HRV/EV and HCoV were detected in 33.29% and 22.90% of samples, respectively. Interestingly, nearly 50% of HCoV infections were detected in association with another virus. Since the distributions of respiratory viruses in multiply infected patients were subject to preferential association patterns between viruses, we propose complex interactions between different respiratory viruses and host factors.
Sensitive and Specific Quantitative Detection of Rotavirus A by One-Step Real-Time Reverse Transcription-PCR Assay without Antecedent Double-Stranded-RNA Denaturation
Authors: Mijatovic-Rustempasic Slavica , Tam Ka Ian , Kerin Tara K. , Lewis Jamie M. , Gautam Rashi , Quaye Osbourne , Gentsch Jon R. , Bowen Michael D.
Published: July 2013

A real-time quantitative reverse transcription-PCR (qRT-PCR) assay using the recombinant thermostable
Thermus thermophilus
(r
Tth
) enzyme was developed to detect and quantify rotavirus A (RVA). By using r
Tth
polymerase, significant improvement was achieved over the existing real-time RT-PCR assays, which require denaturation of the RVA double-stranded RNA (dsRNA) prior to assay setup. Using a dsRNA transcript for segment 7, which encodes the assay target NSP3 gene, the limit of detection for the improved assay was calculated to be approximately 1 genome copy per reaction. The NSP3 qRT-PCR assay was validated using a panel of 1,906 stool samples, 23 reference RVA strains, and 14 nontarget enteric virus samples. The assay detected a diverse number of RVA genotypes and did not detect other enteric viruses, demonstrating analytical sensitivity and specificity for RVA in testing stool samples. A XenoRNA internal process control was introduced and detected in a multiplexed qRT-PCR format. Because it does not require an antecedent dsRNA denaturation step, this assay reduces the possibility of sample cross-contamination and requires less hands-on time than other published qRT-PCR protocols for RVA detection.
Outbreak Caused by an Ertapenem-Resistant, CTX-M-15-Producing Klebsiella pneumoniae Sequence Type 101 Clone Carrying an OmpK36 Porin Variant
Authors: Poulou Aggeliki , Voulgari Evangelia , Vrioni Georgia , Koumaki Vasiliki , Xidopoulos Grigorios , Chatzipantazi Vasiliki , Markou Fani , Tsakris Athanassios
Published: July 2013

Although numerous studies have documented outbreaks of carbapenem-resistant
Klebsiella pneumoniae
(CRKP) possessing various carbapenemases, reports on outbreaks due to CRKP possessing extended-spectrum β-lactamases (ESBLs) and/or AmpCs with porin lesions have been limited. Here, we describe an outbreak caused by an ertapenem-resistant, CTX-M-15-producing clonal
K. pneumoniae
strain expressing an OmpK36 porin variant. From May 2012 to November 2012, 37 ertapenem-resistant
K. pneumoniae
isolates phenotypically negative for carbapenemase production were recovered from 19 patients hospitalized in the intensive care unit of a Greek hospital. The isolates were either susceptible or intermediate to other carbapenems and resistant to all remaining β-lactams but cefotetan. Phenotypic and molecular analysis revealed the presence in all isolates of the
bla
CTX-M-15
gene on a conjugative 100-kb plasmid, disruption in the expression of the
ompK35
gene, and the production of an Ompk36 porin variant. The index case was a patient admitted from another hospital. Active surveillance upon admission and on a weekly basis was immediately initiated; environmental samples were also periodically tested. Molecular typing showed that all clinical isolates as well as two ertapenem-resistant environmental
K. pneumoniae
isolates belonged to the same clonal type and were assigned to multilocus sequence typing (MLST) sequence type 101 (ST101). As all colonized/infected patients were hospitalized during overlapping periods, cross-infection was considered the main route for the dissemination of the outbreak strain. Despite reinforcement of infection control measures and active surveillance, the outbreak lasted approximately 7 months. Identification of hidden carriers upon admission and by screening on a weekly basis was found valuable for early recognition and subsequent successful management of the outbreak.
Value of Superficial Cultures for Prediction of Catheter-Related Bloodstream Infection in Long-Term Catheters: a Prospective Study
Authors: Guembe M. , Martín-Rabadán P. , Echenagusia A. , Camúñez F. , Rodríguez-Rosales G. , Simó G. , Echenagusia M. , Bouza E.
Published: July 2013

Cultures taken from the skin and from the hubs of short-term central venous catheters can help us to predict catheter-related bloodstream infections (C-RBSIs). The value of these cultures for such predictions has not been assessed in long-term catheters. Our objective was to assess the value of superficial cultures for the prediction of C-RBSI among patients with long-term catheters. Over a 2-year period, we prospectively obtained cultures from the skin overlying reservoir ports (group A) and from the skin insertion site and hubs of all tunneled catheters (group B). This routine was performed by vascular and interventional radiologists immediately before catheter removal (irrespective of the reason for withdrawal). Swabs were processed semiquantitatively. Catheter tips from both groups were cultured using Maki's semiquantitative technique and sonication. We also performed cultures of the reservoir ports at different sites. C-RBSI was defined as the isolation of the same species of microorganism(s) both in the colonized catheter and in at least 1 peripheral blood culture. We included 372 catheters (group A, 223; group B, 149) during the study period. The catheter colonization rate was 23.4% (87/372), and 28 patients had C-RBSI. Validity index values for the capacity of surface cultures to predict C-RBSI in groups A and B were, respectively, as follows: sensitivity, 23.5% and 45.5%; specificity, 59.7% and 63.0%; positive predictive value, 4.6% and 8.9%; and negative predictive value, 90.4% and 93.5%. Superficial cultures of patients with long-term catheters could help us to rule out the catheter as the portal of entry of bloodstream infections. Superficial cultures (from skin and hubs) proved to be a useful conservative diagnostic tool for ruling out C-RBSI among patients with long-term tunneled catheters and totally implantable venous access ports.
Point-Counterpoint: β-
d
-Glucan Testing Is Important for Diagnosis of Invasive Fungal Infections
Authors: Theel Elitza S. , Doern Christopher D.
Published: July 2013

Invasive fungal infections are a significant cause of morbidity and mortality in patients who receive immunosuppressive therapy, such as solid organ and hematopoietic stem cell transplant (HSCT) recipients. Many of the fungi associated with these infections are angioinvasive and are best diagnosed by visualizing the organism in or culturing the organism from deep tissue. However, obtaining such tissue often requires an invasive procedure. Many HSCT recipients are thrombocytopenic, making such procedure too risky because of potential bleeding complications. Additionally, positive blood cultures are rare for patients with angioinvasive fungal infections, making this diagnostic strategy of little value. Undiagnosed fungal infections in these patient populations are a significant cause of mortality. Prophylactic use of antifungal agents, such as the echinocandins, during periods of neutropenia or graft-versus-host disease may prevent some fungal infections but increase the risk for others. Detection of fungal antigens in body fluids, including cryptococcus capsular polysaccharide, histoplasma antigen, galactomannan, and β-
d
-glucan, is viewed as being clinically useful for at least the presumptive diagnosis of invasive fungal infections. β-
d
-Glucan is an attractive antigen in that it is found in a broad range of fungal agents, including the commonly encountered agents
Candida
spp.,
Aspergillus
spp., and
Pneumocystis jirovecii.
Cross-reactions with certain hemodialysis filters, beta-lactam antimicrobials, and immunoglobulins, which raise concerns about false-positive tests, have also been described. As a result, the use of this testing must be closely monitored. In this point-counterpoint, we have asked Elitza Theel, who directs the Infectious Disease Serology Laboratory at the Mayo Clinic, to address why she believes that this test has value in the diagnosis of invasive fungal infections. We have asked Christopher Doern, Director of Clinical Microbiology at Children's Medical Center of Dallas, why he questions the clinical value of β-
d
-glucan testing.
Herpes zoster ophthalmicus progressing to encephalitis: beware pain preceding the rash
Authors: Nandi Novoneel , Morris Paul , Blundell Adrian
Published: July 2013

We present a challenging case in which the dermatomal pain associated with herpes zoster ophthalmicus preceded the cutaneous rash by several days. It thus highlights the need to consider this diagnosis among the differentials for severe unilateral headache in the elderly. The patient unfortunately progressed to develop encephalitis, an uncommon but serious complication of zoster reactivation and a reminder that this remains an important cause of morbidity and mortality in the elderly population.
Ewing sarcoma of the adrenal gland: a rare entity
Authors: Blas Joseph-Vincent V , Smith Maxwell L , Wasif Nabil , Cook Curtiss B , Schlinkert Richard T
Published: July 2013

A 63-year-old man was referred to our office with an enlarging left adrenal mass found on work-up for prostate cancer. Imaging performed over the course of 6 months demonstrated an increasing left adrenal mass from 2.8 to 3.6 cm. Functional testing of the adrenal lesion was performed. The adrenal mass was non-functional. Owing to the enlarging size, the patient underwent a laparoscopic left adrenalectomy without complication and was discharged home the following day. Gross pathological evaluation demonstrated a 3.2 cm, well-encapsulated, partially cystic mass. Histological evaluation demonstrated a small round blue cell tumour suspicious of sarcoma. Immunohistochemical testing revealed strong CD99 positivity consistent with Ewing family of tumours. Reverse transcriptase PCR demonstrated the presence of the Ewing sarcoma fusion transcript. The patient is currently enrolled in an ongoing research chemotherapy protocol at our institution using vincristine, doxorubicin, cyclophosphamide, ifosfamide and etoposide.
Acute psychosis as a presentation of hypopituitarism
Authors: Kate Shruti , Dhanwal Dinesh Kumar , Kumar Shishir , Bharti Praveen
Published: July 2013

Acute onset neuropsychiatric manifestations in hypopituitarism are uncommon. We report a case of a 60-year-old man who was a follow-up case of macroprolactinoma with hypopituitarism for the last 9 years. He was on medical treatment with cabergoline, thyroxine and depot testosterone. During the last 2 years he was non-adherent to medications especially cabergoline. He was hospitalised for 2 days through emergency services following acute onset psychosis. His pituitary hormone profile was suggestive of adrenal insufficiency, secondary hypothyroidism and hypogonadism. MRI of the hypothalamic pituitary region revealed a pituitary macroadenoma which was larger in size compared to the previous scan. Further, this lesion was compressing on the adjoining structures including optic chiasma. The patient was treated with intravenous fluids, hydrocortisone and thyroxine replacement therapy. With this treatment he completely recovered from psychosis within 48 h.
Paget-Schrotter syndrome and complications of management
Authors: Dep A , Concannon E , Mc Hugh S M , Burke P
Published: July 2013

An 18-year-old man presented to the emergency department with an acutely swollen right upper limb having spent the previous day canoeing. Venography confirmed right subclavian venous thrombosis at middle one-third of right clavicle with no evidence of cervical rib or other structural abnormalities. Following heparinisation, catheter directed thrombolysis was performed which restored luminal flow. Postprocedure the patient developed spontaneous small-volume haemoperitoneum and acute renal failure. The patient was admitted to the intensive care unit for haemodialysis and supportive management. The patients’ renal function improved and he was discharged well following his 28th day of admission. Paget-Schroetter syndrome or effort thrombosis involves subclavian venous thrombosis associated with strenuous activity of upper extremities. In these cases, catheter directed thrombolysis with first rib resection provides greater patency rate than anticoagulation therapy alone. Acute kidney injury following mechanical thrombolysis is rarely reported in the literature.
Fracture tooth fragment reattachment
Authors: Maitin Nitin , Maitin Shipra Nangalia , Rastogi Khushboo , Bhushan Rajarshi
Published: July 2013

Coronal fractures of the anterior teeth are a common form of dental trauma and its sequelae may impair the establishment and accomplishment of an adequate treatment plan. Among the various treatment options, reattachment of a crown fragment is a conservative treatment that should be considered for crown fractures of anterior teeth. This clinical case reports the management of two coronal tooth fracture cases that were successfully treated using tooth fragment reattachment using glass-fibre-reinforced composite post.
Hepatic visceral larva migrans
Authors: Rohilla Seema , Jain Nitin , Yadav Rohtas , Dhaulakhandi Dhara Ballabh
Published: July 2013

Visceral larva migrans (VLM) is a systemic manifestation of migration of second stage larvae of nematodes through the tissue of human viscera. It is not uncommon but is underdiagnosed in developing countries. The liver is the most common organ to be involved due to its portal venous blood supply. The imaging findings are subtle and differentiation from hepatocellular carcinoma (HCC), metastases, cystic mesenchymal hamartoma and granulomatous diseases is difficult. This case report highlights the imaging features of hepatic lesions of VLM along with clinical and laboratory data which help in clinching the diagnosis.
Cardiac involvement as the main presenting feature in eosinophilic granulomatosis with polyangiitis
Authors: McAleavey Neil , Millar Auleen , Pendleton Adrian
Published: July 2013

Eosinophilic granulomatosis with polyangiitis is usually characterised by asthma, allergic rhinitis and peripheral eosinophilia. Presentations can vary greatly especially when there is cardiac involvement as demonstrated in these two case reports. Patient A initially presented to casualty with severe sinus pain and was diagnosed with severe sinonasal polyposis. After routine nasal polypectomy he had a cardiac arrest and was transferred to intensive care. Patient B presented to his general practitioner with a 4-week history of breathlessness, joint pain and a rash resulting in admission to hospital. Both patients had significant eosinophilia on routine bloods. High-sensitivity troponin T levels were raised in both; however, patient B's was significantly higher. Patient A had a large pericardial effusion on echo, the aspirate of which revealed numerous eosinophils. Patient B's echo was normal. Patient A's cardiac MRI was normal while Patient B's revealed myocarditis. Both were successfully treated with intravenous methylprednisolone and cyclophosphamide.
Hybrid peripheral ameloblastoma of cheek mucosa
Authors: Yuwanati Monal Bhaurao , Singh Aarti , Gadbail Amol R , Mhaske Shubhangi
Published: July 2013

An unusual case of large buccal tumour has been described. The lesion was clinically compatible with a squamous cell carcinoma, but it had pathological features of an ameloblastoma arising in the soft tissues. Only few cases of extragingival peripheral ameloblastoma were found in a review of the literature. Possible origins of these tumours are still debatable.
Cementifying fibroma
Authors: Mohan Ravi Prakash Sasankoti , Verma Sankalp , Singh Udita , Agarwal Neha
Published: July 2013

Cementifying fibroma is considered as a benign, osseous tumour, which arises from the periodontal ligament and is composed of varying amounts of cementum, bone and fibrous tissue. It is very closely related to other fibro-osseous lesions like fibrous dysplasia, cemental periapical dysplasia and other calcifying odontogenic cysts and tumour. We report a case of this entity along with differentiating radiographic features that set it apart from other fibro-osseous lesions.
Jung's archetype, ‘The Wounded Healer’, mental illness in the medical profession and the role of the health humanities in psychiatry
Authors: Hankir Ahmed , Zaman Rashid
Published: July 2013

Carl Jung used the term, ‘The Wounded Healer’ as an archetype to describe doctors who have suffered from an illness. Reading and writing autobiographical narratives of the ‘Wounded Healer’ is gaining popularity among doctors with mental illness as an effective form of adjunctive therapy. Moreover, reading autobiographical narratives of psychopathology sufferers can ‘augment’ service providers’ humanity by offering valuable qualitative insights into minds afflicted with a psychiatric disorder. The primary author, a doctor of Middle-Eastern descent practicing in the UK, composed an autobiographical narrative about his personal experiences with oscillations in his mood in an attempt to illustrate the cultural, religious and psychosocial factors that influence disease detection, progression, treatment and outcome. An inordinate amount of misconceptions about mental illness abound. We hope that this manuscript will help to lessen the stigma associated with those who suffer from psychopathology (particularly doctors) and encourage sufferers to engage with the appropriate services.
Bilateral renal cell carcinoma in a paediatric patient with tuberous sclerosis complex
Authors: Gil Ana Teresa , Brett Ana , Cordinhã Carolina , Gomes Clara
Published: July 2013

Tuberous sclerosis complex (TSC) is a genetic neurocutaneous disorder characterised by seizures, mental retardation and hamartoma formation in multiple organs, mainly in the brain, skin, kidney, liver, lung and heart. Renal manifestations occur in about 60–80% of all patients with TSC and their rate increases with age. We report the case of a 17-year-old boy with tuberous sclerosis who presented with abdominal pain associated with kidney failure. Investigation revealed bilateral renal lesions, suggesting angiomyolipomas. On further work-up, malignancy was suspected and the patient underwent bilateral partial nephrectomy with histological diagnosis of bilateral renal cell carcinoma. This is a rare complication of TSC, particularly in a paediatric setting. Adequate surveillance of kidney disorders in patients with TSC is warranted, to guarantee an early diagnosis and treatment.
Charcot-Marie-Tooth syndrome and neurofibromatosis type 1 with multiple neurofibromas of the entire spinal nerve roots
Authors: Onu David O , Hunn Andrew W , Peters-Willke Jens
Published: July 2013

The coexistence of polyneuropathy which has the definite clinical and electromyographical findings consistent with Charcot-Marie-Tooth (CMT) syndrome and neurofibromatosis type 1 (NF1) has infrequently been reported. We describe a patient with both CMT and NF1, who had multiple neurofibromas involving the entire spinal neural axis. In addition, he had multiple neurofibromas distributed within the ileopsoas and gluteus muscles and subcutaneous tissues. These lesions were detected readily by MRI and the patient underwent successful surgical resection of the largest tumours compressing bilateral C2 nerve roots. To our knowledge, this is the first reported case of CMT syndrome coexisting with NF1 in which multiple neurofibromas involved the entire spinal nerve roots. We discuss the diagnostic and therapeutic challenges, emphasising the role of MRI and electrophysiology in such cases and provide a literature review.
Neuroleptic malignant syndrome associated with haloperidol use in critical care setting: should haloperidol still be considered the drug of choice for the management of delirium in the critical care setting?
Authors: Dixit Deepali , Shrestha Pranabh , Adelman Marc
Published: July 2013

A 48-year-old man was brought to the emergency department because of intoxication. The patient was in respiratory distress, subsequently intubated for airway protection. On hospital day 5, he was diagnosed with delirium. Haloperidol was initiated at 5 mg intravenous every 6 h and titrated up to a dose of 60 mg /day over 5 days. On hospital day 18, his temperature peaked to 107.1°F. Other symptoms included mental status change, muscular rigidity and autonomic dysfunction. Neuroleptic malignant syndrome (NMS) associated with haloperidol was suspected. No other causes for these symptoms were present. Concurrent medications were reviewed and ruled out for possible drug-induced fever. Haloperidol was discontinued and dantrolene and bromocriptine was initiated. The temperature decreased to 102.2°F within 3 h and other symptoms resolved overtime. The temporal relationship between the patient's fever decline with the discontinuation of haloperidol, and improvement with dantrolene and bromocriptine, the diagnosis was believed to be haloperidol-induced NMS.
Severe eyelid oedema in Graves’ ophthalmopathy
Authors: Anagnostis Panagiotis , Adamidou Fotini , Poulasouchidou Maria , Karras Spyridon
Published: July 2013

We report a case of severe eyelid oedema due to Graves’ ophthalmopathy (GO). The aim was to present a case report and review of the literature about eyelid oedema due to GO. The case report includes a history of patient data and literature review. The patient was offered intravenous methylprednisolone and gave consent. A dosage of 500 mg intravenous methylprednisolone once weekly for 6 weeks, followed by 250 mg intravenous methylprednisolone once weekly for 6 weeks, with a total treatment period of 12 weeks was given. Up to day, minor improvement has been observed. Severe eyelid oedema due to GO is a rare manifestation of Graves’ disease. In cases of active and moderate-to-severe disease, treatment with intravenous glucorticoids is recommended alone or with orbital radiotherapy, followed by rehabilitative surgery.
A popliteal aneurysm with upper thigh extension: a tip of the iceberg finding
Authors: Ahmad Sufian S , Evangelopoulos Dimitrios Stergios , Kohl Sandro
Published: July 2013

A 75-year-old male patient was referred to our orthopaedic department due to progressive weakening of the left leg, noticed while going up and down stairs, and swelling of the thigh. An increase in swelling was noted in association with spicy food. Clinical examination showed a palm-sized non-pulsatile soft mass in the popliteal region and swelling in the posterior-lateral thigh. MRI revealed a space-occupying 40×15×10 cm mass extending into the upper thigh without infiltrating character. Angiography was negative. Open surgical biopsy was performed to rule out a soft tissue tumour, during which, connection to the popliteal artery was identified. The patient underwent excision of the aneurismal sac and a prosthetic graft was interplaced. On follow-up, the patient noticed a rapid increase in muscle strength; stairs were no longer a problem.
Capsular warning syndrome
Authors: Nadarajan Vivek , Adesina Tolu
Published: July 2013

We present a case of a 72-year-old man who presented with fluctuating right-sided weakness and numbness. This was characterised by episodic sudden onset weakness with resolution of symptoms in between. His symptoms and signs were becoming persistent despite the addition of dual antiplatelet therapy. The history we describe is classical of capsular warning syndrome. The patient went on to have further definitive neuroimaging which revealed a pontine infarct, rather than the expected capsular infarct. We discuss the importance of capsular warning syndrome, the proposed pathophysiological mechanisms and different locations of infarction in previous cases of capsular warning syndrome.

We also discuss the lack of consensus (within the literature) in treatment options which are used to try and prevent a completed stroke occurring in cases of capsular warning syndrome.
Reflex gelastic–dacrystic seizures following hypoxic–ischaemic encephalopathy
Authors: Verma Rajesh , Praharaj Heramba Narayan
Published: July 2013

Reflex or stimulus-sensitive epilepsies are uncommon epileptic syndromes triggered by exogenous-specific sensory stimulus or endogenous various mental activities. Gelastic–dacrystic seizures are rare epileptic manifestations characterised by ictal laughter and crying. Gelastic–dacrystic seizures are commonly caused by hypothalamic hamartoma but rarely described due to cortical dysplasia, lesions of frontal and temporal lobes, tumours and vascular malformations. We report a young woman who presented with somatosensory-evoked gelastic–dacrystic seizures. This patient had a positive history of perinatal insult substantiated by MRI findings. Hypoxic–ischaemic encephalopathy as the cause of gelastic–dacrystic seizures has not been reported so far in the literature.
Neurological improvement following reinstitution of a low phenylalanine diet after 20 years in established pnenylketonuria
Authors: Anwar M S , Waddell B , O'Riordan J
Published: July 2013

A 41-year-old woman had meaningful functional improvement following reinstitution of a low phenylalanine diet. She was diagnosed at birth with phenylketonuria and followed strict dietary adherence till the age of 16. Thereafter the diet was discontinued. She subsequently presented with subacute profound visual loss, cognitive dysfunction and paraparesis such that she was bed bound requiring full nursing care. Following dietary intervention there was meaningful improvement such that she was no longer demented and while her vision remains poor she is now independent for activities of daily living. This case report suggests that consideration of reimplementation of dietary intervention is warranted even after a prolonged period of time.
Bilateral radix entomolaris with primary and permanent mandibular first molars
Authors: Gupta Nidhi , Goswami Mousumi , Singh Kunwarjeet
Published: July 2013

Dental practitioners should be aware of the morphological dental anomalies like additional roots; their location, incidence and associated unusual root canal morphology. They should also carefully interpret the intraoral radiographs so that such anomalies do not go unnoticed.
A foreign body of the larynx misdiagnosed as vocal cord paralysis
Authors: Kumar Sunil , Singh Devendra Bahadur , Singh Abhishek Bahadur
Published: July 2013

Foreign bodies in the aerodigestive tract continue to be a common problem that contribute significantly to high morbidity and mortality all over the world. Laryngeal foreign bodies may present with less severe symptoms compared with lower respiratory tract foreign bodies, resulting in misdiagnosis, confusion and delay in diagnosis. Rigid endoscopy with forceps removal under general anaesthesia is the preferred management modality. This case is described to show the importance of a detailed history and examination including X-ray neck in children to rule out any radiopaque laryngeal foreign body as a delay in diagnosis and management can lead to life-threatening complications.
Copenhagen hip and groin outcome score (HAGOS) in male soccer: reference values for hip and groin injury-free players
Authors: Thorborg Kristian , Branci Sonia , Stensbirk Frederik , Jensen Jesper , Hölmich Per
Published: July 2013

Background/aim

Reference values are needed in order to interpret the Copenhagen Hip and Groin Outcome Score (HAGOS) in male soccer players with hip and groin pain. The aim of this study was to establish reference values for HAGOS in hip and groin injury-free male soccer players.

Methods

We included 444 groin injury-free soccer players from 40 clubs (divisions 1–4) in Eastern Denmark, mean age (SD) 23.6 (4.4), training soccer 3.4 (1) times per week. All players were hip and groin injury-free at the time of inclusion (beginning of season, 2011).

Results

Of the 444 hip and groin injury-free players, 301 reported no hip and/or groin pain in either the present or the previous season, and 143 reported that they had experienced hip and/or groin pain in the previous season. Players (n=143) with hip and groin pain in the previous season displayed lower scores than players without (n=301), for all HAGOS subscales (p<0.001). Age and playing level were not related to HAGOS. The 95% reference ranges for HAGOS subscales in hip and groin injury-free soccer players, with no pain in the previous or present season (n=301), are: pain: 80.1–100, symptoms: 64.3–100, activities of daily living: 80.3–100, sport and recreational activities: 71.9–100, participation in physical activity: 75–100 and quality of living: 75–100.

Conclusions

Lower HAGOS subscales are seen in soccer players who have experienced hip and/or groin pain in the previous season, compared with those who have not. Median HAGOS subscale scores in hip and groin injury-free soccer players are in proximity to the maximum score (100 points).
Defining quality outcomes for complex-care patients transitioning across the continuum using a structured panel process
Authors: Jeffs Lianne , Law Madelyn P , Straus Sharon , Cardoso Roberta , Lyons Renee F , Bell Chaim
Published: July 2013

Background

No standardised set of quality measures associated with transitioning complex-care patients across the various healthcare settings and home exists. In this context, a structured panel process was used to define quality measures for care transitions involving complex-care patients across healthcare settings.

Methods

A modified Delphi consensus technique based on the RAND method was used to develop measures of quality care transitions across the continuum of care. Specific stages included a literature review, individual rating of each measure by each of the panelists (n=11), a face-to-face consensus meeting, and final ranking by the panelists.

Results

The literature review produced an initial set of 119 measures. To advance to rounds 1 and 2, an aggregate rating of >75% of the measure was required. This analysis yielded 30/119 measures in round 1 and 11/30 measures in round 2. The final round of scoring yielded the following top five measures: (1) readmission rates within 30 days, (2) primary care visit within 7 days postdischarge for high-risk patients, (3) medication reconciliation completed at admission and prior to discharge, (4) readmission rates within 72 h and (5) time from discharge to homecare nursing visit for high-risk patients.

Conclusions

The five measures identified through this research may be useful as indicators of overall care quality related to care transitions involving complex-care patients across different healthcare settings. Further research efforts are called for to explore the applicability and feasibility of using the quality measures to drive quality improvement across the healthcare system.
Sustained health-economic effects after reorganisation of a Swiss hospital emergency centre: a cost comparison study
Authors: Eichler Klaus , Hess Sascha , Chmiel Corinne , Bögli Karin , Sidler Patrick , Senn Oliver , Rosemann Thomas , Brügger Urs
Published: July 2013

Background

Emergency departments (EDs) are increasingly overcrowded by walk-in patients. However, little is known about health-economic consequences resulting from long waiting times and inefficient use of specialised resources. We have evaluated a quality improvement project of a Swiss urban hospital: In 2009, a triage system and a hospital-associated primary care unit with General Practitioners (H-GP-unit) were implemented beside the conventional hospital ED. This resulted in improved medical service provision with reduced process times and more efficient diagnostic testing. We now report on health-economic effects.

Methods

From the hospital perspective, we performed a cost comparison study analysing treatment costs in the old emergency model (ED, only) versus treatment costs in the new emergency model (triage plus ED plus H-GP-unit) from 2007 to 2011. Hospital cost accounting data were applied. All consecutive outpatient emergency contacts were included for 1 month in each follow-up year.

Results

The annual number of outpatient emergency contacts increased from n=10 440 (2007; baseline) to n=16 326 (2011; after intervention), reflecting a general trend. In 2007, mean treatment costs per outpatient were €358 (95% CI 342 to 375). Until 2011, costs increased in the ED (€423 (396 to 454)), but considerably decreased in the H-GP-unit (€235 (221 to 250)). Compared with 2007, the annual local budget spent for treatment of 16 326 patients in 2011 showed cost reductions of €417 600 (27 200 to 493 600) after adjustment for increasing patient numbers.

Conclusions

From the health-economic point of view, our new service model shows ‘dominance’ over the old model: While quality of service provision improved (reduced waiting times; more efficient resource use in the H-GP-unit), treatment costs sustainably decreased against the secular trend of increase.
Comparison of intubation modalities in a simulated cardiac arrest with uninterrupted chest compressions
Authors: Tandon Navin , McCarthy Matthew , Forehand Brett , Carlson Jestin N
Published: July 2013

Background

Interruptions in chest compressions during cardiopulmonary resuscitation can negatively impact survival. Several new endotracheal intubation (ETI) techniques including video laryngoscopy may allow for ETI with minimal or no interruptions in chest compressions. We sought to determine the impact of three different ETI techniques upon time to intubation (TTI) in a simulated cardiac arrest during uninterrupted chest compression.

Methods

We performed a randomised crossover study with a convenience sample of emergency physicians using three different ETI techniques: direct laryngoscopy (DL), GlideScope video laryngoscopy (GVL) and GlideScope video laryngoscopy with bougie (GVL-B). Providers performed ETI on a manikin on a hospital bed with concurrent chest compressions. Our primary outcome, TTI, was defined as the time from insertion of the laryngoscope blade until first breath. Given the correlated nature of the data, we used the paired t test to assess the differences in mean TTIs between GVL minus DL and GVL-B minus DL. We also ran the analysis stratified by provider experience.

Results

We enrolled 20 providers with a median TTI (IQR) by device of: DL 27 s (20.3, 35.4), GVL 20.6 s (17.7, 27.1) and GVL-B 60.1 s (39.1, 99). The mean GVL—DL difference was −10.1 s (−17.9–2.3) while the mean GVL-B—DL difference was 45.6 s (19.8–71.4) (p<0.001). The GVL-B required the greatest TTI across providers of varying experience levels.

Conclusions

In this simulated model of cardiac arrest with uninterrupted chest compressions, TTI was shorter for GVL than DL while use of the GVL with bougie resulted in longer TTI.