Atypical Presentations of Melioidosis in North India: Report of Two Cases.

Melioidosis is an infection caused by Gram-negative bacterium, Burkholderia pseudomallei. This is a rare disease in India, more so in North India. We present two cases of melioidosis with unusual sites of infection. The first patient was a young diabetic male presenting to us with history of prolonged fever and upper abdominal discomfort, subsequently diagnosed as a case of pyogenic liver abscess. The second patient was a middle aged diabetic complaining of prolonged fever and headache and found to have right frontal lobe brain abscess.The pus cultured from the lesion in both cases showed growth of Burkholderia pseudomallei. These two cases are described to consider melioidosis as a differential diagnosis amongst pyrexia of unknown origin cases.

An in vitro comparison of detection methods for approximal carious lesions in primary molars.

BACKGROUND/AIMS: This study aimed to compare and contrast in vitro six methods to determine the most accurate method for detecting approximal carious lesions in primary molars. METHODS: Extracted primary molars (n = 140) were stored in 0.02% chlorhexidine solution and mounted in light-cured resin in pairs. The six carious lesion detection methods used by the three examiners to assess approximal carious lesions were visual inspection, digital radiography, two transillumination lights (SDI and NSK), and two laser fluorescence instruments (CDD and DDP). Five damaged teeth were discarded. The teeth (n = 135) were sectioned, serially ground, and examined under light microscopy using Downer's histological (HST) criteria as the gold standard. Intra- and inter-examiner reliability, agreement with HST, specificity, sensitivity, receiver operating characteristic (ROC) curves, and areas under the curve were calculated. RESULTS: This study found visual inspection to be the most accurate method when validated by histology. Transillumination with NSK light had the highest specificity, and digital radiography had the highest sensitivity for detecting enamel and/or dentinal carious lesions. Combining specificity and sensitivity into the area under ROC curves, enamel plus dentinal lesions were detected most accurately by visual inspection followed by digital radiography; dentinal lesions were detected most accurately by digital radiography followed by visual inspection. CONCLUSIONS: None of the four newly developed methods can be recommended as suitable replacements for visual inspection and digital radiography in detecting carious lesions on approximal surfaces of primary molars, and further developmental work is needed.

Countering imbalanced datasets to improve adverse drug event predictive models in labor and delivery.

BACKGROUND: The IOM report, Preventing Medication Errors, emphasizes the overall lack of knowledge of the incidence of adverse drug events (ADE). Operating rooms, emergency departments and intensive care units are known to have a higher incidence of ADE. Labor and delivery (L&D) is an emergency care unit that could have an increased risk of ADE, where reported rates remain low and under-reporting is suspected. Risk factor identification with electronic pattern recognition techniques could improve ADE detection rates. OBJECTIVE: The objective of the present study is to apply Synthetic Minority Over Sampling Technique (SMOTE) as an enhanced sampling method in a sparse dataset to generate prediction models to identify ADE in women admitted for labor and delivery based on patient risk factors and comorbidities. RESULTS: By creating synthetic cases with the SMOTE algorithm and using a 10-fold cross-validation technique, we demonstrated improved performance of the Naïve Bayes and the decision tree algorithms. The true positive rate (TPR) of 0.32 in the raw dataset increased to 0.67 in the 800% over-sampled dataset. CONCLUSION: Enhanced performance from classification algorithms can be attained with the use of synthetic minority class oversampling techniques in sparse clinical datasets. Predictive models created in this manner can be used to develop evidence based ADE monitoring systems.

Human interaction in the NICU and its association with outcomes on the Brief Infant-Toddler Social and Emotional Assessment (BITSEA).

BACKGROUND: Extremely preterm infants represent one of the highest risk categories for impairments in social competence. Few studies have explored the impact of the neonatal intensive care unit (NICU) environment on social development. However, none have specifically analyzed the effects of the care structure the infant receives during hospitalization on later social competence indicators. OBJECTIVE: To identify associations between the care structures received by extremely preterm infants in the NICU and scores on the Brief Infant-Toddler Social and Emotional Assessment (BITSEA) post-discharge. PARTICIPANTS: 50 extremely preterm infants (mean gestational age: 25 weeks during hospitalization; mean chronological age during follow-up assessment: 2 years, 4 months). METHODS: A secondary analysis of BITSEA data was performed exploring its relation to care structure data we extracted from electronic medical records (i.e., how much time infants were engaged in human interaction during their first thirty days of hospitalization and what types of interaction they were exposed to). RESULTS: Extremely preterm infants spend a considerable amount of time alone during hospitalization (80%) with nursing care comprising the majority of human interaction. Infants who experienced greater human interaction scored significantly higher on the Social Competence (p = 0.01) and lower on the Dysregulation (p = 0.03) BITSEA subscales. CONCLUSION: Human interaction and isolation in the NICU is associated with social competence and dysregulation outcomes in extremely preterm infants. Further research is needed to understand how various NICU care structures including centralized nursing teams, parental skin-to-skin care, and early therapy may synergistically play a positive role in developing social competence.

Microstructure and deformation behavior of biocompatible TiO2 nanotubes on titanium substrate.

Titanium oxide coatings have been shown to exhibit desirable properties as biocompatible coatings. We report on the quantitative microstructure characterization and deformation behavior of TiO(2) nanotubes on Ti substrate. Nanotubes were processed using anodic oxidation of Ti in a NaF electrolyte solution. Characterization of the as-processed coatings was conducted using scanning electron microscopy and focused ion beam milling. Increases in anodization time had no significant effect on tube diameter or tube wall thickness. Coating thickness, however, increased with time up to 2h of anodization, at which point an equilibrium thickness was established. Nanoindentation was used to probe the mechanical response in terms of Young's modulus and hardness. Progressively higher values of elastic modulus were obtained for thinner films consistent with increasing effects of the Ti substrate. A possible deformation mechanism of densification of the porous oxide and wear of the dense surface is suggested and discussed.

Denosumab in advanced/unresectable giant-cell tumour of bone (GCTB): For how long?

BACKGROUND: Giant-cell tumours of bone (GCTB) are RANK/RANK-ligand (RANKL) positive, aggressive and progressive osteolytic tumours. Denosumab, a RANKL inhibitor, was FDA-approved for adults and skeletally mature adolescents with unresectable GCTB or when surgical resection is likely to result in severe morbidity. Data on long-term toxicity and activity of denosumab monthly 'GCTB-schedule' (120 mg per 12/year, 1440 mg total dose/year) are lacking. METHODS: Patients with GCTB receiving denosumab, 120 mg on days 1, 8, 15, 29 and every 4 weeks thereafter, from 2006 to 2015 treated in two centres were included. Long-term toxicity was evaluated. RESULTS: Ninety-seven patients were identified. 43 patients underwent resection of the tumour with a median time on denosumab treatment of 12 months (range 6-45 months). Fifty-four patients had unresectable GCTB's (male/female 23/31, median age 35 years [range: 13-76 years], 26% presented with lung metastases, 31% had primary tumor located to the spine, 63% were relapsed after previous surgery) with a median time on denosumab of 54 months (9-115 months). In the unresectable GCTB group, tumour control and clinical benefits were observed in all patients undergoing denosumab, whereas 40% of patients discontinuing denosumab had tumour progression after a median of 8 months (range 7-15 months). ADVERSE EVENTS: Overall, six (6%) patients developed osteonecrosis of jaw (ONJ): 1/43 (2%) in the resectable group, 5/54 (9%) in the unresectable group, with a 5-year ONJ-free survival of 92% (95% CI 84-100). Only patients with prolonged treatment experienced mild peripheral neuropathy (6/54, 11%), skin rash (5/54, 9%), hypophosphataemia (2/54, 4%) and atypical femoral fracture (2/54, 4%). CONCLUSIONS: Prolonged treatment with denosumab has sustained activity in GCTB, with a mild toxicity profile. The dose-dependent toxicity observed recommends a careful and strict monitoring of patients who need prolonged treatment. Decreased dose-intensity schedules should be further explored in unresectable GCTB.

Supra-aural gossypiboma: case report of a retained textile surgical sponge in an unusual location.

Gossypiboma or retained surgical sponge is an infrequently encountered surgical complication, more so in the head and neck region. A literature search did not reveal a previously reported case of retained or concealed surgical sponge after microscopic ear surgery. We present a unique and previously unreported case of a 25-year-old male who presented with a cystic swelling in the right supra-aural region 5 months post-modified radical mastoidectomy of the right ear. Surgical excision of the swelling revealed a retained surgical sponge. We emphasise the importance of counting surgical sponges after every surgical step to minimise the incidence of such retained surgical items.

Cholinergic mechanisms in central thermoregulation in pigeons.

1. In unanaesthetized pigeons the effect on cloacal temperature was studied of acetylcholine (ACh), carbachol, atropine and (+)-tubocurarine injected into a cannulated lateral cerebral ventricle. The experiments were carried out at an ambient temperature of 19-25 degrees C. 2. ACh or carbachol injected intraventricularly produced hyperthermia, and in larger doses hyperthermia followed by hypothermia. These were central effects because they were not obtained when these drugs were injected in the same doses intravenously. 3. Atropine injected intraventricularly produced hypothermia which was greater and longer lasting than the hypothermia produced with the same dose of atropine injected intravenously. After the intraventricular injection of atropine the hyperthermic effects of ACh and of carbachol were abolished. 4. (+)-Tubocurarine injected intraventricularly produced a long-lasting hyperthermia in doses which had no effect on temperature when injected intravenously. After the intraventricular injection of tubocurarine the hypothermic effects of ACh and of carbachol were abolished. 5. It is concluded that the effects of ACh had carbachol imitate the effects of ACh released from cholinergic neurones in the central pathway involved in temperature regulation. The hypothermic effect of atropine is attributed to unmasking the activity of continuously released ACh acting on nicotinic receptors, and the hyperthermic effect of tubocurarine to unmasking the activity of continuously released ACh acting on muscarinic receptors.

Effects of catecholamines on thermoregulation in pigeons.

1 In unanaesthetized pigeons, kept at room temperature (20-23 degrees C) the effects on cloacal temperature were examined of catecholamines, phenoxybenzamine and propranolol, injected into the cerebral ventricles.2 Noradrenaline, adrenaline, dopamine and isoprenaline caused a fall in cloacal temperature.3 Phenoxybenzamine produced a long-lasting small rise in cloacal temperature. This rise is attributed to removal of the hypothermic effect of noradrenaline released continuously from adrenergic neurones ending in the anterior hypothalamus. Propranolol produced a slight fall in cloacal temperature.4 The hypothermic effects of noradrenaline, adrenaline and dopamine were prevented by phenoxybenzamine but not by propranolol. They are therefore attributed to activation of alpha-adrenoceptors.5 The hypothermic effect of isoprenaline was not prevented by either phenoxybenzamine or propranolol. The effect can therefore not be attributed to activation of either alpha or beta-adrenoceptors. Propranolol actually accentuated the isoprenaline-induced hypothermia.

Relationship between acute morphine and the course of PTSD in children with burns.

OBJECTIVE: To investigate the relationship between the dose of morphine administered during a child's hospitalization for an acute burn and the course of posttraumatic stress disorder (PTSD) symptoms over the 6-month period following discharge from the hospital. METHOD: Twenty-four children admitted to the hospital for an acute burn were assessed twice with the Child PTSD Reaction Index: while in the hospital and 6 months after discharge. The Colored Analogue Pain Scale was also administered during the hospitalization. All patients received morphine while in the hospital. The mean dose of morphine (mg/kg/day) was calculated for each subject through chart review. RESULTS: The Pearson product moment correlation revealed a significant association between the dose of morphine received while in the hospital and a 6-month reduction in PTSD symptoms. Children receiving higher doses of morphine had a greater reduction in PTSD symptoms over 6 months. CONCLUSIONS: This study suggests the possibility that acute treatment with morphine can secondarily prevent PTSD. This result is discussed in terms of the possible effect of morphine on fear conditioning and the consolidation of traumatic memory.

AIDS screening in North India: clinical spectrum of HIV infection.

PIP: 8 subjects with human immunodeficiency virus (HIV) infection were encountered between June-December 1986 and were diagnosed as having AIDS (3), PGL (1), MLA (1), and asymptomatic HIV carrier state (3). The clinical presentation, immunologic features, and course of those with AIDS or PGL, were similar to those reported from American, European, and tropical African countries, with low T-helper cells, reversed CD4/CD8 ratio, and the presence of antibody to HIV. Asymptomatic carriers also had reversed CD4/CD8 ratio. 6 of these individuals were foreign visitors, 5 from tropical African countries and 1 from the US, while 2 were Indians who had frequent sexual exposure abroad in countries where AIDS is quite prevalent (1 homosexual in West Germany and other possibly had sexual exposure in Uganda). None of the 2046 Indian nationals in the high risk group screened until January 1987 without history of sexual, blood, or blood product exposure abroad were found to seropositive at this center in North India. These findings suggest that HIV infection is not endemic in North India. However, there is a risk of spread of this infection in North India through sexual or blood contact with foreign visitors.^ieng

IMMUNOCHROMATOGRAPHIC TEST: A NEW DIMENSION IN DIAGNOSIS OF PLASMODIUM FALCIPARUM MALARIA.

75 patients with clinical features suggestive of malaria were studied to evaluate the efficacy of immunochromatographic test (ICT), which detects histidine rich protein-2 antigen secreted by Plasmodium falciparum (Pfhrp-2), as against direct microscopy. There were 40 cases of P falciparum malaria, 14 cases of P vivax malaria and 21 cases of non-malarial fevers. Direct microscopy could detect 27(67.5%) P falciparum cases but failed to detect 13 cases (32.5%) whereas ICT could detect 35(87.5%) P falciparum cases out of 40 but failed to detect 5(12.5%) cases. All the P vivax cases and non-malarial fever cases were negative for ICT. The sensitivity and specificity of ICT is 87.5% and 100% respectively where as the positive predictive value and the negative predictive value of the test is 100% and 87.5% respectively. It is concluded that ICT test is a good adjunct to blood smear studies in fever cases with neurological and multiorgan dysfunction and in antenatal ladies.

Bilateral fungiform papilloma with synchronous verrucous carcinoma of the nasal septum: a rare presentation and a literature review.

AIM: Fungiform papillomas are benign mucosal neoplasms presenting as a unilateral exophytic mass involving the anterior portion of the nasal septum. In this study, we present an exceptional case of a bilateral fungiform papilloma with a synchronous verrucous carcinoma of the nasal septum. MATERIAL AND METHODS: A case study with a review of the literature concerning malignant changes in fungiform papilloma. RESULTS: The general consensus in most of the literature is that malignant change in fungiform papilloma is exceptional. Our patient is probably the third reported case of verrucous carcinoma of the nasal septum, and the first report of a bilateral fungiform papilloma with a synchronous verrucous carcinoma. The tumour was subjected to complete surgical removal in the first instance. There was no recurrence at follow up seven months after surgery. CONCLUSION: Although fungiform papillomas are generally not premalignant, occasional malignant transformation may occur. Thus, they must be managed with the utmost cautiousness.