Composite Pheochromocytoma Presenting as Severe Lactic Acidosis and Back Pain: A Case Report.

Pheochromocytoma is a rare, catecholamine secreting tumor arising from chromaffin cells. Presentation of this tumor is highly variable, the most common being hypertension, tachycardia, sweating, and headache. Lactic acidosis and back pain are rare complications of this tumor. We report a 51-year-old gentleman with composite pheochromocytoma, which is rarer than pheochromocytoma, presenting as severe back pain and lactic acidosis.

Retraction notice to "Management of liver hydatid cysts - Current perspectives" [Medical Journal Armed forces India 68 (2012) 304-309].

[This retracts the article DOI: 10.1016/j.mjafi.2012.04.010.].

Liposuction Technique Used as a Treatment Modality for Suicide Attempt by Injection of Mercury.

Elemental mercury poisoning commonly occurs through vapour inhalation as it is well absorbed through the lungs. Administering subcutaneous and intravenous elemental mercury is very uncommon with only a few isolated case reports in literature. We present a case of attempted suicide by subcutaneous injection of elemental mercury, an unusual substance used for suicide. As the attempt at self-injury was not confessed by the patient, diagnosis was challenging. Patient was treated with an initial diagnosis of cellulitis, but with repeated and persistent questioning, a history of self-injection of mercury into the arm was revealed. On confirmation, mercury was aspirated from subcutaneous space similar to liposuction technique under X-ray guidance. Management of subcutaneous injection of elemental mercury with particular emphasis on the need for surgical removal of all available mercury is discussed.

Phosphodiesterase-4 inhibition as a therapeutic strategy for metabolic disorders.

Phosphodiesterase-4 (PDE4) hydrolyses cyclic adenosine monophosphate (cAMP), a crucial secondary messenger for cellular adaptation to diverse external stimuli. The activity of PDE4 is tightly controlled by post-translational regulation, structure-based auto-regulation and locus specific 'compartmentalization' of PDE4 with its interactive proteins (signalsomes). Through these mechanisms, PDE4 regulates cAMP levels and shapes the cAMP signalling, directing signals from the diverse external stimuli to distinct microenvironments exquisitely. Derangement of the PDE4-cAMP signalling represents a pathophysiologically relevant pathway in metabolic disorders as demonstrated through a critical role in the processes including inflammation, disordered glucose and lipid metabolism, hepatic steatosis, abnormal lipolysis, suppressed thermogenic function and deranged neuroendocrine functions. A limited number of PDE4 inhibitors are currently undergoing clinical evaluation for treating disorders such as type 2 diabetes and non-alcoholic steatohepatitis. The discovery of novel PDE4 allosteric inhibitors and signalsome-based strategies targeting individual PDE4 variants may allow PDE4 isoform selective inhibition, which may offer safer strategies for chronic treatment of metabolic disorders.

Abdominal Aortic Aneurysm Diameters: A Study on the Discrepancy between Inner to Inner and Outer to Outer Measurements.

INTRODUCTION: The NHS Abdominal Aortic Aneurysm Screening Programme (NAAASP) uses the maximal anterior to posterior (AP) inner-to-inner (ITI) wall diameter in sizing aortic dimensions when screening with ultrasound. It is recognised that ITI measurements are smaller than outer-to-outer (OTO) measurements, and the primary aim was to calculate the absolute difference in AP ITI and OTO measurements across varying aortic diameters. The secondary aim was to estimate the potential number of patients lost from the screening programme. METHODS: Since April 2012, patients outside the screening programme that undergo ultrasound of abdominal aortas have their ITI and OTO measurements recorded. These measurements were compared retrospectively and analysed for variability at threshold sizes of AAAs. RESULTS: From May 2012 to October 2013, 452 abdominal aortic ultransound scans recorded both ITI and OTO measurements. The majority (81%) were performed on men with the mean age of 78 years. The mean difference between ITI and OTO measurements was 4.21 mm (p < .001). There was no difference between the genders. Thresholds were created for analysis between different ITI and OTO aortic diameters; these were <3 cm, 3.1-4 cm, 4.1-5 cm, and >5 cm. There was no significant difference between the means at each threshold size for ITI diameter (p = .758). In the first 2 years from April 2012, 15,447 men underwent screening.Of these, 177 (1.14%) had sub-threshold ITI aortic diameters between 2.6 cm and 2.9 cm. This would upscale to 5,316 men nationally. CONCLUSION: We have demonstrated a consistent and significant 4mm difference between ITI and OTO diameters in live scanning. Lowering the threshold for entry into a surveillance AAAs to an ITI diameter of 26mm rather than the current 30 mm is advocated. An alternative cost-effective way is to rescreen this small sub-group at 5 or 7 years.

Outcomes in pregnant women with acute aortic dissections: a review of the literature from 2003 to 2013.

BACKGROUND: Acute aortic dissection in pregnant women is a rare but potentially life-threatening event. Our aim was to evaluate maternal and fetal outcomes of acute aortic dissection during pregnancy. METHODS: We conducted a review of literature of the PubMed database to identify publications related to pregnant women with acute aortic dissections during the period 2003-2013: 59 articles were included in the study. RESULTS: A total of 75 patients were included in the analyses. Stanford type A dissections were the most common form, accounting for 77% of all cases. The majority (78%) occurred in the third trimester and immediate postpartum period. Inherited connective tissue disorders were causative in 49% of patients. Maternal mortality was not statistical different between type A and type B dissections (21% vs. 23%), but fetal outcomes were worse in type B dissections (35% vs. 10.3%; P<0.05). Fetal mortality in type A dissections was dependent on the timing of aortic repair, with antepartum aortic repair associated with a higher mortality (36%). CONCLUSION: Despite advances in diagnostic and surgical techniques, maternal and fetal mortalities in pregnant patients with aortic dissection remain high. Patients undergoing combined cesarean section with aortic repair had favorable fetal outcomes.

Evaluation of recombinant human platelet-derived growth factor as an agent for wound bed preparation in traumatic wounds.

BACKGROUND: In patients with life-threatening injuries, simple wounds requiring split-thickness skin grafts (SSG) often get neglected. These then need SSG once they are covered with granulation tissue through wound bed preparation. Traditionally, this is done by daily moist dressings. Recombinant human platelet-derived growth factor (rhPDGF) has been shown to improve healing in chronic wounds. AIM: The present study was undertaken to compare the efficacy of rhPDGF in wound bed preparation with the current practice of daily saline dressings. SETTING AND DESIGN: A prospective randomised, single-blinded study was carried out for evaluation in traumatic wounds. MATERIALS AND METHODS: The patients were randomised and divided into a control group that was subjected to saline dressings and a test group that was treated with rhPDGF gel. Both the groups were then compared. The statistical analysis was carried out using SPSS 16.0 and the quantitative variables were analysed using unpaired "t" test, while the pre- and post-intervention effects were assessed using paired "t" test. The 95% CI values were also included. RESULTS: Of the 155 wounds studied, time taken for appearance of granulation tissue (in days) in the test group had a mean of 13.81 ± 2.68, while that in the control group was 13.36 ± 3.81 (P = 0.401). Complete re-epithelialisation without discharge occurred in the control group with a mean value of 28.9 ± 3.67 days, while that in the test group had a mean of 31.17 ± 4.82 days. CONCLUSION: There was no difference in wound healing between the patients treated with rhPDGF compared to those treated by conventional moist dressings.

Hepatic abscesses.

Hepatic abscesses are potentially lethal diseases if early diagnosis and treatment are not instituted. They are prevalent all over the globe and pyogenic abscesses are predominant over amoebic. With better control of intra abdominal and systemic infections by a spectrum of antibiotics, aetiology of pyogenic abscesses are secondary to interventions and diseases in the biliary tree to a large extent today. The common organisms isolated are the Gram negative group. Amoebic abscesses continue to plague some regions of the world where hygiene and sanitation are questionable. Over the years, diagnosis, treatment and prognosis have evolved remarkably. Imaging modalities like ultrasonography and CT scan have become the cornerstone of diagnosis. The absence of ionizing radiation makes MRI an attractive alternative in patients who require multiple follow up scans. Serological testing in amoebic abscesses has become more reliable. Though antibiotics have remained the principal modality of management, percutaneous drainage of abscesses have vastly improved the chances of cure and bring down the morbidity drastically in pyogenic abscesses. Amoebic abscesses respond well to medical treatment with nitroimidazoles, and minimally invasive surgical drainage is an option in cases where open surgery is indicated.

Management of liver hydatid cysts - Current perspectives.

Human hydatid disease or cystic echinococcosis (CE), caused by the larval form of cestode Echinococcus granulosus still continues to a common problem in health care environments as different as Europe/North America and resource poor countries of the South America and the East. The Liver is the most frequently parasatized organ in humans. While ultrasonography remains the main diagnostic tool, computed tomography and serology improve the accuracy of diagnosis in Liver hydatid cysts (LHC). Although surgery is the only modality applicable over the entire spectrum of the disease, systemic chemotherapy and percutaneous drainage have evolved as alternative therapies in the last three decades. Various laparoscopic techniques have also been described for safe and optimal management of this entity. In this paper, we review the current management procedures of LHC with particular emphasis on the evidence base and setting specific problems.

Lipoic acid attenuates innate immune infiltration and activation in the visceral adipose tissue of obese insulin resistant mice.

Visceral adipose inflammation mediated by innate and adaptive immune alterations plays a critical role in diet-induced obesity and insulin resistance (IR). The dietary supplement α-lipoic acid (αLA) has been shown to ameliorate inflammatory processes in macrophages, however the relative significance of these effects in the context of visceral adipose inflammation and IR remain unknown. In this study we investigated its effects via both intraperitoneal and oral administration in lean and obese transgenic mice expressing yellow fluorescent protein (YFP) under control of a monocyte specific promoter (c-fms(YFP+)). αLA significantly improved indices of insulin-resistance concomitant with a decrease in total (YFP(+)CD11b(+)) and activated (YFP(+)CD11b(+)CD11c(+)) visceral adipose tissue macrophages. Histologically, the visceral adipose tissue of obese mice receiving αLA had fewer "crown-like structures," a hallmark of adipose inflammation in murine obesity. Monocyte adhesion assessed by intravital microscopy of cremasteric venules was attenuated by αLA. In cultured WT and toll-like receptor 4 (TLR4) null primary mouse macrophages, αLA significantly decreased basal CCR-2, MCP-1 and TNF-α expression levels. LPS treatment resulted in increased TNFα, MCP-1, and IL-6 expression while αLA partially abrogated the LPS effect on MCP-1 and TNFα; Interestingly, CCR-2 was not coordinately regulated. AαLA prevented LPS-induced nuclear factor kappa B (NFκB) activation in the same cultured macrophages. These data suggest that αLA may modulate visceral adipose inflammation, a critical determinant of IR via TLR4 and NF-κB pathways.

Osteonecrosis of the distal tibia after a pronation external rotation ankle fracture: literature review and management.

Posttraumatic osteonecrosis of the distal tibia is a rare but recognized complication of Weber C ankle fractures. To our knowledge, we report the first documented case managed with early percutaneous drilling of the defect. The patient noticed an improvement in symptoms, and magnetic resonance imaging confirmed resolution of the avascular area. The previously reported complication of secondary periarticular collapse and subsequent osteoarthritis was avoided. We advocate that a high index of suspicion, early detection, and drilling can encourage neovascularisation and prevent secondary joint destruction.