Application of 7T MRS to High-Grade Gliomas.

MRS, including single-voxel spectroscopy and MR spectroscopic imaging, captures metabolites in high-grade gliomas. Emerging evidence indicates that 7T MRS may be more sensitive to aberrant metabolic activity than lower-field strength MRS. However, the literature on the use of 7T MRS to visualize high-grade gliomas has not been summarized. We aimed to identify metabolic information provided by 7T MRS, optimal spectroscopic sequences, and areas for improvement in and new applications for 7T MRS. Literature was found on PubMed using "high-grade glioma," "malignant glioma," "glioblastoma," "anaplastic astrocytoma," "7T," "MR spectroscopy," and "MR spectroscopic imaging." 7T MRS offers higher SNR, modestly improved spatial resolution, and better resolution of overlapping resonances. 7T MRS also yields reduced Cramér-Rao lower bound values. These features help to quantify D-2-hydroxyglutarate in isocitrate dehydrogenase 1 and 2 gliomas and to isolate variable glutamate, increased glutamine, and increased glycine with higher sensitivity and specificity. 7T MRS may better characterize tumor infiltration and treatment effect in high-grade gliomas, though further study is necessary. 7T MRS will benefit from increased sample size; reductions in field inhomogeneity, specific absorption rate, and acquisition time; and advanced editing techniques. These findings suggest that 7T MRS may advance understanding of high-grade glioma metabolism, with reduced Cramér-Rao lower bound values and better measurement of smaller metabolite signals. Nevertheless, 7T is not widely used clinically, and technical improvements are necessary. 7T MRS isolates metabolites that may be valuable therapeutic targets in high-grade gliomas, potentially resulting in wider ranging neuro-oncologic applications.

Exostosis of Rib: Case Report of an Extremely Rare Giant Osteochondroma at an Unusual Site, Radiopathological Correlation with Brief Review of Literature.

Osteochondromas are common benign tumors developing as an abnormal bony growth in the metaphyseal region. Being more of a developmental anomaly rather than a true neoplasm, they are usually found around the growth plates of long bones such as the knee, hip, and shoulder. These are typically managed conservatively if they are asymptomatic; however, they require excision in symptomatic patients. A 38-year-old woman presented with a huge swelling causing disfigurement measuring 16 × 16 cm on the left side of chest wall. Radiographs and computed tomography scan showed a bony outgrowth at costochondral junction of second rib which was in continuity with the periosteum. Excision via mediastinal sternotomy and left thoracotomy was done. Histopathological features corroborated with the radiological diagnosis of osteochondroma. Osteochondroma should be considered in the differential diagnosis of chest wall tumors. Rib is an extremely rare site of presentation. The cartilaginous cap becomes fully ossified and is lost in longstanding lesions. Huge tumors at such a location can cause irritation of adjacent viscera which can lead to pleural effusion or hemothorax; therefore, a cautious and logical approach to diagnosis is warranted for appropriate therapeutic management.

Association and expression of the antigen-processing gene PSMB8, coding for low-molecular-mass protease 7, with vitiligo in North India: case-control study.

BACKGROUND: Vitiligo is a multifactorial, autoimmune, depigmenting disorder of the skin where aberrant presentation of autoantigens may have a role. OBJECTIVES: To study the association of two antigen-processing genes, PSMB8 and PSMB9, with vitiligo. METHODS: In total 1320 cases of vitiligo (1050 generalized and 270 localized) and 752 healthy controls were studied for the PSMB9 exon 3 G/A single-nucleotide polymorphism (SNP), PSMB8 exon 2 C/A SNP and PSMB8 intron 6 G/T SNP at site 37 360 using polymerase chain reaction (PCR)-restriction fragment length polymorphism. Real-time PCR was used for transcriptional expression of PSMB8 and cytokines. Expression of ubiquitinated proteins and phosphorylated-p38 (P-p38) was studied by Western blotting. RESULTS: Significant increases in PSMB8 exon 2 allele A (P < 2.07 × 10-6 , odds ratio 1·93) and genotypes AA (P < 1.03 × 10-6 , odds ratio 2·51) and AC (P < 1.29 × 10-6 , odds ratio 1·63) were observed in patients with vitiligo. Interferon-γ stimulation induced lower expression of PSMB8 in peripheral blood mononuclear cells of cases compared with controls, suggesting impaired antigen processing, which was confirmed by accumulation of ubiquitinated proteins in both lesional and nonlesional skin of patients with vitiligo. Expression of proinflammatory cytokines - interleukin (IL)-6, IL-1ß and IL-8 - was higher in the lesional skin. P-p38 expression was variable but correlated with the amount of ubiquitinated proteins in the lesional and nonlesional skin, suggesting that the inflammatory cytokine responses in lesional skin could be a result of both P-p38-dependent and -independent pathways. CONCLUSIONS: The PSMB8 exon 2 SNP is significantly associated with vitiligo. Accumulation of ubiquitinated proteins in skin of cases of vitiligo suggests their aberrant processing, which may promote the development of the disease.

Dynamic Contrast-Enhanced MRI-Derived Intracellular Water Lifetime (τ i ): A Prognostic Marker for Patients with Head and Neck Squamous Cell Carcinomas.

BACKGROUND AND PURPOSE: Shutter-speed model analysis of dynamic contrast-enhanced MR imaging allows estimation of mean intracellular water molecule lifetime (a measure of cellular energy metabolism) and volume transfer constant (a measure of hemodynamics). The purpose of this study was to investigate the prognostic utility of pretreatment mean intracellular water molecule lifetime and volume transfer constant in predicting overall survival in patients with squamous cell carcinomas of the head and neck and to stratify p16-positive patients based upon survival outcome. MATERIALS AND METHODS: A cohort of 60 patients underwent dynamic contrast-enhanced MR imaging before treatment. Median, mean intracellular water molecule lifetime and volume transfer constant values from metastatic nodes were computed from each patient. Kaplan-Meier analyses were performed to associate mean intracellular water molecule lifetime and volume transfer constant and their combination with overall survival for the first 2 years, 5 years, and beyond (median duration, >7 years). RESULTS: By the last date of observation, 18 patients had died, and median follow-up for surviving patients (n = 42) was 8.32 years. Patients with high mean intracellular water molecule lifetime (4 deaths) had significantly (P = .01) prolonged overall survival by 5 years compared with those with low mean intracellular water molecule lifetime (13 deaths). Similarly, patients with high mean intracellular water molecule lifetime (4 deaths) had significantly (P = .006) longer overall survival at long-term duration than those with low mean intracellular water molecule lifetime (14 deaths). However, volume transfer constant was a significant predictor for only the 5-year follow-up period. There was some evidence (P < .10) to suggest that mean intracellular water molecule lifetime and volume transfer constant were associated with overall survival for the first 2 years. Patients with high mean intracellular water molecule lifetime and high volume transfer constant were associated with significantly (P < .01) longer overall survival compared with other groups for all follow-up periods. In addition, p16-positive patients with high mean intracellular water molecule lifetime and high volume transfer constant demonstrated a trend toward the longest overall survival. CONCLUSIONS: A combined analysis of mean intracellular water molecule lifetime and volume transfer constant provided the best model to predict overall survival in patients with squamous cell carcinomas of the head and neck.

Nasopharyngeal teratoma, congenital diaphragmatic hernia and Dandy-Walker malformation - a yet uncharacterized syndrome.

An association of congenital diaphragmatic hernia, dandy walker malformation and nasopharyngeal teratoma is very rare. Here, we report a fourth case with this association where chromosomal microarray and whole exome sequencing (WES) was performed to understand the underlying genetic basis. Findings of few variants especially a novel variation in HIRA provided some insights. An association of congenital diaphragmatic hernia, dandy walker malformation and nasopharyngeal teratoma is very rare. Here, we report a fourth case with this association where chromosomal microarray and whole exome sequencing (WES) was performed to understand the underlying genetic basis. Findings of few variants especially a novel variation in HIRA provided some insights.

FLT PET/CT Is Better Than FDG PET/CT in Differentiating Benign From Malignant Pancreatobiliary Lesions.

PURPOSE: F-fluorothymidine (FLT), unlike FDG, is incorporated exclusively into DNA and is considered a specific marker of cell proliferation. The role of FLT PET/CT scan in differentiating benign from malignant pancreatobiliary tumors is unknown. PATIENTS AND METHODS: Twenty-five suspected pancreatobiliary tumors on contrast-enhanced CT (CECT) scan in 23 patients were evaluated by FDG PET/CT and FLT PET/CT scans. The histopathology or fine-needle aspiration cytology was considered as criterion standard for the diagnosis. Surgeons were blinded to FLT PET/CT results. Management decision was guided by clinical and CECT scan and FDG PET/CT. RESULTS: Five of 23 patients had metastatic disease on CECT imaging. The remaining 18 underwent exploratory laparotomy. Two of them had synchronous lesions. Histopathology/fine-needle aspiration cytology confirmed malignancy in 17 lesions and benign disease in the remaining 8 lesions. All 8 benign lesions were negative on FLT PET/CT. Seven of the 8 benign lesions were clinically diagnosed as malignancy on CECT and FDG PET/CT. The specificity, positive predictive value, and accuracy were higher for FLT PET/CT (100%, 100%, and 92%) compared with CECT (12.5%, 70.83%, and 72%) and FDG PET/CT (12.50%, 69.57%, and 68%). However, the sensitivity of FLT PET/CT (88.24%) was similar to CECT (100%) and FDG PET/CT (94.12%). CONCLUSIONS: Molecular-based FLT PET/CT is a better imaging than FDG PET/CT in differentiating benign from malignant lesions in the pancreatobiliary region. It has a potential to bring down the incidence of preventable radical resection in suspected pancreatobiliary tumors.

Spontaneous closure of stoma.

Intestinal loop stoma is a common surgical procedure performed for various benign and malignant abdominal problems, but it rarely undergoes spontaneous closure, without surgical intervention. Two male patients presented to our emergency surgical department with acute abdominal pain. One of them was diagnosed as having rectosigmoid perforation and underwent diversion sigmoid loop colostomy after primary closure of the perforation. The other was a known case of carcinoma of the rectum who had already undergone low anterior resection with covering loop ileostomy; the patient underwent second loop ileostomy, this time for complicated intestinal obstruction. To our surprise, both the loop colostomy and ileostomy closed spontaneously at 8 weeks and 6 weeks, respectively, without any consequences. Spontaneous stoma closure is a rare and interesting event. The exact etiology for spontaneous closure remains unknown, but it may be hypothesized to result from slow retraction of the stoma, added to the concept of a tendency towards spontaneous closure of enterocutaneous fistula.

Thrombocytosis and Raised CRP Levels Predicts Advanced Stage in Esophageal Carcinoma.

PURPOSE: The significance of thrombocytosis and raised C-reactive protein (CRP) as prognostic markers in esophageal cancer is unclear. METHODS: We prospectively studied 50 consecutive patients with esophageal cancer and analyzed the relation of preoperative platelet count and CRP levels with the clinico-pathological characteristics and stage of the disease. The platelet count of 319 × 10(9)/L for thrombocytosis and CRP level >6 mg/dl were taken as cut-off values. RESULTS: The incidence of thrombocytosis as well as raised CRP level was 50 %. Eighty percent of patients with thrombocytosis had raised CRP levels. None of patients with early disease (stage I) had thrombocytosis while patients with advanced stage were associated with thrombocytosis, 81.81 % in stage III and 100 % in stage IV (p < 0.001). The incidence of elevated CRP levels has shown progressive linear co-relation with the stage of carcinoma, i.e., 0 % in pathological stage I, 16.67 % in stage II, 45.45 % in stage III, and 100 % in stage IV disease (p = 0.011). Patients with thrombocytosis and patients with raised CRP were associated with pathological nodal metastases in 84.61 % cases (p 0.005) and 61.53 % (p 0.030), respectively. CONCLUSION: Thrombocytosis alone or in combination with raised CRP had progressive linear relation with the stage of esophageal carcinoma.

Chylothorax after esophagectomy for esophageal cancer: risk factors and management.

BACKGROUND: Chylothorax is an uncommon complication of esophagectomy. It carries significant morbidity and mortality. The predisposing factors are ill-defined. METHODS: We retrospectively evaluated the data of 45 patients of carcinoma esophagus who underwent esophagectomy after neoadjuvant chemoradiotherapy (NACRT) from January 2010 to July 2012 in our tertiary health care center. RESULTS: Four patients (8.88 %) had chylothorax. On analysis of perioperative factors, it was found that patients with chylothorax had tumor in middle third of thoracic esophagus (100 %), shown partial response to neoadjuvant chemoradiation (NACRT) (100 %) and were associated with difficult mediastinal dissection (75 %) leading to higher blood loss requiring transfusion unlike those without chylothorax. There was no significant difference in the incidence of chylothorax following transhiatal, 3/35 = 8.57 % or transthoracic esophagectomy 1/10 = 10 % (p = 0.898). Three patients were managed by transabdominal en masse ligation of tissue between aorta and azygos vein while one patient was managed conservatively. Patients were discharged after a mean hospital stay of 15.5 days. The 30-day mortality rates in the two groups were similar (0 % vs. 4.8 %). CONCLUSION: Difficult mediastinal dissection during esophagectomy in middle esophageal cancer may lead to thoracic duct injury. Complete response to NACRT may reduce the risk of chylothorax. Early transabdominal en masse ligation carries excellent results. Low output fistula following thoracic duct injury can be managed conservatively.

Effect of ethylene glycol on the special counterion binding and microstructures of sodium dioctylsulfosuccinate micelles.

Sodium dioctylsulfosuccinate (AOT) micelle has a special counterion binding behavior (SCB), which refers to the abrupt twofold increase in the counterion binding constant (ß) at a critical concentration (c*) of added NaCl (in water c* ≈ 0.015 mol kg(-1)). In this paper, the SCB of AOT has been studied in a mixture of water and ethylene glycol (EG) by applying surface tension, fluorescence, and small angle neutron scattering (SANS) methods. The SCB exists in water + 10% (w/w) EG as well, but disappears when the EG% is ≥20. It has been found out that the SCB of AOT occurs in media having cohesive energy density values in the range of 2.3-2.75 J m(-3). SANS data indicate co-existence of vesicles and cylindrical micelles of AOT in water + 10% EG when the added NaCl concentration is greater than c* thereby revealing that change in the morphology of aggregated species is the probable cause for the SCB of AOT. From this study it has become clear that the Corrin-Harkins (CH) equation, commonly used for determining ß, can be applied only above a limiting concentration (ce(#)) of added electrolyte. In aqueous organic or pure organic polar solvents below ce(#) sharp deviation from the CH equation occurs with reversal of slope rendering this equation inapplicable for the determination of ß.

Tuberculosis screening for long-term care: a cost-effectiveness analysis.

SETTING: Long-term care facilities in Canada, a low tuberculosis (TB) incidence country. OBJECTIVE: To compare the impact and cost-effectiveness of three screening strategies for TB on entry to long-term care: no screening, screening for latent tuberculous infection (LTBI) using the tuberculin skin test (TST) or screening for active disease with a chest X-ray. DESIGN: Cost effectiveness analysis. RESULTS: With the LTBI screening strategy, the number needed to screen to prevent one active case was 1410 and the cost per case averted was Canadian $109 913. The number needed to screen to prevent one case using the active screening strategy was 1266, and the cost per case averted was $672 298. CONCLUSIONS: Our findings suggest that TB screening strategies on entry to long-term care are costly, with large numbers needed to screen. Screening with TST was more cost-effective than chest X-ray screening. Higher risk of reactivation of LTBI is associated with improved cost-effectiveness of screening. Short time horizons and test performance characteristics place limitations on screening programmes in this setting. Future considerations include the changing demographics of the institutionalised elderly.

Pseudobowel perforation following endoscopic retrograde cholangiopancreatography.

We report two cases of pneumoperitoneum following endoscopic retrograde cholangiopancreatography for retained common bile duct (CBD) stones. These post-cholecystectomy patients underwent sphincterotomy, CBD clearance, and "T" tube removal at the same time. Post-procedure, both of the patients developed pneumoperitoneum. Pneumoperitoneum developed as a result of air traversing from the duodenum to the peritoneum through the ruptured "T" tube tract. "T" tube removal in the same sitting as sphincterotomy and CBD clearance may lead to pneumoperitoneum, which can be managed conservatively.

Traumatic diaphragmatic hernia presenting as a tension fecopneumothorax.

A traumatic diaphragmatic hernia is a well-known complication following blunt abdominal or penetrating thoracic trauma. Although the majority of cases are diagnosed immediately, some patients may present later with a diaphragmatic hernia. It occurs in approximately 3% of abdominal traumas. Diagnosis requires a high index of suspicion since diaphragmatic injury can only reliably be ruled out by direct visualization, i.e., laparoscopy. Hence, delayed presentation with complications secondary to the injury is not uncommon. We discuss a case of a young man who presented in respiratory distress 5 years after a stab wound to the left chest. The patient was hypoxic, with a chest X-ray (CXR) demonstrating a pneumothorax with effusion. A chest tube was placed with a rush of air and feculent drainage. CT scan revealed an incarcerated transverse colon in a diaphragmatic hernia. The laparotomy demonstrated necrotic colon in the chest with gross fecal contamination in the chest. The diaphragmatic defect was closed and a Hartmann's procedure performed. The patient developed empyema in the postoperative period. Our patient is the twelfth reported case of a tension fecopneumothorax resulting from traumatic diaphragmatic herniation. This paper reviews all cases, including the diagnostic workup, operative approach, and expected postoperative course of this unusual condition.

Solitary true cyst of pancreas: report of a case and review of literature.

CONTEXT: Solitary true cysts of the pancreas in adults are extremely rare, and only few cases have been reported in the literature. The etiology and natural history of these lesions remain unknown, and treatment is not standardized. We describe an additional resected case. CASE REPORTS: A 55-year-old female who presented to us with a history of heaviness and pain in right upper abdomen for 1 year. CT scan of abdomen showed a large unilocular cyst in the region of the head of the pancreas. The patient underwent pancreatico-duodenectomy with binding pancreaticojejunostomy. The histology of cyst revealed true unilocular pancreatic cyst lined by cuboidal epithelium. She is well after 3 years of follow-up. CONCLUSIONS: A preoperative work-up alone does not always allow an accurate diagnosis, but it is useful in determining lesion characteristics and guiding therapeutic decision-making. When surgery is indicated, a limited resection is warranted in most cases.

External duodenal fistula following closure of duodenal perforation.

AIM: Retrospective analysis of experience with management of external duodenal fistula (EDF) without using total parenteral nutrition (TPN). METHOD: Medical records of 31 patients with EDF following closure of duodenal ulcer perforation, treated over a 7-year period (1994-2001), were studied. Twenty-one patients (68%) had evidence of sepsis at presentation or during the course of treatment. None could afford TPN for optimum time. All patients received hospital-based enteral nutrition through nasojejunal tube, besides supportive medical treatment and/or surgery. Peritonitis or failure to insert nasojejunal tube for enteric alimentation led to early surgery. RESULTS: Two patients died of septicemia and multi-organ failure within 48 hours of admission. Fourteen patients (48.3%) initially received conservative treatment (Group I); six of them later required surgery. Fifteen patients (51.7%) underwent early surgery due to peritonitis (n=9) or failure to establish enteral feeding (n=6) (Group II); wound infection, intra-abdominal abscess and septicemia were more common in these patients than those in Group I. Survival rate was higher in Group I than in Group II (86% versus 40%; p< 0.05). Septicemia and gastrectomy were the independent factors associated with high mortality. CONCLUSIONS: EDF can be satisfactorily managed without TPN. Successful placement of enteral feeding line, supportive treatment and delayed surgery can achieve survival in 85% of patients. Minimum intervention is recommended when early surgery is performed in peritonitis or to establish enteral feeding line.

Contrast-free unilateral endoscopic palliation in malignant hilar biliary obstruction: new method.

BACKGROUND: Bilateral endoscopic drainage is difficult in malignant hilar biliary obstruction. Recently, unilateral drainage in malignant hilar biliary obstruction has been shown to be equally effective. However, contrast injection leads to cholangitis. There have been no reported studies on contrast-free metal stenting in malignant hilar biliary obstruction. The present study was undertaken to evaluate the results of contrast-free unilateral metal stenting in type II malignant hilar biliary obstruction. METHODS: We prospectively studied the results of unilateral metal stenting in type II malignant hilar biliary obstruction without contrast injection in 18 patients. RESULTS: A successful endoscopic drainage was achieved in 100% (18/18) of patients with hilar strictures. Cholangitis and 30-day mortality occurred in none. CONCLUSIONS: Unilateral endoscopic metal stenting without contrast in type II malignant hilar biliary obstruction is a safe and effective method of palliation.