Failure of diltiazem to prevent 1:1 conduction of atrial flutter: a case report.

BACKGROUND: Atrial flutter with 1:1 conduction to the ventricles is a dangerous cardiac arrhythmia. Contemporary guidelines recommend atrioventricular nodal blocking agents should be co-administered with class 1C anti-arrhythmics, as prophylaxis against 1:1 flutter. No guidance is provided on the type or strength of atrioventricular nodal blockade required, and in practice, these agents are frequently prescribed at low dose, or even omitted, due to their side effect profile. CASE PRESENTATION: A 62 year old Caucasian man with a history of paroxysmal atrial fibrillation treated with flecainide, presented with atrial flutter with 1:1 conduction to the ventricles and was cardioverted. Diltiazem was added to prevent this complication and he again presented with atrial flutter with 1:1 conduction to the ventricles, despite prophylaxis with coadministration of diltiazem. CONCLUSIONS: This case report demonstrates failure of diltiazem to prevent 1:1 flutter in a patient chronically treated with flecainide for paroxysmal atrial fibrillation.

Vomiting, electrolyte disturbance, and medications; the perfect storm for acquired long QT syndrome and cardiac arrest: a case report.

BACKGROUND: Acquired long QT syndrome is an important and preventable cause of cardiac arrest. Certain medications and electrolyte disturbance are common contributors, and often coexist. In this case, we report five contributors to cardiac arrest. CASE PRESENTATION: This case is of a 51-year-old Caucasian female patient who presented with vomiting associated with hypokalemia and hypomagnesemia. She subsequently received ondansetron and metoclopramide, on the background of chronic treatment with fluoxetine. She then suffered an in-hospital monitored cardiac arrest, with features of long QT and torsades de pointes retrospectively noted on her prearrest electrocardiogram. She was diagnosed with acquired long QT syndrome, and her QT interval later normalized after removal of offending causes. CONCLUSIONS: This case highlights the importance of proper consideration prior to prescribing QT prolonging medications, especially in patients who have other risk factors for prolonged QT, such as electrolyte disturbances and pretreatment with QT prolonging medications.

Etiological prevalence and antifungal sensitivity patterns of dermatophytosis in India - A multicentric study.

BACKGROUND: The prevalence of dermatophytes varies with season, geographical area, socio-economic factors and effective management strategies. AIMS: The aim of the study was to assess the prevalence of pathogenic dermatophytes, clinical types of dermatophyte fungal infection, and in vitro antifungal drug susceptibility testing against dermatophytes. METHODS: Three hundred and ninety five patients with dermatophytosis were enrolled from five cities (Mumbai, Delhi, Lucknow, Kolkata and Hyderabad) across India. All patients were subjected to clinical examination and investigations, including potassium hydroxide microscopy, fungal culture and antifungal drug susceptibility testing. RESULTS: Trichophyton rubrum was the most common species identified (68.4%), followed by T. mentagrophytes (29.3%). Within species, T. mentagrophytes was prevalent in humid environmental conditions (Mumbai and Kolkata), whereas T. rubrum was prevalent in noncoastal areas (Delhi, Lucknow and Hyderabad). Tinea corporis (71.4%) and tinea cruris (62.0%) were the common clinical types observed. antifungal drug susceptibility testing data indicated that minimum inhibitory concentration required to inhibit the growth of 90% of organisms (MIC-90) was lowest for griseofulvin (0.25-3.0 µg/mL). Among oral antifungals, the mean MIC of itraconazole was within the range (0.84 [0.252] µg/ mL), whereas high mean MIC values were reported for terbinafine (0.05 [0.043] µg/mL). Among topical agents, lowest mean MIC values were reported for luliconazole (0.29 [0.286] µg/mL), eberconazole (0.32 [0.251]) µg/mL and amorolfine (0.60 [0.306]) µg/mL. LIMITATIONS: Lack of correlation between in vitro antifungal susceptibility and clinical outcome and absence of defined MIC breakpoints. CONCLUSION: T. rubrum was the most common, followed by T. mentagrophytes as an emerging/codominant fungal isolate in India. Tinea corporis was the most common clinical type of dermatophytosis. Mean MIC of terbinafine was above the reference range, while it was within the range for itraconazole; griseofulvin had the lowest mean MIC. Luliconazole presented the lowest mean MIC values across cities.

Observational study comparing pharmacoinvasive strategy with primary percutaneous coronary intervention in patients presenting with ST elevation myocardial infarction to a tertiary care centre in India.

Objective: The objective was to study whether the incidence of composite end points (mortality, cardiogenic shock and re-myocardial infarction [re-MI]) in pharmacoinvasive strategy was noninferior to primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI). Methods: This was an observational study which included 138 patients. The study included patients admitted with a diagnosis of STEMI within 24 h of symptom onset, who underwent primary PCI or pharmacoinvasive therapy in a single center over a 9-month period. Primary end points (death within 30 days, re-MI within 30 days, and cardiogenic shock) and secondary end points (arrhythmias, bleeding manifestations, ischemic stroke, ejection fraction, mechanical complications, and duration of hospital stay) were compared between the two groups at 1 month after intervention. Results: At one month follow-up, the incidence rate for primary end points was 5 events per 43 patients (11.6%) in pharmacoinvasive arm and 18 events per 95 patients (18.9%) in primary PCI arm, a difference of - 7.3% (95% confidence interval: 18.5, 7.1). This finding shows that pharmacoinvasive strategy as compared with primary PCI in the management of STEMI was equivalent in terms of composite primary outcome. There was no significant difference between the secondary outcomes between the two groups. Use of thrombus aspiration device and in turn the thrombus burden was significantly lower in the pharmacoinvasive arm. Conclusion: This observational study showed that pharmacoinvasive strategy was as good as primary PCI in STEMI, in our setting, where primary PCI may be delayed or not possible at all due to financial and logistic constraints.

Deep neural ensemble for retinal vessel segmentation in fundus images towards achieving label-free angiography.

Automated segmentation of retinal blood vessels in label-free fundus images entails a pivotal role in computed aided diagnosis of ophthalmic pathologies, viz., diabetic retinopathy, hypertensive disorders and cardiovascular diseases. The challenge remains active in medical image analysis research due to varied distribution of blood vessels, which manifest variations in their dimensions of physical appearance against a noisy background. In this paper we formulate the segmentation challenge as a classification task. Specifically, we employ unsupervised hierarchical feature learning using ensemble of two level of sparsely trained denoised stacked autoencoder. First level training with bootstrap samples ensures decoupling and second level ensemble formed by different network architectures ensures architectural revision. We show that ensemble training of auto-encoders fosters diversity in learning dictionary of visual kernels for vessel segmentation. SoftMax classifier is used for fine tuning each member autoencoder and multiple strategies are explored for 2-level fusion of ensemble members. On DRIVE dataset, we achieve maximum average accuracy of 95.33% with an impressively low standard deviation of 0.003 and Kappa agreement coefficient of 0.708. Comparison with other major algorithms substantiates the high efficacy of our model.

Abundance of Mycobacterium avium ssp. hominissuis in soil and dust in Germany - implications for the infection route.

UNLABELLED: The nontuberculous mycobacteria (NTM) are a heterogeneous group of bacteria found in soil, water and dust. The spread of NTM infection depends on the exposure to reservoirs with high proportions of mycobacteria, the virulence of the NTM strains, the enhanced sensitivity to infections such as those of immune-compromised hosts and patient risk factors such as Cystic Fibrosis. Since several decades, NTM lung disease has been increasingly observed in slender postmenopausal women. The most important NTM in Germany is Mycobacterium avium ssp. hominissuis (MAH). The routes of MAH infection are in almost all cases unknown, but water is often suspected as source of infection. We wanted to examine this hypothesis by determining the frequency of MAH in environmental samples of water, biofilms, soil and dust originating from Germany. We found MAH in 33% of the dust samples and 20% of the soil samples. No MAH could be isolated from water and biofilm. Dust and soil clearly presented more abundance of MAH in comparison with water and biofilms. Therefore, more attention should be paid to soil and dust in Germany as an important source of Myco. avium infections. SIGNIFICANCE AND IMPACT OF THE STUDY: This study was conducted to investigate the ecological abundance of the most prominent clinical nontuberculous mycobacteria (NTM) in Germany, the Mycobacterium avium ssp. hominissuis (MAH). Examination of soil, water, dust and biofilm samples revealed that MAH in Germany was predominant in soil and dust. No MAH was identified in water and biofilms. Our finding contributes to the identification of the environmental niche of this opportunistic pathogen and proposes soil and dust as sources of MAH infection in Germany.

Penile degloving: an unusual presentation of hidradenitis suppurativa.

Chronic hidradenitis suppurativa (HS) can cause lymphoedema, leading to novel presentations. We present the case of a man with chronic HS causing penile oedema and subsequent degloving. He underwent direct excision with a good result. Chronic HS patients should be warned about problems related to lymphoedema and reviewed regularly to resolve problems early.

High levels of IgM against methylglyoxal-modified apolipoprotein B100 are associated with less coronary artery calcification in patients with type 2 diabetes.

OBJECTIVE: Advanced glycation end products (AGE) have been implicated in diabetic vascular complications through activation of pro-inflammatory genes. AGE-modified proteins are also targeted by the immune system resulting in the generation of AGE-specific autoantibodies, but the association of these immune responses with diabetic vasculopathy remains to be fully elucidated. The aim of this study was to determine whether antibodies against apolipoprotein B100 modified by methylglyoxal (MGO-apoB100) are associated with coronary atherosclerosis in patients with type 2 diabetes. METHODS: We measured antibodies against MGO-apoB100 in plasma from 497 type 2 diabetic patients without clinical signs of cardiovascular disease. Severity of coronary disease was assessed as coronary artery calcium (CAC) imaging. Immunoglobulin (Ig)M and IgG levels recognizing MGO-apoB100 were determined by enzyme-linked immunosorbent assay. RESULTS: Anti-MGO-apoB100 IgM antibody levels were higher in subjects with a low to moderate CAC score (≤400 Agatston units) than in subjects with a high score (>400 Agatston units; 136.8±4.4 vs. 101.6± 7.4 arbitrary units (AU), P<0.0001) and in subjects demonstrating no progression of CAC during 30 months of follow-up (136.4±5.7 vs. 113.9 ± 6.2 AU in subjects with progression, P<0.0001). Subjects with a family history of premature myocardial infarction had lower levels of anti-MGO-apoB100 IgM. Female subjects had higher levels of anti-MGO-apoB100 antibodies and lower CAC than men. Accordingly, high levels of IgM against MGO-apoB100 are associated with less severe and a lower risk of progression of coronary disease in subjects with type 2 diabetes. CONCLUSIONS: Although conclusions regarding causal relationships based on epidemiological observations need to be made with caution, our findings suggest the possibility that anti-MGO-apoB100 IgM may be protective in diabetic vasculopathy.

Correction of the severely inverted nipple: areola- based dermoglandular rhomboid advancement.

Inverted nipple is a relatively common aesthetic problem presenting to a plastic surgeon. Along with the functional problems; recurrent inflammation/infection and an inability to nurse, most patients seek intervention because of the abnormal appearance. Many different surgical techniques have been described, suggesting that no one technique is universally successful. Most techniques employ, either individually or in combination, methods to tighten the nipple base or the use of areolar dermal flaps to support the nipple. We propose two modifications to the dermal flap technique. Firstly, the rhomboid dermal flaps are designed solely on the areola, the bases directed peripherally, improving vasularity and allowing true medial advancement. Secondly, the lactiferous ducts and tethering fibrous bands are released in a conical fashion allowing closure with a vertical V-Y advancement. This gives better projection and support to the nipple proper with medial recruitment of glandular tissue closing the dead space created. This technique has been used successfully by the senior author in 20 patients over a 16 year period, with a high rate of preserved nipple evertion and patient satisfaction. The technique is simple, reliable and provides sustained results over long term follow-up for the correction of the more severely inverted nipple.

Comparative analysis of abscisic acid-regulated transcriptomes in Arabidopsis.

Transcription regulation by the phytohormone abscisic acid (ABA) plays a key role in responses to various stresses and has been extensively studied in Arabidopsis thaliana using different expression analysis techniques. Previous studies on comparative analysis of expression regulation by ABA and ABA-related stresses demonstrated marked differences in the targets of ABA. However, as few expression experiments were available during these studies, they encompass only a subset of ABA-regulated genes. The aim of the present work was to compare gene expression regulated by ABA administration in a wider range of expression experiments. Despite diversity in the actual set of genes regulated by ABA, all ABA-regulated transcriptomes shared some basic features, such as a common induced gene set, common functional targets and involvement of common regulatory mechanisms. Moreover, the cis-regulatory architecture of genes belonging to this set is expected to be of interest because of their sensitivity to ABA and apparent independence from other experimental variables. Comparative analysis of cis-regulatory element (CRE) enrichment also identified a novel CRE that is strongly associated with ABA signalling-mediated transcription repression.

Associations between autoantibodies against apolipoprotein B-100 peptides and vascular complications in patients with type 2 diabetes.

AIMS/HYPOTHESIS: Oxidation of LDL in the arterial extracellular matrix is a key event in the development of atherosclerosis and autoantibodies against oxidised LDL antigens reflect disease severity and the risk of developing acute cardiovascular events. Since type 2 diabetes is associated with increased oxidative stress, we tested the hypothesis that autoantibodies against oxidised LDL antigens are biomarkers for vascular complications in diabetes. METHODS: We studied 497 patients with type 2 diabetes without clinical signs of coronary heart disease. Oxidised LDL autoantibodies were determined by ELISA detecting IgG and IgM specific for native and malondialdehyde (MDA)-modified apolipoprotein B-100 peptides p45 and p210. The severity of coronary disease was assessed as the coronary artery calcium score. RESULTS: Patients affected by retinopathy had significantly higher levels of IgG against MDA-p45 and MDA-p210. In contrast, high levels of autoantibodies against the corresponding native peptides were associated with less coronary calcification and a lower risk of progression of coronary disease. CONCLUSIONS/INTERPRETATION: Our observations suggest that LDL oxidation is involved in the pathogenesis of diabetic retinopathy and that autoantibodies against apolipoprotein B peptides may act as biomarkers for both micro- and macrovascular complications in diabetes.

Hand washing practices in urban and rural communities in and around Kolkata, West Bengal.

BACKGROUND: Public health importance of hand washing was known since 19th century. Many researchers also highlighted how hand washing could bring down the incidence of diarrhea, ARI & other diseases. OBJECTIVE: To find out the extent of hand washing as practiced by the community, to what extent suggested steps of hand washing was followed and to assess the changes in bacteriological count of hand before and after hand washing. METHOD: A community based cross sectional study was carried out during January-February 2007 among 161 respondents in and around Kolkata through interview, observation of hand washing in some situations as well as carrying out microbiological test. RESULT: 100% respondents interviewed practiced hand washing after defecation either with soap (59%) or with plain water, ash & mud (41%). But 64%, 51.6% and only 21.7% practiced hand washing before preparation of food; after using urinals; after changing the babies' nappies and disposing their feces respectively. Only 16.1% respondents washed their hands as per the recommended time of 15-30 seconds. Majority (75%) dried hands with apparently unclean materials. 90.7% followed step1 but none followed all the steps. Swab collection before and after hand washing revealed a decrease in colony count in 60% of the samples. CONCLUSION: It can be concluded that extent of desirable practices regarding hand washing is still lacking and needs to be emphasized.

Interactions of HIPPI, a molecular partner of Huntingtin interacting protein HIP1, with the specific motif present at the putative promoter sequence of the caspase-1, caspase-8 and caspase-10 genes.

To investigate the mechanism of increased expression of caspase-1 caused by exogenous Hippi, observed earlier in HeLa and Neuro2A cells, in this work we identified a specific motif AAAGACATG (- 101 to - 93) at the caspase-1 gene upstream sequence where HIPPI could bind. Various mutations in this specific sequence compromised the interaction, showing the specificity of the interactions. In the luciferase reporter assay, when the reporter gene was driven by caspase-1 gene upstream sequences (- 151 to - 92) with the mutation G to T at position - 98, luciferase activity was decreased significantly in green fluorescent protein-Hippi-expressing HeLa cells in comparison to that obtained with the wild-type caspase-1 gene 60 bp upstream sequence, indicating the biological significance of such binding. It was observed that the C-terminal 'pseudo' death effector domain of HIPPI interacted with the 60 bp (- 151 to - 92) upstream sequence of the caspase-1 gene containing the motif. We further observed that expression of caspase-8 and caspase-10 was increased in green fluorescent protein-Hippi-expressing HeLa cells. In addition, HIPPI interacted in vitro with putative promoter sequences of these genes, containing a similar motif. In summary, we identified a novel function of HIPPI; it binds to specific upstream sequences of the caspase-1, caspase-8 and caspase-10 genes and alters the expression of the genes. This result showed the motif-specific interaction of HIPPI with DNA, and indicates that it could act as transcription regulator.

Hypoplastic thumb in Gorlin's syndrome.

Gorlin's syndrome or naevoid basal cell carcinoma syndrome (NBCCS) is an autosomal dominant disorder that predisposes to basal cell carcinomas of the skin, ovarian fibromas, and medulloblastomas. This condition is due to mutations in the Patched (PTCH) gene which maps to chromosome 9q22 and acts as a tumour suppressor gene. Gorlin's syndrome is characterized by the development of multiple jaw keratocysts and/or basal carcinomas. There is a distinctive coarse facial appearance with macrocephaly, frontal bossing and prognathism. Most individuals have skeletal anomalies such as bifid ribs or wedge-shaped vertebrae. We present a case in which the patient presented with bilateral thumb hypoplasia. Various hand deformities have been reported in patients with Gorlin's syndrome including short metacarpals, cutaneous syndactyly of the second and third fingers, and pre- or post-axial polydactyly, but hypoplasia of the thumb has not been reported previously. These features of Gorlin's syndrome may be helpful diagnostically. The thumbs should be examined carefully in Gorlin's syndrome patients as minor degrees of hypoplasia are easy to miss. However, they still needs a specialist input to give the patient an optimum function of the thumb and the hand.

Breast reconstruction using deep inferior epigastric perforator flaps in EEC syndrome.

Ectrodactyly, ectodermal dysplasia, cleft lip/palate (EEC) syndrome is a rare condition that may result in failure of breast development. Breast reconstruction in these patients may pose a challenging problem, as they are young and reconstructive options should have minimal long-term complications. The use of deep inferior epigastric perforator (DIEP) flaps in breast reconstruction following breast cancer has been well described with good results. The use of DIEP flaps in breast augmentation, however, is far less common. We present the case of a young patient with EEC syndrome and mammary hypoplasia who underwent DIEP flap reconstruction for breast augmentation. The outcome was satisfactory to both patient and surgeon.

The results of limb lengthening by callus distraction using an extending intramedullary nail (Fitbone) in non-traumatic disorders.

Limb lengthening by callus distraction and external fixation has a high rate of complications. We describe our experience using an intramedullary nail (Fitbone) which contains a motorised and programmable sliding mechanism for limb lengthening and bone transport. Between 2001 and 2004 we lengthened 13 femora and 11 tibiae in ten patients (seven men and three women) with a mean age of 32 years (21 to 47) using this nail. The indications for operation were short stature in six patients and developmental or acquired disorders in the rest. The mean lengthening achieved was 40 mm (27 to 60). The mean length of stay in hospital was seven days (5 to 9). The mean healing index was 35 days/cm (18.8 to 70.9). There were no cases of implant-related infection or malunion.