INSTRuCT: Protocol, Infrastructure, and Governance.

Background and Purpose: Very few large scale multicentric stroke clinical trials have been done in India. The Indian Council of Medical Research funded INSTRuCT (Indian Stroke Clinical Trial Network) as a task force project with the objectives to establish a state-of-the-art stroke clinical trial network and to conduct pharmacological and nonpharmacological stroke clinical trials relevant to the nation and globally. The purpose of the article is to enumerate the structure of multicentric stroke network, with emphasis on its scope, challenges and expectations in India. Methods: Multiple expert group meetings were conducted by Indian Council of Medical Research to understand the scope of network to perform stroke clinical trials in the country. Established stroke centers with annual volume of 200 patients with stroke with prior experience of conducting clinical trials were included. Central coordinating center, standard operating procedures, data and safety monitoring board were formed. Discussion: In first phase, 2 trials were initiated namely, SPRINT (Secondary Prevention by Structured Semi-Interactive Stroke Prevention Package in India) and Ayurveda treatment in the rehabilitation of patients with ischemic stroke in India (RESTORE [Rehabilitation of Ischemic stroke Patients in India: A Randomized controlled trial]). In second phase, 4 trials have been approved. SPRINT trial was the first to be initiated. SPRINT trial randomized first patient on April 28, 2018; recruited 3048 patients with an average of 128.5 per month so far. The first follow-up was completed on May 27, 2019. RESTORE trial randomized first patient on May 22, 2019; recruited 49 patients with an average of 3.7 per month so far. The first follow-up was completed on August 30, 2019. Conclusions: In next 5 years, INSTRuCT will be able to complete high-quality large scale stroke trials which are relevant globally. REGISTRATION: URL: http://www.ctri.nic.in/; Unique Identifier: CTRI/2017/05/008507.

Prescriber Attitudes Toward Implementation of Pharmacogenomic Testing in a Family Medicine Residency Program.

INTRODUCTION: Few qualitative studies have explored the attitude of prescribers towards the implementation of pharmacogenomic testing in the family medicine (FM) setting, and none among FM residents. The purpose of this study was to describe the level of engagement and interest in the implementation of pharmacogenomic education and testing in an FM clinic within a residency program. METHODS: A qualitative study utilizing semistructured interviews was conducted among prescribers within the FM clinic at The Brooklyn Hospital Center (TBHC). Voluntary prescribers included FM residents and attendings. No prescribers were excluded. Prior to the interview, informational sheets about pharmacogenomics were provided to standardize participant knowledge base. The research team created an interview guide of specific open-ended questions. Interviews were audio recorded and transcribed until a point of saturation was achieved. Transcripts of interviews served as data for analysis. Coding and analysis were performed to develop a hypothesis. No formal statistical analysis was required. RESULTS: Of the total 28 providers eligible for participation, 15 were recruited and interviewed (53% response rate). Based on analysis of interview data, four key conceptual concerns emerged regarding benefits and risks of testing, feasibility, accessibility, and modification of FM residency training curricula. CONCLUSION: Positive attitudes and perceptions provide support for pharmacogenomic education and testing to be incorporated into FM residency curricula. Addressing practical barriers, such as curricular education and training, will allow for expansion of such initiatives in the future.

A case of testicular tuberculosis mimicking malignancy in a healthy young man.

Genitourinary tuberculosis represents a form of extra-pulmonary tuberculosis that occurs in the kidneys, ureters, seminal vesicles, prostate, testis, vas deferens, and epididymis. Isolated testicular involvement is unusual, and differential diagnosis includes testicular tumor, acute infection, infarction, and granulomatous infection. We report a case of a 36-year-old Ecuadorian man residing in New York, New York, who presented with a painful scrotal mass, weight loss, and purulent discharge from ulcerated lesion in scrotal area 10 years following his immigration to the United States. No other systemic symptoms were noted. Positive QuantiFERON-TB Gold and radio imaging results led to the diagnosis. After extensive workup, acid fast bacilli positive cultures obtained by computed tomography guided fine needle aspiration grew Mycobacterium tuberculosis complex. Anti-tuberculosis chemotherapy was initiated after sensitivity tests were confirmed. Significant recovery after 3 months of directly observed therapy was accomplished.

Jorge Lobo's disease: a case of keloidal blastomycosis (lobomycosis) in a nonendemic area.

Lobomycosis or lacaziosis is a chronic subcutaneous fungal infection, caused by the fungus Lacazia loboi, which is phylogenetically related to Coccidioides, Blastomyces, Histoplasma, and Paracoccidioides. The disease was first recognized in 1931 by Jorge Lobo, who found the disease to be a keloidal blastomycosis and named it Jorge Lobo's disease. This case was perplexing initially as this fungal infection is very uncommon in the USA. However, with the ever-increasing frequency of international travel, many more cases of lobomycosis have been diagnosed in areas of nonendemicity, such as the USA, Europe, and South Africa. The clinical histories of such imported fungal infections often illustrate their long latency periods. In lobomycosis, the onset of the disease is usually insidious and often difficult to document. We describe a case of a New York resident who presented with multiple skin nodules over both his arms and forearms, and was subsequently diagnosed with Jorge Lobo's disease. The case, diagnosis, histopathologic findings, complication, and management of this rare clinical disease are discussed.

Surgical and nonsurgical management of gallstones.

Cholelithiasis, or gallstones, is one of the most common and costly of all the gastrointestinal diseases. The incidence of gallstones increases with age. At-risk populations include persons with diabetes mellitus, persons who are obese, women, rapid weight cyclers, and patients on hormone therapy or taking oral contraceptives. Most patients are asymptomatic; gallstones are discovered incidentally during ultrasonography or other imaging of the abdomen. Asymptomatic patients have a low annual rate of developing symptoms (about 2% per year). Once symptoms appear, the usual presentation of uncomplicated gallstones is biliary colic, caused by the intermittent obstruction of the cystic duct by a stone. The pain is characteristically steady, is usually moderate to severe in intensity, is located in the epigastrium or right upper quadrant of the abdomen, lasts one to five hours, and gradually subsides. If pain persists with the onset of fever or high white blood cell count, it should raise suspicion for complications such as acute cholecystitis, gallstone pancreatitis, and ascending cholangitis. Ultrasonography is the best initial imaging study for most patients, although additional imaging studies may be indicated. The management of acute biliary colic mainly involves pain control with nonsteroidal anti-inflammatory drugs or narcotic pain relievers. Oral dissolution therapy is usually minimally successful and used only if the patient cannot undergo surgery. Laparoscopic cholecystectomy remains the surgical choice for symptomatic and complicated gallstones, with a shorter hospital stay and shorter convalescence period than open cholecystectomy. Percutaneous cholecystostomy is an alternative for patients who are critically ill with gallbladder empyema and sepsis.

Management of influenza.

Influenza is a contagious airborne viral illness characterized by abrupt onset of symptoms. Fever, myalgia, headache, rhinitis, sore throat, and cough are commonly reported symptoms. The diagnosis should be made clinically, and the decision to begin antiviral therapy should not be delayed for laboratory confirmation of influenza. The 2009 pandemic influenza A (H1N1) virus is expected to continue to circulate during the 2010-2011 season, but it is not certain whether it will replace or cocirculate with seasonal influenza A subtypes that have been circulating since 1977. The 2009 H1N1 virus is largely resistant to adamantanes, but it is sensitive to neuraminidase inhibitors such as oseltamivir. Neuraminidase inhibitors have modest effectiveness in reducing influenza-related symptoms in patients at low risk of complications. Patients at high risk of complications, including pregnant women, should be treated with antiviral agents, preferably within 48 hours of symptom onset. Family physicians should follow guidelines from the World Health Organization and the Centers for Disease Control and Prevention when treating patients with influenza or influenza-like symptoms.

Concomitant leiomyosarcoma of the right kidney and squamous cell carcinoma of the cervix - an unusual clinical presentation.

We report a case of right-sided leiomyosarcoma of the kidney with concomitant poorly differentiated squamous cell carcinoma of the cervix diagnosed one month after radical nephrectomy in a previously healthy female patient. This is the first reported case of concomitant leiomyosarcoma of the kidney and squamous cell carcinoma of the cervix, and the diagnosis, clinical presentation, prognosis, and treatment are discussed.

Brief, recurrent, and spontaneous episodes of loss of consciousness in a healthy young male.

INTRODUCTION: Lyme disease is caused by bacterial spirochete Borrelia burgdorferi and is transmitted by Ixodes scapularis and Ixodes pacificus ticks, which get infected while feeding on the reservoir host of the bacteria.1 About 248,074 cases of Lyme disease were reported by the US Centers for Disease Control and Prevention from 1992-2006.2 Over 95% of these cases are reported from the Northeastern and upper Midwestern United States.3 Carditis is usually a clinical manifestation/complication of Lyme disease and is seen in approximately 5% of untreated cases.4. CASE PRESENTATION: A 32-year-old male Hispanic from Chile presented with brief episodes of loss of consciousness and awareness of irregular heart beat, and denied any history of tick bite. The patient was found to have a heart rate of 40 beats per minute and fluctuating variable atrioventricular blocks. A transvenous pacemaker was placed with good capture. The diagnosis was made with serological testing and gallium scanning. Treatment with antibiotics and continuous cardiac monitoring resulted in remarkable symptomatic improvement of the patient. CONCLUSION: Absence of history or evidence of tick bite must not rule out the possibility of Lyme carditis in a patient with a transient heart block. Prompt recognition of this reversible cause of heart block is essential for avoiding implantation of an unnecessary, permanent pacemaker.

Stem cells isolated from adult rat muscle differentiate across all three dermal lineages.

Adult stem cells capable of differentiating into phenotypes from all three dermal layers were isolated from adult rat muscle. Stem cells were obtained by enzymatic digestion, followed by primary culture in Eagle's minimum essential medium +10% preselected horse serum. When the cells reached confluence, they were released by trypsin, filtered to remove differentiated myotubes, and then slow frozen in 7.5% dimethylsulfoxide to -80 degrees C. Thawed cells were the stem cells and were induced to differentiate with the nonspecific differentiating agent dexamethasone at concentrations of 10(-10)-10(-6) M. After a 6-week treatment with dexamethasone, the cells were assayed by immunohistochemistry for phenotypes of the mesodermal, ectodermal, and endodermal lineages. Examples of mesodermal phenotypes identified were as follows: bone, cartilage, and skeletal, smooth, and cardiac muscle. Ectodermal phenotypes identified were as follows: neurons and oligodendrocytes. Hepatocyte phenotypes identified represented the endodermal lineage. All the phenotypes were observed only with treatment with dexamethasone. However, nestin was observed in the absence of dexamethasone and may be a marker for uncommitted pluripotent stem cells. The results show that adult muscle contains pluripotent stem cells capable of differentiating across all three dermal lineages. Such cells could be used in the context of tissue engineering.