Paravertebral paraganglioma with spinal extension: a case report.

BACKGROUND: Paragangliomas are rare neuroendocrine tumors. While paragangliomas of the spine are rare, those located in non-cauda equina areas with spinal canal extension are even rarer. CASE PRESENTATION: We present a case of a 23-year-old female of African descent with a primary thoracic paraganglioma with intervertebral extension resulting in displacement and compression of the spinal cord and extensive local invasion of the surrounding structures. This paraganglioma was functional with typical symptoms of catecholamine excess. Despite the aggressive nature of the paraganglioma, the patient only had isolated sensory symptoms in the left shoulder. Adequate alpha and beta-blockade were instituted prior to her undergoing surgery with near-total resection and complete preserved neurology. There was no underlying pathogenic genetic mutation found. CONCLUSIONS: Even though rare, paraganglioma should be considered in the differential diagnosis of spinal tumors. Genetic testing should be performed in patients with paragangliomas. One should exercise extreme caution in treating such rare tumors that may cause neurological deficits and careful surgical planning should be undertaken to avoid possible catastrophic complications.

Triple-negative breast cancer - a retrospective audit of 151 cases seen at the Charlotte Maxeke Johannesburg Academic Hospital Breast Unit.

BACKGROUND: Triple-negative breast cancer (TNBC) is an aggressive, rapidly lethal subgroup of breast cancer which disproportionately affects women of African descent. Lacking hormone receptor expression and human epidermal growth factor receptor 2 (HER2) overexpression, it is difficult to treat. Despite an initial good response to chemotherapy, relapse is common and survival short. The aim of this study of treatment-naïve women with TNBC was examination of clinicopathological characteristics and any association of these with patient demographics. METHODS: Demographic data was captured together with the clinical, pathological and histological features of the cancers. Statistical analysis was performed. RESULTS: Of the 960 patients entered in the database of the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) Breast Unit (BU) over a 3-year period, 151 (15.7%) had TNBC. All patients were female aged 25 to 98 years, and 60.3% were postmenopausal (mean age 64 years). The majority (80.2%) self-identified as black African. Most patients had clinical stage 3 disease, and 17.2% had distant metastases. One hundred women were HIV negative, 35 positive and 20 untested. Tumour biology revealed high-grade morphology in 70% of cases with a mean Ki-67 value of 60%. Forty patients died within 18 months of entry in the database. CONCLUSION: In this series, most patients with TNBC were older, postmenopausal women. This patient cohort may represent a non-basal subtype of TNBC but gene expression profiling was not available. Tumours were locally advanced, rapidly proliferative but not associated with HIV status. The short survival times emphasise the importance of neoadjuvant chemotherapy as soon as the diagnosis of TNBC is made.

Cytomegalovirus-associated supraglottic mass in a patient on immunosuppressive therapy.

A 33-year-old woman on chronic immunosuppressive treatment for rheumatoid arthritis with a history of inhaled methamphetamine use presented with respiratory failure requiring mechanical ventilation for a prolonged period. After being given plasma exchange, pulses of methylprednisolone and a dose of cyclosporine for suspected ANCA (anti-neutrophilic cytoplasmic autoantibodies) vasculitis, she developed an obstructive supraglottic laryngeal mass that required a tracheostomy to bypass. Biopsy findings revealed the mass to be an inflammatory pseudomass secondary to cytomegalovirus (CMV). The mass resolved after several weeks of intravenous ganciclovir therapy. This is an extremely unusual presentation of localised CMV disease, with only two or three similar cases having been reported worldwide.

A prospective study of receptor profiles in breast cancer and the ipsilateral axillary lymph node metastases measured simultaneously in treatment naïve cases.

BACKGROUND: The heterogeneity of receptor profiles in breast cancer is well known. The differing receptor profiles of primary breast cancer and nodal metastases have been investigated and found to range between 10-50% depending on the hormone receptor tested. A study comparing the hormone status of primary breast cancers and the synchronous ipsilateral involved sentinel lymph node has not been performed in a South African population. METHOD: This is a prospective study where two specialist radiologists performed the simultaneous core needle biopsies of the primary breast cancer and the clinically positive axillary nodes. All receptor status analysis was conducted by one specialist histopathologist. RESULTS: Of 141 patients who gave written informed consent for this study, 29 were excluded; 112 patients met the inclusion criteria. Anonymised demographics of age, clinical stage, HIV status and metastatic screening were recorded. The simultaneous biopsies and receptor measurements identified 10 patients with discordant receptor status in the positive axillary lymph nodes. In each case, the receptor profile of the axillary lymphatic metastases was more aggressive than that of the primary tumour. The luminal A subtype had a significantly greater risk of discordance than other subtypes (p = 0.02). CONCLUSION: Core needle biopsy and receptor analysis should be considered on the positive axillary nodes in breast cancer patients. Adjuvant treatment should be targeted to the receptor profile of the lymph node metastases.

A genetic and immunological comparison of tick-resistance in beef cattle following artificial infestation with Rhipicephalus ticks.

Host resistance to ticks can be explored as a possible approach of combating tick infestations to complement the existing unsustainable tick control methods. Thirty-six beef cattle animals were used, consisting of Angus, Brahman and Nguni breeds, with each breed contributing 12 animals. Half of the animals per breed were artificially challenged with Rhipicephalus microplus and the other half with R. decoloratus unfed larvae per animal. Skin biopsies and blood samples were collected pre-infestation and 12 h post-infestation from the feeding sites of visibly engorging ticks. The success rate of the ticks was high and had an influence even at the early time point. Increased lymphocytes and blood urea nitrogen levels as well as decreased levels of segmented neutrophils were observed in the Angus, which were the opposite of those in the Brahman and Nguni. The increase in cholesterol, which was highest in the Angus and lowest in the Nguni, may be due to altered protein metabolism. The expression profiles of genes TRAF6, TBP, LUM and B2M were significantly different among breeds. Five genes (CCR1, TLR5, TRAF6, TBP, BDA20) had increased or constant expression post-infestation, whereas the expression of CXCL8, IL-10 and TNF-α decreased or remained the same after tick challenge. Genes that showed variation are involved in discouraging long-term supply of blood meal to the tick and those associated with immune responses. The gene LUM is a potential biomarker for tick resistance in cattle. The response to infestation by the breeds was consistent across the tick species.

Enhancement of plastic surgery training by including simulation in education and training programmes

plastic surgery education and training. The objectives entail determining the importance of simulation in plastic surgery training and identifying simulation modalities most suited to attain specific outcomes.Methods.Data were collected by means of a Delphi survey to obtain consensus from an expert panel comprising 9 plastic surgeons, supplemented by semi-structured interviews conducted with 8 national and international role players in simulation and postgraduate education.Results. Learning outcomes, levels of training, possible simulation modalities, cognitive levels and descriptive verbs and phrases were described, as these pertain to learning. Participants agreed that simulation in medical education can be used to enhance postgraduate plastic surgery training, with special reference to specific outcomes and cognitive levels. Participants made recommendations for the planning and support of the implementation, aimed at ensuring the quality of training.Conclusion.The objectives set were achieved and the results of the study serve as encouragement and guidance in the striving for the enhancement of postgraduate plastic surgery education and training, and in other medical disciplines

Vulnerability of pathogenic biofilms to Micavibrio aeruginosavorus.

The host specificity of the gram-negative exoparasitic predatory bacterium Micavibrio aeruginosavorus was examined. M. aeruginosavorus preyed on Pseudomonas aeruginosa, as previously reported, as well as Burkholderia cepacia, Klebsiella pneumoniae, and numerous clinical isolates of these species. In a static assay, a reduction in biofilm biomass was observed as early as 3 hours after exposure to M. aeruginosavorus, and an approximately 100-fold reduction in biofilm cell viability was detected following a 24-h exposure to the predator. We observed that an initial titer of Micavibrio as low as 10 PFU/well or a time of exposure to the predator as short as 30 min was sufficient to reduce a P. aeruginosa biofilm. The ability of Micavibrio to reduce an existing biofilm was confirmed by scanning electron microscopy. In static and flow cell experiments, M. aeruginosavorus was able to modify the overall P. aeruginosa biofilm structure and markedly decreased the viability of P. aeruginosa. The altered biofilm structure was likely caused by an increase in cell-cell interactions brought about by the presence of the predator or active predation. We also conducted a screen to identify genes important for P. aeruginosa-Micavibrio interaction, but no candidates were isolated among the approximately 10,000 mutants tested.

Value of diagnostic techniques for cutaneous leishmaniasis.

BACKGROUND: Traditional diagnostic tests, ie, smear, culture, and histopathology of a skin biopsy specimen, are not always conclusive in patients with a clinical diagnosis of cutaneous leishmaniasis (CL). OBJECTIVE: Our purpose was to find out if a polymerase chain reaction (PCR) specific for Leishmania organisms might be more sensitive than the traditional diagnostic techniques, thereby decreasing the number of false-negative diagnoses. METHODS: In a prospective study, smear, culture, and histopathology of skin biopsy specimens from 46 patients with a possible diagnosis of CL were compared with PCR specific for Leishmania. In addition, the Montenegro test as a measure of cellular immunity against the Leishmania parasite was performed. Proven CL was defined as a case in which at least 1 of the 3 traditional tests showed the presence of Leishmania parasites. RESULTS: Of our 46 patients, 22 had leishmaniasis. Of the traditional tests, culture was the most sensitive but there were no statistically significant differences between the sensitivities of the various tests. PCR results were positive in all cases of proven leishmaniasis. Moreover, 3 patients with the clinical diagnosis of CL and negative findings on traditional tests had positive PCR results. Only 1 patient with a strong clinical suggestion of CL and positive Montenegro test results had negative PCR findings; this patient also had negative smear, culture, and histopathology results. CONCLUSION: PCR appears to be the most sensitive single diagnostic test for CL.

Soluble-fibre concentrate lowers plasminogen activator inhibitor-1 in baboons (Papio ursinus).

The effects of a soluble NSP (fibre) concentrate (SFC) on plasma fibrinogen and plasminogen activator inhibitor-1 (PAI-1), serum and liver lipids and lipoproteins and glucose tolerance were compared with those of bezafibrate (BF), a lipid-lowering drug, in obese baboons (Papio ursinus). The basal diet was a high-fat (37% of total energy), low-NSP (12.4 g/d) Westernized diet, supplemented for 8 weeks with either 20 SFCg/baboon per d or 6.7 mg BF/kg body weight per baboon per d. SFC supplementation significantly lowered PAI-1, total serum cholesterol, HDL-cholesterol and circulating free fatty acid levels. BF significantly lowered total serum cholesterol, but unexpectedly raised serum triacylglycerol levels. Although not statistically significant, the mean liver triacylglycerol concentration of baboons fed on BP was lower than that of baboons fed on SFC supplements. These results suggest that: (1) the mechanism of action of the two cholesterol-lowering treatments differ, with BF having a liver triacylglycerol-lowering effect and (2) the SFC ahd additional beneficial effect on fibrinolysis by lowering PAI-1 levels.

Ruptured abdominal aortic aneurysms--prognostic indicators and complications affecting mortality. A local experience.

Although elective abdominal aortic aneurysm (AAA) repair can be done with a less than 5% mortality rate, ruptured AAAs have a 32-85% mortality rate. The aims of this study were: (i) to identify prognostic factors affecting mortality; (ii) to identify and assess the impact of postoperative complications on mortality; and (iii) to try to identify a subgroup of patients who would not benefit from surgery. The records of 54 patients presenting with ruptured AAAs were reviewed; 49 of these patients were operated on, 43 of them males and 6 females (mean age 67 years). The operative mortality rate was 44%, most patients who died doing so in the intensive care unit. In 14 cases AAA was diagnosed before rupture--6 of these patients died. Factors that had a significant effect on mortality were: (i) associated ischaemic heart disease--83% of these patients died postoperatively; (ii) the degree of shock on admission--66% of patients with a blood pressure on admission of 85 mmHg or less died; and (iii) the number of postoperative complications per patients--those with 2 or more complications had an 83% mortality rate. Factors that did not correlate statistically with mortality were age, time interval to surgery, volume and composition of intra-operative fluid therapy, and length of surgery. The most important correctable error was failure to operate electively. From the factors assessed it was not possible clearly to identify a subgroup of patients in this study who should have been excluded from surgery.

Preoperative nutritional status and prognostic nutritional index in patients with benign disease undergoing abdominal operations--Part I.

OBJECTIVE: The aim of the first part of this study was to detect the incidence of preoperative malnutrition of clinical importance in patients with benign disease. METHODS: The preoperative nutritional status of 52 consecutive adult patients undergoing abdominal operations for benign conditions was studied prospectively by objective and subjective nutritional criteria. The postoperative outcome was monitored until discharge or death. The preoperative nutritional status was correlated with the postoperative outcome. RESULTS: Protein energy malnutrition was identified in 20 (38%) of the 52 patients. Of these 20 malnourished patients, 15 (75%) developed complications after surgery, compared with 7 (22%) of the 32 well-nourished patients (p < 0.01). The most common abnormal values were serum transferrin concentration (n = 8), subscapula skinfold (n = 11), serum urea:serum creatinine ratio (n = 17), loss of appetite for more than 5 days (n = 24), and preoperative stay in hospital of longer than 5 days (n = 19). CONCLUSION: These results indicate that a combination of objective and subjective criteria may be important in the identification of clinical malnutrition.

Preoperative nutritional status and prognostic nutritional index in patients with benign disease undergoing abdominal operations--Part II.

OBJECTIVES: Part II of this study was undertaken to develop a prognostic nutritional index for the identification of high risk patients with benign disease undergoing abdominal operations at the Universitas Hospital in Bloemfontein. METHODS: To accomplish this goal, 52 consecutive adult non-cancer surgical patients, admitted to the Universitas Hospital for a period of one year, were studied prospectively. The postoperative outcome was monitored until discharge or death. Various discriminant analyses were performed on the obtained data. Four prognostic indexes were compiled, including two nutritional and two mixed models. A short and medium length index were derived for both the nutritional and the mixed models. RESULTS/DISCUSSION: The results suggest that the short nutritional index may be the most practical for the prediction of surgical outcome in this specific set of patients. The short nutritional index included diet risk, serum albumin, body mass index, % ideal body weight, triceps skinfold and grip strength. It is further suggested that these indices be tested in another set of patients and be compared with other available prognostic models.