A Curious Case of Cough in a Young Woman

Inflammatory myofibroblastic tumour (IMT) is a rare neoplasm derived from tissue of mesenchymal origin. This tumour occurs predominantly in the lung, though extrapulmonary sites have been documented throughout the body.1 Presentation can be variable depending on location of the tumour and can include constitutional symptoms (fever, weight loss), thrombocytosis, hypergammaglobulinemia, anemia, and mass effect on local structures.2 Majority of patients with intrapulmonary IMT remain asymptomatic but can have symptoms including chest pain, dyspnoea, cough or haemoptysis.3 Most cases of IMT present in younger individuals (under age 40).4 Although the aetiology of IMT is unclear, current hypotheses suggest an inflammatory response to infection or an underlying malignancy could promote such cellular changes. Alternatively, the inflammatory component itself may be a consequence of the development of these mesenchymal tumours.

In light of recently published clinical trials and their implication for clinical practice, does a large catchment area acute hospital require 24 hour CT neck and head angiography and/or neuro-interventional services in the setting of acute ischaemic stroke?

BACKGROUND: Recently published clinical trials have resulted in a significant change in the guidelines used to manage patients suffering an acute ischaemic stroke. New neuro-interventional techniques have revolutionised stroke outcomes. Currently, such services are only available in two specialist centres. AIMS: We attempted to evaluate the need for the provision of routine computed tomography (CT) angiography and neuro-interventional services at a university teaching hospital in Limerick. METHODS: A retrospective study was performed based on data collated by the stroke service, University Hospital Limerick (UHL). All patients with a suspected acute ischaemic stroke of anterior circulation and known evolution were included. Baseline clinical and imaging characteristics, thrombolysis data, stroke unit admission rates and discharge destinations were recorded. RESULTS: All 141 patients were suitable for CT angiography and should be performed in accordance with guidelines. Additionally, 165 patients excluded from the study due to an unknown stroke evolution timeframe may have benefitted. Non-contrast CT scan confirmed just 12 anterior circulation strokes. The need for neuro-interventional services proved more difficult to assess, primarily due to the lack of provision of routine CT angiography, employed to confirm anterior circulation occlusion. Secondary results showed a thrombolysis rate of 10.8% and confirmed that time efficiencies result in higher thrombolysis eligibility rates. Stroke unit admissions and discharge destinations were also recorded. CONCLUSION: UHL should provide routine CT angiography to all patients presenting with acute ischaemic stroke in line with current guidelines. The need for provision of neuro-interventional services on-site proved more difficult to assess and requires further analysis.

Contrast-enhanced magnetic resonance angiography in diabetic patients with infra-genicular peripheral arterial disease: systematic review.

OBJECTIVE: Diabetes is a leading risk factor for the development of peripheral arterial disease (PAD). The optimal imaging modality for patients with diabetes and PAD is uncertain. We sought to analyse the literature to determine the accuracy of contrast enhanced magnetic resonance angiography (CE-MRA) in differentiating extent of disease in patients with infragenicular PAD and diabetes, using digital subtraction angiography (DSA) as the gold standard. METHODS: Online databases were searched for relevant keywords (January 1998-June 2012). Eligible studies prospectively compared CE-MRA and DSA of infragenicular vessels and provided data to construct contingency tables in at least 10 patients with diabetes and PAD symptoms. Pooled sensitivity and specificity values were calculated using random effects modelling. RESULTS: Only three studies (83 patients) provided data regarding the infragenicular vessels. The pooled sensitivity of MRA was 86% while the pooled specificity of MRA was 93%. CONCLUSIONS: The assumptions regarding CE-MRA's efficacy for infragenicular disease in diabetics are based upon low patient numbers. Inadequate diagnostic imaging in this high-risk group risks adoption of incorrect revascularisation strategies. Further studies are required.

Gene expression of regulatory enzymes involved in the intermediate metabolism of sheep subjected to feed restriction.

The effect of feed restriction on gene expression of regulatory enzymes of intermediary metabolism was studied in two sheep breeds (Australian Merino and Dorper) subjected to two nutritional treatments: feed restriction (85% of daily maintenance requirements) and control (ad libitum feeding), during 42 days. The experimental animals (ram lambs) were divided into four groups, n = 5 (Australian Merino control (MC), Australian Merino Restriction (MR), Dorper control (DC) and Dorper Restriction (DR)). After the trial, animals were sacrificed and samples were taken from liver tissue to quantify glucose levels and gene expression of relevant intermediary metabolism enzymes (phosphofructokinase (PFK), pyruvate kinase (PK), phosphoenolpyruvate carboxykinase, fructose 1,6-bisphosphatase, glucose-6-phosphatase, glycogen synthase (GS), fatty acid synthase (FAS), glutamate dehydrogenase (GDH) and carbamoyl phosphate synthase (CPS)) through real-time PCR. During the experimental period, the MR animals lost 12.6% in BW compared with 5.3% lost by the Dorper lambs. MC and DC rams gained, respectively, 8.8% and 14% during the same period. Within the Dorper breed, restricted feed animals revealed a significant decrease over controls in the transcription of PFK (1.95-fold) and PK (2.26-fold), both glycolytic enzymes. The gluconeogenesis showed no change in the feed restricted animals of both breeds. DR feed group presented a significant decrease over the homologous Merino sheep group on GS. In both experimental breeds, FAS mRNA expression was decreased in restricted feed groups. GDH expression was decreased only in the DR animals (1.84-fold) indicating a reduced catabolism of amino acids in these animals. Finally, CPS was significantly (P < 0.05) higher in the Dorper sheep, indicating a facilitated urea synthesis in this breed. These results indicate a better adaptation of metabolic intermediate regulatory enzymes and hepatic glucose production of Dorper sheep to feed restriction concurring with the BW results in the experimental groups.

Meticillin-resistant Staphylococcus aureus (MRSA) environmental contamination in a radiology department.

AIM: To explore the potential risk to patients and healthcare workers of acquiring meticillin-resistant Staphylococcus aureus (MRSA) in clinical and non-clinical areas within a radiology department. MATERIALS AND METHODS: High-risk sites in clinical and non-clinical areas within the Department of Radiology were identified and 125 environmental swabs were obtained by an infection control nurse specialist. Decontamination methods and protocols were reviewed and compared against international decontamination best practice. RESULTS: One of 125 samples was culture positive for MRSA. The positive sample was isolated from the surface of the bore of the magnetic resonance imaging (MRI) unit. A hypochlorite cleaning agent was applied using a long-handled brush to clean the bore of the MRI unit. A repeat environmental screen found the MRI unit to be culture negative for MRSA. CONCLUSION: This study has demonstrated that standard decontamination measures are adequate to prevent environmental contamination with MRSA in a radiology department. However, the MRI unit requires special attention because of its long bore and difficult access.

Case report. Glioblastoma multiforme presenting as a haemorrhagic minimally enhancing mass of the trigone.

Tumours of the trigone are rare, representing less than 2.5% of all intracranial tumours. The most common cause in adults is a meningioma. Glioblastoma multiforme of the trigone is extremely rare, with only six cases reported in the literature. We present a case of a glioblastoma multiforme of the trigone presenting in a 57-year-old man with temporal lobe seizures. Imaging revealed a haemorrhagic minimally enhancing mass of the trigone. Histology showed a high-grade malignant glial-derived neoplasm of World Health Organization Grade IV.

CT guided radiofrequency ablation of intra-articular osteoid osteoma of the hip.

BACKGROUND: Osteoid osteoma is a painful benign bone tumour. Previously the standard therapy was surgical excision. Image guided radiofrequency ablation can be clinically applied to ablate the tumour in a minimally invasive manner. AIMS: We present a case of an 18-year-old boy who presented with features of chronic left hip arthropathy secondary to intra-articular osteoid osteoma, subsequently successfully treated by percutaneous CT guided radiofrequency ablation. RESULTS: The CT guided radiofrequency ablation was technically successful as a day case procedure without complication. The patient returned to normal function within one week. No recurrence occurred in the three-year follow-up period. CONCLUSION: Radiofrequency ablation is a safe, minimally invasive and effective technique for treatment of osteoid osteoma.

Progress in Spinobulbar muscular atrophy research: insights into neuronal dysfunction caused by the polyglutamine-expanded androgen receptor.

Spinobulbar muscular atrophy (SBMA, Kennedy's disease) results from the dysfunction and degeneration of specific motor and sensory neurons. The underlying cause of this ligand-dependent neurodegenerative disease is expansion of the CAG trinucleotide repeat in the androgen receptor (AR) gene which leads to lengthening of the polyglutamine tract in the AR protein. Recently, the effects of the polyglutamine-expanded AR have been explored in a number of cellular and animal models. Common themes include research on polyglutamine-containing nuclear inclusions and the effect of molecular chaperone overexpression on their formation. In addition, investigations have highlighted the role that abnormal transcriptional regulation, proteasome dysfunction and altered axonal transport may play in disease pathogenesis. These studies suggest a number of potential treatments for restoring neuronal function. One of the most interesting advances in SBMA research has been the creation of mouse models that recapitulate the key features of SBMA progression in men. Lowering testosterone levels in affected transgenic male mice rescued, and even reversed the polyglutamine-induced neuromuscular phenotype, indicating that manipulating androgen levels in men could be of therapeutic benefit. Although the question of why only a distinct subset of neurons is affected by polyglutamine expansion of the AR remains unsolved, future research will provide further insights into the mechanisms contributing to disease progression in SBMA.

Effect of daily floor treatment with sodium bisulfate on the fly population of horse stalls.

OBJECTIVE: To determine application rate and effectiveness of sodium bisulfate to decrease the fly population in a horse barn environment. SAMPLE POPULATION: 12 privately owned farms in southeastern Pennsylvania. PROCEDURE: Application rates of sodium bisulfate were approximately 2.3 kg/stall, 1.1 kg/stall, and 0.5 kg/stall. Two or 3 stalls were treated, and 1 or 2 stalls were not treated (control stalls) at each farm. Farm personnel applied sodium bisulfate in treated stalls daily for 7 days. Fly tapes were hung from the same site in treated and control stalls. After 24 hours, the fly tape was removed, flies adhering to the sticky surface were counted and recorded, and a new fly tape was hung. This procedure was repeated daily during each of the testing periods. RESULTS: Following the application of 2.3 kg of sodium bisulfate/stall, the numbers of flies collected on the fly tape were significantly decreased in treated stalls, compared with control stalls during the same time periods on 9 of the 12 farms evaluated. Following the application of 1.1 kg of sodium bisulfate/stall, fly numbers were significantly decreased in treated stalls on 6 of the 9 farms evaluated. Following the application of 0.5 kg of sodium bisulfate/stall, fly numbers were significantly decreased in the treated stalls on 3 of the 4 farms evaluated. CONCLUSIONS AND CLINICAL RELEVANCE: Our findings suggest that sodium bisulfate would be effective for fly control in horse barns.

Nutrient management practices among swine operations of various sizes.

OBJECTIVE: To determine feeding, cropping, and manure-handling practices of swine operations of various sizes. DESIGN: Producer survey. SAMPLE POPULATION: 85 sow units and 132 finish floors. PROCEDURE: Swine producers were surveyed by mail and during farm visits for information regarding herd characteristics and management practices, with emphasis on the 3 components of the nutrient cycle: cropping, feeding and nutrition, and manure handling. Farms were categorized by operation type as sow units or finish floors and, subsequently, stratified by size as small sow units (< 600 head), large sow units (> or = 600 head), small finish floors (< 2,000 head), and large finish floors (2 > or = 2,000 head). RESULTS: Large sow units and large finish floors were approximately twice as likely to use environmentally sound nutrient management practices as small sow units or small finish floors. These large operations were more likely to use progressive feeding practices, to be aware of their nutrient flows, and to be capable of using these nutrients properly. CONCLUSIONS AND CLINICAL RELEVANCE: There is a need for greater environmental awareness among all swine producers, especially among small producers. This provides a possible growth area for large-animal veterinary consultants. Economy of scale and increased governmental regulations allow large farms to use environmentally sound practices. Thus, large swine farms are not necessarily harmful to the environment.

Antibiotics and Wolbachia in filarial nematodes: antifilarial activity of rifampicin, oxytetracycline and chloramphenicol against Onchocerca gutturosa, Onchocerca lienalis and Brugia pahangi.

The activity against filarial parasites of the antibiotics rifampicin, oxytetracycline and chloramphenicol was examined. In addition, transmission electron microscopy was used to study the effects of rifampicin and oxytetracycline on filarial tissues and on the endosymbiont bacterium, Wolbachia. When tested in vitro at a concentration of 50.0 microM, each of the three antibiotics significantly reduced the motility levels of male Onchocerca gutturosa. Rifampicin, however, was the most active, virtually immobilizing the parasite by the end of the 40-day trial and producing an 84% reduction in viability (as measured by formazan-based colorimetry). In tests against O. lienalis microfilariae (mff) in CBA mice, the numbers of mff recovered after treatment with oxytetracycline at 100, 25 or 6.5 mg/kg daily, for 15 days, were 56% (P < or = 0.03), 38% (P> 0.05) and 45% (P = 0.05) less than that recovered from the untreated controls, respectively. In another trial in mice, rifampicin (100 mg/kg daily for 15 days) was found to be the most active (causing a 74% reduction in the number of mff recovered--approximately equal to that achieved with the positive control of a single dose of ivermectin at 2 microg/kg), with chloramphenicol also showing significant activity (39% reduction). In further, in-vivo trials, at three dose levels (100, 25 or 6.25 mg/kg daily, for 15 days), all three antibiotics were tested against adult Brugia pahangi in the peritoneal cavities of jirds. None of the antibiotics produced a significant reduction in the numbers of live worms recovered, although a marginal effect was observed in eight of the nine antibiotic-treated groups. A further extended trial with rifampicin and oxytetracycline resulted in 43% and 38% reductions in worm recoveries, respectively (not statistically significant but consistent with a marginal effect); some of these worms appeared less motile and qualitatively in poor condition compared with those recovered from untreated jirds. Ultrastructural studies of these treated worms revealed that virtually all of the endosymbiont bacteria had been cleared from the parasite tissues. The tissues of the adult worms appeared to be largely intact but with a granulomatous response of host cells adhering to some specimens. However, developing uterine forms appeared to be abnormal and extensively damaged, showing an abrogation of embryogenesis. In contrast, worms recovered from control animals contained large numbers of Wolbachia, had no adherent host cells, and showed normal ultrastructure; the female worms exhibited a full range of intra-uterine developing stages from eggs to stretched mff. It is likely that the activity of these antibiotics against the endosymbiont Wolbachia causes the observed antifilarial activity, although some direct effect of each drug on filarial viability cannot be ruled out.

Street children in Latin America.

PIP: Worldwide, millions of children live on the streets. These children typically have access to neither health care nor education. Sometimes subjected to violence in the home before taking to the street, street children are seen by many as worthless, and many countries have used violent and punitive measures to eliminate them. New approaches have recently been implemented to return these children to society and their families. In the case of South America, children who are on the street are home-based and spend much of the day on the street, but have some family support and usually return home at night. Children of the street are street-based children who spend most days and nights on the street and are functionally without family support. Studies suggest that 80-90% of street children in Latin America have some contact with their families. Surveys also indicate that street children in Latin America are 8-17 years old, with 9 years old being the average age upon entering the street. Girls comprise 10-15% of street children and Black and mixed race children may be over-represented among street children in the region. Both published and unpublished research findings are used to shed light upon the status of street children in South America. The authors consider how many street children there may be, why there are street children, the problems they encounter, and what can be done to help them.^ieng

Patient and surgeon satisfaction with extremity blockade for surgery in remote locations.

In a practice that may be unique to military health care, extremity nerve blocks are established by anesthesiologists before transporting the patient to a remote clinic for surgery without further monitoring by anesthesia personnel. The safety and acceptance of this practice was assessed through a prospective survey of the surgeons and their patients. Six hundred seventy-seven blocks were performed in a 1-yr period with no adverse events related to this practice. Completed surveys were received from 406 (60%) of the surgeons and 232 (34%) of the patients. Of the blocks performed, 638 (94%) were brachial plexus blocks, with axillary blocks accounting for 87% of the brachial plexus blocks. Of the responding patients, 78% stated that they would be willing to undergo a repeat block. The surgeons were satisfied with the operating conditions in 96% of the cases. This study supports the safety and efficacy of this practice.