Airy light-sheet Raman imaging.

Light-sheet fluorescence microscopy has greatly improved the speed and overall photostability of optically sectioning cellular and multi-cellular specimens. Similar gains have also been conferred by light-sheet Raman imaging; these schemes, however, rely on diffraction limited Gaussian beams that hinder the uniformity and size of the imaging field-of-view, and, as such, the resulting throughput rates. Here, we demonstrate that a digitally scanned Airy beam increases the Raman imaging throughput rates by more than an order of magnitude than conventional diffraction-limited beams. Overall, this, spectrometer-less, approach enabled 3D imaging of microparticles with high contrast and 1 µm axial resolution at 300 msec integration times per plane and orders of magnitude lower irradiation density than coherent Raman imaging schemes. We detail the apparatus and its performance, as well as its compatibility with fluorescence light-sheet and quantitative-phase imaging towards rapid and low phototoxicity multimodal imaging.

Integrative quantitative-phase and airy light-sheet imaging.

Light-sheet microscopy enables considerable speed and phototoxicity gains, while quantitative-phase imaging confers label-free recognition of cells and organelles, and quantifies their number-density that, thermodynamically, is more representative of metabolism than size. Here, we report the fusion of these two imaging modalities onto a standard inverted microscope that retains compatibility with microfluidics and open-source software for image acquisition and processing. An accelerating Airy-beam light-sheet critically enabled imaging areas that were greater by more than one order of magnitude than a Gaussian beam illumination and matched exactly those of quantitative-phase imaging. Using this integrative imaging system, we performed a demonstrative multivariate investigation of live-cells in microfluidics that unmasked that cellular noise can affect the compartmental localization of metabolic reactions. We detail the design, assembly, and performance of the integrative imaging system, and discuss potential applications in biotechnology and evolutionary biology.

Correlation of Visual Prostate Symptom Score with International Prostate Symptom Score and Uroflowmetry Parameters in Nepalese Male Patients with Lower Urinary Tract Symptoms.

INTRODUCTION: International prostate symptom score is a validated questionnaire used to evaluate the lower urinary tract symptoms in benign prostatic hyperplasia. Visual prostate symptom score is a new simplified symptom score with pictograms to evaluate the same. We evaluated the correlation of visual prostate symptom score with international prostate symptom score and uroflowmetry parameters in Nepalese male patients with lower urinary tract symptoms. METHODS: Male patients aged ≥40 years attending the Urology clinic were enrolled in the study. They were given international prostate symptom score and visual prostate symptom score questionnaires to complete providing assistance whenever needed. Demographic data, examination findings and uroflowmetry parameters were noted. Correlation and regression analysis was used to identify correlation of the two scoring systems and uroflowmetry parameters. RESULTS: Among the 66 patients enrolled, only 10 (15.15%) patients were able to understand English language. There was a statistically significant correlation between total visual prostate symptom score and international prostate symptom score (r= 0.822; P<0.01). The correlations between individual scores of the two scoring systems related to force of urinary stream, frequency, nocturia and quality of life were also statistically significant. There was also a statistically significant correlation of both scores with maximum flow rate and average flow rate. CONCLUSIONS: There is a statistically significant correlation of visual prostate symptom score with international prostate symptom score and uroflowmetry parameters. IPSS can be replaced with simple VPSS in evaluation of lower urinary tract symptoms in elderly male patients.

Effectiveness of fluoroscopy-guided intra-articular steroid injection for hip osteoarthritis.

AIM: To demonstrate the benefits of fluoroscopy-guided intra-articular steroid injection in the hip with varying degrees of disease severity, and to investigate the financial aspects of the procedure and impact on waiting time. MATERIALS AND METHODS: A prospective study was undertaken of patients who underwent fluoroscopic intra-articular steroid injection over the 9-month study period. Comparative analysis of the Oxford hip pain score pre- and 6-8 weeks post-intra-articular injection was performed. Hip radiographs of all patients were categorised as normal, mild, moderate, or severe disease (four categories) based on the modified Kellgren-Lawrence severity scale, and improvement on the Oxford hip pain score on each of these four severity categories were assessed. RESULTS: Within the study cohort of 100 patients, the mean increase in post-procedure hip score of 7.32 points confirms statistically significant benefits of the therapy (p<0.001, 95% confidence interval: 5.55-9.09). There was no significant difference in pre-injection hip score or change in score between the four severity categories (p=0.51). Significant improvement in hip score (p<0.05) was demonstrated in each of the four severity categories 6-8 weeks post-injection. No associated complications were observed. CONCLUSION: The present study confirms that fluoroscopy-guided intra-articular steroid injection is a highly effective therapeutic measure for hip osteoarthritis across all grades of disease severity with significant cost savings and the potential to reduce waiting times.

MRI of inflammatory spondyloarthropathy following traumatic cauda equina syndrome.

BACKGROUND CONTEXT: Spondyloarthropathy has been described radiographically in patients following paralysis from spinal cord trauma. Onset of these findings after cauda equina syndrome have not been reported previously. Furthermore, the magnetic resonance documentation of its early evolution has not been recorded. PURPOSE: We report a case of early-onset spondyloarthropathy shown by magnetic resonance imaging (MRI) in a patient with cauda equina syndrome due to bilateral sacral insufficiency fractures. STUDY DESIGN: Unique case study review, one case. METHODS: Review of the clinical case notes and imaging including initial and subsequent MR imaging. RESULTS: The initial MRI of the lumbosacral spine showed bilateral sacral insufficiency fractures with a kyphotic deformity. The vertebral bodies were normal on the initial computed tomography and MRI studies, which did not reveal pre-existing features of sacroiliitis. The second MRI performed 5 months later clearly showed spondylitis at multiple vertebral levels with partial resolution 18 months post injury. CONCLUSION: Spondyloarthropathy in patients with paralysis due to spinal cord injury is well documented in the English language literature, but until now this has not been demonstrated by MRI. It is a rare complication of traumatic cauda equina syndrome that commences soon after the traumatic event and can resolve spontaneously.

First Report of Black Leaf Mold of Tomato Caused by Pseudocercospora fuligena in Ohio.

Diseased tomato (Solanum lycopersicum L. cvs. Geronimo, Rebelski, and Big Dena) plants were received for diagnosis from a home gardener in Wayne County, Ohio, in August 2013 and from a 0.14-ha greenhouse in Brown County, Ohio, in September 2013. Approximately 10 and 60% of leaf area was diseased in the home garden and greenhouse, respectively. One or more lesions, each with an indistinct border, were observed on the leaves. Black fungal growth was observed on both sides of the leaf in association with the lesions. Microscopic examination revealed Cercospora-like conidia (2). Three symptomatic leaves from each location were surface-sterilized with 0.5% NaClO for 1 min and cultured on V8 juice agar medium at room temperature under continuous fluorescent lighting. One isolate was selected from each of Wayne Co. (SAM33-13) and Brown Co. (SAM34-13). The fungus produced small, dark-brown colonies within 2 weeks of plating. Mycelium was olive brown and septate, producing fascicles of conidiophores. Conidia were cylindrical, 2 to 14 septate, and 25.8 to 109.7 × 6.5 µm. Genomic DNA was extracted from colonies of isolate SAM33-13 grown on V8 juice agar medium using the Wizard SV Genomic DNA Purification System (Promega, Madison, WI). The internal transcribed spacer (ITS) region of rDNA was amplified by PCR using primer pair ITS1 and ITS4 (5), and the purified amplicon was sequenced (OARDC Molecular and Cellular Imaging Center, Wooster, OH). The ITS sequence was 99% identical to those of GenBank accessions of Pseudocercospora fuligena from Korea (JX290079) and Thailand (GU214675). The sequence was deposited in GenBank (KF931141). Based on morphology (4) and sequence analysis, the fungus was identified as P. fuligena (Roldan) Deighton (basionym Cercospora fuligena). To satisfy Koch's postulates, three 4-week-old tomato plants each of the cultivars L390 (AVRDC, Taiwan) and Mountain Spring (Siegers Seed Co., Holland, MI) were sprayed with a suspension of 1 × 103 conidia/ml of isolates SAM33-13 or SAM34-13 prepared from 3-week-old cultures growing on V8 juice agar medium. Three non-inoculated control plants were sprayed with sterilized water. Plants were maintained in a growth chamber at 25 to 30°C, 80% RH, and a 12 h/12 h day/night cycle. The first symptoms appeared 3 weeks after inoculation as light yellow foliar lesions. The lesions enlarged and turned black due to fungal growth, and the infected leaves dried. Disease severity was 70 and 10% of leaf area for cvs. L390 and Mountain Spring, respectively, for each isolate. Non-inoculated control plants were symptomless, and no fungus was re-isolated from the leaves. P. fuligena was isolated from symptomatic leaves of inoculated plants as described above, and the identity was confirmed based on morphology. In the United States, C. fuligena has not been reported infecting tomato since the first report in Florida in 1974 (1). To our knowledge, this is the first report of black leaf mold of tomato caused by P. fuligena in Ohio. Resistant cultivars, crop sanitation, and fungicides are recommended to manage the disease (3). References: (1) C. H. Blazquez and S. A. Alfieri. Phytopathology 64:443, 1974. (2) U. Braun. IMA Fungus 4:265, 2013. (3) R. Cerkauskas. AVRDC Publication 04-606, 2004. (4) B. Halfeld-Vieira et al. Fitopatol. Bras. 31:3, 2006. (5) T. J. White et al. Page 315 in: PCR Protocols: A Guide to Methods and Applications. Academic Press, San Diego, CA, 1990.

Cystoscopic bladder biopsies: a histopathological study.

Urothelial carcinoma is the most common tumor of the bladder and is a major cause of morbidity and mortality. Cystitis constitutes an important source of clinical signs and symptoms. In this study 31 cystoscopic biopsies subjected for histopathological examination were taken. The study was conducted in the department of Pathology of Nepal Medial College Teaching Hospital over a period of two years (October 2012 to September 2014). The mean age of the patient undergoing cystoscopic biopsy was 61.3 years, most of the patients being elderly male. 51.6% cases were clinically malignant. The most common histopathological diagnoses were cystitis (29%) and non invasive papillary urothelial carcinoma, low grade (29%). 58% are neoplastic lesions. 51.6% of the case was malignant lesions on histopathology. Among the malignant lesion of urinary bladder 93.7% were urothelial tumor and 6.3% were glandular neoplasm (adenocarcinoma, signet ring cell). There was no detrusor muscle in 33.3% cases of urothelial tumor to assess the muscle invasion. 26.7% cases of urothelial tumor shows muscle invasion. Histopathological study of cystoscopic biopsy helps in early detection of tumor and its management.

First Report of Anthracnose of Onion Caused by Colletotrichum coccodes in Ohio.

Dry bulb onion (Allium cepa L. cvs. Pulsar, Bradley, and Livingston) plants with symptoms of anthracnose were observed in three commercial fields totaling 76.5 ha in Huron Co., Ohio, in July 2013. Symptoms were oval leaf lesions and yellowing, curling, twisting, chlorosis, and death of leaves. Nearly half of the plants in a 32.8-ha field of the cv. Pulsar were symptomatic. Concentric rings of acervuli with salmon-colored conidial masses were observed in the lesions. Conidia were straight with tapered ends and 16 to 23 × 3 to 6 µm (2). Colletotrichum coccodes (Wallr.) S. Hughes was regularly isolated from infected plants (2). Culturing diseased leaf tissue on potato dextrose agar (PDA) amended with 30 ppm rifampicin and 100 ppm ampicillin at room temperature yielded white aerial mycelia and salmon-colored conidial masses in acervuli. Numerous spherical, black microsclerotia were produced on the surface of colonies after 10 to 14 days. To confirm pathogen identity, total DNA was extracted directly from a 7-day-old culture of isolate SAM30-13 grown on PDA, using the Wizard SV Genomic DNA Purification System (Promega, Madison, WI) following the manufacturer's instructions. The ribosomal DNA internal transcribed spacer (ITS) region was amplified by PCR using the primer pair ITS1 and ITS4 (2), and sequenced. The sequence, deposited in GenBank (KF894404), was 99% identical to that of a C. coccodes isolate from Michigan (JQ682644) (1). Ten onion seedlings cv. Ebenezer White at the two- to three-leaf stage of growth were spray-inoculated with a conidial suspension (1 × 105 conidia/ml containing 0.01% Tween 20, with 10 ml applied/plant). Plants were maintained in a greenhouse (21 to 23°C) until symptoms appeared. Control plants were sprayed with sterilized water containing 0.01% Tween 20, and maintained in the same environment. After 30 days, sunken, oval lesions each with a salmon-colored center developed on the inoculated plants, and microscopic examination revealed the same pathogen morphology as the original isolates. C. coccodes was re-isolated consistently from leaf lesions. All non-inoculated control plants remained disease-free, and C. coccodes was not re-isolated from leaves of control plants. C. coccodes was reported infecting onions in the United States for the first time in Michigan in 2012 (1). This is the first report of anthracnose of onion caused by C. coccodes in Ohio. Unusually wet, warm conditions in Ohio in 2013 likely contributed to the outbreak of this disease. Timely fungicide applications will be necessary to manage this disease in affected areas. References: (1) A. K. Lees and A. J. Hilton. Plant Pathol. 52:3. 2003. (2) L. M. Rodriguez-Salamanca et al. Plant Dis. 96:769. 2012. (3) T. J. White et al. Page 315 in: PCR Protocols: A Guide to Methods and Applications. Academic Press, San Diego, CA, 1990.

First Report of Bacterial Wilt Caused by Ralstonia solanacearum in Ghana, West Africa.

Tomato and pepper plants exhibiting wilt symptoms were collected from fields in seven villages in Northern (Vea, Tono, Pwalugu), Ashanti (Agogo, Akumadan), and Brong Ahafo (Tanoso, Tuobodom) regions of western Ghana in November 2012. The plants were wilted without leaf yellowing or necrosis. Disease incidence was generally low, with less than 20% symptomatic plants observed. Most of the plants collected produced visible bacterial ooze in water in the field. Ooze was plated on 2,3,5-triphenyltetrazolium chloride-amended (TZC) medium. Isolated colonies were fluidal, irregularly round, white with pink centers, gram-negative, and oxidase positive. One strain from each of seven fields was selected for further study. All strains induced a hypersensitive reaction on tobacco. Randomly selected strains SM855-12 and SM857-12 tested positive in R. solanacearum ImmunoStrip assays (Agdia Inc., IN). An end-point PCR assay with primer set 759/760 (3) generated an R. solanacearum-specific 280-bp amplicon for all seven strains. Two of these strains were biovar I and the remaining five were biovar III based on utilization of cellobiose, lactose, maltose, dulcitol, mannitol, and sorbitol. A phylotype-specific multiplex PCR assay that recognizes four geographically linked monophyletic groups within R. solanacearum (1) indicated that one strain (SM855-12) was phylotype III (African origin), whereas the other six were phylotype I (Asian origin). All strains were subjected to repetitive sequence-based PCR (Rep-PCR) with BOXA1R and REP1R/REP2 primers (4). Strain SM855-12 was grouped with the phylotype III reference strain UW 368 and the remaining six strains were grouped with the phylotype I reference strain GMI 1000. A pathogenicity test was performed with bacterial wilt-susceptible tomato line OH7814. Inoculum was prepared from 48-h cultures of strains SM855-12, SM856-12, and SM858-12 grown on casamino acid peptone glucose (CPG) medium at 30°C. Roots of ten 4-week-old tomato plants per strain were drench-inoculated with 5 ml of a 108 CFU/ml bacterial suspension after wounding with a sterile scalpel. Non-inoculated control plants were drenched with 5 ml distilled water after root wounding. Plants were kept in a greenhouse at 25 to 30°C. By 12 days after inoculation, 80 to 100% of inoculated plants were wilted, whereas no symptoms appeared in non-inoculated plants. Bacteria re-isolated from wilted plants were confirmed to be R. solanacearum using techniques mentioned above. Although an association of bacterial wilt with tomato/pepper was mentioned previously (2), to our knowledge, this is the first documented report of bacterial wilt caused by R. solanacearum in Ghana. The presence of Asian strains (phylotype I) may be the result of one or more accidental introductions. Awareness of this disease in Ghana will lead to deployment of management strategies including use of resistant varieties and grafting desirable varieties onto disease-resistant rootstocks. References: (1) M. Fegan and P. Prior. Page 449 in Bacterial Wilt Disease and the Ralstonia solanacearum Species Complex. C. Allen et al., eds. American Phytopathological Society, St. Paul, MN, 2005. (2) K. A. Oduro. Plant Protection and Regulatory Services Directorate of MOFA, Accra, Ghana, 2000. (3) N. Opina et al. Asia Pac. J. Mol. Biol. Biotechnol. 5:19, 1977. (4) J. Versalovic et al. Methods Mol. Cell Biol. 5:25, 1994.

First Report of Leek yellow stripe virus in Garlic in Ohio.

Leek yellow stripe virus (LYSV), genus Potyvirus, family Potyviridae, infects a wide range of Allium species worldwide. LYSV is one of several viruses that chronically infect garlic, Allium sativum L. The garlic virus complex, which includes LYSV, Onion yellow dwarf virus, and Garlic common latent virus, is perpetuated by asexual propagation (4) and is transmitted to clean planting material by aphids (3). This virus complex can reduce garlic bulb weight by nearly three quarters (2), and LYSV-only infections can result in approximately a one-quarter reduction in bulb weight (2). Garlic is grown as a small-scale, specialty crop in Ohio. During late May and early June 2013, garlic plants with virus-like symptoms were collected from Medina, Holmes, and Wayne counties, Ohio. Plants exhibited chlorotic streaking, foliar dieback, dwarfing, small bulbs, and cylindrical bulbs that failed to differentiate into cloves. Incidence of affected plants in the fields was up to 5% and all fields had early season aphid infestations. Flexuous rods were observed in TEM micrographs of plant sap from symptomatic leaves. Five symptomatic plants and six asymptomatic plants (from fields with symptomatic plants) were evaluated for LYSV by DAS-ELISA (Agdia, Inc., Elkhart, IN). Reverse transcriptase (RT)-PCR with LYSV-specific primers LYSV-WA and LYSV-WAR (3) was performed with cDNA generated by the High Capacity cDNA Reverse Transcription Kit (Applied Biosystems, Foster City, CA). Both foliar and bulb tissues were tested using both detection methods. Forty percent of symptomatic plants and 67% of asymptomatic plants tested positive for LYSV with both ELISA and RT-PCR. LYSV was detected in both foliar and bulb tissues, including both tissues from asymptomatic plants. Five PCR amplicons generated from both foliar and bulb tissue were sequenced and shown to share 96 to 98% maximum identity with an LYSV polyprotein gene accession in GenBank (AY842136). This provided additional support that the detected virus was LYSV. LYSV was initially difficult to detect in Ohio fields due to low disease incidence and subtle symptom development. Use of virus-tested garlic bulbs can improve yield for several years, even following viral reinfection by aphids, compared to growing garlic from chronically infected bulbs (1). However, many growers routinely save bulbs from year to year and lack access to or knowledge of virus-tested sources of garlic bulbs. Conducive conditions, chronic infections, or co-infections with other viruses enhance the severity of symptoms and yield loss (2). LYSV has previously been reported in garlic producing regions of the northwestern United States (3), and to our knowledge, this is the first report of LYSV in garlic in Ohio. References: (1) V. Conci et al. Plant Dis. 87:1411, 2003. (2) P. Lunello et al. Plant Dis. 91:153, 2008. (3) H. Pappu et al. Plant Health Progress 10, 2008. (4) L. Parrano et al. Phytopathol. Mediterr. 51:549, 2012.

Use of CT in the management of anterior cruciate ligament revision surgery.

Anterior cruciate ligament (ACL) injuries occur most commonly in individuals between 18 and 29 years of age and are strongly correlated with sporting activity, with female athletes being at higher risk of ACL rupture than their male counterparts. ACL reconstruction is one of the most frequently performed procedures in orthopaedic surgery, having a reported incidence of 85 per 100,000 head of population in the at-risk age group. Subsequent graft failure is most commonly caused by recurrent trauma, followed by tunnel malpositioning, although the choice of graft type does not appear to affect outcome. The Danish ACL registry reported that ACL revisions accounted for 7.5% of all ACL reconstruction surgery performed between 2005 and 2008. Revision of ACL reconstruction is recognized to carry a worse outcome than primary reconstruction. Preoperative imaging has become a crucial part of surgical planning in these patients, with great reliance placed on computed tomography (CT). The radiologist should be able to recognize the types of primary repair and must be able to assess for the complications of primary surgery, such as tunnel malpositioning, tunnel widening, and fixation device failure. Revision is commonly a two-stage procedure with bone grafting of the tunnels prior to the definitive ligament repair. The radiologist should be able to asses for adequate bone graft incorporation. The purpose of this article is to present a review of the use of CT in the management of ACL revision surgery with examples of commonly used fixation devices; complications, such as tunnel widening and tunnel malpositioning; and bone graft incorporation.

Infant and young child feeding practices in Chepang communities.

BACKGROUND: Infant and young child feeding (IYCF) practices differ in communities due to difference in knowledge, culture, health service utilization, and other socio-economic factors. The objective of this study was to explore the knowledge and practices of Chepang mothers on ICYF and their correlates. METHODS: Cross sectional descriptive study was conducted in Chepang communities of Makawanpur district. Quantitative methodology was used in which 360 mothers of under children under two were randomly selected. Logistic regression analysis of selected child feeding indicators were done to find their association with socio-economic and health related factors. RESULTS: Feeding practices of mothers were found better than their knowledge level. About 35% had knowledge about early initiation of breastfeeding. Exclusive breastfeeding and introduction of complementary foods at the age of six months were 81% and 90% respectively. Literate mothers were found initiating breastfeeding early than the illiterate (OR=2.61, 95% CI, 1.59-4.27). Growth monitoring service utilization was found to have significant association with exclusive breastfeeding practices (OR= 2.75; 95% CI, 1.30-5.78). Feeding diverse complementary foods was associated with average monthly family income and duration of food sufficiency. CONCLUSIONS: Feeding practices in Chepang community were associated with health and socioeconomic determinants. Some of the feeding practices were found good however, meal frequency for the children 9-23 months of age and feeding diverse foods for children 6-23 months were found lower which needs to be improved through health education programs. Qualitative studies are needed to explore cultural factors.

Common reasons for hospitalization among adult patients with diabetes in a private medical college in Kathmandu.

Diabetes Mellitus is one of the important non communicable disease affecting the adult populations around the world. Incidence of diabetes increasing in South Asia. Nepal is also experiencing increasing in diabetes disease burden. Diabetes mellitus is one of the important causes of hospital admission in the western world. In this study we evaluated the causes of hospital admission amongst diabetic population. Most common cause is of diagnosis is some forms of infections commonest (20%) being urinary tract infections. Ten out of total 69 patients had septicemia. Six patients out of 69 had sputum positive pulmonary tuberculosis only one patient presented with metabolic complications of diabetes i.e. diabetic ketoacidosis. Coronary artery disease with heart failure was present in 14 patients. Five patients had diabetic nephropathy and 3 had retinopathy. This shows that infections is the major cause of hospital admission for diabetics followed by heart failure. Tuberculosis is important diagnosis in person with diabetes. This study shows more female patients get admitted and amongst admitted patents glycemic control is poor. This signify that women had more complications than male counter parts.

Study of patients with painless inguinal hernia in the quality of life.

Inguinal hernias are one of the commonest surgical problems in our set up. It is a protrusion of abdominal cavity contents through the inguinal canal. This is a retrospective study done in the Department of Surgery, Nepal Medical College Teaching Hospital (NMCTH) from January 2009 to December 2010. During this period, 120 patients with painless hernia were enrolled in the study. The age range was from 30 years to 76 years with mean age of presentation at 53 years. Out of 120 patients who underwent mesh repair only 74 patients (61.7%) had visible hernia on standing and 46 patients (38.3%) had palpable impulse on cough. 90 patients (75%) were males and indirect hernia (53.3%) was more common than direct hernia. Out of 120 cases, 30 cases underwent inguinal neurectomy which on follow up had no pain at all. In other 90 cases, neurectomy was not confirmed from the operative note. In these 90 cases, 12 patients had mild pain and 10 patients had moderate to severe pain on 6 months follow up. To conclude, surgical repair is recommended for painless inguinal hernia as most of the patients develop symptoms over time and to avoid undue complications.

Signet ring cell carcinoma of the gallbladder: a case report.

Carcinoma of the gall bladder is the most common biliary tract tumor with higher incidence in females and increasing age. The risk is significantly higher in cholelithiasis. Signet ring cell carcinoma is a rare form of mucinous adenocarcinoma and has a worse prognosis. Early diagnosis is rare. We report a case of signet ring cell carcinoma of the gall bladder in a 70 years old female patient. The gross finding was yellowish white mass measuring 4 x 3.5 cm on cut surface of the gall bladder along with thickened wall. Histopathological examination of the specimen shows the sheets of signet ring cells with lateral spread through the lamina propria and large amount of extracellular mucin. There was metastasis in the retroperitoneum and mesenteric lymph node. The tumor was stage IV (according to TNM staging). Patient died 20th post operative day. Since very few cases have been reported, information regarding the behavior and prognosis of gall bladder carcinoma is limited. However it has been seen that stage III and IV carcinoma usually have worse prognosis.

The clinical impact of integrated FDG PET-CT on management decisions in patients with lung cancer.

PURPOSE: To retrospectively evaluate the clinical impact of FDG PET-CT on the management pathway of patients with lung cancer. PATIENTS AND METHODS: One hundred and sixty-one patients with suspected lung cancer undergoing FDG PET-CT during the study period were analyzed. Before PET-CT, lung cancer MDT recorded scan indication, conventional clinical stage, and proposed treatment plan. The accuracy of integrated PET-CT compared with stand alone CT in preoperative staging of lung cancer was evaluated with pathological staging used as the reference standard. The effect of PET-CT on the subsequent management of patients was also evaluated. RESULTS: The agreement between CT and integrated PET-CT in preoperative staging of lung cancer was significant (p<0.001). In 16 (10%) patients PET-CT excluded tumour as there was no FDG uptake. PET-CT revealed occult metastasis in 25 (16%) patients. It was also a better overall predictor for T status (64% vs. 58%) and N status (78% vs. 65%). For N staging PET-CT was more accurate for N1 (82% vs. 72%) and N2 (85% vs. 80%) disease. Regression analyses suggested that PET-CT was a better predictor of overall TNM staging for lung cancer. FDG PET scanning changed or influenced management decisions in 66 (41%) patients with lung cancer. Changes in TNM staging following PET-CT were significant predictors (p=0.02) in making a decision to abandon thoracotomies. CONCLUSION: Addition of PET-CT to comprehensive evaluation of lung cancer can have significant clinical impact. There is marked improvement in staging the disease. Patients were frequently spared unnecessary treatment, and management was more appropriately targeted. PET permits reduction in the number of thoracotomies performed for non-resectable disease with predicted reduction in the morbidity rate and cost associated with unnecessary interventions.

Disoriented and ataxic pilgrims: an epidemiological study of acute mountain sickness and high-altitude cerebral edema at a sacred lake at 4300 m in the Nepal Himalayas.

OBJECTIVE: To determine the incidence of high-altitude cerebral edema (HACE), acute mountain sickness (AMS), and high-altitude pulmonary edema (HAPE) in pilgrims. Although it is well known that western trekkers suffer from acute mountain sickness (AMS) in the Himalayas, not much is documented about the incidence of AMS in the local population of Nepal that go to high altitude. METHODS: The design was a randomized study set at a sacred high-altitude lake at 4300 m at Gosainkund in the Nepal Himalayas. There was a control study at 1300 m at Pashupatinath in Kathmandu, Nepal. The subjects were pilgrims of different ethnic Nepali backgrounds. The Lake Louise consensus for AMS, HACE, and HAPE was used, and oxygen saturation with a pulse oximeter was performed on HACE subjects. RESULTS: Out of 5000 pilgrims, 228 were randomly chosen. Sixty-eight percent had AMS, 31% had HACE, and 5% had HAPE. The mean oxygen saturation of HACE subjects at that altitude was 77%, 87% being normal for 4300 m altitude. Seventy-three percent of the study population were men, yet women had a significantly higher rate of AMS (odds ratio, 4.34; 95% confidence interval, 1.83-10.68), HACE (odds ratio 3.15, confidence interval 1.62-6.12), and HAPE (odds ratio, 5.2; 95% confidence interval, 1.24-24.73). CONCLUSIONS: Such a high incidence of HACE in an epidemiological study using the Lake Louise criteria has, to our knowledge, not been reported before. High-altitude pilgrims, especially women pilgrims in this study, seem to be a very susceptible group. Preventive measures in these pilgrims need to be adopted to avoid AMS, specifically life-threatening HACE and HAPE.