Application of 7T MRS to High-Grade Gliomas.

MRS, including single-voxel spectroscopy and MR spectroscopic imaging, captures metabolites in high-grade gliomas. Emerging evidence indicates that 7T MRS may be more sensitive to aberrant metabolic activity than lower-field strength MRS. However, the literature on the use of 7T MRS to visualize high-grade gliomas has not been summarized. We aimed to identify metabolic information provided by 7T MRS, optimal spectroscopic sequences, and areas for improvement in and new applications for 7T MRS. Literature was found on PubMed using "high-grade glioma," "malignant glioma," "glioblastoma," "anaplastic astrocytoma," "7T," "MR spectroscopy," and "MR spectroscopic imaging." 7T MRS offers higher SNR, modestly improved spatial resolution, and better resolution of overlapping resonances. 7T MRS also yields reduced Cramér-Rao lower bound values. These features help to quantify D-2-hydroxyglutarate in isocitrate dehydrogenase 1 and 2 gliomas and to isolate variable glutamate, increased glutamine, and increased glycine with higher sensitivity and specificity. 7T MRS may better characterize tumor infiltration and treatment effect in high-grade gliomas, though further study is necessary. 7T MRS will benefit from increased sample size; reductions in field inhomogeneity, specific absorption rate, and acquisition time; and advanced editing techniques. These findings suggest that 7T MRS may advance understanding of high-grade glioma metabolism, with reduced Cramér-Rao lower bound values and better measurement of smaller metabolite signals. Nevertheless, 7T is not widely used clinically, and technical improvements are necessary. 7T MRS isolates metabolites that may be valuable therapeutic targets in high-grade gliomas, potentially resulting in wider ranging neuro-oncologic applications.

Exostosis of Rib: Case Report of an Extremely Rare Giant Osteochondroma at an Unusual Site, Radiopathological Correlation with Brief Review of Literature.

Osteochondromas are common benign tumors developing as an abnormal bony growth in the metaphyseal region. Being more of a developmental anomaly rather than a true neoplasm, they are usually found around the growth plates of long bones such as the knee, hip, and shoulder. These are typically managed conservatively if they are asymptomatic; however, they require excision in symptomatic patients. A 38-year-old woman presented with a huge swelling causing disfigurement measuring 16 × 16 cm on the left side of chest wall. Radiographs and computed tomography scan showed a bony outgrowth at costochondral junction of second rib which was in continuity with the periosteum. Excision via mediastinal sternotomy and left thoracotomy was done. Histopathological features corroborated with the radiological diagnosis of osteochondroma. Osteochondroma should be considered in the differential diagnosis of chest wall tumors. Rib is an extremely rare site of presentation. The cartilaginous cap becomes fully ossified and is lost in longstanding lesions. Huge tumors at such a location can cause irritation of adjacent viscera which can lead to pleural effusion or hemothorax; therefore, a cautious and logical approach to diagnosis is warranted for appropriate therapeutic management.

A Study to Evaluate the Role of Intradermal and Intralesional Measles, Mumps, Rubella (MMR) Vaccine in Treatment of Common Warts.

BACKGROUND: Warts are common cutaneous viral infection with a wide range of therapeutic modalities. Various agents have been tried for immunotherapy in warts. OBJECTIVES: Determine the role of intralesional and intradermal measles, mumps, rubella (MMR) vaccine in the treatment of common warts; to compare the efficacy of intralesional versus intradermal MMR vaccine. METHODS AND MATERIALS: Patients diagnosed with verruca vulgaris were divided into two groups. In study group A, the individuals were injected with an intralesional MMR vaccine of 0.3 mL in the representative wart (largest) once in 3 weeks till there is complete clearance or maximum of four injections whichever is earlier, while in study group B, the individuals were injected with an intradermal MMR vaccine of 0.3 mL over the unilateral deltoid muscle area at similar intervals. RESULTS: There were 33 patients in each group. In group A, 10 (30.3%) patients showed complete, 9 (27.3%) marked, 6 (18.2%) moderate, 3 (9.1%) mild, and 5 (15.2%) no response. In group B, seven (21.2%) patients showed complete, one (3.0%) marked, one (3.0%) moderate, four (12.1%) mild, and 20 (60.6%) no response. There were minimal side effects in the form of pain, erythema, itching at the injection site in a few patients, only one patient had syncope. CONCLUSION: We conclude that the MMR vaccine is an effective and safe modality of treatment for verruca vulgaris without any serious adverse effects. Also, the intralesional route showed better results in comparison to the intradermal route when we consider the treatment of a representative wart.

Antimicrobial susceptibility patterns of organisms causing secondary abdominal infections in patients with perforated abdominal viscus.

BACKGROUND: Secondary peritonitis, following intestinal perforation, constitutes a significant proportion of cases admitted as a surgical emergency and has a mortality rate of 6-21% worldwide. As a part of an antimicrobial stewardship program, we noted considerable variation among the choice of empirical regimens among such cases. Hence, we conducted a prospective study to generate the evidence for a rational empiric regimen for patients with secondary peritonitis following intestinal perforation. METHODS: The study included a complete follow up of 77 cases of secondary peritonitis admitted during a 12 month period. The intraoperative fluid (peritoneal) sample of the patient was sent for culture and sensitivity pattern analysis. RESULTS: The sites of perforation as seen in decreasing order were lower gastrointestinal (GI) (50.6%), upper GI (36.4%), and unclassified (13%). The most common organism found in the intraoperative fluid was Escherichia coli (47.9%) followed by Klebsiella pneumoniae (12.5%). amikacin, cefoperazone-sulbactam, piperacillin-tazobactam and imipenem were sensitive in 22 (out of 23 tested), 5 (out of 9), 13 (out of 13) and 22 (out of 22) isolates of E. coli and 3 (out of 6), 1 (out of 3), 4 (out of 6), 4 (out of 6) isolates of K. pneumoniae, respectively. The most common empirical antibiotic was cefoperazone-sulbactam (38.7%) followed by piperacillin-tazobactam (29.3%). CONCLUSION: Based on our prospective study, piperacillin-tazobactam or imipenem should be used empirically in patients presenting with complicated intra-abdominal infections secondary to perforated viscus, especially if they have sepsis or septic shock.

Structural MRI at 7T reveals amygdala nuclei and hippocampal subfield volumetric association with Major Depressive Disorder symptom severity.

Subcortical volumetric changes in major depressive disorder (MDD) have been purported to underlie depressive symptomology, however, the evidence to date remains inconsistent. Here, we investigated limbic volumes in MDD, utilizing high-resolution structural images to allow segmentation of the hippocampus and amygdala into their constituent substructures. Twenty-four MDD patients and twenty matched controls underwent structural MRI at 7T field strength. All participants completed the Montgomery-Asberg Depression Rating Scale (MADRS) to quantify depressive symptomology. For the MDD group, volumes of the amygdala right lateral nucleus (p = 0.05, r2 = 0.24), left cortical nucleus (p = 0.032, r2 = 0.35), left accessory basal nucleus (p = 0.04, r2 = 0.28) and bilateral corticoamygdaloid transition area (right hemisphere p = 0.032, r2 = 0.38, left hemisphere p = 0.032, r2 = 0.35) each displayed significant negative associations with MDD severity. The bilateral centrocortical (right hemisphere p = 0.032, r2 = 0.31, left hemisphere p = 0.032, r2 = 0.32) and right basolateral complexes (p = 0.05, r2 = 0.24) also displayed significant negative relationships with depressive symptoms. Using high-field strength MRI, we report the novel finding that MDD severity is consistently negatively associated with amygdala nuclei, linking volumetric reductions with worsening depressive symptoms.

Association and expression of the antigen-processing gene PSMB8, coding for low-molecular-mass protease 7, with vitiligo in North India: case-control study.

BACKGROUND: Vitiligo is a multifactorial, autoimmune, depigmenting disorder of the skin where aberrant presentation of autoantigens may have a role. OBJECTIVES: To study the association of two antigen-processing genes, PSMB8 and PSMB9, with vitiligo. METHODS: In total 1320 cases of vitiligo (1050 generalized and 270 localized) and 752 healthy controls were studied for the PSMB9 exon 3 G/A single-nucleotide polymorphism (SNP), PSMB8 exon 2 C/A SNP and PSMB8 intron 6 G/T SNP at site 37 360 using polymerase chain reaction (PCR)-restriction fragment length polymorphism. Real-time PCR was used for transcriptional expression of PSMB8 and cytokines. Expression of ubiquitinated proteins and phosphorylated-p38 (P-p38) was studied by Western blotting. RESULTS: Significant increases in PSMB8 exon 2 allele A (P < 2.07 × 10-6 , odds ratio 1·93) and genotypes AA (P < 1.03 × 10-6 , odds ratio 2·51) and AC (P < 1.29 × 10-6 , odds ratio 1·63) were observed in patients with vitiligo. Interferon-γ stimulation induced lower expression of PSMB8 in peripheral blood mononuclear cells of cases compared with controls, suggesting impaired antigen processing, which was confirmed by accumulation of ubiquitinated proteins in both lesional and nonlesional skin of patients with vitiligo. Expression of proinflammatory cytokines - interleukin (IL)-6, IL-1ß and IL-8 - was higher in the lesional skin. P-p38 expression was variable but correlated with the amount of ubiquitinated proteins in the lesional and nonlesional skin, suggesting that the inflammatory cytokine responses in lesional skin could be a result of both P-p38-dependent and -independent pathways. CONCLUSIONS: The PSMB8 exon 2 SNP is significantly associated with vitiligo. Accumulation of ubiquitinated proteins in skin of cases of vitiligo suggests their aberrant processing, which may promote the development of the disease.

Dynamic Contrast-Enhanced MRI-Derived Intracellular Water Lifetime (τ i ): A Prognostic Marker for Patients with Head and Neck Squamous Cell Carcinomas.

BACKGROUND AND PURPOSE: Shutter-speed model analysis of dynamic contrast-enhanced MR imaging allows estimation of mean intracellular water molecule lifetime (a measure of cellular energy metabolism) and volume transfer constant (a measure of hemodynamics). The purpose of this study was to investigate the prognostic utility of pretreatment mean intracellular water molecule lifetime and volume transfer constant in predicting overall survival in patients with squamous cell carcinomas of the head and neck and to stratify p16-positive patients based upon survival outcome. MATERIALS AND METHODS: A cohort of 60 patients underwent dynamic contrast-enhanced MR imaging before treatment. Median, mean intracellular water molecule lifetime and volume transfer constant values from metastatic nodes were computed from each patient. Kaplan-Meier analyses were performed to associate mean intracellular water molecule lifetime and volume transfer constant and their combination with overall survival for the first 2 years, 5 years, and beyond (median duration, >7 years). RESULTS: By the last date of observation, 18 patients had died, and median follow-up for surviving patients (n = 42) was 8.32 years. Patients with high mean intracellular water molecule lifetime (4 deaths) had significantly (P = .01) prolonged overall survival by 5 years compared with those with low mean intracellular water molecule lifetime (13 deaths). Similarly, patients with high mean intracellular water molecule lifetime (4 deaths) had significantly (P = .006) longer overall survival at long-term duration than those with low mean intracellular water molecule lifetime (14 deaths). However, volume transfer constant was a significant predictor for only the 5-year follow-up period. There was some evidence (P < .10) to suggest that mean intracellular water molecule lifetime and volume transfer constant were associated with overall survival for the first 2 years. Patients with high mean intracellular water molecule lifetime and high volume transfer constant were associated with significantly (P < .01) longer overall survival compared with other groups for all follow-up periods. In addition, p16-positive patients with high mean intracellular water molecule lifetime and high volume transfer constant demonstrated a trend toward the longest overall survival. CONCLUSIONS: A combined analysis of mean intracellular water molecule lifetime and volume transfer constant provided the best model to predict overall survival in patients with squamous cell carcinomas of the head and neck.

Nasopharyngeal teratoma, congenital diaphragmatic hernia and Dandy-Walker malformation - a yet uncharacterized syndrome.

An association of congenital diaphragmatic hernia, dandy walker malformation and nasopharyngeal teratoma is very rare. Here, we report a fourth case with this association where chromosomal microarray and whole exome sequencing (WES) was performed to understand the underlying genetic basis. Findings of few variants especially a novel variation in HIRA provided some insights. An association of congenital diaphragmatic hernia, dandy walker malformation and nasopharyngeal teratoma is very rare. Here, we report a fourth case with this association where chromosomal microarray and whole exome sequencing (WES) was performed to understand the underlying genetic basis. Findings of few variants especially a novel variation in HIRA provided some insights.

Anagen effluvium secondary to Gloriosa superba ingestion.

Anagen effluvium, the shedding of anagen hair, leads to diffuse non-scarring alopecia. We report two cases of anagen effluvium in the same family secondary to the ingestion of tubers of Gloriosa superba, which contains the antimitotic alkaloid colchicine. Both patients developed anagen effluvium and gastroenteritis 1-2 weeks after consuming the tubers. In addition, one of them had bicytopenia, pleural effusion, hematuria and altered liver function tests. Both were managed conservatively and counseled regarding the reversible nature of the hair loss. Follow-up at 3 months showed regrowth of hair in both the cases.

Necrotizing Soft Tissue Infection Caused by Spilled Gallstones.

We report a case of a 57-year-old woman who presented with a necrotizing soft tissue infection of the right anterior abdominal wall, 1 year after open cholecystectomy for gallbladder perforation. Surgical exploration revealed pigmented gallstones along with pus in the abdominal wall and gallbladder fossa. Intraoperative spillage of gallstones is common during both open and laparoscopic cholecystectomy, but, in rare cases, can lead to serious complications including necrotizing infection of the abdominal wall.

FLT PET/CT Is Better Than FDG PET/CT in Differentiating Benign From Malignant Pancreatobiliary Lesions.

PURPOSE: F-fluorothymidine (FLT), unlike FDG, is incorporated exclusively into DNA and is considered a specific marker of cell proliferation. The role of FLT PET/CT scan in differentiating benign from malignant pancreatobiliary tumors is unknown. PATIENTS AND METHODS: Twenty-five suspected pancreatobiliary tumors on contrast-enhanced CT (CECT) scan in 23 patients were evaluated by FDG PET/CT and FLT PET/CT scans. The histopathology or fine-needle aspiration cytology was considered as criterion standard for the diagnosis. Surgeons were blinded to FLT PET/CT results. Management decision was guided by clinical and CECT scan and FDG PET/CT. RESULTS: Five of 23 patients had metastatic disease on CECT imaging. The remaining 18 underwent exploratory laparotomy. Two of them had synchronous lesions. Histopathology/fine-needle aspiration cytology confirmed malignancy in 17 lesions and benign disease in the remaining 8 lesions. All 8 benign lesions were negative on FLT PET/CT. Seven of the 8 benign lesions were clinically diagnosed as malignancy on CECT and FDG PET/CT. The specificity, positive predictive value, and accuracy were higher for FLT PET/CT (100%, 100%, and 92%) compared with CECT (12.5%, 70.83%, and 72%) and FDG PET/CT (12.50%, 69.57%, and 68%). However, the sensitivity of FLT PET/CT (88.24%) was similar to CECT (100%) and FDG PET/CT (94.12%). CONCLUSIONS: Molecular-based FLT PET/CT is a better imaging than FDG PET/CT in differentiating benign from malignant lesions in the pancreatobiliary region. It has a potential to bring down the incidence of preventable radical resection in suspected pancreatobiliary tumors.

Spontaneous closure of stoma.

Intestinal loop stoma is a common surgical procedure performed for various benign and malignant abdominal problems, but it rarely undergoes spontaneous closure, without surgical intervention. Two male patients presented to our emergency surgical department with acute abdominal pain. One of them was diagnosed as having rectosigmoid perforation and underwent diversion sigmoid loop colostomy after primary closure of the perforation. The other was a known case of carcinoma of the rectum who had already undergone low anterior resection with covering loop ileostomy; the patient underwent second loop ileostomy, this time for complicated intestinal obstruction. To our surprise, both the loop colostomy and ileostomy closed spontaneously at 8 weeks and 6 weeks, respectively, without any consequences. Spontaneous stoma closure is a rare and interesting event. The exact etiology for spontaneous closure remains unknown, but it may be hypothesized to result from slow retraction of the stoma, added to the concept of a tendency towards spontaneous closure of enterocutaneous fistula.

Sexual practices, myths and misconceptions among long distance truck drivers in North India.

BACKGROUND: Long distance truck drivers and helpers constitute a high risk group for human immunodeficiency virus /acquired immune deficiency syndrome (HIV/AIDS). Despite increasing awareness of HIV/AIDS and safe sex practices, they still have a high incidence of new cases of HIV. AIMS: This study carried out at an ART (anti-retroviral treatment) centre in North India aimed to evaluate the sexual myths and misconceptions prevalent among long distance drivers and helpers. DESIGN: This was a retrospective study carried out at apex ART centre. METHODS: Data were collected retrospectively from ART records of 129 long distance Truck drivers and 68 helpers. Details of socio-demographic characteristics, contact with commercial sex workers (CSW'S), pattern of condom usage with CSW'S and factors influencing it were studied. RESULTS: We found that a significant number of drivers and helpers had sexual contact with CSW's and out of these, 30% of drivers and 50% of helpers reported not using condoms and instead resorting to methods like washing genitalia after sex with battery water/urine to avoid getting HIV. There was no significant relationship between pattern of condom usage and educational status, marital status and age. We also found that certain myths like sex with young CSW's was less likely to cause sexually transmitted diseases (STD's) and HIV were also widespread. CONCLUSION: Owing to continuing prevalence of such sexual myths, long distance truck drivers and helpers do not use condoms while having sex with CSW's as they feel that they can enjoy sex with CSW's and still stay protected against STD's/HIV. It is imperative that this battery water/urine antiseptic myth be specifically targeted for better HIV control in this high risk group.

Thrombocytosis and Raised CRP Levels Predicts Advanced Stage in Esophageal Carcinoma.

PURPOSE: The significance of thrombocytosis and raised C-reactive protein (CRP) as prognostic markers in esophageal cancer is unclear. METHODS: We prospectively studied 50 consecutive patients with esophageal cancer and analyzed the relation of preoperative platelet count and CRP levels with the clinico-pathological characteristics and stage of the disease. The platelet count of 319 × 10(9)/L for thrombocytosis and CRP level >6 mg/dl were taken as cut-off values. RESULTS: The incidence of thrombocytosis as well as raised CRP level was 50 %. Eighty percent of patients with thrombocytosis had raised CRP levels. None of patients with early disease (stage I) had thrombocytosis while patients with advanced stage were associated with thrombocytosis, 81.81 % in stage III and 100 % in stage IV (p < 0.001). The incidence of elevated CRP levels has shown progressive linear co-relation with the stage of carcinoma, i.e., 0 % in pathological stage I, 16.67 % in stage II, 45.45 % in stage III, and 100 % in stage IV disease (p = 0.011). Patients with thrombocytosis and patients with raised CRP were associated with pathological nodal metastases in 84.61 % cases (p 0.005) and 61.53 % (p 0.030), respectively. CONCLUSION: Thrombocytosis alone or in combination with raised CRP had progressive linear relation with the stage of esophageal carcinoma.

Chylothorax after esophagectomy for esophageal cancer: risk factors and management.

BACKGROUND: Chylothorax is an uncommon complication of esophagectomy. It carries significant morbidity and mortality. The predisposing factors are ill-defined. METHODS: We retrospectively evaluated the data of 45 patients of carcinoma esophagus who underwent esophagectomy after neoadjuvant chemoradiotherapy (NACRT) from January 2010 to July 2012 in our tertiary health care center. RESULTS: Four patients (8.88 %) had chylothorax. On analysis of perioperative factors, it was found that patients with chylothorax had tumor in middle third of thoracic esophagus (100 %), shown partial response to neoadjuvant chemoradiation (NACRT) (100 %) and were associated with difficult mediastinal dissection (75 %) leading to higher blood loss requiring transfusion unlike those without chylothorax. There was no significant difference in the incidence of chylothorax following transhiatal, 3/35 = 8.57 % or transthoracic esophagectomy 1/10 = 10 % (p = 0.898). Three patients were managed by transabdominal en masse ligation of tissue between aorta and azygos vein while one patient was managed conservatively. Patients were discharged after a mean hospital stay of 15.5 days. The 30-day mortality rates in the two groups were similar (0 % vs. 4.8 %). CONCLUSION: Difficult mediastinal dissection during esophagectomy in middle esophageal cancer may lead to thoracic duct injury. Complete response to NACRT may reduce the risk of chylothorax. Early transabdominal en masse ligation carries excellent results. Low output fistula following thoracic duct injury can be managed conservatively.

Facial lupus vulgaris of bilateral periorbital skin and conjunctiva: a case report and brief review.

A 22-year-old male presented to the Dermatology Department with bilateral plaque lesions distributed symmetrically over malar area, bridge of nose and upper eyelids progressing over 1 year 3 months. Lesion remained unhealed after antibiotic treatment. Microscopy and culture for fungal and mycobacterial infections were negative. The Mantoux test showed an exaggerated response and PCR was positive for Mycobacterium tuberculosis complex. Patient was treated successfully with anti-tubercular therapy.