Atypical theileriosis with cutaneous involvement in a cow in India: a case report.

Bovine tropical theileriosis caused by Theileria annulata is an overwhelming haemoprotozoan tick-borne disease in taurine and cross-bred cattle in Punjab, India. However, there seems to be no report from India of cutaneous nodules associated with the disease. This report describes a five-year-old cross-bred cow presented to a university clinic with a history of fever, inappetence and malaise for the past six to seven days. Clinical examination revealed normal vital parameters, pale mucous membranes, mild enlargement of the prescapular lymph nodes and multiple subcutaneous nodular masses (2-4 cm) on the neck and abdomen. Haematology revealed mild anaemia and leucopenia with 48% neutrophils, 48% lymphocytes and 4% eosinophils. Romanowsky-stained smears of fineneedle aspiration biopsy samples from swollen lymph nodes and subcutaneous masses showed an increased number of lymphoid cells, suggesting cutaneous lymphomatosis. However, a critical examination of the smears from subcutaneous nodules showed a large number of Koch's blue bodies in macrophages and lymphoblasts, and several piroplasms were also noticed within the red blood cells in lymph node smears. A peripheral blood smear revealed mild to moderate parasitaemia. Extracted DNA from the parasitologically positive blood sample was subjected to nested polymerase chain reaction (nPCR) using T. annulata speciesspecific primers encoding the 30-kiloDalton major sporozoite surface antigen. The desired 572-base pair amplified product of the nPCR was comparable to the positive control. This seems to be a rare case of T. annulata in an adult cross-bred cow, showing cutaneous nodular involvement.

La theilériose bovine tropicale est une maladie causée par le protozoaire Theileria annulata et transmise par les tiques, affectant massivement les populations de bovins et de bovidés métis au Pendjab (Inde). Il semble toutefois que la présence de nodules cutanés associés à la maladie n'y ait jamais été rapportée jusqu'à présent. Les auteurs décrivent le cas soumis à une clinique vétérinaire universitaire d'une vache métisse âgée de cinq ans qui présentait depuis six à sept jours un tableau fébrile accompagné d'une perte d'appétit et d'un affaiblissement général. À l'examen clinique, les paramètres vitaux étaient normaux mais une pâleur des membranes muqueuses a été observée, ainsi qu'un gonflement modéré des ganglions lymphatiques préscapulaires et de nombreuses masses nodulaires sous-cutanées (de 2 à 4 cm d'épaisseur) au niveau du cou et de l'abdomen. L'hématologie a mis en évidence une anémie modérée et une leucopénie, les leucocytes se répartissant en 48 % de neutrophiles, 48 % de lymphocytes et 4 % d'éosinophiles. Les frottis à coloration de Romanowsky d'une biopsie par aspiration à l'aiguille fine des ganglions lymphatiques enflés et des masses sous-cutanées ont fait apparaître une augmentation du nombre de cellules lymphatiques évocatrice d'une lymphomatose cutanée. Néanmoins, un examen critique des prélèvements de nodules sous-cutanés a permis de constater la présence d'un grand nombre de corps bleus de Koch dans les macrophages et les lymphoblastes ; en outre, de nombreux piroplasmes ont été trouvés dans les globules rouges des frottis de ganglions lymphatiques. Un frottis de sang périphérique a permis de quantifier la parasitémie comme étant de niveau faible à modéré. L'ADN extrait de l'échantillon de sang à parasitologie positive a été soumis à une amplification en chaîne par polymérase nichée (nPCR) utilisant des amorces spécifiques de T. annulata codant pour l'antigène majeur de surface (30 kDa) du sporozoïte. Le produit amplifié par nPCR de la séquence souhaitée de 572 paires de bases était similaire à celui de l'échantillon de contrôle positif. Il s'agit probablement d'un cas rare d'infection à T. annulata chez une vache adulte métisse présentant des manifestations nodulaires cutanées.

La teileriosis tropical bovina causada por Theileria annulata es una devastadora enfermedad hemoprotozoaria transmitida por garrapatas que afecta al ganado taurino e híbrido del Punjab (India). Ahora bien, en la India no parece haber ningún caso descrito de esta enfermedad que se acompañe de la presencia de nódulos cutáneos. Los autores describen el caso de una vaca de cinco años híbrida que fue presentado a una clínica universitaria con un cuadro de fiebre, pérdida de apetito y decaimiento en los seis a siete días anteriores. El examen clínico puso de manifiesto parámetros vitales normales, mucosas pálidas, leve hipertrofia de los ganglios linfáticos prescapulares y múltiples bultos subcutáneos de tipo nodular (2 a 4 cm) en cuello y abdomen. El análisis hematológico reveló una leve anemia y leucocitopenia, con un 48% de neutrófilos, un 48% de linfocitos y un 4% de eosinófilos. Tras proceder a una biopsia de ganglios inflamados y bultos subcutáneos por aspiración con aguja fina, el examen de frotis de estas muestras con tinción de Romanowsky reveló un número excesivo de células linfáticas, lo que parece apuntar a una linfomatosis cutánea. No obstante, al examinar más a fondo los frotis de nódulos subcutáneos se observó que macrófagos y linfoblastos albergaban un gran número de cuerpos azules de Koch. También se observaron varios piroplasmas dentro de los eritrocitos presentes en los frotis de ganglios linfáticos. Un frotis de sangre periférica reveló una parasitemia entre leve y moderada. El ADN extraído de esta muestra de sangre positiva fue sometido a una técnica de reacción en cadena de la polimerasa (PCR) anidada en la que se emplearon cebadores específicos de la especie T. annulata que codifican el antígeno de superficie principal de 30 kDa del esporozoíto. La deseada secuencia de 572 pares de bases amplificada por PCR resultó comparable con la correspondiente secuencia de la muestra positiva de control. Parece tratarse pues de un caso raro de infestación por T. annulata de una vaca adulta híbrida que se acompaña de nódulos cutáneos.

Circulating T-helper 17 cells and associated cytokines in psoriasis.

BACKGROUND: Recently, a new population of IL-17-producing CD4 T helper (Th) cells, named Th17, was identified and shown to be involved in various inflammatory and autoimmune diseases, including psoriasis. AIM: To determine the frequency of Th17 cells and related cytokines in peripheral blood of patients with psoriasis, and to analyse their association with disease severity. METHODS: This was a prospective study comprising 34 patients with psoriasis and 24 healthy controls. Clinicoepidemiological details of patients were recorded, and severity of psoriasis was assessed by means of the Psoriasis Area and Severity Index. Circulating Th1 and Th17 cells in untreated patients with psoriasis and healthy controls were quantified by flow cytometry. In sera collected from patients with psoriasis and healthy controls, concentrations of IL-17A and IL-23 were examined by ELISA. RESULTS: Increased frequencies of CD4+ IL-17A+ T cells were seen in peripheral blood of patients with psoriasis vulgaris (P < 0.001). Although serum IL-17A and IL-23 concentrations were higher in patients with psoriasis than in controls, the results did not reach statistical significance. We could not find any correlation between the studied T cells or related cytokines and the disease severity. CONCLUSION: Increased serum levels of circulating Th17 cells and related cytokines may contribute to the cutaneous pathology of psoriasis, as well as the inflammatory process that is a hallmark of psoriasis.

Interpretation of Spirometry: Selection of Predicted Values and Defining Abnormality.

Spirometry is the most frequently performed investigation to evaluate pulmonary function. It provides clinically useful information on the mechanical properties of the lung and the thoracic cage and aids in taking management-related decisions in a wide spectrum of diseases and disorders. Few measurements in medicine are so dependent on factors related to equipment, operator and the patient. Good spirometry requires quality assured measurements and a systematic approach to interpretation. Standard guidelines on the technical aspects of equipment and their calibration as well as the test procedure have been developed and revised from time-to-time. Strict compliance with standardisation guidelines ensures quality control. Interpretation of spirometry data is based only on two basic measurements--the forced vital capacity (FVC) and the forced expiratory volume in 1 second (FEV1) and their ratio, FEV1/FVC. A meaningful and clinically useful interpretation of the measured data requires a systematic approach and consideration of several important issues. Central to interpretation is the understanding of the development and application of prediction equations. Selection of prediction equations that are appropriate for the ethnic origin of the patient is vital to avoid erroneous interpretation. Defining abnormal values is a debatable but critical aspect of spirometry. A statistically valid definition of the lower limits of normal has been advocated as the better method over the more commonly used approach of defining abnormality as a fixed percentage of the predicted value. Spirometry rarely provides a specific diagnosis. Examination of the flow-volume curve and the measured data provides information to define patterns of ventilatory impairment. Spirometry must be interpreted in conjunction with clinical information including results of other investigations.

Guidelines for Diagnosis and Management of Bronchial Asthma: Joint Recommendations of National College of Chest Physicians (India) and Indian Chest Society.

Bronchial asthma is an important public health problem in India with significant morbidity. Several international guidelines for diagnosis and management of asthma are available, however there is a need for country-specific guidelines due to vast differences in availability and affordability of health-care facilities across the globe. The Indian Chest Society (ICS) and the National College of Chest Physicians (NCCP) of India have collaborated to develop evidence-based guidelines with an aim to assist physicians at all levels of health-care in diagnosis and management of asthma in a scientific manner. Besides a systematic review of the literature, Indian studies were specifically analysed to arrive at simple and practical recommendations. The evidence is presented under these five headings: (1) definitions, epidemiology and impact, (2) diagnosis, (3) pharmacologic management of stable disease, (4) management of acute exacerbations, and (5) non-pharmacologic management and special situations. The modified grade system was used for classifying the quality of evidence as 1, 2, 3, or usual practice point (UPP). The strength of recommendation was graded as A or B depending upon the level of evidence.

Prediction equations for spirometry in adults from northern India.

BACKGROUND: Most of the Indian studies on prediction equations for spirometry in adults are several decades old and may have lost their utility as these were carried out with equipment and standardisation protocols that have since changed. Their validity is further questionable as the lung health of the population is likely to have changed over time. OBJECTIVE: To develop prediction equations for spirometry in adults of north Indian origin using the 2005 American Thoracic Society/European Respiratory Society (ATS/ERS) recommendations on standardisation. METHODS: Normal healthy non-smoker subjects, both males and females, aged 18 years and above underwent spirometry using a non-heated Fleisch Pneumotach spirometer calibrated daily. The dataset was randomly divided into training (70%) and test (30%) sets and the former was used to develop the equations. These were validated on the test data set. Prediction equations were developed separately for males and females for forced vital capacity (FVC), forced expiratory volume in first second (FEV1), FEV1/FVC ratio, and instantaneous expiratory flow rates using multiple linear regression procedure with different transformations of dependent and/or independent variables to achieve the best-fitting models for the data. The equations were compared with the previous ones developed in the same population in the 1960s. RESULTS: In all, 685 (489 males, 196 females) subjects performed spirometry that was technically acceptable and repeatable. All the spirometry parameters were significantly higher among males except the FEV1/FVC ratio that was significantly higher in females. Overall, age had a negative relationship with the spirometry parameters while height was positively correlated with each, except for the FEV1/FVC ratio that was related only to age. Weight was included in the models for FVC, forced expiratory flow (FEF75) and FEV1/FVC ratio in males, but its contribution was very small. Standard errors of estimate were provided to enable calculation of the lower limits of normal and standardised residuals for these parameters. The equations were found to be valid on the test dataset, and therefore, may be extended to general population. Comparison with the 1960s equations revealed lack of good agreement, and substantially higher predicted FVC with the current equations, especially in the forty-years-plus age group, in both males and females. Even in the age group upto 40 years, the level of agreement was clinically not acceptable. CONCLUSIONS: Validated prediction equations have been developed for spirometry variables in adults of north Indian origin using the current ATS/ERS spirometry standardisation recommendations. The equations suggest an improvement in the lung health of the population over time in the middle-aged and the elderly. These equations should address a long-felt unmet need and enable a more appropriate evaluation of spirometry data in different chest diseases in Indian subjects.

Trends of vulvar cancer.

Vulvar cancer is an uncommon malignancy of the female genital tract in developing countries, accounting for 3% of gynaecological cancers. Here, cervical cancer is an everyday problem; ovarian cancer is the second commonest gynaecological cancer; endometrial is less common and vulvar cancer is rare. It is advanced at admission, though is a visible cancer. Records of women who had histopathologically proven vulvar cancer over 24 years were analysed for epidemiological status and preventive possibilities. During the analysis period, 9,419 total cancer cases were diagnosed; 4,726 (50.17%) were in women. A total of 39.52% (1,868 of 4,726) were gynaecological; 18 cases were vulvar (0.38% of the 4,726 women with cancer) and 0.96% of the 1,868 gynaecological cancer cases. Decreasing trends were 2.25% between 1984 and 1988, down to 0.33% between 2004 and 2008. Leading presenting complaints were: dyspareunia, 88.88% (16 of 18 patients); pruritus 13; ulcers 14; vulvar swelling 12 and urinary problems 13. Dystrophy was present in 8 of 18 cases. Overall, four had stage I, one stage II, three stage III and four stage IV disease at admission; all at labia majora or minora, some too advanced to know origin. Four women with metastasis in the lungs, liver and bones could only be given palliation. While vulvar cancer is uncommon, advanced disease at admission is a concern. Awareness is essential. Research is needed as to why cervical cancer is common and vulvar uncommon, as HPV plays a major aetiological role, so that cervical cancer can be prevented, with early diagnosis, management of vulvar cancer should also be available.

Awareness of eclampsia among rural tribal women of reproductive age.

BACKGROUND: Globally, eclampsia is the leading cause of maternal and neonatal morbidity and mortality. OBJECTIVE: The present community-based study was conducted among rural tribal women of reproductive age in remote villages of central India to determine their awareness of eclampsia and its likely impact. METHODS: This cross-sectional analytic study included randomly selected 4500 tribal women, between 15 and 45 years of age, residing in 140 villages in the proximity of one village with a health facility (study center), and who were willing to undergo a personal interview. In-depth face-to-face interviews (each lasting 15-30 min) of study subjects regarding awareness, knowledge, practices, and perceptions about eclampsia were conducted using a predesigned tool completed by research assistants (not the subjects). RESULTS: Of the 4500 women interviewed, the majority (62.4%) were 20-29 years old, minimally educated (40.6%), laborers (41.3%), and of a low socioeconomic class (40.8%). Of all the participants, only 35.9% were aware of eclampsia, associated events during pregnancy, labor, and the immediate post-delivery period; 81.7% of those who were aware understood about symptoms and signs like headache, blurring of vision, dizziness, swelling over the body, ad high blood pressure. Of all the women who knew about eclampsia, 73.9% were aware that the occurrence of convulsions during antenatal and postnatal periods was an emergency and required urgent management, whereas 88.4% were not aware that severe convulsions affected maternal and neonatal health seriously, only 38.2% knew that eclampsia was a preventable condition. CONCLUSION: There was lack of awareness about eclampsia in many women and, of those who knew, some were not aware that it was dangerous. There is a need for awareness among women and their families of the disorder, its impact, and what action is needed in case it occurs.

Memory binding in clinical and non-clinical psychotic experiences: how does the continuum model fare?

INTRODUCTION: Both clinical and non-clinical auditory hallucinations (AH) have been associated with source memory deficits, supporting a continuum of underlying cognitive mechanisms, though few studies have employed the same task in patient and nonpatient samples. Recent commentators have called for more debate on the continuum model of psychosis. Consequently, the current study investigated the continuity model of AH with reference to memory binding. METHODS: We used an identical voice and word recognition memory task to assess binding in two separate studies of: (1) healthy hallucination-prone individuals and controls (30 high and 30 low scorers on the Launay-Slade Hallucination Scale-Revised) and (2) schizophrenia patient samples (32 with AH, 32 without AH) and 32 healthy controls. RESULTS: There was no evidence of impaired binding in high hallucination-prone, compared to low hallucination-prone individuals. In contrast, individuals with schizophrenia (both with and without AH) had difficulties binding (remembering "who said what"), alongside difficulties remembering individual words and voices. Binding ability and memory for voices were also negatively linked to the loudness of hallucinated voices reported by patients with AH. CONCLUSIONS: These findings suggest that different mechanisms may exist in clinical and non-clinical hallucinators, adding to the growing debate on the continuum model of psychotic symptoms.

Evaluation of ultrasound airway assessment parameters in pregnant patients and their comparison with that of non-pregnant women: a prospective cohort study.

BACKGROUND: Clinical airway assessment parameters differ significantly between pregnant and non-pregnant patients, however literature comparing their ultrasound (US) airway parameters is limited. We planned a prospective cohort study to compare US-assessed airway parameters between pregnant and non-pregnant women. METHODS: We enrolled 82 pregnant females scheduled for elective cesarean section under neuraxial anesthesia and 80 age-matched non-pregnant females scheduled for elective surgery. Pre-operative clinical airway assessment was performed in both groups. The US airway assessment was done pre-operatively in non-pregnant and postoperatively in pregnant patients. Our primary objective was to compare US-assessed parameters, and secondary objectives included a comparison of clinical airway assessment parameters and investigating a relationship between a difficult airway (defined as a modified Mallampati grade (MMG) ≥ 3) and other airway assessment parameters. RESULTS: Among several US airway parameters, pregnant patients had significantly higher hyomental distance, anterior neck soft tissue thickness at the hyoid and vocal cord level, and oral cavity height, while the tongue thickness and mandibular condylar movements were significantly lower than in non-pregnant patients. Similarly, for the clinical airway assessment, pregnant patients had significantly higher MMG and upper lip bite test scores, mentohyoid distance, and neck circumference. Pregnancy, the ratio of pre-epiglottic space and epiglottis-to-vocal cords distance (Pre-E/E-VC), and hyoid bone visibility were independent predictors of a difficult airway. CONCLUSION: The US airway assessment parameters differ significantly between pregnant and non-pregnant patients. Pregnancy, hyoid bone visibility, and Pre-E/E-VC ratio were independent predictors of the difficult airway in female patients.

Loss of the Parkinson's disease-linked gene DJ-1 perturbs mitochondrial dynamics.

Growing evidence highlights a role for mitochondrial dysfunction and oxidative stress as underlying contributors to Parkinson's disease (PD) pathogenesis. DJ-1 (PARK7) is a recently identified recessive familial PD gene. Its loss leads to increased susceptibility of neurons to oxidative stress and death. However, its mechanism of action is not fully understood. Presently, we report that DJ-1 deficiency in cell lines, cultured neurons, mouse brain and lymphoblast cells derived from DJ-1 patients display aberrant mitochondrial morphology. We also show that these DJ-1-dependent mitochondrial defects contribute to oxidative stress-induced sensitivity to cell death since reversal of this fragmented mitochondrial phenotype abrogates neuronal cell death. Reactive oxygen species (ROS) appear to play a critical role in the observed defects, as ROS scavengers rescue the phenotype and mitochondria isolated from DJ-1 deficient animals produce more ROS compared with control. Importantly, the aberrant mitochondrial phenotype can be rescued by the expression of Pink1 and Parkin, two PD-linked genes involved in regulating mitochondrial dynamics and quality control. Finally, we show that DJ-1 deficiency leads to altered autophagy in murine and human cells. Our findings define a mechanism by which the DJ-1-dependent mitochondrial defects contribute to the increased sensitivity to oxidative stress-induced cell death that has been previously reported.

Quality of asthma management in an urban community in Delhi, India.

BACKGROUND & OBJECTIVES: High prevalence and poor control of asthma make its management a major public health issue worldwide, especially in developing countries. Optimum review of asthma management in the community is essential to improve asthma control. This study was conducted to investigate the quality of asthma management, knowledge about asthma and quality of life of asthma patients referred to a public tertiary care chest hospital in Delhi. METHODS: Diagnosis of asthma was confirmed by symptoms and reversible spirometry in 50 referred patients on their first visit. Patients were interviewed using three questionnaires on quality of asthma management before visiting referral hospital, asthma knowledge and asthma quality of life (AQLQ). Correlation amongst quality of treatment, asthma quality of life, and asthma knowledge was also determined. RESULTS: Findings revealed that only 60 per cent of patients were informed about their disease, and 10 per cent had undergone lung function tests previously. Only 44 per cent of patients were prescribed inhalers. None were provided with any educational material. Patients had poor knowledge of aetiology, pathophysiology, medication and how to assess the severity of their asthma. The mean scores in AQLQ indicated a moderate degree of impairment in quality of life. INTERPRETATIONS & CONCLUSIONS: This study provides evidence of unsatisfactory asthma management and patient-doctor interaction as patients had limited knowledge of asthma disease, its management and had poor quality of life as measured by a standardized questionnaire. Thus, there is need to implement suitable interventions to improve asthma management according to standard treatment guidelines in the community.

Regression equations for spirometry in children aged 6 to 17 years in Delhi region.

BACKGROUND: Most of the studies carried out in India to develop regression equations for spirometry in children are now several years-to-decades old and had used equipment and measurement protocols that have since changed. Prediction equations using the current standardisation protocols for spirometry are not available. The lung health of the population may have changed too. OBJECTIVE: To develop regression equations for spirometry for children aged 6 to 17 years of north Indian origin in Delhi region. METHODS: School children of north Indian origin, as determined by mother tongue and parentage, aged 6 to 17 years were screened by a health questionnaire and physical examination and those found "normal" underwent spirometry according to the standardised procedure recommended by the American Thoracic Society/European Respiratory Society (ATS/ERS) task force in 2005. Pearson's correlation analysis was carried out to identify the predictor variables for spirometric parameters. Prediction equations were developed using the multiple linear regression procedure. The independent variables were entered in sequence of height, age and weight. R2, adjusted R2 and R2 change, standard errors of the estimate (SEE), and estimates of regression coefficients were obtained and the goodness of fit was examined. RESULTS: Data was obtained in 365 boys and 305 girls. Forced vital capacity (FVC), forced expiratory volume in one second (FEV1) peak expiratory flow rate (PEFR), forced expiratory flow rate at 50% and 75% exhalation of vial capacity (F50 and F75) and mean forced expiratory flow rate over the middle 50% of the vital capacity (F25-75) showed moderate to strong correlations with age, height and weight in both boys and girls. In both genders, the equations explained very high variability of FVC, FEV1 and PEFR as shown by the R2 values. The explained variability for flow rates was lesser, with that for F75 being the least. CONCLUSIONS: Regression equations for spirometry variables for children of north Indian origin in Delhi region have been developed. These represent the first such effort from India after the publication of the ATS/ERS task force 2005 guidelines on standardisation of spirometry.

Combined pulmonary fibrosis and emphysema in a welder.

Combined pulmonary fibrosis and emphysema (CPFE) syndrome is an uncommon entity characterised by emphysema of the upper lobes and diffuse fibrosis of the lower lobes and carries a bad prognosis with the onset of pulmonary hypertension. Lung involvement due to exposures suffered by welders is generally considered benign though, rarely, a diffuse interstitial fibrotic disease has been reported. CPFE syndrome has however never been reported in welders. A 65-year-old man, welder by occupation and an ex-smoker, presented with progressive exertional dyspnoea associated with dry cough noticed for the last four months. On examination, there was mild tachypnea, clubbing and bilateral basal velcro crepitations on chest auscultation. Lung function test revealed mild mixed ventilatory impairment with severe diffusion defect. HRCT chest showed bilateral upper lobe emphysema and diffuse interstitial fibrosis in the lower lobes. Transbronchial lung biopsy revealed interstitial fibrosis, chronic inflammation and iron deposits. A diagnosis of combined pulmonary fibrosis with emphysema (CPFE) with interstitial pulmonary siderofibrosis (IPS) was established. A review of literature did not show any other report of a similar nature.

Late postpartum eclampsia.

Studies lack data regarding incidence, risk factors, optimal treatment and outcome of postpartum eclampsia (PPE), convulsions within 7 days (mostly convulsions occur within 24 - 48 h) after delivery of fetus placenta. However, convulsions can occur late, up to 4 weeks. After 48 h, it is late PPE. Late postpartum eclampsia without preceding pre-eclampsia is rare and poses a diagnostic challenge. An observational study was carried out to find the frequency of PPE, late PPE and clinical profile for prediction/prevention of mortality. PPE cases were analysed from retrospective records and prospective cases. Of 39,050 births, 386 were eclampsia (0.98%); PPE 101 (26.1% eclampsia, 0.26% births); 14.85% were late PPE. Of PPE, 52 (51.48%) were diagnosed hypertensive disorders pre-delivery and 49 (48.51%) were de novo. Prior to convulsions, 56 (55.5%) had headaches, six (5.9%) visual disturbances; nine (8.9) dizziness; four (4.0%) epigastric pain; 18 (17.8%) had no complaints. Research needs to continue and quality care is essential.

Persistence of perinatal mortality due to congenital malformations in resource-poor settings.

Every year, half a million babies are born with malformations, one-third of these life-threatening. The present study aims at analysing trends of perinatal mortality (PM) due to major congenital malformations (MCM) at a rural institute, for preventive possibilities. Records of all perinatal deaths due to MCM over 24 years were analysed. Perinatal deaths (PD) due to MCM were 346; overall 8.3% of PD (287 (82.94%) stillbirths; 59 (17.06%) neonatal deaths). There was a decreasing trend of contribution of MCM to PM: 9.52% in Block A to 6.95% in Block H; 26.87% of PD were due to nervous system anomalies: 3.76% in Block A to 2.02% in Block H. PM due to congenital heart disease increased from 0.87% in Block A to 6.94% in Block H. It is essential that a system exists to diagnose MCM at a gestation when abortion is possible. Research for prevention of anomalies needs to be continued.

Bilateral superficial ulnar artery with high origin from the axillary artery: its anatomy and clinical significance.

The superficial ulnar artery (SUA) is a rare anatomical variant that usually arises either in the axilla or the arm and runs a superficial course in the forearm, enters the hand, and participates in the formation of superficial palmar arch. During the routine dissection of cadavers in the department of anatomy, whilst preparing the specimen for medical students, an unusual bilateral branch of the axillary artery was found in one of the cadavers: a rare variant of the artery known as SUA, which originates from the 2nd part of the axillary arteries of both sides. The SUA is a known anatomical variant, but the bilateral high origin from the 2nd part of the axillary artery is extremely unusual. Its occurrence is of great clinical importance to the surgical and radiological departments.

Generalized schemes for high-throughput manipulation of the Desulfovibrio vulgaris genome.

The ability to conduct advanced functional genomic studies of the thousands of sequenced bacteria has been hampered by the lack of available tools for making high-throughput chromosomal manipulations in a systematic manner that can be applied across diverse species. In this work, we highlight the use of synthetic biological tools to assemble custom suicide vectors with reusable and interchangeable DNA "parts" to facilitate chromosomal modification at designated loci. These constructs enable an array of downstream applications, including gene replacement and the creation of gene fusions with affinity purification or localization tags. We employed this approach to engineer chromosomal modifications in a bacterium that has previously proven difficult to manipulate genetically, Desulfovibrio vulgaris Hildenborough, to generate a library of over 700 strains. Furthermore, we demonstrate how these modifications can be used for examining metabolic pathways, protein-protein interactions, and protein localization. The ubiquity of suicide constructs in gene replacement throughout biology suggests that this approach can be applied to engineer a broad range of species for a diverse array of systems biological applications and is amenable to high-throughput implementation.

Unusual presentation of intussusception: Gallstone ileus.

Gallstone ileus is a rare pathology, occurring in an estimated 0.5% of cases, which preferentially affect females and the elderly population. This rare pathology is the result of a fistulous connection between the bowel and gallbladder. This connection allows gallstones to pass into the bowel leading to mechanical obstruction. On rare occasions the enteric gallstone can act as a lead point causing intussusception. We present a rare case of intussusception secondary to gallstone ileus in a young, relatively asymptomatic patient. CT played a critical role in diagnosis and appropriate management of our patient.

Genome-wide transposon mutagenesis identifies a role for host neuroendocrine stress hormones in regulating the expression of virulence genes in Salmonella.

Bacterial sensing of environmental signals plays a key role in regulating virulence and mediating bacterium-host interactions. The sensing of the neuroendocrine stress hormones epinephrine (adrenaline) and norepinephrine (noradrenaline) plays an important role in modulating bacterial virulence. We used MudJ transposon mutagenesis to globally screen for genes regulated by neuroendocrine stress hormones in Salmonella enterica serovar Typhimurium. We identified eight hormone-regulated genes, including yhaK, iroC, nrdF, accC, yedP, STM3081, and the virulence-related genes virK and mig14. The mammalian alpha-adrenergic receptor antagonist phentolamine reversed the hormone-mediated effects on yhaK, virK, and mig14 but did not affect the other genes. The beta-adrenergic receptor antagonist propranolol had no activity in these assays. The virK and mig14 genes are involved in antimicrobial peptide resistance, and phenotypic screens revealed that exposure to neuroendocrine hormones increased the sensitivity of S. Typhimurium to the antimicrobial peptide LL-37. A virK mutant and a virK mig14 double mutant also displayed increased sensitivity to LL-37. In contrast to enterohemorrhagic Escherichia coli (EHEC), we have found no role for the two-component systems QseBC and QseEF in the adrenergic regulation of any of the identified genes. Furthermore, hormone-regulated gene expression could not be blocked by the QseC inhibitor LED209, suggesting that sensing of hormones is mediated through alternative signaling pathways in S. Typhimurium. This study has identified a role for host-derived neuroendocrine stress hormones in downregulating S. Typhimurium virulence gene expression to the benefit of the host, thus providing further insights into the field of host-pathogen communication.

Subcutaneous phaeohyphomycotic cyst caused by Pyrenochaeta romeroi.

Pyrenochaeta romeroi is a rare agent of chronic, suppurative subcutaneous infections which ultimately lead to mycetoma. It has only rarely been reported from deep, non-mycetomatous infections. We describe a case of a subcutaneous phaeohyphomycotic cyst in a 45-year-old Indian female who suffered from verrucous plaque and a swelling (30 mm in diameter) on the right forearm that gradually increased in size over a period of 3 months. Direct microscopic examination with 10% KOH and histopathological investigation of exudates revealed septate hyphae without granules, the hallmark of mycetoma. The lesion appeared to be a subcutaneous phaeohyphomycotic cyst caused by P. romeroi. The suspected agent was recovered in culture, identified on the basis of morphologic features and its identification confirmed by sequencing of the internal transcribed spacer regions of rDNA. Treatment consisted of surgical excising of the cyst without any antifungal therapy. There was no relapse during a one-year follow-up and the patient was successfully cured. In vitro antifungal susceptibility tests demonstrated that itraconazole (0.5 microg/ml), isavuconazole (0.125 microg/ml) and posaconazole (0.5 microg/ml) had potent activity against this isolate of P. romeroi. High MICs were found with amphotericin B (4 microg/ml), fluconazole (>64 microg/ ml), voriconazole (4 microg/ml) and caspofungin (8 microg/ml). However, their clinical effectiveness in the treatment of P. romeroi infections remains to be evaluated.