Merkel cell carcinoma masquerading as cellulitis: a case report and review of the literature.

Merkel cell carcinoma (mcc) is an uncommon malignancy of the skin arising from cells located in the deeper layers of the epidermis called Merkel cells. This malignancy rarely presents as a metastatic disease, and the field is therefore deficient in regards to management. We report the case of a 49-year-old woman who presented with a presumptive diagnosis of osteomyelitis of the left fifth digit that was resistant to treatment with antibiotics; she underwent debridement of the digit that revealed mcc and was later to have metastatic disease to her lungs, liver, and musculoskeletal system. The management of mcc, although simple in the early stage of the disease, can become challenging when it is more advanced. Multiple new modalities for its treatment have emerged over the last few years, and more recently, clinical trials are being conducted for the use of immunotherapy agents in the treatment of this malignancy.

Macroinfauna responses and recovery trajectories after an oil spill differ from those following saltmarsh restoration.

Given the severity of injuries to biota in coastal wetlands from the Deepwater Horizon oil spill (DWH) and the resulting availability of funding for restoration, information on impacted salt marshes and biotic development of restored marshes may both help inform marsh restoration planning in the near term and for future spills. Accordingly, we performed a meta-analysis to model a restoration trajectory of total macroinfauna density in constructed marshes (studied for ~30 y), and with a previously published restoration trajectory for amphipods, we compared these to recovery curves for total macroinfauna and amphipods from DWH impacted marshes (over 8.5 y). Total macroinfauna and amphipod densities in constructed marshes did not consistently reach equivalency with reference sites before 20 y, yet in heavily oiled marshes recovery occurred by 4.5 y post spill (although it is unlikely that macroinfaunal community composition fully recovered). These differences were probably due to initial conditions (e.g., higher initial levels of belowground organic matter in oiled marshes) that were more conducive to recovery as compared to constructed marshes. Furthermore, we found that amphipod trajectories were distinctly different in constructed and oiled marshes as densities at oiled sites exceeded that of reference sites by as much as 20x during much of the recovery period. Amphipods may have responded to the rapid increase and high biomass of benthic microalgae following the spill. These results indicate that biotic responses after an oil spill may be quantitatively different than those following restoration, even for heavily oiled marshes that were initially denuded of vegetation. Our dual trajectories for oil spill recovery and restoration development for macroinfauna should help guide restoration planning and assessment following the DWH as well as for restoration scaling for future spills.

Hypertension in Delhi: prevalence, awareness, treatment and control.

Two cross-sectional, population-based studies were conducted to assess the prevalence, awareness, treatment and control of hypertension, among people aged 20-59 years and those over 60 years in Delhi. Study 1 (20-59 years): in total,1213 subjects from 120 clusters spread across Delhi were studied. The prevalence of hypertension was 27.5%. Of the hypertensives, 53.3% were aware of their diagnosis; 42.8% were taking treatment and only 10.5% had controlled blood pressure. About 9.0% of the hypertensives had coexisting diabetes mellitus and 8.4% were suffering from coronary disease. The prevalence of hypertension was significantly higher in urban areas, but there was no significant difference in levels of awareness, treatment and control between urban and slum areas. The prevalence of hypertension was comparable in both sexes. Women, however, were more likely to be aware of their condition. Study 2 (> or =60 years): in total,1105 subjects from 110 clusters were studied. Prevalence of hypertension was 63.8%. Isolated systolic hypertension (ISH) was found in 15.3% of the subjects. About 54% of the hypertensives were aware of their diagnosis; 43.4% were taking treatment and only 8.5% had controlled blood pressure. Prevalence of hypertension and ISH were comparable among sexes. Women were more aware and better treated. About 21.3% hypertensives had coexisting diabetes mellitus, and 14.3% were suffering from coronary disease. There was no significant difference between sexes. Urban and slum areas were also found to be comparable. Over 3% of the elderly were controlling their raised blood pressure by non-pharmacological measures. They belonged to the 'aware' category yet could not be labelled as 'hypertensives', highlighting an operational fault in the Joint National Committee definition.

Evaluation of dose calculation accuracy of various algorithms in lung equivalent inhomogeneity: Comparison of calculated data with Gafchromic film measured results.

AIM: To evaluate dose calculation accuracy of various algorithms in lung equivalent inhomogeneity comprising tumor within it and comparison with Gafchromic film data. MATERIALS AND METHODS: Gafchromic film measured central axis absorbed dose in lung insert (-700 Hounsfield unit [HU]), in racemosa wood cylindrical inhomogeneity (-725 HU) and at three surfaces of tumor (-20 HU) created in cylindrical inhomogeneity, put in the cavity of computerized imaging reference systems (CIRS) thorax phantom were compared with convolution (CON), superposition (SP), fast SP (FSP), and X-ray voxel Monte Carlo (XVMC) algorithms calculated dose using 6 MV beams of field size 2 cm × 2 cm, 3 cm × 3 cm, 4 cm × 4 cm, 5 cm × 5 cm, and 8 cm × 8 cm. RESULTS: XVMC was in good agreement with film measured results for all selected field sizes except 3 cm × 3 cm. SP under estimated by 5.7% at the center of the lung insert while deviation up to 6% was found at the cent of wood inhomogeneity in 2 cm × 2 cm. Except CON, increase in dose from proximal to the central surface of the tumor and then dose falloff from central to the distal surface for field size 2 cm × 2 cm to 4 cm × 4 cm was recorded. The change in film measured percentage depth dose from 2 cm × 2 cm to 3 cm × 3 cm field sizes was found -8% however for consecutive field size(s) larger than 3 cm × 3 cm this difference was less. CON and FSP produced overestimated results. CONCLUSION: Out of four algorithms, XVMC found consistent with measured data. The electronic disequilibrium within and at the interface of inhomogeneity make the accurate dose predictions difficult. These limitations results in deviations from the expected results of the treatments.

Late chemo-intensification with cisplatin and 5-fluorouracil as an adjunct to radiotherapy: a pragmatic approach for locally advanced head and neck squamous cell carcinoma.

The aim of this study was to define the feasibility of a late chemo-intensification treatment regimen with conventionally fractionated radiotherapy (70 Gy/7 weeks). Seventy four patients with Stage III and IV biopsy proven squamous cell carcinoma of oropharynx, hypopharynx and larynx were treated with this regimen. Chemotherapy consisted of continuous infusion of 5-FU at 350 mg/m(2)/day and cisplatin as 1h infusion at 10 mg/m(2)/day on days 1-5 of week 6 and 7 of radiotherapy. Grade III mucositis was present in 48 (64.9%) patients. After surgical salvage 59 (79.7%) patients had overall complete response. Locoregional control rate at 3 year was 80.8%. Three year locoregional relapse free survival (LRFS), overall survival (OS) and disease free survival (DFS) was 63.1%, 66.7% and 44.4%, respectively. The late chemo-intensification regimen was feasible in terms of response rate, toxicity and survival functions.

EGFR and HER-2/neu Expression in Gallbladder Carcinoma: An Institutional Experience.

BACKGROUND: Gallbladder cancer (GBC) is the most common malignancy of the biliary tract in India. Despite the recent advancement in the understanding of the cancer biology, the disease still remains a therapeutic challenge with poor prognosis and low survival. Surgery is the primary modality of treatment and rest of the modalities are basically adjuvant in nature. This study was performed to evaluate the epidermal growth factor receptor (EGFR) and human epidermal growth factor receptor-2 HER-2/neu) expression in GBC. METHODS: The present study was prospective and done in tertiary super-specialty institute of northern India. This was a pilot study, and at the time of completion, 29 samples were found suitable which were later submitted for EGFR and HER-2/neu evaluation. The sample includes both cases of GBC (n=18) and cholecystitis (n=11) as control. (Table 1) After performing necessary processing, slides were incubated with primary antibody (EGFR) ready to use (RTU) BioGenex, India and HER-2/neu dilution 1:600, Dakopatts (Denmark). Then slides were incubated with secondary antibody (Real Envision Detection Kit, Dakopatts, Denmark). Finally in mounted slides, cell membrane staining was used to assess positivity for EGFR and HER-2/neu. RESULTS: EGFR was positive in 21/29 (72.41%) overall, out of which 14/18 (77.78%) positive in cases and 7/11 (63.64%) positive in control. (Table 1, 3)(Figure 2). For HER-2/neu, it was positive in 21/29 (72.41%) overall, just like in EGFR mentioned above, but positive 12/18 (66.67%) in cases and 9/11 (81.82%) in control respectively. CONCLUSION: Despite the efforts by many investigators, GBC continues to represent a major challenge in oncology. Surgical resection remains the only curative treatment for this disease. The roles of radiation, chemoradiation, and chemotherapy in neoadjuvant and adjuvant settings remained to be defined in prospective studies. With further studies based on molecular understanding and developing new targeted therapies, we will be in better position to manage GBC and increase the survival rate.

Performance Evaluation of Algorithms in Lung IMRT: A comparison of Monte Carlo, Pencil Beam, Superposition, Fast Superposition and Convolution Algorithms.

BACKGROUND: Inclusion of inhomogeneity corrections in intensity modulated small fields always makes conformal irradiation of lung tumor very complicated in accurate dose delivery. OBJECTIVE: In the present study, the performance of five algorithms via Monte Carlo, Pencil Beam, Convolution, Fast Superposition and Superposition were evaluated in lung cancer Intensity Modulated Radiotherapy planning. MATERIALS AND METHODS: Treatment plans for ten lung cancer patients previously planned on Monte Carlo algorithm were re-planned using same treatment planning indices (gantry angel, rank, power etc.) in other four algorithms. RESULTS: The values of radiotherapy planning parameters such as Mean dose, volume of 95% isodose line, Conformity Index, Homogeneity Index for target, Maximum dose, Mean dose; %Volume receiving 20Gy or more by contralateral lung; % volume receiving 30 Gy or more; % volume receiving 25 Gy or more, Mean dose received by heart; %volume receiving 35Gy or more; %volume receiving 50Gy or more, Mean dose to Easophagous; % Volume receiving 45Gy or more, Maximum dose received by Spinal cord and Total monitor unit, Volume of 50 % isodose lines were recorded for all ten patients. Performance of different algorithms was also evaluated statistically. CONCLUSION: MC and PB algorithms found better as for tumor coverage, dose distribution homogeneity in Planning Target Volume and minimal dose to organ at risks are concerned. Superposition algorithms found to be better than convolution and fast superposition. In the case of tumors located centrally, it is recommended to use Monte Carlo algorithms for the optimal use of radiotherapy.

How useful is immunofluorescence in tropical renal pathology?

A study of 841 renal biopsies from a south Indian hospital showed that immunofluorescence significantly helped in making a diagnosis in 74 cases. This contribution was most useful in biopsies from patients with nephritic or haematuric presentations; in those whose biopsies showed mesangial proliferative, focal proliferative, or crescentic glomerulonephritis; and in biopsies without changes detectable by light microscopy from patients with systemic lupus erythematosus.

Effect of alcohol on serum lipids & lipoproteins in male drinkers.

The evaluation of the effect of moderate and high doses of ethanol on the serum levels of triglyceride (TG), total cholesterol (TC), cholesterol content of very low density lipoprotein (VLDL), low density lipoprotein (LDL), high density lipoprotein (HDL), HDL2, HDL3 subfractions and apoproteins: apo-AI and apo-B was undertaken in 45 (25 controls, 10 moderate and 10 high dose drinkers) healthy males. The results of this preliminary study showed a significant rise in total HDL-cholesterol and apo-AI levels of alcoholics of both the groups. Out of the two subfractions, HDL2 appeared to be induced more. Increased levels of atherogenic lipids (TG, VLDL-chol., LDL-chol. and apo-B) were found in high as well as moderate drinkers. Our results suggest that the benefit of alcohol intake need to be weighed carefully against its considerable risks.

Association of primary intracranial meningioma and cutaneous meningioma of external auditory canal: a case report and review of the literature.

A cutaneous meningioma of the external auditory canal occurred in a 48-year-old Filipino woman who had undergone subtotal resection of a dural-based intracranial meningioma at the ipsilateral cerebellopontine angle 36 months previously. Radiologic findings demonstrated a recurrence of intracranial meningioma with surface erosion and heterogeneous densities of the mastoid bone, without extension to the area of the external auditory canal. Meningioma in the external ear canal is extremely rare. To our knowledge, there have been only two previously reported cases, both without intracranial lesion. In this case, the auditory canal lesion may represent either an ectopic meningioma arising from an arachnoid cell rest or an occult direct extension from intracranial menigioma.

Fine needle aspiration of poorly differentiated rhabdomyosarcoma presenting with quadriparesis. A case report.

BACKGROUND: The diagnosis of metastatic poorly differentiated rhabdomyosarcoma (RMS) in lymph node specimens by fine needle aspiration presents a difficult problem since it is virtually indistinguishable from other small round cell neoplasms. CASE: Fine needle aspiration was performed under radiologic guidance on an extradural, space-occupying lesion of unknown etiology in the region of the C-6 and C-7 vertebrae in a 20-year-old male who was hospitalized with quadriparesis. Cytologic examination suggested a metastatic tumor consistent with the diagnosis of rhabdomyosarcoma. A subsequent search for the primary tumor site revealed a soft tissue swelling in the right calf muscle. Light microscopic, ultrastructural and immunocytochemical examination of multiple Tru-cut biopsy specimens from the swelling in the right calf muscle confirmed the diagnosis of poorly differentiated embryonal rhabdomyosarcoma. CONCLUSION: Immunostaining is useful for muscle proteins in the detection of poorly differentiated forms of embryonal rhabdomyosarcoma. Electron microscopy is of limited use in such cases.

Gastric lesser curve superficial seromyotomy: an experimental study in dogs.

Lesser curve superficial myotomy has been investigated in the dog. The anatomical basis for the operation is discussed. The operation has the advantage of being easily performed and the risk of damage to the nerve of Latarjet or ischemic necrosis of the lesser curvature is obviated. Acid studies in the dogs confirmed that the operation was capable of producing secretory inhibition in keeping with vagotomy of the parietal cell area. The experiment needs further investigation in animals and in man, for assessment of the potential of the operation to replace other forms of vagotomy in patients with duodenal ulcer.

A rational classification of angiofibromas of the post nasal space.

Angiofibromas of the post nasal space have the potential to extend in all directions along predetermined pathways with a definite mode and chronological pattern. In order to understand their clinical behaviour, methods of treatment and prognosis, a system of clinical staging based on conventional and tomographic observations has been found useful in this series of cases. The classification has been evolved according to the extent of the tumour involvement but also the age of onset, duration, size and area of encroachment including the surgical approach and consequent prognosis. Deficiencies in the earlier classifications are discussed.

Angiofibromas of the postnasal space: a critical appraisal of various therapeutic modalities.

Angiofibromas of the postnasal space are an enigma to the treating surgeon in view of their extensions around the skull base. The availability of modern investigative procedures has to some extent facilitated the decision making process in choosing a suitable surgical approach. Proper tumour staging and the earliest and widest possible exposure tailored to the needs of the specific situation together with adequate blood replacement is the key to success in minimizing the chances of the recurrence. The present study aims at an evaluation of the methodology adopted in 100 serial cases of angiofibromas of the postnasal space. After initial surgery, a further 31 procedures were needed for the management of recurrences.

Continuous hyperfractionated accelerated radiotherapy in advanced head and neck malignancies.

58 patients of advanced head and neck cancer were treated by continuous hyperfractionated accelerated radiotherapy (study group) or conventional radiotherapy (control group). The study group of 29 patients had 26/29 (89%) of patients of stage T3 and T4 with 12/29 (41% 0) > N2 disease. The schedule employed was 1.5 Gy 3 times a day in 36 fractions on 12 treatment days without stopping for weekends. The spinal dose has been kept at 40.5 Gy and interfraction interval has been strictly kept at 6 hrs. Clinical, as well as radiological assessment has been encouraging with 23/29 (79.13%) of patients achieving complete regression of the primary tumor and nodal disease. Compared to the conventionally treated controls this value has been significant (P value < 0.001). In stage III disease tumor control has been in 9/10 (90%) cases, while in stage IV disease in 14/19 (73.68%) cases. The acute mucosal reactions have been found to be severe in these cases with 18/29 i.e. 62.06% suffering from grade III reactions. Nasogastric feeding was required in 25.92% of patients.

Japanese B encephalitis with neurocysticercosis.

A case of Japanese encephalitis (JE) with multiple calcified lesions suggestive of calcified neurocysticercosis on CT scan of the head is reported. The presence of nonenhancing calcified lesions and rising antibody titres for JE differentiated it from acute encephalitis neurocysticercosis. Post mortem studies indicate that neurocysticercosis predisposes to fatal JE infection. The present report is of an association of the two diseases which did not result in a fatal outcome.

Computed tomography of brain in symptomatic birth asphyxia.

Twenty five asphyxiated newborns (seventeen term and eight preterm) with mean gestational age of 37 weeks (range 28-48 weeks) and mean birth weight of 2.4 kg (range 0.75 kg to 3.5 kg), respectively, constituted the cases in present study. Normal CT scan was found in five term (29.4%) and two preterm babies (25%). CT abnormalities noted in term babies included hemorrhage (subarachnoid 5.8%, intracerebral 11.6%), hypodensity (mild 23.2%, moderate 11.6% severe 5.8%); hypodensity with hemorrhage 5.8% and cerebral atrophy 5.8%. In the preterm babies abnormalities included intraventricular hemorrhage in 25%, isolated hypodensity in 37.5% and hypodensity with hemorrhage in 12.5% cases. Where as mild hypodensity on CT scan in the absence of hemorrhage or other gross abnormality was indicative of a favourable outcome, moderate to severe hypodensity was indicative of ischemic brain injury and an unfavourable outcome. The presence of intraventricular hemorrhage irrespective of the size of bleed was associated with mortality in all in the present study.

Effect of Prunus amygdalus seeds on lipid profile.

The effect of Prunus amygdalus, which is rich in unsaturated fat, fibre diet and low cholesterol was studied in 36 normolipidemic male albino rabbits for 60 days. Three different doses i.e. whole seeds defatted and oil showed a decrease in serum total cholesterol, triglyceride, LDL cholesterol, VLDL cholesterol and an increase in phospholipid, faecal sterol and HDL cholesterol. The maximum effects where shown by whole seeds followed by oil and defatted.

Changes in the blood lipid profile after administration of Ocimum sanctum (Tulsi) leaves in the normal albino rabbits.

Administration of fresh leaves of Ocimum sanctum (Tulsi) mixed as 1 g and 2 g in 100 gms of diet given for four weeks, brought about significant changes in the lipid profile of normal albino rabbits. This resulted in significant lowering in serum total cholesterol, triglyceride, phospholipid and LDL-cholesterol levels and significant increase in the HDL-cholesterol and total faecal sterol contents.