Antagonizing pathways leading to differential dynamics in colon carcinogenesis in Shugoshin1 (Sgo1)-haploinsufficient chromosome instability model.

Colon cancer is the second most lethal cancer. It is predicted to claim 50,310 lives in 2014. Chromosome Instability (CIN) is observed in 80-90% of colon cancers, and is thought to contribute to colon cancer progression and recurrence. However, there are no animal models of CIN that have been validated for studies of colon cancer development or drug testing. In this study, we sought to validate a mitotic error-induced CIN model mouse, the Shugoshin1 (Sgo1) haploinsufficient mouse, as a colon cancer study model. Wild-type and Sgo1(-/+) mice were treated with the colonic carcinogen, azoxymethane (AOM). We tracked colon tumor development 12, 24, and 36 wk after treatment to assess progression of colon tumorigenesis. Initially, more precancerous lesions, Aberrant Crypt Foci (ACF), developed in Sgo1(-/+) mice. However, the ACF did not develop straightforwardly into larger tumors. At the 36-wk endpoint, the number of gross tumors in Sgo1(-/+) mice was no different from that in wild-type controls. However, Copy Number Variation (CNV) analysis indicated that fully developed colon tumor in Sgo1(-/+) mice carried 13.75 times more CNV. Immunohistological analyses indicated that Sgo1(-/+) mice differentially expressed IL-6, Bcl2, and p16(INK4A) . We propose that formation of ACF in Sgo1(-/+) mice is facilitated by the IL6-STAT3-SOCS3 oncogenic pathway and by the Bcl2-anti-apoptotic pathway, yet further development of the ACF to tumors is inhibited by the p16(INK4A) tumor suppressor pathway. Manipulating these pathways would be beneficial for inhibiting development of colon cancer with CIN.

Tumor-promoting/progressing role of additional chromosome instability in hepatic carcinogenesis in Sgo1 (Shugoshin 1) haploinsufficient mice.

A major etiological risk factor for hepatocellular carcinoma (HCC) is infection by Hepatitis viruses, especially hepatitis B virus and hepatitis C virus. Hepatitis B virus and hepatitis C virus do not cause aggressive activation of an oncogenic pathway, but they transactivate a broad array of genes, cause chronic inflammation, and, through interference with mitotic processes, lead to mitotic error-induced chromosome instability (ME-CIN). However, how ME-CIN is involved in the development of HCC remains unclear. Delineating the effect of ME-CIN on HCC development should help in identifying measures to combat HCC. In this study, we used ME-CIN model mice haploinsufficient in Shugoshin 1 (Sgo1(-/+)) to assess the role of ME-CIN in HCC development. Treatment with the carcinogen azoxymethane caused Sgo1(-/+) ME-CIN model mice to develop HCCs within 6 months, whereas control mice developed no HCC (P < 0.003). The HCC development was associated with expression of early HCC markers (glutamine synthetase, glypican 3, heat shock protein 70, and the serum marker alpha fetoprotein), although without fibrosis. ME-CIN preceded the expression of HCC markers, suggesting that ME-CIN is an important early event in HCC development. In 12-month-old untreated Sgo1 mice, persistent DNA damage, altered gene expression, and spontaneous HCCs were observed. Sgo1 protein accumulated in response to DNA damage in vitro. Overall, Sgo1(-/+)-mediated ME-CIN strongly promoted/progressed development of HCC in the presence of an initiator carcinogen, and it had a mild initiator effect by itself. Use of the ME-CIN model mice should help in identifying drugs to counteract the effects of ME-CIN and should accelerate anti-HCC drug development.

A simple modification to fix the commissural pillar during right ventricular outflow tract reconstruction during the arterial switch operation.

A simplified technique to fix the commissural pillar of the pulmonary valve at the time of right ventricular outflow tract reconstruction during the arterial switch operation is presented.

Diabetes Mellitus as a Risk Factor for Tuberculosis: A Community Based Case Control Study.

Background: Prevention of diabetes in the general population can help reduce the incidence of tuberculosis. Hence it is necessary to document that diabetes is strongly associated with tuberculosis as a risk factor. Objective: To study if diabetes is associated with tuberculosis compared to controls. Materials and Methods: A community based case-control study was carried out. 215 newly diagnosed cases of tuberculosis on treatment for not more than three months were selected randomly from the randomly selected tuberculosis unit. 215 neighbourhood controls were selected. They were matched for the age group of ± 10 years and sex. Fasting blood sugar (FBS) was estimated using a glucometer. Results: Tobacco chewing, residence and family history of TB were significantly more in cases (P < 0.05). Mean BMI was significantly lower in cases compared to controls. The proportion of TB cases among the known cases of diabetes was 67% compared to 33% in controls, which was statistically significant. Mean FBS was significantly higher in cases compared to controls (P < 0.05). The odds of cases being diabetic was 2.456 times more than those of controls. On binary logistic regression, diabetes was an independent risk factor for tuberculosis. Other independent risk factors were tobacco chewing, and family history of TB. Conclusion: Family history of tuberculosis, and tobacco chewing were positively associated with tuberculosis whereas body mass index was negatively associated with tuberculosis. Diabetes was significantly associated with tuberculosis.

Effect of K-wire Reuse and Drill Mode on Heat Generation in Bone.

BACKGROUND: We examined the effect of Kirschner wire (K-wire) reuse and use of oscillating mode on heat generation within cortical bone. METHODS: Two trocar-tipped K-wires were drilled through the diaphysis of each of 30 human metacarpals and phalanges: one K-wire was inserted in rotary mode and another in oscillating mode. Each wire was reused once. Thermocouples placed within the dorsal and volar bone adjacent to the K-wire drill path measured temperatures throughout each test. RESULTS: Peak cortex temperatures were 25°C to 164°C. Rotary drilling achieves peak temperatures quicker (31 ± 78 seconds vs 44 ± 78 seconds, P = .19) than oscillating drilling, but insertion time is also less, resulting in lower overall heat exposure. This effect is also seen when the K-wire is reused (34 ± 70 seconds vs 41 ± 85 seconds, P = .4). The length of time that cortical bone was exposed to critical temperatures (47°C or more) was significantly higher when a wire was reused (36 ± 72 seconds vs 43 ± 82 seconds, P = .008). Peak temperatures greater than 70°C (a temperature associated with instantaneous cell death) were observed on many occasions. CONCLUSIONS: Overall heat exposure may be higher if a K-wire is reused or inserted in oscillating mode. In the absence of external cooling, K-wire insertion into cortical bone can easily expose bone to temperatures that exceed 70°C and may increase the risk of osteonecrosis.

Dysphagia Lusoria: A Rare Cause of Adult Dysphagia.

Dysphagia lusoria is an unusual condition characterized by difficulty swallowing secondary to compression of the esophagus by the aberrant right subclavian artery (ARSA). It occurs due to embryologic anomalies of the brachial arches, which are often unrecognized. Dysphagia is the prime presenting symptom in the majority, in addition to the other tracheoesophageal symptoms. Dysphagia lusoria can be diagnosed using barium swallow and chest computed tomography (CT) scan. We report a case of a young male who presented with complaints of dysphagia.

A rare case of superior vena cava syndrome in a patient on VV-ECMO.

Superior vena cava (SVC) syndrome is caused by either extrinsic compression of SVC or intrinsic lesions within SVC leading to obstruction of SVC and consequently swelling of the face, neck, and upper extremeities. Iatrogenic incidence is on the rise due to the use of long-term indwelling catheters. SVC syndrome in extracorporeal membrane oxygenation (ECMO) has been defined in neonatal and paediatric ECMO cases. Only one case of SVC syndrome in adult has been defined while using a double-lumen ECMO cannula. Our case describes a case of SVC syndrome in a case on veno-venous ECMO (VV-ECMO) with an internal jugular vein (IJV) return cannula which is unheard of. A high index of suspicion is required to diagnose SVC syndrome.

Outcomes of surgical versus transcatheter aortic valve replacement in nonagenarians- a systematic review and meta-analysis.

Introduction: Since the approval of transcatheter aortic valve replacement (TAVR), nonagenarian group patients are being increasingly considered for TAVR. Therefore, we compared the clinical outcomes of surgical aortic valve replacement (SAVR) vs TAVR in nonagenarians with severe aortic stenosis. Methods: A literature search was performed using MEDLINE, Embase, Web of Science, Cochrane, and Clinicaltrials.gov for studies reporting the comparative outcomes of TAVR versus SAVR in nonagenarians. The primary endpoint was short-term mortality. Secondary endpoints were post-operative incidences of stroke or transient ischemic attack (TIA), vascular complications, acute kidney injury (AKI), transfusion requirement, and length of hospital stay. Results: Four retrospective studies qualified for inclusion with a total of 8,389 patients (TAVR = 3,112, SAVR = 5,277). Short-term mortality was similar between the two groups [RR = 0.91 (95% CI: 0.76-1.10), p = 0.318]. The average length of hospital stay was shorter by 3 days in the TAVR group (p = 0.037). TAVR was associated with a significantly lower risk of AKI [RR = 0.72 (95% CI: 0.62-0.83), p < 0.001] and a lower risk of transfusion [RR = 0.71 (95% CI: 0.62-0.81), p < 0.001]. There was no difference in risk of stroke/TIA[RR = 1.01 (95% CI: 0.70-1.45), p = 0.957]. The risk of vascular complications was significantly higher in the TAVR group [RR = 3.39 (95% CI: 2.65-4.333), p < 0.001]. Conclusion: In this high-risk population, TAVR compared to SAVR has similar short-term mortality benefit but has lower risks of perioperative complications and a higher number of patients being discharged to home.

Resident surgical practice patterns for vitreoretinal surgery in ophthalmic training programs in the United States.

PURPOSE: To assess resident surgical experience in vitreoretinal surgery (VRS) in the United States. DESIGN: Anonymous electronic survey over 2 consecutive years. PARTICIPANTS: A total of 287 third-year ophthalmology residents from US residency programs were included. METHODS: To determine the type and amount of surgical experience in VRS. Residents were contacted via e-mail to complete the survey. A series of follow-up e-mails were sent to nonresponders. E-mail correspondence was sent to program directors of the US residency programs to encourage survey participation. An electronic survey instrument (Survey Monkey) was used to distribute the survey and collect the results. Participants were asked about vitrectomy and scleral buckle procedures as primary surgeon and about office procedures (e.g., intravitreal injections and retinal laser procedures). Questions regarding the self-described "comfort" level of the resident and the Accreditation Council for Graduate Medical Education (ACGME) vitreoretinal requirements for ophthalmology were also included. MAIN OUTCOME MEASURES: Vitreoretinal office and surgical procedures. RESULTS: Of the 114 ophthalmology residency programs in the United States, 3 programs declined to participate and 103 of 228 programs (114 programs per year) did not respond to requests during a 2-year period. Of the 287 total respondents, approximately 59.1% had performed vitrectomy and 40.8% had performed a scleral buckle as the primary surgeon. In the survey of office procedures, 96.7% had performed intravitreal injections, 94.8% had performed macular laser therapy, and 99.6% had performed panretinal photocoagulation. In the self-reported resident "comfort" level section, 59% were "fairly comfortable" knowing the theoretic steps for VRS and 55.4% were "fairly satisfied" with VRS training. However, 72% of respondents were unaware of the correct ACGME minimum operative numbers for VRS. CONCLUSIONS: This self-reported electronic survey of third-year residents suggested that VRS experience at ACGME-accredited programs as primary surgeon was suboptimal for surgeries. A modest majority of residents reported comfort and satisfaction with VRS training for surgery, but a majority was satisfied and had adequate experience with office procedures such as intravitreal injection and laser treatment. Unfortunately, the majority of residents were unaware of the actual numeric ACGME VRS requirements for ophthalmology residency programs.

Tumor-induced osteomalacia - Current imaging modalities and a systematic approach for tumor localization.

Paraneoplastic syndromes are symptom complexes that cannot be readily explained by local or distant spread of the tumor. They can occur due to hormone production, autoimmunity or other biologically active products produced by the tumor, etc. Tumor induced osteomalacia is a rare paraneoplastic syndrome in which the manifestation is mainly musculoskeletal such as bone pain, fractures and muscle weakness as a consequence of elaboration of fibroblast growth factor 23 (FGF23) by the tumor. Most of these tumors are solitary and small and hence localization of these tumors is often challenging. This review summarizes the various anatomic imaging modalities such as plain radiographs, computed tomography (CT), and magnetic resonance imaging (MRI) and nuclear medicine imaging techniques in the evaluation of these tumors.

Utility of (18) F-FDG PET/CT and CECT in conjunction with serum CA 19-9 for detecting recurrent pancreatic adenocarcinoma.

PURPOSE: The roles of different cross-sectional imaging in evaluating the recurrence of pancreatic adenocarcinoma are not well established. We evaluated the utility of 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) and contrast-enhanced computed tomography (CECT) in the diagnosis of recurrent pancreatic adenocarcinoma in conjunction with the tumor marker CA 19-9. METHODS: We retrospectively reviewed the records of patients who underwent CECT and FDG PET/CT along with serum CA 19-9 measurement as a follow-up or on a clinical suspicion of recurrent disease after initial surgery for pancreatic adenocarcinoma. Two observers blinded to the other imaging modality results retrospectively reviewed and interpreted the images in consensus using a three-point scale (negative, equivocal, or positive). Pathologic analysis by biopsy or further clinical and radiologic follow-up determined the true status of the suspected recurrences. The imaging results were compared with CA 19-9 levels and true disease status. RESULTS: Thirty-nine patients were included in the study. Thirty-three patients (85%) had proven recurrent cancer and six patients (15%) had no evidence of disease. Twenty-four patients had elevated CA 19-9 and 15 patients had normal CA 19-9. Sensitivity, specificity, and accuracy for recurrence were 90.9%, 100.0%, and 92.3% for PET/CT and 72.2%, 66.6%, and 71.7% for CECT, respectively. Sensitivity for locoregional recurrence was 94.4% for PET/CT but only 61.1% for CECT. PET/CT detected recurrence in 12 patients who had normal levels of CA 19-9. PET/CT showed lesions not visible on CECT in five (15%) patients. Although the sensitivity and specificity of PET/CT were higher than those of CECT, they were not statistically significant (p = 0.489 and p = 0.1489, respectively). CONCLUSION: FDG PET/CT has a high sensitivity for pancreatic cancer recurrence. Normal CA 19-9 does not necessarily exclude these recurrences. FDG PET/CT is useful when CECT is equivocal and can detect recurrence in patients with normal CA 19-9.

Gestational diabetes mellitus is associated with increased CD163 expression and iron storage in the placenta.

PROBLEM: GDM has been associated with disturbances in iron homeostasis and exaggerated immune activation. We sought to investigate the extent to which placental iron storage and macrophage accumulations were altered in GDM. METHOD OF STUDY: We conducted a retrospective, case-control study of archived placental tissues obtained from 22 pregnancies complicated by GDM and 22 unaffected controls. Controls were matched to cases based on maternal age, gestational age at birth, and method of delivery. Placental tissues were assessed for altered histology and CD68 and CD163 staining. Tissue iron was assessed using Prussian blue staining. RESULTS: Maternal hematocrit levels were higher in GDM participants compared to controls (P = 0.02). The presence of meconium-laden macrophages was significantly greater within the amnion of GDM cases (adjusted odds ratio (OR) 12.51). Although the total abundance of CD68-expressing macrophages was not significantly different between groups, we detected a significantly greater abundance of CD163 expression within the chorion and decidua of cases. The total area staining positive for iron was 24% (95% confidence intervals of 2%-46%) greater in GDM placentae versus controls. CONCLUSION: GDM is associated with altered placental histology and increases in meconium-laden macrophages. Greater iron stores within the placentae of women with GDM is consistent with reports that iron excess is associated with an increased risk for GDM. The higher level of expression of CD163 on macrophage-like cells of the chorion and decidua in GDM suggests an increase in M2-like macrophages. Overall, our results add to growing evidence that GDM has direct effects on placental structure.

Development of Multiple-Unit Floating Drug Delivery System of Clarithromycin: Formulation, in vitro Dissolution by Modified Dissolution Apparatus, in vivo Radiographic Studies in Human Volunteers.

Clarithromycin (CM), a broad spectrum macrolide antibiotic used to eradicate H. pylori in peptic ulcer. Clarithromycin (CM) is well absorbed from the gastrointestinal tract, but has a bioavailability of 50% due to rapid biodegradation. The aim of this investigation was to increase the gastric residence time, and to control the drug release of clarithromycin by formulating into multiple unit floating mini-tablets. Floating tablets were prepared by using direct compression method with HPMC K4M and Polyox WSR 1105 as release retarded polymers and sodium bicarbonate as gas generating agent. The prepared mini-tablets were evaluated for thickness, weight variation, friability, hardness, drug content, in vitro buoyancy, swelling studies, in vitro dissolution studies by using modified Rossett-Rice test and in vivo radiographic studies in healthy human volunteers in fasting conditions. DSC analysis revealed that no interaction between drug and excipients. All the physical parameters of the tablets were within the acceptable limits. The optimized formulation (F6) had showed controlled drug release of 99.16±3.22% in 12 h, by zero-order release kinetics, along with floating lag time of 9.5±1.28 s and total floating time of 12±0.14 h. X-ray imaging studies revealed that in vivo gastric residence time of clarithromycin floating mini-tablet in the stomach was about 3.5 h. The results demonstrated that the developed floating mini-tablets of clarithromycin caused significant enhancement in gastric retention time along with sustained effect and increased oral bioavailability.

Association of personal hygiene with common morbidities among upper primary school children in rural Odisha.

CONTEXT: In India, children of upper primary school receive less attention from health-care providers. The majority of their health problems are preventable through hygienic practices. AIMS: The aim of this study was to find out the association of personal hygiene with common morbidities among upper primary school children. SETTINGS AND DESIGN: A cross-sectional study conducted in a rural upper primary school of Odisha. SUBJECTS AND METHODS: A semi-structured schedule based on the Global School Health Survey Questionnaire and necessary instruments for clinical examination were used. STATISTICAL ANALYSIS USED: Data were entered in Microsoft Excel 2007 and analyzed by SPSS version 20 software. RESULTS: Of 90 participants, 58 (64.4%) were girls. The mean age was 11.8 (±1.01) years. The mean body mass index of females was significantly higher than males (16.95 vs. 14.72; P = 0.001). More than 90% of children maintained good personal hygiene such as clean tongue, clean hair, handwashing, and using footwear. The most common morbidities found were dental caries (38.9%), history of worms in stool and lethargy (20%). A mean score of 6.14 ± 0.11 (out of 8) was seen for personal hygiene and not associated with any particular morbidity or gender. Brushing daily was significantly associated with reduced dental caries (χ2 = 8.7; P < 0.005) and foul-smelling breath (χ2 = 4.93; P < 0.05). Fungal infections were significantly less in children who bathed daily (χ2 = 28.7; <0.005) and wore clean clothes (χ2 = 5.06; P < 0.05). CONCLUSION: Dental caries, foul-smelling breath, and fungal infections were significantly associated with poor personal hygiene. School health services should also focus on upper primary school children for improvement of personal hygiene.

A study on nutritional status and tooth crown size among 6-9-year-old children: An observational cross-sectional study.

BACKGROUND: Numerous factors contribute to variation in tooth size. This is broadly described as genetic, epigenetic, and environmental factors. A strong genetic contribution has been shown, but environmental factors may also play a role. AIM: The aim of this study was to determine the relationship between nutritional status and tooth crown size. DESIGN: An observational cross-sectional survey was conducted among 100 school-going children of 6-9 years. The value obtained was plotted on age- and gender-specific percentile curves chart given by the Centers for Disease Control and Prevention; individuals were categorized based on body mass index criteria. The participants were examined for the mesiodistal width of primary second molar and permanent first molar by three different observers using a Vernier Caliper. Data obtained were statistically analyzed. RESULTS: total of 45, 40, and 15 belonged to underweight, normal, and overweight category, respectively. The tooth size of primary molar between healthy, overweight, and underweight children was 9.87 ± 0.23, 9.47 ± 0.48, and 9.61 ± 0.7, respectively, and for permanent molar between healthy, overweight, and underweight children was 10.63 ± 0.2, 10.56 ± 0.5, and 10.57 ± 0.6, respectively. CONCLUSION: The correlation between tooth crown size with an exogenous chronic stressor, i.e., malnutrition, was found to be nonsignificant when compared with the healthy individuals. The findings indicate that nutritional status does not significantly influence the determination of tooth size in humans.

Systemic Chromosome Instability Resulted in Colonic Transcriptomic Changes in Metabolic, Proliferation, and Stem Cell Regulators in Sgo1-/+ Mice.

Colon cancer is the second most lethal cancer and is predicted to claim 49,700 lives in the United States this year. Chromosome instability (CIN) is observed in 80% to 90% of colon cancers and is thought to contribute to colon cancer progression and recurrence. To investigate the impact of CIN on colon cancer development, we developed shugoshin-1 (Sgo1) haploinsufficient (-/+) mice, an animal model focusing on mitotic error-induced CIN. In this study, we analyzed signature changes in the colonic transcriptome of Sgo1(-/+) mice to examine the molecular events underlying the altered carcinogenesis profiles in Sgo1(-/+) mice. We performed next-generation sequencing of normal-looking colonic mucosal tissue from mice treated with the carcinogen azoxymethane after 24 weeks. Transcriptome profiling revealed 349 hits with a 2-fold expression difference threshold (217 upregulated genes, 132 downregulated genes, P < 0.05). Pathway analyses indicated that the Sgo1-CIN tissues upregulated pathways known to be activated in colon cancer, including lipid metabolism (z score 4.47), Notch signaling (4.47), insulin signaling (3.81), and PPAR pathways (3.75), and downregulated pathways involved in immune responses including allograft rejection (6.69) and graft-versus-host disease (6.54). Notably, stem cell markers were also misregulated. Collectively, our findings demonstrate that systemic CIN results in transcriptomic changes in metabolism, proliferation, cell fate, and immune responses in the colon, which may foster a microenvironment amenable to cancer development. Therefore, therapeutic approaches focusing on these identified pathways may be valuable for colon cancer prevention and treatment.

A clinical study of retinoblastoma.

AIM: The aim was to analyze general incidence, age incidence, laterality, common mode of presentation, staging of the tumor, radiological evidence, histopathological confirmation, management and follow-up of cases, which were diagnosed as retinoblastoma. DESIGN: Interventional case series study from April 1997 to March 2000. MATERIALS AND METHODS: Detailed history regarding the symptoms such as white reflex, watering, pain, redness, protrusion of eyeball, squint, hyphema, and defective vision were obtained. Family history regarding consanguinity between parents, health of the siblings and other relatives were recorded. Ocular examination included vision, pupillary reaction, detailed fundus examination, ocular tension, and corneal diameter. Investigations included X-ray orbit and skull, computed tomography scan orbit and brain, B-scan orbit, serum and aqueous lactate dehydrogenase; enucleated eyes were subjected to holoprosencephaly (HPE). Enucleation, radiotherapy, cryotherapy and chemotherapy were modalities of treatment. The empty socket and the other apparently normal eye were examined carefully at each visit. RESULTS: The incidence of retinoblastoma is less when compared to other diseases of the eye. There was no sex predilection. Most of the cases diagnosed were sporadic and unilateral. Age of onset is earlier for bilateral cases than unilateral cases. Consanguinity bears close relationship with bilateral involvement. Predominant clinical sign is white reflex in the pupillary area. Majority of cases presented in the second stage of the disease. Enucleation plays a greater role in the management of retinoblastoma. HPE should include several sections of the optic nerve to find out skip lesions.

A Single Versatile Appliance for Habit Interception and Crossbite Correction.

Digit sucking is a common childhood behavior, which has an adaptive value for children up to the fourth year of life. It is usually associated with oral pleasure and self-comforting behavior. But chronic practice may produce deleterious effect in the form of dental and skeletal deformities. Adjunctive therapy using bluegrass appliance as a permanent reminder and quadhelix appliance as a reminder as well as a slow palatal expander has proven successful in intercepting digit-sucking habit and expanding the arch for crossbite correction. In the present case, a versatile modified quadhelix appliance incorporating a roller was designed to clinically correct the habit and its resulting dentofacial deformities.

Blood pressure measurement in the geriatric population.

As the population above 60 years of age is the fastest growing and hypertension is highly prevalent in this group, accurate blood pressure (BP) measurement in the elderly is a very important and widely applicable subject. As with any other population, an accurate measurement of BP is essential to plan therapy and this remains an important consideration in the elderly as well. There are some unique problems of BP measurement in the elderly, including drug-induced orthostatic hypotension, white-coat hypertension, and advanced atherosclerotic disease with stiff arteries. For clinical use, home blood pressure monitoring (HBPM), office measurement, and ambulatory blood pressure monitoring all play a role in patient management. In the office setting, aneroid devices, hybrid devices with electronic transducers, and oscillometric devices are available; all of these require frequent calibration, well-trained operators and technically sound execution. Because the white-coat effect is common in this group, there is a good case for the use of HBPM, which could also be used to detect orthostatic changes at home. Also, HBPM predicts cardiovascular events better than clinical BP, and is also useful in monitoring treatment. Ambulatory blood pressure monitoring provides the most precise assessment of BP over an extended period, but is more complex and expensive. Finally, the utility of noninvasive central arterial pressure through radial artery applanation tonometry, especially in patients with resistant hypertension and likely in the elderly because of advanced atherosclerotic disease and stiff arteries, may prove to be a useful tool to guide or modify drug therapy in the future and requires further study.

Isolated cerebellar hypermetabolism on FDG PET in a case of remitted primary breast lymphoma.

We present here a case of primary non-Hodgkin's lymphoma of the breast that succumbed in a sub-acute course to death after three months of initial remission. The fluorodeoxyglucose positron emission tomography imaging during the declining clinical status showed isolated cerebellar hypermetabolism.