A conceptual framework linking immunology, pathology, and clinical features in primary membranous nephropathy.

Primary membranous nephropathy is a leading cause of adult nephrotic syndrome. The field took a major step forward with the identification of phospholipase A2 receptor (PLA2R) as a target antigen in the majority of cases and with the ability to measure circulating autoantibodies to PLA2R. Since then, the existence of additional target antigens such as thrombospondin type-1 domain-containing 7A, exostosin 1 and 2, neural EGFL like 1, and semaphorin 3B has been demonstrated. The ability to detect and monitor levels of circulating autoantibodies has opened a new window onto the humoral aspect of primary membranous nephropathy. Clinicians now rely on clinical parameters such as proteinuria, as well as levels of circulating autoantibodies against PLA2R and the results of immunofluorescence staining for PLA2R within kidney biopsy tissue, to guide the management of this disease. The relationship between immunologic and clinical disease course is consistent, but not necessarily intuitive. In addition, kidney biopsy provides only a single snapshot of disease that needs to be interpreted in light of changing clinical and serological findings. A clear understanding of these dynamic parameters is essential for staging, treatment, and management of this disease. This review aims to shed light on current knowledge regarding the development and time course of changes in the serum levels of autoantibodies against PLA2R, proteinuria, and histological findings that underlie the pathophysiology of primary membranous nephropathy.

Effect of air, anesthetic gas mixture, saline, or 2% lignocaine used for tracheal tube cuff inflation on coughing and laryngotracheal morbidity after tracheal extubation.

BACKGROUND AND AIMS: Coughing and sore throat postoperatively are common clinical problems during general anesthesia which can be avoided by various methods including topicalization of airway with local anesthetics, endotracheal tube cuff (ETT) inflation with local anesthetics, use of intravenous drugs such as dexamethasone, maintaining ETT cuff pressure, intubation by an experienced anethesiologist, etc. The aims of the study were to compare postextubation coughing response, mean number of cuff deflations required intraoperatively, and postoperative airway morbidity in terms of sore throat (2 h and 18-24 h), hoarseness of voice, and dysphagia following inflation of ETT cuff with air, anesthetic gas mixture, saline, and 2% lignocaine during general anesthesia. MATERIAL AND METHODS: One hundred and four patients were randomized into 1 of 4 groups depending on whether air, anesthetic gas mixture, saline, or 2% lignocaine was used to inflate the cuff of ETT using computer-generated randomization table. RESULTS: There was no significant difference in the postextubation cough response among the four groups. The mean number of times the ETT cuff was deflated was significantly in favor of liquid media comapred to gaseous media (P < 0.001). The incidence of sore throat at 2 h and at 18-24 h, hoarseness of voice, and dysphagia were comparable in all groups. CONCLUSION: ETT cuff inflation with air, anesthetic gas mixture, 2% lignocaine, and saline are comparable in terms of incidence of postextubation cough and postoperative airway morbidity symptoms such as sore throat, hoarseness of voice, and dysphagia.

Role of laboratory markers in predicting severity of acute appendicitis.

MATERIALS AND METHODS: Record of 233 patients under 18 years of age who underwent appendectomy from 2005 to 2014 was evaluated. Based on perioperative findings of the surgeon, the patients were grouped under categories simple acute appendicitis (SAA) and CAA. Information such as age, gender, and laboratory investigations of the patients were recorded and analyzed. BACKGROUND: Accurately differentiating simple and complicated acute appendicitis (CAA) in children preoperatively can be challenging. The aim of this study is to evaluate the ability of the neutrophil-to-lymphocyte ratio (NLR), total leukocyte count (TLC), percentage lymphocyte, and percentage neutrophil counts to predict the type of appendicitis a patient has preoperatively and to determine the better indicator among these. RESULTS: SAA included 185 patients and CAA included 48 patients. An NLR >4.8, TLC >13,500 cells/mm3, percentage lymphocyte count <14.8%, and percentage neutrophil count >75% were found to be associated with complicated appendicitis. The highest sensitivity and specificity among these findings were found with the percentage lymphocyte count, which were 70.8% and 63.8%, respectively. CONCLUSION: The preoperative percentage lymphocyte count serves as a better indicator than TLC, NLR, and percentage lymphocyte count and is a useful parameter in differentiating simple and complicated appendicitis and can be used as a valuable adjunct to the surgeon's clinical evaluation.

Paroxysmal Atrial Fibrillation due to Venomous Snake Bite.

Snake bites are common all around the world with a great prevalence in South Asia and the Indian subcontinent. Although they are associated with common complications such as local swelling, bleeding at site of bite, coagulopathy, etc., few rare cardiac complications such as myocardial infarctions and arrhythmias have also been described in literature. The following is a case report of a patient who had a snake bite with a Russell's viper which resulted in atrial fibrillation, which resolved on treatment with anti snake venom.

A Rare Cause of Anaemia in HIV/AIDS.

Patients living with HIV are commonly diagnosed with anaemia which can have various aetiologies. However, one of the rare causes of anaemia in such patients is Auto Immune Haemolytic Anaemia (AIHA), which is difficult to diagnose due to the absence of reticulocytosis in HIV patients. Such patients can be treated with corticosteroids which can gradually be tapered off over a period of time. The following is a case of a 52-year-old male living with HIV who was diagnosed to have AIHA and was successfully treated with steroids.

Transient Thyrotoxicosis in Molar Pregnancy.

Molar pregnancy is one of the components of a broader spectrum of diseases known as Gestational Trophoblastic Disease (GTD), presenting with amenorrhoea and irregular bleeding which may be rarely associated with passage of vesicles per vagina. However, it can rarely be associated with hyperthyroidism, which may be associated with clinical features of hyperthyroidism. The following is a report of a 20-year-old woman who presented with amenorrhea followed by irregular bleeding per vagina, thyromegaly and abnormal levels of thyroid hormones. Transvaginal ultrasound revealed features consistent with molar pregnancy. A suction evacuation was done following which serum levels of ß-hCG reduced and the levels of thyroid hormones also reduced. On follow up, six weeks later, ß-hCG and thyroid hormones were within normal limits. The case and relevant literature are presented here.

Enteric Cholestatic Hepatitis with Ascites: A Rare Entity.

Typhoid fever is a very common illness in developing countries. Patients most often present with a history of fever, vomiting, anorexia, abdominal pain, etc. Rarely there is hepatic involvement due to the disease process. This is a case report of a 26-year-old male who had presented with fever, jaundice and ascites. The widal titres were found to be within normal limits (1:80) however the patient was found to have Salmonella typhi on ascitic fluid culture. The patient was treated with the appropriate antibiotics and was later discharged.

Misdiagnosed Roberts Uterus Leading to Surgical Misadventures.

BACKGROUND: Developmental anomalies of the Müllerian duct system are some of the most intriguing and challenging disorders that gynecologists and surgeons encounter in their practice. CASE: We report on a 16-year-old adolescent girl with regular menstrual cycles, who presented with recurrent cyclical abdominal pain for which she had undergone 2 unsuccessful surgeries. When correctly diagnosed with the rare condition of "Robert's uterus," she underwent successful metroplasty and is completely asymptomatic at 2-year follow-up. SUMMARY AND CONCLUSION: To avoid inappropriate management, gynecologists and surgeons should be aware of this rare entity while evaluating cases of severe dysmenorrhoea in previously normal menstruating young girls.