Subcutaneous zygomycosis: report of 10 cases from two institutions in North India

Background Subcutaneous zygomycosis is an uncommon condition observed in tropics. Few series have been published, particularly from the northern regions of India. Objectives The aim of this study was to describe clinical, investigative and therapeutic details in subcutaneous zygomycosis observed in two teaching hospitals in Delhi. Patients and methods Ten patients seen over a period of 10 years (1999–2009) form the material for this report. Results There were four children and six adults. In four children, the presentation was a subcutaneous localized mass or gradually spreading plaque. In the others, it was observed over nasal region of face, spreading inward into mucosal sites and paranasal sinuses, and outward to the contiguous areas. Regional lymphadenopathy was present in two with facial lesions. Majority showed a granulomatous infiltrate with admixture of other cells, mainly eosinophils. Aseptate or poorly septate hyphae were observed in seven. In one patient in whom no hyphae were observed, there was dense perivascular inflammation. Organisms were cultured from four patients, Basidiobolus ranarum in two and Syncephalastrum racemosum in two. The main therapy used was a saturated solution of potassium iodide (KI). Four received only KI of which two attained cure after 3 months and 9 months respectively, and the other two showed signs of regression. In one boy subsidence was associated with reduced circumference of thigh. Ketoconazole or itraconazole was given with KI to hasten regression when response was slow or there were side‐effects to KI. Conclusion Awareness and early recognition will prevent disfigurement produced by advanced disease, misdiagnosis and unnecessary surgical intervention.     

Migraine Education Improves Quality of Life in a Primary Care Setting

(Headache 2010;50:600‐612) Objective.— The objective of this study was to evaluate the effectiveness of the Mercy Migraine Management Program (MMMP), an educational program for physicians and patients. The primary outcome was change in headache days from baseline at 3, 6, and 12 months. Secondary outcomes were changes in migraine‐related disability and quality of life, worry about headaches, self‐efficacy for managing migraines, emergency room (ER) visits for headache, and satisfaction with headache care. Background.— Despite progress in the understanding of the pathophysiology of migraine and development of effective therapeutic agents, many practitioners and patients continue to lack the knowledge and skills to effectively manage migraine. Educational efforts have been helpful in improving the quality of care and quality of life for migraine sufferers. However, little work has been performed to evaluate these changes over a longer period of time. Also, there is a paucity of published research evaluating the influence of education about migraine management on cognitive and emotional factors (for example, self‐efficacy for managing headaches, worry about headaches). Methods.— In this open‐label, prospective study, 284 individuals with migraine (92% female, mean age = 41.6) participated in the MMMP, an educational and skills‐based program. Of the 284 who participated in the program, 228 (80%) provided data about their headache frequency, headache‐related disability (as measured by the Headache Impact Test‐6 (HIT‐6), migraine‐specific quality of life (MSQ), worry about headaches, self‐efficacy for managing headaches, ER visits for headaches, and satisfaction with care at 4 time points over 12 months (baseline, 3 months, 6 months, 12 months). Results.— Overall, 46% (106) of subjects reported a 50% or greater reduction in headache frequency. Over 12 months, patients reported fewer headaches and improvement on the HIT‐6 and MSQ (all P < .001). The improvement in headache impact and quality of life was greater among those who had more worry about their headaches at baseline. There were also significant improvements in “worry about headaches,”“self‐efficacy for managing headaches,” and “satisfaction with headache care.” Conclusion.— The findings demonstrate that patients participating in the MMMP reported improvements in their headache frequency as well as the cognitive and emotional aspects of headache management. This program was especially helpful among those with high amounts of worry about their headaches at the beginning of the program. The findings from this study are impetus for further research that will more clearly evaluate the effects of education and skill development on headache characteristics and the emotional and cognitive factors that influence headache.     

Retro-inverso prosaptide peptides retain bioactivity, are stable In vivo, and are blood-brain barrier permeable

Prosaptide (trademark of Myelos Corporation, San Diego, CA) peptides are based on the 14-amino-acid neurotrophic sequence of human prosaposin and, like the parent protein, have potent neurotrophic and neuroprotective properties. We previously examined the in vivo stability of a series of bioactive Prosaptide peptides and designed peptides with increased enzymatic stability in the central and peripheral nervous systems. In this article, we examined the stability, biological activity, and permeability of the blood-brain barrier to retro-inverso Prosaptide peptidomimetics. Retro-inversion both reverses the primary sequence and replaces L-amino acids with D-amino acids. We examined the bioactivity of five peptidomimetics, Prosaptides D1-D5. Prosaptide D1, a peptide containing all D-amino acids with the primary sequence intact, was inactive. However, four retro-inverso peptidomimetics, Prosaptides D2-D5 retained bioactivity in neurite outgrowth and [(35)S]GTPgammaS binding assays. We focused on Prosaptide D4 as a prototypical retro-inverso Prosaptide peptidomimetic for further study. (125)I-Prosaptide D4 remained intact in brain or serum for 60 min after i.v. administration and was transported across the blood-brain barrier with a unidirectional influx constant of 2.5 x 10(-4) ml. g(-1). min(-1). We conclude that retro-inverso Prosaptide peptidomimetics are excellent candidates for development as therapeutics for central nervous system neurodegeneration.     

Pancreatic duct stents for "obstructive type" pain in pancreatic malignancy

OBJECTIVE: Obstruction of the main pancreatic duct from malignancy with secondary ductal hypertension may be an important contributor to pain. The aim of our study was to determine the efficacy and safety of pancreatic stent placement for patients with "obstructive" pain due to pancreatic malignancy. METHODS: Pancreatic duct stents were placed in 10 consecutive patients with malignant pancreatic duct obstruction and abdominal pain. Seven patients had "obstructive" type pain and three had chronic unremitting pain. Nine had primary pancreatic ductal adenocarcinoma and one had metastatic melanoma. There were eight women and two men. Mean age was 61 yr (range, 47-80 yr). All patients had dominant main pancreatic duct strictures with proximal dilation. Tumors were unresectable. All patients took potent analgesics before endoscopic stent therapy. Polyethylene pancreatic stents, 5- and 7-French, were successfully placed in seven patients, and self-expanding metallic stents were successfully placed in three patients. RESULTS: There were no procedure-related complications. One patient required a single repeat examination to replace a migrated stent. Seven patients (75%) experienced a reduction in pain. Analgesia was no longer required in five (50%). Three patients who did not improve had chronic pain rather than "obstructive" pain. CONCLUSIONS: Pancreatic stent placement for patients with "obstructive" pain secondary to a malignant pancreatic duct stricture appears to be safe and effective. It should be considered as a therapeutic option in these patients. It does not seem to be effective for chronic unremitting pain.     

Weaver syndrome: a case without early overgrowth and review of the literature

A female child with Weaver syndrome is described. She did not show the excessive growth characteristic of this syndrome until after adequate caloric intake was achieved by feeding through a gastric feeding tube. Her inadequate nutrition was a result of feeding difficulties during infancy. In addition, she had recurrent pulmonary infections, apneic spells, and severe developmental delay. She died at 16 months of sepsis, congestive heart failure, and respiratory arrest. The autopsy revealed marked atrophy of the brain and cardiac ventricular hypertrophy. Most of the brain changes were thought to be from hypoxia.     

Attitudes of teenagers toward sun exposure and sunscreen use.

A survey of 220 adolescents attending a multiphysician pediatric office in Virginia was conducted to determine the frequency with which they used sunscreens. Eighty-one percent of the teenagers in the study stated that they spent most weekends in the sun; however, only 9% always used sunscreen, while 33% never did. Factors found to be associated with increased sunscreen use included female sex (odds ratio = 4.5, P less than .0001), having a best friend who routinely used sunscreen (odds ratio = 3.0, P less than .001), having parents who insisted on sunscreen use when the teenagers were children (odds ratio = 3.0, P = .006), and knowing that the maximum time for safe exposure to the sun is short (odds ratio = 6.2, P less than .0001). Adolescents with a history of skin cancer in the family were not more likely to use sunscreens than other teenagers. Thirty-three percent of the girls and 16% of the boys older than 15 years of age reported that they had visited a tanning salon at least once. This survey substantiates poor compliance with sunscreen use by teenagers despite increasing evidence of the dangers of excessive sun exposure.     

Does a front-end nonlinearity confound VEP acuity measures in human infants?

The visual evoked potential is commonly used to estimate visual acuity in infants. The stimulus used is temporally modulated in order to drive the cortical response. Here it is proposed that distortion products generated by a front-end nonlinearity may contaminate the acuity estimate. Specifically, the nonlinearity might convert temporal modulation of a high spatial frequency grating into apparent whole-field flicker. Thus, the VEP may reflect an artifactual response to a high spatial frequency that is not resolved at the cortical level. If this were the case, one could null or attenuate the flicker response by adding whole-field flicker to the grating stimulus. We looked for such nulling effects in 18 infants aged 6-17 weeks. No consistent evidence was found for the nulling effect, so it was concluded that infant VEP acuity estimates are not significantly contaminated by the hypothesized distortion product.