Solitary intraductal papilloma of the breast--a diagnostic dilemma and the role of conferencing between surgeons and cytologist

A 40 year female, presented with the complaints of spontaneous, sticky, blood stained discharge from the nipple of the left breast since 6 months. On examination there was no lump palpable in either breast. Cytology of the nipple discharge (ND) showed scanty cellularity consisting of tight papillary clusters of ductal cells in a hemorrhagic and inflammatory background. The nuclei were bland and showed degenerative atypia. Mammography showed no significant lesion. Our patient underwent microdochechtomy. Histopathology showed intraductal papilloma. Limitations of cytology must be kept in mind by both, the pathologist and the surgeon. The cytological diagnosis of a papillary tumor is provisional and the definitive diagnosis must await histological examination. In view of rarity of this lesion, combined with the overlapping of cytologic features in benign and malignant papillary lesions, conferencing and communication with the surgeon should be an integral part of patient evaluation and management. In our case this approach resulted in less radical excision of breast tissue.     

High C-reactive protein and low paraoxonase1 in diabetes as risk factors for coronary heart disease

BACKGROUND: Paraoxonase1 (PON1) is an anti-inflammatory enzyme located on HDL, which protects against the development of atherosclerosis. C-reactive protein (CRP) is a marker of the inflammatory response in CHD. We hypothesised that low PON1 and high CRP found in CHD may be important markers of CHD and the CRP:PON1 ratio may be an index of the risk of developing atherosclerosis. We have, therefore, compared the levels of PON1 and CRP between control subjects, those with no diabetes and CHD, type 1 diabetes and type 2 diabetes. METHODS AND RESULTS: PON1 activity was different between the populations in the order: controls > type 1 diabetes > type 2 diabetes > CHD with no diabetes (P<0.001). CRP concentration also differed between the populations in the order: controls < type 1 diabetes < type 2 diabetes < CHD with no diabetes (P<0.001). The CRP:PON1 ratio followed the same trend as the CRP concentration (P<0.001). Both CRP and the CRP:PON1 ratio were associated with the presence of CHD. In the control population only, PON1 was a determinant of CRP concentration. Amongst the diabetics, people with CHD had higher levels of CRP (P<0.001) and in comparing the control group with the CHD group, the CHD group had a higher level of CRP (P<0.001). CONCLUSIONS: Higher levels of CRP seem to be generally associated with low levels of PON1 activity, providing a mechanistic link between inflammation and the development of atherosclerosis. However, the relationship between PON1, CRP and atherosclerosis, and the usefulness of the PON1:CRP ratio as a risk factor for CHD requires further evaluation.     

Capreomycin-induced optic neuritis in a case of multidrug resistant pulmonary tuberculosis

A patient of multidrug-resistant pulmonary tuberculosis was prescribed an anti-tubercular regimen containing capreomycin. Patient developed optic neuritis 3 months after starting treatment. Investigations did not reveal any specific cause for this ocular condition and on discontinuing capreomycin his vision recovered. We conclude that capreomycin is the cause of reversible optic neuritis in our case.     

Synthesis and Antitubercular Activity of 2‐(substituted phenyl/benzyl‐amino)‐6‐(4‐chlorophenyl)‐5‐(methoxycarbonyl)‐4‐methyl‐3,6‐dihydropyrimidin‐1‐ium Chlorides

A series of 2‐(substituted phenyl/benzyl‐amino)‐6‐(4‐chlorophenyl)‐5‐(methoxycarbonyl)‐4‐methyl‐3,6‐dihydropyrimidin‐1‐ium chlorides 7–13 and 15 was synthesized in their hydrochloride salt form. The title compounds were characterized by FT‐IR, NMR (¹H and ¹³C) and elemental analysis. They were evaluated for their in vitro antitubercular activity against Mycobacterium tuberculosis H37Rv, multidrug resistance tuberculosis and extensively drug resistance tuberculosis by agar diffusion method and tested for the cytotoxic action on peripheral blood mononuclear cells by MTT assay. Among all the tested compounds in the series, compounds 7 and 11 emerged as promising antitubercular agents at 16 μg/mL against multidrug resistance tuberculosis and over 64 μg/mL against extensively drug resistance tuberculosis. The conformational features and supramolecular assembly of the promising compounds 7 and 11 were determined by single crystal X‐ray study.     

Ocular prodrugs: Attributes and challenges

Ocular drug delivery is one of the most attention-grabbing and challenging endeavors among the numerous existing drug delivery systems. From a drug delivery point of view, eye is an intricate organ to investigate and explore. In spite of many limitations, advancements have been made with the intention of improving the residence time or permeation of the drug in the ocular region. Poor bioavailability of topically administered drugs is the major issue pertaining to ocular drug delivery. Several efforts have been made towards improving precorneal residence time and corneal penetration, e.g. iontophoresis, prodrugs and ion-pairing, etc. Prodrug approach (chemical approach) has been explored by the formulation scientists to optimize the physicochemical and biochemical properties of drug molecules for improving ocular bioavailability. Formulation of ocular prodrugs is a challenging task as they should exhibit optimum chemical stability as well as enzymatic liability so that they are converted into parent drug after administration at the desired pace. This review will encompass the concept of derivatization and recent academic and industrial advancements in the field of ocular prodrugs. The progression in prodrug designing holds a potential future for ophthalmic drug delivery.     

Computed tomography for occult fractures of the proximal femur,pelvis, and sacrum in clinical practice: single institution,dual-site experience

Purpose

The purpose of this study was to evaluate the diagnostic performance of CT for assessment of occult fractures of the proximal femur, pelvis, and sacrum.

Materials and methods

A retrospective review was performed on patients who received a CT of the hip or pelvis for suspected occult fracture after negative or equivocal radiographs performed within 24 h. The official radiology report was utilized for the determination of CT findings and calculation of sensitivity and specificity. Surgical reports, MRI reports, and clinical follow-up were used as the standard of reference. Sensitivity and specificity were calculated with 95% confidence intervals.

Results

Seventy-four patients received CT of the hip or pelvis for clinical concern for occult fracture after negative or equivocal radiographs. By the reference standard, a total of 40 fractures were present in 25/74 (33.8%) patients, including 35 conservatively treated fractures of the greater trochanter, pelvis, and sacrum, and 5 operatively treated proximal femoral fractures. A total of 14/74 (18.9%) of patients had an MRI within 1 day of CT. MRI identified an operatively treated femoral neck fracture not seen on CT and an operatively treated intertrochanteric fracture, which CT described as a greater trochanteric fracture. There were two false negative conservatively treated pelvic fractures not seen on CT but diagnosed on MRI. On a per-patient basis, CT had an overall sensitivity of 88% (22/25; 95% confidence intervals 69–97%), specificity of 98% (48/49; 95% confidence intervals 89–100%), and negative predictive value of 94%. For the five operative proximal femoral fractures, the sensitivity of CT was 60% (3/5; 95% confidence intervals 15–95%), specificity was 99% (68/69; 95% confidence intervals 92–100%), and negative predictive value was 97%.

Conclusions

In the clinical setting of suspected occult fracture, the sensitivity of clinical CT reports for detection of any type of fracture of the proximal femur, pelvis, or sacrum was 88%. For the small number of operatively treated proximal femoral fractures seen in the study, sensitivity of CT was 60% (3/5) and negative predictive value was 97%, although the relatively few patients needing fixation precludes statistical analysis.

     

Osteomyelitis of the lower extremity: pathophysiology,imaging, and classification,with an emphasis on diabetic foot infection

Osteomyelitis is inflammation of the bone caused by an infectious organism, and is a difficult clinical problem. The pathophysiology, imaging, and classification of osteomyelitis are challenging, varying with the age of the patient (child versus adult), the chronicity of the infection (acute versus chronic), and the route of spread (hematogenous versus contiguous focus), as well as the immune and vascular status of the patient and affected region. The two most common classification schemes are those of Lew and Waldvogel, and Cierny and Mader. Brodie’s abscess is seen in subacute osteomyelitis, while sequestrum, involucrum, and cloaca are inter-related entities of chronic osteomyelitis. Imaging workup of suspected osteomyelitis should begin with radiographs, although MRI is the most accurate imaging test. Three patterns of T1 signal change have been described in the setting of suspected osteomyelitis including confluent intramedullary, hazy reticular, and subcortical. The confluent intramedullary pattern is most associated with osteomyelitis, while hazy reticular is rarely associated with hematogenous osteomyelitis, and subcortical is not associated with osteomyelitis. It can be challenging to differentiate neuropathic arthropathy from osteomyelitis. Osteomyelitis tends to involve a single bone subjacent to an ulcer or sinus tract. In contrast, neuropathic arthropathy tends to involve multiple bones of the midfoot. Subchondral cystic change, thin rim enhancement of a joint effusion, and the presence of intra-articular bodies are more indicative of a neuropathic joint without infection. Biopsy can play an important role in diagnosis and treatment of osteomyelitis.     

Feeding Problems and Nutrient Intake in Children with and without Autism: A Comparative Study

Objective

To compare parent reported feeding difficulties and nutritional adequacy of children with Autism Spectrum Disorders (ASD) to an age and socio-economically matched group of typically developing children.

Methods

The scores on Children’s Eating Behavior Inventory (CEBI), three-day food records, anthropometric measures and adequacy of micro- and macro- nutrients were compared for 63 children diagnosed with ASD and 50 typically developing children enrolled from the department of pediatrics of a tertiary care teaching hospital from North India.

Results

The majority (79%) of the parents of ASD children reported some concern regarding their feeding behavior as compared to 64% of the parents of typically developing children. As compared to controls, ASD children had significantly higher CEBI scores (97.28 vs. 89.48, t = 3.15, P = 0.002) and more feeding problems (6.42 vs. 2.70, t = 3.74, P = 0.001). Relative to controls, ASD children consumed fewer number of food items (P = 0.022), particularly fruits (P = 0.004), vegetables (P = 0.011), and proteins (P = 0.015); had significantly lower daily intake of potassium (P = 0.001), copper (P = 0.007), and folate (P = 0.001). Although children with autism did not differ significantly from controls on intake of calories, height, weight, or body mass index, significantly greater proportion of ASD children failed to meet the estimated average requirement of thiamine (P = 0.039), vitamin C (P = 0.013), and copper (P = 0.005).

Conclusions

The findings underscore the need for comprehensive assessment and empirically-supported interventions for eating problems and dietary deficiencies found in ASD children.