Reconstruction of the medial patellofemoral ligament for painful patellar subluxation in distal torsional malalignment: a case report

Complex two-level rotational malalignment of the lower extremity can cause maltracking of the patella with anterior knee pain. Double derotation osteotomy would correct the underlying pathology. However, it carries a high risk of complications such as nerve and vessel damage. We report a case of rotational malalignment in the femur and the tibia associated with trochlear dysplasia, which causes painful patellar instability. The patient was successfully treated with reconstruction of the medial patellofemoral ligament and lateral release. Although the malrotation was not addressed, the position of the patella was corrected, and no dislocation occurred during a follow-up of 10 months.     

Evaluating anorexia-related brain atrophy using MP2RAGE-based morphometry

Aim

To evaluate brain atrophy in anorexic patients by automated cerebral segmentation with the magnetization-prepared 2 rapid acquisition gradient echo (MP2RAGE) MRI sequence.

Material and methods

Twenty patients (female; mean age, 27.9 years), presenting consecutively for brain MRI between August 2014–December 2016 with clinical suspicion of anorexia nervosa and BMI<18.5 kg/m² were included. Controls were ten healthy females (mean age, 26.5 years). Automated brain morphometry was performed based on MP2RAGE. Means of morphometric results in the two groups were compared and correlation with BMI was analysed.

Results

Significantly lower volumes of total brain, grey matter (GM), white matter (WM), cerebellum and insula were found in anorexic patients. Anorexics had higher volumes of CSF, ventricles, lateral ventricles and third ventricle. When adjusted means for weight and height were compared, the volume of WM and cerebellum were not significantly different. However, volume of WM was significantly affected by weight and positively correlated with BMI. Significant positive correlations were found between BMI and volumes of total brain, GM, cortical GM and WM. BMI was negatively correlated with volumes of CSF and third ventricle.

Conclusion

Brain atrophy was demonstrated in anorexic patients with MP2RAGE-based automated segmentation, which seems to reliably estimate brain volume.

Key points

? Automated brain segmentation based on 3-D MRI seems to reliably estimate brain volume.? This technique detected brain atrophy in patients suffering from anorexia nervosa.? Brain changes in anorexia nervosa can be quantitatively and qualitatively followed-up by MRI.

     

Comparitive evaluation of different systems of medicines and the present scenario of chikungunya in Kerala

ObjectiveTo identify the chikungunya outbreaks in both indoor and outdoor patients in some selected hospitals in our locality and the burden and magnitude of the disease, to compare different system of medicines (allopathic, Ayurvedic, homeopathy etc) and to explore the knowledge, attitude and practices of pharmacists and other health care professionals in the treatment of chikungunya.MethodsA six-month study was carried out. Detailed history was taken from the case history, personal interview of doctors and suspected cases. Personal data such as name age, sex, location, date of onset of illness, medical history, general/systemic examination features, drugs used (allopathy, Ayurveda, homeopathy, or traditional) for the treatment, etc. were noted down. A simple questionnaire was prepared and distributed to various doctors practicing various systems of medicines.ResultsA total of 209 suspected cases were identified from July to December, 2009. People in the age group of 20–40 years were more affected. The study revealed that females were more affected than males. The Grade-III (58.73%) population was more prone to chikungunya than Grade-II (38.75%) and Grade-I (2.87%). It showed that fever, pain in muscles, and sleeping disturbances were the intense symptoms of chikungunya. Myocarditis and arthritis were concomitant diseases which worsened chikungunya symptoms. It also indicated the effective medicine for compliance is nonsteroidal antiinflammatory drugs (NSAIDS).ConclusionsFrom our study we found that in some places there is no proper documentation, even though there are proper guidelines framed by the relevant authorities. It can be concluded from the study that all the systems of medicine are equally important for the management of chikungunya. Additional effort in promoting the guidelines at local level and proper documentation helps to achieve the goal of curbing the chikungunya. It is high time to increase our effort and promote these messages at grassroot level which benefits the society/community as a whole.     

Position paper—HPV and the primary prevention of cancer; improving vaccine uptake by paediatricians

A large proportion of sexually active adults are infected with the human papillomaviruses (HPVs). Although largely asymptomatic, some types of HPVs (HPV-16, HPV-18) which infect the genitalia are known to cause cancers, including cervical cancer. Cervical cancer is an important public health concern and is the second most clinically important cancer to breast cancer in women aged 15–44 years. Until recently, cervical cancer strategies focussed on screening. However, as adolescents become sexually active at a much younger age, the focus is on the use of vaccination as an effective measure to prevent progression of HPV infection to cancer. HPV is also involved in the aetiology of cancers of the anus, vagina, vulva and penis as well as genital warts and laryngeal papillomatosis in young children. Primary prevention through vaccination is now possible in Europe using either the quadrivalent HPV vaccine, Gardasil® (Sanofi Pasteur MSD), or the bivalent HPV vaccine, Cervarix® (GSK), which are both highly immunogenic, with their effects persisting for at least 5 years. HPV vaccines are well tolerated, with serious vaccine-related events occurring in less than 0.1% of patients for both vaccines. Here, we review the possibilities for utilising vaccination programmes alongside current cervical cancer screening in comprehensive cervical cancer prevention programmes. The European Academy of Paediatrics Scientific Working Group on Vaccination concluded that the use of HPV vaccines will have a significant impact in primary prevention of cancers and other HPV-related disease.     

Decreased striatal dopamine transporter binding assessed with [<Superscript>123</Superscript>I] FP-CIT in first-episode schizophrenic patients with and without short-term antipsychotic-induced parkinsonism

Rationale Drug-induced parkinsonism (DIP) is one of the main causes of treatment drop-out in schizophrenic patients causing a high incidence of relapse that leads patients to a bad clinical prognosis. The dopaminergic nigrostriatal pathway is involved in the movement control, so the study of the dopamine transporter (DAT) could be of great value to determine its implication in the appearance of DIP. Objective The goal of the study is to determine the striatal DAT binding assessed with [¹²³I] FP-CIT SPECT in first-episode neuroleptic-naive schizophrenic in-patients with DIP after short-term antipsychotic treatment. Method The [¹²³I] FP-CIT binding ratios of ten schizophrenic in-patients who developed DIP during the first 4-week period of risperidone treatment (6±2 mg/day) were compared with ten schizophrenic in-patients treated with the same doses of risperidone and who do not developed DIP and with ten age-matched healthy subjects. Quantitative analyses of SPECTs were performed using regions of interest located in caudate, putamen and occipital cortex. Parkinsonism was assessed by the Simpson–Angus Scale and the psychopathological status by the Clinical General Impression and Positive and Negative Syndrome Scales. Results Whole striatal [¹²³I] FP-CIT binding ratios were significantly lower in patients with and without DIP than in healthy subjects (p<0.001). This was also observed in whole putamen (p<0.001) and caudate nucleus (p<0.001). Females showed higher whole striatal [¹²³I] FP-CIT binding ratios than males (p<0.05). No differences in psychopathological scales were observed between patients with and without DIP. Conclusion Our first-episode schizophrenic patients with and without DIP after short-term risperidone treatment have a decreased striatal DAT binding assessed with [¹²³I] FP-CIT. This alteration could be related to the schizophrenic disease or may be secondary to the antipsychotic treatment.     

Effect of cyclosporine A on the tissue distribution and pharmacokinetics of etoposide

Purpose Cyclosporine A (CyA) is able to inhibit P-glycoprotein (P-gp) and to increase cytotoxicity of some anticancer drugs, including etoposide. However, the effect of CyA on the distribution of etoposide in normal tissues, which could affect their toxicity, has not been studied extensively. The purpose of this study was to investigate the effect of CyA on the pharmacokinetics and tissue distribution of etoposide in rats.Methods Etoposide was administered as an i.v. bolus injection (3 mg) or as a constant-rate i.v. infusion (8 mg/h) 1 h after the beginning of infusion of CyA or saline. Animals were killed 1 h after the bolus administration or after the beginning of infusion of etoposide, and plasma and tissue (testicle, muscle, heart, lung, spleen, kidney, liver, colon, and intestine) concentrations of etoposide, blood concentrations of CyA were determined. All analyses were performed by HPLC.Results Infusion of CyA (1 mg/h) in rats treated with an i.v. bolus of etoposide caused a decrease in the plasma clearance (5.4±2.1 vs 9.3±2.4 ml/min), and an increase in plasma and tissue concentrations of etoposide, but the tissue-to-plasma concentration ratios of etoposide were not affected. When etoposide was infused at a constant rate to reach a steady-state plasma level, coinfusion of CyA (10 mg/h) also caused a decrease in the plasma clearance (4.8±1.5 vs 9.8±4.7 ml/min), and an increase in plasma and tissue concentrations of etoposide. Only lung and spleen showed tissue-to-plasma ratios of etoposide significantly higher than obtained in rats coinfused with saline, but the differences were small.Conclusions The higher tissue concentrations of etoposide caused by CyA administration were mainly a direct consequence of the higher plasma concentration resulting from a decrease in the clearance of etoposide rather than a consequence of changes in the tissue distribution of etoposide. Extrapolation of the results obtained in rats to clinical practice suggests that the coadministration of etoposide and CyA would not lead to an increase in the toxicity of etoposide if the dose were decreased in the same proportion as clearance of etoposide is decreased by CyA administration.     

Isolation of <Emphasis Type="Italic">Aspergillus</Emphasis> spp. from the respiratory tract in critically ill patients: risk factors,clinical presentation and outcome

Introduction  

Our aims were to assess risk factors, clinical features, management and outcomes in critically ill patients in whom Aspergillus spp. were isolated from respiratory secretions, using a database from a study designed to assess fungal infections.     

Screening of chemicals for human bioaccumulative potential with a physiologically based toxicokinetic model

Human bioaccumulative potential is an important element in the risk assessment of chemicals. Due to the high number of synthetic chemicals, there exists the need to develop prioritisation strategies. The purpose of this study was to develop a predictive tool for human bioaccumulation risk assessment that incorporates not only the chemical properties of the compounds, but also the processes that tend to decrease the concentration of the compound such as metabolisation. We used a generic physiologically based toxicokinetic model that based on in vitro human liver metabolism data, minimal renal excretion and a constant exposure was able to assess the bioaccumulative potential of a chemical. The approach has been analysed using literature data on well-known bioaccumulative compounds and liver metabolism data from the ECVAM database and a subset of the ToxCast phase I chemical library—in total 94 compounds covering pharmaceuticals, plant protection products and industrial chemicals. Our results provide further evidence that partitioning properties do not allow for a reliable screening criteria for human chemical hazard. Our model, based on a 100% intestinal absorption assumption, suggests that metabolic clearance, plasma protein-binding properties and renal excretion are the main factors in determining whether bioaccumulation will occur and its amount. It is essential that in vitro metabolic clearance tests with metabolic competent cell lines as well as plasma protein-binding assays be performed for suspected bioaccumulative compounds.     

Quantification of Immunoglobulin Free Light Chains in CerebroSpinal Fluid by Nephelometry

Oligoclonal free light chains (FLC) banding has been described in multiple sclerosis (MS) and should be correlated with disease activity. However, discrepancies between studies have been reported because of differences in methods. A new quantitative, rapid, and automated method using nephelometry is now available. Our objective was to investigate the interest of this method for the diagnosis and prognosis of MS. For this purpose, FLC index was determined in paired samples of CSF and serum from consecutive and unselected patients from the same department of neurology. We enrolled 89 patients (33 MS, 15 “possible MS”, and 41 controls) and correlated with IgG index, IgG oligoclonal banding, and clinical MS progression criteria. The main results were (1) FLC kappa index was more sensitive but less specific than IgG index for the diagnosis of MS, (2) two MS patients were negative for oligoclonal banding but exhibited a positive kappa index, (3) no relation between FLC kappa indices, MS clinical criteria, and disease progression was found. In conclusion, FLC kappa index should be considered as a useful complementary test for MS diagnosis. Its pronostic interest remains to be determined on a larger cohort of possible MS patients.