Malnutrition modifies the response to multimodal prehabilitation: a pooled analysis of prehabilitation trials.

Patients with colorectal cancer are at risk of malnutrition before surgery. Multimodal prehabilitation (nutrition, exercise, stress reduction) readies patients physically and mentally for their operation. However, it is unclear whether extent of malnutrition influences prehabilitation outcomes. We conducted a pooled analysis from five 4-week multimodal prehabilitation trials in colorectal cancer surgery (prehabilitation: n = 195; control: n = 71). Each patient's nutritional status was evaluated at baseline using the Patient-Generated Subjective Global Assessment (PG-SGA; higher score, greater need for treatment of malnutrition). Functional walking capacity was measured with the 6-minute walk test distance (6MWD) at baseline and before surgery. A multivariable mixed effects logistic regression model evaluated the potential modifying effect of PG-SGA on a clinically meaningful change of ≥19 m in 6MWD before surgery. Multimodal prehabilitation increased the odds by 3.4 times that colorectal cancer patients improved their 6MWD before surgery as compared with control (95% confidence interval (CI): 1.6 to 7.3; P = 0.001, n = 220). Nutritional status significantly modified this outcome (P = 0.007): Neither those patients with PG-SGA ≥9 (adjusted odds ratio: 1.3; 95% CI: 0.23 to 7.2, P = 0.771, n = 39) nor PG-SGA <4 (adjusted odds ratio: 1.3; 95% CI: 0.5 to 3.8, P = 0.574, n = 87) improved in 6MWD with prehabilitation. In conclusion, baseline nutritional status modifies prehabilitation effectiveness before colorectal cancer surgery. Patients with a PG-SGA score 4-8 appear to benefit most (physically) from 4 weeks of multimodal prehabilitation. Novelty: Nutritional status is an effect modifier of prehabilitation physical function outcomes. Patients with a PG-SGA score 4-8 benefited physically from 4 weeks of multimodal prehabilitation.

Dental Negligence: Accidental Administration of Formalin Instead of Local Anesthetic.

A solution like formalin used as a fixative has to be handled with lot of care and needs to be stored with utmost care. Negligence on part of the dental professional by accidentally injecting formalin instead of the local anesthetic can lead to permanent tissue damage and also may induce a life threatening situation. The operating dentist injected formalin accidentally instead of the local anesthetic and the patient experienced severe pain and burning sensation. The general practice of formalin being stored in the local anesthetic bottles and being assisted by untrained assistant is the most common reason for mishaps to happen. The dentist operating should be careful and aware of the drugs and chemicals being available in the operatory and re-check the solution being injected in the patient as to not land up in complications because of the negligence.

Immunotherapy for Alzheimer's Disease: Current Scenario and Future Perspectives.

Alzheimer's disease (AD) is a global health concern owing to its complexity, which often poses a great challenge to the development of therapeutic approaches. No single theory has yet accounted for the various risk factors leading to the pathological and clinical manifestations of dementia-type AD. Therefore, treatment options targeting various molecules involved in the pathogenesis of the disease have been unsuccessful. However, the exploration of various immunotherapeutic avenues revitalizes hope after decades of disappointment. The hallmark of a good immunotherapeutic candidate is not only to remove amyloid plaques but also to slow cognitive decline. In line with this, both active and passive immunotherapy have shown success and limitations. Recent approval of aducanumab for the treatment of AD demonstrates how close passive immunotherapy is to being successful. However, several major bottlenecks still need to be resolved. This review outlines recent successes and challenges in the pursuit of an AD vaccine.

T1-weighted dynamic contrast-enhanced MR evaluation of different stages of neurocysticercosis and its relationship with serum MMP-9 expression.

BACKGROUND AND PURPOSE: Epileptogenesis in NCC is associated with perilesional inflammation and disruption in BBB. We quantified BBB in different stages of NCC by using DCE-MR imaging to look for the differences in perfusion indices and to correlate these indices with serum MMP-9 expression. MATERIALS AND METHODS: DCE-MR imaging along with conventional MR imaging was performed in 57 single cysticercous brain lesions to quantify the kep, K(trans), and ve around the lesions, which were in different stages of evolution. There were 6 lesions in the vesicular stage and 17 lesions each in the colloidal, granular-nodular, and calcified stages. Serum MMP-9 was quantified from all patients, whereas perfusion indices were quantified from all stages except for the vesicular stage. RESULTS: We observed significant differences among the 3 stages of NCC in serum MMP-9 expression as well as DCE-derived kep values. In addition, kep showed a strongly significant positive correlation with MMP-9 expression when modeled with the individual stage of the disease as well as with all stages when pooled together. Other DCE-derived hemodynamic and pharmacokinetic parameters showed inconsistent differences with each stage of the disease. The correlation of DCE-derived parameters with serum MMP-9 expression and edema volume also showed inconsistency with the stage of the disease. CONCLUSIONS: We conclude that kep correlates best with serum MMP-9 expression among the pharmacokinetic indices and most closely represents the degree of BBB breakdown, which is highest in the colloidal stage and lowest in the calcified stage. kep may be used as a noninvasive image biomarker of BBB breakdown in different stages of NCC.

An exploratory study into the role of dynamic contrast-enhanced (DCE) MRI metrics as predictors of response in head and neck cancers.

AIM: To assess the efficacy of dynamic contrast-enhanced magnetic resonance imaging (DCE MRI) in prediction of the response to treatment in patients with head and neck cancers (HNCs). METHODS AND MATERIALS: Twenty-one patients with advanced HNC, suitable for concurrent chemoradiotherapy underwent DCE MRI, for the quantification of blood flow (BF) and volume (BV). All the patients received radical doses of conventionally fractionated radiotherapy up to a dose of 70 Gy along with concurrent weekly cisplatin. RESULTS: The values of BV and BF were higher in complete responders as compared to partial responders at primary as well as nodes. Both BF and BV were found to be significantly higher in patients with high T-stage as compared to patients with lower T-stage. CONCLUSIONS: DCE metrics can be used as a predictor of response to treatment in locally advanced HNCs after validation of these observations in a larger number of patients.

Biochemical and physiological responses of rice (Oryza sativa L.) as influenced by Trichoderma harzianum under drought stress.

Rice is one of the most important food crops drastically affected by drought in lowland rice ecosystems. In the present study, the impact of drought tolerant isolates of endophytic fungus Trichoderma harzianum on rice response to drought was investigated. Out of 43 Trichoderma isolates studied, only five isolates viz., Th 56, Th 69, Th 75, Th 82 and Th 89 were selected to be drought tolerant as these were able to colonize well on cow dung at low moisture content of 10-20 percent, though two isolates, Th 56 and Th 75, grew even at 5 percent moisture content. Trichoderma-colonized rice seedlings were slower to wilt in response to drought. Colonization delayed drought induced changes like stomatal conductance, net photosynthesis and leaf greenness. Drought conditions varying from 3 to 9 days of withholding water led to an increase in the concentration of many stress induced metabolites in rice leaves and decrease of MSI, while Trichoderma colonization caused a decrease in proline, MDA and H2O2 contents, and increase in phenolics concentration and MSI. Among test isolates, Th 56 induced maximum drought tolerance as treated plants recorded only 20-40 percent wilting even at 9 DDS. With or without exposure to drought, colonization by Trichoderma promoted seedling growth, with Th 56 giving the most consistent effect. The primary direct effect of Trichoderma colonization was promotion of root growth, regardless of water status, which caused delay in the drought responses of rice plants.

Understanding epileptogenesis in calcified neurocysticercosis with perfusion MRI.

OBJECTIVES: Calcified cysticercus larva with perilesional abnormality is thought to be responsible for seizures in patients with neurocysticercosis (NCC). However, it is not well understood why some calcified cysts are associated with seizures even without perilesional abnormality. METHODS: The study group consists of 30 subjects from an ongoing survey for disease burden estimation of a swine farming community who had a single calcified lesion without any perilesional abnormality with or without presentation of seizures. Each group consisted of 15 patients with calcified cysts and was labeled as asymptomatic and symptomatic. We performed dynamic contrast-enhanced (DCE) MRI on all these subjects and determined serum matrix metalloproteinase-9 (MMP-9) levels and MMP-9 gene polymorphisms. RESULTS: DCE-MRI-derived rate transfer constant (k(ep)) and serum MMP-9 levels showed significant differences between symptomatic and asymptomatic subjects. We observed an increase in the MMP-9 levels, k(ep), and the volume transfer coefficient (k(trans)) in these lesions. We also observed a significant increase in MMP-9 (R279Q) gene polymorphism in symptomatic subjects compared with asymptomatic and control subjects. CONCLUSIONS: Perilesional inflammation, which varies from symptomatic to asymptomatic subjects, can be quantified using DCE-MRI in calcified cysticercosis and may help distinguish these 2 groups with similar imaging findings. The observed increase in k(ep) with serum MMP-9 levels suggests that the former may serve as a biomarker of MMP-9 levels in these subjects. The significant MMP-9 (R279Q) gene polymorphism in symptomatic subjects might explain the differences in the observed DCE-MRI indices between symptomatic and asymptomatic subjects.

Comparative study on the effect of chemicals on Alternaria blight in Indian mustard--a multi-location study in India.

High severity of Altemaria blight disease is a major constraint in production of rapeseed-mustard in India. The aim of this study was to investigate the suppressive potential of chemicals viz., zinc sulphate, borax, sulphur, potash and calcium sulphate, aqueous extracts viz., Eucalyptus globosus (50 g l-1) leaf extract and garlic (Allium sativum) bulb (20 g l-1) extract, cow urine and bio-agents Trichoderma harzianum, Pseudomonas fluorescence in comparison with the recommended chemical fungicide (mancozeb), against foliar disease Alternaria blight of Indian mustard [Brassica juncea (L.) Czern. and Coss] under five different geographical locations of India. Mancozeb recorded the lowest mean severity (leaf: 33.1%; pod: 26.3%) of Alternaria blight with efficacy of garlic bulb extract alone (leaf = 34.4%; pod = 27.3%) or in combination with cow urine (leaf = 34.2%; pod = 28.6%) being statistically at par with the recommended chemical fungicide. Chemicals also proved effective in reducing Alternaria blight severity on leaves and pods of Indian mustard (leaf = 36.3-37.9%; pod = 27.5-30.1%). The effective treatments besides providing significant reduction in disease severity also enabled increase in dry seed yield of the crop (mancozeb = 2052 kg ha-1; garlic = 2006 kg ha-1; control = 1561 kg ha-1).

Correlation of phase values with CT Hounsfield and R2* values in calcified neurocysticercosis.

PURPOSE: To correlate phase and R2* derived from susceptibility-weighted magnetic resonance imaging (MRI) with computed tomography-Hounsfield (CT-HU) values in calcified neurocysticercosis and to evaluate phase imaging in the assessment of calcified neurocysticercosis. MATERIALS AND METHODS: Thirty-five patients with 52 calcified lesions underwent both CT and MRI. Phase and R2* were calculated from multi-echo 3D-T2-star-weighted-angiography data. MRI and CT data were coregistered using mutual information. Spearman's correlation was performed between quantitative phase and CT-HU and R2* values. The Mann-Whitney U-test was used to see differences between CT-HU and R2* values from corresponding positive and negative phase regions. RESULTS: The median values of CT-HU and R2* from regions with positive and negative phase were found to be 142.10 (range: 41.89-491.75) and 68.5/sec (range: 20-110/sec) and 137.30 (range: 30.83-458.88) and 69/sec (range: 0-110/sec), respectively. There was a significant correlation of positive phase values with corresponding CT-HU and R2* values. In addition, there was a significant correlation of R2* and CT-HU with negative phase values. CONCLUSION: We conclude that there is a significant correlation between negative and positive phase with CT-HU and R2* values, suggesting that the CT hyperdense lesion may have both calcium and other minerals, which can be differentiated using phase imaging. Conventional MRI should include phase imaging to detect calcified neurocysticercosis.

Apparent diffusion coefficient with higher b-value correlates better with viable cell count quantified from the cavity of brain abscess.

BACKGROUND AND PURPOSE: DWI by using higher b-values provides tissue diffusivity with less T2 shinethrough effect. VCD in the abscess cavity correlates with ADC values. The purpose of this study was to investigate which b-value-derived ADC correlates better with VCD. MATERIALS AND METHODS: Thirty patients with brain abscess underwent conventional MR imaging and DWI with b = 1000, 2000, and 3000 s/mm(2) on a 3T MR imaging scanner. ADC values were quantified by placing regions of interest inside the abscess cavity in all sections where the lesion was apparent on coregistered ADC maps derived from different b-values. VCD was measured on pus aspirated. RESULTS: An increase in b-value was associated with a decrease in ADC values in normal parenchyma as well as in the abscess cavity. The most significant negative correlation of VCD was observed with b = 3000 s/mm(2) (r = -0.98, P = .01). CONCLUSIONS: VCD in the abscess cavity can be best assessed at b = 3000 s/mm(2) secondary to the reduction in the T2 shinethrough effect. DWI with b = 3000 s/mm(2) is of promising value in the assessment of the therapeutic response of brain abscess.

Cerebellar ataxia following snake bite.

Neurotoxic snake envenomations are frequently encountered in medicine emergencies. Here we report a case of snakebite who presented with neuromuscular paralysis and respiratory failure, showed full recovery after effective treatment. Patient however developed cerebellar ataxia possibly due to delayed neurotoxicity of venom.

Primary synovial osteochondromatosis of the first metatarsophalangeal joint, literature review of a rare presentation and a case report.

Synovial osteochondromatosis is a rare condition, found mainly in larger joints, where as it is particularly rarer in small joints especially the metatarsophalangeal joint. We report the case of a 45-year-old man with primary synovial osteochondromatosis in the first metatarsophalangeal joint. Following surgical intervention, the diagnosis was confirmed with histological examination. The patient had successful management and is completely symptom free on 12-month review. A summary of the case and review of the current literature with the incidence of this condition and risks involved are discussed.

Diffusion tensor MR imaging in children with pantothenate kinase-associated neurodegeneration with brain iron accumulation and their siblings.

BACKGROUND AND PURPOSE: It has been reported that iron concentration influences DTI metrics in deep gray matter nuclei. We hypothesized that increased FA in the deep gray nuclei may indicate abnormal iron accumulation in patients with PKAN and their siblings. MATERIALS AND METHODS: Seven patients with the characteristic "eye-of-the-tiger sign," their 5 siblings, and 5 age-matched controls were prospectively studied. One-way ANOVA with Bonferroni post hoc multiple comparisons was used to compare DTI metrics (FA and MD) among subject groups in the putamen, CN, GP, SN, and ALIC. In addition, hypointense and hyperintense regions of the eye-of-the-tiger sign were segmented, and their DTI metrics were compared. In the patient group, the values of DTI metrics in hypointense regions were also compared with those of the ALIC. RESULTS: A significant increase in FA values of the GP and SN from controls to the patient group to siblings was observed. In the GP, MD values were significantly higher in patients compared with controls and siblings. The patients showed significantly increased FA with decreased MD in hypointense compared with hyperintense regions of the eye-of-the-tiger sign. No difference in FA values were observed between the ALIC and hypointense regions of the eye-of-the-tiger sign in patients. CONCLUSIONS: High FA values in siblings of patients with PKAN suggest the presence of abnormal iron in deep gray matter nuclei, even in the absence of its demonstration on T2*-weighted GRE.

Placenta accreta.

Total placenta accreta is a rare condition. Its management is a dilemma. Attempted separation of the placenta in placenta accreta can cause torrential blood loss. Therefore an antenatal diagnosis of placenta accreta permits advance planning of delivery. Two alternatives are caesarean section through the fundus with subsequent immediate hysterectomy, which has traditionally been the treatment of choice or if the patient wishes more children, leaving the placenta in place and managing conservatively. We present a 38 year old lady who was diagnosed to have placenta accreta while performing a caesarean section for a breech presentation. We had to proceed with a total hysterectomy.

Biphasic solitary fibrous tumour: a report of two cases with epithelioid features.

We present two cases of solitary fibrous tumour (SFT) showing biphasic morphology with a spectrum of malignant epithelioid components. Slides prepared from formalin-fixed and paraffin-embedded tissue from both cases were stained with haematoxylin and eosin and by immunohistochemistry. Interphase fluorescent in situ hybridisation studies were performed in both cases using paraffin-embedded tissue to look for the t(X;18) translocation, thereby to exclude synovial sarcoma. Both cases showed biphasic morphology with some areas having typical benign spindled SFT morphology (including CD34 expression) and other areas having a malignant epithelioid appearance. In one of the cases, the epithelioid area, which was well circumscribed and showed packeting of cell groups, demonstrated expression of cytokeratin and epithelial cadherin but not of CD34. In the second case, the immunophenotype of the epithelioid component was similar to that of the benign SFT component. These findings suggest that epithelioid change in SFT shows a range of differentiation at one end, similar to that of a standard SFT, and at the other end, possibly acquiring epithelial characteristics.

Severe haematoma of the vulva--a report of two cases and a clinical review.

Haematoma of the vulva may occur following blunt trauma due to its highly vascular structure. We present two cases of haematoma of the vulva caused by domestic violence, following a kick on the perineum and falling astride on the perineum. Evacuation of the haematoma and repair of lacerated tissues were successfully performed.

Evaluation of perineurial differentiation in epithelioid sarcoma.

AIMS: To investigate the differentiation pattern of epithelioid sarcoma in terms of perineurial and endothelial differentiation, and its relationship to that of meningioma. METHODS AND RESULTS: Nine cases of epithelioid sarcoma and five cases of meningioma were studied in an immunohistochemical analysis of 'perineurial' antigens [GLUT-1, claudin-1, epithelial membrane antigen (EMA) and VE-cadherin] and of 'endothelial' antigens not present on normal perineurium (CD34, CD31, Fli-1). Both epithelioid sarcoma and meningioma showed frequent expression of the perineurial markers GLUT-1, claudin-1 and EMA. VE-cadherin was identified in one of five meningiomas, and in the only case of epithelioid sarcoma in which suitably fixed material was available. CD34 was expressed by all epithelioid sarcomas studied but by none of the meningiomas. Fli-1 was present in a substantial majority of epithelioid sarcomas and by all the meningiomas. CD31 was not detected in any epithelioid sarcoma or meningioma. CONCLUSIONS: The results were evaluated in the context of previous immunohistochemical, ultrastructural and genetic studies and suggest that epithelioid sarcoma may be a form of malignant perineurioma with a range of differentiation (epithelial features) akin to that seen in meningioma, reflecting the close relationship between perineurium and meningothelium.

Pedunculated angiomyxoma of the vulva - a rare clinical entity.

BACKGROUND: Aggressive angiomyxoma is an uncommon mesenchymal tumor that preferentially involves the pelvic and perineal regions of females. Since its initial description in 1983, approximately 65 cases have been reported in the English literature. CASE: A 33-year-old parous woman with a slow growing pedunculated soft tissue tumour of the vulva which later underwent surface ulceration. Pathological findings in the case were suggestive of an aggressive angiomyxoma, a distinctive soft tissue non-malignant tumour, which could, at times be locally aggressive.

Benign mixed tumour of the skin with extensive ossification and marrow formation: a case report.

Benign mixed tumour of the skin (chondroid syringoma) is an uncommon skin adnexal tumour, usually presenting as a slow growing solitary painless nodule. The morphological appearances are similar to those of a pleomorphic adenoma of the salivary gland. Hair matrix and sebaceous differentiation can be seen in some lesions. Focal ossification is a rare finding. This report presents a case of a similar tumour arising in the cheek of a 43 year old white man, showing extensive ossification. Clinical, radiological, and pathological correlation and diagnosis proved to be difficult preoperatively. Only two cases of a benign mixed tumour with pronounced ossification have been reported so far, both in Japanese patients. This is the first reported case seen in a white man. Awareness of these lesions will avoid potential diagnostic pitfalls.