Signet Ring Cell Carcinoma Presenting as a Necrotic Duodenocolic Fistulizing Mass.

A 79-year-old female was referred for endoscopic evaluation after a positive fecal occult blood test. There was a long-standing history of iron deficiency anemia, weight loss with intermittent touts of intractable vomiting, and nausea. Esophagogastroduodenoscopy revealed a secondary lumen between the duodenum and transverse colon with necrotic mucosa and a blind opening. Subsequent colonoscopy revealed similar necrotic mucosa at the transverse colon and fistula formation with communication into the duodenum. Signet ring cell carcinoma (SRCC) was evident in histologic analysis. SRCC carries a poorer prognosis than other variants of colorectal carcinoma (CRC). Proposed mechanisms of increased mucin production can lead to mucosal wall destruction and have profound manifestations, such as in our patient with duodenocolic fistula.

Experience With Normal Breathhold Planning Scans for Radiosurgery of Moving Targets With Live Tracking.

PURPOSE: Utilization of breathhold scans with live tracking has a long track record of good published outcomes for stereotactic body radiation therapy (SBRT) and is recommended by the manufacturer of the Synchrony tracking system. However, the popularity of four-dimensional computed tomography (4DCT) scans challenges the validity of the breathhold scan with live tracking technique. Although this study is not intended to prove the superiority of either method, we demonstrate the feasibility of using the breathhold scans with a phantom test and clinical examples. METHODS: A 4DCT of a perfect sphere was scanned at 20 breaths per minute and compared to a 4DCT of a small lung tumor in one patient and a 4DCT of a larger renal tumor in another patient, as well as to fiducial matching in a patient with pancreatic cancer. Normal exhale and normal inhale breathhold CT scans were performed for the pancreatic cancer patient, combined with Synchrony tracking on CyberKnife (Sunnyvale, CA: Accuray) for treatment. RESULTS: The 4DCT scan of the phantom exhibited considerable apparent deformation, which must be entirely due to imaging artifact since the perfect sphere in the phantom is known to be completely rigid. The 4DCT of the lung and renal tumors in patients had similar apparent deformation. Usually in patients, from 4DCT alone, it is difficult to determine how much was due to deformation and how much was due to artifact. Fiducial positions in the final normal exhale and normal inhale breathhold scans for Synchrony matched each other within 1mm for the pancreatic cancer patient. CONCLUSION: We demonstrated the feasibility of breathhold scans with Synchrony live tracking, as recommended by the manufacturer. More studies will be needed to determine whether this method is better than using a 4DCT.

Early Detection of Immune-Mediated Hypophysitis With Use of Checkpoint Inhibitor Immunotherapy.

Hypophysitis is the inflammation of the pituitary gland with varying effects on hormone function that may be present secondary to the use of certain medications, infections, systemic inflammatory disorders, and other etiologies. Immunotherapy-related hypophysitis is a rare phenomenon. However, it represents an indication of treatment interruption. We report a 60-year-old female with renal clear cell carcinoma on Nivolumab and Ipilimumab (NIVO/IPI) intravenously (IV). After the second cycle of therapy, the patient reported a fall, with associated lightheadedness, dizziness, nausea, vomiting, and hot flashes. The patient's symptoms and history were concerning for hypophysitis, so early treatment and cessation of the checkpoint inhibitors led to the patient's clinical improvement.

Evaluation of pharyngeal carriage of Neisseria meningitidis in Tehran, Iran.

Meningitis and meningococcal septicemia are potentially life-threatening illnesses; young people in educational institutions have been repeatedly exposed to outbreaks of meningococcal infections. Since invasive meningococcal disease is preceded by pharyngeal carriage of Neisseria meningitidis, ascertaining the prevalence of meningococcal carriage in this population is of utmost importance. The aim of this study was to determine the rate of meningococcal carriage in students of Shahid Beheshti University of Medical Sciences. This cross-sectional study was conducted on pharyngeal swab specimens of 251 healthy asymptomatic students from November 2019 for one year. A questionnaire was used to find correlation between isolation of Neisseria spp. and the place of residence, number of roommates, antibiotic use in the last month, and smoking. One sample from each student was used for culture on general and selective culture media for Neisseria spp. Polymerase chain reaction was used for the final diagnosis of Neisseria meningitidis. Participants in the study included 222 medical students (88.4%), 23 nursing students (9.2%) and 6 radiology students (2.4%). Mean (IQR1) age of students was 23 years, 134 students were female, (53.4%); 234 students were single, (93.2%). 92 students (36.7%) lived in dormitories. Neisseria were isolated from 18 specimens (7.2%), of which 11 (4.4%) were pigmented bacteria. PCR assay did not detect Neisseria meningitidis in any of the samples. This study showed that meningococcal bacteria were not detected in any of the oropharyngeal specimens from students participating in the study during the one-year study period.

Late Manifestation of Massive Jejunal and Cecal Varices Post Liver and Small Bowel Transplantation in a Patient With Microvillus Inclusion Disease.

We report the case of an 18-year-old male with a medical history of microvillous inclusion disease (MID) and notable surgical history of small bowel, liver, and pancreas transplant who presented with massive jejunal and cecal varices. Endoscopy findings demonstrated a large grape-like cluster, with subsequent CT angiography (CTA) showing other variceal lesions in the cecum. The patient was transferred to the original transplant center for recommended open surgical evaluation and combined interventional radiology (IR) embolization of varices. MID is a rare genetic disorder caused by mutations in the Myosin VB (MYO5B) gene leading to a lack of myosin Vb. Patients subsequently develop liver damage at birth, which necessitates a small bowel/liver transplant in childhood.

Effect of fasting in Ramadan on body composition and nutritional intake: a prospective study.

BACKGROUND: The present study aimed to assess the effects of Ramadan intermittent fasting on body weight and composition and the effects of age and sex. METHODS: Body weight, height, waist and hip circumferences were measured, body mass index (BMI) was calculated and fat mass, fat-free mass and percentage body fat were assessed by bioelectrical impedance on 240 adult subjects (male: 158) who fasted between sunrise and sunset for at least 20 days. Measurements were taken 1 week before and 1 week after Ramadan. Energy and macronutrient intakes were assessed using a 3-day food frequency questionnaire on a sub-sample of subjects before and during Ramadan. RESULTS: Subjects were grouped according to age and sex: ≤35 years (n = 82, males: 31) and 36-70 years (n = 158, males: 127). There were significant reductions in weight and BMI (P < 0.001) in almost all subjects, with the biggest being in males ≤35 years [-2.2% (SE 2.2%), P < 0.001]. Waist and hip circumferences fell in most subjects, except females aged 36-70 years. Fat mass fell in most subjects, ranging from 2.3% to 4.3% from baseline, except in females aged 36-70 years who did not experience a significant change. Fat-free mass was significantly reduced in all subjects (P < 0.001), whereas percentage body fat was lower only in males by 2.5% (SE 3.2%) (P = 0.029) in those aged ≤35 years and by 1.1% (SE 1.5%) (P < 0.001) in those aged 36-70 years. Dietary intake was similar before and during Ramadan, except in males whose protein intake fell during Ramadan (P = 0.032). CONCLUSIONS: Ramadan fasting leads to weight loss and fat-free mass reductions. Body composition changes vary depending on age and sex.

The use of baby walkers in Iranian infants.

INTRODUCTION: A study was conducted to define the pattern of baby walker usage and the rate of walker-related injuries in infants, as well as to determine the effects of baby walkers on the start of independent walking among infants. METHODS: Families of infants aged six months to two years who presented at health facility clinics in 2007 and 2008 were enrolled in the study. The study team interviewed the primary caregiver and documented the relevant data on a pre-designed questionnaire. The data of users of baby walkers was compared with that of non-users. RESULTS: Walkers were used by 54.5 percent of 414 infants. Their use was significantly higher in one-child families (p-value is 0.009) and in those with higher parental education levels (p-value is less than 0.001). 78.6 percent of users and 85 percent of non-users were walking by 12 months of age (p-value is 0.283); no significant difference was observed between the two groups in terms of the age at which the infants starting walking (p-value is 0.401). 76.8 percent of parents of users versus 8.2 percent of parents of non-users believed that walkers promote early walking (p-value is less than 0.001). 44.7 percent of parents of users knew that walkers can be hazardous, as compared to 22.3 percent of parents of non-users. No serious injury was reported, but 14.1 percent of infants sustained trivial walker-associated injuries. CONCLUSION: Baby walkers do not hasten independent walking and may be associated with injuries. However, it was noted that knowledge of the associated hazards has not deterred parents from using baby walkers for their infants.

An iron-capped metal-organic polyyne: {[Fe](C[triple bond]C)2[W][triple bond]CC[triple bond]CC[triple bond][W](C[triple bond]C)2[Fe]}.

The organometallic conjugated complex H(C[triple bond]C)(2)[W][triple bond]CC[triple bond]CC[triple bond][W](C[triple bond]C)(2)H {[W] = W(dppe)(2); dppe = 1,2-bis(diphenylphosphino)ethane} containing a ditungstenatetradecaheptayne unit was synthesized by utilizing a new and efficient coupling method. The stannylated derivative was converted to the tetranuclear complex, which exhibits efficient long-range electron transfer.

Effects of passive smoking on common respiratory symptoms in young children.

AIM: To observe the effects of fathers' smoking on respiratory symptoms in children between the ages of 6 mo and 5 y living in Tehran during the period January to December 2001. METHODS: The caregivers of 622 children attending resident-based clinics in two university hospitals were interviewed about the respiratory illnesses incurred by the child during the previous 12 mo and the smoking habits of those living with the child. Children who lived in households in which any person, other than the father, smoked were excluded. RESULTS: The analysis included 595 children, 40.6% of whom were living in homes where fathers smoked cigarettes. About 35% of smokers admitted to unrestricted smoking at home. In children not living with a smoker, 81.6% had experienced at least one episode of upper respiratory tract infection (URTI) during the previous year and the rate increased to 95.2% in passive smokers whose fathers were not restricted from smoking in front of the children, (p-value <0.01). A similar pattern was found for otitis media and asthma (p-value <0.05 and <0.01, respectively). The average number of URTI episodes during the previous year was significantly higher in children exposed to unrestricted smoking (p <0.01). CONCLUSION: The study outlines the detrimental effects of paternal smoking on the respiratory health of children from a part of world in which this problem has not been studied previously, and highlights the importance of educating fathers to alter their smoking habits so that even if they do not stop smoking altogether, they should discontinue smoking indoors.

Febrile seizures: clinical course and diagnostic evaluation.

A study was done on 111 children admitted in a university hospital in Tehran with fever and seizures to document the pattern of illness and to define indications for performing a lumbar puncture in children with fever and convulsions. Bacterial meningitis was diagnosed in 4 patients, aseptic meningitis in 2 and 105 children had febrile seizures. The cause of fever was gastro-enteritis in 39 patients and upper respiratory tract infection with or without Otitis media in 40. Although most patients were drowsy on admission (n = 93), none had any signs of meningeal irritation, except one child with slight nuchal rigidity. Out of the 4 children with bacterial meningitis, 3 had meningeal signs, but in one 10 month old baby with no signs, the diagnosis was made on the cerebro-spinal fluid findings after a lumbar puncture. These results support the view that a lumbar puncture should be performed on all infants under 12 months who present with fever and convulsions and strongly considered between 12 and 18 months. After 18 months a lumbar puncture is mandatory in the presence of signs of meningeal irritation.

Acute glomerulonephritis in children.

Acute glomerulonephritis (AGN) remains fairly common in the developing world although its frequency has declined in the industrial countries. The pattern of AGN was studied in one hundred hospitalised children. We recorded an increased prevalence in school age, i.e., 6-15 years (75%) and the occurrence of a streptococcal infection (90%), most often a pharyngeal infection (86%), one to three weeks preceding the illness. The problems that needed specific management during the acute phase were hypertension (39%), encephalopathy (5%) and ARF with hyperkalemia, 2% of the patients needing haemodialysis. Most of our patients (98%) recovered with 2% progressing to RPGN. The excellent prognosis of AGN with proper management emphasises the need for optimal care during the acute phase in the hospitalised children.