A Randomized Controlled Trial of Intravenous versus Oral Cyclophosphamide in Steroid-resistant Nephrotic Syndrome in Children.

This is a randomized, parallel group, active-controlled trial to compare the efficacy of intravenous cyclophosphamide (IVCP) with oral cyclophosphamide (OCP) in patients with steroid-resistant nephrotic syndrome (SRNS) in children. Fifty consecutive children with idiopathic SRNS were biopsied and then randomized to receive either OCP at a dose of 2 mg/kg/day for 12 weeks or IVCP at a dose of 500 mg/m2/month for 6 months. Both groups received tapering doses of oral steroids. The response was evaluated in terms of induction of complete remission (CR) or partial remission (PR), time to remit, and side effects. The groups were followed up to determine the duration of remission, percentage of patients who remain in sustained remission for more than 1 year after completion of therapy, change in steroid response status, progression to chronic kidney disease stage 3 or more. Of the fifty patients, OCP was given to 25 children and IVCP to 25 children. The demographic data, histopathology, biochemical profile, and duration of follow-up in the two groups were comparable. The rates of induction of CR were 52% versus 44% and of PR were 8% versus 8% in the intravenous (IV) and oral group, respectively. Time to remit was shorter with OCP than IVCP (53 days vs. 84.4 days). Incidence of side effects (both major and minor) was 36% in IVCP versus 20% in OCP group. The actuarial cumulative sustained remission in our study was 12% in IVCP compared with 16% in OCP at 1 year after completion of therapy. Twelve percent children in both the groups exhibited restoration of steroid sensitivity. Thus, in our study, overall, more than half of SRNS patients showed initial response to cyclophosphamide, but only one-fourth patients had sustained remission on follow-up. OCP and IVCP were equally efficacious and safe in idiopathic SRNS in children.

Acute renal failure secondary to ingestion of ayurvedic medicine containing mercury.

Several traditional medicines contain potentially toxic heavy metals. Heavy metal poisoning is not an uncommon cause of renal damage, although the diagnosis can be easily missed. We report a case of chronic ingestion of an ayurvedic medicine containing mercury in a 2-year-old girl, resulting in anuric renal failure due to acute interstitial nephritis.

Epidural labour analgesia using Bupivacaine and Clonidine.

BACKGROUND: To compare the effects of addition of Clonidine (60 µg) to Epidural Bupivacaine (0.125%) for labour analgesia, with regard to duration of analgesia, duration of labour, ambulation, incidence of instrumentation and caesarean section, foetal outcome, patient satisfaction and side effects. PATIENTS #ENTITYSTARTX00026; METHODS: On demand, epidural labour analgesia was given to 50 nulliparous healthy term parturients (cephalic presentation), divided in two groups randomly. Group I received bupivacaine (0.125%) alone, whereas Group II received bupivacaine (0.125%) along with Clonidine (60 µg). 10 ml of 0.125% bupivacaine was injected as first dose and further doses titrated with patient relief (Numerical Rating Scale <3). Top ups were given whenever Numerical Rating Scale went above 5. RESULTS: There was statistically significant prolongation of duration of analgesia in Group II, with no difference in duration of labour, ambulation, incidence of instrumentation and caesarean section or foetal outcome. Also clonidine gave dose sparing effect to bupivacaine and there was better patient satisfaction without any significant side effects in Group II. CONCLUSION: Clonidine is a useful adjunct to bupivacaine for epidural labour analgesia and can be considered as alternative to opioids.

Liposarcoma of the breast--a case report.

Sarcoma of the breast constitutes less than 1% of all malignant breast tumors and liposarcoma of the breast has an incidence of 0.3% of all the mammary sarcomas. A 90-year-old woman presented with a mass in the upper outer quadrant of the right breast measuring 25 x 15 x 7 cm. Mammography was performed and the mass was diagnosed as a liposarcoma. A wide excision was performed with a 2 cm margin of healthy tissue. The tumor was diagnosed histologically as a fibrous liposarcoma. The patient was discharged and her postoperative recovery was uneventful. We report a case of liposarcoma of the breast and discuss this rare malignant tumor together with the various diagnostic and therapeutic modalities used.

Anatomic landmarks: their usefulness in safe laparoscopic cholecystectomy.

The incidence of bile duct injury in laparoscopic cholecystectomy is 0.3% to 1.0%. This is higher than the incidence reported for open cholecystectomy (i.e., 0.1-0.2%), and the surgeons all over the world are relentlessly trying to find the ways and means to lower this incidence. Various operating strategies, techniques, and instrumentations such as the 0 degrees telescope, intraoperative cholangiogram, hydrodissection, and peanut gauze dissection have been claimed by various authors to minimize the risk of bile duct injury during cholecystectomy. However, the surgical fraternity agrees that there has been no substitute for meticulous dissection and display of various vital structures near the common bile duct. The authors describe seven anatomic landmarks encountered during laparoscopic cholecystectomy that assist in safe dissection to prevent bile duct and vascular injury. On the basis of their experience, they believe that if surgeons adhere to these landmarks, excellent results can be achieved.

Primary branchial cleft carcinoma--a case report.

Primary branchial cleft carcinoma is a diagnostic challenge. The majority of cases have been shown, following the application of rigid criteria, to have developed from an occult metastasis elsewhere. We describe what we believe to be only the second reported case in a patient who fulfils all of the established criteria.

Evidence for thyroid development from the fourth branchial pouch.

Fourth branchial pouch anomalies are rarely reported. A case is described of an isolated branchial cyst which was found to contain ectopic thyroid tissue. This case, together with four others previously reported, support the theory that the thyroid gland may receive contributions from the fourth branchial pouch during development.

Ileal conduit for reconstruction of the duodenum following right hemicolectomy and pancreaticoduodenectomy for malignant duodenocolic fistula.

We describe a case of malignant duodenocolic fistula in which after a radical resection of right hemicolectomy and pancreaticoduodenectomy, the duodenal defect was reconstructed using a conduit of transposed ileum. This technique, not previously described, offers an alternative to 'duodenal patching', which allows only limited duodenal resection, or gastroenterostomy with its attendant side-effects such as dumping syndrome.

The relationship between clinical staging, oestrogen receptor status and silver-binding nucleolar organiser regions (AgNOR) in breast carcinoma.

Forty benign and 31 malignant breast tissues were examined using a one stage colloid-stabilising silver technique for argyrophilic nucleolar organiser regions (AgNOR). In 31 patients TNM staging was correlated to AgNOR score. There was a positive correlation with the T-stage and AgNOR score of the tumor (Spearman's rank correlation coefficient = 0.437). The N-stage and AgNOR score for breast cancers (n = 10) were inversely related, and there was a significant difference between the lymph node positive and negative groups (P less than 0.05). No significant relationship was identified between oestrogen receptor negative and positive groups and AgNOR score (P = 0.63). Mean regression analysis suggests that independent of the Bloom's grade, the AgNOR score is an indicator of tumour size.

Influence of microinjection of insulin into the ventromedial hypothalamus on acetate metabolism in rumen epithelium of sheep.

Injections of 50 microU insulin into the ventromedial hypothalamic nuclei (VMH) in intact sheep decreased the rates of 14C transfer from 14C-1-acetate into CO2, glucose, ketone bodies, and increased the rates into triglyceride and phospholipids in rumen epithelium of sheep. Insulin injections into the parietal cortex of intact sheep or into the VMH of sheep with VMH lesions had no effect on the acetate metabolism in rumen epithelium as compared with the control groups which received saline injections into the same brain regions. These results support the view that the VMH serves as an integral part of an insulin-sensitive brain regulatory system in the acetate metabolism of rumen epithelium.

Influence of microinjection of corticosterone into ventromedial hypothalamus on hepatic acetate metabolism in rabbits.

Corticosterone was injected into the ventromedial hypothalamus (VMH) of rabbits, and changes in hepatic acetate metabolism were studied. The microinjection of corticosterone with seasame oil into the VMH of intact rabbits increased the rates of 14C transfer from 14C-1-acetate into CO2, glucose, ketone bodies, triglyceride, free cholesterol, free fatty acids and phospholipids but decreased those of 14C transfer into cholesterol ester. However, corticosterone injected into the VMH of rabbits with VMH lesions or the parietal cortex of intact rabbits was without effect on the hepatic acetate metabolism. From these results it might be suggested that the VMH is an integral part of the corticosterone-sensitive brain regulator system in the hepatic acetate metabolism.

Influence of microinjection of corticosterone into hippocampus on hepatic acetate metabolism in rabbits.

Corticosterone was injected directly into the hippocampus of rabbits, and changes in hepatic acetate metabolism were studied. The microinjection of corticosterone with seasame oil into hippocampus decreased the rates of 14C transfer from 14C-1-acetate into CO2 and free cholesterol, and increased 14C transfer into glucose, ketone bodies, triglyceride, free fatty acids and phospholipids. But after microinjection of corticosterone into the hippocampus of rabbits with lesions of dorsal fornix, hepatic acetate metabolism did not differ from that of control rabbits, which received injection of seasame oil into the same brain region. From these results it might be suggested that the hippocampus is a part of corticosterone-sensitive brain regulator system in the hepatic acetate metabolism.

Orthostatic responses in heat tolerant and intolerant subjects compared by three different methods.

The orthostatic responses of 10 heat tolerant and five intolerant subjects were evaluated by three different test methods--standing, head-up tilt (HUT), and head-up tilt after prolonged exercise (HUTPE)--in a hot environment of 40 degrees C, 40% RH. No difference was found within the normal group between responses in the standing and HUT test. In the HUTPE test, orthostatic responses were inadequate and 5 of 10 subjects fainted. The heat intolerant subjects reacted to all three tests similarly to the normal group, though their heart rate was higher and 3 out of 5 fainted at an earlier phase in the HUTPE test.

Histocompatibility (HLA) antigens in heterotopic ossification associated with neurological injury.

Twenty patients with heterotopic ossification were HLA typed. The group consisted of 12 patients with severe cranio-cerebral injury and 8 with spinal cord injury. No significant differences in the frequency of any HLA antigens were found in these patients when compared to 631 healthy matched controls. None of the patients was B27 positive.

Age and sex difference in response to short exposure to extreme dry heat.

Sixty volunteers, 33 males and 27 females (18-63 yr), were divided according to age and sex. They were exposed for 10 min to extreme dry heat: 80-90 degrees C dry bulb temperature and 3-4% relative humidity. Their rectal temperature, skin temperature at eight different points, weight, and heart rate were recorded prior to and immediately following the exposure. A mean rise of only 0.5 degrees C in rectal temperature was recorded following exposure as compared to a mean rise of 5.2 degrees C in mean weighted skin temperature (MWST). Female subjects showed a significantly higher rise in MWST than the male subjects. Similarly, a significantly higher rise in MWST was observed in elderly male subjects as compared to the youngest male group (P less than 0.05). The differences in MWST possibly resulted from differences in mean skin blood flow causing differences in skin conductance. Large individual variation in heat response was recorded in rectal temperature, as well as in weighted skin temperatures. The increase in skin temperature during the first 10 min of exposure to extreme dry heat may serve as an indicator for heat tolerance time, and may help predicting heatstroke susceptible individuals.