There is more to this fever than meets the eye: A case of neuroleptic malignant-like syndrome (NMLS) secondary to withdrawal of procyclidine and L-dopa on a background of long-standing flupenthixol depot use.

This case report highlights the risk of development of Neuroleptic Malignant-Like Syndrome secondary to withdrawal of procyclidine with brief withdrawal of L-dopa and long-term typical antipsychotic depot. The patient responded to reintroduction of procyclidine, sedation and supportive treatment. The mechanism and management of NMS and NMLS is also reviewed. This case emphasises that any changes in antipsychotic and antiparkinsonian medications should be undertaken with extreme caution and patient should be closely monitored for development of NMLS after alteration in these medications.

Comparison of Glioblastoma Outcomes in Two Geographically and Ethnically Distinct Patient Populations in Disparate Health Care Systems.

Introduction Variations in glioblastoma (GBM) outcomes between geographically and ethnically distinct patient populations has been rarely studied. To explore the possible similarities and differences, we performed a comparative analysis of GBM patients at the University of Kentucky (UK) in the United States and the Aga Khan University Hospital (AKUH) in Pakistan. Methods A retrospective review was conducted of consecutive patients who underwent surgery for GBM between January 2013 and December 2016 at UK, and July 2014 and December 2017 at AKUH. Patients with recurrent or multifocal disease on presentation and those who underwent only a biopsy were excluded. SPSS (v.25 IBM, Armonk, New York, United States) was used to collect and analyze data. Results Eighty-six patients at UK (mean age: 58.8 years; 37 [43%] < 60 years and 49 [57%] > 60 years) and 38 patients at AKUH (mean age: 49.1 years; 30 (79%) < 60 years and 8 (21%) > 60 years) with confirmed GBM were studied. At UK, median overall survival (OS) was 11.5 (95% confidence interval [CI]: 8.9-14) months, while at AKUH, median OS was 18 (95% CI: 13.9-22) months ( p = 0.002). With gross-total resection (GTR), median OS at UK was 16 (95% CI: 9.5-22.4) months, whereas at AKUH, it was 24 (95% CI: 17.6-30.3) months ( p = 0.011). Conclusion Median OS at UK was consistent with U.S. data but was noted to be longer at AKUH, likely due to a younger patient cohort and higher preoperative Karnofsky's performance scale (KPS). GTR, particularly in patients younger than 60 years of age and a higher preoperative KPS had a significant positive impact on OS and progression-free survival (PFS) at both institutions.

Clinical and ultrasonographic features in cancer risk stratification of indeterminate thyroid nodules.

OBJECTIVES: To estimate the risk of malignancy in indeterminate thyroid nodules and to determine whether certain clinical or radiological parameters can predict the risk of malignancy. METHODS: This retrospective study enrolled all adult patients (age ≥14 years) with a cytological diagnosis of atypia/follicular lesion of undetermined significance and follicular neoplasm/suspicious for a follicular neoplasm between January 2014 and January 2020. Fifty patients with surgically treated primary thyroid nodules, documented final histological diagnosis, and ultrasound examination records were included. Thyroid nodules were evaluated radiologically using Thyroid Imaging Reporting and Data System introduced by the American College of Radiology (2017). RESULTS: Forty-two (84.0%) female and 8 (16.0%) male patients were enrolled in the study. The malignancy risks were 44.8% for Bethesda III and 28.6% for Bethesda IV. The malignancy risks for the Thyroid Imaging Reporting and Data System categories were 33.3% (TR2), 39.1% (TR3), 35.3% (TR4), and 50% (TR5). No significant associations were observed between age, gender, Bethesda category, and Thyroid Imaging Reporting and Data System and the risk of malignancy. CONCLUSION: None of the clinical or radiological characteristics evaluated in this study contributed to the cancer risk stratification of thyroid nodules with indeterminate cytology. A prospective multicenter study is needed to better understand cytologically indeterminate thyroid nodules.

Structural and Binding Effects of Chemical Modifications on Thrombin Binding Aptamer (TBA).

The thrombin binding aptamer (TBA) is a promising nucleic acid-based anticoagulant. We studied the effects of chemical modifications, such as dendrimer Trebler and NHS carboxy group, on TBA with respect to its structures and thrombin binding affinity. The two dendrimer modifications were incorporated into the TBA at the 5' end and the NHS carboxy group was added into the thymine residues in the thrombin binding site of the TBA G-quadruplex (at T4, T13 and both T4/T13) using solid phase oligonucleotide synthesis. Circular dichroism (CD) spectroscopy confirmed that all of these modified TBA variants fold into a stable G-quadruplex. The binding affinity of TBA variants with thrombin was measured by surface plasmon resonance (SPR). The binding patterns and equilibrium dissociation constants (KD) of the modified TBAs are very similar to that of the native TBA. Molecular dynamics simulations studies indicate that the additional interactions or stability enhancement introduced by the modifications are minimized either by the disruption of TBA-thrombin interactions or destabilization elsewhere in the aptamer, providing a rational explanation for our experimental data. Overall, this study identifies potential positions on the TBA that can be modified without adversely affecting its structure and thrombin binding preference, which could be useful in the design and development of more functional TBA analogues.

HIV and Pneumocystis Jiroveci Pneumonia (PJP) Managed With Extracorporeal Membrane Oxygenation (ECMO).

Presentation A 40-year-old Irish female presented with a new diagnosis of HIV, advanced immunosuppression and severe respiratory failure. Diagnosis Patient was subsequently diagnosed with Pneumocystis jiroveci Pneumonia (PJP). Treatment The patient was treated for HIV and PJP and required mechanical ventilation. She continued to deteriorate and veno-venous Extracorporeal Membrane Oxygenation (V-V ECMO) was deployed in her management after 18 days of mechanical ventilation. Conclusion HIV presenting with extensive pneumonia secondary to PJP and advanced immunosuppression is still a treatable condition. All available respiratory support including ECMO should be considered for patients even if they have been on mechanical ventilation for more than 7 days.

Genome-wide identification and evolution of Dof transcription factor family in cultivated and ancestral cotton species.

The DNA-binding with one finger (Dof) proteins are transcription factors involved in many biological processes in plants. To predict the evolutionary pattern, a genome-wide in-silico analysis of Dof TFs family in diploid (Gossypium arboreum and Gossypium raimondii) and allotetraploid (Gossypium hirsutum and Gossypium barbadense) cotton species were carried out. In G. arboreum, we have identified 58 non-redundant genes encoding Dof proteins renamed as GaDof (G. arboreum Dof), 55 Dof genes were identified in G. raimondii (GrDof), 89 were predicted ffrom G. hirsutum (GhDof) and the highest, 110 Dof genes were identified in G. barbadense (GbDof). The phylogenetic analysis, physical location, gene structure, conserved domain analyses were also investigated for G. arboreum, G. raimondii, and G. hirsutum. The gene expression pattern in G. hirsutum, at different growth stages, revealing the probable involvement of some GhDof genes in growth and development. These genes may improve seed germination and growth in cotton.

What Stops Doctors Switching from Intravenous to Oral Antibiotics?

Aims To explore doctors' perceptions of the motivators and barriers to complying with intravenous to oral switch antibiotic guidelines in a Model 4 Irish hospital. Methods A cross-sectional study was carried out amongst doctors attending hospital-wide educational sessions in November 2018 via a validated paper-based survey post ethical approval. Data were independently analysed using SPSS. Results One hundred and seventy four doctors of all grades and a variety of specialties participated. Respondents felt they were aware of the local intravenous to oral switch criteria but expressed they required prompts to consider switching to oral agents when appropriate, inclusive of alert stickers in the Kardex and medical notes as well as reminders from nursing and pharmacy staff. Other interventions to assist with improved decision-making included further education to junior doctors on the benefits of an intravenous to oral switch, electronic prescribing, and better accessibility to laboratory results. Conclusion Results will assist in implementing quality improvement initiatives to increase the rate of guideline compliance.

A Unique Case of Concurrent Long Bone Osteomyelitis and Empyema Caused by Fusobacterium nucleatum.

We describe a patient presenting with constitutional symptoms, poor oral hygiene and leg swelling who was diagnosed with Fusobacterium nucleatum osteomyelitis of femur and empyema. Long bone osteomyelitis is rarely caused by this microorganism. This unusual case was successfully managed with drainage and antimicrobial therapy.

Medical Students' Opinion Toward the Application of Complementary and Alternative Medicine in Healthcare.

CONTEXT: An accelerated approach to popularize complementary and alternative medicine (CAM) in healthcare services has led to the need to assess medical students' knowledge of CAM. Furthermore, their attitude toward its efficacy and usage will determine its growing popularity in healthcare. Another key idea is to integrate CAM with conventional medical teaching to make it a part of the mainstream medical curriculum. The objectives were to assess the medical students' perceptions about integrating CAM with conventional medicine and to assess the attitude of prescribing different CAM modalities to patients presenting with a particular disease or health disorder. SETTINGS AND DESIGN: This is a descriptive, institutional based study conducted on undergraduate 3rd year medical students. MATERIALS AND METHODS: Data were collected by a structured and pretested questionnaire to be filled in by the participants in the presence of the investigator. Statistical data were entered in SPSS software, and descriptive analysis was conducted. RESULTS: Most of the students (74%) agreed that conventional and CAM therapy can be integrated to achieve a better health care outcome. Forty-eight percent of the participants were positive that knowledge of CAM is important since many patients still prefer this option, particularly for chronic illnesses. CONCLUSIONS: The students were receptive to the introduction of a new treatment method in their curriculum, which although unconventional, presents an alternative and traditional form of treatment even if it does not have major backing from the scientific community. The participants felt that more knowledge is required to make an informed opinion about its usefulness to the community as a whole.

Cyclosporin induced effects on foetal kidney in albino mice.

BACKGROUND: Cyclosporin A (CsA) is an immunosuppressive agent which is used to prevent graft rejection and to treat autoimmune disorders. Its teratogenic effects remain unexplored despite its extensive use even during pregnancy. Current study was, therefore, undertaken to investigate the effects of CsA on the developing kidney. METHODS: Twelve pregnant mice were divided into two groups, A and B, having six animals each. Cyclosporin was freshly prepared in normal saline daily and administered subcutaneously by a single dose of 50 mg/kg in the morning to experimental group B during pregnancy from day 0 to day 18. The control group A was given comparable volume of normal saline only. The pregnant mice were sacrificed at the end of experimental period. The foetal kidneys were dissected and fixed in 10% formalin for histological preparations. RESULTS: The results showed that weight of the foetuses and their kidneys exposed to CsA was consistently reduced. The mean weight of the foetuses exposed to CsA was 1.34 +/- 0.08 g as compared to 1.48 +/- 0.18 g in the control group whereas the mean kidney weight from CsA treated group was 9.47 +/- 0.27 mg when compared to the control having 10.79 +/- 0.53 mg. Morphometric analysis revealed reduction in total number of glomeruli and hypertrophy of remaining glomeruli. The total number of glomeruli/mm2 in the kidneys from CsA treated group was 26.85 +/- 4.43 as compared to 41.33 +/- 3.66 from the control group and the mean diameter of glomeruli from the foetuses of groups A and B was 7.11 +/- 0.47 mm and 8.66 +/- 0.63 mm respectively; the differences between the groups A and B of the animals on all the parameters above were statistically significant (p < 0.000). CONCLUSION: The results of the investigation indicated that CsA administration to the pregnant dams produced deleterious effects of on the developing kidney in mice. On the analogy of the results, comparable effects of CsA are expected in case of human; this, however, needs further investigations.

Teratogenic effects of lead acetate on kidney.

BACKGROUND: Lead remains a considerable occupational and public health problem, which is known to cause a number of adverse effects in both men and women. Conflicting reports have appeared on lead induced nephrotoxicity in experimental studies in the past. There is hardly any work on its teratogenic effects on kidney. Present study was therefore designed to investigate the effects of lead acetate on developing kidney. METHODS: Twelve mice were used as experimental model and were divided into two groups of six animals each; group A served as control group and B was used as an experimental group. Lead acetate (10 mg/kg) dissolved in 0.02 ml of distilled water was administered as a single daily dose orally to group B whereas weight related amount of distilled water was given to group A for the entire period of experiment. On 18th day of gestation foetuses were dissected free of uterine wall under the dissecting microscope and were sacrificed; kidneys were removed and fixed in 10% formalin, dehydrated in ascending grades of alcohol, cleared in xylene and infiltrated with filtered paraffin. The paraffin blocks were made and five micron thin sections were obtained using a rotary microtome. The sections were stained with Hematoxylin and eosin and, PAS; these were examined under light microscope. RESULTS: Significant decrease in cortical thickness was observed which varied from 578.61 +/- 1.4 microm in group A to 515.6 +/- 5 microm in group B (p < 0.001). Diameter of renal corpuscles varied from 57.7 +/- 0.07 microm in group A to 50.5 +/- 0.07 microm in group B (p < 0.001). Moderate cortical tubular atrophy showing thickening of endothelial basement membrane in glomeruli, desquamated epithelium with degenerated nuclei in proximal and distal tubules were observed in group B in contrast to group A. CONCLUSION: The results of the investigation indicated that lead acetate administration to the dams produced deleterious effects on the developing kidney in mice.

"Pseudo" Faraday cage: a solution for telemetry link interaction between a left ventricular assist device and an implantable cardioverter defibrillator.

Patients implanted with left ventricular assist devices (LVAD) may have implantable cardioverter defibrillators (ICD) implanted for sudden cardiac death prevention. This opens the possibility of device-device communication interactions and thus interferences. We present a case of such interaction that led to ICD communication failure following the activation of an LVAD. In this paper, we describe a practical solution to circumvent the communication interference and review the communication links of ICDs and possible mechanisms of ICD-LVAD interactions.

Endocardial catheter ablation of ventricular tachycardia in patients with ventricular assist devices.

BACKGROUND: The outcomes of patients with ventricular assist devices (VADs) who undergo catheter ablation for ventricular tachycardia (VT) have not been reported. OBJECTIVE: The purpose of this study was to assess the feasibility, safety, and efficacy of endocardial VT ablation in patients with VADs. METHODS: We retrospectively reviewed three cases at our institution where endocardial catheter ablation was performed in patients with VADs and incessant VT. RESULTS: Three patients with underlying cardiomyopathies and VADs underwent VT ablation for incessant VT refractory to multiple antiarrhythmic medications. In each case, VT was either eliminated or significantly ameliorated by catheter ablation. No procedure-related complications occurred. The hemodynamic stability afforded by the VAD played an important role in facilitating ablation in two of the cases. CONCLUSION: Catheter ablation for VT in VAD patients appears to be feasible, safe, and effective based on our initial experience. Several technical issues, such as decreases in ventricular volumes that can limit maneuverability of the ablation catheter and potential entrapment of the mapping catheter in the inflow cannula, need to be considered at the time of ablation.