Kayser-Fleischer (K-F) ring seen in Wilson's disease (WD) is due to copper deposition in the Descemet's membrane in the sclero-corneal junction. Although believed to be pathognomic of WD, it may be seen in many other hepatic conditions and intraocular copper-containing foreign bodies. The K-F ring detected in pre-symptomatic cases of WD may lead to speedy diagnosis and early management. Co-relation of K-F ring in WD to the disease severity, disappearance with successful treatment, reappearance with non-compliant treatment may aid in optimum management of WD. The importance of K-F ring detection in first-degree relatives of the index case cannot be over-emphasized.

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In this article, we test the hypothesis that randomized clinical trials of acupuncture for pain with certain design features (A + B versus B) are likely to generate false positive results. Based on electronic searches in six databases, 13 studies were found that met our inclusion criteria. They all suggested that acupuncture is effected (one only showing a positive trend, all others had significant results). We conclude that the 'A + B versus B' design is prone to false positive results and discuss the design features that might prevent or exacerbate this problem.

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Background: Japanese encephalitis (JE) is a major public health concern in Asia including India. Objectives: To evaluate an in-house developed dipstick enzyme-linked immunosorbent assay (ELISA) test vis-à-vis two commercial kits for detection of JE virus-specific IgM antibodies. Setting and Design: Comparative study carried out in Research and Development centre. Materials and Methods: A total of 136 specimens comprising 84 serum and 52 CSF samples were tested by in-house dipstick ELISA, Pan-Bio IgM capture ELISA (Pan-Bio, Australia) and JEV CheX IgM capture ELISA (XCyton, India). Results: The overall agreement among all three tests was found to be 92% with both serum and cerebrospinal fluid (CSF) samples. The sensitivity of the dipstick ELISA was found to be 91% with serum and 89% with CSF samples respectively. The specificity of the dipstick ELISA with reference to both commercial assays was found to be 100% in serum and CSF samples in this study. Conclusions: The in-house dipstick ELISA with its comparable sensitivity and specificity can be used as a promising test in field conditions since it is simple, rapid and requires no specialized equipment.

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In the past decade, mucormycosis has emerged as an important lethal infection in diabetics and other immunocompromised hosts. Rhinosinusitis, pansinusitis, rhino-orbital and rhinocerebral are the common classical manifestations of mucormycosis. However, primary gastrointestinal (GI) mucormycosis is an uncommon disease associated with a high mortality rate. Stomach is the most common site involved in GI mucormycosis. Reported cases of GI mucormycosis in an immunocompetent host are very few in the literature. Here we present a case of a young male with fungal sepsis secondary to GI mucormycosis in an immunocompetent person.

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Background: The skeletal morphology of the temporo-mandibular joint (TMJ) is constantly remodeled. Aims and Objectives: A comparative study was undertaken to determine and characterize the differences in the skeletal morphology of TMJ of children and adults. Materials and Methods: The study was conducted on 30 children cadavers and 30 adult volunteers. Parameters that could reflect TMJ skeletal morphology were measured with a new technology combining helical computed tomography (CT) scan with multi-planar reformation (MPR) imaging. Results: Significant differences between children cadavers and adults were found in the following parameters ( P < 0.05): Condylar axis inclination, smallest area of condylar neck/largest area of condylar process, inclination of anterior slope in inner, middle, and outer one-third of condyle, anteroposterior/mediolateral dimension of condyle, length of anterior slope/posterior slope in inner and middle one-third of condyle, anteroposterior dimension of condyle/glenoid fossa, mediolateral dimension of condyle/glenoid fossa, inclination of anterior slope of glenoid fossa, depth of glenoid fossa, and anteroposterior/mediolateral dimension of glenoid fossa. Conclusion: There are significant differences of TMJ skeletal morphology between children and adults.

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Background: Central nervous system fungal infections (FI) are important complications and a cause of mortality in patients who receive hematopoietic stem cell transplantation (HSCT). Aims: To study the clinical aspects of fungal encephalitis (FE). Settings and Design: The study was carried out at the HSCT Center of the Hospital de Clνnicas, Federal University of Paranα, Curitiba, Brazil. Materials and Methods: Clinical records and autopsy reports from patients submitted to HSCT with a diagnosis of FE. Results: Twelve patients were diagnosed with FE presenting with lowered level of consciousness, hemiparesis and seizures. We were able to identify two subgroups regarding susceptibility to FE: (1) patients with early onset FI and severe leucopoenia, and (2) patients with later onset FI with graft-versus-host disease using immunosuppressive drugs. Eleven of the patients died directly due to the neurological complication, all had post-mortem confirmation of the diagnosis of FI. Conclusions: These clinical, paraclinical and temporal patterns may provide the opportunity for earlier diagnosis and interventions.

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Background: Aeromonas species are gram-negative rods usually isolated from the gastrointestinal tract. They have been occasionally reported as a cause of extra-intestinal infections such as cellulitis, cholangitis, necrotizing fascitis, meningitis, bacteremia, or peritonitis in both immunocompetent and immunocompromised patients . Aim: To determine the role and possible pathogenesis of Aeromonas in extra-intestinal infections.Settings and Design: Retrospective analysis carried out at Kasturba Hospital Manipal, Karnataka in the months of January and February 2007. Materials and Methods: Clinical manifestations and management of eight cases of extra-intestinal infections caused by A. hydrophila , from the south Karnataka coastal region were reviewed. The isolates were identified with the help of biochemical tests using standard guidelines.Results: All patients acquired Aeromonas infections in the community. Five (62.5%) had underlying illnesses, such as liver disease, diabetes mellitus or malignancy. Five (62.5%) had polymicrobial infections, and three (37.5%) were complicated with bacteremia. These included three patients with ulcers or abscess over the lower leg, two with cellulitis due to snake bite and one each with pelvic inflammatory disease, spontaneous bacterial peritonitis and pneumonia. A. hydrophila was found to be a causative agent of pelvic inflammatory disease or cellulitis following sea snake bite, and such a clinical scenario has not been previously described. Seven patients survived the illness. Conclusions: Isolation of A. hydrophila from extra-intestinal specimens demands utmost clinical and microbiological vigilance in diagnosis, since the organism can cause serious infections among immunocompromised as well as immunocompetent individuals.

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There has been a tremendous increase in the number of new and generic drugs coming into the market. The busy practitioner obtains the information from various sources, of which promotional literature forms an important source. The promotional literature provided by the pharmaceutical companies cannot be entirely relied upon; moreover, very few physicians are equipped with the skills of critically appraising it. The new drug should be relevant to the clinician's practice in terms of population studied, the disease and the need for new treatment. The methodology of the study should be carefully judged to determine the authenticity of the evidence. The new drug should be preferred over the existing one if it offers clear advantages in terms of safety, tolerability, efficacy and price. Critical appraisal of promotional literature can provide valuable information to the busy physician to practice evidence-based medicine.

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Primary hyperoxaluria is a rare autosomal recessive disease due to deficiency of an oxalate-metabolizing liver enzyme, which results in nephrolithiasis and renal failure. Concomitant liver and kidney transplant is recommended as isolated kidney transplant is inevitably complicated by recurrence of the disease. We present a 25-year-old man with end-stage nephrolithiatic renal disease who underwent bilateral nephrectomy, followed by kidney transplantation. There was progressive worsening of kidney function two weeks post transplant. Review of nephrectomy and transplant kidney biopsy showed abundant calcium oxalate crystals and further workup revealed hyperoxaluria, which was previously unsuspected. Later he developed fever, breathlessness, hemiparesis and died 10 weeks after transplant. Autopsy revealed multi-organ deposits of oxalate crystals as well as widespread zygomycosis. This case emphasizes the need for careful pre-transplant evaluation of patients with renal calculus disease in order to exclude primary hyperoxaluria.

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Background: Prevention of rise in intraocular pressure (IOP) is essential in patients undergoing surgery for perforated eye injuries. Metoclopramide, a prokinetic agent, is commonly used to hasten gastric emptying in emergency surgeries. Aim: To study the change in IOP after intravenous metoclopramide and to study the influence of metoclopramide on change in IOP after succinylcholine and tracheal intubation. Settings and Design: A randomized, double-blind, placebo-controlled study of 60 patients undergoing non-ophthalmic elective surgery. Materials and Methods: Sixty American Society of Anesthesiologists (ASA) I adult patients were randomly assigned to receive normal saline (Group C) or metoclopramide 10 mg (Group M) 30 min before the induction of anesthesia. Thiopentone was used for induction and succinylcholine for tracheal intubation. Intraocular pressure was measured in both the eyes pre and post drug treatment and succinylcholine and tracheal intubation using Perkins applanation tonometer. Statistical Analysis: Student's t-test and repeated measures ANOVA were used. A P value <0.05 was considered as significant. Results: Intraocular pressure was consistently lower in Group M than in Group C after the test drug, though the difference was not statistically significant. Intraocular pressure decreased significantly after administration of thiopentone and increased significantly in Groups C and M after tracheal intubation ( P < 0.01). Intraocular pressure was comparable between the groups at all the times. Conclusions: Metoclopramide does not cause a clinically significant change in IOP nor does it influence the changes in IOP during anesthesia and tracheal intubation. Metoclopramide shows a trend towards decrease in IOP, though clinically insignificant. Therefore metoclopramide can be used to promote gastric emptying in patients with perforated eye injury.

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Background: The 12 tumor markers' (TMs) biochip diagnostic (C12) system has been proven useful in some previous studies but its value for colorectal cancer (CRC) only was not systematically investigated. Aims: To evaluate the value of C12 system for CRC. Settings and Design: The associations between TMs and clinicopathological characteristics were evaluated. The most relevant TMs, the most useful combinations, and the correlations between TM levels were assessed. Materials and Methods: The TMs detected by the C12 system in the sera of 170 pathologically confirmed CRC patients were analyzed. One or more TMs higher than or equal to reference value were defined as positive. Statistical Analysis: Chi-square test, Spearman rank correlation test and Receiver-operating characteristic (ROC) curves were used for the analysis. Results: The overall positive rate was 41.76%, and was low in stage 0-I (12.90%). Carcinoembryonic cantigen (CEA) had the highest positive rate of 36.47%. The positive rates were significantly correlated to clinical stages and lymph node status, but not to age, sex, tumor location and pathological types. Any combinations of the five highest positive TMs did not have significantly improvements. The levels of three most related TMs (CEA, CA19-9, CA242) of CRC had positive correlation with each other. CA242 and β-HCG levels were associated with lymph node metastasis. Conclusions: C12 system has some value in advanced CRC, but not in early CRC.

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Bleeding from a Zenker's diverticulum is rare. A 71-year-old man was urgently admitted with massive hematemesis. It was known that he had a Zenker's diverticulum, but on emergency endoscopy, the source of bleeding was not detected due to large blood clots in the esophagus, hypo-pharynx and also into the tracheal-bronchial tree. Computerized tomography angiography demonstrated a blush of intravenous contrast arising from the diverticulum. The patient was operated upon urgently; the diverticle had a deep ulceration which was the source of the bleeding. The cause of the ulceration is unknown but it is possible that it was caused by the direct effect of an aspirin pill within the diverticle. A similar case with the same conclusion has been published in the past and since the use of aspirin has become common, especially in the elder population, we present this case report to highlight this possible life-threatening complication of Zenker's diverticulum in patients receiving aspirin.

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