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We assessed the role of Panton-Valentine leukocidin (PVL) and SCCmec type in community associated (CA) and healthcare associated (HC) Staphylococcus aureus (SA) skin/soft-tissue infections (STI). We prospectively monitored microbiology results (11 January 2005 to 6 January 2006), screened inpatients with SA in tissue samples or blood, and selected adults with STI. We recorded clinical/microbiological characteristics, and tested saved isolates for PVL genes (real time PCR) and SCCmec type (conventional multiplex PCR). We encountered 204 patients. MRSA strains that accounted for 70.5% CA and 66.0% HC cases, caused more abscesses (55.7% vs 29.7%; p=0.001) and were often PVL-positive (68.9% vs 4.8%; p <0.001). PVL-positive isolates caused more abscesses (72.9% vs 26.5%; p<0.001) but similar bacteremia (7.3% vs 7.1%). SCCmec IVa made up 95.8% of PVL-positive strains and accounted for 69.8% of the abscesses. SCCmec II caused higher mortality (14.8% vs 0-3.1%; p=0.02). PVL was a predictor of abscesses (p<0.001). Predictors of bacteremia were age>=65 y (p=0.004), necrotizing infection (p=0.014), and head/neck location (p=0.05). These findings suggest that SCCmec type and PVL status influence STI manifestations and contribute to MRSA-MSSA differences. PVL is implicated in abscess formation but not bacteremia. Bacteremia is likely related to host condition and/or other virulence factors that were not studied. [ABSTRACT FROM AUTHOR]

Background Chyle leak is an uncommon form of ascites occurring due to the accumulation of lipid‐rich lymph into the peritoneal cavity. Traumatic injury to the lymphatic system due to pancreaticobiliary surgery can lead to this phenomenon. Method We retrospectively evaluated the data of 159 patients of pancreticobiliary surgery from January 2012 to December 2016. Five patients (5/137, 3.6%) sustained a chylous leak following pancreaticoduodenectomy and one patient (1/22, 4.5%) sustained a chylous leak following Roux‐en‐Y hepaticojejunostomy for postcholecystectomy biliary stricture. Results Average daily output was 441 mL (range: 150–800 mL/day), and total duration of output was 16.5 days (range: 4–35 days). Mean hospital stay increased to 19.1 days (range: 10–40 days). All the patients were successfully managed conservatively with a combination of customized enteral feeds, supplemental parenteral nutrition, and octreotide. One patient required additional percutaneous drainage. Conclusion Chyle leak can be successfully treated with conservative management but at the cost of increased hospital stay.

Abstract: BCOR-rearranged sarcomas (BRS) constitute relatively newly described sarcomas, which, within the musculoskeletal sites, usually occur in the bones, followed by soft tissues. Primary BRS involving the visceral organs is very rare, and only a single case is reported in the lung. These tumors share overlapping morphological and immunohistochemical (IHC) features with other neoplasms, such as synovial sarcoma, Ewing sarcoma, as well as carcinosarcoma, the latter especially when occurring in the visceral organs. BCOR immunostaining is useful in triaging a tumor for molecular diagnosis, which constitutes the "essential" diagnostic criterion for these tumors. To report an extremely rare case of a BRS, confirmed by BCOR-rearrangement by fluorescence in situ hybridization (FISH), primarily occurring in the lung, emphasizing the diagnostic approach and management, along with review of literature. An18-year-old boy presented with complaints of left-sided chest pain, along with cough, fever, loss of appetite, and weight. On radio imaging, there was a complete collapse of the left lower lobe of lung with moderate pleural effusion. The biopsy showed a biphasic tumor comprising primitive round cells admixed with spindle cells. Immunohistochemically, the tumor cells were positive for BCOR, TLE1, and p53. FISH showed BCOR gene rearrangement. A diagnosis of primary BRS of lung was offered. The patient had a favorable response to the chemotherapy regime. BRS is an ultra-rare tumor, which rarely involves visceral organs. The lung is an exceptionally rare site, with only single reported case previously. An exact confirmation by molecular testing has treatment-associated implications. A review of similar reported cases is presented herewith., (Copyright © 2024 Copyright: © 2024 Indian Journal of Pathology and Microbiology.)

Introduction: Pleural effusion is due to the pathological accumulation of pleural fluid in the pleural space, 25%-30% of which may remain undiagnosed despite the combination of biochemical, microbiological, and pathological tests and closed pleural biopsy. Medical thoracoscopy may help physicians diagnose such cases. We aimed to study the diagnostic yield of medical thoracoscopy in patients with undiagnosed exudative pleural effusion and assess the safety profile of the medical thoracoscopy., Methodology: A cross-sectional descriptive study was conducted on 105 patients with undiagnosed pleural effusion. Medical thoracoscopy was performed using an Olympus semi-rigid thoracoscope (LTF 160 Evis Pleurovideoscope, Japan) as per standard protocol. Multiple pleural biopsies were taken and sent for histopathology examination, NAAT (nucleic acid amplification test), and MGIT (mycobacteria growth indicator tube). Post-procedure, the patients were evaluated for any complications., Results: A total of 105 patients were enrolled in the study. The mean ± SD age was 55.1 ± 13.6 years. Sixty-three (60%) patients were males. The diagnostic utility of medical thoracoscopy was found in 94 (89.5%) patients. The diagnosis of tuberculosis (TB) was made in 34 (32.3%) patients, and 48 (45.7%) patients were diagnosed with malignant pleural effusion. Adenocarcinoma of the lung was the most common malignancy diagnosed (32 patients, 66.6%). Five (5.31%) patients had dual etiology of pleural effusion: tubercular and malignancy. The most common complication was chest pain following the procedure (99.4%). One patient developed pneumomediastinum and was managed conservatively. There were no major adverse events after the procedure., Conclusions: Medical thoracoscopy has a high diagnostic yield and favorable safety profile with minimal complications. Excessive reliance on the level of ADA (adenosine deaminase) may further delay the diagnosis. Dual etiologies like TB coexisting with malignancy should be considered in TB high-burden countries., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Institute Ethics Committee, All India Institute of Medical Sciences, Raipur issued approval AIIMSRPR/IEC/2022/1056. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Behera et al.)

Background & Objectives: Interstitial lung disease (ILD) in rheumatoid arthritis (RA) is a serious complication with varied prevalence ranging from 4% to as high as 68%, with varied presentation. Immunosuppressants and antifibrotics are used in the management of RA ILD. The clinicodemographic profile and presentation in our country need to be further explored. We assessed the efficacy and safety profile of antifibrotic drugs in combination with immunosuppressants among RA ILD patients., Methods: A prospective observational study was conducted in the Interstitial Lung Disease (ILD) Clinic in the Department of Pulmonary Medicine, All India Institute of Medical Sciences Raipur, India, between January 2022 to January 2023. RA patients with dyspnea and chronic cough were referred to us for evaluation of ILD. Patients underwent clinical examination, complete lung function study including spirometry, single breath diffusion capacity for carbon monoxide (DLCO), six-minute walk test, and high-resolution computed tomography of the thorax. Quality of life was assessed using the King's Brief Interstitial Lung Disease (KBILD) questionnaire., Results: Two hundred eighteen RA patients were evaluated and out of these, 43 (20.8%) had features of ILD on high-resolution computed tomogram (HRCT) thorax. Twenty-six (2.18%) met the inclusion criteria for starting antifibrotics. The mean ± SD. age of the patients was 52.96 ± 14.04 and the majority (77%) were females. Fourteen (53.38%) patients had usual interstitial pneumonia (UIP)/probable UIP pattern and 12 (46.22%) had nonspecific interstitial pneumonia (NSIP) patterns on HRCT. Out of 26 patients, 24 (92.3%) were started on antifibrotics. Fourteen (53.8%) patients were on nintedanib and 10 (38.4%) were on pirfenidone. The mean ± SD forced vital capacity (FVC)% predictedwas 62.5 ± 20.04. The mean ± SD. The DLCO percentage predicted was 54.4 ± 22.8. Twenty-two (84.6%) patients did not experience any side effects. The mean ± SD. KBILD score was 59.9 ± 11.17 and was similar in both sexes., Conclusion: In our study, the prevalence of RA ILD was nearly 20.8% and more common in females. Twenty-four (2%) patients were included for antifibrotic treatment. There was an improvement in lung function at the end of six months, but the change was not significant. All patients tolerated antifibrotics well without any serious adverse events., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Institute Ethics Committee, All India Institute of Medical Sciences, Raipur issued approval AIIMSRPR/IEC/2020/551. The study was approved by IEC AIIMS Raipur as part of ICMR ILD Registry. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: Grants were sanctioned for developing ILD registry as part of Multicentre study ICMR INPF network with grant no: 5/8/4-6/INPF/2021-NCD-II. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Behera et al.)

The coronavirus disease 2019 (COVID-19) is a global pandemic caused by severe acute respiratory syndrome coronavirus 2. Rapid spread with rampant growth of cases and deaths brought forth an urgent need for novel therapies including vaccinations. The mRNA vaccines for COVID-19 disease have been implemented at an unprecedented scale in an effort to combat the unrelenting pandemic. Such a massive scale vaccination program is bound to coincide with adverse events related to treatment. We present a case of massive cervical lymphadenopathy in a 58-year-old male patient post-Moderna COVID-19 vaccination. Additional investigations did not identify malignancy and he was diagnosed with vaccine-related lymphadenopathy. Patient significantly improved with corticosteroid treatment within 2 days of admission. Lymphadenopathy is reported as the second most common local reaction to the Moderna vaccine. Promoting knowledge of this side effect, particularly in the setting widespread vaccination efforts, would allow for better management of cases, especially in relation to oncologic patients., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: Given the complex nature of integrated care systems (ICSs), the geographical spread and the large number of organisations involved in partnership delivery, the importance of leadership cannot be overstated. This paper aims to present novel findings from a rapid realist review of ICS leadership in England. The overall review question was: how does leadership in ICSs work, for whom and in what circumstances?, Design/methodology/approach: Development of initial programme theories and associated context-mechanism-outcome configurations (CMOCs) were supported by the theory-gleaning activities of a review of ICS strategies and guidance documents, a scoping review of the literature and interviews with key informants. A refined programme theory was then developed by testing these CMOCs against empirical data published in academic literature. Following screening and testing, six CMOCs were extracted from 18 documents. The study design, conduct and reporting were informed by the Realist And Metanarrative Evidence Syntheses: Evolving Standards (RAMESES) training materials (Wong et al. , 2013)., Findings: The review informed four programme theories explaining that leadership in ICSs works when ICS leaders hold themselves and others to account for improving population health, a sense of purpose is fostered through a clear vision, partners across the system are engaged in problem ownership and relationships are built at all levels of the system., Research Limitations/implications: Despite being a rigorous and comprehensive investigation, stakeholder input was limited to one ICS, potentially restricting insights from varied geographical contexts. In addition, the recent establishment of ICSs meant limited literature availability, with few empirical studies conducted. Although this emphasises the importance and originality of the research, this scarcity posed challenges in extracting and applying certain programme theory elements, particularly context., Originality/value: This review will be of relevance to academics and health-care leaders within ICSs in England, offering critical insights into ICS leadership, integrating diverse evidence to develop new evidence-based recommendations, filling a gap in the current literature and informing leadership practice and health-care systems., (© Emerald Publishing Limited.)

Language is a complex multidimensional cognitive system that is connected to many neurocognitive capacities. The development of language is therefore strongly intertwined with the development of these capacities and their neurobiological substrates. Consequently, language problems, for example those of children with Developmental Language Disorder (DLD), are explained by a variety of etiological pathways and each of these pathways will be associated with specific risk factors. In this review, we attempt to link previously described factors that may interfere with language development to putative underlying neurobiological mechanisms of language development, hoping to uncover openings for future therapeutical approaches or interventions that can help children to optimally develop their language skills., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Low colorectal anastomoses carry a high anastomotic leak (AL) rate (up to 20%) and thus are commonly diverted. Much less is known about mid-to-high colorectal anastomosis, which carries a leak rate of 2-4%. The objective of this study was to determine our AL rate after mid-to-high colorectal anastomosis and associated risk factors., Methods: A single center retrospective cohort study of patients undergoing left colonic resections with mid-to-high colorectal anastomosis (≥7 cm from the anal verge) from January 2008 to October 2017 was utilized. Main outcome, AL, defined as clinical suspicion supported by radiological or intraoperative findings, was calculated and risk factors assessed using multivariable logistic regression analysis., Results: 977 patients were included; 487 (49.9%) were male, with a mean age of 59.8 (+/-12.1) years. Mean BMI was 27.5 (+/-5.5) kg/m 2 . Diverticular disease (67.5%), malignancy (17.4%), and inflammatory bowel disease (2.2%) were the main indications for resection. Mean length of stay was 6.7 (+/-4.5) days. 455 (46.8%) colonic resections were performed by laparoscopy, 283 (29.1%) by hand assisted surgery, 219 (22.5%) by laparotomy, and 16 (1.6%) by robotics. Majority of patients had complete donuts (99.6%) and a negative air leak test (97.7%). 149 patients (15.3%) underwent construction of a diverting stoma. The overall AL rate was 2.1% (n = 20). Increased BMI (>30 kg/m 2 ), P = .02, was an independent risk factor for AL and a trend observed for positive air leak tests ( P = .05), with other factors failing to achieve statistical significance., Conclusions: Patients with mid-to-high colorectal anastomosis have a 2% AL risk. Increased BMI was a risk factor for AL.

Introduction: NAFLD is emerging as one of the leading causes of end stage liver disease worldwide. Metabolic syndrome is one of the central mechanism in the development of NAFLD. Hypothyroidism is one of the conditions associated with metabolic syndrome. In this study we assess the NAFLD induced by hypothyroidism., Materials: This study was conducted in tertiary care hospitals attached to BMCRI. 44 patients including both clinical and subclinical hypothyroidism, who were non-diabetic and had no significant alcohol intake, were included in the study. The level of NAFLD was assessed by ultrasound and fibroscan and the same was compared between clinical and subclinical hypothyroid patients., Result: On comparing the Ultrasonography grading of hepatic steatosis between the clinical and subclinical hypothyroidism group it was found that a significantly higher grade (p &lt; 0.05) of hepatic steatosis was seen in the clinical hypothyroidism group i.e 11 out of 29 subjects had grade III hepatic steatosis (37.9%), Out of the 29 subjects in the clinical hypothyroidism group, F2 F3 and F4 fibrosis grade was seen in 5,5 and 6 individuals respectively. While in the subclinical group 14 out of the 15 individuals had F0 to F1 grade of fibrosis. There was a significantly higher (p &lt; 0.0.5) fibrosis score in Clinical hypothyroidism group when compared to subclinical group., Conclusion: In our study we observed that Clinical and Subclinical Hypothyroidism are independent risk factors for the development of NAFLD. There was significantly higher level of NAFLD in Clinical Hypothyroidism patients when compared with Subclinical Hypothyroidism subjects. References Younossi Z, Anstee QM, Marietti M, et al. Global burden of NAFLD and NASH: trends, predictions, risk factors and prevention. Nat Rev Gastroenterol Hepatol 2018;15(1):11-20. Kalra S, Vithalani M, Gulati G, et al. Study of prevalence of nonalcoholic fatty liver disease (NAFLD) in type 2 diabetes patients in India (SPRINT). J Assoc Physicians India 2013;61(7):448-53. Taylor PN, Albrecht D, Scholz A, et al. Global epidemiology of hyperthyroidism and hypothyroidism. Nat Rev Endocrinol 2018;14(5):301-316. Kim YA, Park Y. Prevalence and risk factors of subclinical thyroid disease. Endocrinol Metab (Seoul) 2014;29(1):20-29., (© Journal of the Association of Physicians of India 2011.)

Living Labs (LL) are a novel and potentially robust way of addressing real-life health challenges, especially within the dementia field. Generally, LLs focus on co-creating through implementing the quadruple helix partnership as a user-centric approach to co-creating. In the context of this paper, the users were people with dementia and their informal carers. LL are not necessarily environments that evaluate these co-created innovations within the real world. Considering this disconnect between co-creation and real-world evaluation, this paper, as a critical commentary, will reflect on the methodological lessons learnt during the development of an LL model aimed at addressing this discrepancy. The LL at Liverpool John Moores University (LJMU) was commissioned to co-create and then evaluate a new Dementia Reablement Service. The case study findings revealed that the Dementia Reablement Service had a positive impact on the quality of life of people with dementia, suggesting that the service is a catalyst for positive change. In addition, the critical learning from this case study highlights the potential role of LLs in seamlessly co-creating and then evaluating the co-created solution within the real world. A benefit of this way of working is that it provides opportunities for LLs to secure access to traditional research funding.

Pulmonary aplasia is a rare developmental lung anomaly with unknown etiology. Multiloculated effusion and pericardial defects are even less common with no cases reported up until now. Here, we report the first case of an unusual presentation of a 25-year-old female with recurrent cough for four months, who was diagnosed with left pulmonary aplasia with multiloculated effusion and partial pericardial defects, and who underwent uniportal thoracoscopic drainage and pleurectomy., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background and Aims: Direct antiviral agents (DAAs) have revolutionised the standard of care for the treatment of hepatitis even in patients with hemoglobinopathies. The aim of this study is to show how, thanks to DAAs, HCV infection has been substantially eradicated in one of the biggest Centres for the management of Thalassemia in Europe., Methods: Thalassemia major patients regularly transfused and iron chelated in Cagliari (Italy) who were HCV-RNA positive were evaluated for the potential prescription of antiviral therapy., Results: A total of 99 patients, 26 of whom had been diagnosed with cirrhosis, were treated with at least one dose of DAAs, which proved to be safe and well tolerated. Two of the patients died during the treatment after becoming HCV-RNA negative while another voluntarily interrupted the therapy. The final SVR in the patients who completed the treatment was 100%, while measuring 97% (96/99) in the Intention-to-Treat analysis. After DAAs, no new cases of hepatocellular carcinoma have been reported., Conclusions: The use of DAAs in patients suffering from beta-Thalassemia major with chronic hepatitis C or cirrhosis can be considered safe and effective. Close monitoring for hepatocellular carcinoma development is, in any case, recommended indefinitely post-SVR., (Copyright © 2019 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background and Aims: Tenofovir disoproxil fumarate (TDF) is recommended for chronic hepatitis B (CHB) treatment, but it may induce kidney dysfunction whose management is not yet known. This Italian, multicentre, retrospective study aimed to assess the efficacy and safety of switching to entecavir (ETV) patients who developed TDF-associated glomerular and/or tubular dysfunction., Methods: A total of 103 TDF-treated patients were included as follows: age 64 years, 83% male, 49% cirrhotics, 98% with undetectable HBV DNA, 47% with previous lamivudine resistance (LMV-R) and 71% previously treated with adefovir. Twenty-nine (28%) were switched to ETV because estimated glomerular filtration rate (eGFR MDRD ) was <60 mL/min, 37 (36%) because blood phosphate (P) levels were <2.5 mg/dL and 37 (36%) for both reasons. Kidney, liver and virological parameters were recorded every 4 months thereafter., Results: During 46 (4-115) months of ETV treatment, all patients' renal parameters significantly improved as follows: creatinine from 1.30 to 1.10 mg/dL (P < 0.0001), eGFR MDRD from 54 to 65 mL/min (P = 0.002), P from 2.2 to 2.6 mg/dL (P < 0.0001) and maximal tubule phosphate reabsorption (TmPO4/eGFR) from 0.47 to 0.62 mmol/L (P < 0.0001). Thirteen patients (52%) improved their eGFR MDRD class, P levels were normalised in 13 (35%), and eight (22%) showed improvements in both parameters. Viral suppression was maintained in all but five patients (5%), all of whom had been LMV-R. The 5-year cumulative probability of ETV-R was 0% in LMV-naïve patients, and 11% in LMV-R patients (P = 0.018)., Conclusions: Entecavir is an effective and safe rescue strategy for CHB patients who develop renal dysfunction during long-term TDF treatment., (© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Introduction: Lymphangioma is a rare benign tumor found in gastrointestinal tract. Most lymphangiomas can occur at any age and but mostly are found in children and infants. They are mainly due to malformation of the lymphatic system. They occur mainly in the head, neck and oral cavity, but less commonly develop in the abdominal cavity. Colonoscopy and endoscopic ultrasonography are frequently used to diagnose lymphangiomas of the small bowel. Ileo-ileal intussusception due to small bowel lymphangiomas has been rarely reported., Presentation of Case: We report a case of 24 year old female who presented to the hospital with sudden onset of right sided upper and lower abominal pain with nausea and vomiting, elevated WBC count of 15.1 μL. After careful examination and CT scan of Abdomen patient was found to have an ileo-ileal intussusception secondary to small bowel lymphangioma. In a rare clinical presented case, we performed a diagnostic laparoscopy (Fig. 1), exploratory laparotomy, small bowel resection, and stable primary anastomosis. Post-operative patient did well and was discharged on 4th post-operative day without complications., Discussion: Lymphangiomas are rare benign tumors which have soft tissue consistency and often congenital malformation of the lymphatic system. Ileo-ileal intussusception in an adults can be a life threatening condition which requires prompt diagnosis and urgent intervention due to the risk of developing ischemic bowel. Prompt diagnosis and urgent intervention can lead to favourable., Conclusion: We present this rare case of ileo-ileal intussusception secondary to small bowel lymphangioma with literature review.

Background: Rotavirus as a causative agent of childhood diarrhea is known to cause serious illness among children less than 5 years of age. This study examined the epidemiology of rotavirus disease burden and diversity of G and P genotypes of rotavirus in Nepal., Methods: Stool samples were tested for rotavirus by Enzyme Immuno Assay and Group A rotaviruses were detected by using both ELISA and RT-PCR in 2718 samples between 2009 and 2011., Results: Rotavirus was more frequently detected among inpatients (28.5%) than outpatients (15.2%). Over the three-year study period, 653 (24.4%) cases were positive for rotavirus by ELISA. Genotyping by RT-PCR was done on 638 samples. The most prevalent genotype was G12P [6] (60.4%). Mixed infections were not uncommon (14% in 2009, 29% in 2010 an 7% in 2011). However, 41 were partially typed and 23 were completely untyped over the study period., Conclusions: This study highlights the rotavirus disease burden and diversity of rotavirus strains circulating in Nepal. Continued sentinel surveillance will provide useful information to policy makers with regard to rotavirus vaccine introduction.

This essay examines three examples of political treatment of the dead (specifically their bones) in the Republic of the Congo: the return of the remains of its capital's founder, Savorgnan de Brazza; the disappearance of the body of André Matswa, hailed by the people as their messianic ‘saviour’ guardian; and finally, the treatment of unidentified victims of the various armed conflicts that occurred during the years 1990–2002. These events can be analysed through the prism of two different historical perspectives: in terms of the moyenne durée, the treatment of Matswa's bones paved the way for the subsequent occurrences by creating a precedent; in the context of the ‘present of history’, the construction of a Brazza mausoleum is contemporaneous with official denial of the presence of human remains scattered across the capital city of Brazzaville as a result of armed conflicts. The comparative analysis of these historical configurations posits a set of circumstances whereby the bones become a symbolic buttress of the capital. The historical puzzle here is to understand how that which came together in claiming Matswa's bones becomes, in the context of democratization of the regime, an aesthetic sense of the ‘beauty of death’ as expressed by people when they see the shrine as their country's finest architectural accomplishment. Through the splendour of the monument, this aesthetic sense articulates the denial of the presence of the nameless dead.

The mode of action of highly unsaturated fatty acids (HUFA) in regulating gilthead sea bream (Sparus aurata) head kidney (HK) cortisol production was studied through in vitro trials using a dynamic superfusion system. Fish were previously fed with different diets containing several inclusion levels of linseed oil (LO) or soyabean oil (SO) for 26 weeks. Five diets were tested; anchovy oil was the only lipid source for the control diet (fish oil, FO) and two different substitution levels (70 and 100 %) were tested using either LO or SO (70LO, 70SO, 100LO and 100SO). Fatty acid compositions of the HK reflected the dietary input, thus EPA, DHA, arachidonic acid and n-3 HUFA were significantly (P < 0·05) reduced in fish fed vegetable oils compared with fish fed the FO diet. Feeding 70 or 100 % LO increased significantly (P < 0·05) cortisol release in HK after stimulation with adrenocorticotrophic hormone (ACTH), while feeding SO had no effect on this response. Cortisol stimulation factor (SF) was increased in fish fed the 70LO and 100LO diets compared with fish fed the control diet. Moreover, eicosanoid inhibition by incubating the HK tissue with indomethacin (INDO) as a cyclo-oxygenase (COX) inhibitor, or nordihydroguaiaretic acid (NDGA) as a lipoxygenase (LOX) inhibitor, significantly reduced (P < 0·05) the cortisol release after ACTH stimulation in the 70LO and 100LO diets. Cortisol SF was reduced in the FO, 70LO and 100LO diets when incubating the HK with INDO or NDGA, while it was increased in the 70SO diet. The present results indicate that changing the fatty acid profile of gilthead sea bream HK by including LO and/or SO in the fish diet affected the in vitro cortisol release, and this effect is partly mediated by COX and/or LOX metabolites.

Background: Biliary leak is an uncommon but significant complication following cholecystectomy. Endotherapy is an established method of treatment. However, the optimal intervention is not known., Method: Eighty-five patients with postcholecystectomy biliary leaks from July 2000 to March 2009 were retrospectively evaluated., Results: The study population was 20 males and 65 females with a mean age of 42.47 years. Patients presented with abdominal pain (46), jaundice (23), fever (23), abdominal distension (42), or bilious abdominal drain (67). Endoscopic retrograde cholangiopancreatography detected a leak at the cystic duct stump in 45 patients, stricture with middle common bile duct leak in 4, leak from the right hepatic duct in 3, and a ligated common bile duct in 32. Twelve also had bile duct stones. One had a broken T-tube with stones. Endotherapy was possible in 53 patients. Three patients with stones, one with a broken T-tube with stones, and 4 with stricture of the common bile duct with a leak were managed with sphincterotomy and stenting. Eight patients with a cystic duct stump leak with stones were managed with sphincterotomy and stone extraction. Three outpatients and 12 inpatients with a cystic duct stump leak were managed with sphincterotomy and stent and sphincterotomy and nasobiliary drain, respectively. Five patients with a cystic duct stump leak were managed with stenting. Sixteen with coagulopathy were managed with only nasobiliary drain (9) or stent (7). Leak closure was achieved in 100% patients. Four developed mild pancreatitis which improved with conservative treatment., Conclusions: Endoscopic intervention is a safe and effective method of treatment of postcholecystectomy biliary leaks. However, management should be individualized based on factors such as outpatients or inpatients, presence of stone, stricture, ligature, or coagulopathy.

Background: EWS is frequently used to monitor acute admissions requiring emergency surgery. This study examined preoperative early warning scoring (EWS) and its ability to predict mortality and critical care admission. Postoperative EWS was also evaluated as a predictor of mortality., Methods: Preoperative EWS, age, physiologic and operative severity (POSSUM) scores, ASA grade, and serology were compared in 280 patients undergoing emergency surgery., Results: Two hundred eighty patients were identified with a mortality of 15%. Among the physiological scoring systems, ASA grade and POSSUM scores were the best predictors of mortality (AUC values of 0.81). EWS, APACHE II, and age were the next best predictors (AUC values of 0.70). Postoperative APACHE II and EWS both predicted mortality. EWS on day 2 postoperatively was the best overall predictor of mortality of all the variables studied (AUC value of 0.83). Survival between patients with "improving or stable" EWS and those with "deteriorating or failing to improve" EWS was also found to be significantly different (P < 0.001). In addition, both EWS on admission and EWS 1 h preoperatively were found to predict critical care requirement postoperatively (AUC value of 0.78)., Conclusions: EWS can predict the need for critical care admission and mortality following emergency surgery. In particular, the progression of EWS preoperatively, that is, whether scores improve or deteriorate, is a highly significant factor in predicting survival following emergency surgery. These findings support the use of EWS in monitoring the acute surgical patient.

Staphylococcus aureus virulence factors may determine infection presentation. Whether SCCmec type-associated factors play a role in S. aureus bacteremia is unclear. We conducted a prospective observation of adult inpatients with S. aureus bacteremia (1 November 2005 to 31 December 2006), performed SCCmec typing of methicillin-resistant S. aureus (MRSA) isolates, and stratified the results according to SCCmec type. We studied 253 patients. MRSA accounted for 163 (64.4%) cases. The illness severity index was similar in MRSA and methicillin-sensitive S. aureus (MSSA) cases. MRSA caused higher in-hospital mortality (23.9% versus 8.9%; P=0.003), longer bacteremia (4.7+/-6.5 days versus 2.7+/-2.9 days; P=0.01), but similar metastatic infection (14.7% versus 15.6%). Stratifying the results according to SCCmec type revealed significant differences. SCCmec type II caused highest mortality (33.3%) versus type IVa (13.5%), other MRSA (12.5%), and MSSA (8.9%). SCCmec IVa produced the highest metastatic infection (26.9% versus 9.1% [SCCmec II], 8.3% [other MRSA], and 15.6% [MSSA]). Persistent bacteremia (>or= 7 days) was similar in all SCCmec types (16.7 to 20.7%); each exceeded MSSA (6.7%; P=0.05). In multivariate analysis, SCCmec II was a predictor of mortality (odds ratio [OR]=3.73; 95% confidence interval [CI] = 1.81 to 7.66; P=0.009), SCCmec IVa was a predictor of metastatic infection (OR=3.52; CI=1.50 to 8.23; P=0.004), and MRSA (independent of SCCmec type) was a predictor of persistent bacteremia (OR=4.16; CI=1.47 to 11.73; P=0.007). These findings suggest that SCCmec-associated virulence factors play a role in the outcome of S. aureus bacteremia. Additional studies are needed to identify which virulence factors are the determinants of increased mortality with SCCmec type II and metastatic infection with SCCmec type IVa.

Organophosphorus and carbamate insecticides inhibit the carboxylesterases found in plasma. Therefore, these carboxylesterases might be used as biomarkers of exposure to these insecticides. This work initiates the characterization of the phenylacetate (PA) and 1-nafthylacetate (NA) hydrolyzing activities (PAase and NAase) in the plasma of 11 different wild bird species and aims to determine their suitability as biomarkers of exposure. PAase activity values, expressed as mumol product/30min/mL plasma, ranged between 38+/-2.3 (black vulture) and 27+/-0.85 (barn owl), while NAase values ranged between 6.0+/-5.2 (griffon vulture) and 38+/-0.85 (barn owl). In all assayed species, NAase was between 1.1 and 2.8 times higher than the corresponding PAase. PAase and NAase of chicken white stork were 1.6 and 1.7 times higher, respectively, than the corresponding activities of adult individuals. Nocturnal raptors, eagle owl and barn owl, exhibited PAase and NAase between 1.3 and 8.0 times higher than activities exhibited by diurnal raptors (Montagu's harrier, common buzzard, booted eagle, Spanish imperial eagle, black kite, griffon vulture and black vulture). Data presented in this work suggest that plasma PAase and NAase of the studied birds might be used as biomarkers of exposure to organophosphorus and carbamate insecticides, although further studies of inhibition of these activities are still needed.

Release of amine products from azo compounds is of considerable interest, since most of the metabolized amine products have toxic and carcinogenic characters. Moreover, most of the azo dyes are extensively used as coloring agents in inks, textiles, leathers, food and pharmaceutical industries. The present study emphasis on the quantification and comparison of amines released from water soluble dyes by (i) extra cellular protein (ECP) of Streptomyces sp. SS07 and by (ii) chemical methods. It has been observed that both the methods release considerable quantities of similar type of amine products. Release of amine compounds by ECP and chemical reduction in acid and alkaline sweat medium from a leather garment sample was also assessed. ECP (0.7852 mg protein/mg of ECP) releases benzidine and 4-amino biphenyl from Direct Black 38 and Direct Brown 1 as stable products at pH 9.2 and at 37 degrees C for a contact period of 24 h. On comparison with chemical reduction, it was observed that about 5-20% increase in the release of amine products by ECP was observed. However, more than 60% of amine products were released by chemical method from leather garment samples than direct treatment with ECP.