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Gynecomastia, defined as a benign proliferation of the breasts in males, is a common pathology of breasts among adolescent males. The root cause behind the condition is the hormonal imbalance between androgens and estrogens at the time of puberty. Different treatment options can be used; however, surgery is the preferred option. The quality of life (QoL) of affected Individuals is usually affected in all aspects.The aim of the study is to assess the QoL of male Saudi patients diagnosed with gynecomastia and their desire to undergo surgical treatment.A cross-sectional study was conducted using an Arabic self-administered online questionnaire that targeted males in Saudi Arabia and was distributed throughout the kingdom.A total of 681 participants were involved in this study. Most of the participants were Saudi (n = 607; 90.6%) and married (n = 158; 79%). Approximately, half of the participants were between 18 and 29 years of age (n = 337; 49.5%), while 41.1% and 9.3% were between 30 and 49 years and more than 50 years old, respectively. About 29.5% of the participants were from the middle region, while 26.7% of them were from the northern region, followed by 19.5% of participants from the western region, and only 14.4% and 9.8% from the eastern or southern region. On analysis of different domains, there was no statistically significant difference between participants with gynecomastia and the control group in QoL.Patients showed no statistically significant change in the QoL between those diagnosed with gynecomastia and those in the control group. Also, more than one-third of our patients did not want to undergo breast reduction surgery.

Background: It is estimated that over 75.0% of households in sub-Saharan Africa are involved in agriculture, and the majority of the poor in rural areas rely on agriculture for their livelihoods. One billion people living with disabilities in low- and middle-income countries are argued to make up the poorest of the poor, yet to our knowledge, no literature has captured the livelihood of people living with disabilities in the context of farming in Nigeria, specifically northern Nigeria where most of the households are involved in agriculture and related activities.Objectives: This article reports on findings from a study that sought to understand disability in the context of northern Nigerian farming, with a particular focus on the role and lived experiences of people living with disabilities working in the agricultural sector.Method: A survey questionnaire was developed and captured the experiences of 1067 people living with disabilities working in the agricultural sector across five states (Adamawa, Bauchi, Jigawa, Kaduna and Yobe) in northern Nigeria.Results: Findings indicate that people with disabilities are actively participating in agricultural activities for several reasons, which specifically included ‘forced to and for survival’. When participants reported needing care, this was predominantly provided by family members. Findings also showed that participants with disabilities experienced several economic and sociocultural challenges because of their impairments.Conclusion: This study adds to the very limited literature on farmers living with disabilities in sub-Saharan Africa and so highlights the need for more research to be conducted with farmers living with disabilities in Nigeria, particularly female farmers living with disabilities. These will provide more evidence pertaining to the experiences of farmers living with disabilities in order to provide effective disability- and gender-inclusive agricultural and entrepreneurship programmes in Nigeria.Contribution: The results of this research reveal important insights relating to the experiences of farmers living with disabilities in northern Nigeria, which can contribute to informing future developmental projects to achieve effective inclusion and actively benefit people living with disabilities.

This study aims at reporting the indigenous knowledge of the medicinal flora from the inhabitants of surroundings of the World’s largest artificial planted forest “Changa Manga”, Pakistan. Data were collected by direct interviews and group meetings from 81 inhabitants including 32 local healers having information regarding the use of indigenous medicinal plants over a period of one year. Different statistical tools were applied to analyze the data including Frequency citation (FC), Relative frequency citation (RFC), Use Value, Factor of informants consensus and fidelity level. This study reported 73 plant species belonging to 37 plant families and 46 genera. The majority of plant species belong to compositae family. The most commonly used medicinal plants were P. hysterophorus L., P. dactylifera L., S. indicum L, P. harmala L., P. emblica L., and A. indica A.Juss. The greatest number of species was used to cure gastrointestinal disorders. The highest fidelity level (68.18%) was of E. helioscopia to cure gastrointestinal disorders. Maximum fresh uses (17) were reported by C. dactylon (L.) Pars. While the highest number of species reporting fresh uses in similar number was 13. In this study, five novel plants are being reported for the first time in Pakistan for their ethnomedicinal worth. Our data reflect unique usage of the medicinal plants in the study area. The statistical tools used in the study proved useful in pointing the most important and disease category specific plants. High use value plant and the new reported medicinal plants might prove an important source of the isolation of pharmacologically active compounds. Resumo Este estudo tem como objetivo relatar o conhecimento indígena sobre a flora medicinal dos habitantes do entorno da maior floresta artificial plantada do mundo, a Changa Manga, no Paquistão. Os dados foram coletados por meio de entrevistas diretas e reuniões em grupo de 81 habitantes, incluindo 32 curandeiros locais, com informações sobre o uso de plantas medicinais indígenas durante o período de um ano. Diferentes ferramentas estatísticas foram aplicadas para analisar os dados, incluindo citação de frequência (FC), citação de frequência relativa (RFC), valor de uso, fator de consenso dos informantes e nível de fidelidade. Este estudo relatou 73 espécies de plantas pertencentes a 37 famílias de plantas e 46 gêneros. A maioria das espécies de plantas pertence à família Compositae. As plantas medicinais mais utilizadas foram P. hysterophorus L., P. dactylifera L., S. indicum L., P. harmala L., P. emblica L. e A. indica A. Juss. O maior número de espécies foi usado para curar distúrbios gastrointestinais. O maior nível de fidelidade (68,18%) foi de E. helioscopia para cura de distúrbios gastrointestinais. Os usos máximos em fresco (17) foram relatados por C. dactylon (L.) Pars. enquanto o maior número de espécies relatando usos frescos em número semelhante foi de 13. Neste estudo, cinco novas plantas estão sendo relatadas pela primeira vez no Paquistão por seu valor etnomedicinal. Nossos dados refletem o uso exclusivo das plantas medicinais na área de estudo. As ferramentas estatísticas utilizadas no estudo mostraram-se úteis para apontar as plantas mais importantes e específicas da categoria de doença. Plantas de alto valor de uso e as novas plantas medicinais relatadas podem ser uma importante fonte de isolamento de compostos farmacologicamente ativos.

Current agricultural production depends on very limited species grown as monocultures that are highly vulnerable to climate change, presenting a threat to the sustainability of agri-food systems. However, many hundreds of neglected crop species have the potential to cater to the challenges of climate change by means of resilience to adverse climate conditions. Proso millet (Panicum miliaceum L.), one of the underutilised minor millets grown as a rainfed subsistence crop, was selected in this study as an exemplary climate-resilient crop. Using a previously calibrated version of the Agricultural Production Systems Simulator (APSIM), the sensitivity of the crop to changes in temperature and precipitation was studied using the protocol of the Coordinated Climate Crop Modelling Project (C3MP). The future (2040–2069) production was simulated using bias-corrected climate data from 20 general circulation models of the Coupled Model Intercomparison Project (CMIP5) under RCP4.5 and 8.5 scenarios. According to the C3MP analysis, we found a 1°C increment of temperature decreased the yield by 5–10% at zero rainfall change. However, Proso millet yields increased by 5% within a restricted climate change space of up to 2°C of warming with increased rainfall. Simulated future climate yields were lower than the simulated yields under the baseline climate of the 1980–2009 period (mean 1707 kg ha–1) under both RCP4.5 (–7.3%) and RCP8.5 (–16.6%) though these changes were not significantly (p > 0.05) different from the baseline yields. Proso millet is currently cultivated in limited areas of Sri Lanka, but our yield mapping shows the potential for expansion of the crop to new areas under both current and future climates. The results of the study, indicating minor impacts from projected climate change, reveal that Proso millet is an excellent candidate for low-input farming systems under changing climate. More generally, through this study, a framework that can be used to assess the climate sensitivity of underutilized crops was also developed.

Following the development of a database that was specifically designed to store value chain information, particularly for underutilised crops, this article describes the data that are currently stored in the database and accessible through its web portal. The data includes various datasets on utilisation status, agro-ecological requirements and season lengths, potential yield and nutritional composition of crops. The data are stored in the form of tables with fixed data elements (column attributes). This article outlines the standard procedures (SOPs) that were developed in-house for data collection, metadata creation and data curation. These processes were used to ensure the quality and reusability of the data that is made available publicly through the database interface. Various statistics and example visualisations are provided to demonstrate the significance of such data for developing solutions for sustainable agricultural diversification.

An evidence base was developed to facilitate adoption of hemp (Cannabis sativa L.) in tropical environments (Wimalasiri et al. (2021)). Agro-ecological requirements data of hemp were acquired from international databases and was contrasted against local climate and soil conditions using an augmented species ecological niche modeling. The outputs were then used to map the suitability for all locations for 12 possible calendar-year seasons within peninsular Malaysia. The most probable seasonal map was then used to generate a land suitability map for agricultural areas across 5 standard land suitability categories. Having developed the general suitability maps of hemp in Malaysia, detailed crop growth data were collected from literature and was then used to simulate an ideotype crop model (for both seed and fiber) for selected locations across Malaysia, where detailed daily climate data and soil information were available. Following the development of a downscaled future climate dataset, a simulated dataset of yield for the future conditions were also developed. Next, the simulated seed and fiber yield data were used to create yield maps for hemp across peninsular Malaysia. An economic value and cost-benefit analyses were also carried out using data that were collected from literature and local sources to simulate the true cost and benefit of growing hemp both for now and future conditions. This data provides the first ever evidence base for an underutilized crop in Southeast Asia. All data that was generated using the proposed published framework for the adoption of hemp in the future are stored in their original format in an online repository and is described in this article. The data can be used to map the suitability at finer scales, analyze and re-calibrate a yield model using any climate scenario and evaluate the economics of production using the standard methodology described in the above-mentioned publication.

It is estimated that over 75.0% of households in sub-Saharan Africa are involved in agriculture, and the majority of the poor in rural areas rely on agriculture for their livelihoods. One billion people living with disabilities in low- and middle-income countries are argued to make up the poorest of the poor, yet to our knowledge, no literature has captured the livelihood of people living with disabilities in the context of farming in Nigeria, specifically northern Nigeria where most of the households are involved in agriculture and related activities.This article reports on findings from a study that sought to understand disability in the context of northern Nigerian farming, with a particular focus on the role and lived experiences of people living with disabilities working in the agricultural sector.A survey questionnaire was developed and captured the experiences of 1067 people living with disabilities working in the agricultural sector across five states (Adamawa, Bauchi, Jigawa, Kaduna and Yobe) in northern Nigeria.Findings indicate that people with disabilities are actively participating in agricultural activities for several reasons, which specifically included 'forced to and for survival'. When participants reported needing care, this was predominantly provided by family members. Findings also showed that participants with disabilities experienced several economic and sociocultural challenges because of their impairments.This study adds to the very limited literature on farmers living with disabilities in sub-Saharan Africa and so highlights the need for more research to be conducted with farmers living with disabilities in Nigeria, particularly female farmers living with disabilities. These will provide more evidence pertaining to the experiences of farmers living with disabilities in order to provide effective disability- and gender-inclusive agricultural and entrepreneurship programmes in Nigeria.The results of this research reveal important insights relating to the experiences of farmers living with disabilities in northern Nigeria, which can contribute to informing future developmental projects to achieve effective inclusion and actively benefit people living with disabilities.

Bambara groundnut (BG, Vigna subterranea) and moringa (Moringa oleifera) are underutilized crops that improve nutritional quality of diets locally. The objectives of this study were to measure the performance of both crops on a marginal soil, analyze the harvested plant parts and noodles produced from them, and to undertake taste testing and survey consumer reactions. The noodles contained either 100% wheat flour or wheat with either BG flour (20%) or moringa powder (6%). BG yielded 0.70 t ha−1 of dry nuts and moringa 1.54 t ha−1 of dry leaflets. Both plant products were high in nutrients (especially K, and Ca in moringa) and some amino acids. Inclusion in noodles significantly enhanced their nutritional composition particularly energy content, crude fat, crude fiber and carbohydrate. Significant increases (p < 0.05) of Mg, Mn, P, K, and Zn occurred. Total essential amino acid concentration increased from 34.1% in the pure wheat noodles to 38.2% in BG and 34.8% in moringa noodles. Sensory analysis showed acceptability of all three noodle types was above the “Neither like nor dislike” category leaning toward the liking end for almost all the attributes tested. A consumer reaction survey showed there were internal and external factors motivating respondents to choose both products. Weak correlations were found between some of these factors and respondents' willingness to pay more for the BG and moringa noodles. We conclude that adopting a comprehensive research approach from plant to plate can assist transfer of underutilized crops from field studies to acceptable consumer products with enhanced nutritional profiles.

An evidence base was developed to facilitate adoption of hemp (Cannabis sativa L.) in tropical environments (Wimalasiri et al. (2021)). Agro-ecological requirements data of hemp were acquired from international databases and was contrasted against local climate and soil conditions using an augmented species ecological niche modeling. The outputs were then used to map the suitability for all locations for 12 possible calendar-year seasons within peninsular Malaysia. The most probable seasonal map was then used to generate a land suitability map for agricultural areas across 5 standard land suitability categories. Having developed the general suitability maps of hemp in Malaysia, detailed crop growth data were collected from literature and was then used to simulate an ideotype crop model (for both seed and fiber) for selected locations across Malaysia, where detailed daily climate data and soil information were available. Following the development of a downscaled future climate dataset, a simulated dataset of yield for the future conditions were also developed. Next, the simulated seed and fiber yield data were used to create yield maps for hemp across peninsular Malaysia. An economic value and cost-benefit analyses were also carried out using data that were collected from literature and local sources to simulate the true cost and benefit of growing hemp both for now and future conditions. This data provides the first ever evidence base for an underutilized crop in Southeast Asia. All data that was generated using the proposed published framework for the adoption of hemp in the future are stored in their original format in an online repository and is described in this article. The data can be used to map the suitability at finer scales, analyze and re-calibrate a yield model using any climate scenario and evaluate the economics of production using the standard methodology described in the above-mentioned publication.

This paper reviewed the immobilization strategy on cyclodextrin glucanotransferase (CGTase) producing Escherichia coli as whole cell biocatalyst. Biotransformation of insoluble substrate such as starch and lignocellulosic biomass with whole cell leads to the application of biological steps to chemocatalysis, which makes the whole process more effective. In this whole cell biocatalysis process, the excretion of the enzymes into the extracellular space by the cell is crucial. However, the use of free whole cell biocatalysts especially Escherichia coli often face with problem related to the cell lysis and stability. Due to that, the biotransformation process becomes inefficient. Thus, in this study the immobilization strategy was investigated to overcome the bottle necks mentioned. First, this study began with a focus in Escherichia coli, immobilization techniques, cyclodextrin, cyclodextrin glucanotransferase and recombinant Escherichia coli, in which can give a better understanding and a bigger picture in order to overcome the bottle necks mentioned. The different immobilization strategy and condition identified expected to improve the whole cell stability and reusability which lead to efficient biotransformation process. The output of the research also will elucidate the mechanism on how different immobilization material, strategy and cultural conditions improve the overall cell performance.

In this study, titanium alloy (Ti6Al4V) which is also known as difficult to cut material is used as workpiece. Seven main parameters namely pulse duration (A), pulse interval (B), servo voltage (C), ignition pulse current (D), wire tension (E), wire speed (F) and dielectric pressure (G) have been experimentally studied by using Taguchi method as well as the determination of optimum parameters for material removal rate (MRR). Analysis of variance (ANOVA) has been used for recognizing the level of significant of WEDM cutting parameter for optimizing MRR and the result found that pulse duration and servo voltage give significant effect on MRR. While according to Signal to Noise (S/N) ratio response table for MRR, the parameters combination of A3B3C3D3E1F3G3 give the optimum value for MRR. It is also observed that the predicted results agree with the experimental values within an error of 4.6 %.

Palm oil and textile industries are important contributors to Malaysia's economic growth. However, these industries also generate various pollutants of the environment. This research explores the possibility of using a low cost adsorbent i.e. ash produced from palm oil factory, for the removal of dyes from aqueous solution. For the treatment to be truly low cost, not only should the adsorbent be easily and cheaply available in abundance but it should also require minimal or no pre-treatment, for expensive pre-treatment procedures would add to the overall treatment cost. Two commercial dyes i.e. disperse blue and disperse red were used. The study incorporates both batch as well as continuous flow experiments. The effects of different system variables, viz., pH, initial dye concentration and agitation time were studied in the batch tests. Acidic pH was found to favour dye removal. The optimum pH and agitation time for the removal of the two dyes were 2 and 60 min, respectively. Both Langmuir and Freundlich isotherms could be used to describe the adsorption of the dyes, with the former yielding somewhat better fits. The experimental data fitted well to the pseudo-second-order kinetic model with R2 > 0.98 for all concentrations (50–250 mg/l) tested. Column plugging was the main problem encountered due to the fine particle size of the ash. Pelletisation of ash using calcium oxide and calcium sulphate was not successful. For industrial application, pelletisation will have cost implications and may not be recommended. Ash may be better used in its natural form in batch process.

This paper tests the hypothesis that habitat differences affect the migratory ability of the Chilean predatory mite, Phytoseiulus persimilis, an introduced biological control agent of the spider mite, Tetranychus urticae. It is suggested that habitat resistance accounts for the species’ inability to invade rainforests in south-eastern Queensland, Australia. Like its prey, P. persimilis migrates to distant plants on air currents. To test our hypothesis, populations of the Chilean predatory mite were established on potted bean plants in both remnant rainforest and adjacent open fields, and their migration monitored using sticky traps. Overall it was found that prey populations on leaves were similar in both habitats, but those of predators were about 20% lower in rainforest. However, the numbers of both predators and prey caught on sticky traps in rainforest were about 6% and 25%, respectively, of those caught in open fields, indicating a strongly reduced rate of aerial migration in the forest. The number of P. persimilis caught on the sticky traps increased with increasing populations of predators on foliage. Thus, dense vegetation inhibits the movement of air currents and inhibits colonisation by both predators and, to a lesser extent, spider mites. These results suggest that the inhibition of aerial migration is one reason for lower numbers of P. persimilis in forest habitats, both because its own vagility is restricted, and because its prey is less able to disperse.

We retrospectively reviewed the clinical records and radiographs of 100 patients who had had supernumerary teeth removed. Their mean (SD) age was 9 years 3 months (2). The 100 patients had a total of 127 unerupted maxillary incisors associated with supernumerary teeth. The supernumerary tooth was removed without exposure of the permanent tooth more often among the 79 younger children (aged 10 years or less) (SND=3.52, P

Aim To obtain the views of specialist registrars on specialty care in the community. Method Specialist registrars from five Deaneries in England completed an online questionnaire about their views on employment prospects, the role of specialty care in the community, and the need for additional training in this area. Results One hundred and twenty seven replies were received over a four week period. Thirty (24%) viewed their future employment prospects as consultants as poor or very worrying. Seventy seven (61%) specialist registrars considered that as consultants they will need to work directly in the community. Thirty nine of these (51%) considered the need to work close to patients directly in the community as either a “bad” or “very bad” development. However, 102 (80%) specialist registrars believed that they should receive training on the delivery of specialty care in the community and 96 (76%) wanted this in the form of a university based degree.

The diagnosis of diabetes mellitus by the available criteria is controversial and relies heavily on fasting glucose results. This cross-sectional study in 2010-2011 aimed to measure the frequency of impaired glucose tolerance and diabetes mellitus in 127 subjects having fasting blood glucose7.0 mmol/L and to measure the agreement between different standard diagnostic criteria. Subjects presenting to a laboratory for analysis of fasting blood glucose for excluding diabetes mellitus underwent a 2-hour 75 g oral glucose challenge. A total of 40.6% of subjects with fasting blood glucose from 5.6-6.0 mmol/L had abnormal glucose regulation on the basis ofthe gold standard glucose challenge. Agreement between American Diabetes Association and World Health Organization diagnostic criteria was only fair (kappa = 0.32). Abnormalities of glucose metabolism including impaired glucose tolerance and diabetes mellitus can exist at fasting blood glucose results6.1 mmol/L (110 mg/dL).

SUMMARYBetween 1980 and 1986, six field experiments were conducted to investigate the relations between planting density, total dry matter and pod yield of groundnut (Arachis hypogaea L. cv. TMV2) grown at different levels of irrigation and rainfall at two sites in central India. In general, the relationship between total dry matter and planting density for most treatments was well described by the function:where W is the crop dry weight per unit ground area, wm is the maximum weight per plant, Wm is the maximum crop weight per unit ground area and P is the plant population. Because the harvest index, h, was constant for each treatment irrespective of plant population, a similar equation described the relationship between pod yield and planting density. When nine of the eleven treatments planted in a square (i.e. 1:1) arrangement were compared, the asymptotic value Wm varied between treatments depending on available soil water and atmospheric demand. To quantify the effects of plant and environmental factors on crop productivity, a ‘transpiration equivalent’ (ωw; (g/kg)/kPa), i.e. the product of the dry matter/water ratio and mean seasonal saturation deficit D, was used as a crop constant to calculate productivity at each site or season from a knowledge of seasonal rainfall and/or irrigation and soil water-holding capacity. Thus, total crop productivity, W'8, was calculated using the equation W'8 = ωwS/D where S (mm) is a soil supply term dependent on soil water-holding capacity and monthly values of rainfall and/or irrigation. When values for Wm and W'8 were plotted against each other, a linear regression was obtained with a slope = 1·02 (R2 = 0·78). The mean harvest index of 0·38 was used to predict pod yield from a knowledge of W'8. It was concluded that of all the climatic, soil and management factors that influence crop growth in semi-arid situations, it is the interaction between the supply of and demand for water that ultimately determines total productivity, pod yield and optimum plant population.

Aim and Methods To assess the way different terms used to describe a fracture affect the understanding a patient has of that fracture. The perceived severity of the injury and how the patient expects to be treated were also recorded with a view to optimising patient understanding. Results There was a very significant difference between what doctors can potentially say and what the patient ultimately understood about the consultation. This could have a direct effect on the management the patient expects from the initial description and diagnosis. Conclusions It is important that doctors in the emergency department use terminology that is understood by the patient, as well as emphasising the potential seriousness of the injury. It is possibly better therefore to use informed lay terminology such as ‘a break in a bone’ rather than more formal vocabulary such ‘a fracture’ when discussing the diagnosis and treatment options.

Increased diversity and complexity of software systems derived the need for test automation. Test Automation is the use of software for automatic execution of tests, comparison of results with expected outcome, setting up preconditions for test and test reporting functions. Model based testing is a test automation approach that generates and maintains more useful and flexible tests from explicit descriptions of the application. Graph theory techniques have been an important part of model based testing and several graph theory techniques have been proposed in the literature. We used a famous graph theory technique called maximum network flows for generating minimum number of test cases covering all features of a system. We used a web based case study to describe the working of the proposed optimum path finding algorithm. We found certain constraints on web navigation graph in order to completely reflect the system in the form of a graph. The resulting web navigation graph is given as input to the algorithm that we implemented, that returns the optimal test cases for the web application system. We then graphically showed the optimality and feature coverage of the algorithm with respect to the case study.

The implementation of a suitable solid waste management programme with appropriate methods of recycling as an inherent element is vital to the alleviation of the problems associated with solid waste generation, handling and disposal, environmental conservation, public hygiene, etc. The present work is a case study on solid waste collection and recycling practices in Nibong Tebal town, Penang, Malaysia. The amount and types of domestic waste generated, household participation in recycling, identification of existing problems related to the implementation of the recycling programme, etc. formed the basis of this study. Surveys (interviews/questionnaires) and on-site observations were conducted to gather information on the solid waste collection and recycling practice of the residents. A focus group of 60 individuals was selected and their response to a questionnaire, prepared according to a Likert scale, was obtained and analysed. The majority of the respondents expressed concerns about recycling and wanted more to be done in this regard. Illegal collection, aesthetically displeasing sites and a lack of public awareness were problems of major concern. Issues related to inadequate funding and manpower as well as end market are also addressed and suggestions made.

A 40-year-old man presented to the accident and emergency department having suffering a generalized tonic-clonic seizure. Despite intravenous diazepam and phenytoin he continued to have focal seizures. His Glasgow Coma Scale fluctuated between 6 and 11 out of 15, he was haemodynamically stable and, apart from focal seizures, systemic examination was unremarkable. Investigations revealed a mild leucocytosis. Biochemical parameters (urea and electrolytes, liver function tests including gamma glutamyl transferase) were within normal range. A computed tomography scan of the brain showed generalized white matter changes (low attenuation) particularly in the frontal lobes. The patient was sedated, ventilated and transferred to the intensive therapy unit. Initial history from relatives suggested that he suffered with Addison's disease and was on replacement hydrocortisone and fludrocortisone for this. His former partner claimed alcohol abuse and behavioural problems, which had worsened recently. He had suffered a head injury a few months earlier but had been discharged within 24 hours as observations had remained stable. There was no other significant past medical history. It transpired that his alcohol intake was moderate. At the time of his admission there was an outbreak of echo 30 virus meningoencephalitis in Merseyside. His presentation with confusion, fluctuating levels of conscious and seizures led to a working diagnosis of encephalitis and aciclovir was commenced. Differential diagnoses included alcohol excess or withdrawal fits and stimulant drug overdose. A toxicology screen was negative and no alcohol was detected in the blood. A diagnostic lumbar puncture showed clear and colourless CSF with glucose 2.8 mmol/litre (blood glucose 4.6 mmol/litre), protein 0.91 g/litre (normal 0.15–0.4 g/litre), red blood cell count 2×106/litre, white blood cell count Following successful extubation he was transferred to the infectious diseases unit but behavioural problems persisted. A more extensive history revealed multiple family episodes of Addison's disease, all four of his male siblings having been diagnosed, two of whom had died as young children. His sister's son also suffered from Addison's disease, suggesting a pattern of recessive X-linked inheritance. A magnetic resonance scan of the brain was performed. This revealed high intensity signal changes in the periventricular white matter, sparing the basal ganglia and most marked in the frontal and occipital areas (Figure 1). This appearance could be seen in inflammatory, ischaemic, neoplastic or degenerative processes, but the distribution was more suggestive of a white matter degenerative disease. Adrenoleukodystrophy was suggested to account for hypoadrenalism, white matter changes and the suggested inheritance pattern. Further information from his family revealed that he had undergone tests for an inherited disorder 10 years earlier but there was no ongoing follow up. An assay of very long chain fatty acids and genetic studies were requested. However, recovery of old notes confirmed that these tests had indeed been previously undertaken and that the patient was already diagnosed with X-linked adrenoleukodystrophy. Seizure free, but with some behavioural and cognitive dysfunction, he was discharged with neurological follow up arranged.

MyD118 and Gadd45 are related genes encoding for proteins that play important roles in negative growth control, including growth suppression and apoptosis. MyD118 and Gadd45 are related proteins that previously were shown to interact with proliferating cell nuclear antigen (PCNA), implicated in DNA replication, DNA repair, and cell cycle progression. To establish the role of MyD118 and Gadd45 interactions with PCNA, in this work we sought to identify the interacting domains and analyze the significance of this interaction in negative growth control. Using complementary in vivo and in vitro interaction assays the N-terminal (1-46) and middle (100-127) regions of PCNA were identified as harboring MyD118- and Gadd45 interacting domains, whereas PCNA interacting domains within MyD118 and Gadd45 were localized to the C termini of these proteins (amino acids 114-156 and 137-165, respectively). These findings provide first evidence that similar domains within MyD118 and Gadd45 mediate interactions with PCNA. Importantly, ectopic expression of MyD118 or Gadd45 N-terminal peptides, lacking the PCNA interacting domain, was found to suppress colony formation or induce apoptosis more efficiently than the full-length proteins. These findings suggest that interaction of MyD118 or Gadd45 with PCNA, in essence, serves to impede negative growth control.

Heparin is almost universally used as an anticoagulant during hemodialysis. Rare but serious side effects of heparin therapy include heparin-induced thrombocytopenia (HIT) and anaphylaxis, and these may lead to significant mortality and morbidity if left unrecognized. We are reporting a patient who developed HIT followed by an anaphylactoid reaction. This 8-year-old girl with Joubert's syndrome developed end-stage renal disease secondary to nephronophthisis. She had a Permacath double-lumen hemodialysis catheter placed in the right internal jugular vein and was started on hemodialysis using an Asahi B10 65 Dialyzer on 1/28/03. The platelet count at that time was 246 × 103/mL. Beef lung heparin was used for anticoagulation. She was admitted for living related donor renal transplant on 2/10/03 but was found to be thrombocytopenic with a platelet count of 49 × 103/mL. The transplant was postponed, a sepsis work-up was performed, and she was started on antibiotics pending culture results. Hemodialysis was continued with heparin anticoagulation, and despite an improvement in the platelet count she had an acute anaphylactoid reaction 2 days later. The reaction occurred 20 min after starting her hemodialysis treatment and presented as acute onset of bronchospasm, agitation, and chest discomfort. She improved with nebulized albuterol and subcutaneous epinephrine. A review of her records revealed that she had received 6 hemodialysis treatments. The platelet count on 2/3/03, after 3 hemodialysis treatments, had been 242 × 103/mL and on 2/8/03 after 5 treatments the platelet count was 72 × 103/mL. HIT with anaphylaxis was suspected. Heparin was discontinued and the platelet count had returned to normal within 2 days. The diagnosis was confirmed by a positive heparin-associated antibody test. While HIT is recognized as a complication in 1–5% of patients treated with heparin and has been well described in the literature, we could only find 2 reported cases of heparin-induced anaphylaxis and in both cases there was accompanying thrombocytopenia. This patient further illustrates a possible linkage between these two phenomena. HIT is an important cause of thrombocytopenia in a patient on hemodialysis and continued exposure to heparin may induce anaphylaxis.

Interleukin-8 (IL-8), soluble intercellular adhesion molecule-1 (sICAM), elastase and neutrophils were assessed in bronchoalveolar lavage fluid from nine infants who developed chronic lung disease (CLD) after respiratory distress syndrome (RDS), seven who had recovered from RDS, and in four control infants. IL-8, sICAM, elastase and neutrophils in bronchoalveolar lavage fluid were increased in the CLD group, the differences being most pronounced at 10 days of age. When babies with and without CLD were compared at 10 days of age, bronchoalveolar lavage fluid from the babies with CLD had significantly increased IL-8 (114.0 vs 12.7 ng/ml), sICAM (19.0 vs 1.1 micrograms/ml), elastase (6.9 vs 0.9 micrograms/ml) and neutrophils (1.9 vs 0.4 x 10(9)/l). In serum the increased concentration of IL-8 observed at birth in the CLD (247 pg/ml) and RDS (192 pg/ml) groups decreased over three weeks to the concentrations observed in the controls (< 70 pg/ml). Persistent inflammation could be a major contributory factor in the development of CLD.