Purposeful use of multimodality imaging in the diagnosis of caseous mitral annular calcification: a case series report

Background Caseous mitral annular calcification (CMAC) is a rare liquefactive variant of mitral annular calcification (MAC) and superficially mimics a cardiac vegetation or abscess. CMAC is viewed as a benign condition of MAC, while MAC has clinical implications for patients’ lives. Correctly diagnosing CMAC is essential in order to avoid unnecessary interventions, cardiac surgery or even psychological suffering for the patient. Case presentation We report on 6 patients with suspected intra-cardiac masses of the mitral annulus that were referred to our institution for further clarification. A definitive diagnosis of CMAC was achieved by combining echocardiography (Echo), cardiac magnetic resonance imaging (MRI) and cardiac computed tomography (CT) for these patients. Echo assessed the mass itself and possible interactions with the mitral valve. MRI was useful in differentiating the tissue from other benign or malign neoplasms. CT revealed the typical structure of CMAC with a “soft” liquefied centre and an outer capsule with calcification. Conclusion CMAC is a rare condition, and most clinicians and even radiologists are not familiar with it. CMAC can be mistaken for an intra-cardiac tumour, thombus, vegetation, or abscess. Non-invasive multimodality imaging (i.e. Echo, MRI, and CT) helps to establish a definitive diagnosis of CMAC and avoid unnecessary interventions especially in uncertain cases.

The Effect of Capsule-in-Capsule Combinations on In Vivo Disintegration in Human Volunteers: A Combined Imaging and Salivary Tracer Study

Controlling the time point and site of the release of active ingredients within the gastrointestinal tract after administration of oral delivery systems is still a challenge. In this study, the effect of the combination of small capsules (size 3) and large capsules (size 00) on the disintegration site and time was investigated using magnetic resonance imaging (MRI) in combination with a salivary tracer technique. As capsule shells, Vcaps® HPMC capsules, Vcaps® Plus HPMC capsules, gelatin and DRcaps® designed release capsules were used. The three HPMC-based capsules (Vcaps®, Vcaps® Plus and DRcaps® capsules) were tested as single capsules; furthermore, seven DUOCAP® capsule-in-capsule combinations were tested in a 10-way crossover open-label study in six healthy volunteers. The capsules contained iron oxide and hibiscus tea powder as tracers for visualization in MRI, and two different caffeine species (natural caffeine and 13C3) to follow caffeine release and absorption as measured by salivary levels. Results showed that the timing and location of disintegration in the gastrointestinal tract can be measured and differed when using different combinations of capsule shells. Increased variability among the six subjects was observed in most of the capsule combinations. The lowest variability in gastrointestinal localization of disintegration was observed for the DUOCAP® capsule-in-capsule configuration using a DRcaps® designed release capsule within a DRcaps® designed release outer capsule. In this combination, the inner DRcaps® designed release capsule always opened reliably after reaching the ileum. Thus, this combination enables targeted delivery to the distal small intestine. Among the single capsules tested, Vcaps® Plus HPMC capsules showed the fastest and most consistent disintegration.

Repair of a Complete Radial Tear of the Lateral Meniscus

Background: Recognizing and repairing a lateral meniscus complete radial tear is critical, as this tear pattern makes the meniscus nonfunctional for load sharing of axial forces, and the convex shape of the lateral tibial plateau increases contact pressure. Indications: The diagnosis of a lateral meniscus complete radial tear was supported by joint effusion, lateral joint line tenderness, positive McMurray test, and magnetic resonance imaging findings. Arthroscopy confirmed the complete radial tear. Technique Description: During the procedure, a self-capturing suture passer was used to pass a size 0 high-strength suture through the meniscus. To start the repair, the free ends of the suture were passed from top to bottom on both sides of the tear. These free ends were then crossed on the bottom of the meniscus to create an X configuration and passed from the bottom to top slightly further back from the first suture passes. A spinal needle and a chia were used from outside-in to create a side-to-side suture across the tear to reinforce the repair, and a knot was then tied on the outer capsule. The chia was used once again to shuttle the size 0 sutures to the exterior portion of the knee and the knots were tied on top of the capsule. Results: Postoperatively, patients are 25% weightbearing with a 0° to 90° range of motion restriction for 6 weeks, with no deep squatting for 3 months. With an isolated radial tear repair, the patient can expect to return to sport by 5 months. Radial tear repair outcomes demonstrate reduced lateral meniscus extrusion, complete meniscus healing in 86.4% of patients, and significantly improved International Knee Documentation Committee, Lysholm, and Tegner scores. Discussion/Conclusion: Repairing a complete radial tear of the lateral meniscus restores the function of the meniscus. This surgical technique provides a high rate of complete meniscus healing and excellent patient satisfaction.

Survival of a probiotic-containing product using capsule-within-capsule technology in an in vitro model of the stomach and small intestine (TIM-1)

The aim of the research was to compare the survival of a blend of five probiotic strains (2 bifidobacteria and 3 lactobacilli) in a capsule within capsule (Duocap®) containing Ahiflower® oil, as compared to the strains in the powder (with or without Ahiflower oil), or the strains when present in the inner capsule only. This was tested in a validated, dynamic in vitro model of the stomach and small intestine (TIM-1), simulating human adults. Experiments were performed both in the gastric compartment of the model, as well as in the complete system (stomach + small intestine). Survival of the strains after transit through the gastric compartment in the Duocap capsule was higher by about a factor of 1.5 compared to the other 3 variables. In these gastric experiments, the Ahiflower oil did not seem to have an additional benefit, in the sense that it did not increase survival over the strains alone. After transit through the complete gastrointestinal tract survival was approximately 2-fold higher for the strains within the Duocap capsule, compared to the strains within the inner capsule or the powder. In these experiments, Ahiflower oil did have an additional benefit. The survival of the strains in the combination of powder with Ahiflower oil showed a similar survival as that of the Duocap, although in the first few hours of the experiments survival of both species lagged behind, and only caught up at the end of the test. In conclusion, the developed capsule-in-capsule technology increased the amount of viable cells in the upper gastrointestinal tract, mainly due to the presence of the polyunsaturated fatty acids contained in the outer capsule, which particularly protected the blend of probiotics in the small intestine.

Infections Due to Streptococcus pneumoniae

Pneumococci, or Streptococcus pneumoniae, are gram-positive, lancet-shaped diplococci but may also grow in short chains. The polysaccharide polymer that forms the outer capsule of S pneumoniae is chemically and antigenically unique and is crucial to virulence. There are at least 90 distinct serotypes. The capsule allows the bacteria to resist phagocytosis by leukocytes unless the organisms have been opsonized by antibody or serum complement components. Certain pneumococcal serotypes, such as the heavily encapsulated type 3 pneumococcus, are particularly virulent. In fact, only 23 serotypes account for 80% of bacteremic pneumococcal infections in the United States; capsular polysaccharides from these 23 serotypes are incorporated into the polyvalent polysaccharide pneumococcal vaccine (PPSV23), which has been available since 1983. This review covers the epidemiology and pathogenesis of pneumococcal infections, clinical pneumococcal infections, and prevention of pneumococcal infections. Adverse outcomes in pneumococcal pneumonia, antibiotic treatment for penicillin-resistant S pneumoniae, and Centers for Disease Control and Prevention child and adolescent immunization schedules are discussed. This review contains 1 figure, 6 tables, and 41 references. Key words: bacterial pneumonia, PCV13, penicillin-resistant Streptococcus pneumoniae, pneumococcal pneumonia, pneumococcus, PPSV23, pneumonia vaccine, Streptococcus pneumoniae

Resuscitation-Promoting Factors Are Required for Mycobacterium smegmatis Biofilm Formation

ABSTRACT Resuscitation-promoting factors (Rpfs) have previously been shown to act as growth-stimulatory molecules via their lysozyme-like activity on peptidoglycan in the bacterial cell wall. In this study, we investigated the ability of Mycobacterium smegmatis strains lacking rpf genes to form biofilms and tested their susceptibilities to cell wall-targeting agents. M. smegmatis contains four distinct rpf homologues, namely, MSMEG_5700 (rpfA), MSMEG_5439 (rpfB), MSMEG_4640 (rpfE2), and MSMEG_4643 (rpfE). During axenic growth of the wild-type strain, all four mRNA transcripts were expressed to various degrees, but the expression of MSMEG_4643 was significantly greater during exponential growth. Similarly, all rpf mRNA transcripts could be detected in biofilms grown for 7, 14, and 28 days, with MSMEG_4643 expressed at the highest abundance after 7 days. In-frame unmarked deletion mutants (single and combinatorial) were generated and displayed altered colony morphologies and the inability to form typical biofilms. Moreover, any strain lacking rpfA and rpfB simultaneously exhibited increased susceptibility to rifampin, vancomycin, and SDS. Exogenous Rpf supplementation in the form of culture filtrate failed to restore biofilm formation. Liquid chromatography-mass spectrometry (LC-MS) analysis of peptidoglycan (PG) suggested a reduction in 4-3 cross-linked PG in the ΔrpfABEE2 mutant strain. In addition, the level of PG-repeat units terminating in 1,6-anhydroMurNAc appeared to be significantly reduced in the quadruple rpf mutant. Collectively, our data have shown that Rpfs play an important role in biofilm formation, possibly through alterations in PG cross-linking and the production of signaling molecules. IMPORTANCE The cell wall of pathogenic mycobacteria is composed of peptidoglycan, arabinogalactan, mycolic acids, and an outer capsule. This inherent complexity renders it resistant to many antibiotics. Consequently, its biosynthesis and remodeling during growth directly impact viability. Resuscitation-promoting factors (Rpfs), enzymes with lytic transglycosylase activity, have been associated with the revival of dormant cells and subsequent resumption of vegetative growth. Mycobacterium smegmatis, a soil saprophyte and close relative of the human pathogen Mycobacterium tuberculosis, encodes four distinct Rpfs. Herein, we assessed the relationship between Rpfs and biofilm formation, which is used as a model to study drug tolerance and bacterial signaling in mycobacteria. We demonstrated that progressive deletion of rpf genes hampered the development of biofilms and reduced drug tolerance. These effects were accompanied by a reduction in muropeptide production and altered peptidoglycan cross-linking. Collectively, these observations point to an important role for Rpfs in mycobacterial communication and drug tolerance.

Chronic Subdural Hematoma Spontaneous Resolution

Introduction Chronic subdural hematoma (CSH) is a hemorrhagic brain injury that persists for more than 21 days after its initial formation. The incidence is predominantly among the elderly population (> 65 years), and varies from 58 to 74/100,000 inhabitants. Spontaneous resolution is considered variable; in the literature series, it is < 1–20% of cases. Objectives To expose the CSH pathophysiological mechanisms of spontaneous resolution and some treatments that lead to hematoma volume reduction. Methods Literature review between 1971 to 2016, using the PubMed, Medline, Embase, Scielo, LILACS and Cochrane databases using key-words, with inclusion and exclusion criteria. Discussion Spontaneous resolution of the CSH pathophysiology is controversial; however, it can be attributed to four basic mechanisms: 1) outer capsule membrane maturation; 2) decreased fibrinolysis; 3) bidirectional flow of blood vessels; and 4) platelet plug. Some drugs, such as mannitol, corticosteroids, tranexamic acid and atorvastatin, contribute to CSH resolution, since they change the capsule membrane permeability, and inhibit the fibrinolytic and inflammatory systems. Conclusion Spontaneous resolution is unpredictable; in some cases, it has a large temporal evolution (of up to 6 years). It occurs in small or laminar collections, asymptomatic or with transient neurological symptoms, and the pathophysiology is still controversial to this day. Therefore, surgical treatment should remain the first option, even though the conservative management is adopted for some patients. Rigorous outpatient and radiological follow-up are recommended.

PEMBUATAN RADIONUKLIDA MOLIBDENUM-99 (99Mo) HASIL AKTIVASI NEUTRON DARI MOLIBDENUM ALAM UNTUK MEMPEROLEH TEKNESIUM-99m (99mTc)

PEMBUATAN RADIONUKLIDA MOLIBDENUM-99 (99Mo) HASIL AKTIVASI NEUTRON DARI MOLIBDENUM ALAM UNTUK MEMPEROLEH TEKNESIUM-99m (99mTc). Pembatasan penggunaan uranium sebagai target untuk produksi 99mTc menyebabkan rumah sakit di Indonesia kesulitan mendapatkan pasokan 99mTc. Saat ini 99mTc diperoleh dari 99Mo hasil fisi (pembelahan uranium). Pembuatan radionuklida 99Mo dari aktivasi neutron molibdenum alam (MoO3) di teras reaktor G.A Siwabessy digunakan sebagai metode alternatif untuk memperoleh 99mTc. Tujuan penelitian ini adalah untuk melakukan pembuatan radionuklida 99Mo dari aktivasi neutron molibdenum alam untuk memperoleh 99mTc. Serbuk MoO3 alam sebanyak 5 gram dikemas dalam ampul kuarsa dan dimasukkan ke dalam inner capsul selanjutnya dikemas menggunakan outer capsul sebagai bahan target. Bahan target diiradiasi di reaktor G.A Siwabessy selama 100 jam. Hasil perhitungan diperoleh aktivitas 99Mo sebesar 65 % dari nilai maksimum yang dapat diperoleh. MoO3 paska iradiasi dilarutkan dengan NaOH 4 M sehingga diperoleh larutan natrium molibdat (Na2MoO4). Radionuklida 99Mo dan 99mTc diukur menggunakan spektrometer gamma. Radionuklida 99Mo terdeteksi dalam produk larutan Na2MoO4 dengan aktivitas jenis 99Mo yang diperoleh sebesar 0,81 Ci 99Mo/g Mo. Radionuklida anak luruh 99mTc dipisahkan dari radionuklida induk 99Mo menggunakan kolom pemisah yang berisi material berbasis zirkonium (MBZ) sebagai penyerap 99Mo. Radionuklida 99mTc hasil pemisahan diperoleh dalam bentuk natrium pertehnetat (Na99mTcO4).dengan recovery yang masih rendah yaitu sekitar 52 hingga 71 %.Kata kunci: Molibdenum, teknesium, radionuklida, pemisahan, iradiasi. PRODUCTION OF ACTIVATED NEUTRON MOLYBDENUM-99 (99Mo) RADIONUCLIDE FROM NATURAL MOLYBDENUM TO OBTAIN TECHNETIUM-99m (99mTc). Uranium usage restriction causes the hospitals in indonesia difficult to obtain the suply of 99mTc. At Present, 99mTc is obtanied from molybdenum as a uranium fission product. Production of 99Mo radionuclide resulted from neutron activated natural molybdenum (MoO3) in G.A Siwabessy reactor could be used as a alternatif method for producing 99mTc. The aim of this research is synthesize of 99Mo radionuclide from neutron activated natural molybdenum (MoO3) to obtain 99mTc. The five grams of MoO3 powder was packed in a quartz ampule and inserted into inner capsule then also inserted into outer capsule as a target material. It was iradiated in G.A Siwabessy reactor for 100hours. Based on theoritical calculation, about 65 % of maximum 99Mo activity could be recovered. After Irradiation, MoO3 was dissolved by NaOH 4 M solution so it was natrium molybdate (Na2MoO4) solution. 99Mo and 99mTc radionuclide were analyzed using gamma spectrometer. 99Mo radionuclide was detected on Na2MoO4 solution as product that had specific activity of 0.81 Ci 99Mo/ g Mo. 99mTc as daughter radionuclide was separated from 99Mo as parent radionuclide using separated column containing zirconium based material (ZBM) as 99Mo adsobent. 99mTc radionuclide has been succesfully separated using ZBM column although recovery of 99mTc was quite low in which approximately 52 to 71 %. The 99mTc radionuclide was recovered in the form of sodium pertechnetate (NaTcO4) solution.Keywords: Molybdenum, technetium, radionuclide, separation, irradiation.

PEMBUATAN SUMBER RADIASI GAMMA 137Cs DENGAN AKTIVITAS 20 mCi DARI PEB U3Si2-Al PASCA IRADIASI DALAM CONTAINER STAINLESS STEEL

PEMBUATAN SUMBER RADIASI GAMMA ISOTOP 137Cs DENGAN AKTIVITAS 20 mCi DARI PEB U3Si2-Al PASCA IRADIASI DALAM CONTAINER STAINLESS STEEL. Kegiatan uji pasca iradiasi pelat elemen bakar (PEB) U3Si2-Al banyak menghasilkan larutan dengan keaktifan yang sangat tinggi. Larutan tersebut mengandung isotop 137Cs, uranium serta transuranium yang mempunyai waktu paroh panjang dan berbahaya bagi lingkungan. Namun larutan tersebut memiliki nilai ekonomis tinggi karena dapat dimanfaatkan sebagai bahan baku untuk pembuatan sumber radiasi sinar gamma isotop 137Cs. Hal ini dapat membantu bidang industri dalam memenuhi kebutuhan sumber radioaktif dalam negeri karena selama ini kebutuhan isotop 137Cs di Indonesia masih tergantung dari industri luar negeri. Selain itu, pengadaan dan transportasi isotop 137Cs dari luar negeri serta dalam penggunaannya memerlukan persyaratan yang cukup ketat dari Badan Pengawas Tenaga Nuklir Nasional (BAPETEN), sehingga menyebabkan harga isotop 137Cs menjadi mahal sampai di Indonesia. Dengan alasan tersebut, BATAN sebagai lembaga litbang nuklir di Indonesia perlu mempelajari pembuatan sumber radiasi gamma isotop 137Cs dari larutan hasil pengujian bahan bakar nuklir U3Si2-Al pasca iradiasi. Manfaat isotop 137Cs sangat luas antara lain digunakan dalam menganalisis sampel lingkungan, industri migas, konstruksi, radiografi, perikanan, rumah sakit dan pertambangan. Pembuatan sumber radiasi gamma isotop 137Cs dimulai dari pengumpulan larutan hasil pengujian PEB U3Si2-Al. Larutan larutan hasil pengujian mengandung isotop 137Cs dan isotop lainnya dikumpulkan menjadi satu dalam botol dengan volume 65 mL. Pemisahan isotop 137Cs dari hasil fisi lainnya dilakukan dengan metode penukar kation menggunakan zeolit Lampung dengan berat 45 gr. Hasil pemisahan diperoleh 137Cs-zeolit dalam fasa padat dan isotop lainnya berada dalam fasa cair. Padatan137Cs-zeolit kering kemudian kemudian ditimbang dan diukur aktivitasnya menggunakan spektrometer-g. Hasil analisis dengan spektrometer-g diperoleh aktivitas padatan 137Cs-zeolit sebesar 20 mCi. Untuk menjadi sumber radiasi gamma 137Cs, padatan 137Cs-zeolit dengan aktivitas 20 mCi dikemas dengan cara memasukkan ke dalam inner-outer capsule terbuat dari stainless steel yang telah dirancang sebelumnya. Container stainless steel diproses menjadi sumber radiasi gamma tertutup (shield source) untuk selanjutnya disertifikasi oleh PTKMR-BATAN sebagai lembaga kalibtrator bahan radioaktif di BATAN.Kata kunci: Larutan proses PEB U3Si2-Al, radioaktif gamma, isotop 137Cs, penukar kation, zeolit Lampung dan container. MANUCFACTURING OF 137Cs GAMMA RAY SOURCE WITH ACTIVITY 20 mCi FROM PEB U3Si2-Al POST IRRADIATION IN STAINLESS STEEL CONTAINER. In the post-irradiation examination of fuel element plate (PEB) U3Si2-Al), a solution of high activity as a result of testing nuclear fuel stored in hotcell with enough volume. The solution can not be discarded as waste because it still contains fission isotop such as137Cs, uranium and transuranium, which has a long half life and dangerous for the environment. This can help the industry in order to fulfill the needs of a radioactive source in Indonesia, because until now 137Cs isotope is derived from foreign industries. In addition, the procurement and transportation of isotopes 137Cs require stringent requirements, because they have toget permission from the National Nuclear Energy Agency (BAPETEN), thus causing the price of high activity 137Cs isotopes becomes expensive to Indonesia. For these reasons, BATAN as nuclear R&D institutions in Indonesia need to study make isotopes 137Cs gamma radiation source, which is contained in the waste from spent fuel test results U3Si2-Al. Isotope 137Cs can be used very widely, such as in the analysis of environmental samples, the oil and gas industry, construction, radiography, fisheries, hospitals, and mining. Making isotope 137Cs gamma radiation source starting from the collection of waste from the test results PEB U3Si2- Al. Waste solution was collected in a bottle with volume 65 mL. Collection of 137Cs isotopes of other fission carried out using the method of cation exchange with weight 45 gr of zeolite Lampung. The results of separation are 137Cs-zeolite in the solid phase and the other isotopes are in the liquid phase. 137Cs-zeolite solid is then dried and then weighed and measured its activity using a spectrometer-g. Result of analisys by spectrometer-g was obtained acitivity of 137Cs-zeolite solids was 20 mCi.137Cs-zeolite solids then packed in sealed containers (shield source) capsule-shaped stainless steel and than certificate by PTKMR-BATAN.Keywords: Process wastle of PEB U3Si2-Al, gamma radioactive, isotope 137Cs, cation exchange, zeolite Lampung and container.

Deformation of spherical compound capsules in simple shear flow

The deformation of a compound capsule (an elastic capsule with a smaller capsule inside) in simple shear flow is studied by using three-dimensional numerical simulations based on a front tracking method. The inner and outer capsules are concentric and initially spherical. Skalaket al.’s constitutive law is employed for the mechanics of both the inner and outer membranes. Our results concerning the deformation of homogeneous capsules (i.e. capsules without the inner capsules) are quantitatively in agreement with the predictions of previous numerical simulations and perturbation theories. Compared to homogeneous capsules, compound capsules exhibit smaller deformation. The deformations of both the inner and outer capsules are significantly affected by the capillary numbers of the inner and outer membranes and the volume ratio of the inner to the outer capsule. When the inner capsule is small, it presents smaller deformation than the outer capsule. However, when the inner capsule is sufficiently large, it can present larger deformation than the outer capsule, even if the inner membrane has much lower capillary number than the outer membrane. The underlying mechanisms are discussed: (i) the inner capsule is deformed by rotational flow with lower rate of strain rather than by simple shear flow that deforms the outer capsule, and thus the inner capsule exhibits smaller deformation; and (ii) when the inner and outer membranes are sufficiently close (i.e. the inner capsule is sufficiently large), the hydrodynamic interaction between the two membranes becomes significant, which is found to inhibit the deformation of the outer capsule but to promote the deformation of the inner capsule.