Accelerated platelet activation in Asian Indians with diabetes and coronary artery disease--The Chennai Urban Population Study (CUPS-13)

AIM

To assess platelet activation in south Indian type 2 diabetic subjects with and without CAD.

METHODS

Four groups of subjects were studied; Group 1 comprised of non-diabetic subjects without coronary artery disease (CAD) (n = 30). Type 2 diabetic subjects without CAD formed Group 2 (n = 30); Group 3 comprised of type 2 diabetic subjects with CAD (n = 30) and Group 4 consisted of non- diabetic subjects with CAD (n=14). CAD was diagnosed based on coronary angiographic evidence of severe double or triple vessel disease. Platelet activation was tested after an overnight fast in blood obtained from a bleeding wound at 1 minute post-incision (wound-induced activation) as well as venous blood stimulated in vitro with collagen, using whole blood flow cytometry. In subjects with CAD, aspirin was withdrawn for 7 days and nitrates for 24 hours.

RESULTS

Collagen induced GP IIb/IIIa binding was significantly higher among diabetic subjects with (28.10 +/-19.89; p<0.05) and without CAD (21.02+/-19.62; p<0.05) and non-diabetic subjects with CAD (23.89+/-15.65; p<0.05) compared to non-diabetic subjects without CAD (11.69+/-13.69). Regression analysis showed collagen induced GP IIb/IIIa binding to be significantly associated with CAD [odds ratio (OR): 1.029, p = 0.025] and diabetes (OR: 1.037, p = 0.007).

CONCLUSION

Increased platelet activation is seen in urban south Indians with diabetes and CAD.

Successful management of melanocytomaassociated choroidal neovascularization with photodynamic therapy

PURPOSE

To report the efficacy of photodynamic therapy in treatment of choroidal neovascular membrane (CNV) associated with melanocytoma of the optic disc.

METHODS

A middle-aged man with visual acuity of 20/200 in right eye was treated with photodynamic therapy for juxtafoveal classic CNV overlying the papillomacular bundle. CNV was secondary to ocular melanocytoma, a rare event.

RESULTS

At the 6-month follow-up, a scarred CNV with final visual acuity of 20/30 was noted clinically and angiographically. Tomography revealed high reflective scar tissue with flat macula and microperimetry showed restoration of retinal sensitivity over the papillomacular bundle.

CONCLUSIONS

Photodynamic therapy effectively resolved CNV that involved papillomacular bundle (secondary to melanocytoma) and restored retinal function in papillomacular bundle.

Successful management of melanocytoma-associated choroidal neovascularization with photodynamic therapy

PURPOSE

To report the efficacy of photodynamic therapy in treatment of choroidal neovascular membrane (CNV) associated with melanocytoma of the optic disc.

METHODS

A middle-aged man with visual acuity of 20/200 in right eye was treated with photodynamic therapy for juxtafoveal classic CNV overlying the papillomacular bundle. CNV was secondary to ocular melanocytoma, a rare event.

RESULTS

At the 6-month follow-up, a scarred CNV with final visual acuity of 20/30 was noted clinically and angiographically. Tomography revealed high reflective scar tissue with flat macula and microperimetry showed restoration of retinal sensitivity over the papillomacular bundle.

CONCLUSIONS

Photodynamic therapy effectively resolved CNV that involved papillomacular bundle (secondary to melanocytoma) and restored retinal function in papillomacular bundle.

Sustained benefit in rheumatoid arthritis following one course of rituximab: improvements in physical function over 2 years

OBJECTIVES

To evaluate the long-term impact on physical function of a single course of rituximab in rheumatoid factor, seropositive patients with active rheumatoid arthritis (RA) despite ongoing methotrexate treatment.

METHODS

A randomized, controlled trial comparing rituximab alone [1,000 mg intravenously (iv) on days 1 and 15, n= 40], or in combination with cyclophosphamide (750 mg iv on days 3 and 7, n= 41) or oral methotrexate (> or =10 mg/week, n= 40) with placebo + methotrexate (> or =10 mg/week, n= 40), resulted in significant reductions in disease activity at weeks 24 and 48. Sustained improvements in physical function and standard effect sizes (SES) for changes in components of ACR and EULAR criteria were evaluated over 2 yrs.

RESULTS

More patients receiving rituximab + methotrexate completed a 2-yr follow-up without further treatment than those receiving placebo + methotrexate (45% vs 15%, respectively), rituximab alone (10%) or rituximab + cyclophosphamide (22%). This reflected a higher percentage of patients receiving rituximab + methotrexate reporting improvements in Health Assessment Questionnaire Disability Index > or = minimum clinically important difference at 1 and 2 yrs (68% and 30%, respectively) compared with placebo + methotrexate (28% and 15%), rituximab monotherapy (43% and 10%) or rituximab + cyclophosphamide (39% and 12%). SES were high in all rituximab groups and revealed differing patterns of response over time.

CONCLUSION

A single course of rituximab with continuing methotrexate in patients with active RA provided clinically meaningful improvements in physical function over 2 yrs, with lower discontinuation rates and larger SES for improvements in ACR and EULAR criteria components.

Application of the polymerase chain reaction on formalin-fixed, paraffin-embedded tissue in the recognition of tuberculous osteomyelitis

A retrospective series of 45 cases of chronic osteomyelitis collected over a period of 14 years was histologically classified into tuberculous osteomyelitis (25) and chronic non-granulomatous osteomyelitis (20). The tuberculous osteomyelitis group was divided into three subgroups: a) typical granulomas (13 cases); b) ill-defined granulomas (seven cases), and c) suspected granulomas (five cases). An in-house polymerase chain reaction amplifying the 245 bp nucleotide sequence, and capable of detecting 10 fg of DNA of Mycobacterium tuberculosis, was used on the DNA extracted from the paraffin blocks. The polymerase chain reaction was positive in 72% of cases (18) of tuberculous osteomyelitis, but when typical cases of tuberculous osteomyelitis with confirmed granulomas were considered (13), this increased to 84.6% (11). The chronic non-granulomatous osteomyelitis group gave positive polymerase chain reaction results in 20% of the cases (4).

Our preliminary study on tuberculous osteomyelitis shows that the polymerase chain reaction can be a very useful diagnostic tool, since a good correlation was seen between typical granulomas and polymerase chain reaction with a sensitivity of 84.6% and a specificity of 80%. In addition, our study shows that tuberculous osteomyelitis can be diagnosed in formalin-fixed paraffin-embedded tissues in the absence of typical granulomas.

Nonstarter lactic acid bacteria biofilms and calcium lactate crystals in Cheddar cheese

A sanitized cheese plant was swabbed for the presence of nonstarter lactic acid bacteria (NSLAB) biofilms. Swabs were analyzed to determine the sources and microorganisms responsible for contamination. In pilot plant experiments, cheese vats filled with standard cheese milk (lactose:protein = 1.47) and ultrafiltered cheese milk (lactose:protein = 1.23) were inoculated with Lactococcus lactis ssp. cremoris starter culture (8 log cfu/mL) with or without Lactobacillus curvatus or Pediococci acidilactici as adjunct cultures (2 log cfu/mL). Cheddar cheeses were aged at 7.2 or 10 degrees C for 168 d. The raw milk silo, ultrafiltration unit, cheddaring belt, and cheese tower had NSLAB biofilms ranging from 2 to 4 log cfu/100 cm2. The population of Lb. curvatus reached 8 log cfu/g, whereas P. acidilactici reached 7 log cfu/g of experimental Cheddar cheese in 14 d. Higher NSLAB counts were observed in the first 14 d of aging in cheese stored at 10 degrees C compared with that stored at 7.2 degrees C. However, microbial counts decreased more quickly in Cheddar cheeses aged at 10 degrees C compared with 7.2 degrees C after 28 d. In cheeses without specific adjunct cultures (Lb. curvatus or P. acidilactici), calcium lactate crystals were not observed within 168 d. However, crystals were observed after only 56 d in cheeses containing Lb. curvatus, which also had increased concentration of D(-)-lactic acid compared with control cheeses. Our research shows that low levels of contamination with certain NSLAB can result in calcium lactate crystals, regardless of lactose:protein ratio.

Variations in fat and fatty acid intakes of adult males from three regions of India

Fat and fatty acid intakes of 25 healthy adult urban males from Ghaziabad, U.P.; Goa and Kolkata, W.Bengal, respectively were studied. Fat intakes were estimated using dietary records, food frequency questionnaires and chemical analysis of the diets consumed. Fatty acid intakes were estimated by gas chromatography. Total fat intakes ranged from 26.9 g/day to 163.2g/ day. Percent subjects having intakes above the desirable level were 72% in Kolkata, 36% in Ghaziabad, U.P. and only 10% in Goa. Visible fat constituted more than 60 percent of total fat. In all 3 areas, SFA intakes were higher and MUFA lower than desirable levels. Palmitic acid constituted at least 50% of SFA intakes. In Goa, lauric acid, in Ghaziabad and Kolkata, stearic acid and myristic acid were major dietary SFAs, In Kolkata, erucic acid was 17.3+/-8.3%. Overall 60% of subjects had n-6:n-3 intakes close to the desirable ratio. Linoleic acid constituted almost the entire n-6 intake. Alpha linolenic acid constituted most of the n-3 intakes in Ghaziabad, U.P. and Kolkata. The ratios of SFA:MUFA--PUFA vaned widely and percent subjects with intakes close to the desirable ratios were 12% in Goa, 23% in Ghaziabad and 40% in Kolkata. The data highlights the need for limiting fat intakes and modifying diets to provide fatty acids in desirable ratios.

Variation in clinical and genitourinary lesions associated with pulmonary hypoplasia in Potter's syndrome--two autopsy reports

Potter's syndrome is a rare entity with an incidence of 1 in 2000 to 1 in 5000 live births. All babies born with this condition are either stillborn or die very early within neonatal period. We present two autopsy cases which presented with abnormal facies, oligohydramnios, pulmonary hypoplasia and genitourinary abnormality. One case presented with infantile polycystic kidney whereas in the other case both the kidneys were normal but had adenomatoid tumour of left testis. Both the children died few hours after birth. In both the cases pulmonary hypoplasia was the cause of death rather than genitourinary abnormality.

Pure esophageal atresia with no gap and associated intra-abdominal calcification

Pure esophageal atresia (PEA) is characterized by a long gap in between the two pouches. Primary anastomosis is usually not feasible and various techniques have been described in the literature to bridge this gap. We describe a case of PEA where there was no gap externally in between the two pouches and associated intra-abdominal calcification.

Modified gemcitabine regime in advanced lung cancers

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Background: Gemcitabine is established treatment modality for NSCLC. However it’s introduction on day 8 is sometimes delayed because of low counts or poor patient acceptance because of effects of d1 dose. Methods: We have used gemcitabine 10000 mg/m2 as d1,d10 regimen in 32 patients of advanced lung cancer incombination with either cisplatin or carboplatin .Colony stimulating factors were required in 2 patients. Results: The patients tolerated the chemotherapy (4 to 6 cycles) satisfactorily and none of the patient required delaying of the d10 therapy. Complete regression was seen in 2 patients,partial regression in 22 patients.the median survival was 10.2 months. Conclusions: The d1–10 schedule of gemcitabine based chemotherapry is safe,effective and better tolerated then the d1-d8 schedule.

No significant financial relationships to disclose.

Occult renal impairment is common in patients with peripheral vascular disease and normal serum creatinine

OBJECTIVE

The incidence of peripheral vascular disease (PVD) and angiography/angioplasty is rising annually. The UK Small Aneurysm Trial and other trials have shown renal function is a predictor of increased mortality and failed infrainguinal bypass despite patent vessels. Renal function is classically assessed by serum creatinine (SCr). However, SCr can be normal despite significant renal impairment. A more sensitive test is creatinine clearance (CrCl) as determined by 24-hour urine collection in combination with SCr. We studied the incidence of renal impairment, as defined by CrCl, in PVD patients with normal SCr.

METHODOLOGY

All patients with PVD sufficient to necessitate angiography and normal SCr (< or =120 micromol/l - men; < or =97 micromol/l - women) had their CrCl assessed prior to angiography: using both 24-hour urine collection and the Cockcroft-Gault formula. Various blood tests, a detailed history and examination were performed. A control group of arthritic patients, age and sex-matched with similar SCr, also had their CrCl determined.

RESULTS

65 of 76 patients (86%) with normal SCr had a subnormal CrCl (<100 ml/min) and 49 (65%) had a CrCl below 60 ml/min. In the control group of arthritic patients, the proportion having impaired CrCl was significantly less - 67% below 100 mls/min (p=0.0471) and only 15% below 60 mls/min (p<0.0001). The median and interquartile range CrCl of 52 [38-81] mls/min for PVD patients was significantly worse than for control patients (80 [68-119] mls/min -p<0.0001). The Cockcroft-Gault formula for calculating CrCl did not correlate well with the urinary CrCl for the control group but did for PVD patients (p<0.0001). Factors associated with a significantly reduced CrCl were age of at least 75 years, SCr of at least 85 micromol/l and a history of coronary heart disease (all p<0.05). This had a sensitivity of 88% and specificity of 82% for identifying subnormal CrCl. Statin use was associated with a significantly improved CrCl (p=0.040).

CONCLUSION

Most PVD patients with normal serum creatinine have occult, significantly impaired renal function as defined by creatinine clearance. Vascular surgeons should include creatinine clearance in pre-operative assessment of renal function especially in patients over 75 years old, with a history of coronary heart disease or a serum creatinine over 85 micromol/l. The method of determining creatinine clearance could be the Cockcroft-Gault calculation or ideally 24-hour urinary creatinine clearance measurement. This would allow appropriate early referral to a nephrologist for further investigation and management. It is worth noting that statin use seems to be associated with a protective effect on renal function.

Effect of biopolymer on the dewatering characteristics of autothermal thermophilic aerobic digestion of sludges

Autothermal thermophilic aerobic digestion of sludge is known to produce poorly dewatering sludges. Laboratory studies were conducted to investigate the reasons for the poor dewatering. It was found that, during digestion, proteins and polysaccharides were released into solution, and that these could be linked to the deterioration in dewatering. The biopolymer release was accompanied by an increase in the monovalent-to-divalent (M/D) cation ratio. The degree to which the M/D caused deterioration of the sludges depended on the presence of iron in sludge. When the iron content was high, the release of protein and polysaccharides was low. When iron was low, the release of protein and polysaccharides increased linearly with the M/D ratio. The dose of conditioning chemicals, cationic polymer or ferric chloride, was related to the amount of colloidal biopolymer present in solution. The findings suggest that the addition of iron during the digestion process has the potential to produce better dewatering sludges.

Regulation of matrix metalloproteinase expression by dynamic tensile strain in rat fibrochondrocytes

OBJECTIVE

We sought to determine the molecular basis for the anticatabolic effects of mechanical signals on fibrocartilage cells by studying the expression of a variety of matrix metalloproteinases (MMPs). Furthermore, we examined whether the effects of biomechanical strain on MMP gene expression are sustained.

METHODS

Fibrochondrocytes from temporomandibular joint (TMJ) discs were exposed to dynamic tensile strain for various time intervals in the presence of interleukin (IL)-1beta. The regulation of the messenger RNA (mRNA) expression and synthesis of MMPs and tissue inhibitors of MMPs (TIMPs) were examined by end-point and real-time reverse transcriptase-polymerase chain reaction (RT-PCR) as well as Western blot analysis.

RESULTS

Fibrochondrocytes expressed mRNA for MMP-2, -3, -7, -8, -9, -11, -13, -14, -16, -17, and -19 as well as TIMP-1, -2, and -3, IL-1beta induced a significant (P<0.05) upregulation of mRNA for MMP-3, -7, -8, -9, -13, -16, -17, and -19. The IL-1beta-stimulated upregulation of these MMPs was significantly (P<0.05) abrogated by dynamic tensile strain. However, MMP-2, -11, -14, and TIMPs were not affected by either IL-1beta or tensile strain. Biomechanical strain also inhibited the IL-1beta-stimulated protein synthesis of MMP-3, -7, -8, -9, -13, -16, and -17. Application of mechanical strain for various time intervals during a 24-h incubation with IL-1beta showed that the suppressive effects of mechanical signals are sustained.

CONCLUSIONS

The data provide evidence that biomechanical signals can downregulate the catabolic activity of fibrocartilage cells in an inflammatory environment by inhibiting the expression of a variety of MMPs. Furthermore, the matrix-protective effects of biomechanical signals are sustained even in an inflammatory environment.

Recurrent vulval congenital lymphangioma circumscriptum-a case report and literature review

Lymphangioma circumscriptum (LC) is a defect of lymphatics in deep dermis. This abnormal saccular dilatation of lymphatics occurs in dermal papillae visible as vesicles clinically. The entity may be acquired or congenital. The occurrence of congenital variety of LC in vulva is extremely rare, with only few cases reported in the literature. We communicate one such case presenting as recurrent vulval growth along with a review of literature and treatment modalities.

Doppler Adson’s Test: Predictor of Outcome of Surgery in Non-Specific Thoracic Outlet Syndrome

INTRODUCTION

Outcome of surgery in non-specific thoracic outlet syndrome (TOS) is variable. Duplex imaging of the subclavian artery during Adson's maneuvre may help predict outcome.

PATIENTS AND METHODS

A retrospective study of 16 cases of non-specific TOS who had pre-operative duplex imaging of the subclavian artery during Adson's maneuvre was done and their outcomes following surgical decompression of the thoracic outlet studied.

RESULTS

Of the eight cases with a positive Adson's test, seven (87.5%) had a complete response of symptoms following surgery while in the eight cases with a negative test, only four (50%) had a favorable response to surgery.

CONCLUSION

Duplex scanning of the thoracic outlet during Adson's maneuvre may help predict outcome of thoracic outlet decompression surgery in cases of non-specific TOS.

Fentanyl-augmented MRCP

BACKGROUND

Drugs such as secretin and morphine have been used to augment the visualization of magnetic resonance cholangiopancreatography (MRCP). This study investigated the effectiveness of intravenous administration of a synthetic opioid, fentanyl, in improving the MRCP image quality.

METHODS

Thirty consecutive patients with a provisional diagnosis of benign biliary and/or pancreatic disease underwent MRCP. Coronal single-shot fast spin-echo heavily T2-weighted dynamic MRCP images were generated before and at every minute for 10 min after intravenous administration of fentanyl citrate at a dose of 1.0 mug/kg. Pre- and postinjection images were compared and analyzed qualitatively and quantitatively.

RESULTS

Qualitatively, visualization of intrahepatic bile ducts, common bile duct, and main pancreatic duct improved after fentanyl injection in five (16%), 11 (37%), and 19 (63%) patients, respectively. The pancreatobiliary junction and common channel were visualized better after fentanyl injection in eight of the 18 patients (44%). Quantitatively, signal intensity and diameters of the intrahepatic ducts, common bile duct, and main pancreatic duct measured at corresponding points on pre- and postinjection images showed an increase above preinjection values in 28 (93%), 27 (90%), and 21 (70%) and in 18 (60%), 26 (86%), and 22 (73%), respectively, and these changes were highly significant at all sites (p < 0.001).

CONCLUSIONS

Intravenous administration of fentanyl before MRCP improves qualitative and quantitative visualization of the ductal system anatomy that may be of value in clinical diagnosis and management.

Two simple, reliable and valid tests of proximal muscle function, and their application to the management of idiopathic inflammatory myositis

OBJECTIVE

To develop objective, isotonic, reliable and valid tests of upper (UL) and lower (LL) limb proximal muscle function for use in the management of idiopathic inflammatory myositis (IIM).

METHODS

The '1 kg arm lift' test was devised to assess UL function and the '30 s chair stand' test was used for LL function. The tests were performed in 30 control subjects to determine short (24 h) and long (2 week) interval test-retest reliability. Thirty-two patients with IIM were assessed over a period of 2 yr.

RESULTS

In the control group both tests showed excellent test-retest reliability; Spearman correlation >0.8 for both tests over both time intervals. Twenty-four of the 32 IIM patients remained in remission over a mean period of 20.7 months throughout which scores varied by <5 for the '1 kg arm lift' test and <3 for the '30 s chair stand' test from each patient's mean score. Eight patients relapsed with scores falling by >5 for the '1 kg arm lift' test and by >3 for the '30 s chair stand' test from the mean remission score in each case. Both UL and LL scores correlated inversely with serum creatinine kinase.

CONCLUSION

Two isotonic tests of proximal muscle function are described. They exhibit excellent test-retest reliability and demonstrate construct validity in IIM. Both tests are responsive to changes in disease activity, offer physiological and practical advantages over existing tests of muscle function and are suitable for use in clinical practice.

Methylenetetrahydrofolate reductase gene polymorphism in Indian stroke patients

BACKGROUND AND AIMS

In view of the prevailing controversy about the role of Methylenetetrahydrofolate reductase (MTHFR) C677T mutation in stroke and paucity of studies from India, this study has been undertaken to evaluate MTHFR C677T gene polymorphism in consecutive ischemic stroke patients and correlate these with folic acid, homocysteine (Hcy) and conventional risk factors.

SETTINGS AND DESIGN

Ischemic stroke patients prospectively evaluated in a tertiary care teaching hospital.

MATERIALS AND METHODS

Computerized tomography proven ischemic stroke patients were prospectively evaluated including clinical, family history of stroke, dietary habits and addictions. Their fasting and postprandial blood sugar, lipid profile, vitamin B12, folic acid and MTHFR gene analysis were done.

STATISTICAL ANALYSIS

MTHFR gene polymorphism was correlated with serum folic acid, Vitamin B12 and Hcy levels; family history of stroke in first-degree relatives; and dietary habits; employing Chi-square test.

RESULTS

There were 58 patients with ischemic stroke, whose mean age was 50 (4-79) years; among them, 10 were females. MTHFR gene polymorphism was present in 19 (32.8%) patients, 3 were homozygous and 16 were heterozygous. Both serum folate and B12 levels were low in 29 (50%) patients and Hcy in 48 (83%). Hypertension was present in 28 (48%) patients, diabetes in 12 (21%), hyperlipidemia in 52 (90%), smoking in 17 (29%), obesity in 1 (1.7%) and family history of stroke in first-degree relatives in 13 (22.4%). There was no significant relationship of MTHFR gene polymorphism with folic acid, B12, Hcy levels, dietary habits and number of risk factors. Vitamin B12 level was low in vegetarians (P<0.003). In 3 patients with MTHFR TT alleles, Hcy was elevated in all 3, low folic acid in 2 and family history of stroke in 1 patient.

CONCLUSION

MTHFR gene polymorphism was found in one-third of patients with ischemic stroke and was insignificantly associated with higher frequency of elevated Hcy.