Random blinded rechecking of AFB smears in a pilot project at an intermediate reference laboratory

BACKGROUND

In most developing countries, sputum smear microscopy for acid-fast bacilli remains the front line and often the only diagnostic tool for the diagnosis of tuberculosis (TB), making quality assurance of smear microscopy an important activity.

OBJECTIVE

To evaluate the results of a pilot study, where the random blinded rechecking for the entire state of Delhi was conducted at a reference laboratory.

METHODOLOGY

Slides from 25 Revised National Tuberculosis Control Programme designated districts (200 peripheral microscopy centres) in Delhi were re-read after proper coding by all the Senior Tuberculosis Laboratory Supervisors (STLS) at an intermediate reference laboratory under proper supervision.

RESULTS

Of 12,162 re-read slides, 204 discrepant results were found. Of these, 150 (73.5%) errors were attributed to the peripheral microscopy centres and 54 (26.5%) to STLS. High false-positive errors were observed at a frequency of 12/150 (8%), and high false-negative errors at a frequency of 38/150 (25%). Minor errors, i.e., low false-negative, low false-positive and quantification errors, were observed at frequencies of respectively 68/150 (45.3%), 17/150 (11.3%) and 15/150 (10.0%).

CONCLUSION

Greater stringency in the supervision of random blinded rechecking at the district level is essential to make smear rechecking more efficient and effective.

En Bloc Multivisceral and Kidney Transplantation in an HIV Patient: First Case Report

The continual improvement in outcome with highly active antiretroviral therapy (HAART) for human immunodeficiency virus (HIV) infection and visceral transplantation for gut failure stimulated our interest in lifting HIV infection as a contraindication for intestinal and multivisceral transplantation. This report is the first to describe visceral transplantation in a patient with HIV infection. A HAART regimen was introduced in the setting of short-gut syndrome with successful suppression of HIV viral load. The indication for en bloc multivisceral and kidney transplantation was end-stage liver failure with portomesenteric venous thrombosis and chronic renal insufficiency. The underlying hepatic pathology was alcoholic and home parenteral nutrition-associated cirrhosis. Surgery was complicated due to technical difficulties with excessive blood loss and long operative time. The complex posttransplant course included multiple exploratory laparotomies due to serious intra-abdominal and systemic infections. Heavy immunosuppression was required to treat recurrent episodes of severe allograft rejection. Posttransplant oral HAART successfully sustained undetectable viral load. Unfortunately, the patient succumbed to sepsis 3 months posttransplant. With new insights into the biology of gut immunity, mechanisms of allograft tolerance, and HIV-associated immune dysregulation, successful outcome is anticipated, particularly in patients who are in need of isolated intestinal and less-organ-contained visceral allografts.

Perspectives of health care provider regarding TB-HIV referral strategy and non-uptake of HIV testing in Delhi - A qualitative study

BACKGROUND

DOTS provider and medical officer play an integral role in implementation of RNTCP. Understanding provider perspectives is an integral component of evaluating programme to improve services to identify the areas for quality improvement and universal HIV testing among TB patients.

OBJECTIVE

To describe the perception of health care providers regarding TB-HIV referral strategy and reasons for non-uptake of HIV testing.

METHODOLOGY

A qualitative study was undertaken at DOTS cum microscopic centre of TB-Chest clinic of Lok Nayak Hospital and DOTS cum microscopic centre of rural area of west Delhi. In-depth interview of DOTS provider and medical officer in-charge at DOTS centre was conducted. A topic outline guide used to assess the perception of study subjects. Thematic analysis of qualitative data was done.

RESULTS

The source of knowledge regarding HIV testing among DOTS providers were training and monthly review meetings. All the study participants knew the rational of HIV testing and the consequences of not being tested and are highly motivated for referring the patients for HIV testing at the earliest. Some of the barriers to HIV testing reported by the health care providers were lack of awareness, associated stigma, long distance travel by the patients and non-availability of HIV testing kits.

CONCLUSION

Health care providers were motivated for implementation of the strategy. Barriers to HIV TB testing strategy should be addressed.

Characteristics and treatment response in patients with tuberculosis and diabetes mellitus in New Delhi, India

Diabetes mellitus (DM) is known to increase the risk of tuberculosis (TB) and adversely affect TB treatment outcomes. A descriptive study was carried out in registered TB patients screened for DM at Lok Nayak Hospital, New Delhi, India. Of 458 TB patients, 66 (14%) had DM. In those with dual disease, age ≥40 years, smear-positive pulmonary TB and recurrent TB were significantly more common. There was no effect of DM on TB treatment outcomes, although there was a trend towards smear non-conversion at 2 months. Screening for DM works well, and certain patient characteristics are more common in those with dual disease.

Successful Domino Liver Transplantation from a Patient with Methylmalonic Acidemia

Liver transplantation has been reported in patients with methylmalonic acidemia (MMA), but long-term outcome is controversial. Many patients with other approved indications for liver transplantation die before donor grafts are available. A 28-year-old man with MMA underwent cadaveric liver transplantation. His liver was used as a domino graft for a 61-year-old man with primary sclerosing cholangitis, who had low priority on the transplant waiting list. Surgical outcome was successful, and after transplantation both patients have excellent graft function. The patient with MMA showed substantial decrease in methylmalonate in urine (from 5,277 ± 1,968 preoperatively to 1,068 ± 384 mmol/mol creatinine) and plasma (from 445.9 ± 257.0 to 333.3 ± 117.7 μmol/l) over >1-year follow-up, while dietary protein intake increased from 0.6 to 1.36 ± 0.33 g/kg/day. The domino recipient maintained near-normal levels of plasma amino acids but did develop elevated methylmalonate in blood and urine while receiving an unrestricted diet (peak plasma methylmalonate 119 μmol/l and urine methylmalonate 84-209 mmol/mol creatinine, with 1.0-1.9 g/kg/day protein). Neither patient demonstrated any apparent symptoms of MMA or metabolic decompensation during the postoperative period or following discharge.

CONCLUSION

Liver transplantation substantially corrects methylmalonate metabolism in MMA and greatly attenuates the disease. In this single patient experience, a liver from a patient with MMA functioned well as domino graft although it did result in subclinical methylmalonic acidemia and aciduria in the recipient. Patients with MMA can be considered as domino liver donors for patients who might otherwise spend long times waiting for liver transplantation.

Management of adrenocortical insufficiency with continuous subcutaneous hydrocortisone infusion: long-term experience in three patients

To assess continuous subcutaneous hydrocortisone infusion (CSHI) in patients with adrenocortical insufficiency (AI) and difficulties with oral replacement. Three patients with AI and frequent hospital admissions attributed to adrenal crises were treated with CSHI, which was delivered via a continuous subcutaneous infusion. All three patients preferred CSHI and remained on it long term, which permitted prolonged follow-up analysis. All three patients reported symptomatic improvement, and in two cases, reduced hospital admission rates and inpatient stay lengths were observed. The cost of hospital admissions and overall treatment was reduced in all cases. CSHI offers a practical and acceptable alternative to oral replacement in a subset of patients with AI. The cost of initiating and maintaining the pump is offset in the long term by reduced frequency and duration of emergency admissions. CSHI can therefore be considered in a select group of patients who are resistant to treatment with conventional oral glucocorticoids.

Rifampicin pharmacokinetics in children under the Revised National Tuberculosis Control Programme, India, 2009

OBJECTIVE

To evaluate serum levels of rifampicin (RMP) in children with tuberculosis (TB) at doses administered according to India's Revised National Tuberculosis Control Programme (RNTCP) 2009 report.

METHOD

Prospective, open label, non-randomised single-dose study in 20 children aged 5-12 years.

SETTING

The out-patient chest clinic of a tertiary care hospital, New Delhi, India.

RESULTS

The median RMP dose administered was 9.56 mg/kg (range 9-12.64). Peak RMP concentration (Cmax) attained was 6.24 μg/ml (range 5.44-7.61) at time to Cmax of 3.5 h (range 3-4). RMP levels were significantly lower at 2, 3 and 4 h in children administered <10 mg/kg than those who received ⩾10 mg/kg (P < 0.05). A positive correlation between the RMP dose administered and Cmax was observed (r(2) = 0.748). RMP Cmax was <8 μg/ml in all patients, a level considered too low for therapeutic efficacy.

CONCLUSIONS

Low serum concentrations of RMP were attained in children under the RNTCP 2009 weight band system. Peak RMP levels appear to be lower and the single dose elimination half-life shorter in children than in adults. To optimise treatment outcomes, revisions in RMP dose in children should take into consideration age-related differences in pharmacokinetics.

Red-blue-green solid state light sources using a narrow line-width green phosphor

We demonstrate that using a narrow line-width green phosphor with the peak wavelength closely aligned with the peak in the human eye sensitivity significantly improves the Luminous Efficacy of Radiation (LER) for Red-Green-Blue (RGB) emitters. Compared to the traditional RGB sources, the improvement in LER of 20 lm/W can be achieved. Combining the narrow band green phosphor with conventional wide band red and blue phosphors allows for trading off these improvements against the deviation from the Planckian locus for even higher LER. The light sources with the narrow line green phosphor are particularly promising for high energy efficiency and high intensity illumination, where somewhat compromises can be made in the color quality such as in automotive, outdoor spaces, industrial ware-houses, public places (train stations, airports) etc..

Venous thromboembolism in patients receiving perioperative chemotherapy for esophagogastric cancer

The association between venous thromboembolism and chemotherapy for esophagogastric cancer is well known in patients treated with palliative intent. Whether this risk extends to the neoadjuvant and perioperative setting is unclear. A retrospective interrogation of databases of patients receiving perioperative chemotherapy for potentially curative intent at the Leicester (2006-2011) and Nottingham (2004-2011) esophagogastric cancer centers was performed. Thromboembolic events were diagnosed in 48 of 384 patients (12.5%), 21 (5.5%) at presentation, 12 (3%) during neoadjuvant chemotherapy, and 15 (3.9%) in the postoperative period. There were no deaths from thromboembolic disease. By site these comprised catheter-related axillary vein thrombosis in 7 patients, deep venous thrombosis in 12 patients, and pulmonary embolism in 29 patients. Twenty-five of the 29 pulmonary emboli were incidental findings on staging computed tomography imaging. Combination chemotherapy with epirubicin, cisplatin, and capecitabine appeared to carry the greatest risk for the development of thromboembolism. Seven of the 12 patients (58%) who developed thromboembolism during neoadjuvant chemotherapy did not proceed to surgery because of deterioration in performance status. Preoperative thromboembolic disease resulted in a significant increase in the interval between chemotherapy and surgery, but did not influence either length of hospital stay or survival. Venous thromboembolism will develop in 12.5% of patients treated with potentially curative intent. This adverse event can occur at any time during the patient journey. In contrast to the commonly held view, this did not translate into a poorer prognosis.

Accidental acetaminophen overdose results in liver transplant during second trimester of pregnancy: a case report

Acetaminophen overdose is the most rapidly growing cause of fulminant hepatic failure in Western countries. Pregnant women are counseled that acetaminophen is safe during pregnancy and an alternative to nonsteroidal anti-inflammatory medications. This report describes a case of acetaminophen overdose during the second trimester of pregnancy with resultant fulminant hepatic failure requiring liver transplantation. The fetus was previable at the time of liver transplantation, and methods to preserve viability during and after transplantation are discussed. Despite the best attempts of the team, the fetus expired. The challenges and outcomes of fulminant hepatic failure in pregnancy are discussed in detail.

Reduction of pain following laparoscopic surgery: a double blind prospective randomised controlled trial

The following abstracts won prizes at the 153rd East Midlands Surgical Society meeting held on 9 November 2012 at Leicester General Hospital. First prize was won by George et al. The paper by Ogunbiyi et al was placed second and the paper by Khanna et al was placed third.

Randomized clinical trial of a simple pulmonary recruitment manoeuvre to reduce pain after laparoscopy

Background

Shoulder tip and abdominal pain following laparoscopic procedures are well recognized causes of postoperative morbidity. In this double-blind randomized clinical trial attempts were made to reduce postoperative pain in patients undergoing laparoscopic surgery by implementing a simple intraoperative technique.

Methods

Patients undergoing elective laparoscopic cholecystectomy or laparoscopic transabdominal preperitoneal inguinal hernia repair were randomized to receive either the current standard treatment (control group) or an intervention to remove residual carbon dioxide. In the intervention group, the pneumoperitoneum was removed at the end of the operation by placing the patient in the Trendelenburg position and utilizing a pulmonary recruitment manoeuvre consisting of two manual inflations to a maximum pressure of 60 cmH2O. In the control group, residual pneumoperitoneum was evacuated at the end of the procedure by passive decompression via the open operative ports.

Results

Seventy-six randomly assigned patients, 37 in the intervention group and 39 in the control group, were recruited. Overall postoperative pain scores were significantly lower in the intervention group (P = 0·001). Median (interquartile range) pain scores were significantly lower in the intervention group compared with the control group at both 12 h (3·5 versus 5; P &lt; 0·010) and 24 h (3 versus 4·5; P &lt; 0·010).

Conclusion

Active evacuation of residual pneumoperitoneum following laparoscopic procedures, by means of two pulmonary recruitment manoeuvres in the Trendelenburg position, reduces postoperative pain significantly. This simple and safe technique can be implemented routinely after abdominal laparoscopy. Registration number: NCT01720433 (http://www.clinicaltrials.gov).

Association of Interleukin 1 beta (IL-1B) gene polymorphism with early pregnancy loss risk in the North Indian population

C+3953T IL-1 B single-nucleotide polymorphism (SNP) genotyping was carried out in 140 unrelated early pregnancy loss (EPL) patients and in 198 fertile healthy control women and in chorionic villous samples by PCR-RFLP. In Indian population, this is the first report on association of IL-1 B SNP C+3953T polymorphism and EPL.

Inflammation and oxidative stress induced by cigarette smoke in Lewis rat brains

Exposure to cigarette smoke has been associated with an increased risk of neurological diseases such as stroke, Alzheimer's disease and multiple sclerosis. In these studies, serum and brain sections from Lewis rats or those exposed to cigarette smoke and control rats were examined for evidence of increased inflammation and oxidative stress. Immunocytochemical staining of brain sections from CS-exposed rats showed increased expression of class II MHC and, in ELISA, levels of IFN-gamma and TNF-α were higher than for non-exposed rats. In polymerase chain reaction assays there was increased interferon-gamma, TNF-α, IL-1α, IL-1β, IL-23, IL-6, IL-23, IL-17, IL-10, TGF-β, T-bet and FoxP3 gene expression with CS exposure. There was also markedly elevated MIP-1α/CCL3, less prominent MCP-1/CCL2 and no elevation of SDF-1α gene expression. Analysis of samples from CS-exposed and control rats for anti-oxidant expression showed no significant difference in serum levels of glutathione and, in brain, similar levels of superoxide dismutase and decreased thioredoxin gene expression. In contrast, there was increased brain gene expression for the pro-oxidants iNOS and the NADPH components NOX4, dual oxidase 1 and p22(phox). Nrf2 expression, which is typically triggered as a secondary response to oxidative stress, was also increased in brains from CS-exposed rats with nuclear translocation of this protein from cytoplasm demonstrated in astrocytes in association with increased expression of the aryl hydrocarbon receptor gene, an Nrf2 target. These studies, therefore, demonstrate that CS exposure in these animals can trigger multiple immune and oxidative responses that may have important roles in the pathogenesis of CNS inflammatory neurological diseases.

Collagen sheet dressings for cutaneous lesions of toxic epidermal necrolysis

Toxic epidermal necrolysis (TEN) is associated with a significant mortality of 30–50% and long-term sequelae. Treatment includes early admission to a burn unit, where management with precise fluid, electrolyte, protein, and energy supplementation, moderate mechanical ventilation, and expert wound care can be provided. Specific treatment with immunosuppressive drugs or immunoglobulins did not show an improved outcome in most studies and remains controversial. We have treated the cutaneous lesions of seven patients of TEN with collagen sheet dressings and have found a significant reduction in morbidity. The sheets are a one-time dressing, easy to apply and they reduce fluid loss, prevent infection, reduce pain, avoid repeated dressings and gradually peal off as the underlying lesions heal.

Markers of genital tuberculosis in infertility

INTRODUCTION

Although genital tuberculosis is a condition that is prevalent worldwide, it is still a diagnostic dilemma. This study aimed to find an effective diagnostic modality for the condition.

METHODS

A total of 100 infertile women were clinically evaluated with haemoglobin estimation, total and differential count, Mantoux test, tubercle bacilli enzyme-linked immunosorbent assay (TB ELISA), hysterosalpingography, pelvic ultrasonography, laparohysteroscopy, premenstrual endometrial biopsy for histopathology, culture and tubercle bacilli polymerase chain reaction (TBPCR). The womens' Day 2 hormonal profile (luteinising, follicle-stimulating, prolactin and thyroidstimulating hormones) and their husbands' semen analysis were also conducted.

RESULTS

A total of 58 women had primary infertility and 42 had secondary infertility. Female factor infertility was present in 63 percent of the cases (mostly tubal; 45.97 percent). 26 women tested positive for endometrial TBPCR. Erythrocyte sedimentation rate, Mantoux test, TB ELISA and hysterosalpingography were found to have high negative predictive value (greater than 80 percent), while the positive predictive value was 35-45 percent. Laparoscopy findings were suggestive of tuberculosis in 13 percent of the women, out of which 83.3 percent were positive for endometrial TBPCR. Hysteroscopy revealed intrauterine adhesions in 34.8 percent of the women, with 68.8 percent being positive for tubercular bacilli.

CONCLUSION

Our study established that in cases of genital tuberculosis, the use of expensive endometrial TBPCR tests may be avoided with a detailed workup, which would also help in the institution of anti-tubercular treatment in early disease, thus enhancing the chance of pregnancy.

A systematic review of enhanced recovery protocols in colorectal surgery

INTRODUCTION

Colorectal surgery has been associated with a complication rate of 15-20% and mean post-operative inpatient stays of 6-11 days. The principles of enhanced recovery after surgery (ERAS) are well established and have been developed to optimise peri-operative care and facilitate discharge. The purpose of this systematic review is to present an updated review of peri-operative care in colorectal surgery from the available evidence and ERAS group recommendations.

METHODS

Systematic searches of the PubMed and Embase™ databases and the Cochrane library were conducted. A hand search of bibliographies of identified studies was conducted to identify any additional articles missed by the initial search strategy.

RESULTS

A total of 59 relevant studies were identified. These included six randomised controlled trials and seven clinical controlled trials that fulfilled the inclusion criteria. These studies showed reductions in duration of inpatient stays in the ERAS groups compared with more traditional care as well as reductions in morbidity and mortality rates.

CONCLUSIONS

Reviewing the data reveals that ERAS protocols have a role in reducing post-operative morbidity and result in an accelerated recovery following colorectal surgery. Similarly, both primary and overall hospital stays are reduced significantly. However, the available evidence suggests that ERAS protocols do not reduce hospital readmissions or mortality. These findings help to confirm that ERAS protocols should now be implemented as the standard approach for peri-operative care in colorectal surgery.

Collagen sheet dressings for cutaneous lesions of toxic epidermal necrolysis

Toxic epidermal necrolysis (TEN) is associated with a significant mortality of 30–50% and long-term sequelae. Treatment includes early admission to a burn unit, where management with precise fluid, electrolyte, protein, and energy supplementation, moderate mechanical ventilation, and expert wound care can be provided. Specific treatment with immunosuppressive drugs or immunoglobulins did not show an improved outcome in most studies and remains controversial. We have treated the cutaneous lesions of seven patients of TEN with collagen sheet dressings and have found a significant reduction in morbidity. The sheets are a one-time dressing, easy to apply and they reduce fluid loss, prevent infection, reduce pain, avoid repeated dressings and gradually peal off as the underlying lesions heal.

Digital ischaemia in the digital age

After the accidental injection of epinephrine into a digit, various techniques to try and reverse the ensuing ischaemia were unsuccessful. To identify a further treatment strategy and as members of the admitting team were unfamiliar with digital injection of epinephrine a Google search was performed. Previous cases were described and separate sources indicated appropriate management protocols utilising phentolamine. After administration, an almost immediate reversal of ischaemic symptoms occurred. This highlights the role of the internet as an adjunct in managing unfamiliar situations and practising evidence based medicine.

Crown Cementing Strategy for Naval Divers

BACKGROUND

A large number of personnel working in hyperbaric environment such as divers and submariners during escape drills report to the out patient department with split teeth, displacement of restoration and pain during ascent after diving. These symptoms are probably attributable to dental barotraumas. Therefore, a need was felt to undertake a study in this area, with a specific interest for treating these patients.

METHODS

Sixty extracted single rooted premolar teeth were prepared and full cast crowns were cemented. Out of these, 20 were prepared with zinc phosphate, 20 with glassionomer and 20 with resin cement. After seven days of storage, each of the teeth in experimental group was pressure cycled 15 times to 3 atmospheres after which the force required to dislodge the crowns was tested on an Instron testing machine.

RESULT

A significant difference was found (student's t test p value < 0.01) between the force required to dislodge the crowns with zinc phosphate cemented control group (141.70 ± 38.62) and experimental group (16.92 ± 10.13). Similarly a significant difference was observed in the glassionomer cemented control group (184.33 ± 25.33) and experimental group (90.50 ± 34.07). On the other hand, no difference was found between the resin cemented control group (289.15 ± 81.48) and experimental (279.43±87.48) group.

CONCLUSION

Within the limitations of this study and based on the results, it was concluded that environmental pressure cycling affected the retention of crowns cemented with zinc phosphate and glassionomer cement. Panavia resin cement used in this study appeared to be unaffected by environmental pressure cycling. On the basis of the results of this study, dental surgeons should consider cementing fixed prosthesis with resin cements for patients who are exposed to marked variations in environmental pressure, such as divers and submariners during escape drills.

Factors Influencing Utilization of ASHA Services under NRHM in Relation to Maternal Health in Rural Lucknow

BACKGROUND

Under National Rural Health Mission (NRHM), ASHA (accredited social health activist) has been identified as an effective link to address the poor utilization of maternal and child health (MCH) services by rural pregnant women.

OBJECTIVE

To study the factors influencing utilization of ASHA services in relation to maternal health.

STUDY DESIGN

Cross-sectional.

SETTING

Primary Health Centre (PHC), Sarojininagar, Lucknow and its rural field area.

STUDY PERIOD

September 2007 to August 2008. STUDY UNIT: RDW (recently delivered women) were considered as those who delivered a live newborn at PHC Sarojininagar, within a week of interview and belonged to villages within the confines of the PHC being served by ASHA.

MATERIALS AND METHODS

350 RDW were interviewed at their bedside, by a preformed and pretested schedule and then were followed-up after six weeks.

RESULTS

Utilization of ASHA services for early registration was significantly associated with age and religion of RDW. Young, educated and socio-economic class III RDW utilized ASHA services the maximum for early registration. Utilization of ASHA services for adequate ANC or antenatal care (100 iron and folic acid tablets, 2 tetanus toxoid injection and ≥3 antenatal visits) was also inversely associated with age of RDW. Young, Hindu, scheduled caste, middle school pass, Class III RDW and those with birth order one had high odds for utilization of ASHA services for adequate ANC. With regard to postnatal check-up, again young RDW with birth order one, Hindu RDW in reference to Muslim and RDW in socio-economic class III had higher likelihood for utilization of ASHA services. Caste-wise scheduled caste (SC) and other backward caste (OBC) RDW had higher odds for utilization of ASHA services. Educated RDW and those with educated husband had higher odds for utilization of ASHA services for postnatal check-up.

CONCLUSION

Young, educated RDW with low parity, educated husband and belonging to higher socio-economic class had higher odds of utilization of ASHA services.

Identification of a c-Jun N-terminal kinase-2-dependent signal amplification cascade that regulates c-Myc levels in ras transformation

Ras is one of the most frequently activated oncogenes in cancer. Two mitogen-activated protein kinases (MAPKs) are important for ras transformation: extracellular signal-regulated kinase (ERK) and c-Jun N-terminal kinase 2 (JNK2). Here we present a downstream signal amplification cascade that is critical for ras transformation in murine embryonic fibroblasts. This cascade is coordinated by ERK and JNK2 MAPKs, whose Ras-mediated activation leads to the enhanced levels of three oncogenic transcription factors, namely, c-Myc, activating transcription factor 2 (ATF2) and ATF3, all of which are essential for ras transformation. Previous studies show that ERK-mediated serine 62 phosphorylation protects c-Myc from proteasomal degradation. ERK is, however, not alone sufficient to stabilize c-Myc but requires the cooperation of cancerous inhibitor of protein phosphatase 2A (CIP2A), an oncogene that counteracts protein phosphatase 2A-mediated dephosphorylation of c-Myc. Here we show that JNK2 regulates Cip2a transcription via ATF2. ATF2 and c-Myc cooperate to activate the transcription of ATF3. Remarkably, not only ectopic JNK2, but also ectopic ATF2, CIP2A, c-Myc and ATF3 are sufficient to rescue the defective ras transformation of JNK2-deficient cells. Thus, these data identify the key signal converging point of JNK2 and ERK pathways and underline the central role of CIP2A in ras transformation.

A systematic review on the outcomes of correction of diastasis of the recti

PURPOSE

Diastasis or divarication of the rectus abdominus muscles describes the separation of the recti, usually as a result of the linea alba thinning and stretching. This review examines whether divaricated recti should be repaired and tries to establish if the inherent co-morbidity associated with surgical correction outweighs the benefits derived.

METHODS

EMBASE, MEDLINE and the Cochrane library were searched for ('divarication' OR 'diastasis') AND ('recti' OR 'rectus'). A standard data extraction form was used to extract data from each text. Due to the lack of randomised control trials, meta-analysis was not possible.

RESULTS

Seven studies report that patient satisfaction was high following surgery. The most common complication seen was the development of a seroma. Other common complications included haematomas, minor skin necrosis, wound infections, dehiscence, post-operative pain, nerve damage and recurrence, the rate of which may be as high as 40%.

CONCLUSIONS

Further studies are required to compare laparoscopic and open abdominoplasty techniques. Patients and physicians should be advised that correction is largely cosmetic, and although divarications may be unsightly they do not carry the same risks of actual herniation. Progressive techniques have resulted in risk reduction with no associated surgical mortality. However, the outcomes may be imperfect, with unsightly scarring, local sepsis and the possibility of recurrence.

Blood levels of pyrazinamide in children at doses administered under the Revised National Tuberculosis Control Program

OBJECTIVES

To evaluate the blood levels, pharma-cokinetics and pharmacodynamic indices of pyrazinamide (PZA) in children suffering from tuberculosis, at doses administered under the weight band system of Revised National Tuberculosis Control Program of India (RNTCP) of India.

DESIGN

Prospective, open-label, non-randomized single-dose study.

SETTING

20 children in the age group 5-12 years attending out-patient tuberculosis clinic of a tertiary hospital.

OUTCOME MEASURES

Blood levels of pyrazinamide after single dose administration, as per the weight band system of RNTCP.

RESULTS

Group I (n=7) included children who received pyrazinamide within the recommended 30-35 mg/kg dose (mean 31.9 ± 0.8 mg/kg) and Group II (n=13) included those who received a dose lower than 30 -35 mg/kg (mean 28.1 ± 0.3 mg/kg). The Cmax (95% CI of difference 2.2, 13.2; P=0.008) and AUC (95% CI of difference 28.6, 208.1; P=0.01) were significantly lower in Group II. The duration of time for which the concentration was maintained above 25 ug ml-1 was 4-8 h in Group I and 3-5.5 h in Group II (95% CI of difference 0.1, 2.0; P=0.03). The half life, elimination rate constant, clearance and volume of distribution were comparable in the two groups. The ratios of Cmax and AUC to MIC (25 ug ml-1) in children were lower than that recommended for PZA in adults.

CONCLUSIONS

Lower blood concentrations are being attained in children receiving PZA doses under the existing weight band system of RNTCP of India. The weight bands may need to be revised and dose recommendations be based on pharmacokinetic and efficacy data in children.

Development and characterization of in situ gel system for nasal insulin delivery

The objective of the present study was to develop a thermosensitive in situ gel system based on chitosan and poly vinyl alcohol (PVA) for nasal delivery of insulin. The hydrogel was prepared by mixing chitosan and PVA. The concentration of the components was optimized during formulation development. The prepared hydrogel was characterized for gelation temperature, gelation time, viscosity changes, degree of swelling, in vitro release and in vivo hypoglycemic effect. The prepared hydrogel was liquid at room temperature while underwent thermal transition from solution below or at room temperature to non-flowing hydrogel when incubated at 37 degrees C for approximately 12 minutes with increased viscosity. The in vitro release of insulin from gel network was observed spectrophotometrically which was good enough to maintain blood glucose level for six hour. Furthermore, the formulation when evaluated for their in vivo hypoglycemic effect, demonstrated its ability to reduce glucose level. The observed in vitro and in vivo results indicate that the proposed thermosensitive in situ gelling system has substantial potential as nasal delivery system for insulin.

In vitro characterization and pharmacokinetics of dapagliflozin (BMS-512148), a potent sodium-glucose cotransporter type II inhibitor, in animals and humans

(2S,3R,4R,5S,6R)-2-(3-(4-Ethoxybenzyl)-4-chlorophenyl)-6-hydroxymethyl-tetrahydro-2H-pyran-3,4,5-triol (dapagliflozin; BMS-512148) is a potent sodium-glucose cotransporter type II inhibitor in animals and humans and is currently under development for the treatment of type 2 diabetes. The preclinical characterization of dapagliflozin, to allow compound selection and prediction of pharmacological and dispositional behavior in the clinic, involved Caco-2 cell permeability studies, cytochrome P450 (P450) inhibition and induction studies, P450 reaction phenotyping, metabolite identification in hepatocytes, and pharmacokinetics in rats, dogs, and monkeys. Dapagliflozin was found to have good permeability across Caco-2 cell membranes. It was found to be a substrate for P-glycoprotein (P-gp) but not a significant P-gp inhibitor. Dapagliflozin was not found to be an inhibitor or an inducer of human P450 enzymes. The in vitro metabolic profiles of dapagliflozin after incubation with hepatocytes from mice, rats, dogs, monkeys, and humans were qualitatively similar. Rat hepatocyte incubations showed the highest turnover, and dapagliflozin was most stable in human hepatocytes. Prominent in vitro metabolic pathways observed were glucuronidation, hydroxylation, and O-deethylation. Pharmacokinetic parameters for dapagliflozin in preclinical species revealed a compound with adequate oral exposure, clearance, and elimination half-life, consistent with the potential for single daily dosing in humans. The pharmacokinetics in humans after a single dose of 50 mg of [(14)C]dapagliflozin showed good exposure, low clearance, adequate half-life, and no metabolites with significant pharmacological activity or toxicological concern.

Angled sidewalls in silicon slot waveguides: conformal filling and mode properties

Effect of angled sidewalls on the filling and properties of silicon slot waveguides is discussed. We demonstrate complete filling of slot waveguide structures with oxide material systems using the atomic layer deposition technique and discuss use of various slot filling materials. Properties of the optical modes in angled-sidewall slot waveguides are studied. Enhanced vertical confinement is obtained with certain waveguide parameters. The reduced effective mode area enhances e.g. nonlinear effects in the waveguide. We discuss the use of atomic layer deposition in realization of filled slot waveguides optimized for all-optical functionalities.