Patient-reporting improves estimates of postoperative complication rates: a prospective cohort study in gynaecological oncology

Background:

Most studies use hospital data to calculate postoperative complication rates (PCRs). We report on improving PCR estimates through use of patient-reporting.

Methods:

A prospective cohort study of major surgery performed at 10 UK gynaecological cancer centres was undertaken. Hospitals entered the data contemporaneously into an online database. Patients were sent follow-up letters to capture postoperative complications. Grade II–V (Clavien–Dindo classification) patient-reported postoperative complications were verified from hospital records. Postoperative complication rate was defined as the proportion of surgeries with a Grade II–V postoperative complication.

Results:

Patient replies were received for 1462 (68%) of 2152 surgeries undertaken between April 2010 and February 2012. Overall, 452 Grade II–V (402 II, 50 III–V) complications were reported in 379 of the 1462 surgeries. This included 172 surgeries with 200 hospital-reported complications and 231 with 280 patient-reported complications. All (100% concordance) 36 Grade III–V and 158 of 280 (56.4% concordance) Grade II patient-reported complications were verified on hospital case-note review. The PCR using hospital-reported data was 11.8% (172 out of 1462; 95% CI 11–14), patient-reported was 15.8% (231 out of 1462; 95% CI 14–17.8), hospital and verified patient-reported was 19.4% (283 out of 1462; 95% CI 17.4–21.4) and all data were 25.9% (379 out of 1462; 95% CI 24–28). After excluding Grade II complications, the hospital and patient verified Grade III–V PCR was 3.3% (48 out of 1462; 95% CI 2.5–4.3).

Conclusion:

This is the first prospective study of postoperative complications we are aware of in gynaecological oncology to include the patient-reported data. Patient-reporting is invaluable for obtaining complete information on postoperative complications. Primary care case-note review is likely to improve verification rates of patient-reported Grade II complications.

Rubinstein Taybi Syndrome

Rubinstein Taybi is a rare genetic syndrome with characteristic facial features, broad thumb and toes, mental retardation. Diagnosis is mainly clinical. Here we report a 2 and ½ year old female child with typical facial features and other anomalies characteristics of Rubistein Taybi syndrome. Among the different features described-polydactyly, syndactyly, micrognathia are occasional abnormalities to be found in this syndrome. Bilateral pits on posterior aspect of helix is also a feature described in very few literatures. DOI: http://dx.doi.org/10.3126/jnps.v33i1.7091 J Nepal Paediatr Soc. 2013;33(1):68-69

Benzoxazinones as Human Peroxisome Proliferator Activated Receptor Gamma (PPARγ) Agonists: A Docking Study Using Glide

The purpose of the present study is to undertake a docking study of some benzoxazinone derivatives on human peroxisome proliferator activated receptor co-crystallized with an alpha-aryloxyphenylacetic acid agonist using Glide 4.5. The QikProp program was used to obtain the absorption, distribution, metabolism and excretion properties of the analogues. The intermolecular hydrogen bonding interaction of the best-fit ligands were found to be associated with Tyr473, Ser289, Hie 449, Hip 323, Ser 342 and Gly 284 amino acid residue at the receptor active site. Among all the observed interaction with similar binding pattern, the presence of methyl carboxypentyl side chain (Lig. No. 21) showed additional interaction with Ser 342 and the affinity was increased by carboxyl oxygen (as hydrogen bond acceptor) with a best Glide score of -14.54 as compared to the co-crystallized aryloxyphenyl acetic acid which achieved a glide score of -12.50.

An overview on antiepileptic drugs

Epilepsy is the most common chronic neurological disorder of the brain. For several decades different kinds of medications have been used to treat epilepsy. Even though many surgical advances has been made and implemented, medications remain the basis of treatment. The search for noble antiepileptic drugs (AEDs) with more selective activity and lower toxicity continues to be an area of intensive investigation in medicinal chemistry. Additionally, drug resistance is an important clinical problem in epilepsy and is associated with an increased risk of morbidity and mortality. This review intends to present a comprehensive overview on AED in particular along with discussion on some aspects of associated drug resistance and combination therapy.

Cytokine imbalance in systemic lupus erythematosus: a study on northern Indian subjects

OBJECTIVE

The phenotype of systemic lupus erythematosus (SLE) in Asian Indians is more severe as compared with that in Caucasians. The reason is not clear. In this context, we studied serum levels of interferon-gamma (IFN-γ), tumor necrosis factor-alpha (TNF-α), interleukin-4 (IL-4) and interlekin-10 (IL-10). Their interrelations and correlation with SLEDAI scores were evaluated.

MATERIALS AND METHODS

Forty patients with active SLE and 40 controls were studied. The mean SLEDAI score and anti-ds DNA level of the patients were 21.45 ± 8.61 and 176.68 ± 81.31 (IU/ml), respectively. Cytokines were estimated by enzyme-linked immunosorbent assay.

RESULTS

In controls, the levels of IFN-γ were highest, followed by TNF-α, IL-10 & IL-4. In patients, however, the levels of TNF-α were highest, followed by IFN-γ, IL-10 & IL-4. IL-10 and IL-4 correlated negatively, and IFN-γ and TNF-α correlated positively with the SLEDAI scores. As compared with controls, in patients, the mean values of TNF-α, IL-10 and TNF-α/IL-10 ratio were higher by 6.9, 2.9 and 2.3 times, respectively (p < 0.001). Significant positive correlation was found between these two cytokines in patients (r = 0.327, p < 0.05) but not in controls. The levels and ratio of IL-4 and IFN-γ were comparable between patients and controls. These two cytokines correlated negatively both in controls (r = -0.358, p < 0.05) and patients (r = -0.990, p < 0.001). The ratio of TNF-α/IL-4 was 4.2 times higher, and those of IFN-γ/IL-4 and IFN-γ/IL-10 were 1.89 and 3.40 times lower in patients as compared with controls. A positive correlation between IL-10 and IL-4 (r = 0.345, p < 0.05) and a negative correlation between IL-10 and IFN-γ (r = -0.382, p < 0.05) were observed only in patients.

CONCLUSION

This study showed a distinct profile of cytokine imbalance in patients with SLE from the northern plains of India. The levels, ratios and correlations of cytokines in patients suggested significant deviation from normal. Correlations of cytokines with SLEDAI scores indicated that TNF-α contributes significantly to the pathological manifestations of SLE in patients from the region. A detailed study is warranted.

Expression and significance of leukocyte membrane cofactor protein transcript in systemic lupus erythematosus

Membrane cofactor protein (MCP) is a complement regulatory protein ubiquitously expressed on most nucleated cells. Since MCP protects autologous cells from complement-mediated injury, it is suggested to have a protective role against the self-tissue damage in inflammatory conditions such as systemic lupus erythematosus (SLE). However, the relevance of MCP in human SLE is not well explored. To assess the significance of MCP in SLE, we studied expression of leukocyte MCP transcript in 60 healthy individuals (controls) and 60 patients with SLE and correlated that with the levels of circulating immune complex (CIC), C3, C3d and SLEDAI scores. The levels of leukocyte MCP transcript were significantly higher ( p < 0.001) in patients with SLE than the controls. Furthermore, MCP transcript levels exhibited significant positive correlations with SLEDAI scores and CIC level and a negative correlation with C3d level in patients. Twelve patients were followed-up until remission. The levels of MCP transcripts decreased significantly during remission as compared with the state of active disease. These findings suggest that in SLE, the expression of leukocyte MCP at the mRNA level is closely related to disease activity. A protective role of MCP in response to increased disease burden may be speculated. The follow-up study suggested MCP as a potential disease marker.

The role of nitric oxide in portal hypertension caused by extrahepatic portal vein obstruction

Aims:

Nitric oxide (NO) in peripheral venous blood has been shown to be elevated in experimental portal hypertension. This study aims to determine the serum NO levels in patients with extrahepatic portal venous hypertension (EHPVO) pre- and postoperatively and to analyze whether these can serve as a reliable and early indicator of shunt blockage or malfunction.

Materials and Methods:

During the period 2006–2010, 48 children with EHPVO were included in this prospective study; 40 underwent porto-systemic shunt and eight underwent splenectomy with devascularization. NO was evaluated preoperatively, 14 days after surgery, at 3 months and then 6 monthly thereafter. The median follow-up duration was 21 months. Shunt patency was confirmed with Doppler and computed tomography portography. Forty-eight age-matched children with hypospadias served as controls.

Results:

NO was higher in EHPVO patients as compared with controls (43.16 ± 16.27 vs. 5.76 ± 2.62 μmol/l) (P = 0.0001). There was a significant decline in the NO levels (4.64 ± 3.18 μmol/l) following shunt surgery (P = 0.0001), and it continued to remain low till the shunt was patent. A shunt block was indicated by rising NO levels in all five patients. The devascularization group also demonstrated a significant decline in the NO levels (27.06 ± 3.56 μmol/l) (P = 0.002), but it was less as compared with the shunted patients. The decline in the portal pressure after shunt surgery was found to correlate with the decline in the serum NO levels.

Conclusions:

The blood levels of NO can be used in the diagnosis of portal hypertension, and are useful for monitoring the patency of the shunt.

Relationship of leukocyte CR1 transcript and protein with the pathophysiology and prognosis of systemic lupus erythematosus: a follow-up study

Complement Receptor 1 (CR1) is a key complement regulatory protein (CRP) involved in the clearance of immune complexes. Earlier, we reported a marked decline of leukocyte CR1 (L-CR1) transcript and protein in patients with active systemic lupus erythematosus (SLE) and suggested L-CR1 transcript as a putative non-invasive disease marker for SLE. This follow-up study involving 18 patients with active SLE was conducted for further confirmation of the relationship between L-CR1 and SLE. Blood samples from the patients were collected on day 1 of the diagnosis (0 month) and at different time intervals (3 and 6 months) for analysis of L-CR1 transcript and L-CR1 protein by semi-quantitative reverse-transcriptase-polymerase chain reaction (RT-PCR) and western blotting respectively. Within 6 months, 15 patients entered remission. On day 1, the mean values of L-CR1 transcript (8.42 ± 3.53) and L-CR1 protein (4683 ± 1094) in the SLE patients were 6 times and 12 times lower than the normal controls (n = 103). At the end of month 6, these values increased by 4.5 and 6.5 times respectively for CR1 transcript (37.86 ± 8.52) and protein (30,265 ± 8614). Simultaneously, the SLE Disease Activity Index (SLEDAI) scores decreased by 4.8 times (4.47 ± 3.32) as compared with the scores obtained on day 1 (21.45 ± 5.67). Moreover, CR1 values correlated negatively with the SLEDAI scores. Levels of L-CR1 protein and transcript remained low in the three patients who did not enter remission. All of the above results suggested that an increase in the levels of L-CR1 related to good prognosis. Since the levels of L-CR1 protein is influenced by variables like proteolytic cleavage and secretion from leukocytes, the values of L-CR1 transcript on day 1 and subsequent follow-up points may bring a better insight into the state of the disease activity. An extended follow-up study is needed to confirm the significance of L-CR1 as a prognostic marker for SLE.

Development in malarial vaccine: A review

Malaria, a vector-borne infectious disease, is currently a grave and universal concern with a significant social, economic, and human cost, mainly in developing countries. In addition, the emergence and spread of resistance to antimalarial therapies have further aggravated the global situation. Currently most of the research is focused on development of antimalarial drugs, drug resistance, and novel formulations to maximize the therapeutic effect. A number of novel molecules potentially active against malarial parasites are being developed. A vaccine is still viewed as a critical part of a long-term malaria control strategy. In the last several years various studies have shown significant progress in the development of vaccines against malaria. Advancement in vaccine technology and immunology is being used to develop malaria subunit vaccines that would open up new vistas for effective treatment and control of malaria. The development of an effective malaria vaccine represents one of the most important approaches that would provide a cost-effective intervention in addition to currently available malaria control strategies. An overview on progress in antimalarial vaccines is presented.

Mannosylated liposomal cytidine 5' diphosphocholine prevent age related global moderate cerebral ischemia reperfusion induced mitochondrial cytochrome c release in aged rat brain

Mitochondrial dysfunctions generating from cerebral ischemia-reperfusion exert a potential threat on neuronal cell survival and hence, accelerate the aging process and age dependent neuropathology. Thirty min moderate cerebral ischemia induced by bilateral common carotid artery occlusion (BCCAO) followed by 30 min reperfusion caused an increased diene production, depleted glutathione (GSH) content, reduced superoxide dismutase (SOD) and catalase activities and pyramidal neuronal loss in young (2 months old) and aged (20 months old) rat brain compared to sham operated controls. Cytidine 5' diphosphocholine (CDP-Choline) is a known neuroprotective drug. CDP-Choline after metabolism in the liver suffers hydrolysis and splits into cytidine and choline before entering systemic circulation and hardly circumvents blood brain barrier (BBB) as such. Previous reports show CDP-Choline liposomes significantly increased in vivo uptake compared to "free drug" administration in cerebral ischemia. To enhance the therapeutic concentration build up in brain we sought to formulate mannosylated liposomal CDP-Choline (MLCDP) utilizing the mannose receptors. We tested the therapeutic supremacy of MLCDP over liposomal CDP-Choline (LCDP) in global moderate cerebral ischemia reperfusion induced neuronal damage. CDP-Choline in MLCDP delivery system was found potent to exert substantial protection against global moderate cerebral ischemia reperfusion induced mitochondrial damage in aged rat brain. Membrane lipid peroxidation, GSSG/GSH ratio and reactive oxygen species (ROS) generation in cerebral tissue were found to be higher in aged, compared to young rat. Further decline of those parameters was observed in aged rat brain by the induction of global moderate cerebral ischemia and reperfusion. MLCDP treatment when compared to free or LCDP treatment prevented global moderate cerebral ischemia-reperfusion induced mitochondrial damage as evident ultra structurally and release of cytochrome c (cyt c) from mitochondria into cytosol and protected mitochondria to restore its normal structure and functions.

Importance of laccase in vegetative growth of pleurotus Florida

Mycelial culture of Pleurotus florida produced highest extracellular laccase in optimum growth medium. At least two laccases (L(inf1) and L(inf2)) were shown to be present in the culture filtrate. Low-laccase-yielding mutants with impaired L(inf2) activity had poor mycelial growth and could not form fruit body, whereas the revertants from the same mutants were similar to the parent in mycelial growth and fruit body formation.

Isolation, identification and molecular characterization of Vibrio parahaemolyticus from fish samples in Kolkata

Vibrio parahaemolyticus is a marine bacterium which is also responsible for acute diarrhoeal illness in human beings. Eating raw seafish or contaminated seafood is responsible for acute gastroenteritis. The aim of this study was to investigate the isolation, identification and molecular characterization of Vibrio parahaemolyticus from the fish samples in Kolkata, India.

MATERIALS AND METHODS

In this study 90 fish samples were collected from 8 different market places in Kolkata, India. Fish samples collected were shrimp, prawn, bhetki, pamfret and hilsa. VP-toxR PCR was performed to confirm the presence of species specific toxR. tdh and trh genes PCR for detection of virulence genes were performed separately. GS-PCR was performed in tdh, trh gene positive strains to determine whether they belong to pandemic genotype. Serotyping was also done on the tdh, trh positive strains.

RESULTS

Out of the 90 fish samples collected from different local fish markets 60 were positive for Vibrio parahaemolyticus. 21 (35%) out of 60 Vibrio parahaemolyticus isolates from fish samples harboured the tdh gene. 1 (1.7%) out of 60 Vibrio parahaemolyticus isolates from fish samples carried trh gene. Out of 22 isolates only 2 were positive for GS-PCR. O10:KUT was the serovar maximum isolated.

CONCLUSION

Considerable percentage of Vibrio parahaemolyticus carrying the virulence genes and pandemic genotype among fish in Kolkata indicates that there is potential reservoir in Kolkata and consumption of sea fish or contaminated fish might cause Vibrio parahaemolyticus mediated diarrhea in this region.

The Effects of Aceclofenac and Nabumetone in Osteoarthritis

Introduction: Aceclofenac, a NSAID is widely used in the treatment of pain and infl ammation associated with osteoarthritis. Nabumetone, a recently developed preferential cyclo-oxygenase 2 inhibitor has also proved to be equally effective. The present study was undertaken to evaluate the ‘real better’ drug, amongst these with better effi cacy and gastro-intestinal tolerability as well.Methods:Four hundred and twenty-three patients of either sex, aged 40-64 years with uncomplicated osteoarthritis of knee joint were randomly allocated into three equal groups receiving aceclofenac, nabumetone or placebo. A baseline pain measurement was done with Visual Analogue Scale (VAS: 0-10 scale) and Investigator Global Assessment of Disease status (IGADS: 0-4 point scale). Code was broken at the end of two weeks or earlier to eliminate any real fatal outcome. Final evaluation of efficacy was done at the end of four weeks. The signifi cance of difference between the treatment outcomes was analyzed using one way ANOVA test. Results:During the active comparator controlled period, the most common reason for discontinuation was unacceptable adverse events. While 108 (76.6%) participants could take the full course of treatment with aceclofenac, 118 (83.7 %) of the nabumetone group completed the study. Drop outs were highest in the placebo group (33.9%) followed by the aceclofenac group (12.1%) and nabumetone group (8.5%). Discontinuation due to G.I. intolerance was least in the placebo group (2.1%) followed by the nabumetone group (5%) and aceclofenac group (7.8%). Conclusions:The preferential inhibition of cyclo-oxygenase 2 by nabumetone was postulated to afford better clinical effi cacy and gastrointestinal tolerability in osteoarthritis as compared to aceclofenac.Key Words: aceclofenac, nabumetone, osteoarthritis

The effects of aceclofenac and nabumetone in osteoarthritis

INTRODUCTION

Aceclofenac, a NSAID is widely used in the treatment of pain and inflammation associated with osteoarthritis. Nabumetone, a recently developed preferential cyclo-oxygenase 2 inhibitor has also proved to be equally effective. The present study was undertaken to evaluate the 'real better' drug, amongst these with better efficacy and gastro-intestinal tolerability as well.

METHODS

Four hundred and twenty-three patients of either sex, aged 40-64 years with uncomplicated osteoarthritis of knee joint were randomly allocated into three equal groups receiving aceclofenac, nabumetone or placebo. A baseline pain measurement was done with Visual Analogue Scale (VAS: 0-10 scale) and Investigator Global Assessment of Disease status (IGADS: 0-4 point scale). Code was broken at the end of two weeks or earlier to eliminate any real fatal outcome. Final evaluation of efficacy was done at the end of four weeks. The significance of difference between the treatment outcomes was analyzed using one way ANOVA test.

RESULTS

During the active comparator controlled period, the most common reason for discontinuation was unacceptable adverse events. While 108 (76.6%) participants could take the full course of treatment with aceclofenac, 118 (83.7%) of the nabumetone group completed the study. Drop outs were highest in the placebo group (33.9%) followed by the aceclofenac group (12.1%) and nabumetone group (8.5%). Discontinuation due to G.I. intolerance was least in the placebo group (2.1%) followed by the nabumetone group (5%) and aceclofenac group (7.8%).

CONCLUSIONS

The preferential inhibition of cyclo-oxygenase 2 by nabumetone was postulated to afford better clinical efficacy and gastrointestinal tolerability in osteoarthritis as compared to aceclofenac.

Removal of Cr(VI) by thermally activated weed Salvinia cucullata in a fixed-bed column

The present study evaluates the feasibility of using a thermally activated fresh water weed in removing Cr(VI) from wastewater through column studies. The effect of flow rate, bed height and Cr(VI) concentration of the feed solution on the adsorption capacity of the activated weed was investigated. The adsorption capacity increased with decrease in both flow rate and bed height but increased with an increase in initial adsorbate concentration. Four different kinetic models, such as. Adams-Bohart, Bed Depth Service Time (BDST), Thomas and Yoon-Nelson models were first applied to the experimental data to predict the breakthrough curve and to determine the characteristic parameters of the column useful for designing large-scale column studies. Different statistical methods such as Sum of the Square of the Error (SSE), Sum of the Absolute Error (SAE), Average Relative Error (ARE), Average Relative Standard Error (ARS) and regression coefficient, were applied to evaluate the prominent and unique characteristic features of the experimental and predicted parameters under the respective models to find out the best fit. The performance stability of the adsorbent was tested by continuous adsorption-desorption studies.

APOA1-75 G to A substitution associated with severe forms of CAD, lower levels of HDL and apoA-I among northern Indians

Apolipoprotein A-I (APOA1 gene, apoA-I protein) is the major protein for plasma high density lipoprotein (HDL). The relationship of APOA1-75G/A polymorphism with lipid profile and coronary artery disease (CAD) is unclear. Out of 370 individuals initially recruited, 164 angiographically proven CAD patients (≥ 70% stenosis) and 36 individuals with normal coronaries or insignificant CAD (NCAD, ≤ 50% stenosis) from Delhi and adjoining areas were selected for analysis based on the set criteria. Polymorphism was determined by PCR followed by MspI restriction digestion. Lipid profile was estimated by enzymatic kit and apoA-I levels by immunoturbidimetry. A highly significant increasing trend in ‘A’ allele frequency was observed with the rise in severity of CAD: NCAD (0.097) < SVD (single vessel disease) (0.117) < DVD (double vessel disease) (0.223) < TVD (triple vessel disease) (0.291). In comparison to GG individuals, the OR of ‘A’ allele carriers to develop SVD, DVD, TVD was 1.3, 2.8 and 4.2 respectively (p_trend = 0.007). Analysis of intergenotypic variations in the lipid profile revealed significantly lower levels of HDL and apoA-I among ‘A’ allele carriers as compared to GG (patients). Our study, first of its kind from India, suggests that ‘A’ allele may contribute to severity of CAD and low levels of HDL & apoA-I. However, an in depth study with a larger set of sample is necessary.

A study on the effects of diclofenac sodium and etoricoxib in the treatment of osteoarthritis

Diclofenac sodium, a non-selective cyclo-oxygenase inhibitor and etoricoxib, a selective cyclo-oxygenase-2 inhibitor have been widely used in treatment of patients with osteo-arthritis. Five hundred and eighty-five patients with uncomplicated knee osteo-arthritis were randomly allocated into 3 equal groups and received either diclofenac sodium, etoricoxib or placebo in a double-blind manner. The response in both the drug groups was comparable and much more than placebo group. The study shows that etoricoxib provides better clinical efficacy and gastro-intestinal tolerability in osteo-arthritis in comparison to diclofenac sodium presumably due to the selective inhibition of cyclo-oxygenase-2 by etoricoxib.

Risk adjusted surgical audit in gynaecological oncology: P-POSSUM does not predict outcome

AIMS

To assess the Physiological and Operative Severity Score for the enumeration of mortality and morbidity (POSSUM) and its validity for use in gynaecological oncology surgery.

METHODS

All patients undergoing gynaecological oncology surgery at the Northern Gynaecological Oncology Centre (NGOC) Gateshead, UK over a period of 12months (2002-2003) were assessed prospectively. Mortality and morbidity predictions using the Portsmouth modification of the POSSUM algorithm (P-POSSUM) were compared to the actual outcomes. Performance of the model was also evaluated using the Hosmer and Lemeshow Chi square statistic (testing the goodness of fit).

RESULTS

During this period 468 patients were assessed. The P-POSSUM appeared to over predict mortality rates for our patients. It predicted a 7% mortality rate for our patients compared to an observed rate of 2% (35 predicted deaths in comparison to 10 observed deaths), a difference that was statistically significant (H&L chi(2)=542.9, d.f. 8, p<0.05).

CONCLUSION

The P-POSSUM algorithm overestimates the risk of mortality for gynaecological oncology patients undergoing surgery. The P-POSSUM algorithm will require further adjustments prior to adoption for gynaecological cancer surgery as a risk adjusted surgical audit tool.

Increased cholecystectomy rate in the laparoscopic era: a study of the potential causative factors

BACKGROUND

It has been suggested that an increased cholecystectomy rate in the laparoscopic era may be due to a reduced threshold for surgery or diagnostic confusion with irritable bowel syndrome (IBS). This study aims to determine the validity of these suggestions.

METHODS

Questionnaires were sent to patients who had undergone cholecystectomy between 1988-1990 (open) and 1998-2000 (laparoscopic). Patients were asked about abdominal pain, fatty food intolerance, jaundice, and indigestion pre- and postoperatively. Questionnaires included Rome II criteria for the diagnosis of IBS and SF-36 quality-of-life data. Histological severity of gallbladder disease was assessed using a standard scoring system.

RESULTS

A total of 124 of 196 patients in the open group and 264 of 400 patients in the laparoscopic group replied. There was no difference between the groups in gender, age at surgery, IBS incidence, or quality-of-life scores. The laparoscopic group reported a lower incidence of preoperative fat intolerance (45.8 vs 58.1%, p < 0.05) and a higher incidence of persistent postoperative abdominal pain (27.3 vs 17.7%, p < 0.05). Mean histopathology severity scores were higher in the open group (4.42 vs 3.95, p < 0.01).

CONCLUSIONS

Increased cholecystectomy rate in the laparoscopic era cannot be attributed to diagnostic confusion with IBS. However, a reduction in the threshold for surgery may have contributed to the increased rate of cholecystectomy.

Effect of ascorbic acid on prevention of hypercholesterolemia induced atherosclerosis

The notion that oxidation of lipids and propagation of free radicals may contribute to the pathogenesis of atherosclerosis is supported by a large body of evidence. To circumvent the damage caused by oxygen free radicals, antioxidants are needed which provide the much needed neutralization of free radical by allowing the pairing of electrons. In this study we have investigated the effect of ascorbic acid, a water soluble antioxidant on the development of hypercholesterolemia induced atherosclerosis in rabbits. Rabbits were made hypercholesterolemic and atherosclerotic by feeding 100 mg cholesterol/day. Different doses of ascorbic acid were administered to these rabbits. Low dose of ascorbic acid (0.5 mg/100 g body weight/day) did not have any significant effect on the percent of total area covered by atherosclerotic plaque. However, ascorbic acid when fed at a higher dose (15 mg/100 g body weight/day) was highly effective in reducing the atherogenecity. With this dose the percent of total surface area covered by atherosclerotic plaque was significantly less (p < 0.001). This suggests that use of ascorbic acid may have great promise in the prevention of hypercholesterolemia induced atherosclerosis.

Unilateral groin and pelvic irradiation for unilaterally node-positive women with vulval carcinoma

It is essential that any patient with resected vulval cancer and significant nodal disease receive optimal adjuvant treatment with radiation. Adequate radiotherapy for such patients with unilateral positive groin nodes has not been defined. Whether both groins and pelvic sidewalls should be irradiated or only the affected (node positive) side remains unclear. From our registry, we identified all patients with primary, previously untreated squamous cell carcinoma of the vulva undergoing bilateral inguinofemoral lymphadenectomy (superficial and deep nodes) and having unilaterally positive groin nodes treated with unilateral groin and pelvic radiotherapy (44 Gy in 22 fractions). Clinical and pathologic records were reviewed to identify the anatomical site and timing of recurrences in these patients and determine whether unilateral groin and pelvic irradiation was sufficient for disease control on the node-negative side. From 1983 to 2002, 20 patients with unilateral positive nodes treated with unilateral groin and pelvic irradiation were identified. Nineteen patients were classed as having FIGO stage III disease and one as FIGO stage IV due to involvement of the rectal mucosa. There were nine patients with disease recurrences in this group (45%). The disease-free interval ranged from 4 to 31 months (median time to recurrence, 9 months). All nine patients had local or regional failures, the most common site being the ipsilateral groin (six of nine patients). One patient was also found to have distant metastases. There were no recurrences noted in the contralateral (nonirradiated) groin or pelvic sidewall. Recurrence was generally fatal. Eight of the nine patients subsequently died of their disease. The ninth patient died of another cause. There was a high incidence of regional failure after unilateral groin and pelvic radiotherapy, but there were no recurrences on the nonirradiated, node-negative side. Although a small series, we speculate that there is no apparent disadvantage to administering unilateral adjuvant radiotherapy for unilaterally positive groin nodes and encourage further studies in order to more confidently determine whether the tendency observed in our center holds true.

Apolipoprotein C3 SstI polymorphism in the risk assessment of CAD

Various population studies have reported the association of rare S2 allele of apolipoprotein C3 (APOC3) SstI polymorphism with hypertriglyceridemia (HTG) and coronary artery disease (CAD). We were the first to report an association of S2 allele with high triglyceride (TG) levels in healthy volunteers from Northern India. Since HTG is suggested to be a predominant risk factor for CAD among Indians, we have elucidated the relationship of APOC3 SstI polymorphism with the lipid profile and CAD. A total of 158 patients with > or = 70% stenosis in one or more coronary artery (angiographically proven CAD patients), 35 subjects with < 70% stenosis (NCAD) and 151 normal controls (free of heart disease) from Northern plains of India were recruited in the study. DNA samples were analyzed by polymerase chain reaction (PCR) followed by SstI digestion. Lipid profile was estimated by enzymatic kit. We found a strong association of S2 allele with high TG levels, which was more significant in patients. Prevalence of S2 allele in normal controls and CAD patients were comparable, despite the fact that mean TG level was significantly higher in patients. A greater insight into this observation revealed that the prevalence of high TG, if not coupled with other risk factors (like high total cholesterol, low HDL), was comparable in patients and controls. Thus, our study reveals that rare S2 allele may be employed as a susceptibility marker for high TG. However, high TG or S2 allele alone may not contribute to the etiology of CAD.

Laparoscopically assisted radical vaginal hysterectomy vs. radical abdominal hysterectomy for cervical cancer: a match controlled study

OBJECTIVES

The technical feasibility of laparoscopically assisted radical vaginal hysterectomy has been well described, but its advantages over the open technique remain largely unproven. We reviewed and compared our experiences with both approaches.

METHODS

All patients undergoing laparoscopically assisted radical vaginal hysterectomy (LARVH) between 1996 and 2003 were identified and matched for age, FIGO stage, histological subtype and nodal metastases using a control group of women who underwent radical abdominal hysterectomy (RAH) during the same time period.

RESULTS

Fifty-seven women were listed for LARVH, resulting in five conversions. Fifty cases were matched successfully using the criteria above. The majority of cases were FIGO stage 1B1. Statistically significant differences (P < 0.05) were present when the following were compared for LARVH vs. RAH: duration of surgery (median 180 vs. 120 min), blood loss (median 350 vs. 875 ml), hospital stay (median 5 days vs. 8 days) and duration of continuous bladder catheterisation (median 3 days vs. 7 days). There were no statistically significant differences with regard to nodal yield, completeness of surgical margins or perioperative complication rate. Four major complications (8%, three cystotomies and one enterotomy) occurred in the LARVH group and three in the RAH group (6%, one pulmonary embolism, one ureteric injury and one major haemorrhage). Three women in LARVH group had seen a specialist regarding postoperative bladder dysfunction, versus 12 in the RAH group (P = 0.04). No patients in the LARVH group reported constipation requiring regular laxatives, versus six in the RAH group (P = 0.03). Median follow-up was 52 months for LARVH and 49 months for RAH. There was no significant difference between recurrence rates or overall survival (94% for LARVH vs. 96% for RAH).

CONCLUSIONS

Despite the inherent limitations of LARVH and its associated learning curve, the procedure conveys many advantages over the open technique in terms of blood loss, transfusion requirement and hospital stay. In addition, the incidence of postoperative bladder and bowel dysfunction appears low-suggesting improved quality of life-without compromising survival.

Modulation of urinary CR1 in systemic lupus erythematosus

The decline in the levels of erythrocyte complement receptor 1 (ECR1) in systemic lupus erythematosus (SLE) has been widely reported. The most probable cause for this decline is excessive proteolytic shedding of CR1 from the cell surface. Similarly a decline in glomerular CR1 (GCR1) has also been reported in SLE. Because CR1 is excreted in urine it is imperative to study the relationship of urinary CR1 (uCR1) with ECR1 and GCR1, and their overall correlation with disease activity. We have determined the levels of uCR1, ECR1 and GCR1 in SLE patients and compared them with normal controls and minimal change disease (MCD) patients. We found a significant decline in both uCR1 and GCR1 in SLE but not in MCD; levels of uCR1 in MCD were either comparable to those of controls or higher. Immunofluorescence for GCR1 was very high in MCD. We did not find any correlation between ECR1, uCR1 and kidney function tests on divariate scatter analyses. The correlation coefficient for uCR1 and GCR1 was highly significant and positive. Our findings thus suggest that uCR1 reflects the levels of GCR1 expression, which decline drastically in SLE. Therefore we envisage uCR1 as a potential marker for glomerular involvement in SLE.

Genetic and structural polymorphism of complement receptor 1 in normal Indian subjects

The human complement receptor 1 (C3b/C4b receptor, CD35, CR1), a polymorphic membrane bound glycoprotein, is differentially expressed on erythrocytes, eosinophils, monocytes, B and T-lymphocytes, dendritic cells and kidney podocytes. It also occurs in the plasma as soluble CR1 (sCR1) and in urine as urinary CR1 (uCR1). Different population studies have suggested the functional and physiological significance of the structural (CR1-A/190, CR1-B/220, CR1-C/160 and CR1-D/250 kDa) and genomic (HH, high erythrocyte CR1 expression, HL, intermediate and LL, low expression) polymorphisms in health and disease. However, simultaneous study on the structural and genomic polymorphism in the same group of study subjects is lacking. This is the first study on both quantitative and structural polymorphism in 101 healthy volunteers from different parts of India by random sampling. In our study, AA phenotype was found to be expressed in 84.2% of individuals and 14.8% carried AB phenotype. One individual (0.9%) was found to possess BB phenotype. Homozygous BB pattern was identified for the first time in Indian subjects. The relative gene frequencies for A and B allele were found to be 0.916 and 0.084, respectively. Pertaining to quantitative polymorphism, percentage distribution for HH, HL and LL phenotypes was found to be 23.7, 54.45 and 21.79%, respectively and the gene frequencies were 0.51 and 0.49 for H and L allele, respectively. The observations for quantitative as well as structural polymorphism showed a good probability of fitness with Hardy-Weinberg equilibrium, thus proving that both the types of CR1 polymorphic forms are encoded by autosomal co-dominant alleles. We found a higher frequency of HL and AA phenotypes in the study subjects. Our findings are unique as we found that gene frequencies for structural and quantitative polymorphism in our study subjects were a combination of those found in Caucasian and Oriental populations.

Hepatoprotective effect of Himoliv, a polyherbal formulation in rats

The effect of Himoliv (HV) was evaluated in carbon tetrachloride or paracetamol induced hepatotoxicity in rats. Liver necrosis was produced by administering single dose of either carbon tetrachloride (CCl4, 1 ml/kg, 50% v/v with olive oil, s.c.) or paracetamol (PC, 1 g/kg, p.o.). The liver damage was evidenced by elevated levels of serum glutamate oxaloacetate transaminase (SGOT), serum glutamate pyruvate transaminase (SGPT) and serum alkaline phosphatase (ALP) and hepatic thiobarbituric acid reacting substances (TBARS) and superoxide dismutase (SOD). HV pretreatment (0.5 and 1.0 ml/kg, p.o.) significantly (P < 0.001) reduced CCl4 or PC-induced elevations of the levels of SGOT, SGPT, ALP and TBARS, while the reduced concentration of SOD due to CCl4 or PC was reversed. Silymarin (25 mg/ kg, p.o.), a known hepatoprotective drug showed similar results.

Study of apolipoproteinc3 Sstl polymorphism in healthy volunteers from Northern India

Several studies including a small case-control (hypertriglyceridemic/normotriglyceridemic individuals) study by us revealed close association between rare S2 allele ofAPOC3 Sstl polymorphism and hypertriglyceridemia. With the understanding that Asian Indians are highly vulnerable to the adverse effects of hypertriglyceridemia, we extended the investigation and studied the frequency distribution of this polymorphism in 216 healthy volunteers from Northern plains of India. We found that more than 50% of the study population had one or two S2 allele. This may suggest that a larger fraction of this population is genetically predisposed to hypertriglyceridemia.

Contralateral groin node metastasis following ipsilateral groin node dissection in vulval cancer: a case report

BACKGROUND

The majority of vulval cancers are of the squamous cell type. Current operative management strategies are based on modifications of radical vulvectomy and groin node dissection, enabling a more individualised and conservative approach to surgery. This has led to interesting dilemmas regarding the most appropriate management in certain individuals.

CASE

We describe a case of a contralateral recurrence following unilateral groin node dissection for vulval cancer, with an initial single microscopically positive node. The patient did not receive adjuvant treatment. Evidence regarding the safety of this approach is discussed.

CONCLUSION

The subject remains controversial, and further such cases should be recorded in the literature in order to gather more information on this difficult problem.