Risk factors for diagnostic delay in Crohn's disease and their impact on long-term complications: how do they differ in a tuberculosis endemic region?

BACKGROUND

The diagnosis of Crohn's disease (CD) can be delayed in clinical practice. In tuberculosis endemic areas, empirical anti-tubercular therapy further delays treatment.

AIM(S)

To assess risk factors for diagnostic delay and its impact on the long-term complications of Crohn's disease in India where tuberculosis is endemic.

METHODS

Data from a large prospectively established inflammatory bowel disease registry were analysed retrospectively. The time from onset of symptoms to diagnosis (diagnostic delay) was calculated and categorised into two groups based on median diagnostic delay. The risk factors for delay including anti-tubercular therapy were analysed. Logistic regression analysis was done to assess impact of diagnostic delay on development of stenotic and fistular complications including need for surgery.

RESULTS

Seven hundred and twenty Crohn's disease patients (60.3% male, median: 28 years) were included. Main outcome measures were stenosis, fistula and need for surgery. Subjects with diagnostic delay >18 months (median) developed significantly higher stenotic complications and surgery (OR 4.12; 95% CI: 2.74-6.33, P < 0.001 and OR 2.41, 95% CI: 1.68-3.42, P < 0.001), respectively, compared to those ≤18 months. There was no difference in the development of fistulous complications. 193/720 (27%) received anti-tubercular therapy which significantly contributed to diagnostic delay (OR: 2.47; 95% CI: 1.76-3.47, P < 0.001) with 47% showing initial clinical response (Crohn's disease activity index- CDAI decrease >100). Moreover, the incidence of stenotic complications was significantly higher in patients who had received prior anti-tubercular therapy (55/193 (28.49%) vs 78/527 (14.8%), P < 0.001, OR: 2.60, 95% CI: 1.64-4.12).

CONCLUSIONS

Diagnostic delay in Crohn's disease is associated with significantly higher stenotic complications and need for surgery. Empirical anti-tubercular therapy is the single largest contributor to diagnostic delay in tuberculosis endemic areas. Despite initial clinical response to anti-tubercular therapy, long-term stenotic complications are higher.

Evaluation of Pharmacokinetic and Pharmacodynamic Drug-Drug Interaction of Sacubitril/Valsartan (LCZ696) and Sildenafil in Patients With Mild-to-Moderate Hypertension

Sacubitril/valsartan (LCZ696) is indicated for the treatment of patients with heart failure and reduced ejection fraction (HFrEF). Since patients with HFrEF may receive sacubitril/valsartan and sildenafil, both increasing cyclic guanosine monophosphate, the present study evaluated the pharmacokinetic and pharmacodynamic drug interaction potential between sacubitril/valsartan and sildenafil. In this open‐label, three‐period, single sequence study, patients with mild‐to‐moderate hypertension (153.8 ± 8.2 mmHg mean systolic blood pressure (SBP)) received a single dose of sildenafil 50 mg, sacubitril/valsartan 400 mg once daily for 5 days, and sacubitril/valsartan and sildenafil coadministration. When coadministered with sildenafil, the AUC and C_max of valsartan decreased by 29% and 39%, respectively. Coadministration of sacubitril/valsartan and sildenafil resulted in a greater decrease in BP (–5/–4/–4 mmHg mean ambulatory SBP/DBP/MAP (mean arterial pressure)) than with sacubitril/valsartan alone. Both treatments were generally safe and well tolerated in this study; however, the additional BP reduction suggests that sildenafil should be administered cautiously in patients receiving sacubitril/valsartan. Unique identifier: NCT01601470.

Mitotic Activity in Glioblastoma Correlates with Estimated Extravascular Extracellular Space Derived from Dynamic Contrast-Enhanced MR Imaging

BACKGROUND AND PURPOSE

A number of parameters derived from dynamic contrast-enhanced MR imaging and separate histologic features have been identified as potential prognosticators in high-grade glioma. This study evaluated the relationships between dynamic contrast-enhanced MRI-derived parameters and histologic features in glioblastoma multiforme.

MATERIALS AND METHODS

Twenty-eight patients with newly presenting glioblastoma multiforme underwent preoperative imaging (conventional imaging and T1 dynamic contrast-enhanced MRI). Parametric maps of the initial area under the contrast agent concentration curve, contrast transfer coefficient, estimate of volume of the extravascular extracellular space, and estimate of blood plasma volume were generated, and the enhancing fraction was calculated. Surgical specimens were used to assess subtype and were graded (World Health Organization classification system) and were assessed for necrosis, cell density, cellular atypia, mitotic activity, and overall vascularity scores. Quantitative assessment of endothelial surface area, vascular surface area, and a vascular profile count were made by using CD34 immunostaining. The relationships between MR imaging parameters and histopathologic features were examined.

RESULTS

High values of contrast transfer coefficient were associated with the presence of frank necrosis (P = .005). High values of the estimate of volume of the extravascular extracellular space were associated with a fibrillary histologic pattern (P < .01) and with increased mitotic activity (P < .05). No relationship was found between mitotic activity and histologic pattern, suggesting that the correlation between the estimate of volume of the extravascular extracellular space and mitotic activity was independent of the histologic pattern.

CONCLUSIONS

A correlation between the estimate of volume of the extravascular extracellular space and mitotic activity is reported. Further work is warranted to establish how dynamic contrast-enhanced MRI parameters relate to more quantitative histologic measurements, including markers of proliferation and measures of vascular endothelial growth factor expression.

Dynamics and relaxation of charge carriers in poly(methylmethacrylate)-based polymer electrolytes embedded with ionic liquid

In the present paper, we have studied dynamics and relaxation of the charge carriers in polymethylmethacrylate-lithium bis(trifluoromethane sulfonyl)imide polymer electrolytes embedded with 1-butyl-1-methylpyrrolidinium bis(trifluoromethylsulfonyl)imide ionic liquid. We have analyzed the frequency dependent conductivity spectra using the random free-energy barrier model coupled with the contribution of electrode polarization in the low frequency region. The temperature dependence of ionic conductivity, and relaxation time obtained from the analysis of the spectra exhibits Vogel-Tammann-Fulcher type behavior. The Barton-Nakajima-Namikawa relation is consistent with the results obtained from the random free-energy barrier model. The scaling of ac conductivity spectra has been performed to understand the effect of temperature as well as the composition on the relaxation mechanism. The analysis of the ac conductivity also clearly indicates the existence of a nearly constant loss phenomenon at low temperatures or at high frequencies.

Therapeutic plasma exchange in paediatric SLE: a case series from India

Therapeutic plasma exchange (TPE) has been reported to be a useful adjunct in severe systemic lupus erythematosus (SLE) but paediatric literature continues to be scanty. We hereby present three cases of refractory paediatric SLE (pSLE) with thrombotic thrombocytopenic purpura (TTP), diffuse alveolar haemorrhage (DAH) and crescentic glomerulonephritis which were treated with TPE as an adjunctive therapy. TPE was carried out in haemodialysis units using the membrane filtration technique. Demonstrable benefit of TPE was seen in all three cases. In refractory pSLE, TPE may be a useful tool and should be considered. The report additionally highlights the feasibility of undertaking TPE in haemodialysis units, which is important as haemodialysis units are more readily available than dedicated apheresis units in developing countries.

A nanofiltration-coagulation integrated system for separation and stabilization of arsenic from groundwater

A membrane-integrated hybrid treatment system has been developed for continuous removal of arsenic from contaminated groundwater with simultaneous stabilization of arsenic rejects for safe disposal. Both trivalent and pentavalent arsenic could be removed by cross flow nanofiltration following a chemical pre-oxidation step for conversion of trivalent arsenic into pentavalent form. The very choice of the membrane module and its judicious integration with upstream oxidation and downstream stabilization resulted in continuous removal of more than 98% arsenic from water that contained around 190 mg L(-1) of total suspended solid, 205 mg L(-1) of total dissolved solid, 0.18 mg L(-1) of arsenic and 4.8 mg L(-1) of iron at a pH of 7.2. The used flat sheet cross flow membrane module yielded a high flux of 144-145 L m(-2) h(-1) at a transmembrane pressure of only 16 kgf·cm(-2) without the need for frequent replacement of the membranes. Transmembrane pressure, cross flow rate through the membrane module and oxidant dose were found to have pronounced effects on arsenic rejection and pure water flux. For the first time, an effective scheme for protection of the total environment has been ensured in this context where arsenic separated with high degree of efficiency has been stabilized in a solid matrix of iron and calcium under response surface optimized conditions. The study culminated in a total and sustainable solution to the problem of arsenic contamination of groundwater by offering arsenic-free water at a reasonably low price of only 1.41$·m(-3).

Arsenic removal from contaminated groundwater by membrane-integrated hybrid plant: optimization and control using Visual Basic platform

A simulation software (ARRPA) has been developed in Microsoft Visual Basic platform for optimization and control of a novel membrane-integrated arsenic separation plant in the backdrop of absence of such software. The user-friendly, menu-driven software is based on a dynamic linearized mathematical model, developed for the hybrid treatment scheme. The model captures the chemical kinetics in the pre-treating chemical reactor and the separation and transport phenomena involved in nanofiltration. The software has been validated through extensive experimental investigations. The agreement between the outputs from computer simulation program and the experimental findings are excellent and consistent under varying operating conditions reflecting high degree of accuracy and reliability of the software. High values of the overall correlation coefficient (R (2) = 0.989) and Willmott d-index (0.989) are indicators of the capability of the software in analyzing performance of the plant. The software permits pre-analysis, manipulation of input data, helps in optimization and exhibits performance of an integrated plant visually on a graphical platform. Performance analysis of the whole system as well as the individual units is possible using the tool. The software first of its kind in its domain and in the well-known Microsoft Excel environment is likely to be very useful in successful design, optimization and operation of an advanced hybrid treatment plant for removal of arsenic from contaminated groundwater.

A Visual Basic simulation software tool for performance analysis of a membrane-based advanced water treatment plant

A Visual Basic simulation software (WATTPPA) has been developed to analyse the performance of an advanced wastewater treatment plant. This user-friendly and menu-driven software is based on the dynamic mathematical model for an industrial wastewater treatment scheme that integrates chemical, biological and membrane-based unit operations. The software-predicted results corroborate very well with the experimental findings as indicated in the overall correlation coefficient of the order of 0.99. The software permits pre-analysis and manipulation of input data, helps in optimization and exhibits performance of an integrated plant visually on a graphical platform. It allows quick performance analysis of the whole system as well as the individual units. The software first of its kind in its domain and in the well-known Microsoft Excel environment is likely to be very useful in successful design, optimization and operation of an advanced hybrid treatment plant for hazardous wastewater.