Splenic trauma in the twenty-first century: changing trends in management

Over the past three decades, management of blunt splenic trauma has changed radically. Use of improved diagnostic techniques and proper understanding of disease pathology has led to nonoperative management being chosen as the standard of care in patients who are haemodynamically stable. This review was undertaken to assess available literature regarding changing trends of management of blunt splenic trauma, and to identify the existing lacunae in nonoperative management. The PubMed database was searched for studies published between January 1987 and August 2017, using the keywords 'blunt splenic trauma' and 'nonoperative management'. One hundred and fifty-three articles were reviewed, of which 82 free full texts and free abstracts were used in the current review. There is clear evidence in published literature of the greater success of nonoperative over operative management in patients who are haemodynamically stable and the increasing utility of adjunctive therapies like angiography with embolisation. However, the review revealed a lack of universal guidelines for patient selection criteria and diagnostic and grading procedures needed for nonoperative management. Indications for splenic artery embolisation, the current role of splenectomy and spleen-preserving surgeries, together with the place of minimal access surgery in blunt splenic trauma remain grey areas. Moreover, parameters affecting the outcomes of nonoperative management and its failure and management need to be defined. This shows a need for future studies focused on these shortcomings with the ultimate aim being the formulation and implementation of universally accepted guidelines for safe and efficient management of blunt splenic trauma.

A novel digital method to assess air space loss associated with acute lung injury in experimental acute pancreatitis

BACKGROUND/OBJECTIVES

Respiratory dysfunction and/or failure from acute lung injury (ALI) are common in acute pancreatitis (AP), but assessment of ALI in experimental AP has lacked standardisation.

METHODS

A range of experimental AP models induced in C57BL/6 mice with corresponding controls (n = 6/group). Full double lung or right lung specimens were taken for histopathological assessment and slides analysed by a pre-set pipeline using Aperio Scanner (Leica), ImageJ software and CellProfiler software. Findings were compared to other routinely assessed parameters.

RESULTS

Overall histopathological changes were similar between both lungs. Mean lung field occupancy was significantly different between moderate and severe CER-AP (21.9% v 27.5%, p < 0.05) and corresponded with lung MPO and local injury severity parameters and was mirrored for all models tested.

CONCLUSION

We have developed a novel, simple method for assessment of ALI to improve measurement of systemic organ injury in experimental AP and contribute to preclinical drug development.

A, Kingston J, Singh UK. Detection and classification of Bacteria using Raman Spectroscopy Combined with Multivariate Analysis

<p class="p1">Vibrational spectroscopic techniques have advantages over conventional microbiological approaches towards identification &amp; detection of pathogens. Since unique spectral fingerprint is obtained, one can identify very closely related bacteria using such methods. In this study Raman microspectroscopy in combination with chemometric method has been used to classify four strains of <em>E</em>. <em>coli </em>(two pathogenic &amp; two non-pathogenic). Different multivariate approaches such as hierarchical cluster analysis, principal component analysis &amp; linear discriminant analysis were explored to obtain efficient classification of the Raman signals obtained from the four strains of <em>E.coli</em>. It was observed that multivariate analysis was able to classify the bacteria at strain level. Linear discrimination analysis using PC scores (PC-LDA) was found to give very good result with as high as 100% accuracy. This hybrid technique (Raman spectroscopy &amp; multivariate analysis) has tremendous potential to be developed as a tool for bacterial identification.<span class="Apple-converted-space"> </span></p>

Changes of haemogram and serum biochemistry in neonatal piglet diarrhoea associated with porcine rotavirus type A

Porcine rotavirus type A (RVA) is a major cause of neonatal piglet mortality in India. The effect of the disease on haemogram and serum biochemical profile is not well established in piglets. Accordingly, we assessed the haemogram and serum biochemical profile in the neonatal piglet diarrhoea with RVA infection (n = 17). The diagnosis of RVA was confirmed using RNA-polyacrylamide gel electrophoresis (RNA-PAGE), commercially available enzyme-linked immunosorbent assay (ELISA) kit and reverse transcription-polymerase chain reaction (RT-PCR). Non-infected healthy piglets (n = 6) served as control. The concentrations of total protein, albumin, alanine amino transaminase (ALT), aspartate amino transaminase (AST), blood urea nitrogen (BUN) and creatinine in serum were measured by spectrophotometric method. Haemogram was done in the blood using sodium ethylenediaminetetraacetic acid (Na₂ EDTA) as anticoagulant. The mean values of total protein, albumin and globulin concentrations were significantly (P < 0.001) decreased and concentrations of ALT, AST, BUN and creatinine were significantly increased (P < 0.001) in the RVA-infected piglets. Haemogram showed marked haemoconcentration (P < 0.001), leukopenia (P < 0.01) and neutropenia (P < 0.01) in the presence of RVA infection than healthy piglets. The results indicated a possible extra-intestinal spread of RVA in piglets during neonatal diarrhoea. The finding might be helpful to clinicians and while treating such type of clinical cases, incorporation of organ protective drugs will be helpful for better response in the treatment schedule.

Retinoic acid prevents synaptic deficiencies induced by alcohol exposure during gastrulation in zebrafish embryos

In this study, we examined the effects of alcohol exposure during gastrulation on zebrafish embryos, specifically focusing on excitatory synaptic activity associated with neurons (Mauthner cells) that are born during gastrulation. Furthermore, we determined whether co-treatment of alcohol and retinoic acid (RA) could prevent the effects of alcohol exposure during gastrulation. We exposed zebrafish embryos to ethanol (150mM), RA (1nM), or a combination of RA (1nM) plus ethanol (150mM) for 5.5h from 5.25h post fertilization (hpf) to 10.75 hpf (gastrulation). Ethanol treatment resulted in altered hatching rates, survivability and body lengths. Immunohistochemical analysis of Mauthner cells (M-cells) suggested that ethanol treatment resulted in smaller M-cell bodies and thinner axons, while electrophysiological recordings of AMPA miniature excitatory postsynaptic currents (mEPSCs) associated with M-cells showed that ethanol treated animals had a significantly reduced mEPSC frequency. Other mEPSC parameters such as amplitude, rise times and decay kinetics were not altered by exposure to alcohol. Locomotor studies showed that ethanol treatment resulted in altered C-bend escape responses. For instance, the C-bends of alcohol-treated fish were larger than control embryos. Thus, ethanol treatment during gastrulation altered a range of features in embryonic zebrafish. Importantly, co-treatment with RA prevented all of the effects of ethanol including survivability, body length, M-cell morphology, AMPA mEPSC frequency and escape response movements. Together these findings show that ethanol exposure during the brief period of gastrulation has a significant effect on neuronal morphology and activity, and that this can be prevented with RA co-treatment.

PBPK Modeling - A Predictive, Eco-Friendly, Bio-Waiver Tool for Drug Research

BACKGROUND

The world has witnessed growing complexities in disease scenario influenced by the drastic changes in host-pathogen- environment triadic relation. Pharmaceutical R&Ds are in constant search of novel therapeutic entities to hasten transition of drug molecules from lab bench to patient bedside. Extensive animal studies and human pharmacokinetics are still the "gold standard" in investigational new drug research and bio-equivalency studies. Apart from cost, time and ethical issues on animal experimentation, burning questions arise relating to ecological disturbances, environmental hazards and biodiversity issues. Grave concerns arises when the adverse outcomes of continued studies on one particular disease on environment gives rise to several other pathogenic agents finally complicating the total scenario. Thus Pharma R&Ds face a challenge to develop bio-waiver protocols. Lead optimization, drug candidate selection with favorable pharmacokinetics and pharmacodynamics, toxicity assessment are vital steps in drug development.

METHODS

Simulation tools like Gastro Plus™, PK Sim®, SimCyp find applications for the purpose. Advanced technologies like organ-on-a chip or human-on-a chip where a 3D representation of human organs and systems can mimic the related processes and activities, thereby linking them to major features of human biology can be successfully incorporated in the drug development tool box.

RESULTS

PBPK provides the State of Art to serve as an optional of animal experimentation. PBPK models can successfully bypass bio-equivalency studies, predict bioavailability, drug interactions and on hyphenation with in vitro-in vivo correlation can be extrapolated to humans thus serving as bio-waiver.

CONCLUSION

PBPK can serve as an eco-friendly bio-waiver predictive tool in drug development.

Proinflammatory cytokine interferon-γ and microbiome-derived metabolites dictate epigenetic switch between forkhead box protein 3 isoforms in coeliac disease

Coeliac disease (CD) is an autoimmune enteropathy triggered by gluten and characterized by a strong T helper type 1 (Th1)/Th17 immune response in the small intestine. Regulatory T cells (T_reg ) are CD4⁺ CD25⁺⁺ forkhead box protein 3 (FoxP3⁺ ) cells that regulate the immune response. Conversely to its counterpart, FoxP3 full length (FL), the alternatively spliced isoform FoxP3 Δ2, cannot properly down-regulate the Th17-driven immune response. As the active state of CD has been associated with impairments in T_reg cell function, we aimed at determining whether imbalances between FoxP3 isoforms may be associated with the disease. Intestinal biopsies from patients with active CD showed increased expression of FOXP3 Δ2 isoform over FL, while both isoforms were expressed similarly in non-coeliac control subjects (HC). Conversely to what we saw in the intestine, peripheral blood mononuclear cells (PBMC) from HC subjects did not show the same balance between isoforms. We therefore hypothesized that the intestinal microenvironment may play a role in modulating alternative splicing. The proinflammatory intestinal microenvironment of active patients has been reported to be enriched in butyrate-producing bacteria, while high concentrations of lactate have been shown to characterize the preclinical stage of the disease. We show that the combination of interferon (IFN)-γ and butyrate triggers the balance between FoxP3 isoforms in HC subjects, while the same does not occur in CD patients. Furthermore, we report that lactate increases both isoforms in CD patients. Collectively, these findings highlight the importance of the ratio between FoxP3 isoforms in CD and, for the first time, associate the alternative splicing process mechanistically with microbial-derived metabolites.

Chikungunya virus infection in West Bengal, India

BACKGROUND

Chikungunya virus has recently re-emerged in India.

OBJECTIVES

Assess prevalence of Chikungunya.

MATERIALS AND METHODS

Study conducted from April 2011 to September 2011. Two hundred and six patients (206) of both sexes (100 males and 106 females) of all age groups studied. Serum separated and CHIKV MAC IgM ELISA and Hemagglutination inhibition assay done.

RESULTS

76 cases (36.89%) sero-positive by both the methods.

CONCLUSION

Re-emergence and resurgence of the Chikungunya virus requires continuous monitoring.

Candidate Elastic Quantum Critical Point in LaCu_{6-x}Au_{x}

The structural properties of LaCu_{6-x}Au_{x} are studied using neutron diffraction, x-ray diffraction, and heat capacity measurements. The continuous orthorhombic-monoclinic structural phase transition in LaCu_{6} is suppressed linearly with Au substitution until a complete suppression of the structural phase transition occurs at the critical composition x_{c}=0.3. Heat capacity measurements at low temperatures indicate residual structural instability at x_{c}. The instability is ferroelastic in nature, with density functional theory calculations showing negligible coupling to electronic states near the Fermi level. The data and calculations presented here are consistent with the zero temperature termination of a continuous structural phase transition suggesting that the LaCu_{6-x}Au_{x} series hosts an elastic quantum critical point.

Tension pneumoperitoneum: a very rare complication of acute gangrenous appendicitis

Tension pneumoperitoneum is a very rare consequence of acute gangrenous appendicitis. We report a case of a 32-year-old woman who presented with abdominal pain, progressively increasing abdominal distension, profound hemodynamic instability and ventilatory compromise. The diagnosis of tension pneumoperitoneum was confirmed by computed tomography, which showed compression of the intra-abdominal viscera and liver (saddlebag sign) by a large volume of intraperitoneal free air. Urgent needle decompression was done as an emergency measure. Exploratory laparotomy, planned due to persistent peritonitis, revealed gangrenous appendicitis with perforation near its base. Appendicectomy with excision of gangrenous portion of caecum was performed. The purpose of the reporting this case is to highlight that the tension pneumoperitoneum can be, very rarely, associated with gangrenous appendicitis and timely diagnosis is very important for the emergency management of this deadly condition.

Molecular signature of extended spectrum β-lactamase producing Klebsiella pneumoniae isolated from bovine milk in eastern and north-eastern India

The present study reports on 23 extended spectrum β-lactamase producing Klebsiella pneumoniae (KP), isolated from milk samples (n=340) of healthy cows (n=129) and cows with subclinical (n=159) and clinical (n=52) mastitis, from three different states of India viz. West Bengal, Jharkhand and Mizoram. Seven of them were AmpC type β-lactamase producers, as well. The ESBL producing KP were significantly (P=0.006, χ2=10.04, df=2) and more frequently detected in milk samples of mastitic cows than healthy ones. The β-lactamase genes - blaCTX-M, blaTEM and blaSHV were detected in 19, 8 and 3 isolates, respectively. In all but one CTX-M positive isolates, the genetic platform - ISEcp1-blaCTX-M-orf477 was detected. Ten of the isolates carried plasmid mediated quinolone resistance gene - qnrS and 1 isolate possessed qnrB. Again 11 of them were found to have sulfonamide resistance gene - sul1 and 12 possessed class I integron. Sequencing of the class 1 integron revealed the presence of dfrA12/dfrA17 and aadA2/aadA5 gene cassettes conferring resistance to trimethoprim and aminoglycosides, respectively. All the isolates, characterized by enterobacterial repetitive intergenic consensus (ERIC) PCR, yielded distinct fingerprinting profile. However, most of the isolates from Jharkhand were clustered along with two isolates each from West Bengal and Mizoram indicating their clonal relatedness even though isolated from geographically different areas. Isolation of ESBL producing KP from bovine milk samples implies its public health significance; as such pathogens may enter the human food chain causing severe health hazards.

Unplanned urology readmissions in a district general hospital: are we meeting the standard?

Background

Recent changes in practice standards and remuneration to UK Trusts have been refined to penalise institutions for patient readmission within 30 days of discharge. The purpose of this study was to determine if the target rate of less than 6.5% was attained within the setting of a district general hospital (DGH) and also to comment on readmission trends.

Materials and methods

A retrospective study was performed over 12 months examining all unplanned readmissions to hospital 30 days following discharge from Urology. Elective as well as emergency cases were audited.

Results

A total of 4124 patients were treated and discharged by the department over 12 months. One hundred and eighty-four (4.4%) patients were readmitted: 93 (51%) patients following acute presentations and 91 (49%) following elective procedures. The commonest causes for unplanned readmission were haematuria, 29 cases (16%), acute urinary retention, 28 cases (15%) and ureteric colic, 25 cases (14%). Readmission rates following flexible cystoscopy and TRUS biopsy were 1% and 3%, respectively. Only six of 70 patients (9%) were readmitted following TURP. Five (3%) of the 184 readmissions required a second procedure.

Conclusion

Our department met the predetermined standard in achieving an unplanned readmission rate of less than 6.5%. This study also highlighted the need for discharge policies for common acute presentations.

Supermedia Interface for Internet-based Telediagnostics of Breast Pathology

We present our development of a supermedia interface for telediagnostics of breast pathology via the Internet. Supermedia is the incorporation of multiple media and data streams, such as audio, video, ultrasound images, and tactile and haptic sensor data for enhanced telepresence capabilities. Our supermedia interface comprises an anthropomorphic arm/hand equipped with haptic and tactile sensing, ultrasound imaging capabilities, a physician interface capable of rendering both haptic and tactile information, and two-way audio and video. The supermedia interface was tested via the Internet and enables telediagnostics. Preliminary experiments with silicone breast models have demonstrated the e fectiveness of the supermedia interface for telediagnostics. The interface is expected to enhance and improve the diagnostic performance of breast pathology as well as promote telediagnostics in remote areas and for patients with cultural barriers.

Optimal Trajectory Planning for Mobile Robots using Jacobian Elliptic Functions

In this article, we introduce an approach for planning minimum-control optimal trajectories for a two-wheeled mo bile robot in the absence of obstacles. The trajectory planning problem is first formulated as a minimum-control, fixed-time, optimal control problem with no terminal cost. This results in a two-point boundary value problem that is numerically solved using the relaxation method. Some simulation results of the relaxation method are presented. While we cannot claim rigor ously that the trajectories obtained here are globally optimal, there is strong evidence from numerical robustness tests that they are well-isolated extrema, and are possibly the globally optimal solutions. The two-point boundary value problem is also solved analytically. It is shown that the optimal motion of the two-wheeled mobile robot is similiar to the motion of a pendulum in a gravitational field, and as such, is described by four constants of motion. A procedure for solving the constants of motion is discussed. At the end, it is possible to obtain a closed-form solution to the optimal trajectories in terms of Jacobian elliptic functions.

Discovery and Preclinical Evaluation of BMS-711939, an Oxybenzylglycine Based PPARα Selective Agonist

BMS-711939 (3) is a potent and selective peroxisome proliferator-activated receptor (PPAR) α agonist, with an EC50 of 4 nM for human PPARα and >1000-fold selectivity vs human PPARγ (EC50 = 4.5 μM) and PPARδ (EC50 > 100 μM) in PPAR-GAL4 transactivation assays. Compound 3 also demonstrated excellent in vivo efficacy and safety profiles in preclinical studies and thus was chosen for further preclinical evaluation. The synthesis, structure-activity relationship (SAR) studies, and in vivo pharmacology of 3 in preclinical animal models as well as its ADME profile are described.

Traumatic abdominal wall hernia with concealed colonic perforation

Traumatic abdominal wall hernia (TAWH) is a rare clinical entity in terms of aetiology. It occurs following a blunt abdominal injury with energy high enough to cause disruption of the musculoaponeurotic layer but not the elastic skin layer. It is often associated with underlying intra-abdominal injuries, which can be diagnosed either clinically or radiologically. We report a case of TAWH in a young man with associated large bowel transection, which remained undiagnosed in the preoperative period owing to its masked features. He was managed surgically, with no recurrence to date. Considering the high volume of blunt abdominal trauma cases that present to the accident and emergency department, only few cases of TAWH have been reported in the literature. Confusion still exists regarding the timing and mode of management of this condition.