A 10-year experience of managing acute limb ischaemia in India

BACKGROUND

Acute limb ischaemia is threatening to both limb and life. There is little information about this disease entity from India.

METHODS

We did a retrospective analysis of the clinical profile of patients presenting with non-traumatic acute limb ischaemia to our department (a tertiary care centre in India) from January 1998 to December 2007. The demography, risk factors, time taken to present to the emergency from the onset of symptoms, time taken to administer the first dose of heparin upon arrival to the emergency, primary interventions and outcomes in terms of amputation rates and in-hospital mortality were studied.

RESULTS

The mean (SD) age of the 84 patients was 48.9 (14.3) years. Only one patient died (1.2%) and 24 patients had an amputation (28.6%). Among the predisposing risk factors a significant association was found between smoking and the rate of amputation. Early presentation to emergency and early administration of heparin was associated with lower amputation rates though this did not achieve statistical significance.

CONCLUSION

Acute limb ischaemia is a catastrophic event. Smoking is a risk factor associated with poorer outcomes. Early arrival to the emergency and early administration of heparin was associated with lower amputation rates.

As2O3 toxicity in rat hepatocytes: manifestation of caspase-mediated apoptosis

In India, arsenic contamination in ground water is of immediate environmental concern affecting a large number of inhabitants in Kolkata. Arsenic is known to be one of the most toxic metalloids naturally occurring in the environment giving rise to severe toxic manifestations including cancer. Because arsenic is also used in chemotherapy of leukemia, it was considered worthwhile to concentrate on the mechanism of toxic action in normal hepatocytes which has not been addressed earlier. Rat hepatocytes were isolated and incubated in As2O3 at concentrations of 10, 20, and 40 μM in a time-dependent manner (0, 15, 30 min and 1, 2, and 4 h). The expression of the common stress proteins HSP 70 and 90 throughout the experimental duration confirmed the magnitude of toxic effect imposed by arsenic. Microscopic observations showed clear apoptotic changes in hepatocytes, which were further characterized by DNA ladder formation in time- and concentration-dependent manners. Apoptosis was triggered by caspase activation and over expression of bax at 10 μM As2O3 and at 20 and 40 μM concentrations of As2O3, MAP kinases were found to mediate the apoptotic pathway. Co-treatment of cells with arsenic and caspase inhibitor (Ac-DEVD-Cho) led to over expression of bcl-2, suppression of bax, and cytosolic sequestration of Bid and Bad. It is therefore concluded that caspase activation has a direct role in arsenic-induced apoptosis mediated by mitochondrial factors at 10 μM As2O3, and JUN N-terminal kinase (JNK) and P38 activation are the major mediators of apoptosis at the higher test concentrations (20 and 40 μM) of As2O3.

Epidemiology of nosocomial infections in medicine intensive care unit at a tertiary care hospital in northern India

This prospective observational study describes the rates of nosocomial infections (NI), the sites of infection, the pathogens involved, their antibiogram and the risk factors at a tertiary care hospital in northern India. In 62 of the 182 enrolled patients 95 episodes of NI were recorded (incidence rate 28.6/1000 person days): pneumonia (77%); urinary tract infection (24%) and blood stream infection (24%). All isolates of Acinetobacter, Pseudomonas and Klebsiella and 83.3% of Escherichia coli were resistant to the third generation cephalosporins. An increased duration of the time spent in intensive care units and days of intervention were associated with incident NI.

Evaluation of a single preoperative dose of pregabalin for attenuation of postoperative pain after laparoscopic cholecystectomy

BACKGROUND

Postoperative pain is the dominating complaint and the primary reason for prolonged convalescence after laparoscopic cholecystectomy. We have evaluated the efficacy of a single preoperative dose of pregabalin for attenuating postoperative pain and fentanyl consumption after laparoscopic cholecystectomy.

METHODS

Sixty adults (16-60 yr), ASA physical status I and II, of either sex undergoing elective laparoscopic cholecystectomy were included in this prospective, randomized placebo controlled, double-blind study. Subjects were divided into two groups of 30 each to receive either a matching placebo or pregabalin 150 mg, administered orally 1 h before surgery. Postoperative pain (static and dynamic) was assessed by a 100 mm visual analogue scale, where 0, no pain; 100, worst imaginable pain. Subjects received patient-controlled i.v. fentanyl analgesia during the postoperative period. Results were analysed by Student's t-test, chi(2) test, Mann-Whitney U-test, and Fisher's exact test.

RESULTS

Postoperative pain (static and dynamic) and postoperative patient-controlled fentanyl consumption were reduced in the pregabalin group compared with the placebo group (P<0.05). Side-effects were similar in both groups.

CONCLUSIONS

A single preoperative oral dose of pregabalin 150 mg is an effective method for reducing postoperative pain and fentanyl consumption in patients undergoing laparoscopic cholecystectomy.

Role of information available over the internet: what are the parents of children undergoing tonsillectomy likely to find?

INTRODUCTION

The aim of this study was to assess the quality of information available on the world wide web to parents of children undergoing tonsillectomy.

MATERIALS AND METHODS

The main data source was from internet searches using the five most popular search engines and the keyword 'tonsillectomy' with default settings. The first 50 web links in each search were evaluated with the LIDA Instrument (assessing accessibility, usability and reliability criteria). We also assessed the readability of the sites using the Flesch reading ease score (FRES).

RESULTS

Of the 250 possible links, 113 new links were included the remaining being repetitions, inactive links or restricted access sites. The websites had an average accessibility score of 42/63 (66.7%; range, 26-57), a usability score of 29/54 (53.7%; range, 7-49), and a reliability score of 17/51 (33.3%; range, 0-49). The Flesch reading ease score was 43.8 (range, 3-84.4).

CONCLUSIONS

Health information available on the internet varies greatly. Highly ranked websites on popular search engines may not be the most reliable. Overall, the websites had low scores for reliability, with poor engagability, content production and conflict of interest declaration. Patients should be given previously assessed references on the internet to prevent them being misled by inaccurate or commercially motivated information.

Dietary adequacy in Asian Indians with HIV

Malnutrition is endemic in developing countries, which also bear the brunt of the human immunodeficiency virus (HIV) pandemic. HIV and its complications have a significant impact on nutritional status. Malnutrition and HIV have deleterious interactions. Dietary inadequacy is a major cause of malnutrition and few studies have been done to assess dietary adequacy in HIV-infected individuals and the factors affecting intake. Dietary intake of 71 consecutive patients was determined using 24-hour dietary recall, with the help of a questionnaire and a structured interview, and then compared with the recommended dietary allowances (RDA). The dietary intake of energy, total fat, fibre, vitamin C and iron were significantly less than the recommended RDA. There was no difference in protein intake. Only 5.7% of males and 16.7% of females reached the recommended energy allowance. The recommended protein allowance was reached by 43.4% males and 44.4% females and 41.5% males and 38.9% females consumed more than the upper limit of the recommended fat intake. Intake of major nutrients was also significantly less when compared to the national average intake. On bivariate analysis, the factors affecting these inadequacies were found to be annual per-capita income, dependency on another for livelihood, CD4 counts more than 200/cubic millimeter and absence of antiretroviral therapy. On multivariate analysis, only dependency on another was found to significantly influence energy intake. Dietary intake of many food constituents is significantly less in HIV patients than that recommended. Dietary counselling and efforts to improve food security are important in management of these patients.

One gene, many phenotypes

"Phenotype" is the visible or quantifiable effect of the expression of a gene, whereas the specific genetic constitution responsible for a phenotype is called "genotype". It was hoped that phenotype could be accurately predicted if the genotype could be characterized. But, the relationship between the genotype and phenotype is not straightforward. Similar genetic lesions can have entirely different phenotypes. In recent years, there has been tremendous progress in the understanding of the genetic basis of diseases. The extent to which it will be possible to relate findings at the DNA level to the clinical phenotype is difficult to delineate on many occasions. The elucidation of mechanisms underlying genotype-phenotype discrepancies is important as it will influence the use of DNA-based tests in the diagnosis, therapy and counseling of individuals affected with genetic disorders. This issue is pertinent to almost every aspect of medical practice and research in this post-genome era. In this article, we have tried to summarize those factors which are responsible for varied manifestations of lesion(s) in a single gene.

Intracameral Avastin dramatically resolves iris neovascularization and reverses neovascular glaucoma

PURPOSE

To report the biologic effect of intracameral bevacizumab in patients with iris neovascularization secondary to proliferative retinal vasculopathies.

METHODS

Sixteen eyes of 15 patients with iris neovascularization associated with or without neovascular glaucoma secondary to proliferative retinal vasculopathies received intracameral bevacizumab (1.25 mg). Ophthalmic evaluations included Snellen visual acuity (VA), complete ophthalmic iris angiography, and slit lamp photography. Main outcome measure was change in degree of iris neovascularization. Secondary outcomes included fluorescein iris angiographic leakage, control of intraocular pressure, and changes in VA.

RESULTS

All patients with neovascularization demonstrated by slit lamp photography and fluorescein angiography (16/16 eyes) had complete (or at least partial) reduction in leakage of the neovascularization within 3 weeks after the injection. Leakage from iris neovascularization resolved in 12 of 16 (75%) eyes. In two cases recurrent leakage was seen as early as 4 weeks necessitating repeat injection. Intraocular pressure was controlled with maximum medical therapy in eight of nine eyes reducing the need for glaucoma surgery. Visual acuity improved from a median of hand motions to 20/200.

CONCLUSIONS

In summary, intracameral bevacizumab was effective in reversing iris neovascularization in the majority of patients. It also facilitated intraocular pressure control in patients with associated glaucoma.

Uro-genital bleeding in pre-menarcheal girls: dilemmas of child abuse

Uro-genital bleeding in pre-menarcheal girls always raises concerns regarding child abuse. There are serious social issues involved; however, before labeling it as sexual abuse, all efforts must be made to rule out an organic pathology. We recently encountered two young girls of Afro-Caribbean origin who presented with vaginal bleeding with concerns from referring physicians about child/sexual abuse. On examination both had a rare condition of urethral prolapse. One of them underwent four-quadrant excision and the other was treated conservatively with urethral catherization.

Rituximab in relapsing-remitting multiple sclerosis: a 72-week, open-label, phase I trial

We evaluated the safety, tolerability, pharmacodynamics, and activity of B-cell depletion with rituximab in patients with relapsing-remitting multiple sclerosis, receiving two courses of rituximab 6 months apart, and followed for a total of 72 weeks. No serious adverse events were noted; events were limited to mild-to-moderate infusion-associated events, which tended to decrease with subsequent infusions. Infections were also mild or moderate, and none led to withdrawal. Fewer new gadolinium-enhancing or T2 lesions were seen starting from week 4 and through week 72. An apparent reduction in relapses was also observed over the 72 weeks compared with the year before therapy.

Longitudinal brain MRI study in a mouse model of Rett Syndrome and the effects of choline

Rett Syndrome (RTT), the second most common cause of mental retardation in girls, is associated with mutations of an X-linked gene encoding the transcriptional repressor protein MeCP2. Mecp2(1lox) mutant mice express no functional MeCP2 protein and exhibit behavioral abnormalities similar to those seen in RTT patients. Here we monitor the development of both whole brain and regional volumes between 21 and 42 days of age in this model of RTT using MRI. We see decreases in whole brain volumes in both male and female mutant mice. Cerebellar and ventricular volumes are also decreased in RTT males. Previous work has suggested that perinatal choline supplementation alleviates some of the behavioral deficits in both male and female Mecp2(1lox) mutant mice. Here we show that perinatal choline supplementation also positively affects whole brain volume in heterozygous females, and cerebellar volume in male RTT mice.

Transaxillary endoscopic excision of benign breast lumps: a new technique

BACKGROUND

Benign breast lumps affect 10% of women in their lifetimes. Despite a favorable natural history enabling surveillance as an option, surgical excision continues to be popular. Avoiding a scar on the breast is an inherent feminine desire. Because the breast is a part with a high charge in the culture, women seek to keep it away from the surgical knife. Numerous minimally invasive approaches have evolved as a result of this psychology. These leave much to be desired. Circumareolar incision at best camouflages the scar, which still is sited on the breast. This scar is subject to the same sequelae as any other breast scar. The axilla, an anatomically contiguous space, provides easy access for endoscopic breast surgery. The authors used this access to excise benign breast lumps endoscopically. This spared the breast from a scar.

METHODS

Between January 2002 and March 2005, 14 women with benign breast lumps underwent surgery. Transaxillary endoscopic excision of 18 such lumps was performed.

RESULTS

A total of 14 women with 18 benign breast lumps underwent surgery. The mean operative time per patient was 66.78 min (range, 40-110 min). No axillary injury, bleeding, technical difficulty, surgical emphysema, conversion, hematoma, or rehospitalization occurred. All the women expressed their satisfaction and happiness with the operation.

CONCLUSION

Endoscopic excision of benign breast lumps is a safe and patient-friendly procedure.

B-cell depletion with rituximab in relapsing-remitting multiple sclerosis

BACKGROUND

There is increasing evidence that B lymphocytes are involved in the pathogenesis of multiple sclerosis, and they may be a therapeutic target. Rituximab, a monoclonal antibody, selectively targets and depletes CD20+ B lymphocytes.

METHODS

In a phase 2, double-blind, 48-week trial involving 104 patients with relapsing-remitting multiple sclerosis, we assigned 69 patients to receive 1000 mg of intravenous rituximab and 35 patients to receive placebo on days 1 and 15. The primary end point was the total count of gadolinium-enhancing lesions detected on magnetic resonance imaging scans of the brain at weeks 12, 16, 20, and 24. Clinical outcomes included safety, the proportion of patients who had relapses, and the annualized rate of relapse.

RESULTS

As compared with patients who received placebo, patients who received rituximab had reduced counts of total gadolinium-enhancing lesions at weeks 12, 16, 20, and 24 (P<0.001) and of total new gadolinium-enhancing lesions over the same period (P<0.001); these results were sustained for 48 weeks (P<0.001). As compared with patients in the placebo group, the proportion of patients in the rituximab group with relapses was significantly reduced at week 24 (14.5% vs. 34.3%, P=0.02) and week 48 (20.3% vs. 40.0%, P=0.04). More patients in the rituximab group than in the placebo group had adverse events within 24 hours after the first infusion, most of which were mild-to-moderate events; after the second infusion, the numbers of events were similar in the two groups.

CONCLUSIONS

A single course of rituximab reduced inflammatory brain lesions and clinical relapses for 48 weeks. This trial was not designed to assess long-term safety or to detect uncommon adverse events. The data provide evidence of B-cell involvement in the pathophysiology of relapsing-remitting multiple sclerosis. (ClinicalTrials.gov number, NCT00097188 [ClinicalTrials.gov].).

Safety and efficacy of additional courses of rituximab in patients with active rheumatoid arthritis: an open-label extension analysis

OBJECTIVE

To determine the safety and efficacy of additional courses of rituximab in patients with rheumatoid arthritis (RA).

METHODS

An open-label extension analysis of RA patients previously treated with rituximab was conducted. Patients who had participated in any of 3 double-blind trials were eligible for additional courses (2 infusions of 1,000 mg given 2 weeks apart) if they exhibited a swollen joint count and tender joint count of > or =8 with > or =16 weeks elapsing after the previous course. Safety was assessed in patients receiving all or a portion of a rituximab course. Efficacy was assessed 24 weeks after each course, using the American College of Rheumatology 20% criteria for improvement (ACR20), ACR50, ACR70, European League Against Rheumatism (EULAR) response criteria, Disease Activity Score in 28 joints, the disability index of the Health Assessment Questionnaire, and Short Form 36 scores, stratified according to prior tumor necrosis factor (TNF) inhibitor exposure.

RESULTS

A total of 1,039 patients received > or =1 course of rituximab. Of these, 570 received 2 courses, 191 received 3 courses, and 40 received 4 courses, for a total of 1,669 patient-years. Irrespective of prior TNF inhibitor exposure, ACR20 responses were comparable at week 24 after course 1 and at week 24 after course 2 (65% versus 72%), as were ACR50 and ACR70 responses. EULAR moderate/good responses were also comparable in course 2 relative to course 1 (88% versus 79%), with EULAR remission occurring in a 2-fold higher proportion of patients after course 2 than after course 1 (13% versus 6%). The most common adverse events, which were mild-to-moderate acute infusion-related events, decreased with each course. The serious infection rate after course 1 (5.1 per 100 patient-years) remained stable through additional courses. The proportion of patients with circulating IgM and IgG levels below the lower limit of normal (LLN) increased with subsequent courses; however, serious infection rates in these patients (5.6 per 100 patient-years in patients with low IgM levels and 4.8 per 100 patient-years in patients with low IgG levels were comparable with those in patients with immunoglobulin levels above the LLN (4.7 per 100 patient-years). Patients with human antichimeric antibody (9.2%) did not exhibit decreasing efficacy or present additional safety concerns.

CONCLUSION

These findings indicate that patients treated with repeated courses of rituximab have sustained clinical responses with no new adverse events.