Minithyroidectomy: a preliminary report from a specialised thyroid unit

In the past few years, minimally invasive surgery has replaced the open conventional surgery as the gold standard for many procedures. Here a modified technique was used for thyroid surgery with a 2.5-4.0 cm incision and the results of this technique have been evaluated. During the 3 years of study period, 14 patients underwent hemithyroidectomy using a small incision (2.5-4 cm), placed higher than the conventional incision in selected patients. Mean operative time was 86.2 minutes with an average blood loss of 42.5 ml with two conversions. Mean hospital stay was 32 hours and no drains were used. All patients were satisfied with the scar mark. We found this technique of minithyroidectomy to be feasible and easily reproducible.

Cerebral malaria in adults -- a description of 526 cases admitted to Ispat General Hospital in Rourkela, India

Although the clinical picture of cerebral malaria in children has been reported extensively, scant information is available about cerebral malaria in adults. This report relates to one of the largest series of adult cases of cerebral malaria patients ever described. At Rourkela, in eastern India, 526 adults (aged >12 years) who each satisfied the World Health Organization's criteria for cerebral malaria were admitted to Ispat General Hospital between 1995 and 2001. These cases represented 18% of the 2994 adult patients who were admitted with Plasmodium falciparum malaria over the same period. Most (76%) of the adult cases of cerebral malaria were male, 48% were aged 21-40 years, and only 4% were older than 60 years. The most common presenting symptoms were fever (97.7%), vomiting (54.6%), headache (30.8%) and seizures (17.1%). Most (62.4%) of the cases had associated severe complications: jaundice (47.5%), acute renal failure (28.9%), and/or severe anaemia (9.7%). Overall, 175 (23%) of the cases were fatal, mortality being particularly high (59%) among those with multi-organ failure. Of the fatal cases, 107 (61%) died within the first 24 h of hospitalization, presumably indicative of late presentation. As the management of multiple complications may be inadequate at primary centres, early referral to higher centres is recommended.

Safety and efficacy of surgical management of hyperthyroidism: 15-year experience from a tertiary care center in a developing country

BACKGROUND

Ideal management of toxic goiter still remains elusive. Though surgical management of toxic multinodular goiter (MNG) is well accepted, surgical treatment of Graves' disease (GD) is still controversial in view of the presumed increased incidence of complications. In this paper, we discuss the experience of the surgical management of hyperthyroidism at a specialized tertiary care endocrine center in a developing country, highlighting the minimal morbidity and satisfactory outcome in experienced hands.

MATERIALS AND METHODS

We retrospectively reviewed 325 consecutive patients with hyperthyroidism managed surgically from 1990 to 2005. The etiologic diagnoses were Graves' disease (185), toxic MNG (105), and autonomously functioning thyroid nodules (AFTN) (n = 35). The indications for surgery in Graves' patients were large goiter, relapse after antithyroid drug therapy (ATD), Graves' ophthalmopathy, and presence of nodule. The indications for surgery in toxic MNG were retrosternal extension (n = 15), compressive symptoms (n = 20), and large size (grade II). Among the AFTN nodule size, those greater than 4 cm (85%) formed the major indication for surgery. Subjects with GD and toxic MNG were subjected to subtotal thyroidectomy (n = 93 prior to 1995) or total thyroidectomy (n = 205 post-1995). Hemithyroidectomy was the procedure of choice in patients with AFTN.

RESULTS

Patients with Graves' disease were younger in age, with shorter mean duration of goiter when compared with the other 2 groups. Eight percent of patients with Graves' disease without a clinically palpable nodule and 25% of those with nodules had associated differentiated carcinoma, including papillary, follicular, and medullary thyroid cancer. Four percent of patients with toxic MNG had malignancy. Complications included temporary hypocalcemia (24%), permanent hypocalcemia (3%), and permanent vocal-cord palsy (1%).

CONCLUSIONS

Surgery for hyperthyroidism has negligible mortality and acceptable morbidity in experienced hands. It is a definite option in selected cases. Immediate and permanent cure of hyperthyroidism is achieved, with no recurrences, after total thyroidectomy. The cosmetic outcome is good, with excellent patient satisfaction and acceptance.

Outcome of Adrenalectomy for Cushing’s Syndrome: Experience from a Tertiary Care Center

Adrenalectomy continues to play an important role in the management of Cushing's syndrome (CS). Untreated CS causes considerable physical and mental morbidity and mortality. However, little information is available on the effect of adrenalectomy in ameliorating functional disabilities in CS patients. Our study assesses the long-term outcome of adrenalectomy in patients with CS. This is a retrospective analysis of CS patients managed during 1990-2005 at a tertiary care center. We analyzed the clinical presentation, endocrine evaluation, and surgical management preoperatively and following adrenalectomy. The subjects were 37 patients with CS (age 24.5 +/- 15 years, range 1-60 years; male:female 1.0:1.2). There were various etiologies--unilateral adrenocortical adenoma (n = 11), adrenocortical carcinoma (n = 13), pituitary ACTH-secreting adenoma with failed transsphenoidal surgery (n = 4), ectopic unidentified ACTH source (n = 7), bilateral adrenal macronodular hyperplasia (n = 1), primary pigmented nodular adrenal hyperplasia (n = 1) --for which the patients underwent adrenalectomy: unilateral (n = 22), bilateral (n = 13), or adrenonephrectomy (n = 2). Two patients died during the perioperative period owing to chest infection and sepsis. At the median follow-up of 60 months (range 6-144 months), the patients exhibit significant persistence of obesity (41%), proximal muscle weakness (44%), menstrual irregularity (8%), hypertension (31%), and insulin-dependent diabetes (29%). Hirsutism and psychological abnormalities persisted to a lesser extent. All patients had biochemical cure of CS following surgery evidenced by the 8 a.m. basal cortisol < or = 5 microg/dl. The hypothalamic-pituitary-adrenal axis recovered as shown by normalization of the short synacthen-stimulated cortisol level (peak level > or = 20 microg/dl) after a median follow-up of 9 months (range 6-18 months). Incomplete clinical recovery following adrenalectomy emphasizes the need of early recognition and prompt treatment of CS. Surgery for adrenocortical adenoma is safe and effective; however, survival of patients with CS due to adrenocortical carcinoma remains poor. Bilateral adrenalectomy provides early control of hypercortisolism in selected cases of unlocalized ectopic ACTH syndrome or failed transsphenoidal surgery. Even though functional recovery is incomplete after adrenalectomy, quality of life improves considerably.

Myocardial dysfunction in rheumatic carditis--does it really exist?

OBJECTIVES

Acute rheumatic fever (ARF) continues to affect millions of children in developing countries. Aim of the present study was to evaluate the role of myocardial dysfunction in the genesis of heart failure in patients with rheumatic carditis. There are limited studies on this subject.

METHODS AND RESULTS

In this prospective study, 108 consecutive patients of ARF were evaluated by echocardiography and assay of cardiac troponin I blood levels. The patients were divided into three groups. Group A (n = 30): patients with no evidence of carditis; Group B (n = 45): patients with first attack of carditis; and group C (n = 33): patients with recurrent attacks of carditis. Left ventricular dimensions tended to be larger in Group B and C patients. Left ventricular ejection fraction did not differ between the groups (Group A: 63 +/- 8.1%, Group B: 58 +/- 7.9%, Group C: 61.2 +/- 9%, p = ns). Heart failure was present in 37.7% patients of Group B, and in 60.6% patients of Group C (p = < 0.05). Ejection fraction was normal in majority of heart failure patients (75.7%). It was reduced in 29.4% of patients in Group B and in 20% of Group C patients with heart failure (p = ns). All patients with low ejection fraction had hemodynamically significant regurgitant valvular lesions. Mean cardiac troponin I values, an index of myocardial damage, did not differ between the three groups (Group A: 0.062 +/- 0.027 ng/ml, Group B: 0.068 +/- 0.019 ng/ml, Group C: 0.071 +/- 0.031 ng/ml, p = ns).

CONCLUSION

The present study did not demonstrate any echocardiographic abnormalities or cardiac troponin I elevation suggesting significant myocardial involvement during acute rheumatic fever. This lends credence to the view that myocardial involvement does not play any significant role in the genesis of heart failure in patients with rheumatic carditis.

The external laryngeal nerve in thyroid surgery: the 'no more neglected' nerve

AIMS

To describe a novel surgical technique of 'lateralization' of superior pole to identify and save external branch of superior laryngeal nerve (EBSLN) during thyroidectomy.

SETTINGS AND DESIGN

Prospective, nonrandomized at a tertiary care hospital in a specialized unit.

MATERIAL AND METHODS

Over 30 months, 46 patients underwent thyroidectomy using technique of 1) 'Lateralization' of upper pole and dissection of avascular cricothyroid space 2) identification of EBSLN 3) skeletonization and individual ligation of superior thyroid vessels. Identified nerves were classified according to Cernea's classification. Outcomes were number of nerves identified, number of 'at risk' nerves' bilateral asymmetry and incidence of injury assessed by subjective interview and indirect laryngoscopy.

RESULTS

Of the 78 dissected superior poles, nerves could be identified in 72 (92.31%). There were 22 (28.2%) type I, 42 (53.54%) IIa and 8 (10.25%) IIb 'at risk' nerves. In 32 patients with bilateral dissections, asymmetry of nerve was noted in 15%. Injury to nerve was not recorded in any of the patients. Average weight of glands was 69.59 g. Thyroidectomy was performed for benign disease in 28, malignancy in 4 and thyrotoxicosis in 14 patients.

CONCLUSIONS

With technique of 'lateralization' and 'skeletonization and individual ligation of the superior vessels,' EBSLN identification increases and injury can be prevented. These results relate to the utilization of specific surgical technique and it is reasonable to expect that most surgeons, once familiar with the technique, should be able to achieve similar outcomes.

Effects of oxidizing and reducing agents on ovine pulmonary artery responses to nitric oxide donors, sodium nitroprusside and 3-morpholino-sydnonimine

Nitrovasodilators-sodium nitroprusside (SNP; 10(-9)-10(-4) M) and 3-morpholino-sydnonimine (SIN-1; 10(-9)-10(-4) M) produced concentration-dependent relaxation of the fourth generation sheep pulmonary artery, preconstricted with 5-hydroxytryptamine (1 microM). Oxidizing agents [oxidized glutathione (GSSG, 1 mM) and CuSO4 (5 and 20 microM)] and reducing agents [dithiothreitol (DTT, 0.1 mM), ascorbic acid (1 mM) and reduced glutathione (GSH, 1 mM)] caused opposite effects on nitric oxide (NO)-induced vasodilation in the artery. Ascorbic acid and GSH potentiated the NO responses, while GSSG and CuSO4 inhibited relaxation caused by the nitrovasodilators. DTT, however, reduced the relaxant potency and efficacy of SNP and SIN-1. Pretreatment of the pulmonary artery strips with DTT (0.1 mM) inhibited SNP (10 microM)-induced Na(+)-K(+)-ATPase activity, while ascorbic acid (1 mM) and GSH (1 mM) had no effect either on basal or SNP (10 microM)-stimulated 86Rb uptake, an index of Na(+)-K(+)-ATPase activity, in ovine pulmonary artery. The results suggest that reducing agents like ascorbic acid may have beneficial effect in improving the vascular function under oxidative stress.

Management of severe and complicated malaria

Severe malaria is invariably caused by Plasmodium falciparum. In India, both adults and children are affected by severe malaria. However, children are more prone for developing anemia and convulsions as manifestations of severe malaria, while acute renal failure and jaundice are more common among adults. Pregnant women are vulnerable to hypoglycemia, anemia and pulmonary complications. The case-fatality rate due to severe malaria is 10-15% in spite of therapy but it increases in the presence of renal failure or respiratory distress (pulmonary edema or ARDS). Of late, multi-organ failure and high mortality figures are being reported increasingly from different parts of India. Early diagnosis and prompt treatment will reduce the mortality due to malaria. Cerebral malaria should always be suspected in a patient with altered sensorium in a malaria-endemic area. However, other causes of unconsciousness such as encephalitis, meningitis or hepatic coma should also be excluded. Parenteral quinine is the mainstay of therapy. A recent multi-centric study has demonstrated the efficacy of intravenous artesunate in reducing the mortality by 30%. The usefulness of adjunct therapy is still controversial.

Adjuvant therapy in cerebral malaria

Cerebral malaria is the most common cause of non-traumatic encephalopathy in the world. The mainstay of therapy is either quinine or artemisinin, both of which are effective antimalarials. The clinical picture of cerebral malaria may persist or even become worse in spite of the clearance of parasites from blood. The death rate is unacceptably high even with effective antimalarials in tertiary care hospitals. The mortality increases in presence of multi organ failure (renal failure, jaundice, respiratory distress, severe anaemia, lactic acidosis, etc.). The pathogenesis of cerebral malaria is multifactorial and includes clogging, sequestration, rosette formation, release of cytokines, cerebral oedema, increased intracranial hypertension, etc. Attempts are made to use adjuvant therapy which will act through alternate mechanisms and address one or more of the pathogenetic processes. In this review, we have discussed the role of corticosteroids, pentoxifylline, desferrioxamine, mannitol and newer agents in the treatment of cerebral malaria. Though the literature on adjuvant therapy in cerebral malaria is large enough, there are a number of shortcomings in the clinical trials, many being open and non randomized or of very small sample size. Further research is of utmost importance through large multicentric, double-blind controlled trials to show the efficacy of any of these drugs.

Efficacy and safety of beta-arteether and alpha/beta-arteether for treatment of acute Plasmodium falciparum malaria

One hundred thirty-eight adult patients with acute Plasmodium falciparum malaria were randomized to receive either beta-arteether or alpha/beta-arteether. The drugs were administered in the dose of 150 mg once a day intramuscularly for three consecutive days in hospitalized patients. After one week of hospitalization, patients were followed-up for three weeks after release from the hospital. There was no statistically significant difference between cure rates, mean fever clearance time (FCT), mean parasite clearance time (PCT), and occurrence of side effects in either group. The cure rate was 97.14% for beta-arteether and 97.01 for alpha/beta-arteether (P = 0.9660). The mean PCT was 38.49 hours for beta-arteether and 36.90 hours for alpha/beta-arteether (P = 0.6054), and the mean FCT was 37.27 hours for beta-arteether and 37.9 hours for alpha/beta-arteether (P = 0.8718). Both arteether formulations were safe and efficacious in reducing the clinical symptoms of acute falciparum malaria. There was also rapid clearance of parasitemia with both formulations. Thus, either beta-arteether or alpha/beta-arteether can be used in the treatment of acute falciparum malaria.

Telementoring in Endocrine Surgery: Preliminary Indian Experience

Telemedicine is starting to play an important role in the health field in India. In this case report we describe the successful use of telementoring to remove a parathyroid tumor in a patient with residual hyperparathyroidism after two previous unsuccessful attempts in tumor excision. A 21-yr-old patient crippled with advanced hyperparathyroidism was taken up for third-time exploration at Amrita Institute of Medical Sciences (AIMS), Kochi, with guidance from the Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, using telemedicine technology. These two centers are located 2,500 km apart, and telementoring from the more experienced endocrine surgeons at SGPGIMS resulted in successful tumor localization and removal. For this session both the institutions were provided with a dedicated 512 Kbps very small aperture terminal (VSAT) link and two-way video-audio connectivity. Even though two previous explorations were unsuccessful, with the help of telemedicine technology the same surgeon was successful in locating and removing the tumor. The video and audio quality was of good enough quality for the expert at SGPGIMS to guide the team at AIMS satisfactorily. The patient benefited since he did not have to travel to a far-off specialized center for surgery. This case report testifies to the usefulness of telemedicine in the field of surgery, especially in developing countries, which have few medical experts in certain specialized areas.

Hypothyroid state reduces calcium channel function in 18-day pregnant rat uterus

Hypothyroidism significantly reduced the mean amplitude and increased the mean frequency of spontaneous rhythmic contractions in 18 day pregnant rat uterus. Nifedipine (10(-12)-10(-9) M) and diltiazem (10(-10)-10(-6) M) caused concentration related inhibition of the myogenic responses of the uterine strips obtained from both pregnant and hypothyroid state. However, nifedipine was less potent (IC50:2.11 x 10(-11) M) in pregnant hypothyroid state as compared to pregnant control (IC50: 3.1 x 10(-12) M). Similarly, diltiazem was less potent (IC50: 3.72 x 10(-9) M) in inhibiting the uterine spontaneous contractions in hypothyroid than in pregnant rat uterus (IC50:5.37 x 10(-10) M). A similar decrease in the sensitivity to nifedipine and diltiazem for reversal of K+ (100 mM)-induced tonic contraction and K(+)-stimulated 45Ca2+ influx was observed with these calcium channel antagonists in uterus obtained from hypothyroid pregnant rats compared to the controls. Nifedipine-sensitive influx of 45Ca(2+)-stimulated either by K+ (100 mM) or by Bay K8644 (1,4-dihydro-2,6-methyl-5-nitro-4-[2'-(trifluromethyl)phenyl]-3-pyridine carboxylic acid methyl ester) (10(-9) M) was significantly less in uterine strips from hypothyroid rats compared to controls. The results suggest that the inhibition of uterine rhythmic contractions may be attributable to a reduction in rat myometrial Ca2+ channel function in the hypothyroid state.

Telemedicine: experience at SGPGIMS, Lucknow

Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS) located in Lucknow, capital of Uttar Pradesh, a state in Northern India, is a tertiary level referral academic medical center involved in teaching and training of super specialist medical professionals with 22 academic departments. It is the first tertiary care hospital in public healthcare sector in India to adopt Information Technology (IT) for healthcare delivery. The Hospital Information System (HIS) was implemented in 1998 to record, store, process and retrieve health data of all the patients. This software was developed in-house in collaboration with Center for Development of Advanced Computing (C- DAC), Pune. Later in the year 1999, telemedicine activities were initiated in the form of testing the concept and technology. The first research grant was availed of in the year 2001, which helped in creating an infrastructure for telemedicine. Regular tele-healthcare and tele-educational services were introduced for the postgraduate students of medical colleges of Orissa. These services have now been extended to educate the doctors of other medical colleges and community centers in other states. Besides, the Institute is associated with organizational activities and in policy initiatives of the government. All the activities are in project mode and are being financially supported by government agencies such as Indian Space Research Organisation (ISRO) and Department of Information Technology. Looking at the need of skilled manpower in the field of telemedicine and e-health, a school of telemedicine is coming up in the campus, which will also provide core infrastructure for research and development.

The complete branchial fistula: A case report

The incomplete branchial fistula is not an uncommon congenital anomaly of branchial apparatus but a complete one is rare. Here we report a case of complete congenital branchial fistula with an internal opening near the tonsillar fossa.

Effects of calcium channel blocker, mibefradil, and potassium channel opener, pinacidil, on the contractile response of mid-pregnant goat myometrium

The present study was undertaken to investigate the in vitro influence of mibefradil, a calcium channel blocker, and pinacidil, a potassium channel opener, on pregnant goat myometrial spontaneous rhythmic contractility and contractions induced with the agonist, oxytocin. Longitudinal strips from the distal region of uterus, collected from goats at midgestation, were mounted in an organ bath for recording isometric contractions. Mibefradil (10(-8)-10(-4) M) or pinacidil (10(-10)-10(-4) M), added cumulatively to the bath at an increment of 1 log unit, caused concentration-dependent inhibition of the spontaneous rhythmic contractions of isolated uterine strips. The rhythmic contraction was, respectively, abolished at 100 and 10 microM concentrations of mibefradil and pinacidil. In a concentration-dependent manner, mibefradil (1 and 10 microM) antagonized the contractions elicited with oxytocin (10(-5)-10(-2) IU). Pretreatment of uterine strips with glibenclamide (10 microM), a selective KATP channel blocker, caused a rightward shift of the concentration-response curve of pinacidil with a concomitant decrease in its pD2 value. Pinacidil (0.3, 1 and 3 microM), in a concentration-related manner, antagonized the oxytocin (10(-5)-10(-2) IU)-induced contractile response. The inhibition of spontaneous rhythmic contractions and antagonism of oxytocin-induced contraction by mibefradil in the pregnant goat myometrium may be related to the antagonism of voltage-dependent Ca2+ channels, while by pinacidil suggests that KATP channel could be a therapeutic target for tocolysis.

An outbreak of El Tor cholera in Kavre district, Nepal

Outbreak of cholera still remains major public health problem in most of the developing countries including Nepal. A prospective study was carried out at Dhulikhel Hospital, Kathmandu University Teaching Hospital, Kavrepalanchok during 1st May 2004 to 31st October 2004. A total of 148 stool samples from patients with acute diarrhea were collected and further investigated for cholera. The study was conducted to establish the causes of the outbreak of acute diarrheal disease, antimicrobial profiles of the stool isolates and parasitic co-infection in cholera cases. The samples were subjected to standard recommended microbial procedures and confirmation of the isolates was done by seroagglutination using V.cholerae polyvalent O1 and 0139 antisera and monovalent Ogawa and Inaba antisera. Out of the 148 stool samples, 46 cases (31%) were found to be positive for V.cholerae serogroup O1, biotype ElTor, serotype Ogawa. Both sexes were equally affected. Young age group of less than 30 years were mostly affected. Brahmin was the most affected ethnic group. The isolates were sensitive to all the antibiotics tested except co-trimoxazole. Among the laboratory confirmed cholera cases 30% exhibited co-infection with other parasites among which Giardia lamblia and Ascaris lumbricoides were the most common.

Studies on the adsorption of Brij-35 and CTAB at the coal–water interface

The adsorption behavior of polyoxyethylene (23) lauryl ether (Brij-35) and cetyl trimethyl ammonium bromide (CTAB) on coal sample has been studied. The adsorption process is found to be sensitive to pH, temperature, electrolyte concentration, and the amount of surface active agent. An attempt has been made to explain the adsorption behavior of the surfactants using the Langmuir equation. The extent of adsorption of Brij-35 on coal is found to be the highest at pH 2, which decreases with increase in pH and remains constant in the neutral and alkaline pH regions. But, the adsorption of CTAB exhibits the opposite behavior of that of Brij-35. Adsorption of any of the surfactant at the coal/water interface sharply decreases the apparent viscosity of 55 wt% coal-water slurry (CWS) at a shear rate of 100 s(-1). Electrostatic adsorption of the surfactants on the coal surface decreases the surface charge and renders the coal surface hydrophobic which is manifested in the form of high apparent viscosity of the coal-water slurry under the test conditions.

Telemedicine in neurology: Underutilized potential

Advances in telecommunication which started with telephone lines, FAX, integrated service digital network (ISDN) lines and now internet have provided an unprecedented opportunity for transfer of knowledge and sharing of information. The information can be used for overlapping applications in patient care, teaching and research. In medicine there is increasing utilization of telemedicine; radiology and pathology being regarded as mature specialties and emergency medicine as maturing specialties compared to other evolving specialties which include psychiatry, dermatology, cardiology and ophthalmology. Of the emergencies, status epilepticus and stroke have high potential for improving patient management. Administration of tPA was more frequent when carried out under telemedicine guidance. Telemedicine has great potential for medical education. The principles of education are in congruence with those of telemedicine and can be closely integrated in the existing medical education system. Our experience of telemedicine as a medical education tool is based on video conferencing with SCB Medical College, Cuttack. We had 30 sessions during 2001 to 2004 in which 2-3 cases were discussed in each session. The patients' details, radiological and neurophysiological findings could be successfully transmitted. These conferences improved the knowledge of participants, provided an opportunity for a second opinion as well as modified the treatment decisions in some cases. The advances in telemedicine should be utilized more extensively in neurology, especially in emergency management, epilepsy and stroke patients as well, as it may have a role in neurophysiology and movement disorders.

The influence of hyperbilirubinaemia on malaria-related mortality: an analysis of 1103 patients

The influence of hyperbilirubinaemia on malaria-related mortality was explored among 1103 cases of acute, Plasmodium falciparum malaria at a referral hospital in Orissa, India. Most (64.3%) of the subjects investigated had > 1.2 mg bilirubin/dl serum and were therefore considered hyperbilirubinaemic. Compared with the other patients, those with hyperbilirubinaemia were much more likely to have cerebral malaria (24.1% v. 9.4%; P < 0.0001) or acute renal failure (9.5% v. 2.3%; P < 0.0001), but not severe anaemia (5.9% v. 4.3%; P < 0.22). Mortality was 7.9% among the patients with hyperbilirubinaemia (all the deaths being attributable to cerebral malaria, acute renal failure and/or severe anaemia) but only 1% among the non-hyperbilirubinaemics. There were no deaths, however, among the 506 hyperbilirubinaemics who did not have cerebral malaria, acute renal failure or severe anaemia, even among those with high serum concentrations of bilirubin. It therefore appears that, in acute, Plasmodium falciparum malaria, hyperbilirubinaemia is not in itself a severe complication, and only appears linked with mortality when associated with at least one other complication.

Pollution monitoring with the help of lichen transplant technique at some residential sites of Lucknow City, Uttar Pradesh

Samples of foliose lichen, Dirinaria consimillis (Fr.) Awasthi were transplanted at six residential sites of Lucknow city for monitoring the concentration of Cr, Zn, Pb, Cu and Cd metals at two vertical positions. The concentration of chromium and copper were more at the higher vertical position than the lower one. The maximum zinc was at lower vertical position than the upper one. Lead and cadmium were not detected in the present study.

Adsorption of sodium dodecyl benzenesulfonate onto coal

The adsorption behavior of sodium dodecyl benzenesulfonate (NaDDBS) on a raw (as received) coal sample and its demineralized variety with 11.3% and 1.2% ash contents respectively has been studied. The samples have been characterized by their proximate analysis, particle size distribution, surface area, porosity, density, points of zero charge, etc. Adsorption of NaDDBS on these two samples has been studied as a function of concentration of NaDDBS, temperature, pH, and presence of indifferent electrolyte in the medium. It has been observed that the isotherm exhibits two adsorption plateaus below and above the critical micelle concentration (CMC) of NaDDBS. Low heats of adsorption suggest weak hydrophobic bonding between adsorbent and adsorbate. The present work aims to correlate the adsorption of surfactant onto coal particles with the rheological behavior of coal-water slurry (CWS). The results reveal that addition of a very small amount of NaDDBS (0.3 wt% of coal) to 60% (w/w) CWS results in a marked reduction of the apparent viscosity of the CWS at a shear rate of 100 s(-1). The effect of pH on the apparent viscosity of CWS with and without the presence of the surfactant is also investigated.

Assessment of microsatellite instability in bladder and thyroid malignancies

Microsatellite instability (MSI) is an indicator of a defective DNA mismatch repair system (MMR) that results from somatic mutations. The present work has been planned to investigate MSI and its clinical significance in human urinary bladder and thyroid cancers in Indian patients. Tumor tissues of histologically confirmed cases of urinary bladder and thyroid cancers, respectively, were obtained. Clinical data on tumor stage and histopathological grades were recorded. Corresponding matched peripheral blood was taken as a control. Genomic DNA was isolated from the tumor tissues and blood using a standard phenol-chloroform extraction method. Polymerase chain reaction was done to amplify mononucleotide microsatellite markers, BAT-26, BAT-40, TGFbetaRII, IGFIIR, hMSH3, and Bax by using specific primer sequences. For analysis of allelic patterns, the PCR products were run on 8% denaturing Polyacrylamide gel and sizing was done using a pUC18 sequencing ladder. The instability with BAT-26 and BAT-40 was found to be 20% and 45% in urinary bladder and 33% and 19% in thyroid cancers, respectively. However, no instability was observed with the other four-mononucleotide markers in either of the cancers studied. Eighty-three percent of the unstable urinary bladder cancers were found to have a high grade in a superficial group, whereas only 27% MSI+ve were muscle invasive cancers. Forty percent of unstable thyroid lesions were found to be at high risk of developing metastasis. Association of BAT-26 and BAT-40 instabilities with high grade tumors as well as risk tumors may help in choosing a more definite therapy at the outset.

Muscle sarcopenia: an overview

Sarcopenia is the physiological age related decline in muscle mass and strength. The aetiology is multifactorial involving changes in muscle metabolism, endocrine changes, nutritional factors and mitochondrial & genetic factors. Various treatment modalities have been utilized including hormone replacement therapies but only high resistance training (HIRT) exercise has been of significant benefit. Despite recent advances the exact pathogenesis and therapies are not well understood and need further investigation. This paper reviews the current knowledge of aetiopathogenesis and treatments of sarcopenia and suggests future strategies to enhance the understanding of muscle aging and potential therapies.

Adenosine affects the calcium dynamics of rat portal vein

1. The present study was carried out to characterize the effect of adenosine on calcium dynamics in the rat portal vein. Isolated portal vein of male albino rats was used as the experimental model as it exhibits autorhythmicity. 2. Adenosine and its analogues 2-CAD, N6-CHA and NECA were used to characterize the type of adenosine receptor involved and 2-CAD was used along with adenosine throughout the other part of study to characterize the effect of adenosine on Ca2+ dynamics. Adenosine and its analogues were found to inhibit the spontaneous contractions of rat portal vein in a concentration-related manner. The order of potency was NECA > 2-CAD > N6-CHA > adenosine. Incubation of the tissue with CGS-15943A, an adenosine receptor antagonist, had a per se enhancing effect on autorhythmicity. Adenosine and 2-CAD failed to reverse the contractile response produced by hypertonic KCl (80 or 30 mM). Whereas adenosine and 2-CAD effectively relaxed the tissues contracted with phenylephrine (10(-5) m). 3. Preincubation of the tissue with 2-CAD (10(-4), 10(-5) or 10(-6) m) for 5 min raised the threshold concentration of CaCl2 to evoke contractile response and also significantly increased the mean EC50 values of CaCl2. Nifedipine was found to be more potent than 2-CAD on Ca2+ channels. 4. The results of the present study suggest that the endogenous adenosine plays a significant role in producing vascular relaxation through the participation of A2 receptor subtype. This effect may be due to its inhibitory effect on release of Ca2+ from the intracellular stores. Further to this effect, 2-CAD had a major inhibitory effect on voltage-operated Ca2+ channels compared with receptor-operated Ca2+ channels. 5. It can be concluded that adenosine through its A2 receptor produces vasorelaxant effect by interfering with the release of Ca2+ from the intracellular stores coupled with influx of Ca2+ from the extracellular sources.

Use of telemedicine in evading cholera outbreak in Mahakumbh Mela, Prayag, UP, India: an encouraging experience

Telemedicine (TM) services a process in which expert medical advice from afar is provided using electronic signals to transfer the medical data from one site to another. As a pilot project to assess the efficacy of TM in developing countries like India, a telemedicine center was set up at the main hospital of Mahakumbh mela--a grand religious fair, at Prayag, a city in north India. The daily reporting of the in-patient and outpatient cases at the fair revealed a surge of diarrhea cases among the pilgrims at the fair. This information was communicated to the referral center at Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS), which, with the help of its microbiology department, conducted microbiological examinations of stool samples and rectal swabs of patients along with various water samples. Vibrio cholerae was isolated in 22.6% (7/31) of the samples. This information was immediately relayed to the Main Hospital at the fair online, and then to the health authorities, who took strict and prompt measures to improve hygiene. Subsequently, the number of diarrhea cases decreased considerably in a matter of a few days, and thus an epidemic disaster was averted, which could have created havoc in such a large gathering.

Myxoma of maxilla

A case of Myxoma involving left Maxilla, presenting as swelling of left side of face and Oral cavity with bilateral nasal obstruction is reported.

Primary hyperparathyroidism in India

Background

Primary hyperparathyroidism (PHPT) in Indians has some unique clinical features, such as early age of onset, extreme osteopenia, crippling bone involvement, large parathyroid tumours, higher proportion of malignancy and severe, prolonged postparathyroidectomy hungry bone syndrome. The current study aimed to study (1) whether these features of PHPT in Indians are due to a variant form of PHPT and (2) pathogenetic factors of such variant disease.

Methods

Clinical, investigative and pathological features of 29 consecutive patients with PHPT (24 females, five males) who underwent parathyroidectomy at 13–60 (mean 38) years of age were reviewed. Spearman's correlation coefficient was calculated between serum calcidiol levels and biochemical variables, bone mineral density (BMD) before surgery and parathyroid tumour weight.

Results

Median duration of symptoms was 2·5 (range 1–26) years. Mean total serum calcium, iPTH and ALP levels were 12·4 mg dl−1 (normal 8·5–10·8 mg dl−1), 955 pg ml−1 (normal 9–55 pg ml−1) and 850 units l−1 (normal 35–125 units l−1) respectively, while mean(s.d.) serum calcidiol and calcitriol concentrations were 14(6) ng ml−1 and 52(29) pg ml−1 (versus 9(9) and 30(14) pg ml−1 in matched controls). All patients had symptomatic osteitis fibrosa cystica and eight were bedridden. Single or multiple spontaneous fractures occurred in 14 patients, brown tumours in 20, and long bones were barely visible on plain films in four. BMD z-scores at distal radius and lumbar spine (mean) were −4·2 and −3·8. Palpable parathyroid tumours occurred in 14 patients and nine had renal damage, mainly nephrocalcinosis. Parathyroidectomy invariably resulted in long-standing severe hypocalcaemia, necessitating intravenous calcium infusion for 6 days on average, and long-term oral calcium and vitamin D supplementation. The mean parathyroid gland weight was 8·6 (range 2–36·6) g and signs of carcinoma were found in four. There was a negative correlation (P &lt; 0·05) between serum calcidiol and serum iPTH, and serum ALP and parathyroid gland weight.

Conclusion

PHPT in Indians manifests as severe, symptomatic musculoskeletal and renal disease. In spite of the severe hyperparathyroidism, the serum calcium levels are only moderately raised. These patients have signs of rapid parathyroid tumour growth resulting in large adenomas and a high proportion of parathyroid carcinomas. The signs of rapid cell proliferation, excessive calcium insensitivity of PTH release and peripheral PTH resistance may clarify roles of widely prevalent vitamin D deficiency in pathogenesis of this variant of PHPT.

Unique clinical characteristics of primary hyperparathyroidism in India

Background

The features of primary hyperparathyroidism (PHPT) in developing countries have rarely been examined. This study explored the clinical characteristics of PHPT in India with the hypothesis that this may improve understanding of the pathogenesis of the disease worldwide.

Methods

Consecutive patients with PHPT (24 women, five men) were examined prospectively before and after parathyroidectomy.

Results

All patients had osteitis fibrosa cystica with a median symptom duration of 2·5 (range 1–26) years. Single or multiple fragility fractures were present in 14 patients (eight were bedridden); 20 had brown tumours. Mean preoperative serum calcium was 3·1 mmol/l, while mean serum intact parathyroid hormone (iPTH) and total alkaline phosphatase (ALP) levels were 17-fold and 12-fold higher than normal respectively. Nine patients had overt renal damage, mainly nephrocalcinosis. Parathyroidectomy invariably resulted in severe hypocalcaemia, necessitating long-term vitamin D treatment. The mean parathyroid gland weight was 8·6 (range 2·0–36·6) g and features of carcinoma were found in four patients. Serum calcidiol level correlated inversely (P &lt; 0·05) with serum iPTH and ALP, and parathyroid gland weight.

Conclusion

PHPT in Indians is a severe, symptomatic disorder with skeletal, muscular and renal manifestations at a young age. The presence of this severe variant of PHPT in vitamin D-sufficient Indians, and the lack of skeletal disease in other vitamin D-deficient populations, raises the possibility of additional pathogenetic factors.

Functional analysis of a chromosomal arsenic resistance operon in Pseudomonas fluorescens strain MSP3

We reported earlier about the detection of a chromosomally located arsenic operon (arsRBC) in a gram-negative bacterium Pseudomonas fluorescens strain MSP3, which showed resistance to elevated levels of sodium arsenate and sodium arsenite. The genes for arsenic resistance were cloned into the HindIII site of pBluescript vector producing three clones MSA1, MSA2 and MSI3 conferring resistance to sodium arsenate and arsenite salts. They were further sub-cloned to delineate the insert size and the sub-clones were designated as MSA11, MSA12 and MSI13. The sub-clone pMSA12 (2.6 kb) fragment was further packaged into EcoRI-PstI site of M13mp19 and sequenced. Nucleotide sequencing revealed the presence of three open reading frames homologous to the arsR, arsB and arsC genes of arsenic resistance. Three cistrons of the ars operon encoded polypeptides ArsR, ArsB and ArsC with molecular weights ranging approximately 12, 37and 24 kDa, respectively. These polypeptides were visualized on SDS-PAGE stained with Coomassie blue and measured in a densitometer. The arsenic resistance operon (arsRBC) of strain MSP3 plasmid pMSA12 consists of 3 genes namely, arsR--encoding a repressor regulatory protein, arsB--the determinant of the membrane efflux protein that confers resistance by pumping arsenic from the cells and arsC--a small cytoplasmic polypeptide required for arsenate resistance only, not for arsenite resistance. ArsB protein is believed to use the cell membrane potential to drive the efflux of intracellular arsenite ions. ArsC encodes for the enzyme arsenate reductase which reduces intracellular As(V) (arsenate) to more toxic As(III) (arsenite) and is subsequently extruded from the cell. The arsenate reductase activity was present in the soluble cytoplasmic fraction in E. coli clones. In the context of specified function of the arsenic operon encoded proteins, uptake and efflux mechanisms were studied in the wild strain and the arsenate/arsenite clones. The cell free filtrates of the arsenate clones (MSA11 and MSA12) obtained from P. fluorescens containing the arsC gene showed that arsenate reduction requires glutathione reductase, glutathione (GSH), glutaredoxin and ArsC protein. The protein was purified in an active form and a spectrophotometric assay was developed in which the oxidation of NADPH was coupled to reduction of arsenate. The molecular weights and the location of the polypeptides were obtained from Coomassie stained SDS-PAGE of extracellular and intracellular fractions of the cells.

An ab initio theoretical study of electronic structure and properties of 2'-deoxyguanosine in gas phase and aqueous media

Molecular geometries of two structural forms of 2'-deoxyguanosine (keto-N9R and keto-N7R, R = the sugar moiety) considering both the C2'-endo and C3'-endo conformations of the sugar ring and those of the complexes of these species with two water molecules each were optimized employing the ab initio RHF procedure. A mixed basis set consisting of the 6-311+G* basis set for the nitrogen atom of the amino group and the 4-31G basis set for all the other atoms was used. The RHF calculations were followed by correlation correction of the total energy at the MP2 level. Both the structural forms of 2'-deoxyguanosine were solvated using the polarized continuum model (PCM) of the self-consistent reaction field (SCRF) theory and the corresponding RHF optimized geometries at the RHF and MP2 levels. Geometry optimization was also performed in aqueous media using the Onsager model at the RHF level using the above-mentioned mixed basis set, and subsequently, using the reoptimized geometries, single-point MP2 calculations were performed. It is found that both the keto-N9R and keto-N7R forms of 2'-deoxyguanosine as well as their complexes with two water molecules each would occur, particularly at the water-air interface. Though the normal Watson-Crick-type base pairing would not be possible with the keto-N7R form of 2'-deoxyguanosine(G*), two other (G*-C and G*-T) base pairing schemes may occur with this form of the nucleoside, which may cause mutation. The present calculated geometry of the keto-N9R form of the anti-conformation of 2'-deoxyguanosine including the dihedral angle chi(CN) agree satisfactorily with the available crystallographic results. The present results also agree satisfactorily with those obtained by other authors earlier for the keto-N9R form of 2'-deoxyguanosine using B3LYP and MP2 methods employing the 6-31G* basis set. Using transition state calculations, it is shown that tautomerism of guanine and other similar molecules where the tautomers would coexist would be facilitated by the occurrence of the H(+) and OH(-) fragments of water molecules. Further, this coexistence of the two tautomers appears to make the C8 carbon atom located between the N7 and N9 nitrogen atoms susceptible to attack by the OH(-) group. Thus, an explanation is obtained for the efficient formation of the reaction product 8-hydroxy-2'-deoxyguanosine, which serves as a biomarker for oxidative damage to DNA in biological systems.

Surgical treatment of sternal metastases from thyroid carcinoma: report of two cases

Radioiodine therapy is currently the treatment of choice for metastasizing differentiated thyroid cancer (DTC); however, skeletal metastases are resistant to this form of therapy. The surgical removal of distant metastases from DTC offers the best chance for prolonged survival and improved quality of life. Furthermore, the surgical removal of a resectable skeletal metastasis can be a valuable complement to radioiodine therapy. This report describes two cases of sternal metastases from thyroid carcinoma that were managed successfully by surgery involving partial excision of the sternum followed by reconstruction of the chest wall with Marlex mesh. Both patients recovered uneventfully. Sternal resection with Marlex mesh reconstruction of the chest wall defect proved a simple and effective method for managing sternal metastasis. Thus, the surgical resection of distant bony metastases in patients with DTC is recommended as it can be curative, provide symptomatic palliation, or allow for more effective radioiodine treatment.

Clathrin- and AP-2-binding sites in HIP1 uncover a general assembly role for endocytic accessory proteins

Clathrin-mediated endocytosis is a major pathway for the internalization of macromolecules into the cytoplasm of eukaryotic cells. The principle coat components, clathrin and the AP-2 adaptor complex, assemble a polyhedral lattice at plasma membrane bud sites with the aid of several endocytic accessory proteins. Here, we show that huntingtin-interacting protein 1 (HIP1), a binding partner of huntingtin, copurifies with brain clathrin-coated vesicles and associates directly with both AP-2 and clathrin. The discrete interaction sequences within HIP1 that facilitate binding are analogous to motifs present in other accessory proteins, including AP180, amphiphysin, and epsin. Bound to a phosphoinositide-containing membrane surface via an epsin N-terminal homology (ENTH) domain, HIP1 associates with AP-2 to provide coincident clathrin-binding sites that together efficiently recruit clathrin to the bilayer. Our data implicate HIP1 in endocytosis, and the similar modular architecture and function of HIP1, epsin, and AP180 suggest a common role in lipid-regulated clathrin lattice biogenesis.